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WORLD HEALTH ORGANIZATION

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D i s t r . : LIMITED WHOh4ALl98.1084 ORIGINAL: ENGLISH

MALARIA EPIDEMICS DETECTION AND CONTROL FORECASTING AND PREVENTION

J.A. Najera, R.L. Koumetsov and C. Delacollette

World Health Organization Division of Control of Tropical Diseases


T h i s d o w n ! b no1 issued to the general public, and all
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CEdmrment n ' e s tpes de=?lin& B &be distribue au grand public et tous les droits y affhnts sont & e ~ & par I'organisation Mondiale de la San* (OMS). II ne peut &re wrnmente, &sum&,cite, repmduit ou traduit, partiellement ou en totalfib. saw une autolisatim W b b l e bite de I'OMS. Auwne paltie ne doit &tre chargee dans un systbme de recherche documentaireou diffusbe sous quelque forme ou par quelque moyenque ce soit - i?khmigue,inhnique, W autre sans une autorisation prbalable &rite de I'OMS

The view expressed in documents by named authors are solely the responsibility of those authors.

Les opinions exprimees dans les documents par deg auteurs cabs nomm6menln'engagent que lesdils auteurs.

TABLE OF CONTENTS

LLST OF GRAPHS

...................................... v

LIST OF TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii I. GENERAL CHARACTERISTICS OF MALARIA EPIDEMICS 1 1.Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 .1 . Historical background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 l .2 Major determinants of malaria epidemics . . . . . . . . . . . . . . 4 2 . Epidemic Waves and Periodicity . . . . . . . . . . . . . . . . . . . . . . . . 5 2.1. Epidemic waves of different Plasmodium species . . . . . . . 5 2.2. Epidemic periodicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 3 . Classification of Major Epidemic Types . . . . . . . . . . . . . . . . . 1 1 3.1. True epidemics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 3.2. Resurgences or failures of control . . . . . . . . . . . . . . . . . . 20 4 . Classification of Epidemic Risk . . . . . . . . . . . . . . . . . . . . . . . . 22
1 1 . EARLY DETECTION AND CONTROL OF EPIDEMICS . . . 25 5 . Recognition and Epidemiological Investigation . . . . . . . . . . . 25 5.1. Confirmation and initial assessment . . . . . . . . . . . . . . . . . 25 5.2. Epidemiological investigation . . . . . . . . . . . . . . . . . . . . . . 27 6 . Control of Epidemic Situations . . . . . . . . . . . . . . . . . . . . . . . . 28 6.1. General principles of control . . . . . . . . . . . . . . . . . . . . . . 29 6.2. Formulation and implementation of a control plan . . . . . . 30 6.2.1. Relief operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 6.2.2. Mobilization of resources and logistics . . . . . . . . . . . 30 6.2.3.Planning transmission control . . . . . . . . . . . . . . . . . . 31 7. Disease Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 7.1. Diagnostic and treatment facilities . . . . . . . . . . . . . . . . . . 32 7.2. Improving the quality of care . . . . . . . . . . . . . . . . . . . . . . 33 7.3. Public information and communication . . . . . . . . . . . . . . 35 8. Transmission Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 8.1. Emergency control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 8.2. Prevention and control of transmission . . . . . . . . . . . . . . . 38 8.2.1. Indoor residual spraying ...................... 39 8.2.2. Impregnation of bednets . . . . . . . . . . . . . . . . . . . . . . 43

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I11. EPIDEMIOLOGICAL SURVEILLANCE. FORECASTING AND PREVENTION OF EPIDEMICS . . . . . . . . . . . . . . . . . . . . . . . 44 9. Epidemiological Information Systems . . . . . . . . . . . . . . . . . 44 9.1. Identification of indicators of epidemic risk . . . . . . . . . 46 9.2. Field investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 9.3. Geographical information systems . . . . . . . . . . . . . . . . 51 10. Risk Detection and Forecasting ..................... 52 10.1. Monitoring of morbidity and mortality . . . . . . . . . . . . 53 10.2. The spleen rate as an indicator of herd immunity . . . . 55 10.3. Monitoring entomological variables . . . . . . . . . . . . . . 55 10.4. Monitoring meteorological variables . . . . . . . . . . . . . 56 10.5. Monitoring socioeconomic variables . . . . . . . . . . . . . 58 10.6. Comprehensive monitoring of epidemic risk . . . . . . . 61 11. Emergency Preparedness and Epidemic Prevention . . . . . 63 11.1 Preventive measures . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 REFERENCES

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

ANNEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

LIST OF GRAPHS

Graph 1 Separate and combined curves of epidemic . . . . . . . . . . . . 6 Graph 2 Monthly malaria morbidity. Posada. Sardinia. 1930 . . . . . 6 Graph 3 Malaria cases diagnosed in Palestine . . . . . . . . . . . . . . . . . 7 Graph 4 Paraquinquennial periodicity in the northern para-equatorial zone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S Graph 5a Epidemic malaria death rate due to A. Albimanus . . . . . . 9 Graph 5b Epidemic malaria death rate due to A . Darlingi . . . . . . . . 9 Graph 6 Malaria cases reported in Nicaragua and Honduras (1962 . 1990) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Graph 7 Malaria cases reported in Iran (1962 .1990) . . . . . . . . . . 10 Graph 8a Seasonal malaria incidence in relation to temperature and humidity. Qatif Oasis. l946 . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Graph 8b Seasonal malaria incidence in relation to temperature and humidity. Qatif Oasis. 1947 . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Graph 9 Registered malaria morbidity & mortality in Italy . . . . . . 15 Graph 10 Registered malaria cases and deaths in Spain . . . . . . . . . 16 Graph 11 Malaria prevalence rates in Gerzira. children 2-9 years old . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Graph 12 Malaria cases reported in Sri Lanka . . . . . . . . . . . . . . . . 22 Graph 13 Nile river levels at Khartoum . . . . . . . . . . . . . . . . . . . . . 48 Graph 14 Monthly rainful at Khartoum . . . . . . . . . . . . . . . . . . . . . 49 Graph 15 Blue Nile levels at Wad Medani: normal channel (1970- 1990) . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Graph 16 Brazil .malaria cases reported . . . . . . . . . . . . . . . . . . . . 58 Graph 17 Malaria positive cases in the Cereno district (1970-1974) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Graph 18 Malaria incidence in Costa Rica compared with banana production (1980-1992) . . . . . . . . . . . . . . . . . . . . 60 Graph 19 Malaria incidence in El Salvador compared with cotton production (1980 .1990) . . . . . . . . . . . 60
b

LIST OF TABLES

Table 1 . Insecticides used for residual indoor spraying

.........

41

Table A True Epidemics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Table B Resurgences or Failures of Control . . . . . . . . . . . . . . . . . 81

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I. GENERAL CHARACTERISTICS OF MALARIA EPIDEMICS

1. Introduction

Malaria has been one of the major causes of devastating epidemics in the past. They occur periodically following excessive rains and floods in arid areas or periods of drought in fertile river valleys, compounding the misery often brought about by such meteorological calamities. Malaria epidemics have obstructed efforts to colonize jungle areas or to irrigate dry lands and have plagued displaced populations and refugees. They erupt following the devastation of war and spread with the demobilization of armies, thereby hampering the quick reconstruction of rural life. arrival 1, or The etymology of the word epidemic, from the Greek f ~ n t 8 q p i ~ stay in a country (similar to the English visitation),from the verb krr6q~6o-Q, to come or to reside as a foreigner, shows the essential element of this strange phenomenon. The concept of 'epidemic' is itself a relative one. In principle, any sudden increase in disease incidence beyond what is considered normal will constitute an epidemic. As Brks (1986) comments, it would be an error to consider as an epidemic a hitherto unrecognized endemic situation or a mere seasonal increase in the incidence of a disease. It would also be an error to neglect the significance of a single case of a new disease in a country, which might well be the prelude to a further dramatic spread of disease.
An essential prerequisite for the occurrence of an epidemic is the existence of a large enough number of susceptible persons who are likely to become clinically ill when suddenly exposed to infection. There is therefore an inverse relationship between endemicity and epidemicity: malaria epidemics cannot affect the populations of highly endemic areas who develop sufficient immunity early in life.

The actual impact of epidemics depends not only on the increase in specific morbidity, but also on the general health of the affected population. Many malaria epidemics coincide with periods of famine, economic crisis, war or civil disturbances, affecting impoverished or displaced populations that are not only physically weak, but often affected by other diseases and unable to obtain appropriate medication. Malaria epidemics do not always cause dramatic emergencies; instead, they more frequently affect economic development. They may flare up suddenly and subside at the end of one season and not return for several years, or build up over several transmission seasons. The early stages of an epidemic may often pass unnoticed, as malaria is still easily treated and antimalarial drugs are widely available almost everywhere.

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The presentation and spread of malaria epidemics varies considerably. At one extreme, they may arise in an apparently explosive way, affecting areas covering hundreds of thousands of square kilometres at practically the same time and then subside after a year or two. At the other extreme, they may progress slowly from locality to locality, or valley to valley, taking several years to spread and showing little tendency to subside.
1.1. Historical background

From historical accounts, it may be difficult to ascribe to malaria some of the major fever epidemics of the past with certainty, but during this century, there have been specifically diagnosed malaria epidemics, which clearly show the magnitude of the impact that they can produce: the explosive and disastrous epidemic which affected large parts of India in 1908 was officially estimated to have attacked 100 million people and caused about one million deaths; m the aftermath of the First World War and in the midst of civil war, the 1922-1923 epidemic in the Soviet Union caused more than 10 million cases and at least 60 000 deaths; the Ceylon (Sri Lanka) epidemic of 1934-1935 caused nearly 3 million cases and 82 000 deaths; the epidemic in north-eastern Brazil, following the invasion by A. gambiae, caused over 100 000 cases and at least 14 000 deaths in 1938; in 1942, a similar invasion by A. gambiae of Lower Egypt caused some 160 000 cases and more than 12 000 deaths; n Ethiopia caused more than 3 million cases in 1958, an epidemic i and 150 000 deaths; in 1963, in Haiti, hurricane Flora disrupted the ongoing malaria eradication campaign and caused 75 000 cases; the epidemic in Sri Lanka in 1968, which occurred while most of the country was in the consolidationphase of the eradication programme, caused 1.5 million cases during 1968-1970, thus revealing the fragility of this particular phase of the campaign; the epidemic of 1976-1977 in the Indian subcontinent caused more than 7 million cases; that of south-eastem Turkey in 1977-1978 caused some 270 000 cases (Bruce-Chwatt, 1985).

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Malaria epidemics are not a phenomenon of the past. Severe epidemics have recently occurred: in Afghanistan since the beginning of the civil war in 1979; in northern Iraq and southern Turkey, 1993-1995; in Tajikistan, 1993-1994; in Azerbaijan, 1993-1994; in north-western India, particularly Rajasthan, 1995-1996; in southern and east Africa (Zimbabwe, Botswana, Mozambique, Swaziland and South Africa), 1996. Apart from cyclical meteorological phenomena, new factors increasing the risk of severe evidemics include the economic crises and the widestlread civil unrest affecting many countries of the so-called third world. The disastrous epidemic of 1908 in the Punjab gave rise to a sustained programme for the study of malaria epidemiology, with particular emphasis on meteorological and physiographical conditions (Gill, 1928). The postwar epidemics of 1920-1921, which affected many countries of Europe, particularly the USSR, and pushed the limit of malaria transmission beyond the Arctic Circle, spurred governments to support malaria control and to pay special attention to the prevention and control of epidemics. In the Punjab, Gill (1923) was asked to elaborate a system of epidemic forecasting and control, which was progressively developed and adapted to other epidemic-prone areas and which, after the severe epidemic of 1934-1935 in Ceylon, received the full support of the Malaria Commission of the League of Nations (League of Nations, 1938). The search for methods of epidemic forecasting was nevertheless discontinued as during the 1950s and 1960s, it was believed that malaria could be eradicated. As a result, all the efforts of malariologists were focused on the management of mass campaigns of insecticide spraying or drug distribution, the epidemiology of declining malaria, the detection of residual foci and the prevention or elimination of resurgences of transmission. The return to a strategy of malaria control in the 1970s occurred at a time of economic crisis, the unprecedented development of transport facilities and the globalization of the economy. These factors created population pressures and migration for economic reasons, which resulted in new and sometimes disastrous focal outbreaks of malaria. At the same time, the reduction or discontinuation of control efforts in many areas produced resurgences of sometimes dramatic proportions, while the periodic epidemic waves returned to the well-defined epidemic-prone areas. The rise in temperature over recent

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years may have been an important contributory factor in the occurrence of the numerous local epidemics in highland areas in many parts of the world. 1.2 Major determinants of malaria epidemics
An epidemic is the result of the disturbance of a previously existing equilibrium of the ecological system comprising human, parasite and vector populations in a particular environmental niche. Depending on the resilience of the system, and whether or not the disturbance has changed some of its essential components, it will either return to its previous state of equilibrium after the end of the disturbance, or tend to find a new equilibrium, with or without going through a period of oscillation. The epidemiological history of the area and a study of the current situation will indicate the stability of the possible states of equilibrium which may be reached. In this sense it is useful to distinguish epidemics which are the result o f

temporary disturbances of a stable hypoendemic equilibnum, such as those resulting from abnormal meteorological conditions; these epidemics, if left to themselves, will return to the previous hypo- or mesoendemic situation; major changes in the eco-epidemiological system, shifting towards a new equilibrium of higher endemicity, such as those resulting from major environmental changes, e.g., the introduction of irrigation or the colonization of sparsely populated areas. These changes create the conditions for a higher level of endemicity, so that the epidemics are part of the process of finding a new state of equilibrium. In the absence of intervention, therefore, the higher endemicity will be established and maintained. Environmental modifications for purposes of economic development should not cause increased malaria transmission and, if properly designed, should actually contribute to malaria control. If this has not been the case and an epidemic has occurred, control should be aimed at correcting the defects in the design or implementation of the development project, taking into consideration the sustainability of the controlled situation expected. Somewhat similar situations result from the invasion of an area by an exotic and highly efficient vector which finds a permanently suitable environment, as happened with A. gambiae in Brazil and Egypt. In such cases, it may be possible to eliminate the invading vector before it becomes fully established, as happened with the above-mentionedA. gambiae invasions; interruptions of antimalarial measures which have kept malaria under control, but in an unstable equilibrium, in an area with all the epidemiological characteristics of high endemicity. The resulting epidemics are the true resurgences or failures of control, the real

WHO/MAL/98.1084
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disturbance of the epidemiological equilibrium being the introduction of unsustainable control measures. The magnitude and impact of the outbreak will depend on the length of time that the unstable state of controlled transmission was maintained. Left to itself, the original endemic situation will be re-established after one epidemic-type wave or more over a few transmission seasons. Attempts to reintroduce all the previous control measures should be weighed against the risk of repeated unsustainability, as the impact in terms of human suffering and socioeconomic disturbances of repeated epidemic-type resurgences will generally be greater than that of undisturbed endemic malaria. In most cases, it will be preferable to reduce the peak of transmission so as to arrive at the new endemic situation as painlessly as possible and later to adopt a control strategy based on case management and selective vector control.

