El 221Volume 3

WORLD HEALTH ORGANIZATIONREPORT ON A MISSION TO ZAMBIA: SUMMARY/REPORT COVER PAGE

Reported bv: Program classiflcation/ Registry file(s)

(Name) Dr John Govere (Div/Unit) (Date) NumberSTP/ICP/Southern Africa 29 MAY 2005

Visit to:ZAMBIAInclusive visitin2 dates: Co-workers:(From) (To)23 May 2005 28 May 2005Purpose /Obiective of Mission:To provide technical support in conducting a vector control needs assessment aimed at

identifying malaria control program needs for implementing integrated vector

management in Zambia.Brief Summary:The World Health Assembly Resolution 50.13, adopted in 1997, requests Member States to initiate efforts to reduce the

reliance of vector control programs on chemicals. In response to the Resolution, WHO established a Working Group to

develop an "Action Plan" that calls for a number of activities, including an assessment of national needs for the orderly

transition toward the use of a variety cost-effective, safe, and sustainable methods for malaria vector control. In March

2001, RBM convened a number of meetings of experts in the fields of malaria, vector control, and environmental health

to develop guidelines for vector control needs assessment (VCNA). The assessment tool was developed and focuses on

the programmatic structure and management of vector control programs and on the requirements for delivering specific

interventions. The tool seeks to assist Member States to identify the barriers and needs for strengthening their vector

control programs. The objective of the present mission was to support the program to conduct a vector control needs

assessment (VCNA) using the WHO assessment tool in order to identify the program strengths, weaknesses,

opportunities and threats for effective implementation of a broad mix of control activities, "coined as Integrated Vector

Management (IVM)". The mission attempted to identify the gaps, bottlenecks and needs for effective and efficient IVM

implementation in Zambia. Zambia implements integrated vector management including IRS, ITNs, larviciding and

EM with a strong partnership. DDT and pyrethroids are used for IRS with remarkable success. Malaria vector control

policy, guidelines, protocols and a malaria taskforce are available. There is a clear decentralization decision-making

procedure to manage IVM for vector control. Human, financial and logistic resources/capacity to implement, monitor

and evaluate IVM are adequate. Human resources development plans are implemented and there has been negligible

trained staff tumover in the program. However, to expand IVM implementation, human and financial resources would

need to be added. Partners support insecticide-treated bednets, an intervention promoted by RBM and Abuja

declaration. Technical and operational problems hamper expansion of larviciding, biological control and environmental

management for malaria vector control. There is some interactionl collaboration on insecticide use between NMCC and

other departments including agriculture and environment exists.Vector Control Needs Identified* H human, financial and technical resources are needed to implement IVM

* Guidelines and protocols for IVM implementation required* Entomological facilities at TDRC and at NMCC is weak

* No technicians at district level trained to implement IVM* Stakeholders' coordination is lackingCleared by Distributed to:

Dr Robalo, MAL/AFRODr Soce Fall, ICPC/AFRO

Dr E Nielsen, WR/Zimbabwe Dr S Anyan2we, WR/ZambiaI Dr. N SiDilanyambe, NMCC, Zambia

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WORLD HEAL TH OR GANIZA TIONREGIONAL OFFICE FOR AFRICA

REPORT ON VECTOR CONTROL NEEDSASSESSMENT IN ZAMBIA

DR. J. GOVEREWHO/ICP/MAL ENTOMOLOGIST FOR

SOUTHERN AFRICA

29 MAY 2005

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CONTENTS

Cover page 1

Title 2

Contents 3

1. Introduction 4

2. Terms of reference 4

3. Method of work 5

4. Findings 6

5. Situation analysis at national level 9

5.1 Needs Assessment at National Level 11

6 Situation Analysis in Ndola District 14

6.1 Needs Assessment in Ndola District 17

7 Summary of District Organization 20

8 Profiles of Individual Stakeholders 21

9 Discussion 23

10 Conclusion 24

11 Identified vector control needs 25

12 Recommendation 26

13 Proposed list of stakeholders 27

14 Vector control needs assessment steering committee 27

15 Acknowledgement 27

3

1 INTRODUCTION

Malaria is serious heath problem in Zambia. In a population of just over 10 millionpeople, more than 3.5 million malaria episodes and 50,000 malaria-related deaths arereported each year. Zambia has the most established national malaria control program in

Southern Africa, with a solid leadership. The program has enjoyed additional financialsupport from the national government, HIPC, Global Fund, WHO, USAID and othergrants from other partners. The country has benefited from the GFATM rounds 2 and 4

and development of GFATM Round 5 proposal is underway. Zambia has embraced all

the Global intervention strategies for malaria control, which include prompt and effectivemalaria treatment; prevention of malaria using IRS, ITNs and IPT; and malaria epidemic

and emergency response. The national malaria professional staff component of the

NMCC has been strengthened to provide technical leadership in malaria control in the

country. The organogram comprises of the National Malaria Coordinator who is

specialists in the following areas: case management (1), IEC (1), ITNs (2), IRS (1), IVM

(1), Epidemiology (1), Pasitology (1) and M&E (1). However, a severe shortage of well-

trained staff at the province and district levels to manage effective malaria control

activities. Zambia implements an integrated malaria control strategy. Although the major

strategies such as case management, malaria vector control using ITNs and IRS and IEC

are well established and operational other supplementary vector control measures are not

fully operational to provide optimal impact on the burden of malaria disease.

The World Health Assembly Resolution 50.13, adopted in 1997, requests Member States

to initiate efforts to reduce the reliance of vector control programs on chemicals. In

response to the Resolution, WHO established a Working Group to develop an "Action

Plan" that calls for a number of activities, including an assessment of national needs for

the orderly transition toward the use of a variety cost-effective, safe, and sustainablemethods for malaria vector control. In March 2001, RBM convened a number of

meetings of experts in the fields of mnalaria, vector control, and environmental health to

develop guidelines for vector control needs assessment (VCNA). The assessment tool

was developed and focuses on the programmatic structure and management of vector

control programs and on the requirements for delivering specific interventions. The tool

seeks to assist Member States to identify the barriers and needs for strengthening their

vector control programs. The objective of the present mission was to support the program

to conduct a vector control needs assessment (VCNA) using the WHO assessment tool in

order to identify the program strengths, weaknesses, opportunities and threats for

effective implementation of a broad mix of control activities, "coined as IntegratedVector Management (IVM)". The mission attempted to identify the gaps, bottlenecks andneeds for effective and efficient IVM inmplementation in Zambia.

