Attachment J.11.docx

MINISTRY OF HEALTH ZANZIBAR

ZANZIBAR MALARIA ELIMINATION STRATEGIC PLAN V 2024-2029 ACCELERATING TO ZERO LOCAL MALARIA CASES

CONTENTS

TABLES

FIGURES

ABREVIATIONS

ZaMESP

FOREWORD

Malaria elimination is a national developmental agenda in Zanzibar. The Revolutionary Government of Zanzibar is of the view that investments channeled towards the fight against malaria must reduce local disease transmission and manage malaria importation to the maximum. I am confident that through concerted efforts, the elimination agenda is feasible and attainable as previous cumulative experiences in implementing malaria control and elimination interventions in Zanzibar have demonstrated and pointed towards that. .

The previous National Malaria Strategic Plan (2018 – 2023) outlined the key interventions required to eliminate malaria by 2023. Though this was not achieved, some notable successes were achieved over the last five years in various thematic areas. However, there were some challenges encountered along the way such as high rate of malaria importation, inadequate multisectoral response and the malaria outbreak which occurred in 2020 among others, which certainly contributed to not achieving the malaria elimination agenda.

In view of these challenges and considering that the MSP 2018-2023 ends in June 2023, the need for the development of the 2024-2029 strategic plan is critical.

The underpinning activities in the 2024-2029 strategic plan include; a robust malaria surveillance accompanied by multisectoral response, integrated vector management (IVM) that monitors vector activities for targeted response. It also include prompt case management that provides quality diagnosis and correct treatment for all confirmed cases coupled with reactive case detection which is key for transmission reduction.

Health promotion and behaviour change communication is a cross-cutting pillar that will ensure that maximum benefits are derived from all interventions that target the communities.

Lastly, an enabling programme environment that guarantees effective partnerships through multi-sectoral engagements and sustainable financing by way of harnessing of domestic resources needed for malaria elimination is vital.

I trust that this document whose aim is to build up and accelerate the advancements realized in the previous strategic plan and formulate innovative strategies will meet the aspirations of the people of Zanzibar to ultimately reach the goal of malaria elimination.

Hon. Nassor A. Mazrui

MINISTER FOR HEALTH

ZANZIBAR

ACKNOWLEDGMENTS

The development of this National Malaria Strategic Plan 2024-2029 was made possible through concerted and collaborative efforts from various institutional and individual stakeholders. The Zanzibar Malaria Elimination Programme (ZAMEP) extends its special gratitude to the leadership at the Ministry of Health; the Principal Secretary Dr. Fatma Mrisho and the Director of Preventive Services Dr. Salim Slim for their stewardship, guidance and unwavering support throughout the entire process.

I wish to mention that many Institutions (WHO, PMI/USAID, RBM Partnership To End Malaria, PSI, JHU, ABT, IHI, Swiss THP, PharmAccess Foundation) and individuals from both within and outside the Zanzibar Malaria Elimination Program who made substantial contributions. The Programme is indebted to the technical leads; Dr. Abdullah S. Ali (local Consultant), Fabrizio Molteni (Swiss TPH) and Dr. Anthony Yeta (RBM International Consultant) who availed invaluable technical support and guidance.

We are also very grateful to the Population Service International and PMI/USAID for providing the funding that made this malaria strategic plan conceivable.

Contributors from ZAMEP

Contributors outside ZAMEP

Shija Joseph Shija Acting Program Manager Zanzibar Malaria Elimination Program Ministry of Health

ZANZIBAR.

EXECUTIVE SUMMARY

The Revolutionary Government of Zanzibar through the Ministry of Health in collaboration with her partners are dedicated to accelerate malaria elimination agenda across the Island. The Zanzibar Malaria Elimination Programme (ZAMEP) is mandated to technically guide all implementing actors and document results. Over the decades (since 2007), significant progress has been made culminating in the reduction and subsequent sustaining of malaria prevalence to less than one percent. This National Malaria Strategic Plan, covering the period 2024 to 2028, aims to accelerate the trajectory of malaria elimination to zero indigenous case and prevent re-introduction.