2. Epidemic Waves and Periodicity


As was stressed above, the concept of an epidemic implies the temporary increase in malaria incidence. In most cases, this is followed by a return to normality. The form of an individual epidemic is primarily determined by the species of parasite, its inoculation rate and the proportion of susceptibles in the human population.
2.1. Epidemic waves of different Plasmodium species

Gametocytes of P. falciparum do not appear in the peripheral blood of an infected case until about 10 days after it is invaded by young trophozoites (ring forms), while in P. vivax, garnetocytes and trophozoites develop simultaneously. In addition, the development in the anopheline vector takes longer for P. falciparum at any given temperature. As a result of these differences, the incubation interval, i.e., the length of time between the occurrence of infective gametocytes in a case and their appearance in an infective form in a secondary case derived from it, is longer in P. falciparum than in P. vivax, resulting in the slower buildup of an epidemic. Macdonald (1957) described the typical epidemic curves for both species, estimating the incubation intervals as 20 days for P. vivax and 35 days for P. falciparum (graph 1). These theoretical curves describe the dynamics of epidemics originating from a very small number of cases in a population of susceptibles with no constraints on dissemination. In fact, most epidemics occur in areas of low endemicity or as a result of the mixing of infected and susceptible individuals and thus originate from a rather larger reservoir in a population not fully susceptible.

Graph 1 Separate and combined curves of epidemic


-P.falciparum --.P.vivax Composite curve

.....----.......-..--f---.--..

-,

-.

I
\

l..-----------------\

/
.....-.--------

10

15

20

25

Weeks
(MacDonald, 1957, by permission af Oxford Universily Press]

P. vivax epidemics occur mainly in areas with seasonal transmission, and represent a magnification of normal seasonal peaks in temperate and subtropical areas. The curve is typically bimodal, with a spring wave before transmission actually starts owing to long-term relapses from the previous year and infections with a long incubation period, and a summer-autumn peak which is in general much more marked (graph 2).
Graph 2 Monthly malaria morbidity,

Posada, Sardinia, 1930

P. falciparum epidemics initially grow in a relatively slow, step-wise manner owing to the delay in the development of gametocytes. In fact, because of the protean clinical picture of falciparum malaria, the early cases may not be recognized in an area of low or no endemicity. Later, owing to the rapid development of the parasite, such an epidemic may appear quite explosive in character. P. malariae epidemics are very rare. They may occur in isolated communities, but are mild and develop slowly. One example of this is the epidemic on the island of Grenada in 1978 (Tikasingh et al., 1980). No isolated epidemics of P. ovule have been reported.
Except in tropical Africa, most epidemics are not caused by a single species, but by the superposition of P. v i v a and P. falcipamm epidemics, together with limited transmission of P. malariae. These mixed epidemics can be separated into a bimodal P. vivax and a single-wave P.falciparum epidemic, which is often delayed with respect to the second P. vivax wave, as the former requires a lower temperature for similar development in the vector (graph 3). The geographical spread of an epidemic may involve several chains of transmission following different paths, so that the consolidated data for a relatively large area may appear to show a single prolonged epidemic, which may actually be a number of overlapping local epidemics in different phases.
Graph 3 Malaria cases diagnosed in Palestine by month (1922 - 1924)

0 Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

2.2. Epidemic periodicity


Epidemics may last only one transmission season and, in fact, most of the dramatic regional epidemics due to abnormal meteorological events have been of this type and represent extraordinary exaggerations of the seasonal periodicity of weak malaria transmission in the dry subtropical belt. The exceptional conditions, e.g., rain, floods, and long warm and humid summers, cause local epidemics to recur more or less regularly in most of the epidemicprone areas. However, their effect on transmission may differ in areas relatively close to one another, depending on the nature of the soil, the proximity of rivers, irrigation and agricultural practices and, of course, the distribution of the population and their herd immunity. Most recurrent epidemics follow cycles of two to seven years, which is the paraquinquennial cycle described by Gabaldon (1946) (graph 4). These cycles reflect a similar periodicity of abnormal meteorological conditions (heavy rains, floods, draughts, etc.) which may determine the increased proliferation and survival of vectors responsible for the high transmission potential and of the human distress which aggravates the impact of the disease. Some areas are affected by epidemics in every paraquinquennial meteorological cycle, while others may only be affected by the more intense abnormalities and follow cycles of periodicities of closer to ten years or more.
Graph 4 Paraquinquennialperiodicity in the northern para-equatorial zone
1400
---..-...--..-..--- - . -

Malaria Death Rates State-of Cwabobo, Venezuela

~ - - - . - . . - - . ~~ ... .--. ~ --

--..-..--.--..

~ - - . . - . . - ~ . - - .. .-~ - .~ - - . - ~ . - -

Years

(Galbadon)

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During the interepidemic years, the vector generally survives in a few residual breeding places, such as waterlogged areas, often constituting isolated endemic localities that are important reservoirs of both vectors and parasites. In relatively flat and densely populated areas, epidemic spread can be very rapid. Examples of such periodicity were the epidemics caused by Anopheles albimanus in the Venezuelan llanos (graph 5a), which were mainly owing to increased densities following abnormal rains and which presented the typical one-peak pattern.
Graph 5a Epidemic malaria death rate due to A. Albimanus
l

Graph 5b Epidemic malaria death rate due to A. Darlingi


1001
1

Meteorological cycles often consist of periods of two or three years of heavy rains followed by two or three of drought. In very sparsely populated areas or in hilly areas forming relatively isolated valleys, the vector reservoir may be limited to distant wet or low-lying areas; the vector may then spread during the two or three years of heavy rains and disappear during the period of drought. The resulting epidemics may follow two- or three-peak patterns, e.g., the epidemics caused by A. darlingi in Venezuela. This highly efficient vector was able to extend its area of distribution in relatively wet years, but did so only gradually since the low population density ( 3 2 h 2 ) did not permit the infestation to reach all of the population in one season, requiring instead two or three years to do so. Then, in years of excessive drought, the vector disappeared from the invaded areas, since it was not able to survive the prolonged dry season (graph 5b). The examples shown so far (graphs 1 to 5) all date from before the launching of the Malaria Eradication Campaign in the late 1950s and early 1960s in most of the countries of Asia and the Americas, since which time malaria morbidity has been greatly influenced by fluctuations in control activities. In these countries, the natural periodicity is o h complicated by the common tendency to intensify or revive control efforts following an epidemic wave, after which

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they are progressively reduced. As a result, by the time a new wave occurs, the control programmes have lost most of their effectiveness. This leads to a return to the paraquinquennial pattern, and even to an increase in its oscillations, as efforts to control transmission may have resulted in an increased proportion of susceptibles (graphs 6 & 7 ) .
Graph 6 Malaria cases reported in Nicaragua and Honduras (1962- 1990)
60

Thousands

/
i

+ Nlcaraoua

Honduras

Graph 7 Malaria cases reported in Iran (1962- 1990)


Thousands

Page I I

3. Classification of Major Epidemic Types


Epidemics differ not only in their causality but also in their form of presentation, evolution, incidence by age groups, severity and socioeconomic impact. These characteristics can usually be determined by a study of a given epidemic, since they often fall into certain patterns depending on the main determining factors involved, as well as on the ecology of the area affected, the time of occurrence and the socioeconomic development of the populations concerned, including the degree of development and peripheral coverage of the health services. It is therefore both possible and desirable to establish and develop a typology of malaria epidemics which will assist in controlling them and in designing forecasting systems. The many variables which constitute the causal complex of an epidemic are not fully independent, in that they generally combine a number of patterns which, if recognized, may be useful in forecasting their potential evolution and impact, and therefore in guiding their control.
A preliminary classification of the various types of malaria epidemics may be based on the initial presentation and early evolution as well as on the existence of some obvious ecological or social determinants. While not pretending to be comprehensive or definitive, the following classification may be of assistance to malariologists in their field investigations (see also Annex, Tables A and B . Perhavs the most obvious distinction to be made is that between 'true epidemics' and 'resurgences', or failures of control.

3.1. True epidemics


This broad category groups together those epidemics which are the result of some disturbance of the epidemiological equilibrium, as opposed to the direct effect of interruptions or failures of control. True epidemics can be classified according to whether they are the result of a 'natural' or of a 'man-made' ecological disturbance. Nevertheless, epidemics are often due to a complexity of causes which may include both natural and man-made disturbances. The following classification, based on the form of presentation of epidemics, has therefore been chosen and it is hoped it will be more useful for the purposes of characterizing a developing epidemic. I.

Sudden or explosive malaria epidemics in areas with a high proportion of non-imrnunes in the population. This type of epidemic is generally the result of the rapid build up of an abnormally high vectorial capacity in areas where transmission has been very limited for long periods of time owing to unsuitable ecological conditions, e.g., arid or semi-arid areas highly unfavourable to vector breeding and where vector longevity is
-

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insufficient, or highland areas where parasites cannot complete their sporogonic development because of the low temperature. When caused by P.falciparurn,as is frequently the case in the tropics, these epidemics result in high mortality and great suffering, and are complicated by the fact that the disturbances producing the epidemic (e.g., floods or droughts) . often make populations more vulnerable and reduce their capacity to control its effects. The epidemics may be triggered off either by exceptional meteorological conditions or by massive destruction as a consequence of war or natural disasters followed by large-scale population movements, as discussed below. a) Exceptional meteorological conditions which, as shown by the historical record, occur repeatedly with a periodicity of approximately five or 10 years. These may take the form of: i) abnormally heavy rains (early, persistent and abundant), in arid areas, such as north-west India, Pakistan or Sudan, producing the classic regional epidemics, particularly when they follow an abnormally dry year and affect an impoverished population (Mathur et al., 1992); ii) extensive floods of large rivers crossing dry plains, such as the Nile in north-central Sudan or the Niger, Senegal, Indus, Euphrates, etc.; these floods, mainly caused by heavy rains upstream, may or may not be accompanied by heavy local rains; iii) the abnormal extension of waterlogged areas in lowland plains, associated with extensive irrigation systems and occurring in conjunction with types i) or ii) in neighbouring areas; iv) unusually long warm and humid summers in high-altitude valleys, such as the East Afncan or sub-Andean highland valleys, ofien preceded by an extension of the area occupied by efficient vectors, brought about by events such as the extension of agricultural activities or the building of fish ponds (Marimbu et al., 1993); v) abnormally prolonged dry seasons in relatively humid valleys leading to the pooling of river courses, as found in the central south-west 'intermediate' area (between the dry and wet zones) of Sri Lanka, when the south-west monsoon fails (Sivaguanasundram, 1973; Wijesundera, 1988); vi) prolonged periods of warm and relatively humid conditions in desert areas such as the Arabian peninsula. These give rise to epidemics of 'oasis fever', caused by A. sergenti and A. stephensi, which in the past have wiped out colonies of

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settlers, while at the same time maintaining a relatively stable mesoendemicity among the local populations. The vectors breed in the springs which have produced the oases, causing seasonal epidemics with periodic exacerbations. These are particularly severe among newcomers to the area, as seen in the epidemics among Aramco personnel in 1946 and 1947 (graphs 8a & 8b). These epidemics did not depend directly on rainfall, which seldom surpassed 100 mm in 5-6 rainy days per year. It was the prolongation of the normally very short periods in spring when the combination of increasing temperature and decreasing relative humidity, and in autumn, when the combination of decreasing temperature and increasing relative humidity, permitted sufficient survival for sporogonic development (Daggy, 1959). All these epidemics occur with quasi-regular cycles and should therefore be both predictable within a reasonable degree of precision and preventable, if the health services are adequately prepared. As the epidemics are generally of short duration, if vector control cannot be instituted immediately, preference should be given to case management and to improving the information system for forecasting so that future epidemics can be prevented with timely vector control.
b) Massive destruction followed by the displacement of large numbers of people, either as a consequence of war or natural disasters, such as earthquakes, hurricanes or cyclones, and particularly the latter, which are often followed by heavy rains. Epidemics are the result not only of the increase in vector-breeding places but also, and to an even greater extent, of increased man-vector contact in precarious shelters in partially destroyed homes or temporary camps, and of the disruption of the capacity of both governments and populations to implement control activities. Depending on the degree of destruction and population displacement, the acute epidemic after the disaster may be followed by a sequence of epidemic peaks, often even more serious and lasting for several transmission seasons, which are associated with the process of resettlement and reconstruction.

Graph 8a Seasonal malaria incidence in relation to temperature and humidity, Qatif Oasis, 1946

" ,
Temperature 0 9 0 0 Relative Humidi

Graph 8b Seasonal malaria incidence in relation to temperature and humidity, Qatif Oasis, 1947

Temperature

(Daggy, The American Journal for Tropical Medicine and Hygiene, 1959)

Graph 9 Registered malaria morbidity & mortality in Italy

150,000 100,000

I5

Years [ I Q O l d O )

25

35

45

The magnitude of the destruction and the stability of the previous situation may be such as to: i) produce a major epidemic which subsides after reconstruction, e.g., the epidemics which followed the Second World War in Italy (Benn, 1947; A.C.I.S., 1950; Coluzzi, 1961) (graph 9) and the Spanish civil war (Rico-Avello & Rico, 1950) (graph 10). In both these epidemics, the recorded morbidity reached levels comparable to those attained in 1918 and both subsided quite rapidly, the first with the help of a DDT spraying campaign, but the second without. The most important difference was that, while the Spanish epidemic resulted in high mortality, the Italian one did not, most probably owing to the more rapid and complete mobilization of diagnostic and treatment facilities in Italy; ii) trigger the failure of existing control programmes, compounding the epidemic with a resurgence of the previous endemicity, as was the case with the epidemic which followed hurricane Flora in Haiti in 1962 (Masson & CavaliC, 1965) or cyclone Namu in the Solomon Islands in 1986 (Madeley, 1988); iii) result in socioeconomic upheaval such that there is a tendency towards the establishment of a new epidemiological equilibrium, as happened in northern Iraq following the Gulf War and the subsequent economic embargo. Malaria epidemics occurred as a result of the destruction caused by the war, but the resettlement of previously displaced populations and the rapid intensification of agriculture with temporary concentrations of migrant workers, created new risk situations which resulted in progressively spreading epidemics from 1990 to 1994.

iv) cause mass population displacement and the establishment of refugee camps, which often receive population groups with very different malaria experiences and therefore immune status. These camps differ from labour camps in the dramatic experience of the population's exodus and the frequently high degree of exhaustion and the poor nutrition and health status attendant on the refugees' arrival.
Graph 10 Registered malaria cases and deaths in Spain
"O 700

l\
4

1 +Registered

cases

DeaUls

15

25 Years (1901-48)

35

45

These epidemics, though generally not cyclical in character, are predictable following the occurrence of a disaster. Malaria is only one of the many problems to which the populations affected are exposed. Normally, relief operations will be concerned primarily with meeting the most acute needs for shelter, food and water, followed by measles vaccination and the organization of care for diarrhoea, acute respiratory infections and malaria. Malaria-control measures should include emergency case management and vector control, where possible, of refugee camps and villages in the process of reconstruction. The relief operations, which are part of the health care of displaced populations, are often dependent on external support, including international collaboration, which is more likely to be available for the risks associated with the acute phase of the problem. The resulting equilibrium will depend on the extent of the damage and the more or less rapid reconstruction of villages and health and social services.
1 1 .

