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Introduction

In recent years, large-scale population movements in troubled areas of the world and the suffering associated with these displacements have caught the attention of the media. Often, the media’s attention focuses on the political vulnerabilities of the uprooted populations, the turmoil that caused the displacement, the malnourished state of the displaced, and occasionally, communicable disease epidemics, such as cholera, that occur in such settings. Rarely is it noted, however, that such displacement often occurs in malarious areas and that malaria is frequently a primary cause of death in the displaced population. Nonetheless, humanitarian responses to these situations have rarely given malaria control activities the degree of emphasis and the level of resources that the burden of disease and death due to the disease would seem to demand. In the past, malaria control in complex emergencies was a relatively low-priority activity that was often disorganized, poorly conceived, and, ultimately, inadequate. The field-based practice of malaria control in complex emergencies typically did not reflect a thorough and current understanding of the disease and its contributing factors and failed to adequately capitalize on lessons learned from stable situations. More recently, with the attention given to malaria by global initiatives such as Roll Back Malaria (<http://www.who.int/inf-fs/en/InformationSheet02.pdf>), there has been a noticeable increase in concern about the impact of malaria in complex emergencies and a desire to improve malaria control activities during mass population movements (Rowland and Nosten, 2001; <http://www.who.int/inf-fs/en/InformationSheet07.pdf >).



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Malaria Control During Mass Population Movements and Natural Disasters 1 Introduction In recent years, large-scale population movements in troubled areas of the world and the suffering associated with these displacements have caught the attention of the media. Often, the media’s attention focuses on the political vulnerabilities of the uprooted populations, the turmoil that caused the displacement, the malnourished state of the displaced, and occasionally, communicable disease epidemics, such as cholera, that occur in such settings. Rarely is it noted, however, that such displacement often occurs in malarious areas and that malaria is frequently a primary cause of death in the displaced population. Nonetheless, humanitarian responses to these situations have rarely given malaria control activities the degree of emphasis and the level of resources that the burden of disease and death due to the disease would seem to demand. In the past, malaria control in complex emergencies was a relatively low-priority activity that was often disorganized, poorly conceived, and, ultimately, inadequate. The field-based practice of malaria control in complex emergencies typically did not reflect a thorough and current understanding of the disease and its contributing factors and failed to adequately capitalize on lessons learned from stable situations. More recently, with the attention given to malaria by global initiatives such as Roll Back Malaria (<http://www.who.int/inf-fs/en/InformationSheet02.pdf>), there has been a noticeable increase in concern about the impact of malaria in complex emergencies and a desire to improve malaria control activities during mass population movements (Rowland and Nosten, 2001; <http://www.who.int/inf-fs/en/InformationSheet07.pdf >).

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Malaria Control During Mass Population Movements and Natural Disasters This is not to say that achieving effective malaria control is easy. Even among stable communities, the level of commitment and resources needed is substantial. As there is no simple “one size fits all” approach to malaria control, and in recognition of the multitude of factors influencing the potential success of any malaria control program, it becomes incumbent on those providing the services to base their decisions on the best practices available for the given situation. This, in turn, requires a familiarity with the technical aspects of malaria, an ability to obtain the information needed to make informed decisions, and a flexibility to match or adapt interventions to the local situation. An ability to facilitate effective communication and coordination among those involved (not just the relief community but the displaced and host communities as well) in order to develop an integrated plan of action is essential. Finally, adherence to best practices requires a commitment to address malaria with as much serious planning and forethought as are applied to the provision of water, sanitation, food, and shelter. In many situations the burden of disease and death attributable to malaria easily justifies this commitment. This monograph is intended to provide humanitarian workers with a comprehensive review of those aspects of malaria control that are most relevant to designing and implementing a program in response to mass population movements. Where possible, field-based examples from complex emergencies have been used to illustrate different approaches, some successful and others not. The intent is not to present a “cookbook” for malaria control but rather to provide the relief generalist with an overview of proven or promising malaria control interventions and enough background information to make informed decisions or to facilitate the recognition of when outside expertise and advice are required. Effective malaria control during mass population movements is more likely to be achievable given a willingness to become informed and prepared beforehand; it is hoped that this report will assist relief organizations to become better prepared to deal with this potentially devastating disease.1 1   Use of trade names throughout this monograph is for identification only and does not imply endorsement by the U.S. Public Health Service or the U.S. Department of Health and Human Services.

