Maction Komwa [mkomwa@gmu.edu], PhD Candidate George Mason University Global Community Health Fairfax, VA 22030 

## Cost-effectiveness approaches in the control of mosquitoes in developing countries: A case study for Public Health Protection in Uganda & Zambia

## Outline  Main Objective  Introduction  Malaria and Lyme disease  Intervention strategies  Malaria and Lyme disease  

### Environmental management 

### /Home Management Malaria  Lessons learned/conclusion

## Questions to the audience?  

### Are there any historical programs that have been used with the aim to eradicate Malaria or Lyme diseases?  

### Were these programs a success or a failure?  

### Discuss Reasons ...............

## Main Objective  

### To highlight cost
- effective approaches to reduce mosquito 

### infestations and ensure minimal exposure to humans through the analytical evaluation of mosquito behavior and control programs.  

### To apply lessons learned from this analytical approach to the control program efforts of Lyme diseases

## Introduction Similarities between Malaria & Lyme diseases  Both are all transmitted through arthropods (insects or arachnids)  Ticks & mosquitoes are classified as parasites  Transmit diseases to people by blood
- sucking  Both diseases are strongly influenced by environmental factors.  Both are of important public health parasites to be discussed  Control of these can be partially attained through the spraying of insecticides or other methods of reducing the insect population such as Environmental Management

## Malaria  Malaria caused by one of the 4 types of protozoa is a major health problem in much of the tropics and subtropics.  

### It is spread by mosquito bites  The CDC estimates: 300
- 500 million cases of malaria each year, and more than 1 million people die Problem: Resistant to insecticides  This has led to difficulty in controlling both the rate of infection and spread of the disease

## Lyme disease  

### Lyme disease is most common tick
-borne illness in the northern hemisphere.  

### Caused by infection with a bacterium called 

### Borrelia burgdorferi .  

### Spread by deer ticks bites that harbor the bacterium.  

### Just like malaria the disease if left undiagnosed, the effects can be devastating.  

### Arthritis and neurologic symptoms• 

### Malaria is a major public health problem in Uganda • 

### Accounting for 25
-40% 

### of all outpatient attendances, • 

### 9
- 14% of admissions and a case fatality rate of 3% in Uganda (Republic of 

### Uganda 2008). 

## Public Health Protection in Uganda

Source: Hopkins et L. 2008 Figure 1. Map of sentinel site health centers

## Preventive interventions - malaria  

### Strategies recommended for vector management in Uganda are:  

### indoor spraying of houses with residual insecticides (IRS) and  

### insecticide
- treated bed nets 

### (ITNs)  

### Treatment through the use of anti - malaria drugs though 

### mosquitoes are becoming drug resistant.

## Lyme disease & Malaria control  

### Deer tick often hides in shady moist places

– this is also true with mosquitoes  Vegetation clearance around homes reduces the infestation of mosquitoes + ticks  House or yard screening (for mosquitoes, tick identification  Environmental management

–Target life cycle of both diseases  Modification of river boundaries, draining swamps, oil application to open water bodies  

### Both malaria and Lyme diseases can be treated if diagnosed early so see a physician as early as possible

## Treatment of – Lyme disease | Malaria  

### Treatment of Lyme disease mostly with antibiotics.  

### Long term use of anti
- malaria drug or antibiotics for Lyme disease can have the following consequences:  

### Costly  

### Inefficient and potentially harmful  

### Due to drug
-resistant conditions  

### What are cost
- effective preventative and control 

### measures being used in malaria control that could be part of lessons to be applied to Lyme disease control?

## Environmental Management to control



## Malaria

## Understanding the Life cycle of the



## diseasesCost-effectiveness of environmental management

Roll back malaria (RBM) : Case study of Zambia

( Utzinger, et al. 2001)  RBM
– (1998) aimed at halving the burden of malaria by the year 2010  (Using Lessons learned from historical data.) HOW? 