Demographically, the Administrative Unit’s population distribution report 2022, noted that the population of Zanzibar has increased about fivefold from 354,815 in 1967 to 1,889,773 in 2022. The report highlighted an average annual inter-census population growth rate of 3.7 percent. These findings in reality have policy implications in rendering key basic socio-services, health inclusive.

Economic indicators reveal prevailing poverty in Zanzibar, with 30% people living below the basic need poverty line and over 48% of households experience varying levels of food insecurity. The adult illiteracy rate in 2014/15 was 16.3%. The 2014/15 Integrated Labour Force Survey reports 27% of youth aged 15-24 being unemployed (45.8% in urban areas).

ZAMEP has a comprehensive malaria database ranging from routine data to survey and study findings. Operational surveys are commonly used to offer timely information at a national level for programmatic decision making.

Despite the ZAMEP, in collaboration with partners and other key stakeholders, making significant progress in fast-tracking malaria elimination, the final goal as envisaged in the just ended MSP has not been attained due to several technical and financial challenges among others.

The Programme conducted its mid-term review in 2020 with the aim of redefining the programmes strategic direction and focus. It aimed to inform actions required to double efforts in the quest of accelerating progress towards malaria elimination targets of the current MSP by 2023.

The MTR findings 2020 noted that, progress towards epidemiological impact had stalled and was at risk of reversal. The malaria incidence target for 2019/2020 was 2.2/1000 but what was attained was 3.7/1000 population.

Overall, the number of malaria cases increased from 4,171 in 2017 to 6,736 in 2019, while the number of deaths increased from 1 in 2017 to 5 in 2019. It is against this background that practical recommendations were brought to the fore aimed at improving the situation.

The Malaria Program Review conducted in 2022 noted that, approximately 87% of the blood films between 2020 and 2022 revealed an infection caused by P. falciparum alone. Increased population movement was linked with rate of malaria importation which varied over the years and also noted that indigenous cases detected were on the upswing during seasonal peaks as well as in 2019-2020 outbreak.

With regards to implementation, 2021/2022 the MPR revealed that a total of 155 activities were planned for implementation of which 59% were fully implemented, 15% partially, 15% low implemented while 10% were not implemented at all due funding reasons.

In view of these findings, it was strongly recommended to mitigate the effect of imported cases and the consequent re-introduced transmission. Moreover, understanding better the dynamics and the determinants of population and ecological vulnerability was emphasized. Therefore, upon the expiration of the 2019/2023 MSP, this new strategic plan will incorporate the recommendations and lessons learnt that will assist in the development of technically sound scientific evidence based new interventions to halt local transmission.

The programme vision of this MSP is having a healthy population free from malaria in Zanzibar and the goal is to accelerate elimination of local malaria transmission and preventing re- introduction. The goal will supported by strategic approaches and objectives and the programme will remain steadfast and keep a vigil on the disease transmission patterns in both Islands and respond accordingly.

I

CHAPTER ONE: INTRODUCTION

BACKGROUND

Over the past two decades, the Islands of Zanzibar have made dramatic progress in reducing malaria transmission, driving the parasite prevalence down from historic levels of more than 20% in 2002 to consistently less than 1% in the last decade. Notably, the last two malaria indicators surveys (MIS) of 2017 and 2022 report zero prevalence in the sampled children. The changed malaria transmission resulted in a dramatic reduction of both morbidity and mortality attributed to malaria. As a result of this success, the Zanzibar Malaria Elimination Program (ZAMEP) is now focusing on a malaria elimination agenda following.

Zanzibar is one of the few countries in Sub-Saharan Africa that expressed its commitment to move from control towards elimination of malaria. Although elimination efforts had twice failed in the Islands: the first time in the 1960’s under the WHO led Global Malaria Elimination Programme and the second time in the 1980’s under a large initiative funded by the USAID. The ZAMEP renewed its viewpoint and re-programmed to address elimination agenda. The implementation of the planned interventions and activities in this document will be based on regional recommendations and best practices aligned to the World Health Organization (WHO) and the Southern African Development Community (SADC) malaria elimination frameworks.