Progressive invasion by a succession of severe local epidemics of an area previously considered to be of low endemicity, because of the low vectorial capacity of local vectors. The epidemiological pattern is that

of a succession of more or less severe epidemics in different neighbouring areas, which often take one season or more to spread from one to another. These epidemics, each of which may be quite dramatic and lethal, often occur without any apparent catastrophic triggering event. They are often seen when: a) an exotic, or previously eliminated, highly efficient vector invades an area providing a very suitable habitat, as was the case with the A. gambiae invasion of north-eastem Brazil in the 1930s (Soper & Wilson, 1943) and of Upper Egypt in the 1940s (Shousha, 1948); b) a dangerous vector periodically extends its range beyond its normal area of distnbution when temporarily suitable conditions occur in neighbouring areas, as happened with A. darlingi in the Venezuelan llanos during the two- or three-peaked epidemics previously mentioned; c) an area is reinvaded by a previously eliminated vector, as was the case in the Madagascar highlands (1986-1990) with A. funestus (Lepers et al., 1990a & b, 1991; Razanamparany, 1989); d) chloroquine resistance occurs in epidemic form (Bastien, 1990), particularly when the wide accessibility of chloroquine has previously kept the disease under control to a certain extent. The spread of chloroquine resistance in tropical Africa can also be considered as an epidemic, even if the incidence of malaria infection does not change (Warsame et al., 1995). Although basically unpredictable, the progress of such epidemics is partially predictable and they can be contained or slowed down by selective vector control once detected. The eradication of the invader may be contemplated, although it should be noted that, while an exotic vector may be eradicated, leaving a fairly stable equilibrium, the elimination of a local vector fi-om an area will be much more difficult and, in most cases, somewhat unstable, as the area will remain vulnerable to reinvasion from neighbouring localities In highly malarious areas, a similar epidemiological pattern has accompanied public works such as railway and road construction or large irrigation projects in the tropics. Even with modem control measures and the wealth of resources available to such projects, malaria continues to threaten them to this day. These epidemics affect not only the project workers, but also the local populations, as a result of the disturbed environment left behind, and the people attracted to create new

settlements. These epidemics are basically predictable and can easily be identified since they follow the path of the particular project concerned. Prevention will depend on the adoption of appropriate engineering practices and the design of new settlements in such a way as to prevent man-made malaria, as well as on vector control in affected localities. Unfortunately, even in well-designed projects which do not produce epidemics in the construction phase, the new economic opportunities created will attract large numbers of people who may, at least for some time, create unplanned settlements. Even later, when the rural economy is better organized, productive farms will attract temporary labourers, often in seasonal waves. Since these workers are often in an illegal situation, they are difficult to contact and protect.
1 1 1 . Focal serious epidemics in areas of increasing stability accompanying

a period of settlement in, and adaptation of non-irnrnunes to, a high-risk area. They may be preceded by a more or less apparent string of focal epidemics affecting the early stages of development projects. These include: a) the colonization of tropical jungle areas by populations which, although originally susceptible, manage to survive and establish successful agricultural settlements, as in many areas of Brazilian Amazonia (Cruz Marques, 1987) or in the outer islands of Indonesia (Binol, 1983). It has been reported that, in both areas, the original malaria epidemics, which were one of the main early obstacles to the success of the colonies, were progressively declining in intensity in surviving settlements, eventually leading to an endemic situation. In contrast, the slow invasion of jungle areas or tropical highlands by people from highly endemic areas results in extensions of the endemic areas without obvious epidemics (Matola et al., 1987); b) the explosive growth of tropical urban areas, where the continuous influx of newcomers creates periurban epidemic foci which may evolve to become highly endemic if large, permanent breeding places are present, or lead to very low endemicity or even non-endemicity, as the result either of urbanization and the elimination of breeding or of the development of more or less permanent slums with high organic contamination of surface waters. Control measures during the epidemic period should take into account possible changes in the situation and the need for adaptation so as to provide a feasible control strategy for the subsequent endemic situation; c) the establishment of highly efficient forest vectors in neighbouring tree plantations, such as occurs in Myanmar (Tun-Lin et al, 1987)

Page 19

where, if feasible and sustainable, local eradication may be considered; if this is not possible, the aim should be the control of the endemicity established. These epidemic areas are also predictable, although very difficult to control in the acute period of the epidemic as even when given official backing and included in vector-control programmes, such resettlement projects have serious local organizational problems. The most effective method of control would be to improve case management and selective vector control, while adapting to the development of the endemic situation. Such situations should be prevented by discouraging unplanned settlements and providing adequate logistical support for authorized settlements, not only to control malaria but to reduce the deleterious ecological impact as well (Sawyer, 1993; Najera, 1993). IV. Creation of foci of high apparent endemicity: a) in gold or gem mining areas in South American or south-east Asian forests, where a continuous flow of mainly temporary migrant groups engaged in open-cast mining for gold or gems is exposed to very high malaria transmission. These are the hotbeds of parasite drug resistance, with the highest malaria incidence outside tropical Africa, although the situation is not one of high endemicity and herd immunity is quite low. It has been described as a pattern of localized permanent epidemics (Verdrager, 1995), since each successive wave of non-immune migrants suffers in turn from epidemic malaria. Diagnostic and treatment facilities in these areas are generally privately operated and often expensive, but the abundance of cash means that all drugs are locally available and often overused. These situations are known, rather than predictable, at the public health level. Control should include information and education, although the marginalized position - often not only social but legal as well - of the miners frequently makes this option, as well as organized vector control, difficult to implement. Malaria clinics or treatment posts at the points of entry into these areas have been used to provide some form of relief; b) in the classic tropical aggregation of labour described in colonial times (Christophers & Bentley, 1908) and still persisting in many large labour-intensive agricultural undertakings in the tropics. A stream of temporary workers, often illegal immigrants, are employed and generally dismissed before they can acquire labour rights. The epidemiological problem is often similar to, and as difficult as, that of the miners previously mentioned, but without the intense drug

WHOLkiAU98.1084 Page 20

pressure because of the lack of cash necessary to pay for medical care or drugs.
3.2. Resurgences or failures of control

A malaria resurgence is actually the return to a state of equilibrium which has been disturbed by the efforts to interrupt transmission. Perhaps the most important characteristic of these outbreaks is the fact that they represent a serious indication of the unsustainability of previous malaria-control policies aimed at the interruption of transmission. Health authorities should therefore consider the need to change to a more conservative control policy which will not recreate similar situations of unstable equilibrium. These situations include:

I.

The explosive resumption of transmission, producing an epidemic situation with an incidence much greater than that previously seen in the endemic situation. This type includes: a) the total loss of the protective effect of control interventions, as observed in the early 1970s following the interruption of two programmes based on mass drug administration (MDA) in a) Central America, where the programme had been instituted following the recognition of multiple resistance to insecticides; and b) in Haiti, where the programme had been instituted following the resurgence after hurricane Flora in 1962. These situations were highly predictable, and could have been better controlled. However, they are now mainly of historical interest, as MDA is no longer normally recommended as a measure for large-scale malaria control. b) the explosive epidemic return to endemicity that may occur in semi-arid areas, traditionally suffering from mesoendemicity with periodical epidemic exacerbations, which have been protected for a number of years by vector control that successfully eliminated transmission for several epidemic cycles. The interruption of vector control, or its gradual loss of effectiveness, will leave the largely non-immune population unprotected for the next epidemic cycle, which will develop into a full-blown epidemic. Such a situation occurred recently in the Gezira Blue Nile Health Project in the Sudan (graph ll), where malaria transmission was more or less completely interrupted for more than 10 years by a control programme dependent on external support. Such a highly predictable situation should be dealt with in the same way as a temporary epidemic by reducing, if possible, the peak of transmission and developing the capacity for case management, and not by the re-establishment of the

full vector-control programme, which will most probably be as unsustainable as in the past.
Graph 11 Malaria prevalence rates in Gerzira, children 2-9 years old

"

II. The progressive return of endemicity in highly endemic areas where


control interventions which reduced or interrupted malaria transmission could not sustain their success. Depending on whether transmission was actually interrupted and on the duration of effective protection, the return to endemicity may result in more or less severe disease manifestations and affect a larger or smaller number of age groups, but in most cases the incidence will increase slowly, often from dispersed foci. This pattern may result from: a) the loss of effectiveness of the insecticides used for indoor residual spraying because of the development of resistance; b) the deterioration in the quality of the spraying operations; or c) the complete interruption of spraying. Even the sudden interruption of an effective spraying programme, on the completion of some successful pilot projects in highly endemic areas of Africa, did not result in dramatic epidemics, because the insecticide deposits retained their effects, either killing or repellent, on some surfaces for quite long and variable periods. This slow decline of insecticidal effect had been studied since the early applications of DDT (Raffaele & Coluzzi, 1953). Another classic example is that of the famous and massive epidemic in Sri Lanka in 1968, which can be traced to a slow buildup, including local epidemics, since 1964, when it was considered that malaria had practically been eradicated in 1962-1963 (graph 12).

WHOMAU98.I 084 Page 22


Graph 12 Malaria cases reported in Sri Lanka
800
I
Tburands

In contrast to the previous type, in the areas of high potential endemicity, transmission is built up as soon, and to the same extent as, the insecticide effect is lost, while in the former the insecticide effect is probably completely lost before the epidemic risk develops, as in Sri Lanka (Pinikahana & Dixon, 1993), India (Sharma & Mehrotra, 1986) and Sao Tome and Principe (Baptists, 1996). These epidemics, which are clearly predictable, should be dealt with by improving case management, while at the same time changing the control strategy to that of managing the ensuing endemic situation.
4. Classification of Epidemic Risk

The formulation of an epidemic forecasting system will require the identification of epidemic-prone areas, based not only in the study of recent or historical epidemics, but also on the recognition of potential epidemic risk factors. For an epidemic to occur, it is necessary that a population with a high proportion of non- immunes be suddenly subjected to intense malaria transmission. Epidemic risk factors may be classified as they relate to these main determinants:
a) The sudden increase in the number of exposed non-immunes, owing to:

i) the arrival en bloc of a non-immune population into a malarious area, the classic examples of which are the deadly outbreaks affecting new settlements in tropical areas, from the European invaders of Africa to the modem colonizers of the Amazonia or the

WHOMAW98.1084 Page 23

Outer Islands of Indonesia, or the prospectors and miners in the jungles of South America or south-east Asia; similar examples are the epidemics suffered by armies operating in malarious areas, police and army camps in jungle areas, and non-immune refugees (e.g., from the Ethiopian or Rwandese highlands) in endemic areas; ii) the introduction of a number of infected individuals into a malaria-free area, where both the Anopheles vector and the conditions of transmission are present, i.e., a receptive area; examples of this type are the re-establishment of malaria in areas from which it had been eradicated and the small focal epidemics resulting from the return of war veterans or infected tourists to the USA or Europe. Historical examples include the introduction of P.falciparum into the Americas which contributed to the epidemic hecatomb of the Amerindian population (Naranjo, 1992), the introduction of malaria into Mauritius, Reunion and Rodrigues (Julvez et al., 1990), and more recently, into isolated populations in Papua New Guinea (Jenkins, 1988); iii) the admixture of large numbers of immunes and non-immunes living under primitive conditions, described as 'tropical aggregation of labour', which still occurs in many temporary labour camps in agricultural exploitations and economic development projects in tropical and subtropical areas, such as the recent epidemic outbreaks associated with the expansion of banana and African palm plantations in some areas of the Atlantic coast of Central ~ m e r i c a (PAHOIWHO, 1993,1994);
b)

The sudden increase in vectorial capacity: i) the sudden increase in Anopheles densities, owing to abnormal rains, andlor their survival, caused by prolonged periods of abnormal warm weather, in hypo- or mesoendemic areas, where transmission is normally absent because of adverse meteorological conditions. In most cases, such epidemics occur with certain periodicity and may affect very large areas quasi-simultaneously, constituting the classic 'regional epidemics' of north-west India and Pakistan, as described by Christophers (Gill, 1928). Development of rural housing, changes in agricultural practices in many areas and continued control activities since the late 1950s in others have prevented the spread of regional epidemics to the extent of the great pandemics of the past, but serious epidemics continue to occur, with their quasi-cyclical pattern in many of the known epidemic-prone areas of the Indian subcontinent, Sri Lanka, the East African highlands and South America;

ii) the invasion of areas of low endemicity by a very efficient vector, owing to the poor vectorial ability of the local anopheline fauna; the classic example is the invasion by A. gamhiae of north-east Brazil in the 1930s and Upper Egypt in the 1940s.
c) Environmental modifications, which may create both increased vector densities and population movements:

i) the modification of the environment for agricultural development, creating conditions more favourable for malaria transmission, e.g., irrigation works in arid areas resulting in increased anopheline density, or tree plantations providing micro-climatic conditions favourable for anopheline survival; in the above examples, there is often a simultaneous increase in population and the demand for temporary labour force, so that the epidemics are the result of a complexity of causes; ii) the rapid unplanned growth of cities in tropical areas, in some way similar to the labour camp situations, as they are formed by the admixture of infected and susceptible people, but which are often spread over a wider area and which, as the population density grows, are progressively urbanized or transformed into slums, where the pollution of surface water prevents the development of anophelines, which are eventually replaced by culicines.
d) Failure to maintain previously effective control. After the general introduction in the 1950s of national malaria control programmes based on vector control and the widespread use of antimalarial drugs, particularly chloroquine, two new forms of malaria epidemic outbreaks are occurring throughout the world:

i) the resurgence of malaria transmission in epidemic form following the discontinuation, weakening or loss of effect of vector-control programmes; they have been described as post-eradication epidemics (WHO, 1974), and classic examples are the massive epidemics of Sri Lanka in 1968, and of India and Pakistan in 1976-1977; ii) the progressive spread of chloroquine resistance, particularly in Africa, over the last two decades, which in some situations has acquired epidemic proporhons (Warsame et al., 1995); conversely, an epidemic often provides a major vehicle for the spread of drug resistant strains (Sharma et al., 1996).

