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Introduction

Malaria Control Manual
Introduction

Malaria Control Manual

Malaria Control
Manual

Table Of Contents

Introduction
Table Of Contents

Malaria Control Manual ....................................................................... 1

Introduction.......................................................................................... 1

Table Of Contents................................................................................ 2

Who are these guidelines for? ........................................................... 5

Malaria – why get involved? ............................................................... 6

Part I ..................................................................................................... 9

Background Information..................................................................... 9

What is malaria? ................................................................................ 10

Malaria control ................................................................................... 21

Monitoring And Evaluation ............................................................... 37

Part II .................................................................................................. 39

Intervention ........................................................................................ 39

Oxfam’s role and collaboration ........................................................ 40

Oxfam Malaria Control Strategy ....................................................... 42

Specialist Support ............................................................................. 46

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Humanitarian Manual

Assessment ....................................................................................... 47

Assessment Methods........................................................................ 53

Malaria Control
Manual
Introduction
Table Of Contents

Analysis.............................................................................................. 59

Planning ............................................................................................. 61

Implementation .................................................................................. 67

Baseline Data ..................................................................................... 76

Information, Education & Communication:..................................... 79

Monitoring & Evaluation ................................................................... 89

Part III ................................................................................................. 94

Resources .......................................................................................... 94

Contacts........................................................................................... 95
GLOSSARY ........................................................................................ 97

Bibliography..................................................................................... 101

Potential Partners............................................................................ 103

EXAMPLE MEMORANDUM OF UNDERSTANDING ....................... 105

SIGNS AND SYMPTOMS ................................................................. 107

Focus Group Discussion Framework ............................................ 109

Terms of Reference ......................................................................... 111

Humanitarian Manual

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Malaria Control
Manual
Introduction

MALARIA QUIZ QUESTIONS .......................................................... 115

ITN Monitoring Form ....................................................................... 118

Table Of Contents

LESSONS ON MALARIA ................................................................. 119

Malaria Songs .................................................................................. 144

STORY ABOUT MALARIA............................................................... 147

MALARIA.......................................................................................... 149
Malaria Advice for Overseas Travellers (from staff health
guidelines) ................................................................................. 154

Example Malaria Budget ................................................................. 161

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Humanitarian Manual

Who are these guidelines for?

Malaria Control
Manual
Introduction
Who are these
guidelines for?

This book is meant for all Oxfam staff who may be involved in initiating a
malaria control project in humanitarian situations specifically although much
of the background information will be useful for longer term programmes.
Knowledge of malaria control is important for Public Health Promoters, Water
and Sanitation Engineers and Project Co-ordinators and Managers in order to
facilitate decision-making and project formulation.

Public Health Promoters and Water and Sanitation engineers especially will
need guidance on how to implement such a project and what lessons have
been learnt from previous malaria control projects. They will also need to be
aware of how to plan an effective vector control project, which targets malaria
vectors.

Non technical managers will need to have a reference book that can guide
them in deciding whether intervention is required or not. It will also help
those seeking funding or writing proposals for malaria control projects and
enable them to present clear arguments for intervention.

Humanitarian Manual

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Malaria Control
Manual

Malaria – why get involved?

Introduction
Malaria – why get
involved?

Malaria is a preventable and curable disease and yet more than one million
people die from it each year. It is a disease that significantly affects the poor
who suffer economic, social and educational deprivation. Malaria is also a
disease that flourishes in conditions of crisis and population displacement and is
therefore of particular concern to those involved in addressing public health in
emergencies. The following factors contribute to its spread during humanitarian
emergencies:

The breakdown of health services and of malaria control programmes

Movements of non-immune people or concentration of people in high
risk areas for malaria

The weakened nutritional state of the displaced population

Environmental deterioration that encourages vector breeding

Limited access to populations at risk

Environmental factors such as flooding

Two billion people in over 100 countries live in areas where malaria is present
(40% of the world’s population). Malaria is accountable for between 1.5 and
2.7 million deaths worldwide each year and at least 30% of all malaria deaths
take place in complex emergencies.

Most malaria related deaths occur in children under five years of age. In
Sub Saharan Africa one in ten deaths of children under 12 months of age and
one in four deaths of children between 1 and 4 years of age are caused by
malaria. Some parts of the world are also experiencing a resurgence of
malaria and malaria has even been recorded in areas where it was previously
unknown.

In the past it has been the policy of many donors funding humanitarian
interventions not to get involved in addressing diseases that are endemic in a
country but only those that are likely to cause severe epidemics. It has become
increasingly clear however, that patterns of malaria transmission are changing
and that complex emergencies provide conditions that enhance the spread of
malaria and make epidemics more likely. In addition the number of natural
disasters, especially flooding, is on the increase, creating ideal conditions for
vector breeding.

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Humanitarian Manual

High mortality rates due to any cause demand humanitarian intervention and
malaria epidemics are no exception. However, even in the absence of an
epidemic, an opportunity to address the increasingly significant problem of
endemic malaria should not be ignored by agencies involved in humanitarian
emergencies.
Any intervention must however, be based on reliable
background information and current evidence of effectiveness.

Humanitarian Manual

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Malaria Control
Manual
Introduction
Malaria – why get
involved?

Part I
Introduction
Malaria – why get
involved?

Page 8

Humanitarian Manual

Part I
Background
Information
Malaria – why get
involved?

Part I
Background Information

Humanitarian Manual

Page 9

Part I
Background
Information

What is malaria?

Malaria is a complex disease. Its severity is a function of the interaction
between the parasite, the Anopheles mosquito vector, the human host and the
environment. The risk of malaria infection is determined by the number of
vectors, their survival rate, the incubation rate for both the vector and the
parasite and the probability of the vector feeding off a human host. These
parameters are directly influenced by meteorological variables such as rainfall,
temperature and humidity that give rise to differences in stability of disease
transmission and seasonal variations in disease incidence. Behavioural traits,
genetic variation and immune status in the human population will also
influence the degree of exposure and the disease outcome.

The Vector: anopheles mosquito
There are over 3,000 species of mosquito of which approximately 100 are
vectors of human disease. Disease is transmitted when the female of the
species takes a blood feed in order to provide nourishment for the
development of her eggs. The female anopheles mosquito is responsible for
transmitting malaria but different species such as aedes and culex mosquitoes
transmit other diseases such as yellow fever, dengue and filariasis. Some
anopheles mosquitoes may also transmit filariasis.

Anopheles mosquitoes usually bite from dusk to dawn although in some
situations they will bite earlier than this. In many localities the principle
vectors of malaria are late night biters and the older mosquitoes (more likely
to be infected) are often found to be biting between 12am to 4am. Different
species of anopheles however, may have different peak biting times,
preferences (animals or humans) and different resting habits (indoor or
outdoors) and these factors will influence the choice of control methods.
Indoor resting is most common in dry or windy areas where safe, outdoor
resting sites are scarce.

The table on page 65 provides details of the common vectors and behaviour.

Anopheles mosquitoes breed in numerous different water habitats from
shaded ponds and pools to hoof prints and tyre tracks. They tend to prefer
water that is not too polluted but some Anopheles gambiae species have been
shown to breed in stagnant drains. Artificial containers such as pots or tanks
are usually only suitable breeding sites for aedes vectors. The exception to this
is An. stephensi in South West Asia.

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The female mosquito lays her eggs on the water and these subsequently
develop into larvae and then into pupae. The pupa finally hatches to produce
a mosquito. This process can take between 7-16 days but is influenced by
humidity and temperature – the higher the temperature and humidity the
more rapid the life cycle. Digestion of the blood meal and simultaneous
development of the eggs takes about two to three days during which time the
mosquito does not usually bite.

Breeding Cycle of the Female Anopheles Mosquito

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Part I
Background
Information
What is malaria?

Table of common vectors and preferences

Vector &
Geographical
area

Breeding Places

Biting Habits

Resting Habitat

An. gambiae
(An. gambiae
complex also
used to refer to
six similar
species
including
arabiensis and
melas)

Mainly temporary
habitats such as
pools, puddles,
hoof prints, borrow
pits but also in rice
fields. Stagnant
water and
irrigation sites

Anthropophilic
(prefers to bite
humans). Exophagic
(bites outdoors) and
endophagic (bites
indoors). Preference
for nocturnal feeding

Predominantly
endophilic (rests
indoors after
feeding) but also
exhibits partial
exophily (rests
outdoors after
feeding)

Swamps, marshes,
edges of streams,
rivers, ditches and
other stagnant
waters especially
along the coastline.
Also irrigation
sites. Prefers
shaded habitats

Predominantly
anthropophilic but
also an amount of
zoophily (prefers to
bite animals).
Exophagic and
endophagic.
Preference for
nocturnal feeding.

Predominantly
endophilic

Breeds in swamps,
marshes, and edges
of streams, rivers,
and ditches.
Prefers sunlit
habitats

May be both
anthropophilic and
zoophilic but shows
a greater tendency
towards zoophily.
May be both
exophagic and
endophagic

Greater tendency
towards exophily
but may also be
endophilic.

A salt water
breeder, occurs
along coastal areas.
Common in
lagoons and
mangrove swamps.
Heaviest breeding
takes place in areas
colonised by the
black mangrove

Anthropophilic; may
show some zoophily
in some areas.
Exophagic and
endophagic

Predominantly
endophilic –
occasionally
exophilic

Prefers marshes,
swamps, rice fields
and ponds,

Anthropophilic and
zoophilic,
endophagic and

Predominantly
endophilic

Sub Saharan
Africa (e.g.
DRC,
Tanzania,
Sierra Leone)
An. funestus
Sub Saharan
Africa (e.g.
Ethiopia)

An. arabiensis
Sub Saharan
Africa (e.g.
Ethiopian
Highlands))

An. melas
Sub Saharan
Africa

An. pharoensis
Sub Saharan
Africa & North

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Africa & North
Africa and
Middle East

especially those
with an abundance
of vegetation

exophagic

An. stephensi

Breeds in man
made habitats
associated with
towns (cisterns,
wells, gutters,
water storage jars
and containers),
fresh or brackish
waters and has
been found even in
polluted waters, in
rural areas breeds
in grassy pools
alongside rivers

Anthropophilic,
endophagic and
exophagic

Predominantly
endophilic

Breeds in flowing
waters such as
foothill streams and
irrigation ditches,
also rice fields and
borrow pits, prefers
shaded areas

Mainly
anthropophilic but
also feeds on
domestic animals,
predominantly
endophagic

Predominantly
endophilic

Muddy and shaded
forest pools, hoof
prints, vehicle ruts

Anthropophilic and
zoophilic.
Predominantly
exophagic

Exophilic

Fresh water
marshes, lagoons,
rice fields, swamps,
lakes, edges of
streams especially
with vegetation,
shaded habitats

Predominantly
anthropophilic and
endophagic

Endophilic

Indian Sub
continent,
North Africa &
Middle East
(e.g.
Afghanistan/
Pakistan)

An. minimus
(includes
flavirostris)
Indian Sub
continent,
South East
Asia
An. dirus (An.
leucosphyrus
group)
Indonesia

An. darlingi
Mexico &
Central
America,
South America

Part I
Background
Information

The Parasite: Plasmodium
Malaria is caused by a parasite known as Plasmodium that is carried by the
mosquito. There are four different species of Plasmodium that infect human
beings, each with different incubation times:

Plasmodium falciparum 9 – 14 days incubation
Plasmodium vivax 12 – 17 days incubation

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What is malaria?

Plasmodium ovale 12 –17 days incubation

Part I

Plasmodium malariae 18 – 40 days incubation

Background
Information
What is malaria?

Plasmodium falciparum is the most dangerous of the malaria parasites. It
causes ‘malignant’ or cerebral malaria that can quickly progress to
unconsciousness and death.

Untreated or poorly treated infections can cause recurring fevers and are
communicable from several months to two years (P.falciparum) and up to fifty
years (P.malariae).

The female anopheles will usually only feed once in a night, however if she is
disturbed she will continue feeding until she has sufficient blood for the
nourishment of her eggs. This may then be from more than one host.
Following ingestion of Plasmodium infected blood, the parasite undergoes
various stages of reproduction and development within the mosquito. The
parasite will then migrate to the salivary glands of the mosquito and once she
bites another host, the parasite will be transmitted. As the female mosquito
feeds, saliva, containing Plasmodium is injected as an anticoagulant and the
host becomes infected. The extrinsic development of the parasite in the
mosquito takes between ten to fourteen days.

Transmission cycle

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Part I

Signs and Symptoms of Malaria
The main symptom of malaria is fever, caused by the simultaneous rupturing
of red blood cells following large-scale parasite multiplication. The fever is
often accompanied by chills and sweating. Other symptoms may be headache
and joint pains. Jaundice, anaemia or diarrhoea may also be signs of malaria.
Severe malaria is usually characterised by coma, delirium and convulsions in
addition to the previous signs and symptoms. A list of signs and symptoms
for complicated and uncomplicated malaria is provided in the appendix.

The anaemia caused by repeated malarial infections can often cause chronic
anaemia that may make the individual more susceptible to other infections
and even to death. In addition infections contracted during pregnancy can
cause low birth weight and a greater tendency to infection in childhood. It is
also common for children to present with both malaria and another infection
such as pneumonia.

A definitive diagnosis of malaria can only be made by examination of a blood
sample. This is a relatively straightforward procedure requiring a finger prick
of blood. However, microscopy facilities are needed to examine the blood
slide and these are often not available. In many highly endemic areas a large
proportion of the population may have parasites in their blood but no
symptoms of malaria, making diagnosis difficult even if a blood sample is
taken. Given the seriousness of the disease however, it is accepted as
appropriate in most endemic countries to treat all cases of fever even though
only a percentage of them may actually be confirmed as malaria. Typhoid,
meningitis and pneumonia are often wrongly diagnosed as malaria on clinical
examination alone.

Treatment
The first choice of treatment (often referred to as ‘first line’) in many countries
in Sub-Saharan Africa remains chloroquine despite increasing resistance of P.
falciparum to the drug. Fansidar is the second drug of choice for treatment (2nd
line) in Sub-Saharan Africa. In Asia where there is multiple drug resistance
the first line treatment will vary.

Quinine is used to treat complicated malaria but is often given inappropriately
by injection to treat simple malaria. Quinine is often given in combination
with another drug, usually doxycycline or tetracycline, to ensure a high cure
rate, although neither doxycycline nor tetracycline is suitable for pregnant
women or children under eight years old.

Interest has recently focused on artemisinin drugs that are rapid acting,
effective against all strains of p. falciparum and p. vivax and are well tolerated.
Artemisinin is derived from a Chinese herbal remedy used for thousands of

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Background
Information
What is malaria?

Part I
Background
Information

years to treat fever. There are concerns that its unregulated use could lead to
parasite resistance but as a result of market pressure, the drug is available in
the private sector in most malaria endemic countries of the world.

What is malaria?

Drug combinations for multidrug resistant malaria are being developed by the
private sector: atovaquone+proguanil (now registered) and artemether+
benflumetol (yet to be registered).

The prophylactic drug of choice for pregnant women remains chloroquine in
Sub-Saharan Africa but in some countries this is supplemented with
Proguanil. Ensuring patient compliance with this drug is difficult as it is
given on a daily basis.

Suggested drugs that may be used for prophylaxis for those with no immunity
is given in the resource section. Some drugs may cause side effects and
information should be available to patients on these. A table of common
treatment regimes is provided below.
Common Treatment Regimes & Possible Side Effects

Generic Name

Chloroquine

Usual
Content per
tablet

Adult Dose

100 or 150mg
(base)

600mg 1st and
2nd day
300mg 3rd day

Possible Side Effects

Gastro intestinal disturbances,
headache, visual disturbances,
depigmentation or loss of hair,
skin reactions

Sulfadoxine/pyri
methamine

500mg +
25mg

1500mg +
75mg (3 tablets
in one dose)

Blood disorder, rashes,
insomnia,

Sulfalene/pyrime
thamine

250mg (base)

1500mg +
75mg (3 tablets
in one dose)

Blood disorder, rashes,
insomnia

Mefloquine

250mg base

1000mg or
15mg/kg of
body weight
(whichever is
lower in one
dose) or
1000mg
initially +
500mg 6-8
hours later

Diarrhoea, abdominal pain,
nausea, vomiting, loss of
balance, headache, sleep
disorders, anxiety, depression,
panic attacks, overt psychosis

Quinine

300mg (salt)

10mg/kg of
body weight 3
times/day for

Tinnitus,, headache, skin
flushes, nausea, visual
disturbances, confusion, blood

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7 days
Quinine +
tetracycline

disorders

Part I

Tinnitus,, headache, skin
flushes, nausea, visual
disturbances, confusion, blood
disorders
500mg +
500mg 6 hours
later + 500 mg
6 hours later

Diarrhoea, abdominal pain,
nausea, vomiting, skin rashes,
ventricular arrhythmias

Halofantrine*

250mg (base)

Artesunate

50mg

Headache, nausea, abdominal
2mg/kg of
pain, vomiting, occasional
body
diarrhoea
weight/day
for 5 days with
a double
(divided) dose
on the first day

Artemisinin

250mg

Headache, nausea, abdominal
15mg/kg of
pain, vomiting, occasional
body
diarrhoea
weight/day
for 5 days with
a double
(divided) dose
on the first day

* Halofantrine can cause serious cardiac arrythmias and Oxfam staff health
does not recommend its use. It is frequently available on the private market in
many countries.

Vaccine Development
In the last decade, considerable progress has been made in the search for a
malaria vaccine. An effective vaccine would constitute a powerful addition to
malaria control. More than a dozen candidate vaccines are currently in
development and some of them are undergoing clinical trials.

Vaccines for malaria are being developed at a global level and clinical trials
are ongoing in USA, Colombia, Switzerland, Australia, Papua New Guinea,
Gambia and Tanzania. A cost -effective vaccine must be capable of being
incorporated into appropriate health delivery programmes, and must provide
a sufficient duration of immunity. At present, it is difficult to predict when
such a vaccine will become available but estimates suggest that one may be
available within the next 15 years.

Malaria Eradication and Control
In the 1950’s efforts were directed at the eradication of malaria following
successes in Europe and other countries such as Singapore. The key to
eradication was believed to be the use of insecticides and this was emphasised

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Page 17

Background
Information
What is malaria?

Part I
Background
Information
What is malaria?

at the expense of a more holistic approach to control. Whilst eradication has
been achieved in many wealthier countries such as the USA, Singapore,
conditions prevailing in sub Saharan Africa especially have failed to make
eradication a reality. WHO and the Roll Back Malaria campaign now focus on
more modest goals of malaria control and the prevention of unnecessary
deaths due to malaria.

Malaria and Pregnancy
Malaria in pregnancy is a risk to both mother and baby. It contributes to
maternal and neonatal mortality, infant anaemia, maternal anaemia and low
birth weight babies, who are more likely to die. Pregnancy reduces a
woman’s immunity to malaria, making her more susceptible to severe malaria
than other adults. Treatment of acute malaria is also more complicated in
pregnancy. Even if an infected mother does not have a fever, the baby is still
at risk. Protecting pregnant women is therefore a priority.

Pregnant women who are also HIV positive have a higher prevalence and
density of malaria parasites in their blood than HIV negative women.
Placental parasitaemia increases the risk of death among infants of HIV
positive pregnant women. Recent research has also shown that malaria
infection in the placenta can increase the risk of HIV being transmitted from
mother to baby.
Two treatment doses of sulfadoxine pyremethamine (SP) given to all pregnant
women (whether they have symptoms or not) has recently been found to
significantly reduce the negative consequences of malaria in pregnancy. This
approach is known as Intermittent Presumptive Treatment (IPT). A recent
survey in Malawi found that 75% of women had received at least one dose
and 30% at least two doses of SP during pregnancy. The women receiving SP
in pregnancy had significantly lower rates of placental infection and low birth
weight babies. The rates of maternal anaemia were also reduced.

Malaria and Malnutrition
The link between malaria and malnutrition appears complex and the existing
research does not yet answer all the questions about the interaction between
these two factors. There is currently renewed interest in researching the link
between malaria and micronutrients. Several research papers seem to provide
evidence that well nourished children have more severe malaria compared to
malnourished children and the existence of severe anaemia in malnourished
children is offered as an explanation for this. Other papers however, have
demonstrated that stunting but not wasting may provide a protective factor
for malaria.

Whilst it has been demonstrated that the incidence of malaria increases
concomitantly with an improvement in nutrition and access to food in the
aftermath of a famine, there is no evidence to prove a causal link between

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these two factors. The explanation for this increase may rest in the
coincidental increase in rainfall and breeding sites.

Background
Information
What is malaria?

Malaria and Floods
There is much current debate about the impact of floods on public health.
Recent research on the health impact of natural disasters related to the El Nino
phenomenon showed marked changes in the incidence of malaria in parallel
with extreme weather conditions associated with El Nino. The complex
interplay between all the factors governing malaria incidence however, must
be taken into account in order to explain the rises in incidence. Thus changes
in the ecology of the mosquito habitat, increased exposure to mosquitoes (e.g.
because shelter had been destroyed) and disruption to malaria control services
may all have a role to play in explaining the increase in incidence and there
does not appear to be a simple correlation between floods and increased
incidence of malaria.

Humanitarian Manual

Part I

Page 19

Part I
Background
Information
What is malaria?

Epidemics
An epidemic is described as an unusual increase in the incidence of disease
compared to normal seasonal variations. The following principle categories of
epidemic should be distinguished (adapted from Najera 1996: Malaria Control
amongst refugees and displaced populations WHO: Geneva):
Epidemic Type

Cause

Government or
Agency Response
Usually intensive but
short transmission –
control measures
generally applied when
epidemic subsiding so
ineffective. Can often be
predicted so should be
possible to prevent earlier
since meteorological
abnormalities generally
follow quasi regular
periodicity (5 to 10 years,
in some areas longer).
Ensure extra availability
of drugs and possibly
prophylaxis for those at
risk.

Epidemics resulting
from an abnormal
increase in disease
transmission in nonendemic areas or areas
of low endemicity,

short-lived increases in
vector density as a result of
high rainfall or floods

Epidemic outbreaks
resulting from
increased arrival of
non-immunes

Large population movements
of non –immunes to areas of
high endemicity (e.g.
Burundi refugees in
Tanzania)

Ensure facilities for
diagnosis and treatment,
community mobilisation
and education, source
reduction where practical,
further assessment to
determine if ITNs or
residual spraying suitable
intervention

Epidemic resurgence of
transmission in
endemic areas

Vector control or
chemoprophylaxis has
succeeded in reducing
malaria incidence to levels
below the ecological
potential of the area but
control measures have
suddenly been discontinued
(e.g. East Timor)

Epidemics reflecting a
new high endemic
potential as a result of
lasting modifications to
environment

Agricultural expansion in
potentially malarious but
previously uncolonised areas

Ensure necessary facilities
for diagnosis and
treatment, vector control
instigated prior to
movement of people

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increased vector survival
following periods of
favourable temperature or
humidity (e.g. Ethiopian
highlands) or movement of
infected groups into area

(e.g. colonisation of Amani
highlands in Tanzania)

Humanitarian Manual

Malaria control

Part I
Background
Information
Malaria control

Malaria control is an organised attempt to carry out appropriate anti malaria
measures to achieve the best possible improvement in the health of any
population affected by malaria or exposed to an increased risk of its
resurgence.

Attempts to control malaria have worked in many areas of Europe and the
Former Soviet Union but most attempts to control the disease in Africa have
failed for a number of reasons amongst which is a lack of resources and a
limited ‘vertical’ approach to control which focused mainly on vector control
and the use of insecticides. Mosquitoes have also become increasingly
resistant to insecticides such as DDT and the malaria parasite has developed
increasing resistance to standard drug treatments such as chloroquine. Rather
than continue to focus on the goal of eradication, WHO now aims to prevent
mortality and limit excess morbidity.

Response Options
The World Health Organisation has defined four key elements of malaria
control:

Early diagnosis and treatment

Prevention including vector control

Early detection, containment and prevention of epidemics

Strengthening national capacity for malaria research and monitoring.

The following table details potential interventions and when they can be used.
Early diagnosis, treatment and community education are the basic responses
that should be included in all programmes. Usually a combination of
responses is required for optimal control.

Potential Responses

Response Option

Method

Suitability for
Oxfam

Drawbacks

Early Diagnosis &
Treatment (may
include active case
finding during

Ensure access to
clinics and
appropriate
treatment and

Oxfam does not
usually provide
clinical care in
emergency settings.