The gains towards malaria elimination have been accelerated and maintained by increase in funding levels since mid-2000’s, mainly through the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM) and the U.S. President’s Malaria Initiative (PMI), coupled with the introduction of highly effective treatment, new diagnostics tools, long-lasting insecticide treated bed nets for prevention, and new insecticides for Indoor Residual Spraying.

The Zanzibar Malaria Elimination Program has set up a functional malaria surveillance able to notify and provide follow up of every single malaria confirmed case. The surveillance system reported 67% and 78% imported cases in 2021 and 2022 respectively. To facilitate tracking of the implementation of Malaria Strategic Plan of 2024 - 2029, an M&E Plan was also developed for use. The M&E Plan guides stakeholders on how to monitor and evaluate the implementation of the National Malaria Strategic plan and determine whether its goals and objectives are being achieved. Furthermore, a cross-cutting national malaria social and behavioural change strategy is currently in place in line with the Strategic Plan. The overall goal is to increase the correct use of malaria-recommended interventions to over 85 percent by 2029 through a well-coordinated SBC activity.

In fostering the elimination efforts, the ZAMEP is planning to launch a national campaign for accelerating malaria elimination. The campaign will compose of a comprehensive intervention in a phased manner aiming to attempting reaching the ultimate goal of zero malaria transmission.

Accordingly, the ZAMEP is engaging stakeholders and partners to provide the required technical support to curb the challenge of malaria importation in Zanzibar through various recommended interventions. The current commitment from various stakeholders at all levels enhances the government’s efforts towards malaria elimination.

POLICY AND PROGRAMMING ENVIRONMENT FOR MALARIA ELIMINATION

The Ministry of Health established the former Malaria Control Programme in 1988 under the Directorate of Preventive Services and Health Education. The current Malaria Elimination Programme operates based on the global and national guidance on malaria prevention and elimination. Furthermore, the implementation is also based on regional recommendations and best practices and in alignment to the World Health Organization (WHO) and the Southern African Development Community (SADC) malaria elimination frameworks.

At global level, the ZAMEP observes the WHO technical recommendations during the implementation of its operational plans. For instance, the World Health Organization’s Global Technical Strategy (GTS) for Malaria 2016-2030[footnoteRef:1] is one among the fundamental guiding documents for malaria control and elimination. The strategy provides a comprehensive framework to guide countries in their efforts to accelerate progress towards malaria elimination. The strategy sets the target of reducing global malaria incidence and mortality rates by at least 90% by 2030. Targets for countries in pre-elimination stage are based on the country context. [1: WHO.2015. The Global Technical Strategy for Malaria – 2016-2030. Geneva, Switzerland. WHA68/2015/REC/1]

Essentially, strategy aims at a world free of malaria. In Zanzibar context, malaria surveillance has been transformed into a key intervention as guided by the GTS. Strengthening malaria surveillance is fundamental to programme planning and implementation and is a crucial factor for accelerating progress.

The Zanzibar Vision 2050 The Zanzibar Development Vision 2050 is a long-term national development plan formulated to guide Zanzibar’s overall development agenda. The Vision is shaped by four pillars. The malaria elimination is linked to the second pillar that is related to human capital and social services that is conducive to a healthy, competitive, innovative and productive society.

The Vision 2050 emphasizes on the provision of basic health services for all people without discrimination and priority shall be given to the most vulnerable population groups and directed at preventive services, combating epidemics, maternal and child care services.

The Health Sector Strategic Plan IV for 2020/21 – 2024/25 The HSSP IV is focused on the goal of moving towards achieving Universal Health Coverage malaria inclusive. The Strategic Plan is fundamental to provide guidance on global and national multi-sectoral strategies as well as providing broad direction in emerging and re-emerging health conditions. The HSSP IV uses a balance score card approach, which is a strategic planning and management system that is used to align and communicate prioritized projects, products, and services. The ZAMEP is using health sector plan to align its activities accordingly.

THE MALARIA STRATEGIC PLAN V

Purpose of the Malaria Strategic Plan The primary purpose of the malaria strategic plan is to articulate the programme goal, objectives and targets for the 2024-2029 period. Additionally, it lays out a plan on how the programme aims to attain the goal and objectives of the strategic plan. The MSP is also used as a resource mobilization document as it spells out the what, how and when activities need to be implemented. In this way, resources can be adequately mobilized and planned for accordingly. In addition, the MSP will be used as a tool for accountability as it provides a tracking mechanism through the performance framework.

