Phase II Report
Progress and Accomplishments from June 2005 to July 2006
By Dr. Claus Bogh
The Sumba Foundation’s Malaria Control Program is based on a series of baseline surveys performed on the Nihiwatu peninsula by Dr. Claus Bogh who, prior to joining The Sumba Foundation, was the Senior Advisor on Mosquito Borne Diseases to the Indonesian Ministry of Health. Dr. Bogh commenced the surveys in November of 2003 with the assistance of his staff from The Indonesian Ministry of Health. The goal of the surveys was to identify the local malaria epidemiology and transmission dynamics, and to recommend to The Sumba Foundation directors the best and most cost effective intervention methods for their planned Malaria Control Program.
The findings from the baseline surveys documented that Sumba Island has one of the highest occurrences of malaria in the world outside the African continent. Of the children below 5 years of age 62% had one or more species of malaria parasites at the time of the survey. Overall 30% of all villagers tested were infected with malaria and all four species of human malaria parasites were found in abundance. The species distribution was: Plasmodium falciparum: 60%, P. vivax: 24%, P. malariae 14%, P. ovale: 2%.
In the first area surveyed 33% of all mothers had lost at least one child and 70% of those died from symptoms indicating the death was caused by malaria. The main malaria vector (mosquito) species are: Anopheles sundaicus and An. barbirostris, both are known as notoriously effective malaria vector species in South East Asia.
The Sumba Foundation Malaria Control Program
The Malaria Control Program was designed to be implemented in two phases in order to optimize the required intervention methods and to use the limited resources available in the most cost effective way possible.
Phase I of The Malaria Control Program was initiated on June 1st 2004. The main objective was to test and fine tune the planned intervention methods and to decide how best to involve the local communities. The initial target population was 6 villages in the Nihiwatu area covering a total population of 550 people. A health clinic was constructed by The Sumba Foundation that included the laboratory facilities required for the The Malaria Control Program. Health staff were recruited, employed and trained to provide the best diagnosis and treatment possible.
The entire Phase I target population received training in malaria recognition as well as in the proper use of impregnated mosquito nets to reduce malaria transmission. Phase I was executed as planned and the combination of intervention methods chosen for Sumba has proven to be highly effective in controlling both malaria mortality and morbidity. During the first year more than 1,500 people were tested and treated for malaria and the lives of 24 children that were within hours of dying from cerebral malaria were saved by our intervention at our clinic that was followed up with emergency evacuation to the nearest hospital.
Prior to the construction of our clinic, and the start of the Malaria Control Program, these 24 children would have certainly died. It is also clear that without the preventative measures of the program, coupled with the right diagnosis and treatment at our clinic, many others, both children and adults, would have died during the one year period of Phase I.
The most important components of the Sumba Malaria Control Strategy are as follows:
- To make high quality malaria diagnosis fully available at clinics that are designed to provide malaria treatment as well as general health care.
- To provide the most effective malaria treatment for all malaria species, free of charge.
- To provide follow up screening of all treated malaria patients to make sure the treatment was effective.
- To conduct mass screening of the target population to identify healthy carriers of malaria and treat all positive cases.
- To reduce malaria transmission by providing high quality wash resistant impregnated mosquito nets to the entire population including training in their proper use.
CAPTION: Project areas of Phase I and II including the location of the Hobawawi and Watukarere Malaria Clinics, and the planned Rua Malaria Clinic in Rua valley.
Phase II is the expansion of The Malaria Control Program to cover a much larger population based on the intervention strategies developed and proven during Phase I. More so we have extended the program to include broader health care to increase compliance and strengthen the overall general health of the population.
Our target is to expand our program to include 8,000 people living in the Wanokaka and Lamboya sub districts by the end of 2006. The long term goal is to demonstrate that with the right methods and approach malaria can be effectively controlled in all of Sumba Island as well as in any highly malaria endemic locations in the world.
