Plan of Action 2004 –2008

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Plan of Action 2004 –2008 Powered By Docstoc
					 Report on malaria Mission to Sao Tome and

                 Awash Teklehaimanot
          Professor of Clinical Epidemiology,
   Director, malaria Program at Columbia University
   And member of the Advisory Project Group to STP

1. Objective of the Malaria Mission
      To assess the malaria situation and its control in the
       country through discussions with government
       authorities, National Center for Malaria Control, visits
       to Central Hospital, District Health Centers, peripheral
       Health Posts, UN Agencies and other partners, Private
       sector, NGOs and through the review of documents and
       consultant reports
      Submit recommendations on observations and
       assessment made
      Suggest a plan of action for scaling –up malaria control
       efforts in STP

2. Travel dates: 13-22 October 2003

3. Program of Visit: The Schedule for the visit organized by
   the Ministry of Health was as follows:
14 October
    Arrival and hotel accommodation
    Courtesy visit with H, Exc. Minister of Health and Director of the Center for
      Endemic Diseases
    Meeting with the WHO Representative and staff
    Meeting with H.Exc. President of the Republic

15 October
    Meeting with the Ambassador of Taiwan and staff relating to their support to the
      malaria program
    Briefing by the national Center of Endemic Diseases on the National Strategic Plan
      on RBM. Briefing was chaired by H.Exc. Minister of Health
    Meeting with UNICEF representative
    Meeting with Catholic Bishop relating to the churches involvement in community
    Reception-given by H.Exc. Minister of Health

16 October
    Visit to Lobata Health Center and review the health situation with the director of
      the Center and staff
    Visit to Micoló health Post
    Visit to Micolo Village to inspect the pilot research intervention of space spraying
      with ultra low volume insecticide
    Visit to Ribeira Afonso Health Post
    Visit to Ribeira Afonso Village to inspect the pilot research intervention of indoor
      insecticide residual spraying

17 October
    Visit the Central Hospital entitled Dr Ayres de Menezes with particular attention to
      pediatrics and laboratory facilities. Briefed on the health situation by the Director
      of the hospital and department heads.
    Visit the Praia Gamboa pilot research intervention of larval control using insect
      growth regulators.
    Technical discussion at the Center of Endemic Diseases on the various research
      activities and on epidemiological surveillance.
    Meeting with UNDP Représentative

18 October     Field visits to inspect different breeding sites

19 October     Meeting with the Chevron/Texaco Representative relating to the
               company’s interest to provide ITNS to the Ministry of Health

20 October
    Presentation on observations and recommendations on the malaria mission to H.
      Exc. Minister of Health and the Advisory Council of the Ministry.
      Briefing H.Exc. President of the Republic on the observations and
       recommendations of the malaria Mission
      Briefing H.Exc. The Prime Minister on the observation and recommendation of
       the malaria mission.

21 October    Departure for Lisbon

   4. Major Observations and Activities

              1. The program for the visit was well organized and I had an ample
                 opportunity to discuss in detail with the Director and staff of the
                 National Malaria Control Center, the Minister, Ministry of Health, UN
                 Agencies (WHO, UNICEF and UNDP), Bilateral development
                 organizations, an NGO, and a private Sector( Chevron Texaco).
                 Documents and consultant reports on various aspects of malaria
                 control and research findings were also made available to me.

              2. The Democratic Republic of Sao Tome and Principe is a small island
                 with a land surface area of 1001 Km2 and a population of about
                 140,000. Most of the populations live along the coast, with over 60%
                 of them concentrated with in a radius of 10 Km from Sao Tome, the
                 capital city.

              3. Malaria in STP can be classified as meso/ hyperendemic with a
                 perennial transmission in most areas. The rainy season extends from
                 September to May. The equatorial climate with annual temperature of
                 over 25 degrees Celsius, relative humidity of about 80% with annual
                 rainfall ranging between 1000 and 7000 mm is quite conducive for
                 mosquito production and malaria transmission..