Access may be
compromised
through insecurity,
payment for drugs

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Part I
Background
Information

is often required
meaning poorest
may not have
access, lack of
supplies of
essential drugs

high risk
situations)

raise awareness of
importance of
seeking treatment
early, community
members or
outreach workers
may be needed to
identify cases
early and refer,

Community
education and
mobilisation*

Working in
partnership with
communities to
identify what
actions they can
take to control
malaria, raising
awareness
through
participatory
learning

All programmes but
must ensure adequate
capacity to address
other high risk issues

Access may be
compromised
through insecurity

Social Marketing

Use of marketing
principles to
price, position
and promote
sale/acceptance
of bednets
especially

Some of principles of
social marketing may
be used to inform
approach to
mobilisation but may
not be sufficient time
available

Extensive
formative research
required but work
with communities
may feed into
longer term
programme

Residual house
spraying

Spray inside walls
with insecticide to
kill resting
mosquitoes

May be suitable.
Effective only where
indoor resting
anopheles,

Requires welltrained staff,
reliable equipment
and financial
support. May cause
environmental
pollution (although
this must be
weighed against
the prevention of
excess mortality)

Malaria control

All programmes
should try to ensure
that adequate facilities
are available, lobbying
other agencies or the
MoH or providing
minimal support are
possible areas of
intervention

high coverage needed,

Insecticide treated
nets, clothing and
bedding

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Polyester nets
dipped in
permethrin or
lambdacyhalothri
n every six
months, other
materials such as
shawls and

May be suitable.
Effective only if
mosquitoes bite after
people go to bed
(young children and
babies may go to bed
early)

May be easily
damaged in camp
situation,
retreatment
necessary every six
months

Humanitarian Manual

blankets have also
shown promising
results: prevent
man-vector
contact and may
initially kill
mosquitoes
resting on net

Part I
Background
Information
Malaria control

Chemoprophylaxis

Provision of
prophylaxis to at
risk groups

Often given as routine
antenatal care –
provision of drugs
(short term) may be
feasible, may be
possible to distribute
prophylaxis to at risk
groups if no other
agencies have the
capacity

Effectiveness of
chloroquine
prophylaxis
controversial,
access to at risk
population
required

Source reduction

Identifying and
destroying
breeding sites,
ensuring
adequate
drainage

May be suitable.
Requires mass
mobilisation and
commitment to be
effective, most
effective in densely
populated areas where
transmission is not
intense but important
long term measure
and education at least
should introduce this
at a household level

Long term
measure, may not
be possible to
achieve impact in
short term time
frame. Little
succcess in trying
to control an.
gambiae using this
method

Larviciding:
chemical

Use of chemicals
to kill larvae or
prevent them
from developing

Specific problem
breeding sites such as
swamps – cannot be
used in rice paddies
(see below)

Not feasible in
many areas due to
large number and
scattered nature of
breeding sites,
larvicides may be
dangerous to
wildlife

Larviciding:
biological

Use of larvae
predators such as
fish or biological
larvicides such as
Bacillus
thuringiensis (Bt
H-14)

Medium to longer
term programmes if
suitable fish can be
bred quickly and
facilities available. Bt
H-14 not toxic to
animals or humans

Similar to above. Bt
H-14 is expensive

Zooprophylaxis

Separation of
humans and

Has been successful in
Afghan refugee camps

May be difficult to
apply and achieve

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animals to draw
vectors away
from former

Part I
Background
Information

in Pakistan and where
applicable should
form part of education

significant results,
people may keep
animals in shelters
for warmth

Malaria control

Early Diagnosis and Treatment & Active Early Case
Finding
WHO suggests that the most important factors that determine the survival of
patients with falciparum malaria are early diagnosis and appropriate
treatment. It is estimated that 52% of deaths occur in the first 48 hours.
Treatment facilities may be few and far between during an emergency or
access by the poorest sections of the community may be denied because of the
fees levied for consultations or drugs. Essential drugs may not be available
and, in the case of chloroquine resistance, may be inappropriate.

An aggressive case finding programme will be justified in high risk situations
in order to start treatment in an early stage of the disease. This will help
prevent progression to severe or complicated cases and possible death.

Case finding is only practical if there are adequate clinic facilities and supplies
of drugs to treat patients. If other international NGO’s are supporting clinics
they may have initiated a system of outreach workers already and coordination with them is essential.

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Part I
Why do people not seek treatment?

‘The principal problem that arose was with regard to health seeking
behaviour due to the poor reputation of curative services in the camps.
Specific problems cited were poorly trained staff, excessive waiting
times (up to two days) and poor patient flow within the hospitals
leading to long waits between initial consultations, diagnostic testing
and receipt of treatment. Some groups also expressed concern about
open conflict between local and Burundian staff leading to delays in the
receipt of treatment. It was recognised that a triage system was in
operation but this has led to patients and carers waiting for the
development of life threatening illness before attending the hospital.
There was a general feeling that hospital staff did not treat patients
with respect. All these factors have led to a failure on the part of
patients and carers to seek prompt medical treatment at the hospital
and to the seeking of alternative treatments such as self treatment with
drugs, traditional healers and witchcraft.’ (Vector Control in the
Greater Lukhole Refugee Camp – Mark Myatt 1999)

Case finding can be done by health workers, community health workers,
community leaders, students, teachers or outreach workers. If the situation is
critical and it is necessary for people to work all day, it will be necessary to
pay people for this job. Special attention should be given to identifying high
risk groups such as children and pregnant women. Often new arrivals to a
camp situation are screened and treated if they have symptoms.
Training for the outreach workers will need to be carried out and they will
need to be supervised and supported. Provision for follow up training should
also be made.

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Background
Information
Malaria control

Part I
Background
Information
Malaria control

Information, Education & Communication (IEC)
Community mobilisation and education
Global Malaria Control Strategy

“The Global Malaria Control Strategy places the greatest emphasis
on the building of local capabilities to understand and solve
problems, more than in the massive use of drugs and insecticides, in
the hope of reaching every house and every patient. The strategy
promotes the establishment of all possible inter sectoral linkages, as
well as community involvement.
The main aim of public
information and education should be to improve peripheral
management of fevers, particularly in young children in highly
endemic areas, to improve the utilisation of health care facilities and
to obtain the active participation of individuals and communities
instead of the passive acceptance of anti malarial drugs or spraying.
The school should play a key role as an instrument of education not
just for children.” (Najera 1996 Malaria Control for refugees and
displaced populations.)

WHO emphasises the importance of working in partnership with people to
address the problem of malaria and community mobilisation and education
should be the lynchpin of any programme. Many programmes have failed
because the importance of community involvement has not been recognised.
Oxfam’s commitment to Public Health Promotion means that it is well placed
to become involved in this aspect of malaria control but only where
community mobilisation and education form part of a well-defined malaria
control programme.

Social Marketing
Social marketing is a communications strategy that draws on the lessons learnt
from marketing. The strategy considers the way the product will be priced
and how it will be ‘positioned’ on the market. Positioning refers to the way
the product is promoted and will be based on substantial formative research.
Messages will then be developed in order to make the product as appealing as
possible and a promotional strategy will be designed for the target audience.
In the early days of an emergency response there will be little time available
for such in depth research and the design of the programme will depend on a
more dynamic process of ongoing assessment and redesign. However, the
concept of obtaining detailed knowledge about the target audience and why
they may or may not value a particular product is very important and in
longer term situations a social marketing approach may be feasible.

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Indoor Residual Spraying

Part I

Indoor spraying of residual insecticide has been the method of control most
often used in chronic refugee situations. It is suitable for refugee populations
who have built or are occupying mud huts or houses but it is not clear how
effective it is on plastic sheeting. To be effective the local mosquito vector
must be indoor resting and all houses must be sprayed as residual spraying
kills mosquitoes which rest on the walls prior to and following a blood meal.
This may have several effects: repelling the mosquito or killing it. The main
effect of spraying however, is to reduce the probability of vector mosquitoes
living long enough to transmit the parasite.

WHO states that house spraying remains useful in the control and prevention
of epidemics, for limited periods provided that it can be applied at the right
time and its effectiveness can be maintained. Residual spraying has been
shown to be effective in West and South Asia when sprayed at the beginning
of the transmission season but is less effective in SE Asia. In areas of high
endemicity in Africa the effectiveness of long term residual spraying
programmes appears to be limited, partly because of the logistical and
financial constraints involved in maintaining spraying programmes.
However, in areas where a population of non immunes moves into an area of
high transmission, residual spraying is an extremely effective public health
measure.

Physiological and behavioural resistance of the vector are also increasing
problems. In the former, the mosquito develops the capacity to survive a toxic
dose of insecticide. In the latter, the mosquito may start to avoid sprayed
surfaces or rooms.

Traditionally, DDT has been the insecticide of choice because of its long
residual effect and low toxicity to humans. However, it has been realised that
it persists for a long time and can enter the environmental food chain
contaminating food supplies. Its use as an indoor spray is still maintained in
some areas however, because of the low probability that sprayed surfaces will
become part of agricultural land or otherwise enter the food chain. Increasing
resistance of the vector to DDT has also undermined its usefulness. Synthetic
pyrethroids such as deltamethrin and lambdacyhalothrin are now considered
the most effective insecticides for indoor spraying but their use will depend on
licensing arrangement within each particular country.

Spraying has to be repeated annually in Asia and at 3-6 month intervals in
stable endemic areas. Repeated application can become expensive in chronic
emergencies.

The effectiveness of any spraying programme depends on public acceptance.
Usually the longer a spraying programme continues the less the public like it.

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Background
Information
Malaria control

Part I
Background
Information
Malaria control

However where spraying is still being carried out on a regular basis, it is
important to plan a reduction and eventual withdrawal rather than an abrupt
finish. An assessment must also be made of people’s customs as practices
such as replastering of walls, which is often done on a yearly basis and may
well undermine the effectiveness of spraying.

House spraying should take place as a pro-active control measure i.e. before
the transmission period. It is limited as a reactive control measure because it
takes three weeks to begin to affect the overall mosquito numbers but it can
still represent a very useful intervention especially in areas where people with
low immunity move into an area of high transmission. In some cases it may
also be effective to spray houses close to breeding sites rather than all the
houses. Effectiveness seems to depend on existing levels of endemicity and
levels of immunity in the population. With some short-lived insecticides,
spraying may take place too far in advance of the transmission season to be
effective. House spraying also requires skilled managers, reliable equipment,
well-trained staff and strong financial support.

Oxfam has carried out residual spraying in camps in Tanzania and Burundi
and in conjunction with Merlin in a camp and surrounding areas in
Newton, Sierra Leone. It has also provided limited amounts of insecticide
to government vector control programmes in Burundi and Ethiopia to
support epidemic residual spraying and emergency preparedness.
Tent spraying during an acute emergency phase
Treating the inner surface of double-sheeted tents with an insecticide such as
permethrin or deltamethrin provides a toxic surface to indoor resting
mosquitoes found in south and central Asia and Africa. (Hewitt et al, 1995). It
has been suggested that the pre-treatment of tents should be routine practice
during new emergencies in malarious epidemic countries.
The jury is out as to whether plastic sheeting can be treated effectively with
sprayed insecticide. It appears that a certain amount will remain on the plastic
when sprayed but generally it is thought that any leaning against the plastic or
brushing past it, will wipe the insecticide off.
It may be possible to treat laminated polyethylene sheeting, which then has a
slow release effect. Some manufacturers are currently working to develop
such products in collaboration with the RBM programme.
Other types of shelter
Mud, straw, brick wood, wattle, thatch, palm leaf and corrugated iron all have
different absorption rates and spraying with insecticide is more or less
effective according to the surface treated. Walls made of earth or mud usually
absorb a lot of insecticide and some soil walls may contain chemicals that
increase the pH, causing rapid breakdown of some insecticides. Walls made of
hardwood or walls that are painted will absorb less and are the best surfaces
to spray.

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Insecticide Treated Materials

Part I

Newer methods of prevention using impregnation of mosquito nets, clothing
and tents with insecticide have been used in emergencies in Afghanistan and
in Africa by various other agencies. Their effectiveness is dependent on the
prevailing vectors and characteristics of the target population. Further
research is needed to determine whether these methods are effective in other
situations and to what extent they alter vector habits and levels of immunity.
Whilst the initial results are promising they should not be used as the only
method of malaria control.

Insecticide Treated Nets (ITN)
Insecticide treated mosquito nets (ITN) are suitable if vectors have their peak
biting time after people go to bed and before they get up and if shelters allow
mosquito nets to be supported or hung. They can be used outdoors if suitable
means to suspend the nets can be found. They are preferred to untreated nets
because they offer more complete personal protection (mosquitoes are
prevented from biting through the nets) and they appear to reduce the
numbers of vectors by killing mosquitoes that land on the nets although the
longevity of this effect seems to be disputed. They also appear to reduce the
incidence of headlice, scabies and bedbugs. They are costly but may last
longer than other methods.

Concern has been raised about the use of bednets in acute emergencies as cost
recovery is often not possible and ensuring adequate retreatment may also be
difficult. However, although it is assumed that distributing nets for free may
undermine people’s desire to purchase replacement nets and pay for
retreatment this may not be true. Providing nets in an emergency may allow
people to see how useful nets are and provide a stimulus for future net
purchase. It would appear that one of the main reasons why people do not
purchase nets at present is the high cost of nets, which is often two to three
times the wholesale price. In many countries bednets are subject to tax.

Nets may be rectangular or conical and come in different sizes. Family nets
are usually the most appropriate but the nets purchased for use in the camps
in Tanzania were found to be too large for the shelters so each situation must
be assessed accordingly.

Rectangular nets hang from strings or frames and are quite spacious, conical
nets are easier to hang and fold up. Sometimes there is an area of sheeting at
the top of a conical net, which strengthens the weight-bearing apex.

Polyester is the most common netting fabric as it absorbs very little water.
Nylon nets prevent the absorption of the insecticide and cotton nets absorb too
much insecticide. A sheeting border protects the bottom edges from being
torn when tucked under a mattress or mat (they can also be weighed down

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Background
Information
Malaria control

Part I
Background
Information

with stones). They vary in durability: 100 denier being the strongest and
longer lasting with 40 denier being more easily torn. 100 denier polyester nets
can last up to five years but have to be dipped every 6 months. The most
commonly used nets are 75 denier and these last approximately 4 years.

Malaria control

Nets come in many colours. Darker greens and blues are preferred as they do
not show the dirt so much. This is important because frequent washing of the
nets will render the insecticide less effective. Some cultures may not accept a
particular colour such as black or white nets because of possible associations
with death. If nets are to be sold or there is some concern about the
acceptance of a particular colour, it may be worthwhile asking people what
colours they prefer.

The specifications for the nets that Oxfam uses are given in the chapter on
implementation and these specifications should be adhered to unless
justification can be given for changing these.

Newer long lasting nets (Trade name Permanet or Olyset) are now available.
These are impregnated with deltamethrin (a type of permethrin) during the
manufacturing process. The manufacturers claim they will last up to 21
washes. They have been used with Nomadic populations where access to
retreatment of nets may be problematic.

Oxfam in Sudan has also been involved in trials of a new type of net made
from the same material as that used for making tsetse fly traps but in
addition impregnated with long lasting insecticide. This material is more
opaque than normal netting and allows for more privacy for people
sleeping outdoors.

The cost of most nets is between US$5 -$10 and retreatment costs US$.50 -$1.00
per year for the insecticide (this may be done once or twice a year depending
on the insecticide used and the pattern of transmission). At present families
who are able to afford it, spend money on insecticide sprays, mosquito coils,
anti malarial drugs and other traditional control methods. In the long term,
treated nets are expected to be more cost effective as nets are durable and can
be re-dipped locally or in the home.

The long term consequences of using nets is still not known and it is possible
that older groups may become more vulnerable to malaria if they use a net
when younger because they have not built up sufficient immunity. It is also
possible, however, that older groups will have a better resistance to sickness
generally than the under fives. Recent research has indicated that immunity is
affected most in areas of intense transmission but further research is needed.
Some researchers have pointed out that the risk of rebound malaria is offset by
the much larger benefits of malaria control against all cause mortality. Indoor
Residual Spraying programmes in Africa have not shown that any rebound

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effect after control has stopped although levels will gradually increase to pre
control levels.
Even if a person sleeps under a net they will still get bitten at other times by
infected mosquitoes. This challenges the body to develop its own protective
immunity. Immunity may take longer to build up than in people not using
nets. It is important that people are aware that using nets will not prevent
malaria completely.

A question that is often asked is whether Insecticide Treated Nets are
dangerous to children. WHO has approved the use of permethrin for use in
bed nets. This insecticide is commonly used as a shampoo or lotion for the
treatment of head lice. It is rapidly broken down in soil and sunlight and does
not have a tendency to bioaccumulate. The treated nets are deadly to
mosquitoes but do not affect people because people are much bigger. Some
side effects have been reported such as sneezing and a runny nose with
lambdacyhalothrin but this is not usually serious.

Net treatment process
Ideally recipients should impregnate the materials themselves as this
reinforces an awareness of the insecticide, its importance in protection, and
encourages proper net care. However, in the acute phase, this might cause
additional delay to implementation, so pre-treatment is acceptable in this
phase. Following the floods in Mozambique in 2000 pre-treated nets were
distributed but this did not affect re-treatment rates. It is widely believed that
this was due to the very thorough IEC campaign undertaken by all of the
seven implementing agencies.

Safety procedures must be followed when retreating nets and education on
safety must form part of the programme. Net re-treatment packs are available
and usually provide gloves and insecticide for individual re-treatment. Some
packs also provide a plastic bag to prevent the contamination of buckets used
for drinking water. Pre packaged kits of insecticide, equipment and
instructions are available from Oxfam for treating large quantities of nets.
Ensure that the insecticide preparations are licensed for use in country before
ordering. A table detailing the amount of insecticide to be used can be found
in the section ‘Tips for carrying out an ITN project’.

Insecticide treated clothing and tents
Permethrin sprayed blankets and other materials may represent an alternative
option where correct use of ITNs is in doubt. Treated bedding has not been
tested however, outside Asia or in highly endemic conditions and more
research is needed
Permethrin treated outer clothing worn in the evening or in bed has been
shown to be effective in Afghanistan but again there is a need for further
research in highly endemic conditions.

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Part I
Background
Information
Malaria control

Part I
Background
Information

Tents made of cloth or plastic sheeting may be sprayed to leave a residual but
there are varying reports of the effectiveness of this (see above). Treatment of
laminated polyethylene sheeting, analogous to the `olyset’ slow release treated
nets is a recent development which may prove to be useful (see above).

Malaria control

Relative efficacy and cost effectiveness of ITNs and residual
spraying (excerpt taken from RBM in emergencies guidelines)
The alpha-cyano pyrethroids, such as deltamethrin and lambdacyhalothrin,
are the most effective insecticides for indoor spraying or treatment of nets.
Permethrin is preferred for topsheets or blankets since it has a very low
human toxicity.

Among Afghan refugees in N.E.Pakistan, insecticide treated nets, tents, and
housing appear to be equally effective against malaria (giving about 60%
protection against falciparum malaria). Treated bedding and clothing are 1020% less effective than treated nets. In endemic Africa, treated bednets are the
most effective intervention (reducing malaria death by 42% and morbidity by
45% in the Gambian trials).

Treated bedding and clothing are cheaper than nets in camps since only
insecticide has to be provided. House spraying is cheaper than nets if done
only once or twice. If people are willing to pay for nets, nets become more
cost-effective than house spraying.

Cost analysis is a useful substitute for cost-effectiveness analysis when local
effectiveness is not known. When the effects of the interventions being
compared are broadly similar such as the use of treated nets or house spraying
then cost analysis on its own may be sufficient to make a choice.

In West Asia (Afghanistan/Pakistan), the cost per person protected* per year
is:

Treated nets

$1.5 (in first year, $0.25 thereafter)

Treated Blankets

$0.25 (cost of blankets excluded)

House Spraying

$0.5

Tent Spraying

$0.25

In Africa residual spraying and bednets appear to be equally effective at
reducing malaria but the cost effectiveness and logistical support needed
differ.

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*Includes cost of insecticide and nets but not of operations. Assumes that house is
occupied by 10 people and a net by 3-4 people.

Part I
Background
Information
Malaria control

Source Reduction
Source reduction refers to any measure that prevents the breeding of
mosquitoes or eliminates their breeding sites. If such measures are long lasting
they are often referred to as environmental modification. When they have a
short-term impact they are referred to as environmental manipulation.
It may be difficult to achieve source reduction during the acute phase of an
emergency except on a local scale, and the impact is often limited especially
where vectors, such as An. Gambiae, are able to make use of footprints and tyre
tracks for breeding.
The following methods of source reduction are often used:
·

drain clean water around tap stands or water points

provide adequate rainwater drainage systems

drain ponds or swamps if this is acceptable to communities

fill in smaller breeding sites with soil, stones or rubble (especially
borrow pits – pits made to obtain mud for building)

sluicing of drains or waterways

Clearing of vegetation from around dwellings is often done to reduce
opportunities for mosquitoes to find resting places. However the impact of
this type of action is minimal unless combined with other control measures
and efforts should not be wasted on mobilising communities to embark on
this type of activity. Cutting back grass and vegetation from the edges of
breeding sites however may help to reduce breeding in some species.

The control of breeding sites needs to be carried out around human
settlements in an area with a radius greater than the flight range of the
mosquito, which is often about 1.5 to 2km, if it is to be effective. Larval
control is thus more costly per person in rural areas than in densely populated
areas. In places with intense transmission of malaria, almost all anopheles
breeding sites need to be eliminated in order to achieve a reduction in the
prevalence of malaria. It may therefore only represent a useful intervention in
areas of less intense transmission.

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Part I
Background
Information
Malaria control

Biological and Chemical Control
Biological control refers to the introduction of natural enemies or predators of
mosquitoes such as bacteria, fungi and fish. The two most common methods
are the use of larvivorous fish and bacterial larvicides. Chemical larvicides are
also available.

Larvivorous fish
Larvivorous fish feed on mosquito larvae. Some of the most successful species
have been the ‘top minnow’ and the guppy. The latter is effective in rice fields
in hot areas. However, larval control using fish may take 1-2 months to
establish and will only be effective when large numbers of fish are bred. In
ponds and marshes where there is dense aquatic vegetation, fish are not very
effective. In some areas larger fish for human consumption have been bred
alongside smaller larvivorous fish.

Larvicides
Larvicides are used on breeding sites that cannot be drained or filled or where
other source reduction methods would be too expensive. However, control
using larvicides is expensive and frequent application can become costly.
They may be appropriate to use where there are specific breeding sites that are
problematic especially near to temporary settlements such as camps or where
people’s immunity to malaria is low.

Fuel oils are sometimes used to prevent larvae from breeding but this can
contaminate the environment and other methods are preferable if available.
The most commonly used chemical larvicides are temephos, fenthion and
malathion.
Only temephos has a low mammalian toxicity and is
recommended as being safe to use in drinking water. Bacillus thuringiensis
H-14 is a bacterial larvicide, available in a slow release briquette that dissolves
over about 30 days. They are intended for the treatment of small breeding
sites and may not be effective in slightly polluted water. It is safe to use in
drinking water.
Temephos, B.t. H-14 and larvivorous fish can all be used in wells to prevent
the breeding of anopheline mosquitoes.

Disease Surveillance and Early Warning Systems
Well-managed communicable disease surveillance systems are crucial to
effective malaria control allowing local outbreaks and unusual increases in
incidence to be identified and the appropriate control measures to be
instigated promptly. Meteorological early warning systems can also have a
role to play in early identification of weather patterns and climate change that
may predispose to epidemics. Unfortunately, in many countries - particularly
those where ongoing conflict has led to a disruption in the normal public

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health structures, access to reliable data may not be possible. Initiatives that
support the collection and analysis of data will help to prioritise areas of
greatest risk and will help to clarify intervention strategies.

Part I
Background
Information
Malaria control

Inappropriate responses
WHO outlines the following strategies as being inappropriate at any stage of
an emergency:

Aerial spraying: this is inappropriate for malaria vectors as they are
night biters and often rest indoors. It has been used for fly control
during emergencies to stop cholera epidemics but is very expensive.

Scrub clearance: there is no evidence that this reduces man-vector
contact although clearing vegetation from around unavoidable breeding
sites can help to make such sites unsuitable for daytime resting sites.

Outdoor space spraying or fogging: this is not cost effective for malaria
vectors and it is environmentally contaminating. It also often fails to
reach the targeted vector and therefore has a limited impact.

However, further research is needed on the usefulness and cost effectiveness
of aerosol spraying as a measure used during the acute phase of an
emergency. Not only may this help to prevent or limit the extent of a malaria
epidemic but it may also reduce the number of flies that may be vectors of
diarrhoeal diseases. It is possible that in such circumstances it may represent
a more cost effective intervention.

Oxfam’s Role
Oxfam’s main operational focus will be on addressing the increased mortality
in complex emergencies in Sub Saharan Africa but the capacity to respond to
potential epidemics in other areas will also be maintained. Response options
will include mobilisation and education and the provision of ITN’s and
residual spraying where necessary. Other vector control measures that may
be used are the reduction of breeding sites or the use of biological and
chemical larviciding.

All interventions should be accompanied by a clear strategy for Information,
Education and Communication (IEC), which will ensure that people have all
the necessary information to enable them to take action to prevent or limit the
effects of malaria. Whilst it is accepted that the more traditional methods of
message dissemination may have a role to play in providing such information,
more innovative and participatory methods are also to be encouraged. Oxfam
supports an approach that sees communities as partners in malaria control
and which enables communities to better address public health problems
such as malaria in the longer term.