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Malaria Control During Mass Population Movements and Natural Disasters WHY MALARIA CONTROL IN EMERGENCY SITUATIONS? Mass population movements are not a new phenomenon; they have resulted from wars and natural disasters since antiquity. During the past several years a large number of conflicts in diverse regions of the world have forced millions of civilians to flee their homes and seek refuge in other areas of their country or in neighboring countries. People have also been forced to leave their homes because of natural disasters such as floods or droughts leading to severe food shortages. Periods of major social or environmental change often cause a secondary migration in which people move to seek better economic opportunities. In recent years many forced population movements have occurred in areas where malaria constitutes a substantial public health threat. The World Health Organization lists environmental disruption for agricultural or economic reasons, sociopolitical unrest, and migration as probable precipitating causes of the most serious malaria problems (World Health Organization, 1996a). Additionally, it has estimated that as many as one-third of malaria deaths in Africa occur in countries that have been affected by complex emergencies (Whyte, 2000). Malaria occurs in over 90 countries worldwide, and 36 percent of the world’s population lives in areas where there is risk of malaria transmission; 29 percent of the world’s population lives in areas where malaria was once transmitted at low levels or not at all but where significant transmission has been reestablished. An additional 7 percent lives in areas where malaria has never been under meaningful control (World Health Organization, 1996a). Each year there are an estimated 200 million to 500 million clinical cases of malaria and 990,000 to 2 million deaths, the majority of the deaths occurring in sub-Saharan Africa. The magnitude of this burden of illness makes malaria one of the world’s most important infectious diseases (World Health Organization, 1996a; Snow et al., 1999; Greenwood and Mutabingwa, 2002). In certain epidemiological circumstances, malaria can be a devastating disease with high morbidity and mortality that deserves rapid and comprehensive response. In other settings, while malaria may not be an important cause of severe illness and death, it may have a more subtle public health impact through increased morbidity, loss of productivity, and exacerbation of other problems, such as anemia and malnutrition. In many malarious areas of the world, especially sub-Saharan Africa, the disease is ranked among the most frequent causes of morbidity and mortality among children

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Malaria Control During Mass Population Movements and Natural Disasters and is often the leading cause of each. If this is the case for the stable host community, it is reasonable to expect that it will also be the case for a displaced population that finds itself in the midst of that host community. For a variety of reasons, malaria may actually be a far worse problem in the displaced population than it is in the surrounding community (Suleman, 1988). Public health responses to mass population movements due to a complex emergency2 or natural disaster typically represent a compromise between competing priorities and finite resources. Informed decisions, at times difficult ones, must be made as early as possible to define which components are most urgently needed and which should receive financial and logistical support. This is especially true during the initial emergency phase of a sudden or unexpected mass population movement. Adequate food, shelter, clean water, and sanitation are clear priorities (Toole and Waldman, 1990; Sphere Project, 2000). Responding to epidemics or the threat of epidemics due to diseases with high attack rates or high mortality (including malaria) is also a clear priority, especially in the case of diseases with an easily defined and practical intervention such as immunization. Defining the appropriate response for endemic diseases without a simple intervention, however, is far more difficult and may come down to a decision favoring what is operationally realistic over what is technologically possible. Such is the case with designing an appropriate ongoing malaria control program. Factors such as the intensity of malaria transmission, the level of immunity in the population, the biology of the locally prevalent parasite and vector, and the ecology of the location can all influence the design of an integrated malaria control effort. While there are technological solutions to most of the uncertainties presented by these variables, many are expensive, complex, or unsustainable. Because of the potential for malaria to be a major cause of illness and death among displaced populations, decisions about what approaches to support and implement need to be made on the basis of a solid understanding of the disease, the local malaria situation, the political/economic context in which relief operations occur, and a familiarity with control options. 2   Complex emergencies are generally defined as situations in which large civilian populations are exposed to war or civil strife, food shortages, and population displacement resulting in excess morbidity and mortality (Duffield, 1994; Palmer and Zwi, 1998; Goodhand and Hulme, 1999).