Process and Steps of Developing the National Malaria Strategic Plan With the 20118-2023 MSP coming to an end, the programme alongside its stakeholders and donors were involved in the Malaria Programme Review (MPR) conducted in September 2022. The review process was diligently guided by the WHO’s 2019 Manual for developing national malaria strategic plans. A task force for the development of the MSP was established to oversee overall implementation. Similarly, the technical working group was instituted comprising of technical officers from the ZAMEP as well as development and implementing partners. Appropriate Terms of Reference were developed for the technical working groups.

The four phases, including planning, thematic desk reviews, validation (field visits, interviews) and programme strengthening were followed accordingly.

Planning: The aim of the planning phase of the MPR was to consult and secure consensus among all partners and stakeholders.

Thematic desk review: It included assembling information from reports and documents. A three-day workshop for the internal reviewer was held and the output of the workshop was a draft MPR report for sharing with the external reviewers and validation during the next phase of the MPR.

Validation: The aim of the validation phase was built upon the thematic review reports through national level consultations and sub-national field visits with the outcome of this process being a finalized MPR report. The external validation consultations were held between the ZAMEP and the WHO country office. A team of 7 senior WHO/RBM external consultants were identified to support the validation exercise. The consultants worked closely with the local consultant and ZAMEP team to form 6 external validation teams visited the selected Government Ministries, District Authorities, health facilities and malaria stakeholders at various levels.

Programme Strengthening: Following this process, the final report was developed and shared to MoH Officials, key stakeholders and partners. The MPR formed a foundation for the development of a new MSP.

Layout of MSP 2024-2029 The MSP 2024-2029 is organized into seven chapters. Subsequent to this introduction, chapter two provides the country profile. Chapter three highlights on the Zanzibar malaria situation analysis. Chapter four runs through a progress made in achieving targets for the 2018-2023 malaria strategic plan. Chapter five provides details of the MSP 2024-2029. Finally, chapter six presents the implementation framework and work-plan and chapter seven outlines the monitoring and evaluation framework.

CHAPTER TWO: COUNTRY PROFILE

OVERVIEW AND ADMINISTRATIVE SET UP

Geography and Climate Zanzibar consists of two main densely populated islands, Unguja (1,666 km2) and Pemba (988 km2), as well as several other smaller islands, some of which are uninhabited. The entire population is closer to two million. The islands are located in the Indian Ocean, about 30 kilometers off the coast of mainland Tanzania between latitudes 5 and 7 degrees south of the Equator.

The climate of Zanzibar is equatorial and humid. The maximum temperature is around 30oC during the hot season, lasting from December to March. The minimum temperature is around 20oC during the cool season, which lasts from June to November. Zanzibar has two main rainy seasons, a long rainy period (Masika) from March to June and a short rainy period (Vuli) that starts in October and ends in December. Precipitation is high, ranging from 900 to 1000 mm during the heavy rains in April and May and 400 to 500 mm during the short rains in November-December. On average, precipitation is slightly higher in Pemba compared to Unguja. Climatic changes especially on rainfall patterns are attributed to the increased number of malaria cases on yearly basis.

Demographic Information The recent national population census was carried out in 2022. Based on the 2022 population census, Zanzibar has a total population of 1,889,773 of whom 915,492 (48.4%) are male and 974,281 (51.6%) female. About 69% of the population lives in Unguja and 31% in Pemba. Zanzibar is subdivided into five administrative regions and eleven districts, of which seven are in Unguja and four in Pemba. Each of the districts is sub-divided into several 388 Shehias which are the smallest administrative areas. A district of Mjini Magharibi is densely populated with 893,169 inhabitants, followed by Kaskazini Pemba with 272091 residents. Kusini Unguja is the lowest with a population of 195,873. The population growth is 3.7%.

