` A Case for Environmental Management Control of ` A Case for Environmental Management Control of Malaria in Anambra State ’Malaria in Anambra State ’

Health and Economic Health and Economic Burden of Malaria and Burden of Malaria and

our Community our Community EnvironmentEnvironment

Henry Debem Henry Debem ((Ph.DPh.D. Student. Student))Walden University, USAWalden University, USA

PUBH 8165PUBH 8165Instructor : Instructor : Dr. Lezah Brown-Dr. Lezah Brown-

EllingtonEllingtonSpring Term, 2013Spring Term, 2013

Learning ObjectivesLearning Objectives What is Malaria?What is Malaria? Global Epidemiological Background of MalariaGlobal Epidemiological Background of Malaria Nigerian Context of Malaria BurdenNigerian Context of Malaria Burden

Health and EconomicHealth and Economic Brief Background of Anambra stateBrief Background of Anambra state Current Malaria Control Measures in Anambra StateCurrent Malaria Control Measures in Anambra State Common Points of Interference for Malaria Control Common Points of Interference for Malaria Control Key Stakeholders of Malaria Control in Anambra StateKey Stakeholders of Malaria Control in Anambra State Environmental Risk Practices in Anambra StateEnvironmental Risk Practices in Anambra State Environmental Management Control (EMC) MeasuresEnvironmental Management Control (EMC) Measures Efficacy and Cost Effectiveness of EMCEfficacy and Cost Effectiveness of EMC Other Advantages of EMCOther Advantages of EMC Recommendations for Malaria Eradication in Anambra Recommendations for Malaria Eradication in Anambra

State.State. Revision of the Learning ObjectivesRevision of the Learning Objectives

Presentation OutlinePresentation Outline

At the end of this presentation, participants At the end of this presentation, participants will be able to:will be able to:

Learn mosquito and malaria cycle Learn mosquito and malaria cycle Understand the health and economic burden Understand the health and economic burden

of malaria in the World and Nigeriaof malaria in the World and Nigeria Learn the current control measures in Learn the current control measures in

Anambra State and their Merits and DemeritsAnambra State and their Merits and Demerits Understand the superiority of Environmental Understand the superiority of Environmental

Management Control over othersManagement Control over others Make better informed and strategic decisions Make better informed and strategic decisions

in the fight against malaria in Anambra in the fight against malaria in Anambra Communities and beyond.Communities and beyond.

Learning ObjectivesLearning Objectives

Vector-borne disease caused by Vector-borne disease caused by

transmission of Plasmodium species transmission of Plasmodium species

by Anopheles mosquitoes.by Anopheles mosquitoes. Plasmodium specie is the malaria Plasmodium specie is the malaria

parasite that causes malaria in parasite that causes malaria in

humanshumans Transmission occurs through Transmission occurs through

mosquito bites on humans during mosquito bites on humans during

blood mealsblood meals Mosquitoes primarily breed in waterMosquitoes primarily breed in water

What is Malaria?What is Malaria?

Plasmodium sp. and Mosquito Life Plasmodium sp. and Mosquito Life CycleCycle

Images Retrieved from: 1. www.scienceblogs.com2. Skeeters. www.bcps.org

1. WHO (2013). Global health observatory. Retrieved from: http://www.who.int/gho/malaria/en/index.html

Global and African Context:Global and African Context: Malaria, a serious global concern particularly in AfricaMalaria, a serious global concern particularly in Africa

About half the world’s population (3.3 billion people) About half the world’s population (3.3 billion people)

are affected by Malariaare affected by Malaria

216 million cases occurred in 2010; 81% in African 216 million cases occurred in 2010; 81% in African

regionregion

Malaria caused over 600,000 deaths in 2010; 91% in Malaria caused over 600,000 deaths in 2010; 91% in

African regionAfrican region

Third leading cause of death for children under 5 yearsThird leading cause of death for children under 5 years

Almost 1 out of 5 deaths of children under 5 in Africa Almost 1 out of 5 deaths of children under 5 in Africa

is caused by Malariais caused by Malaria

Global Epidemiological Background of Global Epidemiological Background of MalariaMalaria

1. Chima, R., Goodman, C., & Mills, A. (2003). The economic impact of malaria in Africa: a critical review of the evidence. Health Policy, 63(1), 17-36.