Page 25

11. EARLY DETECTION AND CONTROL OF EPIDEMICS


5. Recognition and Epidemiological Investigation

Malaria epidemics seldom pose problems of recognition at the local level in epidemic-prone areas, where they are often recognized by laymen. Nevertheless, in areas which are considered free from transmission, it is common for individual malaria cases to be misdiagnosed and for even the initial stages of an epidemic not to be recognized as being due to malaria. Similarly, a fever outbreak not responding to common antimalarials may not be recognized, even for more than one transmission season, as exemplified by the epidemic spread of chloroquine-resistant P. falciparum when, in some areas, malaria was misdiagnosed as typhoid fever since cases responded to antibiotic treatment (Onuigbo, 1990). More often, epidemics occurring in rural areas poorly served by health care or epidemiological services are locally attributed to malaria but the health authorities often only learn about them from newspaper reports or from questions in Parliament. Any outbreak of febrile disease in a potentially malarious area is generally attributed to malaria until proven otherwise. In any case, every fever outbreak requires an epidemiological investigation, and malaria should be suspected whenever the ecological or meteorological conditions are such that malaria transmission is possible. Particular attention should be paid to any clustering or increase in fever cases in areas with a history of malaria epidemics or where malaria has been under control for some time.
5.1. Confirmation and initial assessment

Whatever the original sources of information (reports from local antimalarial or general health services, other official sources, newspapers, etc.), the first action to be taken by the epidemiological service is to check the validity of that information by contacting the local sources of the information as well as the local health services by the fastest available means of communication. It will be necessary to decide to what extent these communications should be kept confidential in order to avoid unjustified public alarm, while at the same time ensuring their maximum speed and accuracy. If the existence of an abnormal situation is confirmed, a number of activities should be undertaken simultaneously, as follows:

I.

A preliminary analysis of the local situation, which in most cases will require a visit by central and/or provincial professional and technical staff for the clinical and laboratory diagnosis of the suspected cases.

Page 26

Even in recent times, some local epidemics of brucellosis, relapsing fever or visceral leishmaniasis (de Beer et al, 1991) were originally thought to be malaria. The analysis should concentrate on: a) the quantification of the problem, i.e., the daily or weekly incidence, the development to date and the initial trend; b) the identification of the disease or diseases involved (in the case of malaria, the species of parasite involved and their frequency), the severity, age and sex distribution, the geographical distribution, clustering or dispersal of cases and the possible existence of certain social characteristics (occupation, place of employment, etc.); c) an assessment of the socioeconomic complicating concomitant processes, such as crop failure, famine or displaced populations; d) an assessment of the local resources available to cope with the problem, including: i) the coverage by the health services and other diagnostic and treatment facilities (e.g., voluntary collaborators, community health workers, local health committees) and their use by the population; ii) the manpower and drugs available; often one early indicator of an epidemic is the rapid exhaustion of drug supplies in some peripheral areas; e) the logistics of case referral; f ) community and private sector participation; g) intersectoral collaboration; if the epidemic is not caused by malaria, it will be necessary to assess what collaborative action may need to be taken by the antimalarial programme; h) the need for support and for strengthening intra- and inter-sectoral collaboration; i) the identification, if possible, of the potential determinant factors (floods, heavy rains, drought with river pooling, population movements, etc.), which may have preceded the epidemic; i) the formulation, if possible, of some hypothesis as to the origin of the -. outbreak.

I I .

The geographical delimitation of the problem by means of a telephone survey andor site visit to neighbouring areas or areas with similar ecology or which may have been subject to similar risk factors to determine possible increases or clusterings of fever cases, deaths, school absenteeisms, drug-stock ruptures, etc., supplemented when necessary by:
a) a malariometric survey including, if the human and material (laboratory) resources permit, a fever survey and spleen andtor

parasite surveys of the general population and any population group already suspected to be at high risk. If resources are available, it may be useful to use a rapid dipstick irnmunodiagnostic test in remote areas when it is necessary to obtain a rapid confirmation of a P. falciparum outbreak (Verle et al., 1996). It should be noted that these tests are quite expensive (c. US$1.60/test), are currently only specific for P.falciparum and are not quantitative; b) a review of general geographical information on ecologically similar areas potentially at risk, to assess the presence of risk factors, and complemented if necessary by rapid geographical reconnaissance; c) the strengthening and local adaptation of existing emergency preparedness plans and the establishment of a system of watching for the occurrence of identified or potential risk factors.
1 1 1 . The identification and mobilization of the necessary support from the

health services, the civil authorities, potential sources of intersectoral collaboration, NGOs and affected or neighbouring communities, particularly to cover the expected requirements for drugs, laboratory supplies and manpower for the affected area and areas at risk.
IV. The mobilization of the necessary logistical resources for any support which may be necessary or the alerting of those responsible for them.
5.2. Epidemiological investigation

The preliminary situation analysis should provide sufficient information to identify the affected areas and the areas at risk of further spread, as well as whether that risk is imminent or likely to occur in the next transmission season. The importance of an epidemic depends not only on the magnitude it has attained but also, and perhaps even more so, on its potential development and spread. In turn, these are dependent on a number of factors, such as the distribution and density of the population, the proportion of susceptibles, the intensity of transmission, the communication facilities, the degree of development of the health services, their coverage and capacity of response, and their use by the population. In any case, it will be necessary to plan an appropriate epidemiological investigation, namely:
I.

Epidemiological analysis of all information pertaining to the affected and neighbouring areas, including: a) the general and malaria-specific morbidity and mortality data from all sources, and in particular, any information on past epidemics and

confirmation of the validity of past diagnoses, if possible; data on drug use and drug susceptibility; demographic and socioeconomic information, particularly with regard to agricultural or other economic development plans, and their state of implementation; d) any previous information on potential risk factors and on the existence of an emergency preparedness plan.
1 1 .

Strengthened epidemiological surveillance and laboratory services


to all these areas through every existing source of information

(dispensaries, health centres, hospitals), which should be alerted to report any alarming situation by the fastest possible means.
1 1 1 . Periodic malariometric surveys, as needed, to supplement surveillance

information; depending on human and material (laboratory) resources, these can include fever surveys and spleen andfor parasite surveys both of the general population and any population group suspected to be at high risk.
W . Entomological studies aimed particularly at identifying vector components of the increased epidemic risk, such as increased density, longevity or man-vector contact; this should be followed by the longitudinal monitoring of:

a) vector distribution, main breeding places and any changes which may occur; b) density, parity, man-vector contact and, when feasible, sporozoite rates; c) susceptibility to insecticides.
6. Control of Epidemic Situations

The main objectives of control should be to: provide adequate relief to the affected population; contain transmission, if possible, in the affected areas; prevent further spread of the epidemic; improve emergency preparedness in order to prevent future epidemics. The first two objectives require the application, as soon as possible, of effective control interventions, while the last two involve the assessment of risk and the application of preventive measures, as discussed in section 10.

Page 29

6.1. Generalprinciples of control It is important to stress that epidemics may differ, not only in their dynamics, but also in the way that they end and in the desirability of investing a major effort in their control. As mentioned in section 1.2, an epidemic is the result of a disturbance in a previously existing ecological system which normally has sufficient resilience to return to its original state once the disturbance has ended. It is clear that there is considerable variation in the degree of stability of different epidemiological equilibria and, similarly, in the degree of sustainability of the results of control efforts. It should be noted that the stable situation is sometimes that of the absence of malaria transmission, and in others that of more or less high endemicity
An etymological metaphor may illustrate these ideas. As explained in the Introduction, the etymology of the word epidemic provides adequate guidance on how to proceed in epidemic control and prevention. When coping with an unwelcome newcomer, the first thing to do is to find out whether he might leave on his own. It must then be decided whether it is worth while trying to accelerate his departure, if feasible. If he intends to stay, it will be necessary to determine whether it will be possible to expel him and, if not, how best to tolerate his presence and reduce the impact of his most objectionable activities.

The first step in dealing with an epidemic is therefore to decide whether it is: an abnormal disturbance of a stable non-malarious equilibrium which will eventually come to an end by itself; in these situations it is important to be prepared for a potential second wave the following transmission season; a return to a more stable endemic situation after the intemption of unsustainable control, in which case the problem to be considered is how to adapt to the new endemicity and implement a control strategy similar to that adopted in other endemic areas; the result of a new ecological disturbance which will not disappear spontaneously, in which case the possibility of some form of environmental sanitation or a control strategy for endemic malaria should be considered. Similarly, the choice and timing of control activities should be based on these decisions. In contrast, most epidemic-control activities in the past have been motivated by the emotional demand for action and, consequently, heroic and often unnecessary measures have been taken. In reality, as most epidemics are self-limiting, practically all anti-epidemic actions have eventually been able to claim success, whether the control activities consisted of swamp drainage, the prohibition of rice cultivation or prayer (Villalba, 1802).

WH0/1MAU98.1084 Page 30

It has unfortunately been a common response to malaria epidemics to mobilize all available resources for implementing standard control measures, such as insecticide spraying or mass drug administration. Often the time required for such mobilization is so long that the epidemic is already over before vector control can be implemented. Moreover, owing to the operational attrition of organized standard control measures, they gradually lose their effectiveness before conditions favourable to a new epidemic return (see graphs 6 & 7).
6.2. Formulation and implementation of a control plan

The priority is to ensure appropriate case management in the affected areas. It is almost as vital to decide whether it is feasible to plan for the implementation of any form of vector control, since its organization may require time and effort and should be started soon if it is going to be implemented in time to be of any use. Such a decision will be based not only on an assessment of its potential effectiveness and the expected duration of the remaining transmission season, but also on the existing or accessible human and material resources in the area and the country. Control operations should therefore include the components described below.
6.2.1. Relief operations

The preliminary situation analysis should have identified the most essential needs of the population, which may differ from those suggested by the original information and may include basic needs, such as famine relief, which should be given the same urgent attention as the supply of antimalarial drugs. When a malaria epidemic occurs after some physical or socioeconomic emergency which has led to destruction, famine andor displaced populations, relief operations may have already been organized to meet the most basic requirements for water, food, shelter and care for those suffering from diseases such as respiratory infections and diarrhoea, or to implement basic preventive measures, such as measles vaccination. The provision of antimalarial drugs and efforts to improve the care of malaria cases should be included in these actions.
6.2.2. Mobilization of resources and logistics

Depending on the existence of an Emergency Health Service Coordinating Authority and on the adequacy of its epidemic preparedness plan, the mobilization of the necessary human and material resources may be more or less rapid and adequate. If such an authority has not been established nor its tasks clearly defined, this must be done as soon as the existence of a major epidemic situation is confirmed.

Depending on the magnitude of the epidemic and the local capacity for immediate response, the coordinating authority should either call on the support of or establish an Emergency Advisory Committee, including representatives of the communities affected, senior officials of public services and, if required, representatives of collaborating international organizations (WHO, UNICEF, Red CrossiRed Crescent, UNDP, etc.), bilateral agencies and nongovernmental organizations. Communications between the field epidemiologists, the local health services and the coordinating authority are essential and should be given the highest priority in the use of the most rapid means of communication. The field requirements should be subject to continuous monitoring. Possible sources of the necessary drugs and equipment and supplies for vector control, as well as the required logistical arrangements, should be immediately identified, so that resources can be mobilized in the most appropriate manner in response to field requirements.
6.2.3. Planning transmission control

The first objective of control, namely the relief of the affected population, must be given the highest priority. The pursuit of other objectives will depend on the epidemiological diagnosis of the situation and therefore on the assessment of the feasibility of attaining them. In the case of true epidemics, any attempt to implement transmission control immediately will depend on a consideration of the stage reached in the evolution of the epidemic wave and on whether the proposed measures can actually be implemented in time to affect that evolution. Costly vector-control measures have often been implemented when transmission has already been naturally interrupted. The spectacular display of control measures (such as aerial or vehicle-mounted ultra-low-volume (ULV) spraying) is sometimes useful as a way of reassuring the population, but is seldom the most cost-effective way of achieving this purpose. In any case, it is important for the health authorities to be aware of what can be expected from different interventions. In the case of localized epidemics, either as a result of the invasion of an area by a new vector or of the concentration of non-immunes in a particular area, the prevention of further spread becomes particularly relevant. Full consideration should be given to selected interventions to be applied immediately and to the selection of areas and interventions (in terms of both surveillance and control) on which to focus in the next transmission season.

In the case of resurgences or increased endemic potential, the magnitude and spread of the resurgence, as well as the availability of resources, will be the main considerations in deciding whether to attempt a renewal of the failed

control efforts or to accept the return of endemicity, and to change the strategy from one based mainly on vector control to one based on case management and selective vector control.

7. Disease Management
Z I. Diagnostic and treatmentfacilities

It is practically impossible to give general guidelines to cover the great variety of requirements in epidemic situations. A number of serious problems may reduce the availability and quality of case care, ranging fi-om poor accessibility of health facilities, negative population athtudes and cultural barriers to poor quality of case management owing to the lack of appropriate training of health staff or insufficient supplies of medicaments and materials. It is obvious that the solutions to these problems will require that action be addressed both to the communities concerned and to the various levels of the health services, and that their urgency and scope will depend on the presence and distribution of life-threatenmg P.falciparum. While not a comprehensive list, problems often encountered include the following:

I)

Practically all epidemics create a demand for antimalarial drugs far in excess of the supplies normally available. In the case of P.falciparum, it will be necessary to determine the appropriate first- and second-line drugs, a choice normally based on the known degree of drug resistance and drug policies in neighbouring endemic areas. In P, falciparum epidemics, the referral of severe cases to hospital may be difficult so that the initiation of treatment at peripheral facilities with intramuscular injections of quinine dihydrochloride, as described below, may be the only way of saving lives. The use of primaquine as a gametocytocide for P.falciparum, in combination with chloroquine, might be considered, but in most cases it will be preferable to follow the local guidelines in neighbouring endemic areas. The acquisition and delivery of the required additional supply of fust-line and appropriate second-line drugs may be a serious problem requiring immediate attention. Many countries, particularly in tropical Africa, have established costsharing or cost-recovery mechanisms to ensure that essential drugs are available at all times at the periphery (Editorial, 1996). Most malaria epidemics, and in particular those affecting impoverished or displaced populations, constitute clear cases of 'market failure', and consideration should therefore be given to some form of compensatory mechanism to ensure the availability of drugs for those population groups which cannot participate in the normal f o m of cost-sharing or recovery.

