Project Proposal for Malaria Control in São Tomé and Príncipe Type of Application: X Country Coordinating Mechanism Proposal Components: X Malaria 1. Eligibility Country / Countries: São Tomé and Príncipe X Low Income 2. Executive Summary Intensifying and updating antimalaria interventions in the small island state of São Tomé and Príncipe (STP) offers a novel opportunity in the fight against malaria. The small size and isolation of STP makes malaria more vulnerable to interventions than nearly any other place in the world where malaria is highly endemic. Prior, interrupted intervention programs have demonstrated the unusual sensitivity of malaria transmission to intervention in STP, temporarily reducing malaria-related mortality to nearly zero in the early 1980s. This experience also revealed the dangers of interventions not sustained, causing an epidemic in a population in which immunity to malaria was depressed by prior interventions. This project proposal is intended to reduce morbidity and mortality from malaria to a level against which interventions can be sustained and provide a basis from which elimination efforts can be seriously considered. STP plans to attack malaria by scaling up existing antimalaria interventions and introducing new strategies with the goal of substantially reducing morbidity and mortality due to malaria by 2009. Existing programs to be scaled up include the free distribution of Insecticide- treated Nets (ITNs), community-based management of malaria and the provision of Information, Education and Communication (IEC) about malaria to the community. Interventions which are new to this country and necessary to combat malaria include Intermittent Preventive Treatment (IPT), which will help prevent the complications of malaria in pregnancy, and artemisinin-based combination therapies (ACT) that will restore the efficacy of first line antimalarials, lost due to resistance. In order to ensure that these new or intensified efforts can be implemented effectively, the overall capacity of the health infrastructure and its human resources will be strengthened through a comprehensive program of health worker and manager training and through the provision and maintenance of essential equipment. Improving the management of severe or complicated malaria in health facilities through enhanced training and supervision will ensure that 95% of patients will receive prompt and effective treatment by 2009. Complications from malaria currently cause more than half of the deaths due to infectious diseases in hospitals. The treatment of uncomplicated malaria will also be enhanced such that 95% of patients will receive prompt and effective treatment by 2009. The primary strategy will involve replacing monotherapies with artemisinin-based combination therapies (ACT). Artesumate-amodiaquine will now become the first-line drug. SP will be used only for Intermittent Preventive Treatment (IPT) in pregnancy. Rapid diagnostic methods will supplement conventional slide diagnostics, assisting health workers to provide prompt access to appropriate treatment. The ability of community health workers to recognize, treat and refer malaria promptly and properly will also be enhanced. Almost 35% of all malaria-related deaths in STP currently occur outside of health facilities. Earlier recognition and management at the community level will lead to better outcomes and fewer deaths. By 2009, we expect that 50% of malaria cases will be detected and treated at the community level. ITNs provided free will reach 80% of the population by 2009. ITN coverage will be intensified under the shield of an independent, bilateral IRS program (not funded by this proposal) whose continuation beyond 2007 is uncertain. Each of these efforts will benefit from a general strengthening of community awareness of malaria and its prevention. Finally, the strengthening of human and institutional resources will provide the platform that will support the success of this integrated array of proven interventions. A sum of 1,144,983 USD is needed in the first year to build the capacity required to fight malaria effectively. These needs will decrease progressively in the years that follow, as malaria transmission is reduced, as new partnerships develop and as the nation builds its capability to sustain malaria intervention programmes. By 2009, this project will greatly reduce the morbidity and mortality of malaria in STP, taking this small island nation one step closer towards the possibility of eliminating malaria transmission. 2.1 Component and Funding Summary Table 2.1 – Total Funding Summary Total funds requested in USD Year 1 Year 2 Year 3 Year 4 Year 5 Total HIV/AIDS ---------------- -------------- -------------- -------------- -------------- ---------------- - - - - Tuberculosis ---------------- -------------- -------------- -------------- -------------- ---------------- - - - - Malaria 1,144,983 796,376 630,000 472,500 441,000 3,484,859 HIV/TB ---------------- -------------- -------------- -------------- -------------- ---------------- - - - - Integrated ---------------- -------------- -------------- -------------- -------------- ---------------- - - - - Total 1,144,983 796,376 630,000 472,500 441,000 3,484,859 2.2 Proposal Evaluation X The Proposal should be evaluated as separate components 2.3 Proposal Summary This project proposal is intended to reduce the burden of malaria in Sao Tome and Principe through a combination of scaling up of existing programs such as Insecticide Treated Net (ITN) distribution, Community-Based Management of Malaria and Information, Education and Communication (IEC) and the introduction of interventions that are new to this country such as Intermittent Preventive Treatment (IPT) in pregnancy and artemisinin-based combination therapies (ACT). The ability to recognize and treat both uncomplicated and complicated malaria