2 TERMS OF REFERENCE

* To provide technical support in conducting a vector control needs assessment aimed

at identifying program needs for implementing cost-effective, safe and sustainablemethods for malaria vector control

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* To contribute to the idenitification of stakeholders and the planning for thestakeholders' meeting.

* To produce a vector control needs assessment report for review and adoption by the

steering committee and stakeholders' consensus meeting.

3. METHOD OF WORK

Date Locality Activity23 May 2005 Lusaka * Briefing Program Coordinator, Dr Sipilanyambe on mission

objectives* Meeting with IVM focal point, Mr. Chanda to develop a

mission work plan* Meeting with National Environmental Health Specialist Dr

Nyirenda, CBH* Meeting with Mr Banda, Lusaka IRS focal point

24 May 2005 Lusaka * Courtesy call on WR-Zambia and briefing on objectives andwork plan for the mission

* Travel to Kabwe* Interview with DHMT in Kabwe* Interview with Deputy Director, environment, Kabwe* Travel to Ndola

25 May 2005 Ndola * Review national malaria control documents* Preparation for meetings on 26 May 2005

26 May 2005 Ndola * Interview with DMHT in Ndola* Meeting with TDRC, Ndola* T ravel to Kitwe

26 May 2005 * Meeting with DHMT in Kitwe* Meeting with Chief EHO, Mopani Mines, Kitwe* Meeting with Copperbelt Energy Corporation, Kitwe* Meeting with municipality EHOs, Kitwe

28 May 2005 Ndola * Collection of completed questionnaire forms from DHMT

* Collection of completed forms from TDRC* Collection of forms from Mopani, Municipal EHOs, Kitwe

28 May 2005 Kabwe * Collection of forms from municipality, Kabwe* Tr avel to Lusaka arriving at 1830* Briefing on mission outcomes to NMCC Coordinator

Two tools, situation analysis and needs assessment questionnaires were used to collectdata. Malaria program managers at the districts were the main respondents.

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4 FINDINGS

4.1 Structure of Malaria Control Activities in Zambia

A meeting with NMCC revealed that the NMCC conducted a VCNA in May 2004 in all

district towns where IRS is implemented. However, no VCNA was done Kabwe andLusaka and some information was missing from the district towns where VCNA wasdone. The mission therefore attempted to collect information from Kabwe and Lusakaand missing information from Ndola and Kitwe. In the company of the IVM focal personthe mission traveled to Kabwe and Ndola on Tuesday. A meeting with DHMT director inKatwe was for a short time because the Director was engaged in another meeting. A

questionnaire was given to her for completion. Again in Kitwe, a meeting was held withthe Environmental Health Deputy Director of Kabwe municipality. Again because of hisother commitment, a form was left for his attention. We arrived in Ndola in the eveningand managed to hand in the form for completion to DHMT. The following day, May 25

was a holiday and no interviews were conducted.

On 26 May 2005, a meeting with an entomologist at TDRC was conducted. The teamtraveled to Kitwe where a short meeting with DHMT Kitwe was held. The meeting wasshort because of the annual agricultural show that was taking place in the town. DHMThad a display of their work including malaria at the show grounds. In Kitwe, meetingswere also held with Mopani Mine Chief EHO and with Copperbelt Energy Corporationmanagement.

4.2 Structure of the National Malaria Control Program

The Central Board of Health (CBoH) is responsible for delivering health care services inZambia. The Roll Back Malaria (RBM) Coordinating Committee comprises a wide range

of partners and institutes and is chaired by the CBoH Director of Public Health andResearch. This National Coordinating Committee, which meets quarterly, is responsiblefor providing guidance and coordination for the implementation and evaluation of RBM.The CBoH reports progress on RBM to the deputy ministerial-level Task Force semi-annually, and quarterly to the Partner's Consultative Meetings.

The day-to-day management of malaria program activities is the responsibility of theNational Malaria Control Centre (NMCC) under the direction of the Malaria Control.Coordinator. The NMCC falls within the CBoH division of Public Health and Research.The NMCC coordinates and provides support for malaria control activities through sixworking groups: Partnerships; Insecticide Treated Nets Materials (ITMs) and VectorControl; IEC and Advocacy; Case Management and Intermittent Presumptive Treatment(IPT); Epidemic Preparedness; and Monitoring, Evaluation, Surveillance and Research.Within the program, there is a specialist in each working group. Zambia has a verydecentralized health system, with management, budgeting and implementation devolvedto the 73 districts grouped in 9 provinces. Technical support to the districts comes fromthe NMCC. However, severe staff shortages at district level limits programimplementation.

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4.3 The Integrated Vector Management

Anopheles arabiensis, An. ganibiae s.s, and An7. funestus are the major malaria vectorsthat transmit Plaslnodiztin falciparumnz, the parasite that accounts for above 96% of allnotified malaria cases in Zambia. Since 2000, Zambia has been implementing anintegrated vector management "coined in the country as integrated vector control"through the use of selective and targeted indoor residual spraying (IRS) with DDT andpyrethroids, insecticide-treated mosquito nets, larviciding and environmentalmanagement.

4.4 Indoor Residual Spraying (IRS)

The NMCC, in collaboration with selected district health management teams and privatecompanies, notably Konkola Copper Mines (KCM Plc) re-introduced the IRS in 2000 inparts of four districts. The success of this initiative resulted in the expansion of IRS tofive additional districts towns in 2003 and to eight in 2004. About 7,726 kg of 75% WPDDT, 3,300 sachets of 25% WP deltamethrin, 3,300 sachets of Icon and 960 sachets of10% WP Fendona were used to spray about 69,774 structures in 2004. Spraying startsfrom November and finishes in January. It is planned that an additional 14 urban centersbringing the total number of district towns under IRS to 22 by the 2006/7-transmissionseason. About 84,000 sachets of DDT and 50,000 sachets of pyrethroids will be requiredfor this exercise.