1 1 )

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1 1 1 ) Existing health services are often overwhelmed and action is needed to

improve accessibility to diagnosis and treatment, particularly in large areas with small and rather scattered villages where it may be necessary: a) to support the establishment of new health posts, mobilize communities and recruit and train local collaborators in affected localities, particularly in those remote from existing posts; the use of voluntary collaborators has a long history in Latin America and south-east Asia; it has also been used successfully in some African countries (Delacollette, et al., 1996). b) to increase public awareness and the availability of home treatment and management. Although it is recognized that home treatment is seldom adequate, it is also true that in many areas, it is the most frequent form of management of the disease. In these situations, public information and education will be one of the most important methods of reducing malaria mortality in areas with P. falciparum and should concentrate on: stressing the importance of immediately initiating treatment with chloroquine of any fever with chills, particularly in children, as well as the importance of taking the full treatment dose; ii) enabling mothers to recognize the signs of severity (e.g., loss of consciousness, convulsions, hyperthermia, severe anaemia, renal failure, icterus), requiring immediate referral to a health centre or hospital; iii) convincing mothers of the dangers of delaying treatment of severe fever cases and the effectiveness of timely medical treatment;
i)

c) to support the establishment of antimalarial drug depots at the periphery health services andlor voluntary collaborators, particularly in villages without easy access to the nearest health post.
7.2. Improving the quality of care

Owing to the previous low frequency of the disease, health care workers may not be familiar with the management of malaria cases in many epidemic situations. It will therefore be necessary to improve not only accessibility and acceptance, but also the quality of the care provided, and particularly diagnostic and treatment practices. For this purpose it may be necessary to: increase the competence of health staff by organizing some form of emergency refresher training, particularly on the management of severe malaria. The WHO guidelines for the management of severe

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and complicated malaria (Gilles, 1991) will be most useful in such refresher training; improve laboratory diagnosis by increasing staff and supplies and prioritizing the development of appropriate malaria microscopy: in all regional hospitals for the diagnosis of severe fever cases and the follow-up of treatment of severe malaria; in health centres in areas where parasite resistance is prevalent, for the differential diagnosis of treatment failures of clinically diagnosed cases.
It may be also necessary to improve the quality of case management at the periphery. Most epidemics not only produce a dramatic increase in the number of malaria cases, but also distort the clinical picture that peripheral auxiliary and lay health personnel have been accustomed to associate with malaria, either because of the introduction of P. falciparum into areas previously free from this parasite or the increased frequency of severe cases in areas where it only had been seen sporadically. As a consequence of the highest prevalence of malaria being seen in rural and poor areas, the management of malaria cases is mainly ensured by paramedical or lay personnel. These persons will require, even more than health staff, clear guidelines on the simplified diagnosis and treatment of common ailments which can be dealt with at that level, as well as on the recognition of symptoms which require referral to the formal health care services. In order to improve and standardize first-line antimalarial treatment, it may be necessary to review existing diagnosis and treatment guidelines for lay health workers, or develop new ones, containing: a clinical definition of cases requiring antimalarial treatment. During the acute phase of the epidemic, it may be decided to treat every acute fever as malaria or to include seasonal or age criteria, depending on the observed or expected age distribution of cases, in accordance with previous epidemic history; a clear definition of the main signs of severity which make immediate referral to a health centre or hospital necessary. Health posts served by auxiliary personnel should be capable of initiating the treatment of severe malaria. As soon as the signs of severity are recognized, an intramuscular injection of quinine dihydrochloride (10 mgkg of body weight) should be administered and repeated every 4 hours for two additional doses and every 8 hours thereafter until transport to a hospital can be obtained (Gilles, 1991); a clear statement of the first-line drug, which in most cases will be oral chloroquine at a total dose of 25 mg of chloroquine base per kg of body weight, divided over three days, with at least 10 mgkg being taken the first day. In local guidelines for use at the periphery, the

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dosages of first-line drugs should be translated from mg per kg of body weight into the number of tablets per age group, according to the strength of the tablets locally available. These guidelines could be based on The WHO guidelines for the management of a sick child (WHO, 1995), adapted to local conditions. Particular attention should be given to the most appropriate and rapid way of reaching peripheral treatment providers, as well as the problems to be expected in that process. Printing the guidelines and distributing them to all peripheral posts served by auxiliary or lay workers may sometimes be appropriate, but in others may be too slow. In addition, oral communication can be necessary for information to be assimilated in some cultures. Every effort should be made to standardize the antimalarial drugs used in the affected area by selecting, whenever possible, a single-tablet formulation of chloroquine so as to permit adequate dosage by lay treatment providers, for whom doses will have to be expressed in numbers of tablets, not mgkg. The concomitant availability of chloroquine tablets of 100 and 150 mg may be the cause of serious underdosage. This may not be completely avoidable when donations are received from various sources, in which case different formulations should be sent to different areas or to services which can cope with them. It will often be necessary to strengthen the monitoring of therapeutic efficacy of antimalarial drugs by: encouraging the reporting of treatment failures from the periphery; developing the capacity to conduct simplified therapeutic efficacy tests in health centres with effective laboratory services and eventually establishing a network of sentinel posts to monitor drug resistance in collaboration with the institutions currently involved. It will also be necessary to review all information on therapeutic efficacy as it is generated in order to ascertain whether a change of fust-line treatment is needed.
7.3. Public information and communication

In all epidemic situations it is very important to organize an appropriate system of public information and communication. In the case of malaria, the system should not only alleviate public concerns and provide information on the activities of the health services but also, and more importantly, guidelines on appropriate case management and the improvement of early treatment at home in particular. All forms of illustrated and written materials should be

developed and used, but emphasis should be placed on repeated verbal communication as a means to obtaining full understanding.

8. Transmission Control
The second objective of epidemic control is the containment of transmission in the affected areas. This requires some form of transmission control which should be introduced unless the epidemic has exhausted itself by the time the health services have recognized it or will do so before the required interventions can be implemented. Epidemics, and resurgences particularly, will usually continue their progress in the following transmission season unless this can be prevented. It is therefore necessary to assess which interventions could and should be implemented as soon as possible, which should be implemented only if it will be possible to do so at the appropriate time, and whose implementation should be carefully planned before the next transmission season to control or mitigate the further development of the epidemic.
8.1. Emergency control

The containment of an epidemic will require the emergency implementation of some of the measures described below:
I.

Mass drug administration (MDA) to all the population considered to be at risk (irrespective of the presence of fever) may be appropriate in a relatively small and well controlled population, as adequate coverage may be difficult to achieve otherwise. However, it is seldom costeffective. Under no circumstances should the drug supplies needed for case treatment be used for its implementation. Chloroquine has often been used in MDA, with the addition of primaquine as a gametocytocide for P. falciparurn. Drugs such as the sulfonamides or amodiaquine, which may cause serious side-effects, are therefore unacceptable for mass distribution to the general population. MDA is perhaps the most effective way of rapidly reducing the parasite population; nevertheless, the widespread risk of P.falciparurn resistance considerably reduces its indications. Even in controlled populations, as in labour or refugee camps, it should not be used as the only control measure, but should be accompanied by vector control in order to reduce the risk of transmission of resistant parasites. Mass fever treatment, i.e., presumptive treatment of all fever cases, may be a more acceptable means of rapidly reducing the parasite population, as long as the necessary human and drug resources are

11.

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available. It should be used as a means of strengthening and further developing any existing system of community health workers, instead of creating a parallel system. It should also be used to ensure the adequate supply of drugs to all peripheral treatment facilities and, if necessary, to establish strategic drug depots.

111. Space spraying of insecticides is, in principle, the best method of rapidly reducing vector density by attacking adult mosquitos. It is nevertheless expensive in insecticides, requires special equipment and vehicle or aircraft resources, and poses serious problems of accessibility. If logistically feasible, it may play an important role as an emergency measure, and is often well accepted by the population, as it has a broad effect on mosquito and other insect nuisances. In general, it is considered that space spraying has only a limited indication for the control of malaria epidemics. Not only it is expensive, but is much less effective than for Aedes or even Culex transmitted diseases. Aedes are normally active during the day, and Culex may become so when disturbed. Also, both vectors are generally fully active at dusk, in comparison with the most efficient malaria vectors. These latter become active in the middle of the night and their populations are more dispersed in their daytime resting places, even those attacking compact human settlements such as refugee camps, so that they are difficult to reach when fogging is done while some daylight remains.
A very important characteristic of space sprays is the size of the droplets being dispersed, since this determines the time that they remain in suspension in the air and their ability to penetrate into spaces that are not fully open. Sprays, measured by their volume median diameter (VMD), are divided in accordance with their droplet size into coarse sprays, with a VMD over 400 pm, fine sprays with a VMD between 100 and 400 pm, mists with a VMD between 50 and 100 pm and fogs or ultra-lowvolume (ULV) sprays with a VMD below 50 pm. Today there is a wide range of equipment for the dispersal of insecticides that is capable of producing droplets of reasonably uniform size. The most common types are: a)

thermal foggers and mist-blowers which are either portable, like Swingfog, or are aircraft- or vehicle-mounted large-capacity machines. Used extensively for nuisance mosquito control and occasionally for the control of malaria outbreaks, they produce a

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b)

very perceptible insecticide cloud, which sometimes has more of a public relations than an epidemiological impact; they are progressively being replaced by: ultra-low-volume (ULV) sprayers, which are available as portable knapsack blowers, aircraft- or vehicle-mounted machines. They produce true aerosols and are widely used for mosquito control in urban areas, as well as for epidemic control of mosquito-borne arboviruses, particularly those responsible for dengue and the encephalitides. Although aerial ULV spraying of malathion was successll in cutting the seasonal peak of transmission in a limited field trial (Krogstad et al., 1975; Taylor et al., 1975), no clear nor cost-effective success has been achieved elsewhere in the control of malaria epidemics. More successful methods include the protection of refugee camps (Meek, 1988) and other settlements in jungle areas by using knapsack blowers to spray peridomestic vegetation and the periodic (weekly or biweekly) indoor ULV application of pyrethroids for the control of multiresistant vectors (Bown et al., 1981). Their more spectacular effect on flies and household pests often results in community acceptance and demand.

.
*

In addition, there are a number of insecticide dispensers for dispersion in the air, used mainly by individual households to reduce mosquito nuisance. However, they can also be used by the population for personal protection, particularly if the appropriate insecticides can be made available. These include: c) d)

e)

flit-guns, which may be widely available as they are used extensively for domestic applications; pressurized aerosols dispensers, which produce much more uniform droplets but are much more expensive and often still use chlorofluorocarbons as the dispersing agent, despite ecological concerns and their ban in a number of countries; smoke generators in the form of mosquito coils, which are used for personal protection.

8.2. Prevention and control of transmission The containment of an epidemic, and particularly the limitation of its spread and the prevention of its recurrence in subsequent transmission seasons, will require the application of sustainable methods of vector control. These include indoor residual spraying and the impregnation of bednets, which are also the methods most commonly available.

8.2.1. Indoor residual spraying

This continues to be the most easily applicable large-scale transmission-control measure, as most countries have the basic material and human resources at least to start its application. Nevertheless, depending on the magnitude of the epidemic, it may be impossible to implement all the necessary spraying operations. The selection of priorities for immediate implementation should therefore be based on an assessment of the state of evolution of the epidemic in the affected areas and the risk of immediate spread to vulnerable areas. Confidence in indoor residual spraying has often been exaggerated. Its main mechanism of action, when an effective insecticide is used against an endophilic vector, is the selective killing of those vectors resting indoors. In fact, most insecticides are only partially effective since many of them, including DDT, have an irritant or repellent action. In addition, since most vectors are partially exophilic, many mosquitos will not be killed indoors, but instead be forced outdoors, thereby avoiding insecticide contact. Their longevity and vectorial capacity, although they will not be eliminated, may thereby be reduced. Spraying, to be fully effective, should achieve total coverage, i.e., the even application of insecticide to all the interior surfaces of all the houses in a locality at an appropriate dose and at regular intervals, as required to maintain an insecticide deposit above the minimum lethal concentration. As most vectors do not rest long enough on the walls before biting, a sprayed house does not protect its occupants from transmission if most of the houses in the neighbourhood are not sprayed, as the vectors survive. People can still be bitten and infected in these unsprayed houses. It is therefore most important to assess the acceptability of spraying to the population, particularly in areas which have a long history of spraying, like most of those suffering malaria resurgences. It is common in such areas to attribute the resurgence to poorquality spraying and to propose a number of measures, such as the training of spraymen, the strengthening of supervision or health education as the solution, which at best may only produce a very limited and short-lived improvement, since the main cause of poor coverage is the lack of acceptance by the population. Apart from acceptability, the choice of indoor spraying as a vector-control method must be based on a determination of the susceptibility of local vectors to available insecticides. Data are often available from the area concerned or neighbouring areas and, if possible, confirmatory tests should be carried out. Indoor residual spraying is indicated in situations where it can be clearly targeted, its application is limited in time, and where, even if periodic applications may be required, the effectiveness and quality of the spraying can

Page 40

be maintained. Such situations, apart from the immediate control of an ongoing epidemic, will include: the reduction of the transmission potential among population groups using mass chemoprophylaxis, as in some refugee camps or in economic development projects; the reduction of the peak of seasonal epidemics through regular yearly spraying, particularly when these are accompanied by a large increase in nuisance mosquitos, so that population acceptability is assured; the prevention of malaria transmission in areas where the epidemic is expected to recur or to spread in the forthcoming transmission season. It is also one of the main methods of preventing epidemics in areas where a forecasting system has detected an increased epidemic risk. Insecticide toxicity and the hazard that it may represent for spraymen and the Inhabitants of sprayed houses, as well as for the environment, should be major concerns when contemplating spraying. Insecticide formulations used for indoor residual spraying must be particularly safe, as it is impossible to prevent contact between people and sprayed surfaces, and it is very difficult to ensure the use of complex protective devices by spraymen in tropical conditions. Toxicity, as shown below in Table 1, is measured in oral and dermal LD,,(rats) for the basic compound, which gives an indication of the general risk of acute poisoning. However, the actual risk of spraying depends to a large extent on the formulation being used. This is taken into account in the WHO Classificationof Pesticides by Hazard ( W H O m P A L O , 1994), in which they ) ,moderately (class 11), are divided into extremely (class Ia), highly (class h and slightly hazardous (class 111) and unlikely to be hazardous (UH). The technical products listed in Table 1 as recommended for malaria control belong to class 11, with the exception of malathion and pyrimiphos-methyl, which belong to class 111. In fact, all the formulations used, at the dilutions actually applied, belong to class 111. Dose and residual effect are important considerations in determining the number of spray rounds needed to protect a population during the whole, or only the peak, of the transmission season. The application doses are set between a minimum and maximum which is determined by effectiveness and toxicity. These doses, acceptable for indoor spraying, represent a range considerably narrower than that for most other applications of insecticides.