in health facilities will also be bolstered through an intensive program of refresher training. Finally, the overall capacity of the health systems will be improved through strengthening of human and institutional resources such that both the new and the scaled up interventions may be implemented effectively. The first objective aims to improve the management of severe malaria in health facilities such that 95% of patients will receive prompt and effective treatment by 2009. Training and updating of health workers in current treatment protocols, stocking and distribution of appropriate drugs and supplies necessary for supportive care and enhanced supervisory activities will be combined to ensure that severely ill malaria patients receive appropriate care. The primary outcome is expected to be reduced mortality. The treatment of uncomplicated malaria will be enhanced according to the second objective, such that 95% of patients will receive prompt and effective treatment by 2009. The primary strategy will involve revising national drug policies to replace chloroquine and SP with combination therapies. The government has approved a change to a drug policy that utilizes artesunate-amodiaquine as the new first-line drug. A minor stock of a second-line combination drug (Coartem) will also be requisitioned to provide additional treatment options in health facilities for special cases and counterindications (e.g. first trimester pregnancy, impaired liver function). SP will be used for IPT, as SP resistance appears to be sufficiently low, and selection pressure against SP will be eased once ACTs become the primary therapy for the general population. Training and updating health workers will also be critical to execute this plan, as well as providing specialized diagnostic training for laboratory technicians, including the use of rapid diagnostic methods. All drugs will be free for pregnant women and children less than 5 years old. In the third objective, these new strategies will be extended to community through the strengthening of community based management of malaria. Almost 35% of all malaria-related deaths in STP occur outside of health facilities. Community health workers will receive training in the early recognition, prompt treatment and appropriate referral of uncomplicated and complicated malaria. Drug kits will be prepackaged to make provision of doses simpler and charts will be produced and distributed to provide a reference for diagnosis and treatment. By 2009, we expect that 50% of malaria cases will be detected and treated at the community level. The scaling up of ITNs, (provided free of cost) as a fourth objective will take advantage of an existing IRS program to protect communities until ITN coverage rates reach 80% by 2009. As with the other objectives, training and IEC will also be critical to the success of the ITN distribution program. All of these efforts will benefit from a general strengthening of community awareness of malaria and its prevention as stated under objective five. The sixth and final objective aims to Strengthen the human capacity and institutional resources to ensure the achievement of the goal. Each of these interventions, implemented together, will participate in a chain of synergism to reduce the burden of malaria in STP. ITNs and IPT will reduce the incidence of malaria infection. Reduced incidence will decrease the need for treatment of uncomplicated malaria in health facilities. Community mobilisation and education will enhance prevention and instill knowledge that will lead people to recognize and seek care for malaria earlier. Earlier and more effective recognition and treatment of uncomplicated malaria in communities and in health facilities will lead to fewer cases of complicated and severe malaria. Those cases of severe or complicated malaria that remain will now be treated much more quickly and more effectively in a health system far better equipped and trained and much less stressed thanks to the overall reduction of incidence. The unique accessibility and geographic constraints and isolation of this small island state also contribute to the synergy of this project. The close proximity of most districts to the central management will facilitate nearly all activities from distribution coverage, training to monitoring and supervision. Although the relatively small population base leads to overhead expenses contributing disproportionately to per capita costs, this is compensated for by the intensity and sustainability of coverage possible as compared to a larger nation with remote, inaccessible rural populations, and high rates of cross-border migration. The greater per capita expense, however, comes with an added value not yet conceivable for nations in continental Africa. When this entire project is implemented, the effect on morbidity and mortality shall be far greater than can be predicted from summing the individual effect of each intervention. Once this occurs, a substantial reduction in Malaria morbidity and mortality would be achieved. The interventions and deployment strategies chosen for this project represent the distillation of the experiences of STP’s malaria control program as well as the evidence-based consensus recommendations of technical experts throughout Africa and the rest of the world. Such existing activities proven to be effective malaria interventions (e.g. ITNs, community-based treatment), but which are underutilized will be scaled up. Interventions that have lost efficacy (e.g. chloroquine and SP) will be replaced with more efficacious ones (e.g. ACT). Preventive interventions proven effective elsewhere (e.g. IPT) will be introduced into this country for the first time. Together, these interventions, established and new, will greatly reduce morbidity and mortality due to malaria in STP.
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