4.5 Insecticide Treated Mosquito Nets (ITNs)

Zambia employs a mix of ITN delivery mechanisms to target different geographic,economic and biologically vulnerable segmenits of society. Mechanisms range fromstraight commercial sales by supermarkets and private retail traders, through a variety oftargeted subsidy mechanisms, including a discount voucher program for pregnant womenin urban areas and direct subsidized sales through antenatal clinics in rural areas. Thereare also a variety of subsidized 'revolving fund' mechanisms by DHMTs and NGOs, andfinally, free distribution to the most vulnerable populations, including people living withHIV/AIDS and orphan headed households. More recently there has been ITN distributionto secondary boarding schools and health facilities, and promotion of employer-basedITN schemes in the agriculture and mining sectors. During 2004 about 570,000 ITNswere distributed and 600,000 re-treated. The 2004 Community and Health Surveys foundabout 40% of households had at least one net, with a slight preponderance towards thenorthern provinces and urban households. Mass ITNs re-treatment campaigns areconducted annually during the SADC malaria week. ITNs have also been distributed inZambia during EPI campaigns.

4.6 Integrated Vector' management (IVM)

Integrated Vector Management (IVM) is defined as the assessment, choice,implementation, and monitoring oF one or more vector control methods against one ormore vector borne diseases. For malaria, the available vector control methods include

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ITNs, IRS, larviciding and environmnental management. Integrated vector management

means the rational use of each of these methods, singly or in combinations appropriate to

local circumstances, and coordinated with other malaria control interventions. To use

IVM effectively, a control program must have the management capacity to assess

options, make decisions based on evidence, and monitor the effectiveness of the methods

employed. The WHO Regional Office for Africa developed a series of guidelines and

training materials on IVM. So far two training courses have been conducted and two

WHO/AFRO sponsored teclnicians and one supported by NMCC Zambia benefited from

the course.

4.7 Larviciding and Environmental management

During the colonial era Zambia successfully implemented integrated vector management

using IRS and larval control methods such as chemical and biological larvicides in their

vector control programs. A number of communities, municipalities and commercial

groups engaged in "environmental management" for malaria control. Although the same

methods are invariably used by mining and commercial agricultural organizations, there

are concerns that these activities are not properly planned, implemented and evaluated.

The specific settings in which larval control methods are appropriate in Zambia, and the

specific roles that governmaent staff at various levels, community organizations, and

private partners would play, need to be defined. The specific skills and training needs

need be assessed.

4.8 Case Management (CM)

Zambia has a good care system delivery, with about 66.1% of the population living

within <10 km from a health facility. The country is implementing Artemisin

Combination therapy for malaria (Coartem).

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5. SITUATION ANALYSIS AT NATIONAL LEVEL

Disease burden

Average malaria parasite prevalence during peak transmission periodAverage malaria parasite prevalence during low transmission periodAverage annual malaria clinical casesAverage annual laboratory confirmed malaria casesAverage annual malaria admissionsAverage annual malaria deathsHospital malaria cases fatality rate

Resource

Parasitological laboratory facilities Hospitals YesHealth centers YesClinics Clinical

Percentage of malaria budget Vector controlCase managementSurveillance and researchInsecticide budget AdequateInsecticides purchased by national funds

Vector bionomics

Main malaria vector * Anophelesgambiae s.s.* Anopheles.funestus

* Anopheles arabiensis

Secondary malar-ia vector Not knownPrimary vector behaviour Adult ecology Fresh water due to human agr activities and

wetlandsAdtult feeding Human and animal feederbehaviour Indoor and outdoor resting and feeding habits

Larval ecology Fresh temporary/ semi permanent habitats

Resting behaviour Indoor and outdoor resting

Vector control and personal protection

Indoor house spraying Average coverage of targeted structures 90%Average coverage of targeted households >80%Percent coverage of at risk population 60%Percent coverage of targeted population 40%Chemical DDT 75% WPActive ingredient 75% WPQuantity used per year Varies with yearsApplication rate 2gM/M2

Average number of structures sprayed 69,774 in 2004Criteria for determining type of insecticide * Susceptibility

* Residual effect* Structure type

Cost of residual house spraying $1.5 per structureTiming of spraying September - OctoberT ype of spraying Selective/targeted

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Criteria for targeting * Population concentration* Malaria burden* Epidemic risk

Number of spraying rounds One

Outdoor space spraying None

Larviciding Chemical Abate 500EQuantity used per year Not known% Formulation 50%Active ingredient TemephosFrequency of application WeeklyCircumstances for larviciding * Dry season

* EpidemicsTotal cost of larviciding Not knownMineral oils used Used in some municipalities

Biological control methods Gambusia fish

Environmental management Limited

Insecticide treated nets Significant with a coverage of 40%Repellents Limited and at individual level*Quantity of other insecticides used each year to spray half of the above mentioned structures include 3,300

sachets of deltamethrin, 3,300 sachets ol Icon and 960 sachets of Fendona in 2004.

Surveillance

Regular surveillance system Yes

Entomological Yes

Epidemiological Yes

KAP Yes

Results used for planning, implementation, M/E of vector control program Yes

Program evaluation, monitoring and supervision

Systematic supervision of program implementation * Routine supervision* Checklist to supervise* Supervisor to each team

Monitoring and evaluation Susceptibility test YesContact bioassays YesTimeliness YesChecking re-plastering of sprayed structures Ad hoc

Checking larviciding YesChecking treated nets Not doneActivity reporting YesMalaria information system Yes

Technical capacity/resources in vector control

Vector control guidelines, protocols and manuals * Vector control manual* Insecticides for IRS* Malaria vector control manual* Application of insecticides for IRS* National malaria control policy* Malaria prophylaxis guidelines

Application equipment plus transport Need to be improvedCapacity to maintain equipment GoodProtective clothing for IRS Very good

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Prevention of human and environment exposure

Warehouse facilities AdequateInsecticide packaging and labeling in local language YesProper procurement procedures of insecticides (timinig and delivery) YesDedicated vector control vehicles YesTraining of spray operators in safe use on insecticides Done annuallyInstruction manuals available In English

IEC and community participation

IEC and commuinity participation in vector control * Community compliance with IRS* Posters for commnunity education* Information from spray operators* Community meetings* Radio and TV* Africa and SADC malaria days

IEC information evaluation through a KAP study YesMalaria vector control IEC staff YesIEC activities for community participation YesBeliefs discouraging use of insecticides NoPolitical commitment ExcellentDemographic changes NoCross-border relations Excellent