2. National Malaria Control Program [NMCP] (2012). Nigeria Malaria Indicator Survey 2010. 3. WHO (2013). Global health observatory. Retrieved from: http://www.who.int/gho/malaria/en/index.html

Nigeria Context of Malaria Burden Nigeria Context of Malaria Burden Health Burden:Health Burden:

Nigeria bears about 25% of the Nigeria bears about 25% of the

Malaria burden in AfricaMalaria burden in Africa

About 97% of the Nigeria’s About 97% of the Nigeria’s

population is at risk of Malariapopulation is at risk of Malaria

Estimated 110 million malaria Estimated 110 million malaria

cases and 300,000 death cases and 300,000 death

annually annually

Estimated 11% of maternal Estimated 11% of maternal

deaths is caused by malariadeaths is caused by malaria

1. Chima, R., Goodman, C., & Mills, A. (2003). The economic impact of malaria in Africa: a critical review of the evidence. Health Policy, 63(1), 17-36.2. Jimoh, A., O. Sofola, A. Petu, and T. Okorosobo. 2007. “Quantifying the Economic Burden of Malaria in Nigeria Using the Willingness to Pay

Approach.” Cost Effectiveness and Resource Allocation 2007, 5:6. doi:10.1186/1478-7547-5-6.3. Shepard, D., Ettling, M., Brinkmann, U., & Sauerborn, R. (1991). The economic cost of malaria in Africa. Tropical Medicine And Parasitology: Official

Organ Of Deutsche Tropenmedizinische Gesellschaft And Of Deutsche Gesellschaft Für Technische Zusammenarbeit (GTZ), 42(3), 199-203.

Nigeria Context of Malaria Nigeria Context of Malaria Burden…2 Burden…2

Economic burden:Economic burden: Costs can be divided into direct and indirect costCosts can be divided into direct and indirect cost

Direct costs – households and government expenditures on treatment and preventionDirect costs – households and government expenditures on treatment and prevention

Indirect costs – losses of labor productive time due to mortality and morbidityIndirect costs – losses of labor productive time due to mortality and morbidity

Nigeria Government losses close to $1 billion ($868,421,052) annually (Jimoh, Nigeria Government losses close to $1 billion ($868,421,052) annually (Jimoh,

et alet al, 2007), 2007) In general context (In general context (Other studies outside NigeriaOther studies outside Nigeria):):

Monthly expenditure on malaria treatment is between $0.41 and $3.88 per Monthly expenditure on malaria treatment is between $0.41 and $3.88 per

personperson

Treatment equivalent between $1.88 and $26 per household (Chima, Treatment equivalent between $1.88 and $26 per household (Chima, et alet al, ,

2003)2003)

Very poor households spend 28% of their income on MalariaVery poor households spend 28% of their income on Malaria

In Africa, government spend estimated $1.83 and $8.01 per person (Shepard, In Africa, government spend estimated $1.83 and $8.01 per person (Shepard, et et

alal, 1991), 1991)

1. National Population Commission [NPC] (2008). Demographic and Health Survey [DHS] 2008.

Brief Background of Anambra Brief Background of Anambra State State

Created in 1991 and Located in the Created in 1991 and Located in the

South Eastern NigeriaSouth Eastern Nigeria Eight most populated state Eight most populated state

(4,055,048) and second most densely (4,055,048) and second most densely

populated (840/kmpopulated (840/km22) in Nigeria.) in Nigeria. Total area of 4,844 kmTotal area of 4,844 km22

Dominated by Igbos by tribe (98%) Dominated by Igbos by tribe (98%) Capital City as Awka, while Onitsha Capital City as Awka, while Onitsha

and Nnewi are the biggest most and Nnewi are the biggest most

commercial citiescommercial cities

1. National Malaria Control Program [NMCP] (2012). Nigeria Malaria Indicator Survey 2010.

Current Malaria Control Strategies in Current Malaria Control Strategies in Anambra Anambra

Most Malaria program in Nigeria, including the 1998 Most Malaria program in Nigeria, including the 1998

WHO RBM program adopted these Strategies:WHO RBM program adopted these Strategies:

Diagnosis and treatment (D&T) with effective medicines Diagnosis and treatment (D&T) with effective medicines