Phase II Achievements - Malaria clinics and project expansions
Phase II commenced on June 1st 2005 and since then it has been expanding as fast as funds and logistics has permitted (see fig.1). Our first clinic constructed at Hobawawi, prior to Phase I, was further expanded at the start of this second phase to include a larger malaria laboratory and a dental/minor surgery facility (see fig. 2A,B). The clinic can now diagnose and treat up to 40 malaria patients a day and has set a record of treating 92 patients in one day.
Equally important is that the general health care provided at the clinic has been significantly improved to cover a whole range of common infectious diseases and ailments. The Hobawawi Clinic was intended to meet the health needs of approximately 4,000 people living in an area of about 24 square miles. However due to its reputation for high quality of diagnosis and treatment we now find that people often walk from well outside this area to come to our medical facilities. On their journey to Hobawawi many patients would be passing by the government clinics.
On January 1st 2006 we opened a second Sumba Foundation Malaria Clinic in Watukarere Village. This clinic is covering a minimum of 3,000 people living in the Lamboya Bawa area. This clinic provides the same services as the Hobawawi Clinic but it does not have a dental care facility.
A third clinic is now under construction in the Rua Valley. This area is notorious for having an extremely large number of malaria cases. Presently patients from this area walk 4 miles and more to our Hobawawi clinic for assistance. The land for the clinic was donated by the community and our schedule is to complete the first phase of the clinic construction by December 2006. The second phase of construction includes housing for the nursing staff that will be posted at this remote facility. At this time the funding for this phase of the project is not yet in place but we anticipate that we will receive the donor support needed for 100% completion of this important project.
This clinic layout is based on the successful model used at our Watukarere Malaria Clinic. The Rua Malaria Clinic will service not only the Rua Valley but also the Pahola Highlands that are some 4 miles distant. This new clinic will serve the health needs of more than 4,000 people in the coming year and allow us to expand outside the Phase II project area as illustrated in figure 1.
The health needs of Sumbanese living within the Phase II area have now been covered. Everyone in the 40 square mile area has been provided with impregnated mosquito nets and has a professionally operating Sumba Foundation clinic that is within reasonable walking distance from their village. It should be mentioned that at the time we distribute the treated mosquito nets we also de-worm all villagers and distribute Vitamin A supplements to them.
Health Program Staff
The Sumba Foundation now employs 4 parasitology trained nurses, 6 generally trained nurses and one storage facility/data manager (see fig. 3A). The Foundation also has a volunteer Medical Doctor from the Philippines. Her primary job is to train all nurses in general medical diagnosis and treatment as well as instilling good clinical practice. Before the end of 2006 we plan to have an additional 2 parasitologists and one mid wife joining our medical team.
Mosquito Net distribution
As of April 2006 the mosquito net program distributed 2,600 long lasting impregnated mosquito nets and had reached all villages in the initially planned Phase II area. Before any net distribution could take place all villages were mapped using Geographical Positioning System (GPS) and all households were visited and family size and net needs estimated. Net distribution was done centrally at the Hobawawi and Watukarere clinics and was combined with our de-worming and Vitamin A supplement program. All households received net certificates and signed for the pre-numbered nets to secure their proper use and to improve compliance with the net program. Continuous surveillance in the Phase I area has shown that 96% of all nets remain after 1.5 years use and that no nets have passed on outside the project areas. This compliance success is the result of the people’s appreciation of the nets as well as our rather strict net distribution policy.
De-worming and Vitamin A program
A de-worming and Vitamin A supplement program was introduced in parallel to the net distribution program to reduce the effects of malnutrition and boost the general health of the people. More so it has been documented that the severity of malaria infections is significantly reduced if the patient has been recently de-wormed. Intestinal worms are known to induce diarrhea and to reduce nutritional uptake by the infected carrier, this is why worms are particularly problematic in areas of high rates of malnutrition such as in rural Sumba.
The medications we used were 400 mg Albendazole tablets and 5,000 u Vitamin A capsules. All villagers between age 1 and 90 received the combined treatment during the nets distribution program. The entire population in the Phase I and Phase II areas have now been given de-worming and Vitamin A. The drugs were donated by Direct Relief International and the program has been a huge success in the project areas. Worms are known to be a big problem in the villages and the results are instant and clearly visable.