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Part I
Background
Information
Malaria control

Measures to ensure adequate drainage must also be an important aspect of
any water and sanitation programme especially in countries where malaria is
endemic. It is recognised that where other control measures are inadequate
Oxfam will lobby or provide limited support to other agencies such as the
Ministry of Health to provide services for disease management and epidemic
surveillance.

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Monitoring And Evaluation

Part I
Background
Information
Monitoring And
Evaluation

Malaria is a complex disease and there is a significant lack of information and
research about malaria control methods in emergency situations. The WHO
Roll Back Malaria programme is thus concerned that programmes endeavour
to monitor the methods they use to inform future interventions. However, the
incidence of malaria can be affected by many variables and monitoring the
impact of the control method using disease indicators is therefore difficult.

Parasite Prevalence
Slide positivity rate as a measure of parasite prevalence is a very useful
malariometric index in unstable malaria areas, since it is independent of
population size and may show a sudden increase during an epidemic. Its
interpretation depends, however, on the criteria used for taking slides. In
such areas Plasmodium parasitaemia is equivalent to a malaria episode. In
areas with stable malaria, asymptomatic malaria is common, slide positivity
may not reflect disease so accurately, and rates must be interpreted cautiously.

Case Control Studies
Case control studies (e.g. comparison of slide positivity rates between
personal protection users and non-users) can also be used to help to determine
the impact on morbidity rates and these do not rely on obtaining baseline
data. Case control studies can also be carried out by sampling families where
there has been a death from malaria and comparing them against a control.
Such studies require specialised advice on design and sampling. Training for
the survey team will be necessary and it is vital that, if families who have been
bereaved are to be interviewed, teams are sensitive to this.

Qualitative Data
Large scale questionnaire studies or case control studies take a significant
amount of time to carry out but time is often limited in most emergency
programmes where funding cycles are usually not longer than six months.
For this reason it is recommended that more participatory forms of data
collection are used which can also provide an opportunity for people to
learn at the same time. Whilst such methods do not necessarily produce
statistically reliable data they are believed to be more appropriate for the
emergency setting and are made more reliable through the use of other
methods which allow for data to be cross checked. It should be remembered
that many studies carried out without adequate attention to design and
sampling methods purport to be reliable but in fact produce data that is
invalid. Such methods extract data from people without allowing them to

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Part I
Background
Information

learn and thus valuable time may be lost in carrying them out without the
benefit of producing useful information. Oxfam is currently investigating
ways to research this hypothesis and to compare the usefulness of different
approaches to data collection.

Monitoring And
Evaluation

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Part II
Intervention
Monitoring And
Evaluation

Part II
Intervention

Humanitarian Manual

Page 39

Part II
Intervention

Oxfam’s role and collaboration

Oxfam’s role and
collaboration

It must be recognised from the start that in order to address the problem of
malaria, a multi faceted approach must be used. Oxfam is rarely in a position
to deliver all the necessary components of an effective malaria control
programme and will need to rely heavily on partner organisations such as the
Ministry of Health, WHO or other NGOs to ensure that adequate provision is
made for diagnosis and treatment especially. In some instances partners may
only have a limited capacity to intervene and Oxfam may find that they are
the main organisation in a position to respond. In this instance lobbying and
advocacy may be needed to encourage others to intervene. In other instances
there may be many other partners involved in malaria control and coordination with them is essential to make the best use of available resources.
A detailed list of potential partner organisations is given in the resources
section.

Co ordination during an emergency might be provided under a UN umbrella
agency or by a special co ordination body which agencies subscribe to. Within
such fora it is possible to establish sector committees to address specific health
issues.

Malaria control is a specialist activity that should be co ordinated through the
general health services. This is as true for a complex emergency as it is for
stable conditions. General health agencies (MOH, UN or NGOs) might, for
example, co ordinate with an agency specialising in laboratory training
services that has taken on the responsibility for ensuring the quality of
diagnosis and treatment in NGO clinics. Another agency specialising in
disease control might take responsibility for malaria prevention, and provide
technical advice, commodities, or training to agencies that want to implement
personal protection or vector control in their specific area of operation.

Agencies such as Oxfam must ensure that they collaborate with these health
agencies if they intend to become involved in malaria control. It is vital that
any programme is planned with the support of these agencies and that
continual feedback is provided to them by attending all health co-ordination
meetings.

Oxfam’s limited experience to date in malaria control has been in residual
spraying, environmental control of breeding sites, distribution of insecticide
treated bednets (ITN) and community education and mobilisation (Public
Health Promotion). Where there are no other agencies providing medical care
and where the capacity of the MoH is over stretched some support for
essential drugs has also been provided.

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Part II

It should also be remembered that any water and sanitation work carried out
by Oxfam should not encourage mosquito breeding and drainage must be
ensured at all water points through appropriate design and community
mobilisation.
Examples of Oxfam’s involvement in malaria control
q

A joint malaria control projects has been carried out with Merlin in Sierra
Leone. A joint proposal was funded by ECHO with Merlin providing
treatment facilities and technical support whilst Oxfam was responsible
for the social mobilisation.

In East Timor ITNs supplied by IRC were distributed and monitored by
the Oxfam community mobilisers. Discussion groups were also held to
ensure people knew how to care for the treated nets and the importance of
seeking treatment early for children with fever.

In refugee and displaced camps in Burundi and Tanzania residual
spraying and bednet distribution was carried out.

In Mozambique Oxfam collaborated with World Relief, Concern and the
MoH to distribute 85,000 ITNs and to provide the necessary community
education and support following the floods in February 2000.

In Ethiopia work was undertaken with the MoH on an epidemic
preparedness plan

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Intervention
Oxfam’s role and
collaboration

Part II
Intervention

Oxfam Malaria Control Strategy

Oxfam Malaria
Control Strategy

The Humanitarian Department has agreed to take a more active role in
responding to the risk of malaria. Work will focus on malaria in complex
emergencies in Sub Saharan Africa where deaths from malaria are most
frequent but Oxfam will maintain the capacity to respond to epidemic risk in
all regions. Wherever possible malaria control programmes must fit into the
National Strategy for Malaria Control. This may thus entail a longer lead time
for the initiation of projects and longer project cycles.

In order to achieve this the department will need to commit itself to
improving training and support for Oxford based technical staff as well as
staff deployed to the field. The department will also need to draw on the
expertise of malaria specialists where there is insufficient data available to
inform decisions about intervention. A database of suitably qualified
specialists will be compiled but until this is functioning adequately, specialists
will be identified through the Malaria Consortium.

The areas of response will be mainly limited to community education
combined with indoor residual spraying or the distribution of ITN’s. Other
areas of intervention will only be undertaken on the advice of a specialist
following discussions with the technical (health and engineering) advisors.
Where malaria treatment is not available or is severely compromised, Oxfam
will lobby other medical agencies to intervene.

The Humanitarian department does not have the capacity to respond to all
situations where there is endemic malaria and the initial focus for intervention
will be Sub Saharan Africa where Pl. falciparum malaria causes the highest
mortality rates. However, the Public Health Assessment for all programmes
must include an initial appraisal of malaria related morbidity, mortality and
epidemic risk. Where these are high a more detailed examination of potential
responses should be undertaken.

Therefore:
All assessments will include an initial assessment of malaria risk and the
capacity and intention of other agencies (including the government) to
intervene. This will be the responsibility of both the Public Health Engineer
and the Public Health Promoter

In epidemic prone or high risk areas, where there is an imminent risk of a
malaria epidemic, an assessment will be carried out by a suitably qualified
specialist who will make recommendations for Oxfam’s involvement.

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The aims and objectives of the programme must be defined along with
indicators and means of verification. All programmes must be evaluated
either internally or externally and an evaluation report sent to the Public
Health Team co-ordinator in the Humanitarian Department.

In medium risk areas where malaria is usually still a cause of significant
mortality, the Public Health Team will assess its capacity to intervene based
on public health priorities, project time frame, access to communities and
government policy.
(Whilst the decision to intervene or not should not be based on access to
funding, this may, in reality, also compromise our ability to intervene.)

The decision on how to intervene must be based on knowledge of the malaria
profile for the area. (Accessing all the necessary information is not always
possible but some information should be available nationally to identify, at
least, the probable vectors. RBM complex emergency country profiles are
available on the WHO website.)

Permission from the National Malaria Control Programme or Ministry of
Health must be sought before any intervention is initiated.

This document concerns the role that Oxfam has to play in addressing the risk
of malaria in Humanitarian situations. This will necessarily entail having an
impact in a short time frame. It will often not be possible to employ the
methods and procedures used in longer term malaria programmes.

The following principles should always be adhered to:

Bednets:

The provision of bednets should not be seen as the only possible
intervention.

The contingency supply of insecticide treated nets currently held in stock
by Oxfam will be piloted. If, following evaluation, they are found to be
unacceptable, modifications will be made.

Nets may be ordered from a local supplier but will adhere to the
specifications (except colour) in the Oxfam Equipment catalogue unless
proof of unacceptability can be provided. Long lasting ITN’s may also be

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Intervention
Oxfam Malaria
Control Strategy

purchased if thought to be more suitable for a particular area following
discussion with the health advisor.

Part II
Intervention
Oxfam Malaria
Control Strategy

Nets should already be impregnated as specified in the equipment
catalogue but if sourced locally, impregnation policy should be discussed
with one of the technical advisors for the region (either health or
engineering). Every effort should be made to include a retreatment phase
in the programme cycle but this may not always be possible.

Baseline data on knowledge of malaria and use of nets must be obtained
but it is not recommended that this is gathered through carrying out a
questionnaire KAP survey unless the project time frame is a year or more.
The Malaria Control Guidelines provide information on gathering Baseline
Data and on monitoring and evaluation.

Reasonable access to the community must be possible to ensure adequate
information and education is provided on the use of nets and prevention
of malaria if there is little evidence of previous net use.

Nets must not be distributed in an area where there has previously been
little bednet use without providing the necessary education component.

Indoor Residual Spraying
·

Indoor residual spraying should usually be confined to camp situations
but support may be given to the government to carry out IRS in urban or
rural settings if necessary.

Permission must be sought from the government to carry out IRS and the
insecticide used must be licensed in country.

If IRS is to be carried out it is preferable that existing spray teams are used.
Adequate training and careful supervision must be provided. Procedures
which ensure the safety of personnel and beneficiaries must be followed.

Other Technologies
·

Spraying of textiles (e.g. blankets) and use of larvicides may also be used
but must be dependent on specialist recommendation.

Involvement in disease surveillance, emergency preparedness measures or
supporting Early Warning Systems may be potential areas of intervention
but specialist support must be sought.

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Use of Insecticides
·

Part II

Safety procedures must be adhered to when using insecticides for
spraying or treating of nets.

Intervention
Oxfam Malaria
Control Strategy

DDT should not be purchased using Oxfam funding.

Provision of Drugs
The Humanitarian Department does not normally get involved in clinical
care but adequate access to malaria treatment is important for malaria
control to be successful. If access to health care or malaria treatment is
severely compromised, Oxfam will lobby for the involvement of other
agencies. In some instances the provision of essential drugs to the MoH or
a partner agency may be made but the rationale for this must be discussed
with the health advisors in Oxfam House.

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Intervention

Specialist Support

Do I need an expert?
Designing an appropriate malaria control programme which is cost effective
and which is likely to deliver rapid results within the limited time frame of
most emergency interventions is not without pitfalls.

Expertise in designing such programmes is undoubtedly valuable but the
right kind of expertise is crucial. If communications allow, discussion with the
technical and health advisors in Oxfam House should be sought to identify if
outside specialists are required and the profile of such specialists.

For example in the assessment phase someone with both vector control
knowledge and experience of designing appropriate interventions would be
important. In the implementation phase the team may need help with
carrying out a residual spraying campaign or organising the targeting and
distribution of bednets. Support may also be needed to conduct case control
studies if these are to be used for assessing impact.

One of the key aspects of a malaria control programme is the community
mobilisation and education (often known as IEC – Information, Education and
Communication) and adequate human resources must be ensured to maintain
this aspect of the programme.

If Oxfam is to learn from its programmes and develop its capacity to carry out
malaria control effectively, it is vital that monitoring and evaluation of
programmes is carried out. Specialist support may be needed to carry out a
comprehensive evaluation.

Local expertise may also be available. Health ministries usually have
epidemiologists and entomologists who may be able to provide information
on patterns of disease, malaria vectors and current government strategy.
Some countries have a National Malaria Control programme and their advice
and support should always be sought. Expertise may also be found within
other organisations such as WHO or other International NGOs.

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Assessment

Part II
Intervention
Assessment

Initial data will be required in order to make decisions on whether to
intervene or not and what is the most appropriate response. This should be
gathered in a variety of ways. Discussions must be held with the MoH and
especially with representatives from the National Malaria Control Project.
The opinions and views of epidemiologists and entomologists from both the
MoH and WHO, if available, should also be sought.

If possible written research on vectors should be accessed using both internal
and external mechanisms. RBM country profiles should be available on the
internet as well as malaria maps detailing rainfall and other data to assist in
predicting epidemics (addresses are available in the resources section).
Discussions with both female and male community members will help to give
a more detailed picture of the situation and will also provide important
information for decision making. A more thorough analysis of the malaria
profile for the region will also provide some insight into the extent of the
problem and will provide information necessary for designing a response.

What do I need to know?
The following key factors have been known to make the risk of an epidemic
more acute and are thus considered as RISK A situations. An assessment of
these factors should be undertaken as soon as possible:

migration of non-immune groups into areas with current malaria
transmission

migration of infected groups into malaria-free areas which are capable
of supporting renewed transmission

any areas where there is a significant risk of epidemic for reasons not
specified in the above

In addition Oxfam will consider as a priority area of intervention:
·

areas of high endemicity in Sub Saharan Africa where a breakdown in
normal Public Health Structures undermines usual malaria control
efforts. (In such situations certain groups such as pregnant women and
young children may be more at risk of malaria).

These may be exacerbated by environmental and structural changes that
favour vector breeding, increased man-vector contact or increased

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Intervention

transmission such as an increase in breeding sites or the lack of health
services.

Assessment

RISK B situations are areas where malaria is highly endemic and where there
is often a high mortality amongst pregnant women and children but where it
may not always be possible to intervene in the short term because of e.g. lack
of adequate access to populations, lack of government support or lack of
funding.
RISK C situations are those where malaria is endemic but is well controlled
by existing structures or where the prevailing vector is P.vivax (South and East
Asia and Central and South America – excepting epidemic situations)

The categorisation of malaria into RISK A, B and C situations over
simplifies a very complex subject. It is done for the purpose of guiding
decision making in emergencies where intervention is often constrained by
a shortage of time and resources. Such a simplification does not apply to
situations outside of the emergency context where a more detailed analysis
and response is both possible and preferred.

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Part II
Intervention

Planning Model for Emergencies

Assessment

The following planning model is suggested. Details of how to assess and
when to intervene are given in the following chapters.
Assessment

Analysis:

Is intervention
necessary or possible?

RISK B or C: lack
of access to
population, limited
time available, low
risk situation (well
controlled), P.vivax
predominant vector

YES

Significant Risk or
appropriate conditions
for intervention?

RISK A: non immune population,
unstable malaria with risk of epidemic,
breakdown of normal Public Health
Structures in area of high endemicity

RISK B: (high endemicity) &
access to population, funding
& time

Planning: What type
of intervention?

Implementation

Baseline Data
Collection

Monitoring &
Evaluation of Impact

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Intervention
Assessment

Initial Assessment
The following list of questions provides a guide to determining initially
whether or not intervention is necessary:
·

Is there an outbreak of malaria or potential risk of epidemic*?

Have non-immune people moved into an area where malaria is highly
endemic?

Have conditions altered to favour vector breeding or parasite development
in areas where people have low immunity?

High Risk Situations

In Tanzania in 1998 large numbers of Rwandan and Burundian refugees
suffered an epidemic of malaria with a high death toll especially amongst the
under fives following movement from an area of low endemicity to high
endemicity. In areas of low endemicity, immunity to malaria often does not
develop adequately and people are then more at risk of epidemics.

Have existing malaria control services been undermined?

*An epidemic is usually defined as an unusual increase in the number of cases
of a disease compared to the usual pattern for the particular time of year.
·

Is the clinical diagnosis confirmed by laboratory tests? Could the rise in
‘unconfirmed’ malaria be due to other causes of fever and if so what?
Which plasmodium species causes the majority of malaria cases (if
Pl.falciparum is the main cause higher mortality rates would be expected).
Diagnosing Malaria

The symptoms of malaria, especially in children, are very similar to those
for several diseases such as meningitis, typhoid, dengue fever or
pneumonia. In many countries diagnostic facilities are not available and
therefore cases are diagnosed on clinical symptoms and fever is treated
as if it might be malaria in order to achieve greater coverage for what can
often be a fatal disease if left untreated.
·

What is the ‘normal’ mortality rate for malaria? In areas of stable
transmission such as Sub Saharan Africa this will often be high and
intervention may therefore be appropriate. Data can be obtained by
asking the population what people die from and who dies (age and sex) as
well as asking Ministry of Health officials.

What is the size of the population at risk?

Is the outbreak spreading? Where?

How many cases and deaths have there been so far – does this represent a
significant increase taking into account seasonal variations?

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What are the possible sources, modes of transmission? (areas of swamp or
flood waters that haven’t receded)

In many emergency situations the displaced are often accommodated on
land that nobody else will live on. One of the reasons for people’s
avoidance of this land may be because it is close to mosquito breeding
sites. It is vital that this is taken into consideration when camp sites are
planned and that every effort is made to house IDPs or refugees on land
which does not undermine their health.

What is the capacity and intention of other agencies (including the
Government) to intervene?

Further Assessment
In order to determine what intervention is appropriate the following
information is also important:
Vector and Parasite Characteristics
·

Anopheles species and habits – resting location, feeding time and location,
host preferences, breeding sites, insecticide susceptibility

Epidemiological characteristics: is this an area of stable or unstable
transmission and what is the endemicity (low, medium, high or intense)?

Environmental risk factors: climate (areas of high temperature and
humidity allow more rapid development of the parasite), timing of rainy
season (usually peak incidence of malaria follows end of rainy season
when breeding sites are undisturbed by frequent, heavy downpours but
for residual spraying to have any effect this must be conducted at least
three weeks prior to the end of the rains), breeding sites (may have
increased because of unusually heavy rains and/or flooding or drought
which may dry normally running water to areas of still water)

Plasmodium species and resistance to treatment

Population characteristics
·

Number of people at risk and groups at risk (new arrivals, pregnant
women and children)

Immune status of the population

Have semi or non-immune people passed through an area of high
endemicity?

Capacity of clinics and health centres to provide first and second line
treatment

Treatment seeking behaviour for malaria (do people delay in seeking
treatment?)

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Assessment

Site Planning

Part II

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Part II
Cultural Beliefs and Practices

Intervention

In some areas women have to obtain permission from their husband or
mother in law before taking their child to the health post/ traditional
healer. In other areas mild malaria and cerebral malaria are seen as two
separate diseases. Fitting children are often taken to a traditional healer
first. Health centres and hospitals are often seen as places where people
die. Different treatments may be tried before people seek conventional
medicine and serious complications may have arisen by the time the child
is taken to a hospital. Focus group discussions with separate groups of
men and women are a good way to find out about such beliefs and
practices and to identify strategies to overcome specific problems.

Assessment

Shelter type – permanent mud/brick walls, plastic sheeting, matting etc –
is residual spraying appropriate for this type of shelter?

Sleeping habits – how do families sleep – do several family members share
a bed – what time do people of different ages go to sleep and get up?

Sleeping preferences

People may choose to sleep outdoors and therefore hanging bednets may be
problematic or they may feel that it is too hot to sleep under a net. In one
programme in Ethiopia bednets were thought to be inappropriate because
people lit fires inside their shelters at night and nets are highly flammable. All
of these issues must be understood before an appropriate response can be
designed.
·

Cultural beliefs and knowledge about malaria cause and prevention

Other cultural practices which may affect the type of intervention e.g.
replastering walls may be a problem if this is usually done following the
rains (and residual spraying if carried out)

It may be useful to fill in a malaria profile for the area as detailed on page 56

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Assessment Methods

Part II
Intervention
Assessment
Methods

Communicable Disease Surveillance
In order to determine whether there is the risk of a malaria epidemic, timely
and comprehensive data collection systems, especially epidemic surveillance
systems, need to be in place. These should work by collating all the
attendance data from clinics in a particular region in order to obtain
forewarning of increasing incidence rates. In addition most clinics should be
reporting unusual disease cases and patterns of disease and cases that are
resistant to treatment as rapidly as possible so that the necessary
investigations can be carried out.

Unfortunately in many countries disease surveillance systems do not function
adequately and there is no central body available for giving timely
information on potential outbreaks.

The Public Health Promoter should be liaising with clinics and health facilities
to try to obtain this information. Trends in disease incidence and seasonal
variations are also important so data needs to be obtained over a period of
several years if possible. Epidemics in some areas seem to follow a cyclical
pattern over 5- 10 years.

If no data is available, clinic staff may be facilitated to do this by asking them
what help they need to carry out this aspect of their work and assessing to
what extent Oxfam resources can support this. Limited help in the form of
stationary etc. may be provided on a short-term basis. However, such support
will have a limited impact on the capacity to predict epidemics.

Discussions must also be held with the MoH and especially the National
Malaria Control Programme representatives (NMCP) if one exists as well as
representatives from WHO and other medical organisations who will all have
an interest in epidemic preparedness. This should provide an overview of the
vectors involved, transmission and likelihood of epidemics.

Community Data Collection
It is also important for the PHP to ensure that communities are also consulted
on the incidence of diseases in their area. Participatory tools such as seasonal
calendars can be constructed, if there is time, with community groups or key
informants to obtain an overview of the seasonal pattern of disease and to
discuss current trends. This can also act as a springboard for suggesting that

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Intervention
Assessment
Methods

community groups or leaders maintain their own records of sickness and
death although it is difficult to ensure the smooth functioning of such a system
within the short time frame afforded by most emergency programmes.
Focus group discussions
A framework of questions is provided in the resources section at the end of
this manual. This can be used for the initial assessment stage and
subsequently when obtaining baseline data for future monitoring and
evaluation.
It is a very useful way to rapidly understand people’s
understanding of malaria, the effect malaria has on them and who is affected
and even to obtain an idea of the biting and resting habits of the common
mosquito species.

Seasonal Calendar
Seasonal calendars can also be constructed on the ground or on paper. They
can detail the months or seasons of the year, rainfall patterns, food availability
and incidence of malaria and diarrhoeal disease allowing people to see the
connections between such factors and triggering further discussion and
understanding between participants and facilitators. They are useful in the
assessment phase especially when there is very little statistical health data
available.

Co-ordination meetings
Regular co-ordination meetings with the health agencies working in the
region are also an important means of collating information in most
emergency situations and both the local and headquarters meetings should be
attended if possible.

Mosquito surveys
There are various types of vector studies that might be used if data is not
already available. It may be necessary to deploy an international consultant to
carry out the survey if there are no national specialists available in country.
Surveys are carried out in order to determine the vector involved in
transmission if this is not already known. Not all biting mosquitoes will be
transmitting malaria and examining mosquitoes for the presence of malaria
parasites may need to be carried out. This is a specialist task involving
examination of the salivary glands of the mosquito.
In addition it may also be useful to clarify the spatial distribution of the vector
(where biting or breeding take place) so that control interventions can be
better targeted e.g. if all biting occurs on the edge of a camp or settlement then
control measures can be targeted to these areas. More precise knowledge of
biting times may also be useful as this should clarify if people are indoors,
asleep, or asleep under a net during peak biting times.

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If surveys are carried out it will be necessary to explain to communities how
the studies are conducted and why and the role they have to play in carrying
them out.
In longer term malaria control programmes the above information is
important for monitoring the situation but insecurity or the urgency the
situation may preclude carrying out such surveys in an emergency.
If
specialist help is available, however valuable information can be obtained
fairly rapidly and this will help to improve the targeting of the programme.

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Intervention
Assessment
Methods

Resting
Location

Predominantly
endophilic but
exhibits partial
exophily

Anopheles
Species

An. Gambiae s.s

Preference for
nocturnal
feeding, peak
biting time
21.00-04.00
bites indoors and
out

Feeding
Time/location

Anthropophilic

Host
preferences

Falciparum 80%

Temporary
habitats –
puddles, hoof
print, tyre tracks
and borrow pits.
Will breed in
stagnant water
Ovale 10%

Plasmodium
species/resista
nce

Breeding Sites

Meso endemic to
hyperendemic,
areas of unstable
transmission. Last
epidemic in 1990,
usual seasonal
increase but
numbers higher
than usual this
year. Cyclical
pattern of
epidemics every 10
years

Epidemiological
data and
transmission

Current malaria
epidemic in
South Nyapondo
region

Epidemic Risk

Example Malaria Profile
Part II

Intervention
Assessment
Methods

Humanitarian Manual
Treatment
seeking
behaviour and
availability and
appropriatenes
s of treatment

Very few clinics
– people may
walk up to two
hours to nearest
clinic, limited
drug supply cost recovery –
poorest cannot
afford to pay.
Women
expected to seek
permission of
husbands

Shelter/
housing type

Semi nomadic
people living in
shelters made
from grass
matting

At risk groups

Predominantly
pregnant women
and children but
people living in
lowlands may
also have
increased risk

Very little
experience of
bednets – some
people do own
them – thought
to be useful to
allow a good
night’s sleep,
general ration
adequate and
people have
some resources
camels, sheep
and goats

(if vector
characteristics
indicate this as
a possible
option)

Will people
use/retain
bednets?