              4. All the four forms of human malaria parasite species are found in the
                 island with over 96% of the infections being due to Plasmodium
                 falciparum, the most fatal form responsible for severe and complicated

              5.    Anopheles gambiae s.s., forest cytoform is the only vector in the
                   country. It is primarily anthropophilic with opportunistic tendency to
                   be zoophilic and exophagic. It is resistance to DDT and sensitive to

              6. Malaria is a major public health problem in the island responsible for
                 68% of hospitalization and 48% of hospital deaths. Mortality due to
                 severe anemia is around 11 % and malaria is the single most
                 contributing risk factor. Over 49% of the beds in Dr Ayres de Menzes
                 Central Hospital in Sao Tome is occupied by malaria patients, less
   than five years of age. At the time of the visit, the occupancy in the
   pediatric ward was full with malaria patients. We observed a number
   of children sharing a hospital bed. Thus a greater proportion of the
   hospital facilities and staff are being utilized for the diagnosis and
   treatment of malaria. According to the MOH data, the proportional
   hospital mortality of malaria in under fives during 1995-2001 was in
   the range of 48% to 75%( tables 1 and 2). Mortality and morbidity data
   from health institutions for the period 2000-2002 is summarized in
   table 3.

7. Chloroquine and sulfadoxine /pyrimethamine are the first and second
   line treatment antimalarial drugs for uncomplicated malaria with
   quinine reserved for the treatment of severe malaria. The prevalence
   of Plasmodium falciparum resistance to chloroquine and
   sulfadoxine/pyrimethamine is reported to be 69% and 19%
   respectively. However, in spite of such documented evidence of such
   unacceptable level of resistance, chloroquine is still being used due to
   financial constraints and lack of donor support to acquire effective but
   more expensive drugs.

8. Diagnosis and treatment of malaria cases at the health post level is
   provided based on clinical signs and symptoms in accordance of WHO
   guidelines. In addition, blood smears are taken from the presumptively
   treated patients and sent by courier to the nearest health centre for
   microscopic examination which may take two or three days to process
   the blood examination and provide feed back to the health post
   concerned. The lab results which usually arrive after the patients
   complete their treatment are not relevant to the diagnosis and treatment
   practices at the health post level. Such practice is not in line with the
   current Malaria Global Control Strategy and much needed resources
   are being wasted.

9. The health information and surveillance system is quite weak and
   hinder proper program planning and implementation. Data recording
   and management at district health centers and health posts is not
   conducive for follow-up and situation analysis of the respective
   catchment areas. Charts and graphs on the malaria burden were not
   displayed by of the health facilities we visited. It was necessary to
   sieve through log books and records to find out the number of malaria
   cases reported.
10. The National Malaria Program which is part of the National Center of
Endemic Diseases, appears to be well organized with moderate facilities and an
active team, knowledgeable of the malaria situation in the country. The team is
involved in planning and implementation as well as undertaking malaria related
research activities. However, it appears that the team spends a great deal of its
time on operational research at the expense of intervention activities. The team
while quite strong on vector control issues lack training and experience in the
area of epidemiology and health management.

11. A number of partners such as the UN agencies (WHO & UNICEF), bilateral
development organizations (Republic of Taiwan, USAID, Portuguese Research
Centers) and the private sector are involved in malaria control and operational
research. The input of the Taiwanese group is the most sustentative. Chevron
Texaco, Oil Company is collaborating with the Ministry of Health in the
provision of ITNs to children and pregnant women free of charge in line with the
policy of the Ministry of Health.

12. The national Center for Endemic Diseases, Ministry of Health has developed
    a ten year strategic plan (2001-2010) on malaria prevention and control. The
    components of the strategic plan include the following:

      Case management (diagnosis and treatment)
      Chemoprophylaxis for pregnant women and other non-immunes
      Vector Control (indoor spraying, ITNs, larval control & environmental
      Epidemiological surveillance
      Training and supervision
      Operational research
      Institutional strengthening
      Information, Education and Communication
      Resource Mobilization (financial and human).

The components indicated in the plan are in line with the Global Malaria Control
Strategy, but with a significant focus on vector control. Nevertheless, the strategic
ten-year plan intended to start in 2001 is not yet implemented due to financial
constraints. At the moment, the Center is involved in undertaking intervention
trials on a series of vector control measures such as indoor spraying, fogging with
ULV, use of insect growth regulators etc to select one or more of the above for
routine application.