Socio-Economic Status Economic indicators depict prevailing poverty in Zanzibar, with 30% people living below the basic need poverty line and over 48% of households experience varying levels of food insecurity. The adult illiteracy rate in 2014/15 was 16.3%. The 2014/15 Integrated Labour Force Survey reports 27% of youth aged 15-24 being unemployed (45.8% in urban areas). In 2015, agriculture contributed 19.2% of the total Gross Domestic Product of Zanzibar, also accounted for the livelihoods of over 30% of Zanzibari. Furthermore, 21% Zanzibar residents are engaged in shops, stalls, street vending and informal economic activities. Another 21% are occupied in crafts and elementary occupations while 7% are fishermen.

Tourism industry plays a major role in domestic revenues in Tanzania mainland and Zanzibar. According to National Bureau of Statistics – Press release of May 2022, the number of tourist arrivals for the period of January – April 2022 has increased significantly. A total of 367,632 tourists visited various tourism attractions compared to 275,097 tourists who entered the country during the similar period in 2021. This is an increase of 92,535 tourists, equivalent to 33.6 percent. Out of 367,632 tourist arrivals, 124,212 tourists entered the country via Zanzibar, which is equivalent to 33.8 percent of total visitors. Zanzibar is becoming an attractive destination for a large number of tourists. Low prevalence of malaria for (almost two decades is one of the possible contributing factors.

HEALTH SYSTEM ANALYSIS AND ORGANIZATION

The Public Sector The Ministry of Health is overall responsible for the strategic direction of the sector. The organization of the public health care system is based on a district model consisting of a network of primary health care units (PHCU) complemented by several secondary (Primary Health Care Centers, and newly constructed District Hospitals) and tertiary referral structures. In theory there are two types of primary health care units: PHCU (basic primary health care services) and PHCU plus (same plus obstetric, laboratory and dental services). The Zanzibar health care system is comprised of 263 health facilities, 178 (68.0%) are public owned. Out of 178 public health facilities, 105(57.9%) are in Unguja island and 75 (42.1%) are in Pemba while the private health facilities, 71 (83.5%) are in Unguja and 14 (16.5%) in Pemba. All these facilities have malaria diagnostic capacity - MRDTs at the PHCU level and microscopy for Primary Health Care Centers (PHCC) and above - and dispense ACTs. According to the most recent Malaria Indicator Survey, almost 95% of the facilities have at least one staff member trained on malaria and IMCI (MIS, 2007).

Zanzibar has an impressive primary health care infrastructure that places almost all (99.1%) households in Unguja and Pemba within five kilometers of a health facility. [footnoteRef:2] The provision of health care services has been further disseminated to primary, secondary, and tertiary levels that allow good access to health care. There are 161 primary health care facilities that are supported by 2 Primary Health Care Centers (Cottage Hospitals), 4 district hospitals, 1 regional hospital and 2 specialized hospitals (psychiatry and maternity). At the apex of the Zanzibar health system, Mnazi Mmoja Hospital supports all districts and regional hospitals as a referral hospital for all Islands of Zanzibar. In Zanzibar, geographical access to public health facilities is good, but the necessary human resources are not always in place to ensure access to treatment for the population. Ensuring the necessary human resource capacity, in terms of both skills and numbers, at all levels of the health care system remains a challenge. [2: Source: 2019/20 Household Budget Survey]

There are various Health Professional Boards and Councils under the MoH which are responsible for the promotion of transparency, professionalism, and accountability within the professions. The Boards and Councils also have a mandate on the provision of technical advice to improve health service delivery at all levels including assuring technical standards of staff and ethics. There is also a Private Hospital Advisory Board that ensures private facilities provide quality health services by qualified and skilled health personnel.

The private sector Zanzibar has a flourishing private health care sector that consists of 154 private hospitals, providing outpatient care, 175 registered pharmacies and 480 over the counter (OTC) outlets selling over-the-counter drugs, excluding malaria treatments. About two-thirds of these private facilities are in and around Zanzibar town. Although the proportion of mothers seeking care through the public sector has been increasing, the private sector remains an important source of minor alignments.

