MEZA - Accelerating Malaria Elimination in Zanzibar
Project Abstract
In recent years, Zanzibar has made significant progress in reducing the burden of malaria. Through domestic and international support from the Global Fund to Fight AIDS, TB, and Malaria (GF), the United States President’s Malaria Initiative (PMI), as well as other international partners, the Zanzibar Malaria Elimination Program (ZAMEP) has achieved improved access to efficacious medicines, insecticide treated mosquito nets, effective indoor residual spray, universal coverage of malaria diagnostic tests, and implemented case-based surveillance, all contributing to Zanzibar reaching its lowest historical malaria prevalence (below 1 percent) between 2004 and 2007. Despite these significant gains, progress has stalled over the last 15 years, and Zanzibar has not yet reached malaria elimination (zero local transmitted cases). Among the identified challenges include: a) persistent high receptivity to malaria vectors, b) malaria vector population bio-dynamics (insecticide resistance, feeding, and resting behaviors), c) increased rate of imported malaria cases, and d) lack of innovative additional tools targeting malaria elimination.
The region's equatorial and humid climate, characterized by two primary rainy seasons, significantly influence malaria transmission dynamics. Unguja and Pemba islands are at different epidemiological transmission levels and exhibit different receptivity. Apart from the macro-malaria heterogeneity within the two islands, there is a remarkable micro-heterogeneity within the same island. Since case classification started in 2019 it is noted that the local vs imported case ratio (a marker for the reproduction rate under control measures, Rc) has been less than 1 every year, except for 2023, indicating favorable conditions for malaria elimination with declining receptivity despite high vulnerability. Nevertheless, local transmission, fueled by local receptivity and introduced cases, is still a reality. The 2023 El Niño year brought significant rainfall, which, in conjunction with extensive construction and development, contributed to the largest outbreak Zanzibar has recorded in years. While ZAMEP immediately sprang into action, coordinating across units and targeting response activities to effectively control malaria was a significant challenge.
Until recently, response activities were centralized and led by ZAMEP which resulted in logistical and operational challenges adequately identifying and responding to foci during the malaria surges. During the surges, collaboration with the Districts became stronger, but malaria surveillance and response activities were still largely conducted by ZAMEP and coordination weakened as caseloads declined. Additionally, the malaria surveillance system currently in use, Coconut Malaria Surveillance System, experienced significant challenges managing the caseloads during the surges in 2023/2024. Coconut is a custom-built system that manages malaria case-based notification, investigation, and response, and runs parallel to other Zanzibar Ministry of Health (ZMOH) systems, including DHIS2 and eIDSR. While Coconut helped ZAMEP achieve incredible progress to date, ZAMEP lacks technical expertise to maintain the custom-built system and their needs have outgrown what Coconut is able to provide. Lastly, inconsistent documentation of response activities hinders ZAMEPs’ ability to monitor the effectiveness of foci response and course correct as needed. While a disruption in the status quo has been necessary for some time to achieve malaria elimination in Zanzibar, the recent surges highlight the critical need for restructured and decentralized malaria surveillance and response activities, a more nuanced understanding of transmission dynamics across the islands, and innovative approaches to targeting the drivers of malaria transmission, particularly in Pemba and Mjini Magharibi Region of Unguja island.
The National Campaign for Accelerating Malaria Elimination in Zanzibar
Alongside the new National Malaria Strategic Plan (NMSP) 2024-2029, ZAMEP developed a conceptual framework to accelerate malaria elimination in Zanzibar. The plan outlines a comprehensive set of interventions aimed to achieve zero malaria transmission by 2029 across the islands and consists of two phases; the first is dedicated to establishing systems and processes creating an enabling environment that is adapted and responsive to heterogeneity across the islands, and the second is focused on expanding, iterating, and improving efforts from the first phase to further strengthen surveillance and coordinated, nimble foci management.
The framework includes four separate yet interconnected initiatives, each co-designed by ZAMEP and partners, with specific objectives. This proposal focuses on the first phase of the National Campaign for Accelerating Malaria Elimination in Zanzibar.
Grant Objective
To achieve the goals and objectives outlined in the NMSP and the conceptual framework, this project is designed to accelerate the elimination of local malaria transmission and to support the setup of a resilient Program to prevent re-establishment by 2029. Specifically, the Malaria Elimination in ZAnzibar (MEZA Project) aims to enable ZAMEP and District Malaria Response Teams to efficiently implement malaria elimination activities in Zanzibar by 2027, in support of zero local cases in Pemba by 2026 and in Unguja by 2029.
Grant Outline
The Conceptual Framework comprises four interconnected initiatives. In the context of Phase 1 and this Project, each of the initiatives play an important role in achieving the MEZA objective:
1. The first initiative, MAlaria eLImination in ZAnzibar (MALIZA - Swahili for finish it), focuses on creating an enabling environment through political engagement, and multisectoral collaboration. It aims to recharge malaria elimination efforts through robust multisectoral engagement, improved partner coordination, enhanced and effective surveillance, and through resource efficiencies by targeted and data-driven responses.
2. The second initiative, MAnaging Pemba Elimination of MAlaria (MAPEMA – Swahili for soon), targets the swift elimination of malaria in Pemba by intensifying interventions to block local transmission and mitigate imported cases.
3. The third initiative, ELImination of Malaria in Unguja (ELIMU - Swahili for education), aims for longer-term elimination in Unguja by first better understanding, then addressing the complex malaria epidemiology in the urban and peri-urban settings of Mjini Magharibi, and designing and testing innovative proactive interventions to combat urban malaria.
4. The final initiative, Joint TAnzania mainland & ZAnzibar MAlaria (TAZAMA – Swahili for lookup) emphasizes the use of molecular surveillance to understand the origin and relatedness of malaria parasites in Zanzibar, which will then support the refinement of geographically tailored interventions to effectively interrupt transmission, reduce importation, and prevent re-establishment.
These interconnected objectives will accelerate progress towards and achieve malaria elimination in Zanzibar by 2029.
