Summary of malaria assessment visit to Dili, East Timor



REPORT OF PRELIMINARY MALARIA ASSESSMENT MISSION TO DILI, EAST TIMOR

October 26-28 1999

Report prepared by:

Dr Nick Anstey

Tropical Medicine and International Health Unit

Menzies School of Health Research (MSHR) and Territory Health Services (THS)

Darwin, Northern Territory, Australia

and

Member of RBM Complex Emergencies Network

The mission was conducted by Dr Anstey as part of 4 member team of experts from Territory Health Services, Darwin, Northern Territory, Australia who assessed malaria, TB and laboratory services in East Timor at the request of WHO.

PRELIMINARY MALARIA ASSESSMENT MISSION TO DILI, EAST TIMOR

I. Aim

To undertake a preliminary malaria situation analysis as part of an initial communicable diseases assessment by Territory Health Services

II. Situation Analysis, Dili, East Timor

1. Geography of East Timor

East Timor is 14,609 sq km, approximately 80% hills/mountains, 20% lowland. The highest mountain, Gunung Tata Mai Lau, is 2,963m and directly south of Dili. Of the 75 rivers in East Timor only 5 are described as having water in them by the end of the dry season. The wet season is from November-April. Under Indonesian administration, the province was divided into 13 districts, and 62 sub-districts, including 442 villages (East Timor Provincial Health Office 1993 report).

Dili on the north coast follows the coastal strip and is limited on all sides by hilly ranges, with a relatively steep and constant slope down to the sea. Full details of climate, topography and agriculture are found in “East Timor’s Potential Profile” by the Regional Investment Coordinating Board 1991.

2. Population

Pre-referendum population of East Timor estimated at 875,989, with an IMR of 70/1000 (1998 Indonesian Government data on file at RBM).

The population of Dili in the last week of October 1999 is estimated by Dili WHO staff at approximately 80,000 people. There is continuing spontaneous and structured movement of displaced people back to Dili. These include Dili residents and those from other cities and villages throughout East Timor. Many (but not all) of these are then moving back to regional towns and villages of origin. Despite widespread destruction of housing and public buildings there are no refugee camps within Dili, and none are planned. Returnees are living in the minority of houses that escaped destruction, or alternatively in partially-repaired houses. Economic activity is restarting, with increasing numbers of street vendors.

3. Malaria epidemiology

Existing data suggests mesoendemicity in at least 4 districts of East Timor (see below), with lower rates seen at higher altitudes.

3.1 Background malaria epidemiology based on past Indonesian Ministry of Health data

3.1.1 1993 report by Provincial Health Office Malaria Control Unit (Dr Alex Un Usfinit):

Malaria second commonest cause of disease according to government primary health care clinic data. Both species found in all 13 administrative districts (relative proportions not reported). Parasite rate in 0-9 years averaged 8% province-wide in 1992.

Parasite rate in 0-9 years reported as >10 % in 4 districts of East Timor: Dili, Bomonaro, Baucau and Manufahi. Two peaks in Anopheles vector density in East Timor reported in June/July and December/January.

3.1.2 Ministry of Health 1998 Health Profile (on file in Dili WHO Office):

Malaria is listed as second or third commonest cause of disease in all age groups. This is based on a clinical rather than laboratory diagnosis in most cases, and in view of high rates of clinical malaria reported in the 0-28 day and >60 years age groups (which do not usually have high rates of clinical malaria), these are likely overestimates. Malaria and dengue haemorrhagic fever were each reported to account for 11.1% of East Timor hospital inpatient deaths in 1998.

3.1.3 Ministry of Health slide positivity rates (year not reported) in WHO databases (Sept 1999 RBM report) were reported as being10% in Ermera, 55% in Dili (?whether sampled from rural or urban areas of Dili district) and 73% in Manufahi, averaging 49% province-wide.

2 Malaria epidemiology in post-referendum evacuees to Darwin from Dili (including those seeking refuge in the UNAMET compound) in September 1999:

In the first group of 347 evacuees (UNAMET employees and families from Dili), all patients were screened for malaria by thick and thin film: only 3/347 (0.9%) were thick film-positive (0/31 children 14 years), with one each of P. falciparum, P. vivax and P. malariae. In the second group of 1517 evacuees (Refugees who had taken refuge in the UNAMET compound, including 16.8% children Hb on D0. In summary only 7/66 (11%) of patients treated with chloroquine had an adequate clinical response with any degree of haematological recovery. 36 of the 37 LTF were retreated with SP, and only 32 cases could be followed for another 28 days, with a cure rate of 100%; 81.2% (26/32) had a haematological recovery with HbD28>HbD0.

V. Recommendations

Most parts of East Timor appear to be in the post-emergency phase, however with the upcoming wet season, malaria morbidity and mortality may increase more than in previous years, for reasons outlined in section I 3.4. The following are recommended:

1. Vector control activities/Prevention:

1.1 Vector control interventions in Dili before the onset of the November-December wet season:

1 Clear urban drains, to improve drainage of surrounding fields/swamps.

2 Create a landfill site for receptacles found in debris within burnt houses that are suitable for Aedes aegypti breeding.