5.1. NEEDS ASSESSMENT AT NATIONAL LEVEL

Policy framework

National health policy YesPriority of malaria among other health issties HighNational malaria control policy including vector control interventions YesNational policy guidelines on vector control YesPolicy translated into strategies and plans of action for RBM in country YesPlan of action with clearly defined Activities Yes

Outcomes YesIndicators YesResources required YesCosts Yes

Gaps between what is stated in policy and what is implemented NoComponent of program evaluation in plan of action YesPolicy on decentralization or/and health reforms YesVector control intervention decentralization YesProportion of national health budget for malaria control No dataResource allocation consistent with malaria control national priority YesPublic health insecticides exempted fi-om tax YesBednets exempted from tax Yes

Organization

Position of malaria control unit within MOH CBoHMalaria control core group/taskforce to provide technical support YesRelationship between vector contiol and environmental health program YesVector control vertical or decentralized DecentralizedVarious vector borne diseases cointro programs integrated into a single unit No

Proper rocureent prcedure of inecticies (tiing an delivry) Ye

Municipality providing malaria/vector control operations in urban areas Yes

Collaboration between municipality and national vector control programs Yes

Proportion of the DHMTs with vector control staff 100%

Decisions on vector control in districts made by vector control specialists Yes

Vector control represented in the DHMT Yes

Resources

Number and level of training for VC personnel at national * Manager MD & MSc 1

level * Entomologists MSc 2

* IEC specialist 1* ITNs specialist 2* Parasitologists MSc 2* MIS Officer MSc I

Capacity for planning, implementation and M/E * National Yes

* Provincial Yes* District Yes

Capacity at national level to provide technical support at provincial and district levels Yes

Qualified and skilled personnel to implement program for * National Yes

safe use and disposal of pesticides * Provincial Yes* District Yes

Skills for safe use and disposal of pesticides exist in Ministry of Health Yes

Training

System of in-service training and upgrading of skilled malaria vector control personnel Yes

Opportunities for university level and postgraduate training in country Yes

Availability of up to date training materials and guidelines * National Yes

on VC * Provincial Yes

* District No

Availability of funds for training at regional and international institutions Yes

Proportion of trained in past retained by malaria vector control 100%

Insecticide suppliers providing technical support and training in VC Yes

Research

Availability of VC research capabilities * TDRC Yes

* University Yes* NGOs No

Department of medical research linked to vector-borne disease program including malaria TDRC

Research institutions following a strategic research planning process involving malaria Yes- TDRC

vector control program

Facilities

Basic entomology laboratory to moniitor vector bionomnics and insecticide resistance Yes

Insectary for rearing mosquitoes Yes but noequipment

Authority and tunction

Function of malaria vector control clearly definedl Yes

Post/job description for malaria VC staff Yes

Human resource development plan for malaria VC personnel Yes

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Career opportunity and job secuirity for malaria VC unit Yes

Effective performance appraisal for malaria VC personnel Yes

Effective supervision of VC at provincial and district levels Yes

Availability of funds for supervision Yes

Mechanism for information exchange between national, provincial and district levels Yes

Regulatory

National regulatory body for public health use of ECZ

insecticidesRegistration requirements for public health * Effectiveness

insecticides * Toxicological data

Insecticides used for VC * DDT and pyrethroids

Volumes used Varies in years

Regulations for storage, distribution and sales of * ECZ and WHO guidelines

public health insecticidesProcedures for monitoring adverse health and ECZenvironment impact of public health insecticides

Quality assurance

Facilities for quality of insecticides No

Perceived problems with poor quality, counterfeit, illegal or obsolete pesticides Yes

Environmental policy

Policies and regulations for production and safe use of pesticides ECZ

Policies and regulation within the environment division Yes

Policies regarding EIA or HIA Yes

VC issues included in EIA/HIA Yes

Mechanism for monitoring and enforcement of policies Yes

Municipal codes and enforcement on VC Yes

Policies on promoting research on alternatives to pesticides including IPM No information

Agriculture policies

National policy for IPM and rational use of pesticides No information

Pilot projects for IPM No information

Policies and implemented plans for rural development that include extension workers No information

Method used by Department of Agriculture to deliver information on pest control to No information

farmersNGOs and private companies involved in agricultural pest control No information

Mechanisms to ensure quality of service to consumers No information

Legal instrument banning use of DDT for agriculture Yes

Capacity to monitor and enforce agriculture pesticides policies including the use of DDT No information

for agricultural purposesPolicies restricting use of pesticides for agricultLre and public health No information

Policy for exemption of agricultural pesticides from tax and tariffs No information

Group of chemicals promoted for use in agriculture No information

Intersectoral collaboration

Forum for agriculture and health meeting to discuss policy issues relating to Yes but ad hoc

pesticides use

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C cross border or regional collaboration with other malaria control programs Yes with Zimbabwe

National government part to POPs Yes

Structure to develop plans to comply with provisions of POPs convention Yes

6. SITUATION ANALYSIS IN NDOLA DISTRICT

Ndola district is the provincial capital of the Copperbelt Province in Zambia. It is located

360km north of Lusaka the capital city of Zambia and about 56km from Kitwe town on

the western side. The city covers 1,124 square meters of land. Ndola district has a

population of 413,000. Ndola city has numerous streams, the major one being the Kafubu

River, which originates from marshlands swampy lagoons east of the city. The city also

has pine forests managed by Zaffico to the west towards Kitwe and along Mufulira road.

A survey conducted by the Tropical Disease Research Centre (TDRC) in 1998 revealed

that field ridges, wells, man made streams, mines and others are also breeding sites for

mosquitoes. The survey further revealed that Culex mosquitoes are more prevalent than

anopheline mosquitoes and 60% of the surveyed sites represented Anopheles gambiae

while 20% Anophelesffinestus, both being vectors of malaria parasites.

The general incidence rate of malaria in Ndola has been ranging from 324 - 430 per 1000

population for past 5years. These figures are a clear testimony of burden of malaria in the

district. Effective malaria control was achieved in Ndola prior to 1980 through indoor

residual spraying, larviciding and environmental management. Subsequent efforts to

control malaria have been hampered by lack of resources hence annual incidence rates

have steadily over the years. Indoor residual spraying has since been re-introduced in

2003 with remarkable success in reducing malaria transmission.