Of recent, Zanzibar has made progress towards achieving the Health Sector Strategic Plan III goals with improvement in many of the health outputs, outcomes and impacts including maintaining lower HIV prevalence (0.4%) and malaria prevalence (1%). Life expectancy has improved from 63.25 years for male and 67 years for females in 2011 to 65.7 years for males and 70.8 years for females in 2021.[footnoteRef:3] Access and uptake of reproductive health services have improved as well. There is a reduction of maternal mortality from 228/100,000 live births in 2011 to 118/100,000 live births in 2021.[footnoteRef:4] Under five mortality has also declined from 75/1,000 live births in 2010 to 56/1,000 live births in 2015/16. Infant mortality has also declined from 54/1,000 live births in 2010 to 45/1,000 live births in 2015/16.[footnoteRef:5] [3: Zanzibar Planning Commission, Evaluation of Zanzibar Vision 2020, September 2020] [4: Ministry of Health, Health Sector Progress Report, 58 years after Zanzibar Revolution, January 2022] [5: Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC), (Tanzania Mainland), Ministry of Health (MoH Zanzibar), National Bureau of Statistics (NBS), Office of the Chief Government Statistician (OCGS) and ICF. 2016. 2015-16 TDHS-MIS.]

THE ZANZIBAR MALARIA ELIMINATION PROGRAMME

The ZAMEP is responsible for the coordination of all malaria activities in Zanzibar. ZAMEP is one among the development programmes under the Directorate of Preventive Services and Health Promotion of the Ministry of Health.

The ZAMEP is relatively well staffed and has various units responsible for the coordination and implementation of different activities related to the objectives of the strategic plan. However, vector management unit requires strengthening of human resource. A data analyst with strong background in epidemiology need to be in place. Overall social behaviour change communication and effective community engagement necessitates for a specific knowledge and skills of which are lacking at programme level. Graphic designer is missing in the entire Ministry to the extent that all art work have to be out-sourced.

The program is financially mainly supported by the RGoZ, GF, USAID/PMI, and is also a beneficiary of technical assistance from various key stakeholders such as the WHO, Swiss TPH among others. Furthermore, national and international research institutions play a major role in providing evidence base data for programmatic decision making.

CHAPTER THREE: MALARIA SITUATION ANALYSIS

HISTORY OF MALARIA CONTROL IN ZANZIBAR

Historically, malaria has been a major public health, social and economic problem in Zanzibar, except for a short period during the malaria eradication program from 1958 to 1968. In the mid-1920’s, an early document on the epidemiology of malaria in Unguja reported a parasite prevalence of 68% among children 1-6 years of age[footnoteRef:6]. In the 1930’s and 1950’s similar parasite prevalence was found in both Unguja and Pemba, [6: Manfield-Aders, 1927]

Before World War II; environmental management, chemical larviciding and quinine distributions to school children were the main malaria control intervention tools in Zanzibar. Larvivorous fish and mosquito nets were also used but with limited success. After World War II spraying activities with DDT and dieldrin were started. In 1961 the malaria control program was upgraded to an eradication program. The eradication program continued the bi-annual cycles of IRS with dieldrin and started mass distribution of amodiaquine and primaquine resulting in community parasite prevalence below 5%. However, the eradication program failed to interrupt transmission, which was blamed on technical, administrative and operational shortcomings[footnoteRef:7]. The eradication program was terminated in 1968, though malaria control activities continued, largely through the support of community volunteers. By the late 1970s, parasite prevalence had again increased to around 40% in Unguja[footnoteRef:8]. In 1982, a blood slide survey of symptom-free school children showed a point prevalence of 36% P. falciparum parasitemia, suggesting that falciparum malaria was highly endemic in Zanzibar. [7: Delfini, 1969] [8: Matola, 1984]

In 1984 Zanzibar, assisted by USAID, launched a five-year project to control malaria to a level where it no longer would be a major public health problem[footnoteRef:9]. The main strategies included DDT spraying and chloroquine administration through dispensaries. Results, however, were poor due to inadequate coverage and operational problems like what was experienced during the eradication period. In the 1990’s funding for malaria control was limited. Nevertheless, in 1993 the new global strategy for malaria control was adopted emphasizing on prompt and effective malaria treatment rather than IRS. This strategy was, however, highly hampered by an increasing resistance to chloroquine around the time. [9: Minjas et al., 1989]

The Zanzibar Malaria Control Program was implemented from 1984-1989 and adopted similar strategies to the WHO elimination attempt of the 1950s focusing heavily on indoor residual spraying (IRS). The ZMCP began spraying in 1984 with two rounds of IRS, which was credited with the drop in prevalence from 54% in 1984 to 35% in 1985. However, the project was terminated in 1989.