3 Create a centralised stockpile of all tyres, which can be sprayed as one if Aedes breeding becomes a problem in the wet season.

4 Distribution of water containers to Dili residents with an attached lid

These issues were discussed briefly with INTERFET commander Major-General Peter Cosgrove who agreed to explore the possibility of further military assistance with such measures. It would be ideal if these measures could also be undertaken by NGOs involved in environmental health activities, perhaps through mobilising local Dili residents.

1.1.5 Review the need for current outdoor fogging activities. Such fogging usually has little impact on disease-causing and pest mosquito numbers, and unless it can be demonstrated to be effective, the resources are likely to be better utilised elsewhere eg larval surveys and targeted BTI larviciding. If such larval surveys or larviciding are planned by the military or NGOs it would be of great benefit if any Timorese vector control personnel could be identified to assist with these activities as part of capacity building for the future.

1.2 Vector control activities after the start of the wet season will be guided by the results of an entomological assessment to be performed by Peter Whelan of THS in early December and similar ongoing assessments by the Military authorities. This assessment will aim to assess sites in both Dili and Baucau, and ideally wet rice growing areas around Baucau, and will make recommendations based on vector activity identified and in the light of consultations with Military and Timorese vector control personnel. This assessment will also aim to review current Timorese vector control human resources, and identify opportunities for capacity building in the short, medium and long term. Because of the feeding and resting habits of the local Anopheles mosquitoes, it is thought likely that residual house spraying will be of only limited benefit, and that where possible, targeted larviciding guided by larval surveys will be of greater benefit.

3 The IRC and UNICEF plans for the early distribution of impregnated bed nets are fully supported. Followup of uptake and usage are recommended as resources allow. Plans for re-impregnation will need to be made.

1.4 In the medium term integrate malaria control activities with dengue and filariasis control activities

2. Malaria Disease Surveillance.

This is a high priority. Malaria morbidity and mortality surveillance using RBM Complex Emergency Guidelines should be promoted. Current morbidity data for presumed malaria used by WHO Dili suffer from a lack of standardisation of case definitions for presumed malaria and incomplete reporting. It is recommended that at least initially, the case definition should be fever or history of fever in the preceding 48 hours, in the absence of evidence of an alternative diagnosis, that every effort be made to ensure complete reporting and that in the regional NGO clinics that this is supported by microscopy whenever possible for case management as well as surveillance purposes. When microscopy is not possible in every febrile attendee in a busy clinic, microscopy in all patients meeting the case definition seen in a representative time period (eg 4 hour period) on a given day each week could be used to provide a relatively reliable slide positivity rate to compare longitudinally.

In addition to regional NGO clinic reporting of morbidity and mortality, it is recommended that microscopy be done in all febrile patients admitted to the ICRC Hospital, that malaria morbidity, severe malarial morbidity and malaria mortality data is reported to WHO Dili and followed longitudinally.

3. Diagnosis.

Because of limited access to primary health care facilities and to microscopy services, in the short term diagnosis is likely to continue to be based on clinical grounds followed by empirical therapy. It is recommended that microscopic diagnosis be introduced as soon as feasible in regional city NGO and other clinics as above for the purposes of accurate diagnosis for case management but also accurate morbidity/mortality surveillance (as above). Retraining/refreshing of local Timorese microscopists by currently available expatriate microscopists (eg Military Hospitals, AMI) and Central laboratory microscopists, where possible, in both malaria and TB microscopy will assist in capacity building and could be coordinated by the East Timor Health Professionals Work Group. Refreshing/retraining in both malaria and TB microscopy and re-establishment of a quality assurance system with the Central Laboratory is recommended in association with 2 full time expert malaria and TB microscopists funded by the UN appeal from December (see also Central Laboratory Assessment).

An inventory of functioning microscopes salvaged from destroyed health centres in Dili and regional towns should be made prior to the UN appeal funds being made available, to guide decisions on purchasing microscopes to replace those lost/destroyed.

It is suggested that a stock of rapid antigen tests for both P. falciparum and P. vivax (recognising the limitations of immunochromatographic tests for vivax malaria) should be kept for use if there is a sudden surge in fever cases seen in a given NGO clinic and when microscopy services are overwhelmed or unavailable, to help in rapid and accurate confirmation of a malaria epidemic, and rapid implementation of control/case-management strategies as per WHO RBM guidelines.

4. Treatment.

Although no in vivo data from East Timor are available, available chloroquine efficacy data from surrounding islands suggest that chloroquine is no longer likely to be optimal for the first line monotherapy of uncomplicated falciparum malaria. Moreover, for the reasons outlined in I 3.4 above, potentially impaired immunity and reduced ability to return for second line therapy in the event of treatment failure would make increased risk of morbidity and mortality more likely if chloroquine monotherapy is retained as the first line antimalarial for uncomplicated falciparum malaria.