Table 1. Insecticides used for residual indoor spraying

Source: Chevasse & Yap, 1997

The residual effect depends on the action of the insecticide on the environment (e.g., on photosensitive pyrethrins) or on water-dispersible insecticide formulations by most mud surfaces, (e.g., the adsorption of insecticides by some mud surfaces, and the inactivation of some carbamates and organophosphorus compounds by alkaline surfaces). Another factor which will affect the residual effect obtained in practice is the replastering, whitewashing, etc., of the sprayed surfaces. It is important to distinguish residual effect from biodegradability, i.e., the inactivation of the insecticide by environmental or metabolic processes. Persistent insecticides, which have very low biodegradability, tend to accumulate through the food chain and become toxic to predator species. Certain insecticides, such as some synthetic pyrethroids, may combine a long residual effect and a relatively high biodegradability.

WH0/1MAW98.1084 Page 42

The standard method of application of indoor residual insecticides was devised and perfected for applying water-dispersible DDT powders to mud surfaces and thatched roofs. which are the most cornmonlv svraved surfaces in the tropics. It involves the use of pressure pumps, nozzles that deliver a flat swath, a spraying technique that ensures a pressure range, and a rhythm and a distance to the wall such that the insecticide formulation will reach the wall at a speed which, with minimum bouncing, will ensure that the appropriate dosage is deposited just before run-off. Newer insecticides have been formulated to use the same equipment and method of application. However, roof materials such as tin or corrugated iron, and some plastic prefabricated wall materials, are becoming more commonly used and may not retain an adequate dose with the standard method of application.

In labour and refugee camps, which are often at risk of epidemic malaria, the use of tents made of plastic sheets and other forms of prefabricated wall materials requires some important modifications of the spraying technique described above to avoid most of the insecticide being wasted as a result of bouncing and run-off. This is not only a matter of waste. The accumulation of insecticide on the floor may be toxic to infants, while the walls may not have retained enough insecticide to be effective. Another serious problem is that the size and shape of many tents are not such as to prevent spraymen adopting the nozzle-wall distance required by the technique. Until the various modified techniques are standardized, it may be difficult to estimate the dose of application, e.g., when nozzle pressure is reduced and spraying speed increased, or when the insecticide is applied with a mop. In some planned camps it may be possible to preimpregnate tents before dishbution. However, this is unusual, and reimpregnation will be required unless the tents are used only for short periods of time. Safety precautions should be strictly followed. Great care must be taken to protect food, drinking-water, cooking and eating utensils and the spraymen themselves, who may be in continuous contact with the insecticide. Even if an insecticide is considered safe, it is never totally innocuous. The choice of insecticides should take into consideration availability, cost and acceptability to the population, as well as the expected local effectiveness, which will depend on the susceptibility and irritability of the local vectors. Traditionally, DDT has been considered the insecticide of first choice because of its low toxicity to humans, its relatively long residual effect, and the slow development of resistance. However, the use of insecticides for epidemic control should not involve long spraying programmes, but only applications during the seasons of epidemic risk, so that choice should be based on current susceptibility.

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The long persistence of DDT in the environment prohibits its use outdoors, particularly as a larvicide. Nevertheless, its use as an indoor spray has been continued because of the low probability that sprayed surfaces, even of demolished houses, will become agricultural land or otherwise enter environmental food chains. WHO approves its use for vector control only for indoor spraying, provided that it is effective, it complies with WHO specifications and the necessary safety precautions are taken in its use and disposal (WHO, 1995). New synthetic pyrethroids with long residual effect, such as deltamethrin and lambda-cyhalothrm,which are effective at very low doses (25-50 mg/m2),and are of very low toxicity, are also competitive with DDT in terms of the cost of applications for malaria control. As recognized cross-resistance to them is mainly with DDT, they have been suggested as first-choice insecticides. However, the choice of these insecticides is complicated by the fact that at least some vectors are imtated by pyrethroids to such an extent that, although they normally bite indoors, they cannot rest on a sprayed surface and therefore leave the house before acquiring a lethal dose. This will be even more dangerous when the surrounding environment offers suitable daytime resting places for mosquitos to survive, as in the case of thick vegetation. Such effects should be considered before embarking on large-scale spraying operations.

8.2.2.Impregnation of bednets
During the last few years, more and more malaria control programmes throughout the world have been investing considerable efforts in the promotion and support of the use of bednets impregnated with residual pyrethroid insecticides. It is highly unlikely that, in an epidemic situation, there will be tlme for the slow process of introducing the use of bednets or for solving the various problems which may hamper their widespread use. Nevertheless, in areas where bednets are already widely used, e.g., in epidemic-prone areas with a high density of nuisance mosquitos, the reimpregnation of bednets may be the most effective way of controlling transmission and preventing its spread to new areas or its renewal in subsequent transmission seasons. Practically the only insecticides suitable for bednet impregnation are the new synthetic pyrethroids, because of their low toxic hazard and residual effect. Permethrin, deltamethrin and lambda-cyhalothrin, which are those currently recommended for indoor residual spraying or bednet impregnation, are included in Table 1. However, other residual pyrethroids are being rapidly developed and several that are currently being tested seem to offer characteristics at least as good as those mentioned. It is advisable, therefore, to check which pyrethroids are suitable for bednet impregnation and to consider any others that may be available.

WHOLMAAW98.I 084
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111. EPIDEMIOLOGICAL SURVEILLANCE, FORECASTING AND PREVENTION OF EPIDEMICS


9. Epidemiological Information Systems

There can be no doubt that an information system is vital for the proper functioning of any programme. Information systems have been designed to provide the managerial and epidemiological data necessary to monitor the impact of interventions on the malaria problem and the implementation of programmed activities. Such information systems have led to the belief that the main causes of changes in the epidemiological situation are the control interventions themselves, and that the only response to an unexpected deterioration in the situation is to intensify those interventions. A broader look at concomitant processes might have suggested a more critical determinant factor and a more effective control policy. While information is essential for the management of any control activity, it must be kept in mind that the objective is control and not the acquisition of information for its own sake, no matter how interesting it may be. During an epidemic, the first priority should be the appropriate care of the cases, which in most instances will require an improvement in the accessibility and efficiency of diagnostic and treatment facilities. This must take precedence in the distribution of resources and an important aspect to consider is the optimization of the deployment of microscopical diagnostic facilities. At present, most of the established antimalarial programmes are reorganizing their information systems in response to the emphasis on disease management required by the Global Malaria Control Strategy, in contrast with the almost exclusive attention previously given to parasite infections during the eradication era. There is therefore a need for certain redefinitions of reportable variables and a search for relationships between the new and the old variables. This is particularly important for trend analyses, which will require the establishment of relationships between old and new time series of not fully comparable variables. It will also be necessary to collect information from general health services that had not previously been received by malaria programmes. The new emphasis on disease management requires the separate monitoring of 'clinical malaria' and 'laboratory confirmed cases' reported by formal health services and by lay community health workers. It can be assumed that reported 'clinical malaria' will be more or less equivalent to the 'slides collected' previously by formal health services and by community workers. Both time series can be compared to test their hypothesis and to see how previous

Page 45

definitions of normality may be translated to the varaibles used in the new systems. New time series will have to be started for the new data collected on the main forms of severe malaria, treatment failures and deaths. An information system should not be limited to the routine reporting and subsequent analysis of data. It is essential that all echelons of the health services should be aware of the importance of particular indicators of risk defined for each area, and that they should be required to communicate abnormalities in those indicators to the level capable of generating an appropriate response as soon as possible. Routine information and trend analyses should then be supplemented by properly planned epidemiological surveys or specific studies conducted by the specialized services to confirm, evaluate or study particular problems or situations, especially when an emerging epidemic is suspected. All echelons of the services reporting epidemiological information should be considered full participants in the overall process of malaria control. Peripheral services should receive not only consolidated reports but also be able to exchange information with neighbouring areas and receive technical assistance when necessary, so that they appreciate the usefulness of reporting. This should never become a burden and a cause of non-compliance or inaccurate reports. It is also essential to stress, reinforce or stimulate an interest in understanding time and spatial variability and to avoid the tendency to rely only on averages of scattered observations, to extrapolate to large areas or to disregard past information. It is unfortunately still very common for epidemiological analyses to be limited only to the comparison of current data with past year indicators. It is also common to find services that neglect or destroy past reports. The renewed interest in malaria epidemics has made malariologists aware of the fact that most epidemics are owing to, or greatly influenced by, meteorological or social determinants (Koumetzov, 1989; Najera and Beales, 1989), yet most antimalarial services still fail to monitor these variables since the indicators of risk for their epidemic-prone areas have not been determined. Thus in most of the recent descriptions of malaria epidemics, and even in those where exceptionally heavy rains or population displacements are recognized as the main cause, those concerned fail to analyse the details of that relationship, or to show any interest in monitoring such determinants. As a result, they continue to build so-called warning systems based on the classic malariometric variables. The recognition that the risk of malaria epidemics is in most cases determined by ecological and social variables should lead to their monitoring. Most of the variables concerned are carefully studied by other public services, such as

WHO/MAu98.1084 P a ~ 46 e

those responsible for agriculture, public works or economic development. Their monitoring therefore requircs the involvement of a variety of collaborating partners through the establishment of truly functional intersectoral links. As examples of these situations, graphs 13-15 show how known epidemic years in Khartoum and Wad Medani in Sudan are linked to early deviations from normal Nile river levels and rainfall. Epidemics seem to have been caused by the floods resulting from the joint effects of river overflow and excessive local rainfall, the latter being of particular importance in 1988 in Khartoum and in 1975 in Wad Medani. 9.1. IdentiJication of indicators of epidemic risk Although a considerable number of determinants may precipitate an epidemic, in any particular situation, most of them are interrelated. Therefore, there is seldom more than one major risk factor or at most only a few with a high predictive value. Nevertheless, in areas of varied and isolated ecological features, such as highland valleys, or of highly concentrated socioeconomic development, there may be large differences in epidemic potential and risk factors between neighbouring areas. The identification of local epidemic-prone areas and risk factors should be based on the retrospective analysis of the malariometric indicators, including the history of past epidemics and the records of potential risk factors suggested by the ecology of the area. In most antimalarial programmes, the main epidemic risks are known, even if the epidemiological services may not have the recorded information to document that knowledge. For example, in some areas, a major event such as the opening of a road, the beginning of a colonization programme, or the appearance and spread of drug resistance, marks the introduction of new risk factors. These factors may sometimes have been identified several decades previously and their monitoring may have been terminated, as in the case of the Punjab, where a sophisticated epidemic forecasting system was discontinued following the adoption of the national malaria control campaign in the 1950s. In such situations, it is generally possible to obtain the missing records from the relevant services, as well as any information which may indicate an important change in the epidemiological conditions in the area. A simple statistical analysis will then indicate the validity or otherwise of the original epidemiological hypotheses. In areas where there are no reliable epidemiological records but reasonably accurate records of deaths or hospital records, it may be possible to study the correlation between mortality and potential risk factors, as was done in the Punjab in the first quarter of this century (Christophers, 1949). In other areas, there may be no epidemiological records, but meteorological senices may have kept detailed records for many decades, and the ecology of

<

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the area may suggest the most probable risk factors. In general, the impact of malaria epidemics is sufficicntly serious to remain in people's memory for some years, so that it may be possible to determine whether the years of remembered epidemics were also years of exceptional meteorological or socioeconomic conditions (graphs 13-15).

9.2. Field investigations

In principle, malaria epidemics should be foreseeable, at least from the time of occurrence of the causative disturbances. The occurrence of an epidemic may therefore be considered as:
a) a failure to understand the local epidemiology of the disease, and particularly the interrelation of ecological and socioeconomic processes; b) a failure to appreciate the consequences of certain economic development or health policies; c) a failure to translate existing knowledge into appropriate monitoring and preventive activities. Every epidemic provides an opportunity to refine epidemiological knowledge, detect changes in the geographical limits of the areas considered at risk and, in areas with a risk-monitoring system, find its weaknesses. The follow-up of epidemic control should therefore include the mobilization not only of the resources of the health services, but also those of other sectors and research institutions for the support of epidemiological studies to improve the capacity to forecast and prevent epidemics and the organization of epidemic preparedness. The recognition of an area as subject to a particular category of epidemic risk gives some indication as to the set of risk factors which should be monitored. However, the further analysis of the local variability of malaria experience and the monitored indicators may show important variations in epidemic risk which should serve to refine the accuracy of the forecasting system. Those events which are not in line with expectations, and in particular unforeseen epidemics, should receive the most intense study. Such studies should be seen not only as means of improving the accuracy of the system and of adapting it to changing circumstances, but also as opportunities for extending intersectoral collaboration to obtain timely information on relevant variables and to improve the speed and relevance of preventive activities.