The start of the Global Fund to Fight Aids, Tuberculosis and Malaria (GFATM) 2003 and the President’s Malaria Initiative (PMI) in 2006 marked a new era in malaria control for Zanzibar with a consistently well-funded program resulting in the above-described reduction in the malaria burden to date.

MALARIA VECTORS

Vector species In both Pemba and Unguja most species detected by PCR are An. arabiensis. An. gambiae s.s. has been virtually eliminated in the islands while a few samples of An. funestus group were detected in recent years (Figure 1). Sporozoite rate in the last decade was extremely low, but in the recent years, a relative upsurge is observed from 0.1% in 2019 to 1.1% in 2021.

Figure 1: Vector species aggregated by location (upper charts) and disaggregated by year Pemba and Unguja 2010-2021 (bottom charts) Proportion of anopheline species analysed by PCR Zanzibar (left) and Islands (right) 2020- 2021 (see key below)

Annual anopheline species % (PCR) by island; Pemba (left) an Unguja (right) 2010-2021 (see key above)

Source: ZAMEP Database 2023 Entomological surveillance is carried out in 10 sentinel sites of Unguja and Pemba. The emergence of new mosquito species An. stephensi in Africa –considered as an efficient vector of urban malaria, requires a constant watch. To date, surveillance reports indicate non-existence of the An. stephensi in Zanzibar.

Insecticide Resistance Resistance to pyrethroid has been progressively detected since the early 2010s, first in Pemba and then in Unguja islands. Other classes of insecticides so far do not show signs of resistance (figure 2). The high level of pyrethroid resistance is a direct threat to the effectiveness of conventional ITNs.

Figure 2: Resistance profile by type of insecticide

MALARIA PARASITES

Approximately, 87% of the blood films between 2020 and 2022 revealed infections caused by P. falciparum, alone (77%) or mixed with other parasites (10%). Few differences were observed in the same period in Pemba and Unguja islands. Figure 3 below illustrates health facilities findings.

Figure 3: Proportion of parasite species identified in health facilities 2020-2022

MALARIA TRANSMISSION AND ENDEMICITY

Malaria transmission has historically been holoendemic with a trend towards hyperendemicity in the 1990s[footnoteRef:10] and perennial with two peaks associated with seasonal rainfalls in March–June and October–November. Despite these trends from the past few years, malaria transmission remains unstable, correlating with undetermined annual rainfall levels and increased population movement and socio-economic activities. [10: Schwartz E, Pener H, Issa SM, Golenser J. An overview of the malaria situation in Zanzibar. J Community Health. 1997; 22(1):33–44.

Bhattarai A, Ali AS, Kachur SP, et al. Impact of artemisinin-based combination therapy and insecticide-treated nets on malaria burden in Zanzibar. PLoS Med. 2007;4(11):e309.

Smith DL, Hay SI. Endemicity response timelines for Plasmodium falciparum elimination. Mal J. 2009;8:87.]

The highly seasonal and unstable nature of malaria transmission suggests that acquired immunity by at-risk populations is undetermined, and all age groups are thus at risk of developing clinical malaria which may turn into severe if no medical consultation is sought. In 2008 the MoH with the support from the PMI/USAID launched a Malaria Early Epidemic Detection System (MEEDS) based on weekly malaria aggregated reporting and later, in 2012, an individual Malaria Case Notification (MCN) system of all cases diagnosed at health facility level and subsequent follow up of the index cases in the respective households with active case detection of all contacts as part of improved epidemiological surveillance.

Malaria Transmission Risk, Stratification and Mapping Malaria transmission in Zanzibar is heterogeneous with higher malaria risk notified in Unguja island with an annual parasite incidence (API) rate, in the years 2017-2022, ranging from 2.2 (Magharibi B district in 2017) to 18.1 (Kati district in 2020) per 1000 population. The API in Pemba is remarkably lower with a minimum of 0.2 (Mkoani district 2022) to a maximum of 4.5 (Micheweni districts in 2020) per 1000 population. See table below.