Disease burden

Average malaria parasite prevalence during peak transmission period No data

Average malaria parasite prevalence during low transmission period No data

Average annual inalaria clinical cases <5 2551>5 2,274

Average annual laboratory confirmed malaria cases No information

Average annual malaria admissions <5 2,446>5 2,241

Average annual malaria deaths <5 59% of all deaths>5 305

Hospital malaria cases fatality rate <5 36.6/1000>5 18.8/1000

Resource

Parasitological laboratory facilities Hospital YesHealth centers YesClinics None

Percentage of malaria budget Vector control No informationCase management No informationSurveillance and research NoneInsecticide budget NationalInsecticides purchased by national funds

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Vector bionomics

Main malaria vector An. gambiae s.s. An. funestus andAn. arabiensis

Secondary malaria vector Not known

Primary vector behaviour Adult ecology Fresh water breeders, indoorresting & feeding behaviour

Adult feeding behaviour Human and animal feeder

Larval ecology Fresh water habitatsResting behaviour Indoor and outdoor resting

Vector control and personal protection

Indoor house spraying Average coverage of targeted structures 86%Average coverage of targeted households 80%Percent coverage of at risk population 80%Percent coverage of targeted population 54%Chemical DDT 75% WPActive ingredient DDTQuantity tised per year 7603 sachetsApplication rate 2gm/m2Average number of structures sprayed 32,596Average number of households sprayed/yr IncrementalCriteria for determining type of inlsecticide * Susceptibility

* Residual effect* Structure type

Cost of residual house spraying 1.7$/structureTiming of spraying November -JanuaryT ype of spraying Selective/targetedCriteria for targeting * Malaria burden

* Vector burdenNumber of spraying rounds One

Outdoor space spraying None

Larviciding Chenmical CoopexQuantity used per year 500 liters°' Formulation 50m1l/OlitresActive ingredient permethrinFrequency of application 4x per monthCircumstances iOr larviciding Areas with well defined

breeding sitesTotal cost of larviciding No information

Mineral oils used OilBiological control methods Gambusia fish

Environmental management YesComponent of VC Yeslmplementers VC staff, community &

partner - BMMLCriteria for EV Breeding sitesOther sectors Public works

Community groupsCoordination Yes by DHMTTypes of sites Ponds, run-offs

Insecticide treated nets Yes - treated with K-Othrin and FendonaRepellents Limited and only distributed during epidemics/outbreaks by public & private

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Surveillance

Regular surveillance system Yes

Entomological Yes

Epidemiological Yes

KAP Yes

Results used for planning, implemeintation, M/E of vector control program Yes

Program evaluation, monitoring and supervision

Systematic supervision of program implementation * Routine carried out* Checklist to supervise* Supervisor to each team

Monitoring and evaluation Susceptibility test Yes - NMCCContact bioassays Yes - NMCCTimeliness YesChecking re-plastering of sprayed Ad hocstructuresChecking larviciding YesChecking treated ncts NoActivity reporting YesMalaria information system Yes

Technical capacity/resources in vector control

Vector control guidelines, protocols and manuals * Vector control manual* Insecticides for IRS* Malaria vector control manual* Application of insecticides for IRS* National malaria control policy* Malaria prophylaxis guidelines

Application equipment plus transport SatisfactoryCapacity to maintain equipment l'oorProtective clothing for IRS Satisfactory

Prevention of human and environment exposure

Warehouse facilities Yes

Insecticide packaging and labeling in local language In English

Proper procurement procedures of insecticides (timinig and delivery) Yes

Dedicated vector control vehicles * 2 open truck* Hire duringspraying

Training of spray operators in safe use on insecticides Yes - annually

Instruction manuals available In English only

IEC and community participation

IEC and community participation in vector contr ol * Community compliance with IRS

* Posters for community education* Information from spray operators* Community meetings* Radio and TV* Africa and SADC malaria days

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IEC information evaluation through a KAP study YesMalaria vector control IEC staff Program staff conduct IECIEC activities for community participation Opening houses for sprayingIEC staff available in MOH Yes but not for malaria IEC onlyBeliefs discouraging use of insecticides NoPolitical commitment SatisfactoryDemographic changes NoCross-border relations No

6.1 NEEDS ASSESSMENT IN NDOLA DISTRICT

Policy framework

National health policy YesPriority of malaria among other health issues AverageNational and provincial malaria control policies including vector control interventions YesNational policy guidelines on vector control YesPolicy translated into strategies and plans of action for RBM in country YesPlan of action witlh clearly defined Activities Yes

Outcomes YesIndicators YesResources required YesCosts Yes

Gaps between what is stated in policy and what is implemented NoComponent of program evaluation in plan of action YesPolicy on decentralization or/and health reforms YesVector control intervention decentralization YesProportion of provincial health budget for malaria control No informationResource allocation consistent with malaria control national priority Not enoughPublic health insecticides exempted from tax YesBednets exempted from tax Yes

Organization

Position of malaria control unit within MOH CBHMalaria control core group/taskforce to provide technical support YesRelationship between vector control and environmenital health program GoodVector control vertical or decentralized DecentralizedVarious vector borne diseases control programs integrated into a single unit NoMunicipality providing malaria/vector control operations in urban areas YesCollaboration between municipality and national vector control programs GoodProportion of the DlHlTs with vector control staff Fully representedDecisions on vector control in district level made by vector control specialists YesVector control represented in the DTM Yes

Resources

Number and level of training for VC personnel in province * Manager (Diploma EHO)* Deputy managers* EHOs (Diploma EHO)* Team leaders* Foremen* Spray operators

Capacity for plaining, implemlenltation and M/E * National Yes* Provincial Yes

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* District Yes

Capacity at national level to provide technical support at provincial and district levels Yes

Qualified and skilled personnel to implement program for * National Yes

safe use and disposal of pesticides * Provincial Yes

* District Yes

Skills for safe use and disposal of pesticides exist in Ministry of Health Yes

Training

System of in-service training and upgrading of skilled malaria vector control personnel No

Opportunities for university level and postgraduate training in country Yes

Availability of Up to date training materials and guidelines * National Do not know

on VC * Provincial* District

Availability of funds for training at regional and international institutions No

Proportion of trained in past retained by malaria vector control No information

Insecticide suppliers providing technical support and training in VC Yes

Research

Availability of VC research capabilities * University No

* NGOs* Commercial sector

Department of medical research linked to vector-borne disease program including malaria * TDRC