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Historical research plays a major role, not only in helping to provide the most solid link with the studies and tested hypotheses of the past, but also in providing, for some specific areas, historical data which may help to identify associations of past epidemics with certain ecological or social variables, thus suggesting possible etiological relations, and therefore playing a role in the search for useful indicators of epidemic risk. The study of actual epidemics may also show the importance of certain vectors, hitherto considered as secondary, in the genesis of some epidemics, as compared with the main vectors in the area concerned, e.g., A. annularis in parts of Bangladesh, rather than A. philippinensis (Rosenberg & Maheswary, 1982; Maheswary et al., 1993), or A. albitarsis in some epidemics in Colombia, rather than A. darlingi.
9.3. Geographical information systems

Since epidemics are catastrophic events, their study requires the precise definition of both time and space. Both for the implementation of control interventions and for the understanding of the dynamics of risk, it is necessary to define as accurately as possible the geographical limits of each phenomenon. Most countries have good-quality topographical and political maps, showing the main physical features, the altitude, the hydrological network, the administrative boundaries, the location of villages and population centres, and national and secondary roads. They also have some form of geographical information system, providing information on agricultural areas, the distribution of main crops, irrigated areas, etc. Most of the malarious countries of the Americas and Asia made detailed geographical reconnaissances in support of the spraying operations of the malaria eradication campaigns, which in some cases provided the best available information at the time on population distribution in peripheral areas. In other countries, similar efforts have been made by other services, including the use of satellite information on surface water, vegetation and land occupation and use, of certain areas of interest to hydrological or agricultural services (Thomson et al., 1996). Computer and communications technology provide cost-effective tools for the establishment of a dynamic information system. The existing geographical information systems (GIS) provide the programmes needed to give the required geographical dimension to epidemiological studies, and their use is spreading rapidly in most countries. Health programmes, particularly those for the elimination of dracunculiasis, the control of schistosomiasis, immunization and, in some areas, malaria control, have started to incorporate GIS in their information systems.

A computer-based GIS allows the collection of data linked to geographical location from different sources, and stores it in a form which permits subsequent analysis and synthetic presentation in map form. It is not only a system for the production of computerized maps but also, and more importantly, for the integration and spatial analysis of data from different sources such as population distribution (location of towns, villages, hamlets and road networks), the environment (physical features, land use, surface water), the location of health and other services (hospitals, dispensaries, health posts, schools, post offices, etc.), epidemiology (morbidity, mortality, drug susceptibility), meteorology (rainfall, temperature, humidity), agriculture (irrigation, main crops, land productivity), the socioeconomic situation and any other subject in which the data are linked to geographical location. Using these databases, it is possible to establish, confirm and monitor spatial and time correlations among the different data, and eventually formulate predictive hypotheses.
The study of epidemic potential should make the best possible use of any existing resources for GIS and stimulate their development where they do not exist. It is clear that GIS should be integrated in the general epidemiological services of the country. It should define the basic geographical unit of analysis of routine health data, the distribution of responsibilities for reporting, epidemiological analysis, and the communications system.

The epidemiologist responsible for malaria, whether in a specialized or an integrated service, should identify the sources of the ecological and socioeconomic data selected for monitoring. Through intersectoral collaboration, it will be necessary to ensure the automatic flow of data after agreement has been reached on the timing and points of reception as well as on their use and distribution. The strengthening or the development of GIS for epidemic prevention and control will require financial, human and technical resources for the planning, acquisition, installation and maintenance of equipment and software, for training, supervision and evaluation, as well as for the verification, validation, correction and maintenance of related databases.
10. Risk Detection and Forecasting

Ideally, epidemics should be forecast and prevented. If this is not possible, they should be detected early enough in their evolution to prevent, as far as possible, their impact on mortality and incapacity. The concept of risk detection must be expressed in terms of the real time available for implementing an appropriate response after the recognition of the imminent

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risk. It is particularly important in the case of an incipient epidemic to be able to estimate the potential slope of the forthcoming epidemic wave, as well as the area of potential spread. It is therefore necessary to establish a monitoring system capable of detecting the earliest indicators of the triggering of the chain of determinant events, as well as an emergency-preparedness system to respond to it. The effectiveness of preventive action will ultimately depend on the degree of preparedness of the health services to mobilize the necessary resources in the available time. For an epidemic to occur, the conjunction of several factors is necessary, one or more of which are absent in the interepidemic, or 'normal' years. The speed with which an epidemic is triggered depends on whether the missing factors come together quickly or develop in stages. Knowledge of the local epidemiology, ecology and the biology of the vectors involved is essential if accurate estimates are to be made. Interest in epidemic prevention disappeared after the early 1950s, as it was assumed that the risk of malaria epidemics would no longer exist following establishment of malaria eradication campaigns. The search for actual forecasting systems used, or even proposed, must therefore rely heavily on historical records and a few recent experiences.
10.1. Monitoring of morbidity and mortality

This is obviously the most direct method of detecting the actual occurrence of an epidemic although, even with rapid methods of communication, it will seldom provide sufficient time for effective preventive action. Early detection may allow some containment action and, in geographically spreading epidemics such as invasions by new vectors, may give time for preventive measures in neighbouring areas.

Morbidity monitoring has been the classic method of epidemiological surveillance, in which one of the standard methods of detecting deviations from normality has been the plotting of endemoepidemic indices. Normality is defined on the basis of past experience over a period of at least 5-10 years. During this period, there should not have been any changes in the system of data collection or case definition. A graph showing the first and third quartile around the median (or the mean plus and minus one or two standard deviations) of all monthly or weekly data for the whole period, will define a normal or endemic channel on which it will be easy to see any departure from normality of the data for the current year as they are plotted on it. The use of the median and the third quartile does not require any selection of past data. Similarly, if all past data are used for the calculation of the mean, one standard deviation should be used to define the normal channel. When abnormal data

are eliminated, however, it will be preferable to use two standard deviations around the mean. This method was used in northern Thailand by selecting the years of 'acceptable' or normal transmission during the previous eight years and defining the normal channel as given by the mean plus and minus two standard deviations (Cullen et al., 1984). The monitoring of malaria morbidity has nevertheless been hampered by the slow, complicated procedures used in most of the established antimalarial services, which generally insist on processing only data on microscopically confirmed cases, even if most laboratories operate with large backlogs of slides (Prasad et al., 1992). The sensitivity of the system could be improved by requiring peripheral services to report, via emergency channels, abnormal increases in fever cases or the risk of running out of antimalarial drugs. If there is some form of emergency preparedness, it may be possible to strengthen the case-management capability, proceed to a rapid confirmation and, if necessary, start emergency transmission control. Unfortunately, during most epidemics, once the increase in morbidity has been recognized, there may be too little time to mobilize the required resources for effective vector control before the transmission season reaches its peak. Retrospective studies of mortality statistics, generally more complete and reliable than those of morbidity, have been found very useful in delimiting epidemic-prone areas, determining past periodicity and initiating the search for possible determinants. In his classic study of the great epidemic of 1908 in the Punjab (Christophers, 1949) which affected a population of some 30 million in an area of 500 000 square miles, Christophers showed that similar epidemics had occurred in the same area at intervals of about eight years, and devised a method of mapping the spread of these epidemics by calculating an epidemicmre. This was obtained by dividing the deaths recorded during the month of greatest epidemic prevalence by the normal monthly mortality. These figures, calculated by regrstrar unit (thana), were then mapped and lines of equal mortality were drawn, which showed the extent of each epidemic. The Malaria Commission of the League of Nations defined an index of epidemic potential as the coefficient of variation of mortality established over as long a period as possible. Similar indicators of epidemic potential can be based on morbidity data for those areas where the sources of such data show a certain consistency over the years.

10.2. The spleen rate as an indicator of herd immunity

The spleen rate, and particularly the average enlarged spleen, has long been recognized as a good indicator of the immunity of the population, since it has been shown that epidemics did not occur in areas where the spleen rate was consistently high, while a declining spleen rate was an indication of increasing epidemic risk. The Kampala conference of 1950 (WHO, 1951) based its definition of endemicity on the spleen rate. Nevertheless, it included as part of the definition of hyper- and holoendemic malaria the condition that the spleen rates in children aged 2-9 years should at all times be greater than 75% for holoendemic and between 50% and 75% for hyperendemic malaria. Repeated surveys were therefore necessary to determine whether these conditions were satisfied. The spleen rate combined with the value of the average enlarged spleen (AES) should make it possible to distinguish clearly between an endemic situation and a current or recent epidemic. Even after a single survey, areas of high endemicity have high values for both indices (spleen rates above 50% and AES above 2), while a high spleen rate with a low AES is an indication of a recent epidemic. Even if spleen enlargement has lost much of its value as an epidemiological indicator in areas where antimalarial drugs are very widely used, there are still many malarious areas not so well served where a spleen survey in school children may perhaps provide epidemiological information most quickly. It could in particular serve to identify scattered endemic villages in hypoendemic areas which maintain the parasite reservoir during the interepidemic periods and from which explosive epidemics may spread.
10.3. Monitoring entomological variables

The monitoring of entomological indicators such as increased vector density or longevity should theoretically provide some time to introduce measures to reduce transmission, e.g., house spraying, reimpregnation of bednets or, if affordable, space spraying. Nevertheless, the difficulties and cost of obtaining representative relevant entomological information often makes this impossible. Moreover. even in the best circumstances. detection can coincide with active transmission, leaving very little time for effective action to be taken against it. The entomological inoculation rate has been proposed as a comprehensive indicator of epidemic risk on which to base forecasting (Onori & Grab, 1980). It is defined as the mean daily number of bites inflicted on an individual by

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mosquitos infected with sporozoites, and therefore requires the determination of the man-biting and sporozoite rates which, particularly the latter, may be practically impossible to determine in many epidemic-prone areas. Epidemics may occur with very low sporozoite rates, often undetectable by common practices of entomological services, particularly in areas where the vectors are only partially anthropophilic, such as most areas of the Americas and the Indian subcontinent. 10.4. Monitoring meteorological variables Long before the discovery of the mosquito transmission of malaria, experience showed that some abnormal meteorological events, such as extensive floods, could be followed by epidemics of intermittent fevers. Associations of this type vary considerably from area to area, depending on the abnormal event which triggers the epidemic process. Although the association is not fully deterministic, the detection bf the meteorological abnormality is usually relatively easy and will give a good indication of the increased epidemic risk. Meteorological monitoring should aim at the detection of: early, prolonged rains in arid areas such as north-west India and Pakistan, where the main vector, A. culicifacies,normally breeds in pools on stream margins or in drying streams, small irrigation channels and areas receiving canal seepage, thereby maintaining endemic malaria in the adjacent villages. In years of prolonged abundant rains, however, it breeds profusely in all manner of temporary rain pools, producing high densities everywhere. In addition, the prolonged rainy season maintains favourable humidity conditions, thus ensuring the expectation of infective life of the vector necessary to produce an epidemic. The detection of early rains should initiate the preparatory phase of control, and further confirmation of the rain pattern will still allow more than a month of real time to mobilize vector control; periods of unusual drought in areas such as the medium-altitude valleys of the 'intermediate zone' (located between the dry and wet zones) of south-western Sri Lanka, where the vector will not find many favourable breeding places in normal wet years in the wellcultivated land, but will breed profusely in the numerous pools formed in the river beds when the flow decreases markedly following the failure of the south-western monsoon. Such failure in Sri Lanka would give about two months for preparation and preventive action;

periods of flooding or increased water-logging caused by an excessive rise in the water level of desert rivers. In such areas e.g., the Nile, Indus and Senegal river valleys, increased vector breeding occurs in the pools resulting from the withdrawal of the flood waters, so that between the time of the flood and that of maximum vector breeding, another period of two to four weeks is added on to the two periods described above. In addition, in most desert rivers, the high levels originate in remote upstream areas, and it may thus be possible to sound the alarm several weeks earlier; periods of temperature and humidity favourable to vector survival, as would be required for epidemics of oasis malaria. These provide a short time for action to be taken as they correspond to the periods when longevity is increased and transmission is therefore occurring. Depending on the extent of preparedness, they may allow some effective transmission control or at least the emergency supply of drugs. Epidemics due to abnormal meteorological conditions are rare events which occur with a certain periodicity. Epidemic forecasting should therefore be a progressive process, in which the time elapsed since the previous episode of increased risk should trigger the first stage of emergency preparedness. The first alarm signal from the monitoring system should then lead to the strengthening of diagnosis and treatment facilities, the building up of drug stocks, and the logistic measures for the mobilization of vector control when the imminent risk is finally confirmed. As many meteorological abnormalities appear to be linked to the El NiiioSouthern Oscillation (Bouma and van der Kaay, 1996), it is important to determine the correlations between the local epidemic risk and the El Niiio or their opposite La Niiia years. The global climatic disturbances associated with these phenomena may result in abnormal spells of wet or dry weather, which may in turn result in changes in malaria transmission potential. For example, the well-documented malaria history of the Punjab shows that, in that area, the El Niiio years are particularly warm and dry and malaria epidemics occur most frequently in the year following El Niiio phenomenon. In contrast, the malaria epidemics of Central-South Sri Lanka seem to be associated with La Niiia years, when the south-west monsoon fails. The analysis of these correlations could define the possible predictive value that could be given to those global meteorological events in a certain area which could provide an early preparatory warning, alerting the antimalaria service to intensify the monitoring and rapid reporting of local indicators of epidemic risk.