2 rainy seasons
from March to
June and
October to
January –
heavier rainfall
than usual this
year

Rainfall and
weather
patterns

Pregnant women
often sleep early
as it is believed
to be beneficial
but depends on
workload and
husbands

Children under
five sleep early –
usually by 7pm

Sleeping habits
(time and place
for different age
groups)

No NMCP

Ad hoc residual
spraying in
towns – said to
be a response to
epidemics but
not conducted
this year
because no
insecticide
available

Existing vector
control
strategies

Smoke leaves to
deter
mosquitoes

People unaware
that malaria
transmitted by
mosquitoes, do
not usually take
their children to
clinic for fever
but treat this with
herbal medicines
– if deteriorates
then will seek
help but do not
like going to
health centres or
clinics

Knowledge
about
prevention and
treatment of
malaria

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Assessment
Methods

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Analysis

Part II
Intervention
Analysis

Analysis of the above information should give some indication of the most
appropriate response but the initial decision to intervene or not can be
controversial. The decision to intervene should be based on the degree of
epidemic risk and/or high mortality rates. The situations outlined previously
as ‘Priority A’ give the greatest cause for concern. However, in some countries
where there is ‘stable’ malaria transmission, mortality rates may be high
amongst certain groups such as young children and pregnant women. The
breakdown in health facilities caused by conflict or natural disaster may make
such groups even more vulnerable. Intervention may be justified in such
situations, but a longer term perspective is critical, as interventions may do
more harm than good if not planned and carried out in a sustainable fashion.

In times of acute crisis there may also be other public health problems such as
diarrhoea or malnutrition which are responsible for increased mortality.
Resources may be better employed in addressing these more significant health
risks than in trying to tackle malaria in a population where there is a degree of
immunity already in the adult population and where the time available for
intervention is limited.

Interventions such as the provision of bednets stand a better chance of success
where there is the opportunity for ongoing follow up such as in the case of
long term government supported programmes. The National Malaria Control
Programme of a country may have such a strategy in mind and they may feel
that the free distribution of nets will undermine their attempts to ensure that
there is some degree of cost recovery for the nets to enable re dipping to take
place. In such a case it may be preferable not to provide bednets as part of a
short-term response unless there is a high risk of an epidemic or unless the
government structures can be incorporated into the response. Adequate
access to the population and a long funding cycle also make the provision of
bednets in such situations more viable.

In some countries long term complex emergencies may have caused a
significant breakdown in health services. In a population where immunity is
low this may leave people very vulnerable to disease. Where there is little
hope of the situation ameliorating in the near future and no significant
capacity within the existing government Ministry of Health, it could be
argued that in such extreme conditions even short term interventions are
acceptable to alleviate suffering and death. In such a case the distribution of
bednets – so long as it is accompanied by information and education may be
justifiable even though there may not be adequate provision for retreatment of
nets. Nets are easy to transport and in situations where people are continually
vulnerable to upheaval, nets (if retained) may be one of the few interventions
available to reduce the toll of mortality and morbidity due to malaria. If

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Intervention
Analysis

funding is available, the provision of bednets may be justified if there is
adequate scope for community education. Documentation and further
appraisal of the effectiveness of such interventions under such conditions is
necessary in order to determine their usefulness.

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Planning

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Intervention
Planning

A logical framework should be used to plan the intervention to ensure that
objectives and indicators are defined as clearly as possible (see page 65 for
example logical framework). A list of possible indicators is given on page 90.
These are not all included in the logical framework in order to make it as
simple as possible. However, process indicators involving gender issues or
community problem solving should be included in the monitoring framework.

Decision making
The decision-making matrix on the next page is meant as a guide only for
possible interventions in areas where malaria is endemic. The choice of
intervention for disease prevention in the acute phase cannot be prescriptive
and will vary according to funding available, feasibility of the response and
the cost and speed of supply.

The human resources available for such a response and the logistics required
will also need to be taken into account to determine whether an intervention is
likely to be effective. All interventions to date have been undertaken in
addition to water and sanitation interventions and it is important that work on
malaria control does not compromise efforts to mobilise communities to
prevent high mortality and morbidity due to other water and sanitation
related disease.

The decision about the kind of intervention should also be taken in the light of
existing country programmes and their strategic change objectives. If the right
to health and education is seen as a strategic change objective, it may be
possible to initiate emergency programmes which can be subsequently
supported by the country programme. The provision of ITNs or longer-term
drainage works might be appropriate and the country programme staff
should be involved as much as possible in the design and execution of such
projects.

If possible any intervention should be defined in consultation with the
Ministry of Health or the equivalent. A Memorandum of Understanding
should be drawn up with the authorities detailing the responsibilities of both
(an example MOU is given in the resources section).

The information from the initial assessment should help to determine if
epidemics are likely and what the possible responses might be. For example
bednets will be inappropriate in a population where the anopheles mosquito
bites outside and predominantly before people go to bed. Residual spraying
will not be of use where the anopheles rests outdoors (exophilic) or at the

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Part II
Intervention

height of an epidemic unless it is believed that the epidemic will last for some
time.

Planning

If clinics are unable to provide adequate treatment the best response might be
to provide the MoH with essential drugs for a limited period or to lobby other
organisations to provide this support. Access to clinics may also be limited for
many people either because they are not willing or able to travel long
distances or because they cannot afford the drugs. In some cases village level
Community Health Workers have been trained to dispense first line malaria
treatment such as chloroquine but any such initiative must be undertaken
with the approval and support of the MoH.

Deciding How to Intervene

In Burundi – a country where people have been forced to flee their homes on
numerous occasions- residual spraying was carried out in the camps around
Bujumbura. As security improved and plans were made for people to return to
their homes it was decided that ITNs would be distributed to each family
ensuring that intensive education on bed net care and maintenance was
provided prior to their departure. As people came from long distances, it
would have been difficult to continue working with all the affected population
and it was known that on their return home they would have only minimal
access to health care. It was believed that this population already weakened by
malnutrition would thus be even more vulnerable to malaria.

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Decision making matrix

Part II

Priority
Status

Indoor/
outdoor
resting
mosquito

Peak
Biting
time

Other
influencing
factors
(examples
only)

Potential
Oxfam
Response

Priority A –
unstable
transmission
or non
immune
population

Indoor

Before
people go
to bed

a) Walls
suitable for
spraying,
people sleep
indoors,
government
approval
obtained,
spray teams
available

Education,
active case
finding if
epidemic,
source
reduction

a)Walls
suitable for
spraying,
people sleep
indoors,
government
approval
obtained,
spray teams
available

Education,
active case
finding during
epidemic,
source
reduction

Priority A –
unstable
transmission
or non
immune
population

Indoor

After
people go
to bed and
before
they get
up

b) see below

Priority A –
unstable
transmission
or non
immune
population

Priority A –
unstable
transmission
or non

Indoor

Outdoor

Humanitarian Manual

After
people go
to bed and
before
they get
up

b) Access to
population,
population
used to using
nets, suitable
shelters for
hanging nets

After
b) Access to
people go population or
to bed
population
used to using

a)Residual
spraying only
(prophylaxis
for pregnant
mothers and
children if
practicable)

a) Residual
spraying & b)
ITN provision
(prophylaxis for
pregnant
mothers if
practicable &
acceptable)

Education,
active case
finding if
epidemic,
source
reduction
b) ITN
provision

Education,
active case
finding, source
reduction,

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Intervention
Planning

Part II
Intervention

immune
population

nets suitable
shelters for
hanging nets

b)ITN
provision
only, ((possible
prophylaxis)

Planning

Priority B –:
Expected
seasonal
peaks in
transmission
causing
significant
mortality
exacerbated
by social or
environmenta
l factors.
Other risk
factors for
disease
transmission
not significant

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Indoor

After
c) Adequate
people go access to
to bed
population,
long term
support from
government or
other agency,
adequate
funding cycle

Education,
source
reduction, c)
selective
provision of
ITNs to
pregnant
women and
children under
five

Humanitarian Manual

NARRATIVE
SUMMARY

MEASURABLE
INDICATORS

MEANS OF
VERIFICATION

IMPORTANT
ASSUMPTIONS

mortality and
morbidity rates from
all causes

health centre
records, mortality
records from

assumes that
stability is
maintained and that
further migration or
flooding does not
take place, assumes
easy access to
population

Appropriate use of
ITNs

Project records,
community
discussions

Assumes target
group will learn to
value ITNs and that
other needs are
being met

AIM
To contribute to
improving the health of
the at risk population

PURPOSE 1
Ensure that community
capacity to respond to
malaria risk is enhanced

organisation of
health committees
and action taken by
them

Mini surveys

OUTPUT 1
People have the means
to protect themselves
from malaria and dengue
vectors and the number
of vectors is kept to an
acceptable level (Sphere
Vector Control
Standards 1 and 2 )

Provision of 10,000
insecticide treated
bednets to families
with pregnant
women and children
under five, Malaria
and Dengue
awareness
campaign targeting
whole population
and schools,
reduction in
breeding sites

Household
assessment forms,
group discussions,
mapping of breeding
sites and leaking
pipes

Assumes
government support
for project
continues, flood
waters subside and
there is no new
flooding

Increase in timely
under five
consultations for
malaria, reduction in
breeding sites
around dwellings,
use of bednets by
pregnant women
and children under
five

Health centre
records, focus group
discussions, pocket
charts, observation

Assumes
accessibility of
health facilities,

Representation from
all sections of
community in
detailed assessment
and community
defined objectives
for action

project records,
focus group
discussions and
interviews with key
informants

Assumes that
defined priorities of
the various groups
are considered
important by the
team and facilitated
by the management
structures

Numbers of staff
identified and
training completed

Project records,
training evaluation

Assumes willingness
of Ministry of Health
to second
counterparts

OUTPUT 2
All sections of the
community are aware of
what they can do to
prevent malaria and
dengue fever and are
mobilised to take action
to control these
diseases.
(Sphere Hygiene
Promotion Standard 1)
OUTPUT 3
The disaster affected
population has the
opportunity to participate
in the design and
implementation of the
assistance programme
(Sphere Analysis
Standard 3)
ACTIVITY 1
Identify Public Health
counterparts and provide
three day orientation

Part II
Intervention

Malaria Control Example Logical Framework

Part II

NARRATIVE
SUMMARY

Intervention

ACTIVITY 2

Planning

Conduct baseline survey
to ascertain knowledge
of malaria and dengue,
bednet use and
treatment seeking
behaviour

MEASURABLE
INDICATORS

MEANS OF
VERIFICATION

IMPORTANT
ASSUMPTIONS

number of focus
groups and research
sessions held with
different groups,
quality and quantity
of data gathered

Project records and
reports

Assumes ability to
communicate with
target population

Identification of
major leaks

Project maps

Assumes community
knowledge of
location of major
problem areas and
willingness to
divulge this
information

Number of leaks
repaired

project records,
maps and
observation

Assumes community
willingness to have
leaks repaired

Number of
volunteers identified
and trained

project records,
training evaluations,
community action
plans

Assumes willingness
of community to
volunteer for these
activities

Number of nets
distributed

Project records,
household
assessment forms

Assumes prompt
purchase and
delivery of nets

Number and quality
of leaflets designed

project records

Assumes availability
of printing facilities

Number of
workshops held

project records,
training evaluation

Assumes willingness
of Ministry of
Education and
teachers to take part
in activities

Number of meetings
attended

project records

Assumes adequate
co-ordination
maintained

quality and quantity
of data obtained,

project records

Assumes situation
remains stable and
access remains
possible

ACTIVITY 3
Carry out mapping
exercise within all of the
target communities to
identify leaks in water
supply network

ACTIVITY 4
Repair leaks in the water
supply systems which
enhance vector breeding
ACTIVITY 5
Identify and train
community volunteers to
promote use of nets and
other vector control
measures
ACTIVITY 6
Distribute insecticide
nets to pregnant women
and families with children
five years old
ACTIVITY 7
Design malaria and
dengue leaflets to
provide key information
ACTIVITY 8
Organise 10 teacher’s
workshops to promote
control of mosquito
vectors
ACTIVITY 9
Ensure close liaison with
government and other
agencies
ACTIVITY 10
Ensure ongoing
assessment, planning
and monitoring of the
project (update log frame
as necessary)

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Implementation

Part II
Intervention
Implementation

Priority A Interventions
Intervention should focus on areas of unstable malaria transmission and low
to medium endemicity or where non-immune or semi immune populations
have moved into an area of medium to high endemicity. In acute periods of
crisis where there are large population movements, it is probably not useful to
try to undertake work on malaria control where other diseases are a more
significant risk and where the population already has a high degree of
immunity. In this acute period there is the danger that the provision of
bednets especially, may not be well planned and such an intervention may
stand a better chance of success if undertaken when risks have been reduced.

At the height of a crisis when there may be widespread need, there may not be
time to find out all the information necessary and assumptions may have to be
made. Such assumptions should be based on as much locally gathered
information as possible. Assess the potential for all public health epidemics
and define which poses the most immediate risk.

Information may be available in the form of country profiles or research,
which can be sourced from outside the country at the same time as the initial
assessment is taking place. Co-ordination with Oxfam house and with other
agencies is vital at this stage to ensure that any initial response is as well
planned as possible.

If diarrhoeal disease and malaria carry an equal risk, ensure that resources are
available to address both in co-ordination with other agencies.

Community members should also be given as much information as possible
about the risks they face and what can be done about them.

Priority B Interventions
Agencies do not always begin working in critical emergencies and each
situation must be assessed accordingly. In such a situation there may still be
the risk of future epidemics and an assessment of the risk of future epidemics
and epidemic preparedness plans should be made by all agencies concerned.

Agencies need to review the control measures that have been identified as
emergency needs change and mortality is brought under control. As malaria

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Intervention

is a focal and controllable disease it may be necessary to re deploy resources to
where they are most needed if the situation warrants it.

Implementation

In areas of stable malaria transmission, where epidemics are not predicted,
there may be opportunities to become involved in malaria control but such
interventions should be part of a longer term strategy supported by
government structures.

In some situations it may be possible to instigate cost recovery for ITNs or at
least for the retreatment process. Free or reduced cost distribution may be
necessary for the most vulnerable (widows with young children, orphans etc.).
Repayment schemes may also be introduced as a means of helping people to
spread the cost over several months. Where funding is only available for three
to six months such an intervention may not be appropriate unless this can be
handed over to the government and/or another NGO.

In the IDP camps in Kenema in Sierra Leone, Merlin provided bednets for
pregnant women and children at a cost of the equivalent of $2.50. The money
that was raised was used to pay for community projects which were chosen by
the camp members. Treatment of nets was carried out when several people had
made requests for the nets and a record taken of when retreatment was required.

Source reduction may become more possible as the situation stabilises.
Rehabilitation of irrigation and water supply sources should always ensure
that breeding sites are minimised. House spraying should become
increasingly focal as the situation stabilises and the prioritization of camps for
spraying should be based on sound indicators such as malaria incidence rates
to ensure cost-effectiveness.

Staffing (see resource section for job descriptions)
The staff required will depend on the type of intervention chosen but it is
critical that at least one staff member is skilled in IEC (information, education
and communication) methodologies and particularly in participatory learning
methods. If a residual spraying campaign is to be carried out there may be
skilled spray teams available locally but it is important that this work is
supervised adequately. If large-scale source reduction such as drainage works
is to be carried out then an engineer with experience of work in similar
conditions will be required.

Public Health promoters might come from a health education or
environmental health background. They could also be social workers or
teachers involved in adult education. Environmental health supervisors may
also have experience of carrying out residual spraying. All of these people

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will both have skills to contribute but also will learn from their involvement in
a malaria control project. Ideally the relevant ministries should be approached
in order to identify appropriate staff.

Part II
Intervention
Implementation

Integration of work is an important element of any Oxfam programme as
beneficiaries will not perceive different sectors of a programme and will
simply refer to what ‘Oxfam’ is doing. A programme should aim to provide a
co-ordinated approach which maximises the synergy or ‘value added’ impact
possible from integration. At the community level therefore, it makes sense to
have only one system of outreach workers or public health promoters. At the
management level it may also be preferable to have one person who ensures
integration. However, in a high-risk situation it may also be necessary to have
additional people whose sole responsibility is the malaria control project.
These people would be responsible for managing the data collection,
negotiation with government officials, designing promotional aspects and
supervising community level activities.

Other Resources
Adequate logistical support including transport will be necessary and must be
budgeted for. If ITNs are to be distributed extra transport and logistic support
may also be necessary. If residual spraying is to be carried out, equipment
and protective clothing will be necessary as well as transport for spray teams
and supervisors. Maintenance of equipment must also be considered. Lead
times for ordering materials such as ITNs or insecticides should also be
ascertained as early as possible.

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Intervention
Implementation

Tips for carrying out residual spraying (see WEDC
manual on Emergency Vector Control)
·

Residual spraying is usually carried out using a hand compression sprayer
and equipment that meets WHO standards must be purchased along with
protective clothing for all those handling insecticide. Spare masks and
gloves should also be purchased.

Plan the residual spraying in conjunction with those normally responsible
for such activities if possible and ensure that adequate numbers of spray
personnel and supervisors are identified.

Ensure that the insecticide that is ordered is licensed for use in country. Be
aware that delivery often has a long lead-time. (see page 72 for more
details on purchasing insecticides)

Adequate and secure warehousing facilities must be identified.

The teams of spray people must be adequately trained and it is preferable
if they have had some experience of residual spraying prior to
implementation. Even if they have had prior experience, their technique
should be verified and a refresher training undertaken.

If there are no teams with prior experience of spraying, training must be
instigated ensuring that each person meets the practical standard required.
A wall is usually used for training purposes and spray equipment filled
with water. Health and safety measures must form part of this training
and it is vital that everyone involves knows what to do if there is an
accident. They must also know the signs of insecticide poisoning to look
out for (pyrethroids can cause paralysis of the face and hand, irritation of
the upper respiratory tract and excessive salivation). Communication
skills should also be a part of this training ensuring that those involved
are able to provide appropriate information, answer people’s questions
and are respectful of people’s homes.

If inexperienced teams have to be recruited, it is recommended that they
have basic education and are at least literate.

The number of spray people required will depend on how critical the
emergency is, the number of homes to be treated and access. Teams
usually comprise one spray man and one assistant. Five to seven teams
can be managed by one supervisor and if there are more than seven teams
an overall co-ordinator will be required.

Ensure that the community is well informed of the planned spraying and
that they have a chance to raise any objections or issues that have been
problematic in the past.

Define a plan detailing which spray teams will cover which areas.

Identify an area where insecticide and equipment can be stored and
cleaned. Ensure there is access to water to prepare the solutions and soakaway pits for the disposal of polluted water. This area should be located at
least 1km from any settlement.

Ensure that the local health facility has necessary facilities to deal with
insecticide poisoning.

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Spray men should work a maximum of four hours per day only and five
days per week, to avoid contamination and poisoning.

Ensure that the community is reminded about the spraying programme on
the evening before it starts and that people are required to leave their
shelters during spraying and remain outside until the insecticide has
dried. Food and drink must be taken out of the shelter and any animals
should be tethered (see page 88)

Supervisors should monitor the work of the spray teams and address any
complaints from community members.

Care must be taken in disposing of all excess insecticide and empty
containers which should be cleaned and buried.

Supply of chemicals/insecticides
Chemicals may be provided in different formulations and the exact
formulation required should be specified. For indoor spraying purposes, the
water dispersible powder is the most effective formulation in most countries
because it is most suited for porous surfaces such as mud or brick. The
following tips may be helpful:
·

All chemicals imported/bought for spraying need a licence for retail in
country and this must be checked with the government authorities

Vector susceptibility should be checked prior to purchase

All containers must have a batch number, a manufacture date and an
expiry date –

A sample from each batch should be checked to ensure that these criteria
are fulfilled. The name of the insecticide should be associated with an ISO
number (International Standardisation Organisation).

A sample of each batch should be checked to ensure that it is insecticide as
it has been known for harmless powder to be sold as insecticide. The
insecticide should have a WHOPES number which means that it has been
tested to ensure that it meets WHO specifications

Always buy from a reputable supplier which should provide a ‘servicelevel’ contract

Maintain an audit of supplies, delivery and where used

A list of suppliers for each country is given in the RBM country profiles. The
logistics department maintains a list of UK suppliers of insecticide and which
have branches or contacts overseas. The Oxfam equipment catalogue details
insecticide for the treatment of bednets.

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Intervention
Implementation

Important Lessons from Tanzania

An order for ICON 10-WP was placed with Twiga chemicals. They delivered two
types of ICON 10-WP. One type had neither batch number, neither manufacture
date nor expiry date. A second type had a batch number and a manufacture date
but no expiry date. The spraying programme started in the first week of August
but the programme co-ordinator at Oxfam’s Ngara office was suspicious of the
chemicals delivered and dispatched four samples to the Tanzania Tropical
Pesticide Research Institute (TPRI) for analysis on 8/8/98. The TPRI replied on
14/9/98 requesting payment of $1000 before releasing the resulting analysis. This
request was refused and the TPRI have subsequently revealed that the chemical
delivered was ‘expired’ ICON 10-WP and they hinted that spraying with the
sampled chemical would not have been effective. They remained reluctant to
disclose the full results prior to receipt of payment. (from Vector Control in the
Greater Lukole refugee camp – Mark Myatt)

Health and Safety
If spraying is to be implemented the health and safety of those involved must
be ensured. All spray workers should be provided with protective clothing
(broad rim hat, goggles or face shield, face mask, long sleeved overalls, rubber
gloves, boots) and soap and given training on safe handling of insecticides.

Curative medical services should hold sufficient stocks of drugs required to
treat acute or chronic insecticide poisoning. If these are not available then
Oxfam should supply them with instructions for use. Extra insecticide should
be disposed of in the latrine and not in open water courses as it is hazardous
to fish and other wildlife. Adequate information must be provided to people
having their homes sprayed. Details of what community members need to
know is given on page 50. Sprayers must adhere to the following safety
regulations:

Do not eat, drink or smoke whilst working

Wash your hands and face with soap and water after spraying and before
eating, smoking or drinking

Shower or bathe at the end of every day’s work and change into clean
clothes

Wash your overalls and other protective clothing at the end of each
working day in soap and water and keep them separate from the rest of
the family’s clothes

If the insecticide gets onto your skin, wash off immediately with soap and
water

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Change your clothes immediately if they become contaminated with
insecticides

Inform your supervisor immediately if you do not feel well

Intervention
Implementation

Instruction and safety booklets are available from WHO.

Tips for the provision of ITNs (see ‘Insecticide
Treated Net Projects, A handbook for Managers’)
·

Ensure that discussion has been held with the Ministry of Health and
especially with the National Malaria Control Project if one exists. A
memorandum of understanding will need to be drawn up so that all
parties involved are clear about what is expected of them in terms of initial
management and longer-term support.

Plan and budget for at least one retreatment cycle at the start of the project.
Leaflets providing information about retreatment should also be budgeted
for.

Use the specifications detailed in the Equipment catalogue for ordering
nets. These specifications have been researched by the Humanitarian
Department and should not be changed unless there is significant
justification:

Bednet Material

knitted polyester

Denier

Mesh

156

Size

130x180x150cms

Impregnation

Permethrin Public Health Grade

Distribution lists will need to be drawn up and verified. Such lists may
already be available in a camp situation. It is helpful to have lists of
potential beneficiaries even if nets are to be ‘sold’ as this will help to
identify if there are any abuses of the system.

Ensure that adequate records are maintained of where nets go to and
when retreatment is required. If possible these records should be
maintained by a community based structure.

Nets are usually provided at a subsidised price but some vulnerable
groups may need an additional subsidy. Payment methods should also be
explored if people have trouble in purchasing the nets.

Ensure that community based education and information is provided prior
to the distribution of nets and that net use is monitored following the
distribution. The actual distribution can be used as an opportunity to
reinforce some of the information provided but should not be used as the
only education provision.

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Part II

Ensure that people know that the nets have been treated and need to be
retreated in six months, that the nets should not be washed and if they are
they will need to be retreated, who should have priority in their use, care
should be taken in hanging them and preventing or mending holes.

People also need to be aware that bednets alone will not completely
prevent malaria and emphasis should be made on seeking early treatment
and reducing avoidable breeding sites.

If time allows purchase untreated nets and treat as the nets are given out.
In more critical emergency situations treated nets will have to be
purchased.