Table 1: API per district per year (Source: MEEDS/IDSR)

API per 1000

Kati

Kusini

Mjini

Wete

Micheweni

District count by API level

API per 1000

<1

1-<5

5-<10

10+

Malaria is stratified according to foci, which are classified as residual, cleared and active. Comprehensive case investigation and detection is ongoing to understand the factors that contribute to repeated transmission and to halt it through targeted interventions. The former operational definition of foci was referring to the entire Shehia. In this strategic plan, the definition has changed from the Shehia to the small hamlets. In 2021 the active foci reported local cases were 296 out of 388 (76%).

Figure 4: Malaria foci classification.

The API distribution by shehia is also extremely variable with large majority of shehias reporting less than 5 cases per 1,000 population. The annual variation of endemicity is also remarkable and is summarized in the table and map below.

Table 2: Shehia count by annual level of parasite incidence (per 1000)

Figure 5: API per 1,000 population by shehia in Pemba and Unguja 2021 (source MCN)

Current Malaria Situation In Zanzibar The package of interventions deployed have significantly reduced malaria prevalence rates to very low over a decade; rates went down to below 1% from 2008 to date (2023). As a result of this major achievement, the ZAMEP shifted from malaria control to elimination to the extent that malaria surveillance is the nucleus of the program (ZAMEP Annual Report 2019-2020). The malaria control interventions mainly indoor house spraying and use of insecticidal treated mosquito nets together with prompt and correct treatment through the use of artemisinin combination therapy beginning in 2003/04, have proven to be efficacious malaria control strategies.

According to the ZAMEP comprehensive malaria programme review (MPR) 2022, malaria cases reported in Unguja Island have been fluctuating during the past 10 years between 500 to 1,000 annual cases. It has been noted with great concern that the number of malaria cases reported in Unguja island were constantly on the upswing from around 2,000 cases in 2012 to over 5,000 in both 2019 and 2021. However, in 2020, a malaria epidemic erupted and the cases reached slightly above 12,000. Of great note, young males between 15-29 years were disproportionally the most affected age group. This represents about ¾ of the infections compared to the females of the same age group. Older age groups maintained the same proportion of affected males and females but with a much lower incidence.

Figure 6: Malaria cases per year, by country and islands 2008-2022 (upper charts) and malaria cases per month by country (middle chart) and island (bottom chart)

Case Classification The establishment of malaria case notification (MCN) allowed the programme to perform case classification in order to identify where the transmission occurred. Over the past three years there has been an increase in the proportion of imported malaria cases that almost doubled from around two per every five cases in the 2020 (epidemic year) to almost four per five cases in 2022. The weekly and annual decrease of local transmission is well documented in the charts below.

Figure 7: Case classification by years and week

Malaria Admissions and Deaths Over the last five years the programme’s malaria case management unit has been conducting trainings and refresher trainings for health care providers at all levels of service delivery areas. These trainings are followed by supportive supervisions on a quarterly basis. The table 8 below shows a downward trend of admissions and deaths as reported by ZAMEP database.

Figure 8: Malaria admissions and deaths 2020-2022

CHAPTER FOUR: PROGRESS MADE IN ACHIEVING 2017/18 - 2022/23 TARGETS

OVERALL PROGRESS ON EPIDEMIOLOGICAL INDICATORS AND TARGETS

The Monitoring and Evaluation Unit of ZAMEP is responsible for day-to-day programmatic monitoring of the implemented activities (outputs) and the related specific outcomes and impact. The outgoing MSP set operational indicators that were used to measure the overall impact of the malaria programme. It was noted that the programme did not reach most of the impact targets. Table 3, shows impact indicators assessing the progress towards epidemiological impact of the MSP.

Table 3: Performance of Impact Indicators

0.17

0.14

Source, ZAMEP MRP Report 2020 Note: The program changed the definition of foci from village to Shehia. The target set in the strategic plan 2018/2023 was based on foci being an entire Shehia. Until March 2023, there were 216 active foci out of 388 Shehia of Zanzibar.

Progress in MSP Morbidity and Mortality Impact Targets The number of confirmed…