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Malaria Control During Mass Population Movements and Natural Disasters Provision of easily accessible and effective malaria therapy is an essential component of health care in areas where malaria transmission occurs, as well as in epidemic-prone areas and situations where populations are arriving from malaria-endemic areas. However, many agencies fail to make an effective transition from the initial stages in a complex emergency where the focus is on malaria case management, to the later stages where control activities should broaden to include both curative and preventive services. While malaria can certainly be an epidemic disease, with high attack rates and high mortality rates, its potential impact in nonepidemic settings should not be ignored. Objectives of This Report Any agency accepting responsibility for providing medical or public health services to a displaced population in or from an area where malaria transmission occurs will need to be prepared to deal effectively with malaria control. Similarly, organizations responding to public health needs following natural disasters or governments anticipating environmental disruption due to development projects must consider the possibility of increases in malaria transmission and the need for enhanced malaria control efforts on a temporary or permanent basis. Our objectives in this report are to describe in detail aspects that are most relevant to designing a malaria control program in response to a mass movement of people. The focus is primarily on situations of displacement, such as can occur with complex emergencies, natural disasters, or some development projects. The principles discussed here can also be applied to more stable nonemergency situations. There is a growing body of evidence and literature that address malaria control in situations of mass population movement; however, much still needs to be better understood. Wherever possible, examples and experiences from displacement situations are given here. However, many interventions and programs that have been successfully evaluated in stable communities have not been satisfactorily evaluated among displaced populations. Nonetheless, these experiences may offer insights and lessons into approaches that could be modified to address the needs of displaced populations. Making sound decisions regarding malaria control in any situation requires a familiarity with malaria itself, including the epidemiology of the disease; the life cycle of the parasite; and the interaction between parasite,

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Malaria Control During Mass Population Movements and Natural Disasters human host, environment, and mosquito vector. On the other hand, the realities of addressing an evolving complex emergency argue strongly in favor of providing straightforward and practical advice. Further complicating the situation, any mass movement of people will also have implications for the host population. A basic tenet of humanitarian relief is that assistance should be offered to those in need in a refugee- or displacement-affected area, but this tenet is often forgotten or ignored due to constraints associated with lack of funding, poor access and utilization, and political sensitivities (Wilson, 1992). Health care and other essential services should be integrated, whenever possible, into the existing services and policies of the host population (Cromwell, 1988; Van Damme et al., 1998). The intended audience for this monograph is primarily generalist relief workers who are in the position to develop, implement, and support disease control programs at the field, country, or home office level. While recommendations are provided that would be of use to clinical staff regarding the management of malaria, this paper is not intended as a handbook for action without first understanding the context of a situation. Approaches that may work in one setting may fail in another; decisions about which approaches are practical, logistically feasible, or economically justifiable in any given situation can only be made on a case-by-case basis. The intent is to (1) provide a basic technical background on malaria; (2) offer practical advice based on available evidence; and (3) where possible, provide field-based examples. Together, this information should help those involved in humanitarian relief efforts make reasonable policy and programmatic decisions that address the local malaria situation and the political realities in the field. Nonetheless, no written review can offer the quality of information provided by a consulting expert. To help the reader obtain qualified assistance, potential sources of technical assistance are also provided (see Appendix D). Addressing malaria in complex emergencies requires proper preparation and planning as well as adequate training for field personnel. RECOMMENDATIONS Require training in the fundamentals of malaria control, including the basics of epidemiology, entomology, clinical and behavioral considerations, and political factors that affect the provision and receipt of malaria services.

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Malaria Control During Mass Population Movements and Natural Disasters Develop generalized contingency plans to address malaria control pro-actively. Initially, these plans could be devised using existing information to reflect the malaria situation regionally (such as for Tropical sub-Saharan Africa, Southeast Asia, or Central Asia) and then modified as needed for specific local conditions (see Appendix D for information resources). These contingency plans should form the framework for developing a comprehensive and locally appropriate malaria control program. Be prepared to conduct a rapid initial assessment of the local malaria situation in order to be able to modify contingency plans as well as properly prioritize malaria control in relation to other locally relevant health needs. Provide or generate adequate financial resources for implementation of malaria control activities. Produce and implement a plan for monitoring and evaluating the effectiveness of the control program. Why Malaria Control in Emergency Situations? Key Points Mass population movements often occur in areas where malaria is transmitted. Given certain epidemiological conditions, malaria can be responsible for substantial levels of morbidity and mortality, especially in displaced populations. Effective malaria control, which is challenging in stable situations, becomes even more difficult in situations of displacement. Decisions about the most appropriate malaria control strategies to employ during a complex emergency are best made with an understanding of all the factors involved (epidemiological, entomological, clinical, behavioral, and political).