It is important that a central outlet is available for the supply of nets but
community health workers or other outreach workers could be charged
with actually handing them over to community members. They can then
show people how to dip and hang the nets appropriately and provide
other information on correct care of the nets. In some programmes
community committees have managed the funds made from the sale of the
nets. This is subsequently available for purchasing more nets or retreating
nets.

Ensure that people are aware of the safety precautions they need to follow
when retreating nets. Gloves should be worn and excess insecticide must
be disposed off safely in the latrine. Containers used for dipping nets
should not be used subsequently for food or drinking water.

Centres can be identified where nets are dipped en masse or individual
treatment sachets and instructions can be distributed for people to dip the
nets at home.

Intervention
Implementation

The table on the following page gives estimated amounts of insecticides that
are required to treat nets en masse:

Amount of water and insecticides required to impregnate bednets

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Area of

Amount of water needed in ml

Part II

Amount of insecticide required in ml

Intervention

netting
Polyethyl
ene

11.6m2

Cotton

Permethrin

polyester

1 m2

Nylon /

25%

Deltamethrin

Icon

2.5%

130

1.2

2.0

0.4

1508

13.9

23.2

4.6

163

348
Oxfam net

1630

3480

15.08 l

139.2

232

46.4

3260

6960

150.8

278.4

464

92.8

8.2

17.4 l

75.4 l

696

1160

232

bednets
20
bednets
50
bednets

Recommended doses/m2 for selected insecticides used in bednet
impregnation

Insecticides

Recommended
doses in g/m2

Range of acceptable
doses

permethrin

0.3

0.2 - 0.5

deltamethrin

0.2

0.01 - 0.025

Lambda-cyhalothrin (Icon)

0.01

0.01 - 0.015

In order to distribute nets effectively, a list of beneficiaries will need to be
drawn up. In some situations such as in camps or where other relief
distributions are being made, lists will already be available. In other
situations it may be necessary to verify community produced lists or to
carry out a registration of beneficiaries. Details of how to do this can be
found in the Oxfam series: Working in Emergencies, Practical Guidance
from the field: ‘Registration and Distribution’.

Following the distribution it is important to carry out a household
assessment to verify if the target group is actually using the nets and if
people are satisfied that the distribution was fair and people have received
their entitlement. The checklist used should be as simple as possible.
Only 8 to10 households should be chosen for each area up to a maximum
of 100 households to provide some feedback on the outcome of the
distribution rather than to provide data that is wholly representative. This
tool is adequate to identify problems quickly and should be cross-checked
at subsequent focus group discussions or community training groups. An
example household assessment form is given in the resources section.

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Implementation

Part II
Intervention

Baseline Data

This should be gathered within the first month of the project but in an
emergency situation it may be necessary to commence implementation at the
same time as gathering baseline data. Many participatory assessment
methods allow for such an approach as open discussions are held and people
asked to define solutions to the problems identified. For example if a map is
drawn of breeding sites this provides baseline data. Subsequent discussion on
what can be done about those breeding sites can then generate action to
address the problem.
Similarly focus groups can concentrate on
understanding what people know already but then use the opportunity to
discuss what can be done to prevent malaria or serious complications of
malaria.

Baseline data will need to focus on the educational intervention and on what
people know, do and think at the beginning of the project. Evaluation of
impact will subsequently attempt to determine what people have learnt and
what they have done in response to the mobilisation and education sessions
and to what extent this has made a difference to their lives.

The conventional form of data collection for malaria control projects is known
as the KAP study which is often reduced to a questionnaire survey on what
people know, do and think. This may yield some interesting data but usually
such information is limited and such a technique does not provide enough
depth to allow a real understanding of the issues. It must also be realised that
the analysis of such data will be very time consuming and resources may need
to be made available for this if the actual implementation of the work is not to
be interrupted.

In some countries you may find that the MoH insists on the use of KAP
surveys. If used they should be designed and supplemented by information
from other more participatory and in-depth methods. Any information
gained should be discussed with people in the community at a general
meeting.

Participatory Data Collection
This approach to data collection is perhaps the most useful for the emergency
context as it allows for an understanding of the situation to be gained at the
same time as mobilisation of communities and groups. In order to make the
data as reliable as possible it needs to be collected in a systematic way and
cross checked by using a variety of methods.

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Try to find out as much about the geographical area you intend to work in –
looking at differences in population characteristics e.g. urban/rural, ethnic
group, main occupation or predominantly male or female and divide these
areas into clusters which have similar characteristics. Conduct at least four
focus group discussions – two with men and two with women with similar
backgrounds – in each cluster. Ensure that these discussions are either
recorded or that notes are taken. In addition carry out two mapping exercises
and two seasonal calendars in each cluster (again one male and one female if
possible). It should also be possible to carry out such an exercise with a group
of TBA’s, teachers or leaders as part of the training process.

Focus group discussions
Use a question framework as provided in the resource section but adapt this to
suit the situation as you come to understand the situation better. The focus
groups need to be carried out in a systematic way and separate, homogenous
groups of men and women should be identified. Even if public health
promoters think that they understand the problem and people’s views on
malaria this information cannot be assumed to apply to the present
community. Try to ensure that a quiet place is found to conduct the
discussion and make it as interesting as possible by using e.g. pictures or
samples of larvae.

Mapping
Maps can be constructed on the ground or on paper depending on what the
group prefers. Such maps can detail both water and sanitation facilities as
well as vector breeding sites, homes of pregnant women and under fives and
general information about the community or settlement. The process of
drawing such maps can also stimulate discussion about malaria and its control
and motivate people to take action to address some of the problems.

Health data
Whilst the main focus of the baseline data collection will be on people’s
knowledge and practices, it is also important to examine whether the
intervention has an effect on mortality and morbidity rates. Such indicators
cannot be used on their own as these rates even for malaria alone will be
affected by many factors outside of the project control such as temperature,

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Intervention
Baseline Data

Part II
Intervention

rainfall, health status, malnutrition etc. and within a short time frame will not
provide a reliable indication of the effect of the intervention.

Baseline Data

Attendance data from clinics should be monitored. If possible try to ensure
that this data is disaggregated by sex (especially if there is some suspicion that
female children are not treated the same as male children) and gives data for
adults and under fives. If such data is not collected, negotiations could be
held with the MoH to identify possible short term support or to offer training
to motivate staff.

Prevalence studies may be helpful in determining whether the intervention
has had an effect on morbidity and mortality rates. Such studies must be
repeated at the same time of year in order to reveal any reliable results.
Oxfam does not at present have the capacity to carry out such studies but
other organisations involved in malaria control may be in a position to do so.

Often a Prevalence Survey & KAP study are carried out at the same time.
Three teams of four to six people are involved and each made responsible for
one aspect of the survey. Blood samples are taken by one team, the KAP
survey is administered by another team and the third team provides treatment
for those with positive blood tests or those with clinical symptoms. Two
people are charged with identifying the sample through a random selection
working from a central point in the camp or settlement if no census or
registration lists are available. All members of the household have blood
samples taken and all are asked the questions on the KAP survey with parents
answering on behalf of younger members. Rapid diagnostic tests allow for an
immediate recording of results and are to be preferred to taking slides for
subsequent examination.

Oxfam staff will probably not be involved in carrying out blood tests but may
need to explain how this process will work to community members. It will be
important to find out such details from the other agencies involved and to
ensure that community members are given accurate information.

Once enough information has been gathered from whatever means it is vital to
compile a BASELINE DATA REPORT as much information is often lost
because it is not recorded. It may be useful to hold a meeting with the team
to try to define the information more clearly and to ensure that all available
information is collated. Meetings to discuss this data with community groups
should also be held.

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Information, Education &
Communication:

Part II
Intervention
Information,
Education &
Communication:

Raising awareness in the community
In order to raise awareness in the community, a variety of approaches such as
community mobilisation or social marketing may be used. These approaches
are not necessarily mutually exclusive although they may be based on
different philosophies.

Social marketing is a means of reaching a large target group through the use
of marketing strategies such as advertising. The promotion of a particular
product such as ITNs or condoms is based on significant formative research to
determine the nature of the target group and the best way to persuade them to
accept the product. This will also involve research into appropriate pricing
and outlets for the product.

Community mobilisation works on a more local level and stresses the need for
participation in decision making, mobilising communities to take collective
responsibility for protecting their health. It requires more intensive human
resources to work closely with groups and communities but does not need to
rely on gathering all the information before designing a response as continual
interaction and feedback allow for immediate intervention. Similar education
techniques may be used by both approaches such as the use of songs, drama
or slogans to raise awareness but Oxfam’s approach to community
mobilisation also stresses the use of more participatory techniques such as
interactive games, mapping and seasonal calendars to stimulate action.

Use aspects of social marketing when you have adequately understood the
situation but as far as possible try to encourage people themselves to think
through the problems and identify some of the possible solutions. Do not just
rely on message based information and never assume that you have all the
information necessary to make decisions for people. Always be ready to listen
to what different groups of people have to say.

Who to work with
Even if a malaria control project is targeting women and under fives with a
distribution of bednets it is vital that the accompanying public health
promotion targets all sections of a community. Malaria affects everybody so
everyone needs to know what will help to prevent malaria or prevent
unnecessary death from malaria. The distribution of bednets may be targeted
at pregnant women and children under five but if husbands and fathers are

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not aware of the reasons for this the nets may not be used appropriately.
Many women may also depend on permission from their husbands before
seeking treatment for their children and therefore it is vital that such issues are
discussed with both men and women.

Key Informants, community leaders and committees
It is unwise to just rely on outreach workers to carry out the promotional
work. Public health promotion must be dynamic if it is to achieve results and
it must try to explore every possible means of motivating community
involvement.

It may be useful however to work specifically with certain groups who may be
influential. Community leaders are an important group to work with, as are
teachers who may be very influential in the community and with their pupils.

Traditional birth attendants may be able to encourage mothers to use bednets
or to seek antenatal care. Street vendors who sell medicines for malaria need
to know the importance of taking the full treatment and can advise their
customers accordingly. In some countries they are provided with certificates
which allows them to sell malarial drugs but any such initiative should be
undertaken with the support of the Ministry of Health.

In some countries there may be health or development committees or councils
already in operation and it is useful to identify these and to initiate some work
with them. The extent of involvement with such committees will depend on
how representative they are of the population.

The following is a list of potential community partners:
Camp or village leaders
Women’s leaders and groups
Traditional Birth Attendants
Community Health Workers
Pregnant women & Mothers
Teachers and children
Clinic Staff
Street vendors (selling malaria treatments)
Youth groups
Religious Leaders
Trade Unions

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Training sessions or regular meetings may be held for these groups. Each
group should also be asked how useful information may be spread to the rest
of the community and they should be encouraged to be a part of this process
feeding back issues and problems to Oxfam staff.

Community mobilisation and education
Addressing the problem of malaria is not easy and it has been recognised that
in order for programmes to be successful it is important for all those
concerned to work in partnership. This includes working in an open and
transparent way with community members and providing them with all the
available information in a way that allows them to also make choices and
decisions.

Community meetings should be held in order to explain to people the nature
of the problem and to enable them to define what the possible solutions are. It
is inevitable that the presence of outsiders in a community will give rise to
raised expectations of what they are able to provide. It is important that
openness and honesty is used to counter this rather than attempting to carry
out investigations such as vector studies without adequate explanation. Every
community can do something to try to limit the spread of malaria and even if
it is decided that a bednet distribution or residual spraying will not be carried
out people will need to know the reasons why and what else they can do.

Community meetings, training sessions with community groups and house to
house visits can all serve as means to both provide information and to allow
people to learn more about the problem of malaria. If such meetings are held
in a participatory way they can also stimulate people to take responsibility
and action to tackle the problems. Training and mobilisation will involve a
combination of providing information and giving people the chance to share
the information and understanding they already have and how they interpret
the new information that has been provided. It should also lead to people
defining actions they will take to try to address the problem of malaria.

Working with Children
It is important to ensure that some aspect of the programme focuses efforts on
raising awareness of the prevention of malaria with children. Child-to-Child
produce an activity sheet on malaria (provided in the resources section) which
could be adapted to the local situation. More information is specifically
required on the use and maintenance of ITNs. Workshops can be held with
teachers but should be planned with the Ministry of Education or the
equivalent to ensure that this supports existing health education work. In a
camp situation teachers may have been recruited by other agencies and
temporary schools set up. In this instance negotiation about the content of the
syllabus will have to be held with the agency and teachers themselves.

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Intervention
Information,
Education &
Communication:

Integration with other Public Health Promotion
Activities
Having separate teams of public health promotion staff to address malaria and
other water and sanitation related disease will not allow adequate integration
of the response and it is probably preferable to work using a phased approach
– addressing the most important issues first and consequently bringing in
other issues. If community mobilisation and participation are seen as key
elements of the Oxfam response, the use of separate systems of outreach
workers or community mobilisers may work counter to achieving community
defined action with each system competing for the community’s time and
commitment. However, as discussed earlier, it may be useful to have some
Oxfam staff who are devoted to addressing the issue of malaria but who are
part of the public health team. In this way initial community meetings should
be attended by representatives from both sectors but the collection of baseline
data and other specific activities can be managed by different people. It may
also be possible to hold joint training programmes.

Learning and Training
It should be recognised that learning does not just take place in formal
workshops and every contact with community members is an opportunity to
enhance your understanding of the problem and people’s knowledge about
what can be done to tackle the problem. Even during the initial investigations
into the types of vectors and breeding sites community members should be
involved. A ladle and pipette can be used to collect specimens as part of a
training exercise especially if people are unaware of the fact that larvae
develop into mosquitoes.
The content of the training must of course be based on the information
gathered from the initial studies and the detail of the proposed intervention.
Raising Awareness

In East Timor community mobilisers were provided with ladles and
pipettes and conducted surveys to identify the proportion of potential
breeding sites where mosquito larvae were identified. By carrying out the
survey with householders they were able to show people exactly where
the breeding sites for dengue mosquitoes were and they then asked them
to think of how to stop further breeding. Most people were horrified to
find that mosquitoes were breeding in their water containers – they simply
hadn’t noticed this. Although this method is particularly useful to use in
Dengue control programmes as aedes mosquitoes breed in water
containers found in compounds, it is also possible to take people to
anopheles breeding sites so they can see for themselves the ‘at risk areas’.

The importance of using participatory methods for

training cannot be over stressed. The simple didactic dissemination of
messages is not enough to stimulate action and what is needed is discussion to

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motivate people to become involved and to work both individually and
collectively to prevent malaria.

The following timetable for a two day training for public health promoters
could be conducted over the course of several days or weeks depending on the
situation and the urgency of intervention. All theoretical training should be
supplemented by fieldwork and on the job training.
Two Day Training Timetable For Field Officers

Time

Day 1

Day 2

9.00-10.00

Malaria Quiz (see appendix)

Mapping
Calendar

10.00-10.30

Break

10.30-11.30

Malaria Overview

Mapping
&
Seasonal
Calendars Continued

11.30-12.30

Country Specific Information

Objectives and Indicators
Activity

12.30-1.30

Lunch

1.30-2.30

Response Options Activity

Who to work with & How

2.30-3.30

Focus Group Discussion & Feedback

What people need to
know
activity:
using
training modules

3.30-4.00

Break

4.00-5.00

Review & Evaluation

Review and Evaluation

Seasonal

A community training timetable for village elders might look something like
this:
Training Timetable for Village Elders or TBAs

Time

Activity

1st Session

What do we know about malaria?: Focus Group Discussion
using pictures

2nd Session

Malaria Overview (use pre prepared visual aids)

3rd Session

Mapping of breeding sites and problem solving

4th Session

Seasonal Calendar

5th Session

Review of local malaria problems and prioritisation (ranking
exercise)
(Include information on importance of early diagnosis and
treatment and bednets or residual spraying if applicable)

6th Session

Plan of Action – who will do what

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Social Marketing
Message based promotional work may help to raise awareness over a large
target area but messages must be based on a sound understanding of the
situation and how people will perceive the message. Promotional campaigns
can be designed using any available media.

Radio
Radio is often useful but it is important to determine whether people own
radios, when they listen to them and which programmes they listen to.
Children’s radio programmes may be particularly popular and children can be
involved in designing the content of the radio programme themselves.

Posters & leaflets
The value of posters on their own appears to be limited but they may reinforce
information gained from elsewhere. In areas where literacy is minimal it is
important to pretest posters and to ensure that the information is interpreted
correctly. Where literacy is high, leaflets may be of more use than posters as
they can provide more detailed information. During times of crisis people
may be eager to obtain any reading material and a series of newsletters or a
one of newsletter could be produced to provide information about vector
control and other emergency services available. If money is not available for
mass production of newsletters, they could be posted in areas where people
congregate such as markets or religious institutions. Leaflets are often
designed and distributed to inform people about retreatment of nets. Even
where literacy is not high, someone in the family such as a schoolchild may be
able to read out the instructions.

Community Gatherings
If religious leaders are in agreement, talks could be held after services to
provide information about planned interventions or particular details about
the use of ITN’s. It may also be possible to have a soapbox in the local market
or to hold impromptu or organised shows within the camp. Locally based
artists (acrobats, musicians or actors) may be happy to work with the
programme and to promote both themselves and the programme. If funding
is available it may be possible to construct a meeting room of some sort and
organise different events for different groups in a camp situation. A safe
space might also be provided for women and discussions and facilities might
be arranged to meet their particular needs.

What do people need to know?
In the initial stages of an emergency you may have to rely on a more didactic
provision of information but wherever possible the responsibility for problem

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solving should be handed over to the people you are working with. For
example in a community meeting you can present people with information
and then ask them what they think can be done about the situation - try to list
four or five actions which will then be carried out before the next meeting. In
a training seminar do not tell people what they should be doing but ask them
to suggest what should be done and how they will do it.

Malaria is a very difficult problem to tackle but if people work collectively on
the problem progress can be made.

Some or all of the following responses might be useful in trying to tackle
malaria:

Ensure that people (especially those most at risk – usually young children
and pregnant mothers) receive treatment EARLY and take the FULL
treatment.

Reduce the number of breeding sites by ensuring no standing water or
pools etc. and by keeping vegetation around pools and rivers to a
minimum. It is difficult to clear all the breeding sites such as rice paddies
and large areas of swamp but it may be possible to introduce larvae eating
fish into these areas. There are also some types of insecticides and bacteria
which get rid of larvae but these need to be applied regularly and may be
harmful to birds and fish.

Use treated bednets – BUT mosquitoes that cause malaria bite at different
times and if they bite in the early evening before people go to bed then
bednets won’t work.

Residual Spraying of walls – BUT the mosquitoes that cause malaria can
rest indoors and outdoors. Residual spraying won’t work if they rest
outdoors so this needs to be determined as soon as possible.

Treatment
Sometimes people don’t take the full course of treatment because it is
expensive – they take some and then stop and save the remaining tablets for
the next time. This means that the parasite is not killed completely and
becomes resistant to the drug and the drug can stop working. In areas of
stable transmission most adults have developed some degree of resistance to
malaria – they may still get sick but don’t usually die just from malaria.
However young children and pregnant women have a lowered immunity and
are more at risk. Often children are not taken early enough for treatment.
Cerebral malaria can develop very quickly (within 48 hours) so all children
with fever need to be seen in the clinic promptly. Families need to know how
to care for children with uncomplicated malaria and when it is important to
take the child to the clinic.
Try to identify the reasons why people may not go to the clinic and if possible
try to address this. If clinic staff are involved in some of the problem solving
groups they may be helpful in suggesting ways of dealing with long waiting
times or staff who do not show patients enough respect. It is vital that men

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Education &
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are involved in discussions about seeking early treatment as women may have
to seek their permission before being able to take their children or may need to
be accompanied by a man.

In some remote areas it may be possible for Community Health Workers to
distribute simple medication for malaria either as treatment or prophylaxis to
at risk groups but if this is to happen it will need the help and support of the
MoH. It may be possible for Oxfam to support such an initiative in the short
term if there is an epidemic of malaria.

Pregnant women
Pregnant women are usually more at risk of developing malaria especially
during their first and second pregnancies as their immunity is reduced during
pregnancy (this is believed to occur in order to prevent early rejection of the
foetus). Regular attendance at antenatal clinic is important. Pregnant women
are usually given treatment on their first visit as parasitaemia (malaria
parasites in the blood) may be present without any clinical signs. They will
then be given prophylaxis (preventative treatment )each time they visit. They
may need to be reminded of the importance of taking this weekly or
encouraged to go to the clinic for antenatal care. It is important to find out
what advice is recommended by the Ministry of Health in the area you are
working in.

In Mozambique it was thought to be unhelpful to target a bednet distribution
at women who were pregnant at the time of distribution and therefore all
fertile women were targeted. In some programmes nets are distributed at the
clinic when mothers attend for antenatal care and this may be a useful
incentive to encourage attendance.

It is important to work with women who are either pregnant or likely to
become pregnant to explain to them the specific risks that they face and what
they can do to protect themselves.

Source reduction
Mosquitoes can breed in many different environments even hoof prints and
tyre tracks. Reducing the number of breeding sites will thus reduce the
number of vectors (although this has to be significant to reduce the
transmission of disease). It is difficult to manage the problem just by getting
rid of breeding sites because mosquitoes can fly quite a long way so breeding
sites might be up to 2km away and some species such as An. gambiae can
breed in even the small amounts of water found in a footprint. It is probably
not helpful for communities to put all their efforts into source reduction only
to find that the incidence of malaria stays the same so if source reduction is
advocated, this should be backed up by more effective methods.

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However, it could be argued that the long term sustainability of any malaria
control efforts will eventually depend on limiting the number of breeding
sites.
Treated bed nets (ITNs)
If it is decided that bednets are an appropriate response the following
information will be useful:

In many projects bednets are targeted at the most vulnerable groups. This will
often be pregnant women and children under five especially those from the
poorest families who may not be able to afford prompt treatment and cannot
afford to buy a bednet. In certain circumstances other groups may also be
more vulnerable than the rest of the population such as people exposed to
mosquitoes in the course of their work. Vulnerable groups are most likely to
become seriously sick or to die from malaria whereas less vulnerable groups
may become ill with malaria but will have built up a certain degree of
immunity to the disease.

If bednets are given free of charge, people may not value them enough so
many projects insist that a fee is paid for the nets which should be based on
how much people can afford and how much they are willing to spend. In
humanitarian situations however, people may not have the resources to even
pay a token fee and it may be decided that the nets should be distributed free
of charge. Whilst the common belief is that this undermines the sustainability
of the project, more research is needed to verify this belief. It may also be true
that in emergency situations people are more willing to take on new ideas and
that this may then subsequently create a demand for a product where
previously there was none.

When discussing the cost of nets with people, it is useful to discuss what they
currently spend on treating and preventing malaria. People may spend
money on coils and medicine, which may amount to as much as a net over the
course of six months or a year.

Nets work best if they are treated with insecticide. This needs to be done
every six months and the nets should not be washed during this time.
Coloured nets are usually preferred so they do not show the dirt so easily. In
some projects untreated nets are distributed and then treated with community
members.
Education must focus strongly on the need for regular
reimpregnation, maintenance and eventual replacement of the net. The
project will need to consider options for this even if Oxfam cannot carry out
this phase of the project themselves.

In some programmes mending kits are also provided with the nets and people
will need to know the importance of checking the nets for holes and mending
them as soon as possible.

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It is vital to keep accurate community based records (if possible) of who has
received a net and when the net will need re dipping. Ledgers and pens
should be provided to committee members or outreach workers who are
responsible for this and support may need to be given to help them maintain
them accurately.

Residual spraying
If residual spraying is considered necessary it is important to discuss this with
people to ensure they accept this is necessary and will allow spray teams into
their shelters or homes. People will need to know when the spraying will be
carried out and how in addition to the following safety information:

Insecticides can be dangerous and must be treated with caution. Residual
spraying can last between six to eight months.

Safety precautions must be adhered to when the house/shelter is being
sprayed:

Remove all cooking utensils, drinking water and food from houses.

Ensure food and water is covered.

Keep animals in cages or secure away from spraying.

Remain out of house for one hour until the spray is dry

Sweep all insects and dispose of in the latrine (do not give to chickens!)

Do not stand downwind of spraying

Wash all utensils on return to house

Ensure children do not scrape walls on return to house

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Monitoring & Evaluation

Part II
Intervention
Monitoring &
Evaluation

It is important to consider the issue of monitoring and evaluation as soon as
possible at the inception of the project. One of Oxfam’s most significant
failings is the lack of systematic evaluation of its humanitarian programmes.

If a programme is planned using a logical framework, it should be possible for
monitoring and evaluation to be carried out in a way that will allow future
learning and accountability. An example Logical Framework for a malaria
control programme is provided in the section on planning. This details the
indicators and methods for measuring those indicators that might be required.

It is important to rationalise the number of indicators that are used as
attempting to gather too much information may well undermine the success of
the evaluation process and it is important to differentiate between monitoring
and evaluation. Monitoring attempts to look more broadly at what is being
done and the processes that are used. Regular monitoring reports should be
provided which can provide a basis for future evaluations or impact
assessments. A monitoring system should have the capacity to identify newer,
more appropriate indicators that should be used to update the logical
framework as necessary. Regular team meetings should provide a venue for
attempting to assess what has been achieved and how.