Distribution and use of insecticide-treated nets (ITNs) to Distribution and use of insecticide-treated nets (ITNs) to

achieve coverage of populations at risk, with particular achieve coverage of populations at risk, with particular

focus on Children under 5 and Pregnant womenfocus on Children under 5 and Pregnant women

Indoor residual spraying (IRS) to curtail transmission Indoor residual spraying (IRS) to curtail transmission

Intermittent preventive treatment (IPT)Intermittent preventive treatment (IPT)

1. Image retrieved from: www.crick.ac.uk2. National Malaria Control Program [NMCP] (2012). Nigeria Malaria Indicator Survey 2010.

Common Points of Interference for Malaria Common Points of Interference for Malaria ControlsControls

ConcernsConcerns No emphasis on the vectors No emphasis on the vectors

life cycle (life cycle (Weak interventionWeak intervention)) Expensive particularly in Expensive particularly in

poor regions (poor regions (Cost of regular

purchases and maintenance) ) High behavioral High behavioral

adherence / compliance adherence / compliance

requirements. requirements. E.g. only 35% of E.g. only 35% of

the population in the South Eastern the population in the South Eastern

Nigeria use at least one bed netNigeria use at least one bed net

(NMCP, 2012).(NMCP, 2012).

1. National Malaria Control Program [NMCP] (2012). Nigeria Malaria Indicator Survey 2010.

Stakeholders of Malaria in Stakeholders of Malaria in Anambra StateAnambra State

Government:Government: Federal and State of Ministries of HealthFederal and State of Ministries of Health National and State Malaria Control ProgramsNational and State Malaria Control Programs Local Health DepartmentsLocal Health Departments Primary Health Care DepartmentsPrimary Health Care Departments

Non Governmental Organizations (NGOs)Non Governmental Organizations (NGOs) Community based Non-Governmental OrganizationsCommunity based Non-Governmental Organizations Community groups and CoalitionsCommunity groups and Coalitions

Major Donor AgenciesMajor Donor Agencies WHOWHO USAIDUSAID DFIDDFID World BankWorld Bank Global FundGlobal Fund

1. Utzinger, J., Tozan, Y., & Singer, B. (2001). Efficacy and cost-effectiveness of environmental management for malaria control. Tropical Medicine & International Health: TM & IH, 6(9), 677-687.

Environmental Management Control Environmental Management Control (EMC) Strategies (EMC) Strategies

Vegetation ClearanceVegetation Clearance

Fumigation of bushesFumigation of bushes

Draining swampsDraining swamps

Surface application of oil to Surface application of oil to

open water bodiesopen water bodies

Modification of River Modification of River

boundariesboundaries

Disposal of all potential open Disposal of all potential open

water storage facilities and water storage facilities and

objects away from residential objects away from residential

area. area.

Environmental Risk Practices in Environmental Risk Practices in Anambra State Anambra State

Indiscriminate dumps of Indiscriminate dumps of

refuses and wastes close to refuses and wastes close to

residencesresidences

Dumps in swamps and Dumps in swamps and

drainages causing stagnant drainages causing stagnant

waterswaters

Abandonment of vegetation's Abandonment of vegetation's

and bushes within residential and bushes within residential

areas. areas.

Farming within residential Farming within residential

areasareas

1. Utzinger, J., Tozan, Y., & Singer, B. (2001). Efficacy and cost-effectiveness of environmental management for malaria control. Tropical Medicine & International Health: TM & IH, 6(9), 677-687.

Efficacy and Cost Effectiveness of EMCEfficacy and Cost Effectiveness of EMC Studies have shown that EMC in combination with Studies have shown that EMC in combination with

quinine and ITN is capable of:quinine and ITN is capable of:

Reducing malaria related incidence, morbidity, and Reducing malaria related incidence, morbidity, and

mortality rates by 70 – 95% within 3 - 5 yearsmortality rates by 70 – 95% within 3 - 5 years

Averting estimated 4173 deaths and 161,205 Averting estimated 4173 deaths and 161,205

malaria attacks in one local community in 20 yearsmalaria attacks in one local community in 20 years

Saving estimated $858 per death and $22.20 per Saving estimated $858 per death and $22.20 per

attack .attack .