13. It was thus necessary to review the existing strategic plan in order to
formulate a package of cost effective interventions for implementation during the
next five years (2004-2008).
14. Objectives of the proposed plan will be:

              To reduce malaria attributed mortality to Zero
              To reduce the incidence of malaria by 80% as compared to the
               level of 2003
                           PLAN OF ACTION 2004 –2008

Sao Tome Principe is a small island, which is located in the Gulf of Guinea, 240 km from
the African Coast. Its relative small land-surface, small population (about 140,000) and
its distance from the African mainland make it amenable for an effective malaria control
program activities. Past intervention efforts with indoor residual spraying between 1980
and 1983 have demonstrated the technical feasibility of malaria elimination from the
island. After three cycles of indoor spraying, mortality was brought down to zero and
morbidity level was drastically reduced. However, the program activities were not
maintained and resulted in the incidence of malaria and mortality rate bouncing back to
epidemic proportions. Thus, while it is technically feasible to drastically reduce malaria
in the island, the challenge is the issue of sustainability due to premature withdrawal of
control activities.

The Ministry of Health is concerned about the health and economic burden of Malaria
and is committed to its effective control. The following package of interventions are
proposed for implementation during the next five years (2004 – 2008).

1. Case Management (Diagnosis and treatment)

The physical coverage of the health services in the country is quite good and it will be
feasible to undertake prompt malaria diagnosis and treatment.

   Malaria diagnosis

Malaria diagnosis at the central hospital and district Health Centers (where laboratory
facilities are available) should be supported by microscopic examinations of blood
smears. At the health post and community level, diagnostics should be based on clinical
determination only (based on signs and symptoms) and the present practice of taking
blood smears to be sent to the nearest health center for examination be discontinued as
the blood examination results would not be available in time (would take about 3 days) to
influence the treatment decision. It will be essential to provide refresher training to the
health centers on case management dealing with prompt diagnosis and treatment.

   Treatment of cases

The prevalence of Plasmodium falciparum resistance to chloroquine and sulfadoxine/
pyrimethamine is quite high and it is critical that these drugs be replaced by Artimesinine
based combinations of anti malarial drugs such as Coartem to serve as first line drugs for
treatment of non-complicated malaria. Quinine is still effective and be continued for the
treatment of severe and complicated malaria.
   Malaria in Pregnancy

Over 96% of the infections in STP are due to falciparum malaria. In such situations of
stable malaria, pregnant women are at risk of contracting infection and developing severe
malaria and anemia leading to maternal death and low birth weight. It is recommended
that women in their first and second pregnancies should receive intermittent preventive
treatment (IPT) with an effective anti-malarial drug, as part of antenatal care service. The
drug of choice for intermittent preventive treatment is sulfadoxine/ pyrimethamine and
use of chloroquine as Chemoprophylaetic drugs for pregnant women and other
population groups should be discontinued.

2. Vector Control

Various aspects of vector control measures including use of Insecticide Treated Nets
(ITNs) indoor residual spraying, space spraying with ultra low volume (fogging), larval
control through insect growth regulators and environmental management are practiced in
STP. In an environment where there is almost a year round rainfall and wide spread of
breeding sites, use of larval control employing insect growth regulators and application of
space spraying with ULV will not be appropriate and should be discontinued. Use of
ITNs should be the primary vector control measure supplemented by indoor residual
spraying if the sustainability of such measures can be ascertained; and source reduction
through environmental management in urban area wherever it will be feasible.

   2.1 Insecticide Impregnated Bed Nets

The government is committed to the mass use of ITNs through out the country with a
policy of free provision to children under-five years of age and pregnant women. The
rest of population groups would be provided at subsidized cost. ITNs are well accepted
in STP and their use has reached a relatively high coverage.

It will be preferable to use ITNs that require impregnation instead of the so-called
permanently impregnated bed nets or Permanets. Except for the permanently treated
Olyset nets, all other nets claimed to be permanently treated are being tested by WHO/
WHOPES to validate such claims. Re-impregnation of bed nets with alpha cypermethrin,
delta methrine or permethrine can be coordinated by the National Center for Epidemic
Diseases and carried out by the peripheral health services free of charge through the
involvement of communities. Free re-impregnation of bed nets will ensure the
participation of the communities to have all their nets impregnated in time and thus
maintain their protective efficacy. The health workers in the designated re-impregnation
centers need to be trained on re-impregnation techniques.
   2.2 Indoor Residual Spraying (IRS)

Indoor residual spraying is a very effective control measure for speedy reduction of
malaria incidence and interruption of transmission if applied in an organized manner to
attain a total coverage of the designated area. However, IRS should not be started unless
there is a government commitment to sustain the spraying program. The 1985-86 malaria
epidemics was the result of the 1984 suspension of spraying operations after successful
three years spraying program of 1980-1983 with DDT. DDT is no more effective in STP
as Anopheles gambiae s.s has developed resistance to the insecticide. IT is replaced by
the pyrethroid groups such as bifenthrin.