What to monitor and how
The most important indicators that the programme should be monitoring are
proxy indicators of impact such as the appropriate use of nets or action taken
by beneficiary groups. This is explained in more detail on the following page.
Health Indicators
Disease indicators should be set from the outset and monitored regularly to
ensure progress, coverage, and to guide strategic direction. The disease
indicators selected will depend on the state of the surveillance system. The
following list provides a choice of potential disease indicators but only one or
two indicators should be selected: As Oxfam does not normally provide
clinical care it may not always be easy to access clinical data. It may however
be possible to encourage the community to record deaths or severe sickness.

Number of patients with acute febrile illness seen in health facility in given
period (week/month)

Number of laboratory confirmed cases of malaria in a given period

Number of laboratory confirmed deaths due to malaria in a given period

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Number of deaths following a febrile illness as recorded by community
leaders or from recording burials or cremations

Such indicators are insensitive however and should be used with caution.
Crude mortality rates should also be monitored as it is difficult to assess
deaths from malaria where acute respiratory infections and diarrhoeal
diseases are common.
Proxy Indicators
The incidence of disease is affected by many variables and it is therefore
difficult to draw any direct conclusions about the impact that your project will
have had on malaria from health data alone. It is therefore suggested that
PROXY INDICATORS are used which serve as a viable substitute for health
data. In the case of an ITN project, this would be the appropriate use of and
retreatment of nets. In a residual spraying programme it would be a
combination of adequate coverage of households and appropriate spraying
technique used by spray teams. These indicators allow us to draw inferences
about the impact of our programme because they have been shown to have an
impact on health in previous research. Other indicators of the success of a
malaria control programme might be:

Increase in timely consultations for fever in under five population (or
decrease in late referrals to clinic)

Increase in regular antenatal consultations

In addition there should be some attempt to measure participation, gender
equity and sustainability. The following indicators might be used:

The design of the programme operates a mechanism for representative
input from all users and when questioned women and men state that they
have been involved in the process and provided with information to allow
them to make informed decisions

Community groups have set their own objectives for action to control
malaria

The viewpoints of men and women are provided in the baseline and
monitoring data

All sections of the community have been provided with information and
learning opportunities

Women particularly have been facilitated to make decisions concerning
the project

Gender training has been provided to all new Oxfam staff

Sphere Standards
The Sphere minimum standards provides the following indicators with
regards to malaria control and it may be useful to add these to the monitoring

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framework or to fill in the form given below. Depending on each particular
situation some or all of these indicators may be applicable:

Comments

Vulnerable populations
outside the malarial zone

The population of malaria bearing
mosquitoes is kept low enough to avoid
the risk of excessive malaria infection

Mosquito breeding or resting sites are
modified
where
necessary
and
practicable.

There is no standing waste water around
water points or elsewhere in the
settlement

Storm water flows away

Water point drainage is well planned,
built and maintained. This includes
drainage from washing and bathing
areas as well as water points.

Sufficient numbers of appropriately
designed tools are provided to people
for
small
drainage
works
and
maintenance where necessary.

People with treated mosquito nets keep,
use and retreat them correctly

People avoid exposure to mosquitoes
during biting times using the means
available to them

10.

Breeding sites are removed, emptied of
water regularly or covered.

11.

The purchase, transport, storage and
disposal of pesticides and application
equipment follows international norms
and can be accounted for at all times

12.

Personnel are protected by the provision
of training, protective clothing & a
restriction on the number of hours
handling pesticides

13.

People are protected during and after the
application of pesticides according to
internationally agreed procedures

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are

Intervention
Monitoring &
Evaluation

SPHERE MINIMUM INDICATORS FOR VECTOR CONTROL & DRAINAGE

Key Indicator

Part II

settled

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Part II

14.

The quality of pesticides conforms to
international norms

15.

The quality of treated bednets conforms
to international norms

16.

The design of the programme operates a
mechanism for representative input from
all users

Intervention
Monitoring &
Evaluation

Whilst these indicators are not complete, they provide a basic outline of what
a malaria control project might be aiming to achieve.

Methods for Monitoring
The methods used for monitoring can be similar to those used for gathering
baseline data. Household assessments can be used to ascertain if people are
using ITNs and who is using them. Spot check assessments might endeavour
to gather a large number of observations of bednet use or domestic breeding
sites in order to provide more quantitative and representative data.
Household assessments however are used to provide rapid information on the
success of a distribution and must state clearly that this is not necessarily
representative. The number of households ‘sampled’ must be given if
numbers are converted to percentages.

Key informant interviews and focus group discussions can also be used to
monitor what is happening in the community and whether there has been a
change in people’s perception and knowledge of malaria. Repeating the
mapping exercise in different communities can allow people to see if there has
been a change in the number of breeding sites.

Details on methods for monitoring and evaluation are to be found in the
Oxfam Guidelines on Public Health Promotion.

Evaluation
In evaluating a project, an attempt is made to gain an overview of how the
project was carried out. The following areas are often examined: impact,
effectiveness, appropriateness, connectedness, cost effectiveness and
efficiency. Impact is a key area that is often not evaluated sufficiently.
Recently Oxfam has provided a framework for impact assessment that looks at
five different areas of impact:

changes in people’s lives,

sustainability,

participation,

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impact on gender equity

changes in policy and practice

Part II
Intervention

This framework can also be used in the emergency context depending on the
acuteness of the situation. Initially it may not be possible to achieve change in
all these areas in the short time frame afforded by emergency situations but all
aspects should be considered and the opportunity should be taken where
possible to ensure that objectives encompass these goals.

It is important that any impact assessment undertaken seeks the opinions and
participation of the community and uses the exercise as an opportunity for
learning not only for project staff but also for community members.

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Monitoring &
Evaluation

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Resources
Monitoring &
Evaluation

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Resources

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Contacts

Part III
Resources
Contacts

Several agencies can provide specialist assistance on malaria:
Malaria Consortium
Dr. Sylvia Meek or Dr. Jayne Webster
Malaria Consortium UK
London School of Hygiene & Tropical Medicine,
Keppel Street,
WC1E 7HT
Tel: 00 44 171 927 2439
Fax: 00 44 171 580 9075
E-mail: sylvia.meek@lshtm.ac.uk
jayne.webster@lshtm.ac.uk

CDC (focal point for US NGOs – may have more detailed information on
countries where US involvement)
Dr. Holly Williams
Malaria Epidemiology Section
National Centre for Disease Control and Prevention
Mailstop F22
4770 Buford HWY
N.E. Atlanta, GA 30341
USA
Tel: 00 1 770 488 7764
Fax: 00 1 770 488 7761
E-mail: hbw2@cdc.gov

RBM network for Complex Emergencies
Dr. Richard Allan
World Health Organisation
20 Avenue Appia
1211 Geneva 27
Switzerland

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Resources
Contacts

Tel: 00 41 22 791 4316
Fax: 00 41 22 791 4824
E-mail: allanr@who.int

Malaria Network established by WHO in 1998 aimed at malaria control
managers and ministry of health staff
http://www.malarianetwork.org

Asian Collaborative Training Network for Malaria (ACTMalaria)
http://actmalaria.org

Multilateral Initiative on Malaria (MIM) Newsletter, published by the
Wellcome trust since mid 1998 to provide information on current activities
http://www.wellcome.ac.uk

Mapping Malaria in Africa (MARA) which produces theoretical maps of
malaria risk
http://www.mara.za.org

MALSAT research Group: the role of Environmental Information /systems is
an operational research group working towards the establishment of
improved methods of malaria stratification, monitoring and surveillance and
epidemic preparedness.
www.liv.ac.uk/lstm/malsat.html
A volunteer web site providing country profiles and other references
http://www.anopheles.com

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GLOSSARY

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Resources
GLOSSARY

Levels of Malaria endemicity:

Hypoendemic: Little transmission, malaria does not affect the general
population importantly (spleen rate in children aged 2-9 years is less than10%)

Mesoendemic: Typically found in rural communities with varying intensity of
transmission (spleen rate in children 11-50%)

Hyperendemic: Areas with intense but seasonal transmission where
immunity is insufficient to prevent effects of malaria in all age groups (spleen
rate in children constantly more than 50% and in adults more than 25%)

Holoendemic: Areas with perennial high-degree transmission producing
considerable immunity in all age groups, particularly adults (spleen rate in
children constantly more than 75%, but low spleen rate in adults)

Aerial Spraying
A type of space spraying of insecticide from low flying aircraft over large
areas of land. This is usually done with the ULV method using the same
insecticides as for ground fogging programmes but using different
preparations.

Aerosol Spraying
Use of aerosols producing very tiny liquid or solid particles suspended in the
air.

Anaemia - decrease in number of red blood cells and/or quantity of
hemoglobin. Malaria causes anemia through rupture of red blood cells during
merozoite release. The anaemia caused may be extreme. Pallor may be visible
in the patient..

API - Annual Parasite Incidence. API = (confirmed cases during 1
year/population under surveillance) X 1000.

Autochthonous - locally transmitted by mosquitoes. Differentiated from
imported, congenital, or blood-borne malaria.

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Case Fatality Rate (CFR):

GLOSSARY

The number of case deaths during a certain period (usually one week) divided
by the total number of cases in the same period x 100 = CFR as %

Cerebral malaria - this grave complication of malaria happens at times with P.
falciparum infection and involves malaria infection of the very small capillaries
that flow through the tissues of the brain. This complication has a fatality rate
of 15% or more, even when treated and is extremely serious.

Fogging –
Thermal fogging is a type of space spraying usually applied by handheld or
shoulder carried pulse jet machines or a two stroke engine exhaust fog
generator. Vehicle mounted fogging machines are also available.

Incidence Rate:
The number of new cases during a certain period (usually a week), divided by
the total population exposed during the same period x 100 = incidence rate as
a percentage
Number of new cases X 100
Total population exposed

Prevalence rate:
The number of cases both old and new occurring at a fixed moment in time
divided by the total population and expressed as a percentage

Total number of cases X 100
Total Population

Recrudescense - a repeated attack of malaria (short term relapse or delayed),
due to the survival of malaria parasites in red blood cells. Characteristic of P.
malariae infections.

Recurrence - a repeated attack weeks, months, or occasionally years, after
initial malaria infection, also called a long-term relapse. Due to re-infection of
red blood cells from malaria parasites (hypnozoites) that persisted in liver
cells (hepatocytes).

Relapsing malaria - Renewed manifestation (of clinical symptoms and/or
parasitemia) of malaria infection that is separated from previous
manifestations of the same infection by an interval greater than any interval
resulting from the normal periodicity of the paroxysms

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Residual treatment - treatment of houses, animal sheds, and other buildings
where people or animals spend nighttime hours with insecticide that has
residual efficacy. The goal of residual treatment is to block transmission by
stopping human-vector contact.

Space Spraying – This may be done through thermal fogging on the ground
or from aircraft. Space spraying must be restricted to an hour or two in the
early morning or evening when the temperature is lowest and when thermal
currents, which cause excessive dispersion of the insecticide, are at their
lowest.

Splenomegaly - an enlarged spleen. A common finding in malaria patients
that sometimes can be detected by physical examination. May occur in
otherwise asymptomatic patients and is of use in conducting malaria surveys
of a community, although it should not be the only factor considered when
counting cases.

Stable Malaria – is characterised by a vector with frequent human biting habit
and a high daily survival rate, environmental and climatic conditions
favourable for rapid development of the parasite, normally high endemicity,
Plasmodium falciparum prevalent parasite, high immunity in adults but may be
low in children and pregnant women. Although there may be seasonal
fluctuations in incidence these are not usually marked. These factors
combined make epidemics unlikely but also makes malaria very difficult to
control especially in rural areas. (see Unstable Malaria)

Temperature - the optimal temperature for development of P. falciparum is
30oC [86oF], while the optimal temperature for development of P. vivax is 25oC
[77oF]. The time required for development of the sexual phases of the malaria
parasite in the mosquito is 10-11 days at these temperatures.

Transmission – the passing of disease from one individual to another. In the
case of malaria transmission is usually indirect requiring the anopheles vector
to transmit the plasmodium parasite. Direct transmission may occur through
contaminated blood or vertically from mother to foetus.

Unstable Malaria – is characterised by a vector with infrequent human biting
habit and/or a low daily survival rate. The environmental conditions are not
favourable for rapid development of parasite, endemicity is usually low to
moderate and immunity variable with some groups with low immunity.
There are usually pronounced seasonal changes in incidence. P. vivax is
usually the main parasite. Epidemic outbreaks are likely when climatic or
other conditions are suitable but control is also easier than in areas of Stable
Malaria.

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GLOSSARY

Part III
Resources
GLOSSARY

High risk groups
All refugees/displaced populations from a malaria free region entering an
endemic area.
Certain groups whose work obliges them to stay in high risk areas such as
forest fringes
Children under 5 years and pregnant women in endemic areas.

Vector Behaviour:
Anthropophilic – used to describe vector biting preference for humans

Zoophilic - used to describe vector biting preference for animals

Endophilic – vector that prefers to rest indoors

Exophilic – vector that prefers to rest outdoors

Endophagic – vector that prefers to feed indoors

Exophagic - vector that prefers to feed outdoors

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Bibliography

Part III
Resources
Bibliography

General
“Outline Strategy for Malaria Control in Complex Emergencies”
by the Malaria Consortium for the WHO Roll Back Malaria (RBM)/
Emergency and Humanitarian Action(EHA).
“Partnerships for Change and Communication”
Malaria Consortium – WHO

Bruce-Chwatt’s Essential Malariology Third Edition
H.M. Gilles & D.A. Warrell

ITN
Insecticide Treated Net Projects - A Handbook for Managers”
By Chavasse,D. Reed,C. Attawell,K.
(Malaria Consortium, London School of Tropical Medicine and Hygiene,
DFID)

“Registration and Distribution - Working in Emergencies, Practical
guidance from the field” Book 9 Oxfam.

Residual Spraying
Vector Control – Methods for use by Individuals and Communities
By Jan A. Rozendahl WHO: Geneva

Vector and Pest Control in Refugee Situations
PTSS/UNHCR & ISS/WHO April 1997: Geneva

Manual for Indoor Residual Spraying – Application of Residual Sprays for
Vector Control
WHO: Geneva 2000

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Resources

Emergency Vector Control using Chemicals: A handbook for relief workers
Christophe Lacarin and Bob Reed, WEDC, Loughborough

Bibliography

IEC
Buzzing Children: Living Health Reader, Damien Morgan: Macmillan: Hong
Kong (available from TALC)

Child To Child – A Resource Book Part 2 Child to Child Activity Sheets,
The Child To Child Trust

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Potential Partners

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Resources
Potential Partners

Any Oxfam malaria control activities must be incorporated into the wider
public health programme. However it is extremely important that they also fit
in with the host country's national malaria strategy. The Ministry of Health
should be responsible for malaria prevention and treatment policies that fit in
with the WHO Role Back Malaria Initiative. Before beginning, any project it is
necessary to have a Memorandum of Understanding, which stipulates any
terms of collaboration.
In conflict areas where it is not clear whether there is a functioning MOH
usually one UN organisation becomes the co-ordinating body (WHO,
UNICEF, UNHCR)
POTENTIAL PARTNERS

Comments

Ministry of Health:
Central level

Find out if there is a National Programme for Malaria
Control.
How does it fit in with RBM initiative.
guidance and support for malaria control
May co-ordinate control programme
Technical assistance. Legislative +admin support
Monitoring and evaluation

Provincial level

Co-ordination of all activities
Technical assistance
Supervision of district/municipality
?monitoring and evaluation

District /Municipal level

Local project development, co-ordination, supervision
monitoring and evaluation

Health Centre/community level

Implementation of project activities partnerships
Mobilise communities for participation
Communication
Monitoring

Other Government Institutions
Provincial/district directorate/department of

?mobilise education officials to include malaria activities

Education

in curriculum and stimulate other educational activities

Local administrations/localities

Introduce programme -assist in mobilising community
participation

Other institutions and organisations

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WHO (Roll Back Malaria Initiative)

Co-ordinates global action to fight malaria Provides
technical support and ensures partner governments

Resources

adopt appropriate malaria control strategies

Potential Partners
Malaria Consortium

Collaborative project of the Liverpool School of Tropical
Medicine and the London School of Tropical Medicine
and Hygiene. Co-ordinates with RBMI. Books
/guidelines written by consortium.

UNICEF

Works in partnership with governments - funds some
bed net distribution programmes

Tropical Medicine Institutes

Regions/countries doing own research etc

PSI (Population Services International)

Operates ITN social marketing programmes in Benin,
Bolivia, Kenya, Malawi, Mozambique, Rwanda, Tanzania,
Uganda, Zambia. Possible future countries: Cameroon,
Côte d'Ivoire, India, Mauritania and Peru.
Does monitoring and evaluation
Develops clear simple instructions sheets in local
languages with pictures on how to treat nets and
overcome concerns about handling the insecticide.

NGOs International/national

Planning and Implementation for:
Distribution of materials
health education at community levels
Formation of community councils, groups, activists.
Education dissemination
monitoring(including drugs) and evaluation
Advocacy roles. Demand generation

Coalition group /community leadership

Mobilisation of community; distribution monitoring and
evaluation; community decision making; referral systems

Community Partners:

Communication and health education

Includes community agents, village mobilisers,

Mobilisation of community

health and other activists form religious
institutions, traditional healers and birth

Distribution

attendants etc

Monitoring and evaluation

Private sector

Buying and selling of Mosquito nets re-treatment
materials and malaria treatment
New technology
Marketing/advertising

Mass Media

Disseminate key messages to sensitise, inform, educate
and mobilise population

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EXAMPLE MEMORANDUM OF
UNDERSTANDING

MEMORANDUM OF UNDERSTANDING BETWEEN: OXFAM AND THE
MINISTRY OF HEALTH REGARDING THE PROVISION OF INSECTICIDE
TREATED MOSQUITO NETS (ITN)

.
Oxfam intends to work in partnership with the Ministry of Health in order to
provide Insecticide Treated Nets (ITN’s) to the following communities
…………………………………………………………………………………………
…………………………………….. Individual households are expected to
purchase the nets at a subsidised rate of $…………. The ITN’s are intended
primarily for pregnant women and children under five but each household
will be allowed to purchase one extra net to be used for other family members.
The ITN’s will require retreatment every six months to maintain their full
effectiveness and will also need to be repaired as necessary. It is expected that
the nets will last at least three years but may last up to five years.
Communities will need continued support to ensure safe and effective
retreatment of nets but Oxfam is not in a position to support communities for
longer than the length of the project (six months) and following this time it is
expected that the Ministry of Health will continue to seek the means to
provide ongoing minimal support to the above communities.

UNDER THE TERMS OF THE AGREEMENT THE MINISTRY OF
HEALTH WILL HAVE THE FOLLOWING OBLIGATIONS:
STAFFING
The MoH will second three health promotion officers to the programme who
will receive a stipend from Oxfam.

RETREATMENT OF NETS
The MoH agrees to support these communities to carry out subsequent
retreatment of nets following Oxfam’s withdrawal from the programme.

ONGOING SUPPORT
The MoH will lobby for the cancellation of import taxation on mosquito nets
in order to make nets more affordable in the future.

PROVISION OF MALARIA TREATMENT SERVICES:

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EXAMPLE
MEMORANDUM
OF
UNDERSTANDING

In line with current health policy, the MoH will ensure the timely delivery of
essential malaria treatment drugs to health centres and clinics.

UNDER THE TERMS OF THE AGREEMENT OXFAM WILL HAVE THE
FOLLOWING OBLIGATIONS:
COMMUNITY MOBILISATION & EDUCATION
Oxfam will work alongside village health committees to ensure they are in a
position to administer the funds and keep accurate records of the sale of nets
and when nets are due for retreatment.

Use of the nets will be promoted amongst pregnant women and children
primarily but households will also be able to purchase one extra net if they so
wish.

Oxfam will ensure that varied learning opportunities are provided to all
community members to raise awareness about the prevention of malaria. In
addition training seminars will be provided to committee members, village
leaders and elders and volunteer health workers.

Oxfam will produce 20,000 leaflets on retreatment of nets and 1,000 posters on
prevention of malaria. These materials will be designed in conjunction with
the MoH.
ITN SUPPLY
Oxfam will source and supply 45,000 nets treated with deltamethrin
insecticide
ITN RETREATMENT
Oxfam will provide retreatment kits and help to promote and organise the
initial retreatment after four months in order to ensure that the project cycle
can end on time.
In case of a deterioration in the security situation or during the period of
heaviest rains, Oxfam reserves the right to cease all work. This work will be
resumed as soon as conditions allow.
Both Parties reserve the right to sever relations if either side does not comply
with the terms of the agreement or if materials supplied by either party are
misappropriated.
SIGNATORIES OF THE AGREEMENT
Ministry of Health representative:
Oxfam Representative:
DATE:

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SIGNS AND SYMPTOMS

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Resources
SIGNS AND
SYMPTOMS

UNCOMPLICATED MALARIA

Uncomplicated Malaria

Community Beliefs
Tick what signs community associates
with malaria

Main Signs:
Fever
Chills
Sweating
Other signs often seen:
Headache
Aches
Joint pains
Anaemia
Jaundice
Enlarged spleen or liver
Add any other signs people mention:

Complicated Malaria

Community Beliefs
Severe or Complicated Malaria

Tick what signs the community
associates with malaria

Main signs in addition to those for
uncomplicated malaria:
Coma
Delirium
Agitation
Somnolence
Convulsions
Very High Fever
Very Pale colour

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Much Vomiting

Resources

Dehydration

SIGNS AND
SYMPTOMS

Little Urine of Dark colour
Hypoglycaemia
Haemoglobinuria
Add below any other signs that people
think of as severe malaria:

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Focus Group Discussion
Framework

Part III
Resources
Focus Group
Discussion
Framework

What are the most common diseases at present and which are the most
serious?

Who gets these diseases? Men, Women, Young children older children?

What do you do when someone has Malaria/Fever/Fits? (find out if people
classify these separately)

Who do you go to?

When do you go?

What do they do?

What do you do if this treatment doesn’t work?

Do you give any home treatments? What are they – who do you get them
from?

Is this what happens to all members of the family?

Is this what everybody does?

Who gets malaria?

What causes malaria? – (probe for other answers)

How can it be prevented?

At what time do mosquitoes bite most?

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Do people use bednets here?

Resources
Focus Group
Discussion
Framework

How much did they cost – how much do they cost now / are they available?

Do they dip them in anything?

Who uses them (how many in a family)– why do they use them – who do they
use them for? Are there people or family members who don’t use them – if not
do they take any other precaution?

How long do they last – what happens when they get torn?

How often do you wash them?

Where and how do people sleep?

What time do young children go to sleep?

What time do adults sleep and get up?

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Terms of Reference

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Resources
Terms of
Reference

MALARIA ASSESSMENT SPECIALIST

Key Activities
To work with Oxfam’s Public Health team to assess the specific risks
associated with malaria in the area of operation
In conjunction with the central and local MoH personnel assess possible
effective responses which may help to prevent malaria epidemics in the region
taking into account the limited resources of both the MoH and Oxfam.

This may include:
·

Selective residual spraying

Use of larvicides

Distribution of ITN’s to targeted groups (possibly as a trial in limited
areas)

Use of environmental control methods

Or a combination of the above methods

Liaise with the National Organisation for the control of malaria and other
vector borne diseases (NOCMVD) and the regional malaria control
departments to determine their malaria control policy for the country and
areas of priority need

In conjunction with the Public Health Specialist and the MoH assess the
provision of essential malaria control drugs to clinics to ensure that limited
resources are used most effectively to address the most significant
problems

Make recommendations for monitoring and evaluation of any malaria
control project and if necessary conduct training which will enable this to
be carried out

To contribute to the writing of proposals and developing budgets to
procure funding for proposed malaria control activities, which will be
identified during the assessments.

To ensure that all work is carried out in a way that is sensitive to
community needs and gender issues.

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Resources

To produce written recommendations for the development of the
programme by the end of the contract period

Terms of
Reference

Key competencies
·

Expertise in vector and especially malaria control

Experience of carrying out public health assessments in emergency
situations

Experience of planning, implementing and malaria control activities.

Ability to liaise effectively and appropriately with partner agencies

Overseas experience is required, covering both relief and development
work in different locations.

Ability to represent Oxfam to other agencies and to contribute towards the
co-ordination of the response with other relevant agencies

Well developed analytical, assessment and planning skills.

Good oral and written reporting skills.

Diplomacy, tact and negotiating skills.

The capacity to remain calm under pressure, flexible to respond to
changing needs yet not lose sight of strategic priorities. Must be organised
and efficient.

Ability to work as part of a team.

A good understanding of relief and development issues.

Commitment to humanitarian principles and action.

Commitment to Oxfam's equal opportunity and gender policies.