Averting disability adjusted life year (DALY) to the Averting disability adjusted life year (DALY) to the

cost of $524 – 591 per DALYcost of $524 – 591 per DALY

Other Advantages of EMCOther Advantages of EMC Strong benefits of the EMC strategy is the potential to: Strong benefits of the EMC strategy is the potential to:

Leverage the available community resources; hence, Leverage the available community resources; hence,

saving great costsaving great cost

Create more effective community sustainability and Create more effective community sustainability and

ownership. ownership.

Encourage sound community participation and communal Encourage sound community participation and communal

efforts. efforts.

Provide less stringent behavioral complianceProvide less stringent behavioral compliance

No significant side effectNo significant side effect

Address other of other environmental issues unrelated to Address other of other environmental issues unrelated to

malaria. malaria.

1. Utzinger, J., Tozan, Y., & Singer, B. (2001). Efficacy and cost-effectiveness of environmental management for malaria control. Tropical Medicine & International Health: TM & IH, 6(9), 677-687.

Recommendations for Malaria Recommendations for Malaria Eradication in our CommunitiesEradication in our Communities

First, malaria eradication, rather than malaria control should First, malaria eradication, rather than malaria control should

be emphasized in the state policy and strategic plan for be emphasized in the state policy and strategic plan for

communities.communities. Channel more proportion of Malaria control donor and Channel more proportion of Malaria control donor and

government funds to community EMCgovernment funds to community EMC Empower and involve the State environmental Protection Empower and involve the State environmental Protection

Agency (EPA) as active stakeholders in the fight against Agency (EPA) as active stakeholders in the fight against

MalariaMalaria Strengthen the community participation in the community Strengthen the community participation in the community

EMC EMC Leverage the community resources to support this strategyLeverage the community resources to support this strategy Empower the community leaderships to support this course in Empower the community leaderships to support this course in

every community.every community.

ReferenceReferenceChima, R., Goodman, C., & Mills, A. (2003). The economic impact of malaria in Africa:

a critical review of the evidence. Health Policy, 63(1), 17-36.Jimoh, A., O. Sofola, A. Petu, and T. Okorosobo. 2007. “Quantifying the Economic

Burden of Malaria in Nigeria Using the Willingness to Pay Approach.” Cost Effectiveness and Resource Allocation 2007, 5:6. doi:10.1186/1478-7547-5-6.

National Malaria Control Program [NMCP] (2012). Nigeria Malaria Indicator Survey 2010.

National Population Commission [NPC] (2008). Demographic and Health Survey [DHS] 2008.

Shepard, D., Ettling, M., Brinkmann, U., & Sauerborn, R. (1991). The economic cost of malaria in Africa. Tropical Medicine And Parasitology: Official Organ Of Deutsche Tropenmedizinische Gesellschaft And Of Deutsche Gesellschaft Für Technische Zusammenarbeit (GTZ), 42(3), 199-203.

Utzinger, J., Tozan, Y., & Singer, B. (2001). Efficacy and cost-effectiveness of environmental management for malaria control. Tropical Medicine & International

Health: TM & IH, 6(9), 677-687.WHO (2013). Global health observatory. Retrieved from:

http://www.who.int/gho/malaria/en/index.html

1. Utzinger, J., Tozan, Y., & Singer, B. (2001). Efficacy and cost-effectiveness of environmental management for malaria control. Tropical Medicine & International Health: TM & IH, 6(9), 677-687.

Revision of Learning ObjectivesRevision of Learning Objectives Have we achieved the objectives of this presentation, Have we achieved the objectives of this presentation,

otherwise ask questions for further clarifications?otherwise ask questions for further clarifications? Do you understand the mosquito and malaria cycle?Do you understand the mosquito and malaria cycle? Do you understand the health and economic? burden of Do you understand the health and economic? burden of

malaria in the World and Nigeria?malaria in the World and Nigeria? Do you know the available malaria control measures in Do you know the available malaria control measures in

Anambra State and their Merits and Demerits?Anambra State and their Merits and Demerits? Do you know the advantages of EMC over others?Do you know the advantages of EMC over others? Can you now make better informed and strategic Can you now make better informed and strategic

decisions on the fight against malaria in your decisions on the fight against malaria in your

communities?communities?