1970, a malaria epidemic started, mainly of P. vivax followed by P. falciparum, peaking in 1972 with more than 3 000 cases (graph 17). The Malaria Service brought in supplies of chloroquine at the beginning of 1970, but an all-out campaign which included mass drug administration and DDT spraying and fogging was not initiated until April 1972. From June 1972, intramuscular injections of the experimental drug cycloguanil parnoate (camolar) were given to everyone entering the area for a period of time (Bruce-Chwatt et al., 1974). The epidemic risk ended with the end of the diamond rush; Graph 17 Malaria positive cases in the Cereno district (1970-1974)

Q U A R T E R S ( 1970

- 1974 )

(Brute-Chwattetal., 1 9 7 4 )

on the Pacific coast of Central America, malaria control had been hampered since the 1950s by the high vulnerability of cotton workers, owing to the primitive and crowded conditions of their camps and their high mobiitliy because of the temporary nature of their employment. In contrast, malaria control was highly effective in the well-established bnana plantations of the the Atlantic coast. The collapse of cotton cultivation in the early 1980s resulted in a mass exodus of migrant workers who then provided very cheap labour, allowing the expansion of the banana plantations on the Atlantic coasts of Costa Rica and Honduras. This led to serious focal malaria outbreaks on the Atlantic coast and the success of malaria control on the Pacific coast. These developments are illustrated by the evolution of national malaria statistics in Costa Rica, which had achieved a high level of control before the expansion of banana plantations (graph 18) and in El Salvador, which has no Atlantic coast (graph 19), and where malaria disappeared as cotton cultivation declined. In addition to the impact of man-made modifications on the environment and migration in search of work as determinant factors of epidemics, economic depression and famine are important determinants of the severity of their impact on morbidity and mortality (Packard, 1986; Zubbrigg,

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Graph 18 Malaria incidence in Costa Rica compared with banana production (1980-1992)
+Banana producion
t

MalaM incidence

1980

1985

1990

Graph 19 Malaria incidence in El Salvador compared with cotton production (1980 1990)

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/ +Cotton production

Malaria incidence (

200
150

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10.6. Comprehensive monitoring of epidemic risk Fully developed forecasting services will make it possible to refine progressively the understanding not only of the main determining factors, but also of some complementary ones which may be responsible for the more rapid development or greater severity of epidemics. The history of epidemic forecasting, particularly in the Punjab between 1920 and 1940 (now north-west India and north-east Pakistan), provides an illustration of the development of a comprehensive system and of its adaptation to changing situations (Christophers, 1949). In his earlier studies in the Punjab, Christophers had found a high correlation between fever and rainfall (correlation coefficient 0.67, probable error 0.168), but an even higher correlation when an indicator of hunger (the 'human factor', indicated by the price of food grains) was introduced. When this was done, the correlation coefficient between fever and the product of prices and rainfall was 0.80 (probable error 0.099). Further studies by Perry, and by Gill in 1914, showed that the spleen rate fell considerably after an epidemic, and that epidemics could be largely owing to the low endemicity prevailing during the interepidemic periods, leading to an absence of immunity in children, as well as to a general decline in immunity. These epidemics not only showed a certain periodicity, but also always affected parts of the same general areas, and were therefore designated as 'regional epidemics'. Following Gill's recommendations, forecasting continued in the Punjab up to the early 1950s, based on the study of four factors:

1. A rainfall factor based on the measurements of rain in July and August in 192 recording stations, which gave an indication of the transmission potential. Rainfall alone was used because humidity, which was recorded only in 10 stations in the Punjab, was very closely correlated with rainfall in the critical months of July and August.
2. A spleen-index factor based on spleen rates in schoolchildren in 286 representative communities, routinely taken during the previous two or three, and eventually five years, which gave an indication of immune status and therefore of the areas more likely to be affected by an epidemic. 3. An economic or human factor given by the average price of food grains during the preceding two years; although not direct causes of an epidemic, famine and stress strongly influence its severity and intensity.

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4. An epidemic potential factor for each locality (registration centre), giving a coefficient of variability, calculated by multiplying the standard deviation of the October fever mortality for the years 1868-1921 (excluding 1918) by l00 and dividing it by the number of observations (53 years); this coefficient varied from 31 in Kangra to 106 in Sialkot. The first factor, indicating the imminent risk of increased transmission, was actually a determinant factor, while the other three factors indicated the expected impact and spread of the epidemic. Districts were characterized by the intensity of recent epidemics. To gauge the actual intensity of a given epidemic, an epidemic figure was defined as the quotient of the mean monthly fever mortality in October-December over that for the four months of April-June of the same year. This figure did not exceed 1 in interepidemic years, but could be as high as 10 in epidemic years. Gill also used a diffusion index, namely the number of registration centres in a district with an epidemic figure greater than 2.5, and an intensity index, namely the percentage of registration centres with an epidemic figure greater than 5.0. Forecasting, although it gave only about one month from the detection of the determinant factor in August and the expected start of the epidemic in September, was extremely useful from the point of view of emergency relief, provided that there was an appropriate organization to deliver it. Such emergency action included: a) the provision of adequate supplies of quinine by special relief units to the villages at risk; and b) the stocking of supplementary essential foods, particularly milk for infants, and the organization of other public services, since epidemics were likely to disrupt the whole way of life of the communities affected and the high mortality was often not only a direct but also a secondary effect of the disease. Stimulated by the severe epidemic in Ceylon of 1934-1935, the Malaria Commission decided in 1937 to draw the attention of Health Administrations to the 'urgent necessity for carrying out research on the subject of great malaria pandemics, not only during the epidemic but also prior to its outbreak', and circulated Covell's report, Methods of forecasting and mitigating malaria epidemics in the Punjab (1938). After reviewing the studies by Christophers and Gill, as well as a report by Parrot and Catanei (League of Nations, 1939) on the determining factors of epidemics in Algeria, the Commission gave its support to the work in Punjab. Recognizing that the main determinant of an epidemic was the disruption of the equilibrium between infection and immunity, it recommended that forecasting should be based on the monitoring of hygrometry and pluviometry, the evolution of the splenic index, the economic factor and the epidemic potential (the coefficient of variation of

mortality established over as long a period as possible) (League of Nations, 1939). The system of epidemic forecasting adopted in the Punjab continued to provide useful predictions until the launching of the large-scale vector-control operations of the 1950s (Yacob & Swarop, 1944; Swaroop, 1949). Nevertheless, the human or economic factor was slowly being neglected in the Punjab in part, as Zubbrig (1994) notes, because fluctuations in the selected indicator (grain prices) decreased so that it lost its value as an indicator of hunger, but perhaps also because of a tendency on the part of malariologists to explain the epidemiology of the disease solely in terms of cases, parasites and vectors. It should be noted that the report of Parrot and Catanei discussed only the influence of premunition, and the detailed study by Covell and Baily (1932) of the regional epidemic in northern Sind in 1929 does not even mention the human factor.
11. Emergency Preparedness and Epidemic Prevention

Emergency preparedness for malaria epidemics should be part of the general organization of emergency health services, which in turn should be an integral part of every health system (Brks, 1986). Similarly, preparedness plans for malaria epidemics and for emergency health services should be included in the National Disaster Preparedness Plan, particularly in areas at recognized risk of natural disasters, such as earthquakes, hurricanes, cyclones or floods. It is obvious that in areas subject to a recurrent risk of malaria epidemics, such services should devote particular attention to the specific requirements to be met In dealing with them effectively. Preparedness for malaria epidemics should be based on an understanding of the epidemiology of malaria and of the epidemic risk factors. The more complete that understanding and the more developed the information system and the monitoring of risk factors, the higher will be the level of preparedness, the more accurate the forecasting and the more adequate the preventive response. An adequate monitoring system will allow between one and three months to implement preventive measures, including the strengthening of diagnosis and treatment facilities. Even a major disaster resulting in widespread destruction of houses and immediate exposure of people, such as hurricane Flora in Haiti, produced a malaria epidemic only after one and half months. The immediate implementation of preventive measures should be possible if the appropriate manpower, supplies, equipment and logistical arrangements are ready to be brought into action. Malaria preparedness should therefore include the identification of these resources and the required mechanisms for their rapid mobilization. In general, the establishment of stocks of insecticides and

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spraying equipment is not advisable. The building-up of sufficient reserves in a neighbouring programme for vector control, or even for some other form of pest control, is more appropriate.
As mentioned above, epidemic risk tends to increase and decrease, often with a five to 10 year periodicity. It would therefore be wise to streamline epidemic preparedness as the risk time approaches, building-up the required stocks of insecticides and drugs, organizing training, etc. For example, in some arid areas of north-western India, epidemics normally follow early and abundant rains, particularly when they occur after a very dry year. A simplified example for preparedness in areas where epidemics are expected to follow a five-year cycle would be to order equipment and insecticides in the third year following an epidemic. Then, in September of a very dry year, preparations should be started and if, in the following year, the rains start early (May-June) and continue during July, sprayrnen should be recruited and trained in July or early August, so that they can start spraying in the first half of August if the rains continue.

11.1 Preventive measures

When a high risk is detected, the first consideration in the selection of a preventive strategy is whether the epidemic should be completely prevented by total coverage with vector-control measures, or whether a more conservative policy should be adopted so as to prevent mortality and incapacity by providing accessible facilities for early diagnosis and prompt treatment everywhere. Transmission control is then restricted to the reduction of the epidemic wave in the most vulnerable areas. The choice between these policies, or any combination of them in different areas, should be guided by: the expected impact of the epidemic based on the immune status of the population, the risk of P. falciparum, drug resistance, etc.; the feasibility of successfully implementing the different alternatives; the possibility of maintaining the capacity to prevent future waves. The much greater appeal of complete prevention of an epidemic often leads to the choice of vector-conh-01campaigns while neglecting the strengthening of case-management facilities. If vector control is not successful, the epidemic may still occur and have a severe impact. In general, it may be advisable to attempt full epidemic prevention only when there is a good infrastructure capable of coping with the disease, whatever form it might take.

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Technically, the preventive measures will be the same as those discussed under epidemic control, but it will be possible to plan and implement them more effectively, without the huny and improvisation often seen in epidemic control. In the case of P. vivax epidemics, it may be advisable to implement mass antirelapse treatment in the winter or early spring, giving all cases from the previous season full primaquine treatment. An important consideration in the selection of this intervention is whether or not P. vivax cases were treated with primaquine and the length of that treatment, i.e., five or 14 days. If winter-spring treatment is contemplated, it should be decided whether to attempt courses of 14 days or the generally more feasible eight weekly doses. As mentioned above, preventive measures will depend on the degree of preparedness and the time between the detection of risk and the expected beginning of the epidemic. When that time is short and preparations for vector control have not been completed, the only choice will be the strengthening of case-management capacity, as it was in the pre-DDT era.

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ANNEX

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Table A True Epidemics


Form of presentation
Sudden or eXploSive epi demic affecting a wide area almost ~rmnediately

Main determinants
Abnormally prolonged and heavy rains Extensive floods of large rivers crossing dry plains Unusually warm, humid and long summer in high-altitude valleys Abnormally prolonged dry seasons in well-drained, humid valleys, leading to formation of pools in river beds Prolonged periods of warm and relatively humid conditions in oases Massive destruction followed by displacement of large numbers of people, due to war or natural disasters

Parasites
In Asia, the Pacific and the Americas, the process starts with a P. v i v a epidemic, followed by a P. falciparum epidemic. If the epidemic potential continues for one or two more years, the P v i v a epidemic will be bimodal In tropical Africa, the epidemic will be due to P. falciparum

Expected evolution
Self-limited in space to the areas affected by determinant factors and in time to the relatively short mnsmission season The epidemic year is o h followed by one or two years of high transmission and then a period of no transmission, forming a paraquinquennial cycle In very arid areas, one or more pamquinquennial periods may be missed; epidemics may also be very focal, limited to particularly favourable microclimates Major epidemic following destruction, but subsiding after reconshuction

Primary control measures


Emergency supply of drugs and strengthening of diagnosis and treatment facilities If feasible, to be camed out before the epidemic peak: space spraying or reimpregnation of bednets, in areas where they are used Strengthening capabilities for epidemic risk monitoring and emergency preparedness for following years If predicted in time: Residual spraying to prevent epidemic Strengthening case management facilities and drug supply Vector control in refugee camps and villages Aid to rewnshuction of watermanagement works Strengthening case management and drug supply Emergency care of refugee populations Space andlor residual spraying, if feasible. in refugee camDs

As above

Failure of ongoing malaria control; return to previous or higher endemicity

Form of presentation

Main determinants

Parasites

Expected evolution
Serious socioeconomic upheaval creating new endemicity aggravated by reconstruction efforts

Primary control measures


Identification and control of new areas of high risk Where endemicity already reestablished, revision of of malaria-control strategy Emergency establishment of diagnostic and treatment facilities for P. falcipamm and management of severe malaria Vector c o n b l aimed at eradicating the invader Mobilizationof intercountry and international resources Strengthening of care services and drug supplies Vector conhol, if feasible before epidemic peak. Monitoring of risk factors for the following years Strengthening of care s e ~ c e s and drug supplies Vector control to reduce epidemic impact in current season, if feasible in time FWparation for vector control in the future, taking into account the feasibility of new vector elimination in the light of the conditions of the current reinvasion

Progressive invasion of a large area by a succession of local severe epidemics

Invasion by an exotic and highly efficient vector of ecologically receptive areas

The highly increased vectorial ability is likely to result in dramatic P. epidemics of falcipmm

Even if locally controlled, it is likely that the new vector will continue to invadeneighbouring areas

Periodic expansion of a dangerous vector beyond its normal area of distribution

P. vivax and P. falciparum as determined by immune status of population.

Periodic cycles of 1-3 epidemic years followed by spontaneous remissions

Reinvasion of an area by a previously eliminated vector

P. vivm and P. falciparum, as determined by the ecology of the area and population immunity

Differs from other failures of control as the eliminated vector has to invade in a similar way to an exotic vector, even if it does so more quickly

Form of presentation

Main determinants
Establishment of highly efficient forest vectors in neighbouring tree plantations

Parasites
Sylvaticvectorsadapted to human environment have produced P. falciparum outbreaks Epidemics of multidrugresistant P. falciparum commonly observed

Expected evolution
Establishment of high endemicity in resident population and continued epidemic outbreaks in labour force Continued high attack rates among newcomers; localized permanent epidemics Intensification of drug resistance Similar to above, but less selection of drug resistance, due to less drug pressure

Primary control measures


Vector control may eliminate the invader

Creation of foci of high appar ent endemicity in relatively l a with very high population turnover

Open-cast mining for gold or gems in jungle areas (high transmission, high consumption of drug) Labour camps (tropical aggregation of labour)

P. vivar or P. faiciparum or both according to the area

Guidance and support to diagnosis and treatment Vector control, impregnation of bednets, curtains and other materials Diagnosis and treahnent * Chemoprophylaxis, if accompanied by vector control

Table B Resurgeuces or Failures of Control


Form of presentation
EXpIosive resumption of transmission

Main determinants
Rapid and complete loss of protective effect of control measures similar to that following the intemption of mass chemoprophylaxis
F

Parasites
P. viva an& P. falcipadepending on remaining parasite reservoir and vectors, as indicated by previous endemicity in the area P. vivax andlor P. folcipanundepending on remaining parasite reservoir and vectors, as indicated by previous endemicity of the area

Expected evolution
After the epldemic wave, the previous endemicity will be reestablished, if there have not been any ecological changes

Primary control measures


Vector control before the peak of the transmission season to reduce the intensity of the epidemic wave Adoption of control strategy for endemic malaria Strengthening health care facilities and drug supplies Seasonal vector control could reduce epidemic impact Establishment of monitoring of epidemic risk indicators

Intemption of vector control in areas previously subject to periodic epidemics where hem transmission has interrupted for several epidemic cycles The first season of epidemic risk will find a highly nonimmune population Progressive return of endemicity Intemption of effective residual spraying in highly endemic area

After one or more epidemic waves, the area will return to the previous meso- or hypoendernic situation and he prone to future epidemics as in the period before control was instituted.

As above

It is important not to reestablish the previous unsustainable and excessive control campaign
Relatively subdued focal outbreaks as transmission is resumed following new construction and progressive loss of insecticidal effect Strengthening of health care facilities and logistics Adoption of control strategy for endemic malaria