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Malaria Control: Public Health Promoter

Resources
Terms of
Reference

Key Activities
·

Plan and implement a community mobilisation and education programme
in the project area ensuring an empowering approach to working with
communities on malaria prevention and control

Organise and implement the collection of baseline data for the malaria
control project. This will involve collecting qualitative and quantitative
data using participatory methods

Continue to assess the public health needs of the community to ensure that
the malaria control intervention is appropriate and that water and
sanitation needs and issues are also addressed as necessary

Ensure that a logical framework is used for planning the programme and
that this is regularly updated to respond to identified needs

Ensure that regular monitoring of the programme is carried out against
agreed objectives and that both process and impact are adequately
monitored

In consultation with the programme manager, identify training needs
within the team and in the community and design and implement training
programmes as required ensuring that evaluation of training is conducted

Ensure regular liaison with the representatives from the National Malaria
Control Programme to ensure that the project is in keeping with their
longer term goals for sustainable malaria control

Ensure regular liaison with other agencies involved in health and malaria
control

Write regular reports adhering to OGB reporting formats at intervals to be
decided by the programme manager (at least monthly). A final report
must be completed before debriefing.

Represent OGB in co-ordination meetings with the government and other
key players as requested

Ensure that all work is carried out in a way that is sensitive to community
needs and gender issues. In particular to promote the full and equal
participation of women in all aspects of the work and to ensure that
Oxfam’s Programme is an opportunity for peace making, rather than
community division.

Ensure that work aims to meet Minimum Standards and adheres to
Oxfam’s emergency guidelines and protocols

Key Competencies
·

Knowledge of public health and one or more other relevant areas (e.g.
health promotion, community development, education, community water
supply). Technical knowledge of malaria is not required but an aptitude
and enthusiasm to learn is preferred.

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The post holder should have at least two years practical experience in
developing countries in appropriate community health programmes.
Some of this time should have been in emergency relief programmes.

Experience and understanding of community mobilisation in relation to
malaria control and water and sanitation activities

Understanding of international health and development and relief issues

Sensitivity to the needs and priorities of disadvantaged populations

Assessment, analytical and planning skills.

Good oral and written reporting skills.

Diplomacy, tact and negotiating skills.

Training/counterpart development skills.

Good communication skills and ability to work well in a team

Ability to work well under pressure and in response to changing needs.

Good written and spoken English essential.

Commitment to equal opportunities and gender equity

Resources
Terms of
Reference

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MALARIA QUIZ QUESTIONS

Part III
Resources
MALARIA QUIZ
QUESTIONS

The following quiz can be used as a training tool for Public Health Promoters
or modified for use with community mobilisers.
1. Malaria is transmitted by a male anopheles mosquito
True

False

2. How many different types of malaria are there?

3. What is the organism that causes malaria?

4. Vertical malaria control programmes are a new approach to malaria
control
True

False

5. In 1998 WHO introduced a new strategy to address the problem of malaria
– what is this new strategy called?

6. Pregnant women should take malaria prophylaxis during the whole of
their pregnancy
True

False

7. Cerebral malaria only affects young children and pregnant women
True

False

8. It is better to take at least half the treatment dose for malaria than none at
all
True

False

9. Residual spraying prevents malaria by killing all mosquitoes
True

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False

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10. Pregnant women and children are more at risk from malaria in _______
than other groups
True

MALARIA QUIZ
QUESTIONS

False

11. What are the main malaria vectors in _________?

12. What is the recommended first line treatment for malaria in _________ and
in what dosage?

13. The most effective method of malaria control is the use of Insecticide
treated bednets?
True

False

True

False

14. There are over 350 species of anopheles mosquitoes

15. Malaria is responsible for 1.5 – 2.7 million deaths world wide each year
True

False

16. In subsaharan Africa there are approximately 270 - 480 million cases of
malaria each year

True

False

17. What are the main species of malaria in ____________?

18. Malaria is easy to diagnose and can be done in all clinics and health
centres
True

False

True

False

19. A malaria vaccine will soon be available

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20. Most adults from Sub Saharan Africa have developed life long immunity
to malaria
True

False

21. Why can treatment for malaria fail? (give as many reasons as possible)

22. __________ is an area of stable malaria transmission
True

False

23. What methods can be used to protect yourself from malaria? (give as many
methods as possible)

24. Severe, life threatening malaria is usually caused by one particular type of
malaria

True

False

25. Insecticide treated bednets need to be reimpregnated every three months
True

False

26. How do ITN’s protect people from malaria?

27. Which groups should be targeted for the distribution of insecticide treated
bednets?

28. Why might bednets fail to protect people from malaria? (give as many
reasons as possible)

29. How can people get rid of mosquito breeding sites?

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MALARIA QUIZ
QUESTIONS

Part III
Resources

ITN Monitoring Form

ITN Monitoring
Form

This rapid assessment might be carried out following the distribution of ITNs.
1. How many children under five and pregnant women in the household?

2. How many bednets did you receive?

3. How many bednets are being used? (Observation)

4. Was the distribution carried out fairly?

5. What do you know about these nets? (record as many things as possible)

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LESSONS ON MALARIA

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Resources
LESSONS ON
MALARIA

The following Malaria Lessons were developed in Mozambique by World
Relief for use with groups of mothers. They can be adapted to different
situations and to different target groups.

These lessons are specifically designed for field workers to teach mothers in
rural areas about how to prevent and treat malaria.

From the lessons you should fully understand the following:

The lessons will teach how malaria is caused, how we can
prevent and treat malaria and how to recognise the signs and
know the risks of malaria. Speak clearly to the mothers so that
they can all understand.

The purpose of this project is to reduce by 50% the numbers of children < 5
years dying from malaria.

Two important ideas from this project are:

1. If children aged between 0-59 months get malaria, they must be
treated the same day that they begin feeling ill.

2. Once the child no longer has malaria the mother must give the child
good wholesome food for the next two weeks.

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LESSON 1
THE CAUSES OF MALARIA

TIME Two hours

METHODS OF TEACHING
Discussion
Questions
Games

GROUPS
Community activists
Volunteers
Mothers

BEFORE STARTING

Greet the group of mothers
Arrange them in a semi-circle around you
Begin with the lesson.

GAME USING ORANGES & PINEAPPLES:
(explain clearly about this game)

Getting to know each other.
Make sure the mothers are comfortable, talk clearly and make yourself
understood. When the game is over, all the mothers should know the names
of all the other mothers.
- When the mothers know each other, they will feel more comfortable to
express their views and ideas.

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TIME: 15 minutes

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1. The mothers will tell the two mothers sitting next to them their name –
saying “My name is ….”.

2. Explain to the mothers about the orange and pineapple (if the mothers do
not know about oranges and pineapples use other fruit that they do know –
make sure they understand the game).

The mother on the left is pineapple; the mother on the right is orange. Say
orange or pineapple to each mother and they must say the name of that
mother. Get all the mothers to change places occasionally. Once everyone
knows each other’s name, start the lesson.

Objectives
When the lesson is finished the mothers will know about the following:
There are a lot of mosquitoes during the rainy season.
During the summer there are a lot of mosquitoes, which is why a lot of people
suffer and die from malaria.
Malaria kills – you must use all the methods you can to prevent your family
from getting malaria.

GOOD MESSAGE:
You must prevent mosquitoes biting because they transmit malaria!
When the mothers have fully understood and repeated the objectives continue
with the lesson:

QUESTION 1
What happens after there has been a lot of rain or after the floods?
Get only one mother to answer at a time.

ANSWER
MOSQUITOES

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QUESTION 2
Explain everything that you saw during the floods and for a few months after.
ANSWERS
Lots of things were happening:
·

There was a lot of rain and everywhere flooded.

Rivers, borrow pits, puddles and ponds became full of water.

After three weeks we saw a lot of mosquitoes.

After the fourth week we saw people becoming sick with malaria.

The numbers of children dying from malaria was much higher.

We also began to see a lot of flies as well.

A lot of people also become sick with diarrhoea.

The numbers of children dying from diarrhoea was also high.

There was a rumour going round that a lot of children were dying because
of witchcraft.

Other things were happening…tell us more.

QUESTION 3
So what can we learn about the events that happened during and after the
floods?

Give us your ideas.
ANSWERS
We can learn about two diseases together:
MALARIA SICKNESS

There is a lot of water about and lots of mosquitoes are born.

We see a lot of mosquitoes and a lot of people sick with
malaria.

We see a lot of malaria sickness and a lot of children dying.

DIARRHOEA SICKNESS

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Dirty water causes diarrhoea sickness.

If there is a lot of rubbish around water they attract flies.

The flies transmit the diarrhoea sickness.

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Diarrhoea sickness kills – especially in children.

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THE RISKS OF DRINKING WATER FROM BORROW PITS / PONDS

Drinking borrow pit or pond water without boiling it first
causes diarrhoea.

QUESTION 4
What sicknesses do we see after there has been a lot of rain or flooding?
ANSWERS:
We saw two types of sickness:

Malaria

Diarrhoea

* we also saw a lot of children dying.
QUESTION 5
So what can we do to prevent these two types of sickness when there is a lot of
rain or if it floods again?
ANSWERS:
We can prevent the sickness by the following methods:
Preventing a lot of mosquitoes
·

Cover up open holes near your house.

Prevent you and your family from getting bitten by mosquitoes.

If someone in your family has a hot body, sponge them with tepid (not
hot, not cold) water.

If someone in your family has malaria sickness, don’t waste time; go
straight to the hospital the same day that they begin feeling ill
especially if they are young or pregnant

If the person is still sick after you have been to the hospital you must
go back to the hospital and explain to the doctors and nurses that the
person has not got better.

If you see signs of malaria, don’t waste time go straight to the hospital.

* - These are the best ways of making sure we reduce the numbers of children
dying from malaria by 50%.

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Preventing diarrhoea

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Throw away dirty water properly.

You must clean all animal and human shit from your yard.

When the children have diarrhoea, make sure they have plenty of
sugar/salt solution, give them breast milk and keep offering them
food.

If they don’t get better, take them to the hospital.

Once you think the mothers have heard clearly and fully understood the
lesson, do the following examination. Help those mothers who have not
understood.

EVALUATION
Ask the mothers the following questions:

What have you learnt from today’s lesson?
(Get the mothers to give their ideas, make sure they speak clearly and
everyone understands them)

Why do lots of children die during the summer or when there has been
a lot of rain or flooding?
(Give the mothers time to give their answers, making sure they speak
clearly).

FINALLY

Close the lesson.

You must arrange the next time and place that you can meet for the next
lesson.

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LESSON 2

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THE METHODS OF PREVENTING MALARIA

TIME: Two hours
METHODS OF TEACHING:

Discussion
Questions & Answers
Pictures
Games

GROUPS:
Animadores
Volunteers
Mothers

BEFORE STARTING:

Greet the group of mothers
Arrange them in a semi-circle around you
Begin with the lesson

Objectives
When the lesson is finished the mothers will know about the following:
The causes of malaria.
The methods of preventing malaria

When the mothers have fully understood and repeated the objectives continue
with the lesson:

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QUESTION 1
What are the causes of malaria sickness?
(Give the mothers the chance to talk to each other and discuss this question)

ANSWERS
Malaria is caused by a parasite, which is transmitted by mosquitoes when they
bite and take blood.

QUESTION 2
How can someone get malaria?

ANSWERS
Someone gets malaria when mosquitoes bite them.
The mosquitoes first bite someone who is sick with malaria.
The mosquito then goes and bites someone who is not sick with malaria and
transfers the parasite.
Within two weeks usually the person who has been bitten becomes sick with
malaria.

QUESTION 3
When do we usually see a lot of mosquitoes?

ANSWERS:

We see a lot of mosquitoes during the summer.
When it is hot and after it has rained a lot.
When the rivers and ponds are full of water.

QUESTION 4

When are the mosquitoes happy to be born?

ANSWERS
(Use the picture to explain when mosquitoes are born)

Mosquitoes are happy when:

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There is a lot of water and when it is hot

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They like to rest under small trees where it is cool

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Mosquitoes like to lay their eggs when it is sunny.

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The mosquitoes quickly break out of their eggs when it is hot
During the summer when it is hot.

(These are the reasons why there are a lot of mosquitoes).

SHOW THE MOTHERS SOME ANOPHELES LARVAE and ask if they have
seen a lot of these where they live

QUESTION 5

So what can you do to prevent mosquitoes?

ANSWERS:
All the families must keep their yard clean from rubbish
Dispose of dirty water properly and burn rubbish
You must cover up all the open holes near you because when it rains they will
fill up with water.

QUESTION 6

What can you do to prevent you and your family from becoming sick with
malaria?

ANSWERS:
Make sure children and pregnant women sleep under the bed net.
If possible use mosquito spray to get rid of the mosquitoes.
Cover yourself up when it gets dark
·

Cover the children when it goes dark

When you have made sure that all the mothers have understood the lesson we
can begin with the game.

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Show the mother the game and make sure she understands how to play
Give them five minutes to understand then start the game.
(When the game is finished, you must say thank you to the mothers).

The game is as follows:
Time: 30 minutes
Choose mothers who are happy to play the game.

We need a family with:
Father
Mother
Happy Children.

We need a family with:
Father
Mother
Children sick with malaria
Somewhere where there a re a lot of mosquitoes
Mosquitoes that are transmitting malaria.
A boy who is looking after cattle and other animals.

Ask the happy mother to explain to the other mothers why she is happy and
why the other mother is not happy. If she has forgotten anything, ask the
other mothers to come up with ideas.

EVALUATION

Ask the mothers the following questions:
Give the mothers chance to talk and express their views

QUESTIONS

1. What causes malaria?
2. Do more people get malaria in the summer or the winter?
3. What can we do to prevent getting malaria?

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FINALLY

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Get the mothers to sing song number one.

Close the lesson.

You must arrange the next time and place that you can meet for the next
lesson.

LESSON 3
BED NETS
The purpose of this lesson is to teach how we can use bed-nets.

Objectives
Why it is good to use a bed net
How to use a bed net correctly
Why we need to treat our bed nets with special medicine.

THE FOLLOWING QUESTIONS GO WITH PICTURE 1.

Show the mother picture 1 then ask them what they can see before asking the
questions.
QUESTION 1
Why is it good to use a bed net?

ANSWERS:

Because:
·

The bed nets stop the mosquitoes from biting us and giving us
malaria.

We can get a good night’s sleep.

The bed net kills fleas and flies and other insects we don’t need.

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QUESTION 2

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How do bed nets stop us from getting malaria?

ANSWERS:
·

Because only mosquitoes transmit malaria.

The mosquitoes bite use during the night whilst we are asleep.

Bed nets stop us from getting bitten by mosquitoes transmitting
malaria.

If we don’t get malaria, we don’t have to find money to buy tablets
to treat malaria.

QUESTION 3

Who is most at risk of getting bitten by mosquitoes and dying from malaria?

ANSWERS:
·

Pregnant women and children under five years are most at risk, so if
there is only one net they should use it.

If there are two nets, the other members of the family should sleep under it
to stop the mosquitoes from biting them and giving them malaria

THE FOLLOWING QUESTIONS GO WITH PICTURE 2

Show the mothers picture 2 and ask them what they can see before asking
the questions.

QUESTION 4

When should we use our bed-nets?
ANSWERS:

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We must use the net every night, all throughout the year

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QUESTION 5

Why do we treat bed-nets with special medicine?
ANSWERS:

The medicine on the bed-nets will scare away or kill all the mosquitoes

The medicine also kills fleas, flies, lice, bedbugs and cockroaches.
·

If we don’t have the medicine the mosquitoes will still make a lot of
noise in our ears and we will not have a good sleep.

QUESTION 6

Why are bed-nets not good?
ANSWERS:

When it is very hot at night, the nets make it hotter – but we must still
use the net. To make it cooler we can take off the blankets and just use a
capelana.

We cannot smoke under our bed-nets

QUESTION 7

How can we still get malaria even if we use a bed-net?
ANSWERS:

If we don’t tuck our bed-nets under our mattress or sleeping mat
the mosquitoes can get inside and we can get malaria

We must hang the nets properly so that the sides of the net don’t
touch us.

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We must mend the holes in the net with our mending kits to stop
the mosquitoes getting in our nets and giving us malaria.

We must be careful not to sleep against the net otherwise the
mosquito may be able to bite us and give us malaria.

We must put a stone in each of the four corners

QUESTION 8

How can we hang the bed nets?
(Show the mothers how to use the bed nets)
ANSWERS:

1. Tie the string from the bed net to the top of the house
2. Make sure that the net is tucked underneath the bed/mattress;
3. Put 4 stones in each corner.

QUESTION 9

What sorts of bed nets are there?
ANSWERS:

There are two types of bed net:
1. Rectangular – These can be attached to each corner of the house
with string. These are good for children and other people that they
sleep with.

2. Conical – These can hang over the bed and are attached to the
house at a single point over the bed/mattress. Three people can
sleep inside, (mother, babies and father).

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THE FOLLOWING QUESTIONS GO WITH PICTURE 3
Show the mother’s picture 3, ask them what they can see before asking the
questions.

QUESTION 10
When can we wash our bed nets?

ANSWERS:
When the medicine on the bed nets no longer has the power to kill mosquitoes
we must wash the bed net with more of the special medicine.

QUESTION 11
When should we re treat our bed nets again?

ANSWERS:
·

When the rains arrive at the start of October, we treat our bed net again
with the special medicine.

We must treat the net with the special medicine every 4-6 months.

If the bed net is not re treated with the special medicine, the mosquitoes
will bite us and we can get malaria.

QUESTION 12
Why must we be careful with the medicine for the net?
ANSWERS:
·
·
·

The medicine can kill when someone drinks it.
If must not wash our bed nets in the rivers or ponds otherwise the medicine
will go in the water and kill all the fish.
After we have re-treated our nets we must throw away the spare medicine
in a latrine.

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LESSON 4
TREATMENT OF MALARIA

TIME : Two hours

METHODS OF TEACHING: Discussion
Questions & Answers
Pictures

GROUPS:

Animadores

BEFORE STARTING:

1. Greet the group of mothers
2. Arrange them in a semi-circle around you
3. Begin with the lesson.

Ask the mothers about the three lessons they have already had, make sure that
they have no problems and make sure that they have not forgotten anything
that they have learnt. Once you are satisfied they have understood everything,
proceed with the next lesson.
PURPOSE OF LESSON:
By the end of the lesson the mothers will know:

- How to recognise the signs of malaria
- How to treat the malaria sickness
GOOD MESSAGE:

Give chloroquine on the first day that someone gets malaria and continue for
the next two days.

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QUESTION 1

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Are a lot of people suffering with malaria in this rural area?

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Yes or No?

QUESTION 2

What are the signs for the malaria sickness?

ANSWERS:

Some of the signs of malaria are as follows:
·

Headache

Body is cold

Body is hot

Vomiting

No appetite

(May be others – ask mothers)

QUESTION 3

How can we treat malaria?

QUESTION 4

What causes malaria?
(Explain the cause of malaria by showing the picture of the mosquito on
today’s lesson).

Give the mothers time to discuss how they can treat malaria and how it is
caused.

Tell the mothers the story about the two mothers, mother Maria and mother
Joana. Show the picture whilst telling the story.

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Picture 1

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Mother Maria is the mother living in this rural area. Like many other
mothers in the area she is leaving her house to go and work in the field.
Paito her child has a very hot body, he has been suffering all night and
didn’t get a good sleep. The child was crying and had no appetite for food.
In the morning Maria felt her son’s body and it was still hot.

Picture 2

Although Paito was feeling ill Maria carried on with her work and went to
the fields leaving Paito with her sister. Paito’s body gets hotter and Paito
begins having convulsions, he is very ill. Meanwhile, Maria is still working
in the field.

Picture 3

When mother Maria returns from the field she finds her son having
convulsions. She quickly throws down her hoe and all the food she has
brought back and quickly takes off her clothing.

Picture 4

She covered her child with her pants and she starts to bang a plate near
Paito;s ears to wake him up like the witchdoctor said. But nothing
happened; Paito never woke up, Paito was dead. – Show Paito’s grave in
picture 5.

Ask all the mothers if they understood what mother Maria did wrong.

Ask two of the mothers to try and explain about mother Maria’s story.

Once this has been done, ask the following questions:

QUESTION 5

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Do you know other mothers in our rural area that treat sickness like mother
Maria treated it?

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QUESTION 6

What caused Paito’s death?

QUESTION 7

What do people in your rural area think causes convulsions?

Give all the mothers time to explain their views. Now all the mothers will
know about the importance of treating malaria and convulsions.

Now tell the story about mother Joana.
(Use pictures to tell the story)

Picture 1

The mother we can see in the bottom pictures is mother Joana. She is
also living in the same rural area as mother Maria. Every morning she
wakes up very early, about 4 o’clock to go and work in the fields. One
day Maezinha’s body was hot all night. She had not slept and she had
been crying all night and didn’t have any appetite. In the morning
mother Joana felt her daughter, Maezinha’s body – it was very hot, just
like it had been during the night. Mother Joana decided that because
Maezinha was ill she would not go to the fields.

Picture 2

Mother Joana decided that she needed to make Maezinha feel colder
and reduce the fever. Joana took some clothing and put them in tepid
water. She then covered Maezinha with the clothes and poured water
over her body until the fever came down. After that she took the child
to the hospital.

Picture 3

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When mother Joana reached the hospital she found the nurse whose name
was Father Mandlhate. The nurses checked Maezinha and gave Joana
some tablets for Maezinha to take; chloroquine and paracetamol. Father
Mandlhate told Joana when they should be taken:

CHLOROQUINE – give one tablet on the first day, then one tablet on the
next two days. (three days)

PARACETAMOL – She must give aspirin three times a day until they are
finished.

The nurses also checked for signs of other illnesses like:
o

Anaemia

High fever / Pneumonia

The nurse told mother Joana that if her daughter was not better after three
days and Maezinho still showed signs of malaria she must go back to the
hospital. She was also told to give Maezinha plenty of good food

Mother Joana did everything that the nurses told her to do. Maezinha started
to feel better after a couple of days. She had no regained her appetite for food
but Joana forced Maezinha to eat as much food as she could. Joana also gave
her plenty of water to drink.

Mother Joana did not go back to work in the field until her child was feeling
better and she had followed what the nurse had said. Now she could go back
to working in the fields.

Now Maezinho felt much better thanks to her mother who stayed at home and
followed the nurses instructions..

Picture 4

We see Maezinha. When you see the signs of malaria, you treat quickly and
properly, making sure to give all the tablets so that Maezinha can get well
soon.

Ask the mothers if they have heard and understood mother Joana’s story
clearly.

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Ask two of the mothers to try and explain the story of mother Joana to the
other mothers. The other mothers can help if that mother forgets anything.

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Now ask the following questions.

QUESTION 8

What is the difference between the two mothers?
(Give the mothers plenty of time to discuss their ideas and the differences
between the mothers)

QUESTION 9

What is the best treatment for malaria?

FINALLY:

Get the mothers to sing one of the songs related to the lesson.

Close the lesson.

You must arrange the next time and place that you can meet for the next
lesson.

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LESSON 5
THE RISKS OF MALARIA

TIME
Two hours

METHODS OF TEACHING
Discussion
Questions

GROUPS
Animadores
Volunteers
Mothers

BEFORE STARTING
Greet the group of mothers
Arrange them in a semi-circle around you.

Before the purpose of today’s lesson
Tell the mothers the good message:

GOOD MESSAGE
The mothers must quickly take their children to hospital when they start
feeling sick with malaria.

Objectives
By the time the lesson has finished the mothers will know the following:
Know the signs and risks of getting malaria
What to do when you see the signs of malaria
Know who are most at risk of getting malaria

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QUESTION 1

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What are the risks of having malaria?

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ANSWERS

Malaria sickness can cause the following risks:
·

There is little blood in the body

Convulsions

If the mother is pregnant she is in danger of dying along with the
baby

Someone can die if they don’t get the tablets they need.

QUESTION 2

Of all the people who live in this rural area, who is most at risk from malaria?

ANSWERS:

It is the children under five years and the pregnant mothers.

QUESTION 3

Why do you think people are in danger when they get malaria?

ANSWERS:

Because in children under five it is hard to prevent sickness:

If the child is not getting enough good food, they can get sick
easily.

Small children do not have much blood so when they get ill with
malaria it affects them the worst.

Because young children can’t explain when they start feeling ill, it
is up to the mother to watch their children carefully.

Pregnant mothers are also at great risk when they get malaria:

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The mother has to share her blood and protection with her baby

A mother who is pregnant for the first time is at greater risk from
malaria than a mother who is pregnant for the second time.

Pregnant mothers are at the following risks from getting malaria:

The baby inside the mother will be getting blood that has the
malaria;

The baby may be born before it should be;

The baby may be born dead;

If the baby survives it may be born too weak and small to survive;

If the mother gets malaria, there is not enough blood for her as she
shares it with her baby

The mother can die.

QUESTION 4

How can you tell that your children do not have enough blood?