4.1 Recommendation:

Option 1. Switch to Sulphadoxine/pyrimethamine (SP) single dose on day 1 PLUS chloroquine daily for 3 days for all cases of falciparum malaria or when the species is not known. The addition of chloroquine to SP (as has been done in coastal Kenya and Madang, PNG) is preferred by patients as it results in more rapid resolution of fever than with SP alone, and may also delay the development of resistance to SP over time (pending adoption of relatively cheap artesunate-based combination therapies once the current WHO/TDR multicentre combination artesunate drug trials are finished and new WHO combination drug recommendations are announced in 1-3 years ). Undertake chloroquine and SP efficacy studies to determine which drug will be suitable to combine with artesunate in 1-3 years’ time.

Option 2. Retain chloroquine as first line therapy (3 day regimen using standard WHO dosing), with SP for treatment failure, but combine CQ with a single dose of SP on day of presentation if the patient will not be able to return in the event of treatment failure. Undertake a chloroquine efficacy study as a matter of urgency (eg starting early December 1999) making a decision to change to SP + CQ as soon as possible if treatment failure is confirmed at >25%.

Option 1 is preferred, but option 2 acceptable if the chloroquine efficacy study is done as a matter of urgency. With either option, more supplies of SP are likely to be required than are currently stocked (10,000 treatment courses).

If resources allow, patients treated with either regimen for uncomplicated malaria at sentinel sites (eg regional NGO clinics) could be followed up on days 3 and/or 7 to assess treatment failure rates.

Other treatment recommendations:

4.2. Chloroquine monotherapy be retained for management of confirmed vivax malaria.

4.3 Once finalised, translate the treatment algorithms into Tetum (and the official language once chosen) and disseminate widely.

4 Retain and disseminate widely the existing WHO parenteral quinine protocol and guidelines for management of severe malaria (used previously by the Indonesian Ministry of Health) and the list of danger signs (in Tetum) warranting parenteral quinine.

NB. Two different concentrations of quinine are being stocked by NGOs. It is essential that concentrations and dosages are checked carefully at the time of administration, to avoid inadvertent under/overdosing.

4.5 Avoid 5 or 14 day radical treatment with primaquine. Although documentation of effectiveness is not ideal, single dose primaquine, as recommended routinely throughout eastern Indonesia, may be useful in reducing transmission of falciparum malaria in this transitional situation

5. Prophylaxis.

5.1 NGOs promote prophylaxis and confirm that all their staff are on doxycycline or mefloquine prophylaxis.

5.2 In pregnant women emphasize the importance of early diagnosis and treatment. As antenatal services are re-established, introduce weekly chloroquine prophylaxis when possible and ideally prior to the start of the wet season, for primigravidae and secundi-gravidae. Chloroquine will protect against the recently-identified deleterious effects of vivax malaria in pregnancy. Whilst unlikely to be fully effective against falciparum malaria, it may attenuate the deleterious effects on mother and fetus. If the chloroquine efficacy study shows major chloroquine resistance, a switch to single dose SP given three times in total in the second and third trimesters should be considered in areas found to have high endemicity. Areas where such intermittent therapy may be useful can be identified by documenting the ratio of low birth weight (LBW) in primigravidae vs multigravidae. NGO and other clinics offering antenatal care should prospectively gather this data.

6. Other standard treatment protocols.

In the medium term, standard treatment protocols for all common Timorese illnesses should be developed in Tetum/official language, perhaps modified from similar protocols used in neighbouring countries (eg Indonesia, PNG) and made suitable for use in primary health care clinics by nurses and other health workers.

7. Operational research.

1 Resources be made available for a chloroquine efficacy study. This is an urgent priority, as above, for falciparum malaria, and should start no later than December1999/January 2000. Funding should include expert microscopist(s) (who can undertake refreshing/retraining with Timorese Reference Laboratory staff as part of the study), local support/study staff wages, supplies, drugs, transport, accommodation, genotyping of recrudescent isolates, chloroquine levels etc... This in vivo study would be usefully complemented by parallel in vitro resistance studies, genotyping for chloroquine resistance. Efficacy studies of SP for falciparum malaria and chloroquine for vivax malaria are also required but with lesser urgency.

2 Bed net, case management and service delivery operational research as outlined in RBM Guidelines.

3 Surveillance for other diseases that may cause morbidity in Timor, eg Japanese Encephalitis (many pigs observed in Dili), dengue, other arboviruses, melioidosis and rickettsiae. Pending ethics approval, seroepidemiology of dengue/JE/melioidosis in deidentified sera in evacuees to Darwin would be useful. Use of Ashdown’s selective media in Military hospitals for skin/soft tissue infections and pneumonia in the wet season would also be useful. See TB report for TB operational research priorities.

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