The withdrawal of spraying should be planned to be carried out in a progressive way after
bed net coverage of 90% and full coverage of case management with effective
Artimesinine combination anti malarial drugs is attained. It will also be important for
National Center for Epidemic Diseases to maintain the readiness and capacity to
undertake focal spraying in the event of small outbreaks and build-up of cases.

   2.3 Source reduction through environmental management

The ecology of urban towns in STP has strong rural/ semi-rural characteristics with
multitude of environmental conditions suitable for breeding of Anopheles gambiae.
These conditions present great difficulty to undertake suitable and cost effective anti-
larval control measures and use of anti-larval chemical agents is not recommended.
However, source reduction measures through general sanitation and environmental
management of cleaning canals, backyards, filling in open ditches and bore-pits should be
encouraged as a supplementary measure. Communities should be sensitized through IEC
to avoid the creation of breeding sites and a regulation should be in place to discourage
the establishment of man-made breeding sites.

3 Information, Education and Communication (IEC)

Promotion of the protective measures with insecticide treated nets, the value of timely re-
impregnation of bed nets, application of regular indoor residual spraying or focal
spraying and the use of intermittent preventive treatment for malaria in pregnancy should
be well understood and appreciated by the health workers and the communities. It is
critical that onset of malaria infection in children are recognized and treated promptly
before they progress to severe disease. Thus raising the awareness and interest both of
health workers and communities through well-designed IEC materials is a pre-requisite
for a successful intervention of malaria control activities. Appropriate IEC materials will
be developed in local languages targeting the health workers and local communities.
4 Epidemiological Information System

Collection and use of epidemiological information, particularly at the district and health
post level is done in haphazard way. None of the health facilities we visited displayed
any graph or chart on the distribution of malaria in their respective areas. At the health
post level, separate logbooks of patients for a visiting nurse or physician and health
assistant is maintained. There is a need to standardize data collection, recording, use and
reporting. The capacity of the health workers needs to be strengthened through refresher
training and recruitment of an epidemiologist to establish the system and oversee its use.
There is a need for strengthening the health information system through the use of
computers to replace the hand-written logbooks.

5 Operational Research

The National Center for Epidemic Diseases is engaged in undertaking operational
research on insecticide resistance, evaluation on therapeutic efficacy of anti malarial
drugs and on knowledge, attitude and behavioral studies related to malaria perception,
treatment seeking behavior and compliance. These studies are critical to the success of
malaria control efforts and should be supported. However, there is a need for
strengthening the capacity of the center through the recruitment of additional staff, as the
center has no epidemiologist to design research protocols and oversee the
epidemiological information system.

6. Institutional Strengthening

The overall malaria Program in STP would require a major re-orientation and capacity
strengthening to undertake a cohesive and standardized implementation activities at all
levels of the health care system.

   1. The national center for Endemic Diseases which appears to spend a great deal of
      its time on operational research need to consider to concentrate more on planning,
      implementation, coordination and guidance of the health services and on
      monitoring and evaluation activities at district and community levels. The
      recruitment of an epidemiologist will strengthen the malaria team in guiding the
      general health services in data collection, analysis, management and reporting as
      the quality of data collection and information flow from health posts to districts
      and national level needs immediate attention.
   2. The health workers in the general health services require additional training
      including in the following areas:
               Training of nurses and medical officers on management of severe and
                  complicated malaria
               Refresher training of laboratory technicians on proper staining
                  technique of blood slides with giemsa and on malaria diagnosis.
   Training of health workers assigned to peripheral health services on
    malaria diagnosis on clinical grounds, prompt and correct treatment
    and re-impregnation of mosquito nets
   Training of district health workers on basic computer skills, data
    recording, analysis and reporting to improve the information flow.
  7. Selected Monitoring and evaluation Indicators