Research institutions following a strategic research planning process involving malaria Yes

vector control program

Facilities

Basic entomology lab to monitor vector bionomics and insecticide resistance TDRC

Insectary for r earing mosquitoes TDRC

Authority and function

Function of malaria vector control clearly defined Yes

Post/job description for malaria VC staff Yes

Human resotirce development plan for malaria VC personnel Yes

Career opportunity and job security for malaria VC unit No

Effective performance appraisal for malaria VC personnel Yes

Effective supervision of VC at provincial and district levels Yes

Availability of funds for supervision No enough

Mechanism for information exchange between national, provincial and district levels Yes

Regulatory

National regulator-y body for public health use of insecticides Yes - ECZ

Registration r equirements for public health insecticides * Effectiveness* Toxicological data

Insecticides used for VC * Pyrethroids and Organochlorines

Volumes used * No information

Regulations for storage, distribution and sales of public health * Yes - supervised by ECZ

insecticidesProcedures for monitoring adverse health and environment By ECZimpact of public health insecticides

18

Quality assurance

Facilities for quality of insecticides No information

Perceived problems with poor quality, counterfeit, illegal or obsolete pesticides Yes - pyrethroids

Environmental policy

Policies and regulations for production and safe use of pesticides Yes

Policies and regulation within the environment division YesPolicies regarding EIA or HIA Yes

VC issues included in EIAIHIA YesMechanism for monitoring and enforcement of policies YesMunicipal codes and enforcement on VC YesPolicies on promoting researclh on alternatives to pesticides including No informationIPM

Agriculture policies

National policy for IPM and rational use of pesticides Yes

Pilot projects for IPM No information

Policies and implemented plans for rural development that include extension workers No information

Method used by Department of Agriculture to deliver inlformation on pest control to No information

farmersNGOs and private companies involved in agricultural pest control No information

Mechanisms to ensure quality of service to consumers Yes

Legal instrument banning use of DDT for agriculture Yes

Capacity to monitor and enforce agriculture pesticides policies including the use of Yes

DDT for agricultural purposesPolicies restricting use of pesticides for agriculture and public health Yes

Policy for exemption of agricultural pesticides from tax and tariffs No information

Group of chemicals promoted for use in agriculture No information

Intersectoral collaboration

Forum for agriculture and health meet to discuss policy issues relating to pesticides Yes

useCross border or regional collaboration with other malaria control programs No

National govermllent part to POPs Yes

Structure to develop plans to comply with provisions of POPs convention No information

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7 SUMMARY OF DISTRICT ORGANIZATION

Organizational structure

District DHMT Local council Mines Other Collaboration

Ndola District Director Health Director Health Bwanamukubwa TDRC Very good

Chief Health Inspector CHI CHI WorldMedical officer Senior Health vision

InspectorsKitwe District Director Health Director Health Mopani TDRC Very good

CHI, Data manager, Manager CHI Medical officerP.Development CHI

Mufulira District Director Health Director Health Mopani TDRC Good

Clill, Medical Officer CHI Chief HealthOfficer

Chililabombwe District Director Health Director Health KCM TDRC Good

CH [, CHIMedical Officer

Livingstone District D)irector Health Director Hlealth Sun hotel Poor

Manager P. Development Housing Officer Railway

CHI SWSC

Medical officer

Population at risk

Item Ndola Kitwe Mufulira Chililabombwe Livingstone

Estimated 413,000 410,000 178,176* 385,000 185,000

population2 Population at 195,553 188,807 59,392* 198,000 30,258

risk3 Vector control 35* 40* Com.

staff4 Amount spent 162,000,000 US$30,000* US$22,000* Nil

on larviciding

Resources

Item Ndola Kitwe Mutfulira Chililabombwe Livingstone

Hudson x-pertStorage facility Yes Yes Yes-miines Yes-mines Yes

Vehicles Adequate-with mines Adequate-with mines None

Integrated Vector Management in visited districts.

1 Item Ndola Kitwe MNufulira Chililabombwe Livingstone

An.gambiae s.s + + + + +

An. Funestus + + - +

An. arabiensis + - + l +

2 EM M inior Major* Major* Medium* Minor

Dambo clearing Done Done* Done* Done* Nil

Fogging Nil Yes* Nil Nil Nil

Ponds Yes Yes* Yes* Yes* Nil

IRS Yes Yes Yes* Yes* Yes

ITNs Yes Yes Yes Yes Yes

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Larviciding Done Done* Yes NilBiological Yes Yes Yes* Yes Nil

l___ control f ma vt c r H e ,m m an E i t e

3 Equipment__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Larviciding Yes Yes Yes Yes Nil

EM Yes Yes Yes Yes Nil

4 Transport Nil Yes, 3 tone truck Yes Yes Nil

5 Storage Yes Yes Yes Yes Yes

6 Safey Yes Yes Yes Yes Yes

7 Larvicides Done* Yes Nil

Type Coopex Oscar! Coopex Abate 500E/ Abate NilLarvex Abate/'Larvex OscarlOO

___Quantity Nil 230/200-4001trs 1.500/2001trs 500 liters Nil

Biological agent Nil GainYbesia cfjinis Gait busia Gambusia affinis Nil

c o n trol_________________ affinis _____________________ ___________________n i

-8 Fogging__ _ _ _ _ _ _ _

Chemical P44. Ches n -Res25S,Pyrethroids Yes YesN

8 PROFILES OF INDIVIDUAL STAKEHOLDERS

Copperbelt Energy Corporation (CEC)

Copperbelt Energy Corporatioe is a private company in Kitwe. CEC provides electricalpower to Mopani and KCM. The company employs about 330 people. CEC provides

health facilities to its employee including spraying of employee houses and provision of

ITNs. The company spends about 5,000 USD of malaria prevention for its employees.

Technicak SLupport comes from KCM. arviciding is also practices around the

employees' compounds. However, management faces a challenge of measuring theimpact of what they are doing and would like to collaborate with DHMT and other

partners. CEC is willing to contribute towards malaria control in Kitwe. It was thereforeagreed that the DHMT produces a plan indication gaps, which, CEC would be willing to

fill.