ANSWERS:

Open your child’s eye

Look under the eye

If the eyelids look white then the child does not have enough blood

When it is red then the child has enough blood.

Pair the mothers up:
·

Get the mothers to look in each other’s eyes.

Teach the mothers to know if someone is short of blood.

Close the lesson after you have carried out the following evaluation

EVALUATION:

What are the good messages that you learnt today?

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What can you do to help the pregnant mothers and children under five
years?

How can the mothers tell if their children don’t have enough blood?

Why must the mothers quickly take their children to hospital?

Repeat some of the evaluation questions from previous sessions to see how
much people have remembered.

FINALLY:

Get the mothers to sing one of the songs about malaria
Close the lesson

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Malaria Songs

SONG ABOUT MALARIA (1)
1. The mother’s must know that malaria
Is a bad thing in the village (2 x)
A bad thing

2. When the children’s body is hot
Without flu no diarrhoea (2 x)
Is malaria

3. When the children’s body is hot
And convulsions also
Is malaria

4. Mothers give Chloroquine
Quick give Chloroquine (2 x)
Chloroquine

5. After three days
If not better take back to hospital (2 x)
To hospital

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SONG ABOUT MALARIA (2)

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Malaria Songs

1. Sick from malaria
Sick from malaria
Sick from malaria
Is bad for the family

2. Especially in the night
Especially in the night
Especially in the night
In the children’s head

“CHORUS”

Kill the mosquitoes
Kill the mosquitoes
Kill the mosquitoes
The cause of malaria. (2 x)

3. Use bed nets (3 x)
Where the children sleep

4. Cover up the holes (3 x)
In our yards
In our village

5. When the children have malaria (3 x)
Take them to hospital
Give them food

6. When the children are well (3 x)
Give them good food and drink

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SONG ABOUT MALARIA (3)

Malaria Songs

Lets go
Lets go to finish with malaria once and for all (2 x)

Malaria kills
Lets go to finish with malaria once and for all (2 x)

Children die
Lets go to finish with malaria once and for all (2 x)

Kill the mosquitoes
Lets go to finish with malaria once and for all (2 x)

Fill the holes
Lets go to finish with malaria once and for all (2 x)

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STORY ABOUT MALARIA

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STORY ABOUT
MALARIA

There were once two families living in one particular village in rural Chokwe,
Maria’s family and Joana’s family. Both families had recently got bed nets and
had been shown how to use them correctly. During the cold dry season both
families had used their bed-nets, the nights were cold and the nets made them
warmer.

It was August and the nights were much warmer now. It was becoming very
warm to sleep under the nets, and soon it would be too warm.

Maria remembered what she had learned from the training session. Once the
warmer nights arrived she could still sleep under her bed nets outside. She
remembered to take the blankets off herself and her children to make them
cooler and remembered to use the nets. None of Maria’s family got malaria
that year and were very pleased that they had a bed net. They had saved a lot
of money not having to buy tablets and they used the money to buy seeds. As
their family were not ill all of them could work in the fields. Once April
arrived they remembered to re treat their nets and have done every six months
ever since.
However, Joana’s family decided that it was too hot to sleep under the nets
and they did not remember what they had learned about removing blankets.
Instead Joana’s family slept without the nets and only slept under the net
when it was cool enough. Instead the net sat in the corner of the room until
one day Joana’s son, Domingos decided it would be great to use the net to
catch fish.
Domingos had forgotten that the net contained medicine that was poisonous
to the fish. All the fish died and because they were full of poison they could
not eat them. The same water they used for fishing they also used for
drinking. They now have to go 2 kms to find water. The children became
weak, two of them were suffering from malaria and all of them were hungry.
There was no fish, not enough seed to grow because they had spent all their
spare money on tablets. Joana was now pregnant, she and her baby were in
great danger of getting malaria. Joana’s youngest child died shortly after and
so did her baby.

It was not a good year for Joana, she had now learned from her mistakes. She
should have used her bed net every night, even when it was really hot. She
managed to save money to buy another bed net as her original net was now
ruined. The following year all of Joana’s family used the net, none of them got
malaria and they began to save money which they could spend on seed, and
they were all much happier.

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Resources

MALARIA

Part III
Resources
MALARIA

THE IDEA
Malaria is a killer disease. One million children
die of it every year. The disease leaves many
others weak and unable to work or study
properly. Malaria is spread by Anopheles
mosquitoes and affects people in many
countries. It is even coming back to countries
from which it has been driven out. There are
important government programmes to control
malaria and we all need to work together to
support these and prevent malaria from
spreading.
Children can also help by preventing
mosquitoes from breeding and biting people,
and by knowing what to do when someone
has malaria.

Malaria: Some important facts
What causes us to become ill? The germ
which causes malaria is called Plasmodium
and it is carried by the female Anopheles
mosquito. Other mosquitoes do not carry
malaria, but they are a nuisance and may
carry other diseases such as dengue fever.

Anopheles mosquitoes can pick up the
Plasmodium germs by biting people who have
malaria. The germs develop inside the
mosquitoes and are then passed on to
another person.
When the female Anopheles mosquito bites a
person, the malaria germ enters the person's
blood. It travels to the liver and then back into
the blood. This takes about 12 days. Then the
person begins to feel unwell and gets fever,
often with sweating, shivering, headache and
diarrhoea. This fever passes, but keeps
coming back, and may get worse unless it is
treated with the correct medicine. it is very
dangerous for young children and for pregnant
women.
Health workers can test for malaria. They take
some blood from the sick person, spread it on
a glass sl ide, and look at it through a
microscope. If there are Plasmodium germs in
the blood, the health worker will be able to see
them.
The more bites you have, the more chance
there is that one of them will be by a female
Anopheles mosquito which is carrying the
Plasmodium germ.

Where and how these activities have been used
In countries where Malaria is common, this sheet is always a priority, but use will vary widely
depending on the local situation which always needs to be checked with the health worker.
For example, it is useful to know:
· What kind of malaria is present? How serious is the problem?
· What are the prevention programmes in the area? How can children help?
· How much protection do people have, and how much can they afford (e.g. nets, window
netting, sprays)?
Although older children may take some responsibility for younger ones, e.g. protecting them at
night, most action here is taken by children working together. It is important for children with
adults to work out realistic things to do and, if possible, ways in which they can see results, e.g.
less mosquitoes, less malaria.

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Part III

How we can prevent malaria

Resources

To prevent malaria we must stop Anopheles
mosquitoes from biting people.

MALARIA

Keeping mosquitoes away
If possible, the windows, doors and other
openings in a house should be screened, so
that mosquitoes can't get into the house. The
best way to prevent mosquitoes from biting at
night is by sleeping under nets.
These nets must be: put over the bed before
dark.
· tucked in well after you get into bed.

The life of the Anopheles mosquito
Female Anopheles mosquitoes lay their eggs
in still water, such as puddles, ditches and
ponds. After the rainy season, there are many
more mosquito breeding places, and therefore
more malaria. Other mosquitoes breed in
places like latrines, cesspits and even water
pots. The Anopheles mosquitoes don't usually
breed in these places.
Mosquito eggs are small and black and float
on the water. They hatch into larvae which
grow quickly. The larvae of the Anopheles
mosquito float parallel to the surface of the
water. The larvae of other mosquitoes hang at
an angle from the surface of the water.

· kept in good repair by sewing up any holes
or tears.
Remember:
· Mosquitoes can bite through the net if you
sleep close to ft.
· Mosquitoes go on biting until ft is light. Stay
under the net until ft gets light.
In some countries nets are now being treated
with a chemical called permethrin. These
nets are the best defence against malaria.
They help keep mosquitoes away and may kill
them. Even if there are holes in the nets,
mosquitoes may be killed as they try to find
and get through them. This helps to keep the
mosquitoes away and can kill them.
In the evening, at night, and until the first light
of day, as long as the mosquitoes are active,
we can wear clothes which cover the arms
and legs to protect them from mosquito bites.
In places where there are no nets or screens,
a blanket or thick cloth can help protect the
body.
Mosquitoes can also be driven away by
putting a repellent on skin or clothes
(especially around the ankles), by using
mosquito coils, or even smoke from grass or
leaves.
Killing mosquitoes

After about a week the larvae of both kinds of
mosquitoes turn into pupae. After another day
or two the pupa becomes a mosquito which is
ready to fly away.
The adult Anopheles mosquito hides in cool
dark places during the day. The female bites
during the night, and sucks up blood to mature
her eggs.

We can also kill mosquitoes when they get
into the house. Regular government spraying
programmes are very helpful, and everyone
should cooperate with these. When the walls
of the house are sprayed, the insecticide
should be allowed to remain on the walls.
Mosquitoes resting on the walls will then die.
Preventing mosquitoes from breeding
We can also try to stop Anopheles mosquitoes
from breeding by:
· filling up puddles of still water around the
house with earth and stones.
· putting small fish which eat larvae into
ditches and ponds.
· putting oil on the surface of small ponds to
stop the larvae from breathing.
Other mosquitoes can be prevented from
breeding by carefully covering water pots and
containers with cloth, or by putting oil or
special chemicals into latrines.

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If a child has malaria
A child with malaria needs to be treated, or the
disease may get worse and the child could
even die. Wherever malaria is common, a
child who has a fever should be taken
Immediately to a health worker. If malaria
appears to be the cause, the child should be
given a full course of an anti-malarial drug.
A child with a fever believed to be caused by
malaria should be given a course of antimalarial tablets (young babies may be given
an anti-malarial syrup). Treatment for malaria
should begin immediately. Even a day's delay
can be fatal. A health worker can advise on
what type of treatment is best and how long it
should last.
A child should be given the full course of
treatment, even K the fever disappears
rapidly. 9 the symptoms continue, the child
should be taken to a health centre or hospital the malaria may be resistant to the drugs.
A child with fever caused by malaria needs to
be kept cool but not cold. Sponge the child's
body with cool water.

Use this information to keep records, or make
simple graphs to show:
· the months of the year in which people get
malaria (mostly in the rainy season).
· .the months in the year when R rained and
there were many puddles.
· the ages of those with malaria.
· who went for treatment.
Children can plan and keep such records
throughout the school year.
Discuss how such information could be useful
to children, their families and the health
workers.
Where do mosquitoes breed?
In the rainy season, make a map of the area
of the school, and mark on it all the places
where mosquitoes might breed. Then check
all those places, to see K there are larvae in
them. Can you get rid of the water in which the
mosquitoes are breeding? How?

Sometimes the child will be shivering. But
putting too many clothes or blankets on a child
with a high fever or at the shivering stage of
an attack of malaria is dangerous. Medicines
like paracetamol can reduce the temperature.
When children sweat, they lose liquid. They
should be given plenty to drink. As soon as
they can eat again, they should be given food
to build up their strength (see Activity Sheet
6.2, Caring for Children Who Are Sick).

ACTIVITIES
Finding out
Where Is malaria common? Some
government programmes have managed to
control malaria in some places, but in others
malaria is spreading. Find out where malaria
is most common. in the world. in your country.
in your district. Ask teachers, health workers
or local malaria control officers. Is ft spreading
or is ft getting less? Are fewer people getting
ill, or more? Why? Draw maps to show where
people are getting sick because of malaria. At
school, find out from other children in the
group:
· how many children or others in their family
have
· had malaria in the last year.
· how often did they have ft?
· in which months did they fall ill?

What do people know about malaria?
Using the information in this activity sheet,
write down the important facts about malaria.
With the help of their teachers, children can
then make up a simple questionnaire to find
out what families believe about malaria, and
what they do about ft. What can children do
once they have collected this information?

Observing the mosquitoes
In the environment Find out where mosquitoes
are most plentiful. Which kind of mosquitoes
are they? Where are larvae found? What kind
of larvae are they?
In the classroom Collect larvae. Put them in a
covered jar or other container with water,
grass and some mud in R. Observe them. You
should put a little bread or flour on the water
for them to feed on.
Children can draw and write about what they
see.

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Part III
Resources
MALARIA

Preventing malaria
Children can help prevent malaria in many
different ways:
· Make sure that nets are properly used. it is
most important to cover sleeping places of
very young children. Older children can
make sure that younger ones stay under
the nets until first light, and that nets are
well tucked in.
· Where chemicals such as permethrin are
available and mosquito nets are used,
children can encourage families to dip their
nets to provide better protection. Schools
could organise "net-dipping days" every six
months.
· Check for holes and tears in nets regularly
and sew them up.
· Kill mosquitoes in the house.

FOLLOW-UP
Children can test themselves and others on
the facts about malaria.
They can keep records and help the school to
do so. Look at the charts after some months.
Have cases of malaria increased or fallen?
Are some months worse than others? Why?
Are more people using nets and protecting
their neighbourhood? What have the children
done to help at home? at school? in the
neighbourhood? Let them describe their
experiences.
Children can and must continue to be aware
of the dangers from mosquitoes, and continue
to take action such as filling puddles. This is
especially important after the rains.

· When the spray teams come, help carry
food and other things out of the house.

USING THIS SHEET

· Destroy breeding places. Fill puddles with
earth and stones. Put oil on shallow ponds
(old engine oil from cars and lorries works
well).

This sheet can be used by health workers
and youth group leaders. There are also
many ways it can be used in schools. It can
help teachers to plan activities in nearly every
subject in school. For example:

· Make and fit covers for water pots and
containers. This helps to prevent other
mosquitoes from breeding there.
Teachers, children, parents and health
workers need to work together to prevent
malaria. Find out what others are doing.
Helping children who are sick
When young children get malaria they need
help quickly, or they may die. Older children
can watch for the signs of malaria and tell
adults when the young ones need treatment.
Children with malaria feel very ill. Older
children can help to comfort them, keep them
cool, and give them drinks (see Activity Sheet
6.2, Caring for Children Who Are Sick).
It is very important that children take the right
course of medicine at the right time.
(Children's doses vary according to the age
and size of the child.) After the first dose they
may feel better, but all the germs are not yet
killed. Older children must help others to
understand how important it is to finish the
medicine.
Passing the message

· in maths, make graphs of malaria spread.
· in social studies, make maps and do
surveys (where
· is malaria found? where do mosquitoes
breed?).
· in science, observe the life cycle of the
mosquito.
· in language, write stories and plays about
malaria.
· in cultural subjects, make up songs and
dances, draw pictures.
REMEMBER: MALARIA IS A KILLER
DISEASE
MOSQUITOES ARE QUICK AND CLEVER
DON'T GET BITTEN
AVOID MALARIA

Children can help spread the important
message about preventing and treating
malaria to parents an other adults, as well as
to other children. They can d this in many
ways.
Make up a play or dance The children can
mime the Plasmodium germs and the
medicine. The medicine (like policemen)
conies in several times. The first time the
medicine catches most of the malaria germs
but some germs hide. it takes three more
times before a the germs are caught.
Children can act, mime or dance:

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· the life cycle of a mosquito.

Part III

· careless and careful families and villages
(some
· an act the part of clever mosquitoes).
· germs and medicine.
· Make posters Posters by the children can
show:
· how malaria is spread.
· how it can be controlled (particularly in
'danger periods' like after it rains).
· that pregnant women need to visit the
health clinic.
· why children need to take the full dose of
medicine.
· Be sure to put the posters where they can
be seen by many people.
· Write stories Children can write and
illustrate stories and share them with others.
Some titles might be:
· Mrs Mosquito and her Friends
· The Day the Spray Team Came to Our
Village
· Careless Moses (who didn't take the full
course of medicine).
Sing songs Children can make up' Prevent
Malaria' songs and teach them to families, f
riends and to other children.

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Resources
MALARIA

Part III
Resources
Malaria Advice for
Overseas
Travellers (from
staff health
guidelines)

Malaria Advice for Overseas
Travellers (from staff health guidelines)
Always obtain the appropriate type and quantity of anti-malarial drugs
before you travel
Remember that prophylactic drugs must be started before you arrive in the
malarious area. Usually at least one week to ten days before.

Introduction
Malaria is the most important and widespread tropical disease in the world. It
causes much chronic ill health in endemic areas, as well as an estimated two
million deaths every year. In recent years, malaria risk has become worse
because:
· Infective mosquitoes have spread or returned to areas which had been free
or only lightly affected
·

Falciparum (‘malignant’) malaria has spread to areas where ‘benign’
(vivax, ovale, malariae) malaria was the only or prevalent form

Malaria parasites, esp. falciparum, have developed drug resistance

Malaria is present in most countries where Oxfam works.

Malaria is the most important preventable cause of illness in Oxfam staff.
It can be insidious in onset and lead very rapidly to unconsciousness and
death. Types of drugs used to prevent malaria attacks vary with the area
you are going to and between individuals. They are not interchangeable.

Causes and spread of malaria
Malaria is caused by a single-celled parasite called Plasmodium which spends
part of its complicated life cycle in mosquitoes. It is spread through the bite of
infected mosquitoes. Humans are affected by four different species of parasite:
Plasmodium falciparum; Plasmodium vivax; Plasmodium ovale;
Plasmodium malariae
P. falciparum is the most dangerous. It causes ‘malignant’ malaria which can
quickly progress to unconsciousness and death. When it affects the brain it is
sometimes called ‘cerebral’ malaria. At present, it is most common in subSaharan Africa, South East Asia and the Amazon basin of Latin America.

Symptoms of malaria
The classic symptoms are:
• fever
• rigor (shivering)

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• vomiting
• diarrhoea

Humanitarian Manual

• sweating

• abdominal pain

• headaches

• jaundice

Part III
Resources

The first attack occurs from seven days and up to one year after being
infected. The attacks are usually intermittent. This periodicity depends on the
type of Plasmodium and is usually 2-3 days. P. falciparum infection can cause
continuous fever without any periodicity. Drowsiness and confusion may be
the first signs of ‘cerebral’ malaria. Note that:
Malaria can sometimes occur without fever; not all feverish attacks are due to
malaria

Diagnosis of malaria
The only definite way of diagnosing malaria is to discover the parasite in the
red blood cells. A drop of blood has to be stained and examined under a
microscope. They can be difficult to detect, especially if the number of
parasites in the blood cells is low. A proper laboratory diagnosis should be
obtained whenever possible. If not, the disease may have to be treated on the
symptoms alone.

Prevention of malaria
Because of the changing geography of spread and increasing drug resistance
of the malaria parasite, our advice on preventing attacks is under constant
review.
Successful personal prevention of malaria must be two-fold:
• avoid being bitten
• take prophylactic anti-malarial drugs

1 Avoid being bitten
Most mosquitoes start biting at dusk:
·

Shower (mosquitoes are attracted by sweat)

Cover up - long sleeves, trousers, socks

Use insect repellent on exposed areas of skin

Various other measures are available: mosquito coils (which burn, producing
insect-repellent fumes), impregnated head, wrist and ankle bands

At night:
·

mosquito nets are the most important physical measure against malaria.
Always use one. Bednets treated with insecticide such as permethrin are
more effective. Oxfam offices provide these for personal use of staff on
deployment to project areas. Permethrin treatment has to be applied every
six months, to re- impregnate the nets.

Fit windows and doors with fine wire mesh.

Sprays can be applied inside the house

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Malaria Advice for
Overseas
Travellers (from
staff health
guidelines)

These measures are important for other mosquito-borne diseases, e.g.
dengue fever, yellow fever, Rift Valley fever

Part III
Resources
Malaria Advice for
Overseas
Travellers (from
staff health
guidelines)

2 Prophylactic anti-malarial drugs
If you were born in and live in an endemic malarial area you will have some natural
immunity to malaria; however if you move to a different area or have been out of the
endemic area for 2 or more years, you may have lost that immunity.
Strictly speaking, taking prophylactic drugs does not prevent malaria, it only
suppresses the symptoms of disease. This is why it is important to take them
before arriving in the malaria-endemic area and continue after departure from
it.
No drug or drug combination gives total protection; whatever you take, it
is important to be aware that it is still possible to become ill with malaria.
However, most malaria attacks will be prevented if the appropriate drugs
are taken regularly for the prescribed period.
Currently, the following drugs are used:
·

Chloroquine (‘Nivaquine’, ‘Avlochlor’) alone, eg Central America

Chloroquine and proguanil (Paludrine), eg India

Chloroquine and Maloprim e.g. some Pacific islands

Mefloquine (‘Lariam’) eg sub-Saharan Africa, parts of Asia

Doxycycline, eg parts of Asia and Sub-saharan Africa, parts of Asia

Malarone (atovoquone and proguanil). This is the newest anti malarial
now available. It is VERY expensive! It is most useful as a stand by
treatment drug., or for use by individuals for whom no other antimalarial
is possible.

Always follow the advice on the drug packet for any possible side effects of
these drugs. Which of these drugs or combinations of drugs you are given
depends on
a. the area you are going to
b. whether you have had past adverse reactions to one of the drugs
c. any factors which might result in problems if you take the drugs - eg.
pregnancy, past health problems, health problems running in the family

Advice to pregnant women and women who might become pregnant
a. Malaria in a pregnant woman increases the risk of maternal death,
miscarriage, stillbirth and death.
b. Some prophylactic and treatment drugs may be unsafe in pregnancy.
c. Be extra diligent in the use of measures to protect against mosquito bites.
d. Take chloroquine and proguanil prophylaxis. Other drugs are either
dangerous or insufficiently investigated to be taken safely in pregnancy.
e. Take folic acid 5mg daily, when taking proguanil.
f. Do not take mefloquine or doxycycline prophylaxis.

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g. Seek medical help immediately if malaria is suspected, and take emergency
stand-by treatment (quinine is the drug of choice) only if no medical help is
immediately available. Medical help must be sought as soon as possible after
stand-by treatment.

Advice to parents of young children
a. Children are at special risk
b. Protect children against mosquito bites. Mosquito nets for cots and small
beds are available. Keep babies under mosquito nets between dusk and dawn.
c. Give prophylaxis to breast-fed as well as to bottle-fed babies. Breast milk
does not give protection.
d. Seek medical help immediately if a child develops a febrile illness. The
symptoms of malaria in children may not be typical and so malaria should
always be suspected. In babies less than 3 months old, malaria should be
suspected even in non-febrile illness.

DRUGS WHICH ARE NOT
HEALTH

RECOMMENDED BY STAFF

HALOFANTRINE ( halfan )
Can cause severe cardiac disturbances, sometimes leading to death. It has
therefore been withdrawn from use in the UK. And many other countries.
Avoid halfan if on mefloquine either as prophylaxis or treatment.

FANSIMEF
Combination of Fansidar and mefloquine.
Not licensed in the UK

AMODIAQUINE (camoquin )
Reported bone marrow depression therefore it is no longer in use.

PYRIMETHAMINE (daraprim )
Widespread resistance has made daraprim ineffective.

DRUGS RECOMMENDED BY OXFAM FOR EMERGENCY STANDBY
TREATMENTS

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Part III
Resources
Malaria Advice for
Overseas
Travellers (from
staff health
guidelines)

Quinine 300mgs (x42 ) and Fansidar ( x3 )
Take 2 tabs of quinine three times a day for 7 days followed by 3 tabs of
Fansidar once.
·

Quinine may cause tinnitus (ringing in the ears ) headache / dizziness /
and nausea.

Fansidar should not be taken if you have a sensitivity to sulpha based
drugs, neither should it be taken as a prophylaxis.

Not safe in pregnancy and while breast feeding.

Mefloquine

250mgs ( x4 )

( Larium )

Take 2 tabs. immediately and 2 tabs. six hours later.
·

There is a risk of neuropsychiatry side effects e.g. vivid dreams / dizziness
/ and rarely, hallucinations with a therapeutic dose, but the hazards of
untreated malaria are greater.

Not safe as a treatment if mefloquine is being taken as a prophylaxis.

Not safe in children less than 2 years old.

Atovaquone 250mgs and Proguanil 100mgs
(Malarone)

Adult; Take 4 tabs as a single dose on each of three consecutive days. (x12
tabs)

Not suitable as a treatment for children under 11kgs.
·

Suitable in chloroquine resistant areas.

Not safe in pregnancy or breast feeding.

Do not take concurrently with rifampicin or riabutin.

Co-artemether and benflumetol

( Riamet x

24 )

Take 6 doses of 4 tabs over a period of 60 hours. i.e. 10 hours apart
Derived from the Chinese herbal drug quinghaosu. The main ones are
artemether, artesunate and arteether.
Contains artemether and lumefantrine (benflumetol)
Can be used in children over 5kgs.
If used alone, malaria can recur.
Not recommended in pregnancy or breast feeding.
Not yet licensed in the UK but available and used widely in some parts of the
world.

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Artemisinin

Part III

(Artemether / Artenam )

Resources

Is a synthetic derivative of Artemisinin which is a new anti malarial drug of
Chinese / Vietnamese origin. Artemisinin is extracted from quinghaosu which
has been used for centuries in Chinese medicine.
(Not available in the UK but readily available in many countries usually as a
combination drug – see above.)

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Malaria Advice for
Overseas
Travellers (from
staff health
guidelines)

Part III
Resources
Malaria Advice for
Overseas
Travellers (from
staff health
guidelines)

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Example Malaria Budget

Part III
Resources
Example Malaria
Budget

Humanitarian Manual

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