 I. Disease Management: Early diagnosis and treatment

           Proportion of patients with uncomplicated malaria getting correct treatment according
            to national guidelines within 24 hours of onset of symptoms
           Proportion of malarious localities with CHWs trained in malaria control and
            appropriate antimalarial drugs/treatment available
           Proportion of patients hospitalized with a diagnosis of severe malaria who received
            correct management according to the national guidelines
           Proportion of peripheral health facilities reporting no disruption of stocks of first line
            antimalarials as specified in the national guidelines for more than one week during the
            pervious three months
           Proportion of referral health facilities reporting no disruption of stocks of quinine and
            other supplies for more than one week during the pervious three months

II. Vector Control

           Proportion of target population protected by indoor residual spraying
           Proportion of target population protected by insecticide treated bed nets
           Proportion of households having at least one treated bed net
           Number of people mobilized for source reduction

III. Prevention and Control of malaria in Pregnancy

           Proportion of pregnant women who have taken IPT in the target areas (stable malaria
            transmission areas).
           Proportion of pregnant women who have at least one ITN.

IV. Information Education and Communication and Social Mobilization

           Number of health education materials produced and distributed by type in targeted
           Increases in level of awareness

V. Operational Research

           Therapeutic efficacy tests of antimalarial drugs conducted
           Effectiveness of ITNs and IRS evaluated

VI. Human Resource Development

           Number of health institutions with revised curricula for malaria control
           Proportion of nurses, physicians trained on severe malaria
           Number of primary health workers and voluntary health workers trained on
            management of uncomplicated malaria.
VII. Monitoring and Evaluation

               Proportion of districts regularly reporting health management information and who
                have used health information for planning

VIII. Impact Indicators;

    The following are indicators to be monitored on yearly basis:

               Crude death rate among target groups
               Malaria hospital case fatality rate
               Incidence of confirmed malaria
               Incidence of unconfirmed malaria
               Slide positivity rate
               Proportion of P.falciparum malaria
               Proportion of P.vivax malaria
               Malaria proportional mortality rate among targeted groups
               Proportional morbidity rate of confirmed malaria
               Proportional morbidity of clinical malaria
                                               Funding Requirement (2004-2008)