Kitwe District

The DHMT in Kitwe, in collaboaation with partners imbuplements IRS, ITNs, EM and

larviciding for malaria vector control. However, implementation of EM is at a veryminimal scale. Larviciding is done twice a year using chemicals, mineral oils and

biological (fish) control methods. Program evaluation and monitoring is done by TDRC.However, LEG eaterials and organizational structure on EM, larviciding and screening of

houses are lacking.

Malaria control in Kitwe involves par-tn-ers such as DHMT, municipal councils (CC) andMopani mines. The malaria control programs for Mopani and DHMT have incorporatedboth EM and Larvicididg whereas City Coiincil malaria control program is not fully

operational due to lack of resources. All the partners, however, have shown determination

21

and commitment to implement an integrated approach to malaria control by augmentingthe existing interventionis with EM and Larviciding,

Mopani

Mopani copper mine implemenits EM as a major intervention protecting about 80% of the

population at risk. The program has a 35-man full-time vector control team (skilled and

semi-skilled) with at least grade 12 level of education. Only community sensitizationteam is drawn from the community itself. Communities are encouraged to manage theenvironment around their homes. EM activities are confined to the former mine control

areas covering about one third of Kitwe district. Larviciding is also implemented using

both chemical and biological control methods and its done in winter when breeding sitesare minimal and identifiable. A mixture of engine oil with little paraffin is also used but

not in streams and gardens. Breeding sites in the area are mostly perennial. Fogging is

also implemenited by the Mopani mines. Eucalyptus trees are also being planted inWuzakile in partnership with the forestry department as an additional EM strategy in

marshy lands (Dambos). The IRS teaim does larviciding whereas and fogging has its own

team. Monitoring and evaluation is conducted by TDRC. Though Environmental Health

Officers and Technologists are available, vector control guidelines are not available. IECmaterials on EM, screening of houses and general personal protection are also available.IRS and ITN are being implemented as well. Growing of rice and sugarcanes is donealong the riverbanks, thus creating open shallow wells for mosquito breeding.

Livingstone District

Four partners are involved in malaria control in Livingstone: DHMT, city council (CC),

Southern Water and Sewerage Company (SWSC) and Sun International Hotel. IRS and

ITNs are the main interventions used in the district. Except for the CC whose malariacontrol programs crumbled as a result of financial constraints, the DHMT, SWSC andSun Hotel implement EM on a minor scale. Larviciding is also done minimally usingused engine oil. Programii monitoring and evaluation, intersect oral collaboration and IECmaterials in the context of EM and larviciding are lacking. However, Human resource is

available especially in the CC. There is an explicit expression of determination andcommitment to expand EM activities and larviciding in Livingstone.

Ndola District

DHMT in Ndola implements IRS and ITNs as major interventions for malaria vectorcontrol. Three partiners for malaria vector control exist in Ndola. These include DHMT,Ndola city council (NCC) and B1vanaamukubwa mine. Implementation of EM protectsabout 50% of the population at risk. NCC uses chemicals for larviciding. EM andlarviciding program evaluation and monitoring does not exist. The DHMT has adequatehuman and transport resources whereas the NCC is strong in human resources (14 stafffor EM and 5 for Larviciding) and Bwanamukubwa. Provides equipment and protectiveclothing. IEC materials are not available.

22

Mufulira District

There are three partners for malaria control in Mufulira: Mopani copper mines, DHMT

and the CC but only Mopani is implementing an integrated malaria control program in all

the former mine areas. EM is implemented as a major vector control program by 36

vector control staff; 5 workers from the CC complement this labour force. The EM

activities include drainage clearing, dambo draining, empting of disused water bodies and

swimming pools. Larviciding using both chemical and biological control measures is

implemented. Chemllical control is done once weekly by 10 vector control staff. However,

partnership is still weak. Program evaluation and monitoring is done by Mopani mine

workers. Mopani has satisfactory technical capacity and resources for EM and

larviciding. However, no guidelines are available on vector control. Generally

maintenance of vector control equipmenit is satisfactory. IEC materials on EM,

larviciding and screening of houses in clifferent languages are readily available and the

communities participate fully. Health education is also done at all levels. Vector control

personnel are given periodic training in EM and larviciding on quarterly basis although

there are no instructioni maniuals available.

There is an organization structure for EM and Larviciding, a relationship between vector

control and Environmental Health Programs exists. Although the municipality does not

provide malaria vector control operations for the urban areas, codes and enforcements

related to vector control are available. Other vector control programs being implemented

include, IRS and ITNs. Out-door space spraying is done to a lesser extent, the fogging is

specifically done in thickets.

Konkola Copper Mines

IRS using DDT has been the main vector control strategy in Konkola protecting a

population of 198,000 people. Supplementary strategies include ITNs, EM and

larviciding. Larviciding is by the use of chemical and biological methods. The KCM

malaria control program management in supported by TDRC conducts program

evaluation, monitor-ing and supervision. Resources, which include trained manpower for

the larviciding and IRS is satisfactory. Vector control guidelines on larviciding to control

malaria are available. However, the availability of application equipment including

transport and the capacity for there maintenianice is poor. IEC materials for community

participation in EM, larviciding and screening of houses are available. Vector control

personnel are given training in EM and larviciding twice a year using the available

instruction manuals. There is no organizational structure for EM and larviciding. There is

collaboration between malaria vector control program and the Environmental Health

Program. Presently the municipality is not providin-g vector control operations for the

urban areas despite the availability of codes and enforcement related to vector control.

9. DISCUSSION

The major malaria vector control strategies Zambia are IRS and ITNs. The program is

well managed and funded and has succeeded to expand the two interventions over the

23

past three years. Other interventions that include larviciding, environmental management,and biological control are not optimally implemented. Outdoor spraying is practiced in

mines. Program implementation in district towns follows a similar pattern. This is so

because they are coordinated by NMCC.

Routine vector surveillance is a component of malaria vector control program in Zambia.

Three malaria vectors; An. gCalinbiae s.s, An. (araabiensi and An. funestus are found in

sympatry in all their geographical distribution. Entomological, epidemiological and

sociological monitoring and evaluation is part of the malaria control program and

provided by TDRC.

Malaria treatmenit in Zambia is based on definitive diagnosis in hospitals and clinical

diagnosis at comnmunity level.