 

### Data Assembled (1929
- 1949):  

### Results:  3
- 5 Yrs  70 ± 95% low malaria related mortality, morbidity and incidence rates  Estimated costs per disability adjusted life year (DALY) averted  were US$ 524 ± 591.  Within 20 years  E stimated 4173 deaths and 161 205 malaria attacks.  Estimated costs per death and malaria attack [US$ 858 and US$ 22.20 respectively]

### Community low cost control measures



### Case study of Uganda  

### Community
- implemented malaria control programme  

### Tailored strategy to the prevailing ecological & epidemiological conditions  

### Understanding the ecological conditions which affect & regulate the distribution and abundance of mosquito populations.  Local priorities depends on local resources in order to have sustainable program (through the support of government agencies) 

## .  

### Home Management of Malaria

### Community low cost control measures

– Case study of Uganda  

### Home Management of Malaria  

### Providing training of the community members as medicine distributors (travel cost reduction to clinics )  

### Distribution of anti
-malarial medicines  

### Campaign, and community sensitization to caregivers (Adherence by caregivers, home cleanliness campaign 

### etc.)  

### Accessibility of anti
- malarial medicine in many villages  “bring appropriate drugs closer to home”  

### Availability of anti
- malarial medicine at an affordable price

### Efforts by Volunteers  

### Volunteers from the community (Community Medicine Distributors (CMD) are trained  Normally two are selected per village and trained  They evaluate and treat febrile children and are provided with ant
malarial drugs to household care takers  

### CMDs report to the nearest Health facility for supplies etc.  

### This is part of cost
- effective since household caretakers don’t travel a long distance to seek for emergency treatment  Risks are minimized (a journey of 5km to the nearest clinic including poor infrastructure can ultimately reduce preventable conditions and deaths)Advantages of community low cost control measures  

### Likely to be most effective and cost
- effective in areas with high malaria transmission  

### Limited health care infrastructure  

### Poor access to ant
- malarial treatment  

### Communities understand that malaria is the main 

### killer disease therefore becomes excited to participate.  

### Lubell , et al. 2010

### Funding of community based control programs  

### National Malaria Control Programme (NMCP) & MoH  

### Private Sector in Uganda  

### Non
- governmental organizations  

### WHO
- Geneva through the Makerere University  

### U.S. President’s Malaria Initiative (PMI)  

### UNICEF
- UNDP
- WORLD BANK
- WHO Special 

### Programme for Research and Training in Tropical Diseases (TDR)

### Difference between Uganda & US  

### The control program of these diseases are scientific, technical activity that requires skilled personnel  

### The majority of Ugandans are not well educated 

### compared to US so this can have different settings  

### Availability of local resources will dictate local 

### priorities.  

### Funding is a problem and as a result in Uganda most villages rely on community efforts to sustain their programs.

## Lessons learned  

### Considering the similarities of the behavior of mosquitoes and ticks behavior employing both prevention interventions combined with alternative low cost 

### strategies can help to reduce malaria and Lyme diseases.  

### Community efforts in Uganda can be a foundation for further research that could help to develop effective local strategies that can ensure sustainability.  

### Historical studies can help to modify strategies to control mosquitoes and likely ticks infestation.

### Conclusion  Ticks, and mosquitoes will continue to be important public health parasites for discussions.  Effective control measures will not only be measured by the effectiveness of a particular method or combination of methods, but also in the methodology that will ensure sustainability and minimal exposure to humans.  Community involvement & institutional participation could also strengthen the control measures.  Environmental management has a long
- term track record of successful malaria control in a diversity of ecological, epidemiological and socio
- economic settings.  Specific control strategies should be developed for specific country conditions

## References  Ajayi , I.O. et al. 2008. Effectiveness of artemisinin -based combination therapy used in the context of home management of malaria: A report from three study sites in sub
- Saharan Africa Malaria Journal, 7:190.  Centers for Disease Control & Prevention. Malaria. http://www.cdc.gov/malaria/  Hopkins, H. et al. 2008. Rapid Diagnostic Tests for Malaria at Sites. of Varying Transmission Intensity in Uganda JID 2008:197 (15 February)
 Jacobson, K. H. (2008). Introduction to global health. Sudbury, MA: Jones and Bartlett Publishers.
 Lubell Y, Mills AJ, Whitty CJM, Staedke SG (2010) An Economic Evaluation of Home Management of Malaria in Uganda: An Interactive Markov Model. PLoS ONE 5(8): e12439. doi:10.1371/journal.pone.0012439  Utzinge et al. 2001. Effcacy and cost
- effectiveness of environmental management for malaria control. Tropical Medicine and International Health. 6:9 pp 677
- 687

# Thank you

# Discussions