Category           Activities, Supplies/ equipment          Unit     Total Unit                 Allocation by year (2004-2008)            Total
                                                                     #      cost                                                          cost
                                                                     needed (USD)     04          05        06        07        08        (USD)
Drugs and          3 day Artemisinin + SP treatment
related supplies   tabs, for children under five years of   tab      episode
                                                                               1.7    142,800     142,800   142,800   142,800   142,800   714,000
                   Co-artem, treatment tabs, for five
                                                            box      500       120    120,000     120,000   120,000   120,000   120,000   600,000
                   years of age and above
                   Quinine, 300mg base, 1000tabs            tin      315       30     1890        1890      1890      1890      1890      9450
                   Quinine, 300mg base, 100 ampoules        box      7000      13     18,200      18,200    18,200    18,200    18,200    91,000
                   Sulphadoxine/ pyrimethamine,
                   525mg, 1000tabs for IPT in               tin      1250      22     5500        5500      5500      5500      5500      27,500
                   IV fluid, 50% dextrose, 50 ml, 25
                                                            box      5000      12     12000       12000     12000     12000     12000     60,000
                   Dextrose, 5% in water, 1000ml, 10
                                                            box      5000      12     12000       12000     12000     12000     12000     60,000
                   5% DW, 1000ml, with IV set, bags         box      2500      12     6000        6000      6000      6000      6000      30,000
                   Sodium Chloride, 0.9% 1000ml, IV
                                                            box      2500      10     5000        5000      5000      5000      5000      25,000
                   set, 12 bags
Laboratory         Micro-slides, frosted (tropical) pack
equipment &        of 5000                                  pack     150       140    7000        -         7000      -         7000      21,000
                   Microscopes, binocular                   each     30        2200   66,000      -         -         -         -         66,000
                   Gloves, latex, box of 50 pieces          box      1000      2      400         400       400       400       400       2000
                   Immersion oil, 100ml                     Bottle   150       2      60          60        60        60        60        300
                   Giemsa powder, 25mg                      Bottle   150       5      150         150       150       150       150       750
                   Glycerol (neutral anhydrous), 500ml      Bottle   100       5      100         100       100       100       100       500
Funding requirement, Continued …
Intervention    Activities, Supplies/ equipment           Unit   Total Unit                  Allocation by year (2004-2008)            Total
types                                                            #     cost                                                            cost
                                                                 needed            04          05        06        07        08
Laboratory        Methanol, A.R., 2.5 liter               Jar    50        12      120         120       120       120       120       600
equipment &       75% Ethanol, 1 liter                    Jar    50        5       50          50        50        50        50        250
supplies          Staining racks, metal of 50 slots       Each   100       50      5000        -         -         -         -         5000
                  Cotton, roll of 500 gm, B.P.            roll   500       2       200         200       200       200       200       1000
                  Counter (for parasite count)            each   100       20      2000        -         -         -         -         2000
                  Needles & syringes                      Pack   500       30      3000        3000      3000      3000      3000      15000
                  Blood Lancets, box of 200 pieces        box    250       2       100         100       100       100       100       500
                  Graduated cylinders, of 100ml-
                                                          Each   15        120     1800        -         -         -         -         1800
                  1000ml of 30 each
                  Registration books, 2 per health post   each   1000    5         5000        -         -         -         -         5000
                  Thermometer, digital                    each   300     15        1500        -         1500      -         1500      4500
Equipment &       Bed nets, family size                   Each   280,000 3         420,000     -         -         420,000   -         840,000
supplies for ITNs Insecticides, kiotabs (delta-
                                                          Kit    1400000   0.65    182 000     182 000   182 000   182 000   182 000   910 000
and IRS           methrine)
                  Alpha cypermethrine@50mg/ m2 for        ml     397500 0.05       19,875      19,875    19,875    19,875    19,875    99,375
                  50,000 houses (100 m2 / per house,
                  total spray-able area 7,950,000 m2 )
                  Spray pumps, 8 liters, including        Each   100       200     20,000      -         -         -         -         20,000
                  10% for spare parts
                  Gloves                                  Each   100       5       500         -         500       -         500       1500
                  Gowns                                   Each   100       5       500         -         500       -         500       1500
Logistics         Vehicle, Single cab. pickup truck for   Each   7         27000   189,000     -         -         -         -         189,000
                  district health centers
                  Vehicle spare parts @ 3000USD/                 7                 21000       21000     21000     21000     21000     105000
                  Vehicle/ year
                  Fuel @ 100 USD/ vehicle/ month                 7                 8400        8400      8400      8400      8400      42000
Funding requirement, Continued …
Intervention    Activities, Supplies/ equipment        Unit   Total Unit              Allocation by year (2004-2008)        Total
types                                                         #     cost                                                    cost
                                                              needed        04          05       06       07       08
Logistics         Motorcycles for peripheral health    Each   20     5000   100,000     -        -        -        -        100,000
                  Motorcycle spare parts @ 500                20            10000       10000    10000    10000    10000    50,000
                  /motorcycle/ year
                  Fuel @ 50 USD/ motorcycle/ month            20            12,000      12,000   12,000   12,000   12,000   60,000
                  Personal computers for district      Each   7      3000   21,000      -        -        -        -        21,000
                  health centers
Information,      Create awareness of communities in                        20,000      20,000   20,000   20,000   20,000   100,000
Education and     malaria control and prevention
Communication     through use of leaflets, radio spots
(IEC)             and TV programs
                  Production of IEC material for the                        30,000      30,000   30,000   30,000   30,000   150,000
                  promotion of ITN including re-
                  impregnation, case management,
                  general sanitation and IRS
Epidemiological   Developing guidelines on                                  50,000      50,000   50,000   50,000   50,000   250,000
& Health          surveillance system for monitoring
Information       trends of malaria
System            Recruitment of an epidemiologist for                      70,000      70,000   70,000   70,000   70,000   350,000
                  the National Center of Endemic
                  Three person-months consultancy to                        25,000      25,000   25,000   25,000   25,000   125,000
                  monitor progress of implementation
Operational       Monitoring therapeutic efficacy of                        25,000      25,000   25,000   25,000   25,000   125,000
Research          selected anti-malarial drugs
Funding requirement, Continued …
Intervention    Activities, Supplies/ equipment           Unit   Total Unit            Allocation by year (2004-2008)                     Total
types                                                            #     cost                                                               cost
                                                                 needed       04          05            06         07          08
Operational      Monitor the sensitivity of                                   25,000      25,000        25,000     25,000      25,000     125,000
Research         insecticides used for IRS and ITNs.
                 Evaluate the performance of health                           -           -             30,000                 30,000     60,000
                 services relating to malaria control
                 program implementation. Impact
                 assessment will be carried out at the
                 end of 5th year
Training         Training of primary healthcare                               50,000      50,000        50,000     50,000      50,000     250,000
                 workers on re-impregnation and
                 vector control measures by
                 environmental management
                 Training of healthcare workers at                            50,000      50,000        50,000     50,000      50,000     250,000
                 health post level on management of
                 uncomplicated malaria based on
                 clinical diagnosis
                 Training of nurses and physicians on                         30,000      30,000        30,000     30,000      30,000     150,000
                 management of sever malaria
                 Refresher training of lab. technicians                       15,000      15,000        15,000     15,000      15,000     75,000
                 in malaria microscopy
                 Training of spray-men on correct                             3000        3000          3000       3000        3000       15,000
                 techniques of insecticide spraying
                 Training of district health workers                          5000        5000          5000       5000        5000       25,000
                 on basic computer skills, data
                 recording, analysis and reporting