The national malaria control program is well supported by the government. Technical

capacity, operational budgets and other resources are adequate. Malaria vector control

policies and guidelines are in place although their distribution is limited. A taskforce

guides malaria vector control issues.

Zambia uses DDT and pyrethroids for malaria vector control. The use of DDT is by well-

trained spray operators to ensure minimal environmental contamination. Annual training

(refresher) is carried out for supervisors and spray operators. Insecticide suppliers and

distributors have established a strong partnership with the malaria control program.

Dissemination of malaria health information and education has been through malaria

vector control teams and in the formn of posters and radio messages. There is a strong IEC

component of the NMCP with an IEC program focal point.

Malaria vector control in Zambia is decentralized to district level. There is a strong

partnership support and collaboration. Malaria vector control policies and guidelines are

in place but need to be distributed wvidely.

10. CONCLUSION

* Zanmbia implemenits integrated vector management including IRS, ITNs, larviciding

and EM wvith a strong partnership.* DDT and pyrethroids are used for IRS with remarkable success

* Malaria vcctor control policy, guidelines, protocols and a malaria taskforce are

available* Thcrc is a clear decentralization decision-makling procedure to manage IVM for

vector control.* Human, financial and logistic resources/capacity to implement, monitor and evaluate

IVM are adequate. Human resources development plans are implemented and there

has been negligible trained staff turnover in the program. However, to expand IVM

implementation, human and financial resources would need to be added

24

* Partners support insecticide-treated bednets, an intervention promoted by RBM and

Abuja declaration.* Technical and operational problems hamper expansion of larviciding, biological

control and environmental managemenit for malaria vector control.

* Therc is some interaction/ collaboration on insecticide use between NMCC and other

departments incltuding agriculture and environimenit exists.

11. IDENTIFIED VECTOR CONTROL NEEDS

* ITNs and IRS are the major malaria vector control methods in Zambia. Other

interventions such as ITNs, EM, larviciding and biological control are not fully

implemented in the country. The main reason for inadequate implementation of EM

and larviciding relates to resources both human and financial to implement IVM.

* Although malaria vector control in Zambia is administratively decentralized to district

level, community involvenment remains minimal. Partners and community

involvement calls for intensified IEC, technical, financial and human resource input.

* Although regulations for public use of pesticides/insecticides exist, their enforcement

is weak due to lack of capacity in the ECZ.

* IVM thrives where collaboration and frequeLnt communication exist. Collaboration

among stakeholders is key to success.

* Interventions that include EM, larviciding and biological control are labour intensive

and require mass investment in terms of hluman and financial resources.

* Malaria vector control in Zambia relies on ITNs and IRS, which receive national, and

partnerslhip investment. There is need for a similar investment into IVM.

* Impleinentation of other interventions mean added responsibilities on the part of the

program staff. Additional staff at district level to implement additional interventions

would be required.* For effective moniitoring and evaluation of IVM implementation, entomological

capacity is key. Both the national and TDRC insectaries are not functional and

entomology capacity at district level is weak.

* The use of other interventions other than IRS has not received much attention in

Zambia due to sparse local evidence of the effectiveness of the methods.

* There is need to develop IEC strategies aimed at informing both malaria control staff

and the community about the new malaria vector control methods.

* Vector control guidelines and protocols are not available in some districts.

* There is need to strengthen monitoring and evaluation systems through training and

equipment supply.* Management of insecticide resistance is important for effective insecticide use for

malaria vector control. Traininlg and systems to monitor insecticide resistance need to

be strengthened.

25

12 RECOMMENDATIONS.

To Districts

* The KCM and Mopani model of E.M and larviciding showed success and ought to bereplicated in Lusaka, Kabwe, Ndola, Kitwe and Livingstone.

* With help from TDRC and NMCC all districts to obtain entomology baseline data onmalaria and vector density in areas where IVM is to be implemented.

* All Districts to conduct a geographical reconnaissance and produce maps of well-defined mosquito breeding sites in IVM target districts.

* All districts must implement E.M and Larviciding from April to November annually.* Each district oughlt to establish a storage and distribution point for EM equipment.

To NMCC

* NMCC to supply operational guidelines and provide leadership in implementing IVMin target districts.

* All districts need adequate and sufficient support in terms of transport, equipment,larvicides and PPEs.

* To strengtlhen district IVM coordinationi and collaboration between stakeholders andpartners for effective implementation of IVM.

* To support stakeholders or partners joint planning for IVM.* NMCC should provide IEC materials on IVM with special emphasis on EM and

larviciding to all targeted districts.* NMCC in partnership with the DHMTs, Municipal councils and other stakeholders to

organize training of technicians at district level in IVM.* Strengthen vector surveillance capacities by availing the provincial malaria control

centers with mosquito sampling tools such as dippers, manual aspirators, dissectingmicroscopes, etc.

* Establish aqua culture schemes for the development of large -scale breeding of thelarvivorous fish, Gambusia spp in districts.

* Collaborate with ECZ to should facilitate the rapid importation, proper transportation,storage and use of larvicides.

* To carry out VCNA in Lusaka ancl to receive data from Kabwe

To WI1O/AFRO

* To provide technical support in developing IVM guidelinies and implementation plans* To provide technical and logistical support in the training of district technicians* To provide technical support in IVM implementation, monitoring and evaluation.* To provide technical support in docuiiientationl of program implementation

26

I~~1 EOMEDTOS

13. PROPOSED STAKEHOLDERS FOR MALARIA VECTOR CONTROL

* National, Provincial and DHMT* Ministry of Agriculture* Ministry of Environmenit* Environmental Council of Zambia

* Mines* CEC* TDRC* University of Zambia* Private Sector (Companies supplying malaria control commodities)

* WHO/NPO* Water and Sewage Company! Municipalities

14. VECTOR CONTROI, NEEDS ASSESSMENT STEERING COMMITTEE

* National Malaria Control Program Manager

* Three District Malaria Control Managers* Member from ECZ* Member from mines* Member from Agriculture

15. ACKNOWLEDGEMENTS

* Dr Naawa Sipilanyambe, National Malaria Control Coordinator

* Mr. Emmanuel Chanda, IVM focal point, NMCC

* Dr Fred Masaninga, Malaria NPO, WHO Country Office in Zambia

27