                 GRAND TOTAL                                                  1,636,145       796,845    836,345   1,216,845    836,345     5,322,525
Central Hospital, Jan - April 2003

           Fig. 1: Principais motivos de alta Hospitalar

             Other diseases

                6%                                 Malaria
       other causes
          of anemia

               parto unico
Central Hospital, Jan - April 2003

                  Fig. 2: Principal cause of admission

           Other diseases

                   4%                               Malaria
          other causes
            of anemias
              diarrhoea &
CHST, 1º semestre de 2003

                            Fig. 3: Principal causes of mortality



                                   5%                       17%
                                 acute    6%                other
                             bronchitis   diarrhoea &       causes of
   Central Hospital, Jan - April 2003     gastroenteritis   anemias
        Proportional mortality (%), from hospitals, 1995-2001

  Table 1:
 Year    <5y      >=5            Global
1995      63.0       33.0          48.0
1996      75.0       32.0          57.0
1997      78.0       21.0          51.0
1998      59.0       10.0          46.0
1999      65.0       18.0          42.0
2000      48.0       17.0          33.0
2001      49.0       16.0          30.0

                            70                                                         <5y
                            60                                                         >=5
                            50                                                         Global
                                     1995    1996   1997   1998   1999   2000   2001

Source: national Center for Endemic Diseases, MOH
        Malaria Morbidity (per 1000), 1995-2001
  Table 2:
 Year     <5y        >=5          Global
1995        1,460       180          370
1996        1,420       150          340
1997        1,200       270          400
1998        1,140       240          390
1999          740       185          270
2000          880       200          300
2001        1,140       220          360

                                    1995   1996      1997   1998   1999   2000   2001

        Source: National Center for Endemic Diseases, MOH


                Under 5 children                  Above 5 years               Pregnant women            Grand Total
                                   Malaria        Total       Malaria         Total      Malaria        Total     Malaria
         Year   Total cases        cases          cases       cases           cases      cases          cases     cases
         2000            23566           11958        41916         19834            618        293       66100     32085
         2001            32306           16892        47369         22865           1187        530       80862     40287
         2002            36975           20144        54481         29244            775        438       92231     49826


                    Under 5 children             Above 5 years               Pregnant women           Grand Total
                    Total       Malaria          Total      Malaria          Total      Malaria       Total       Malaria
         Year       cases       cases            cases      cases            cases      cases         cases       cases
         2000          13665           9920          16791          6903           3737       517          34193    17340
         2001          12874           9288            9587         4664           3920       483          26381    14435
         2002          13971         10998             6736         4128           3905       739          24612    15865


                    Under 5 children              Above 5 years               Pregnant women           Grand Total
                    Total        Malaria          Total       Malaria         Total       Malaria      Total       Malaria
         Year       deaths       deaths           deaths      deaths          deaths      deaths       deaths      deaths
         2000             227            108            207             38             7          0          441      146
         2001             253            123            309             44             5          2          567      169
         2002             243            148            136             31             4          0          383      179