Eliminating Malaria in Sabang

July 1, 2014

By

Michael Sandler

A UNICEF-supported pilot program in Indonesia shows promise as a replicable, community-based approach to malaria prevention in middle-income countries.

Indonesia has been a middle-income country since the early 1990s and has an annual per capita income of about $4,000. Despite Indonesia’s prosperity, nearly half of the country’s 240 million people are still at risk for malaria. UNICEF Indonesia’s malaria team is led by two experts in the field: Dr. William Hawley, a researcher in mosquito biology and malaria epidemiology on assignment to UNICEF from the U.S. Centers for Disease Control and Prevention, and Dr. Ferdinand Laihad, who served for 11 years as manager of Indonesia’s National Malaria Control Program. Dr. Hawley describes the Sabang pilot program in this UNICEF video.

In 2008, they began a project that focused a broad array of government and community resources on eliminating malaria in Sabang, the first step in creating a replicable, scalable program for the whole country. "Sabang is like a living laboratory," says Dr. Herdiana Herdiana, UNICEF's Child Survival and Development Officer in Aceh. "We've started to build a model for elimination."

The Promise of a Replicable Program

The model requires an extensive range of partnerships. Working with the World Health Organization and the Indonesian Health Ministry, UNICEF rallied local and provincial governments behind the effort, engaging mayors, military officers, health workers, public information officials and even authorities at the island’s ports to prevent the reintroduction of the malaria parasite by sea. Field volunteers were taught to recognize and treat the disease, and lab technicians were trained to test blood samples. This first phase was followed by a powerful public awareness campaign and a massive community-by-community effort. Waves of volunteers went house to house, collecting blood samples, distributing insecticide-treated bed nets and finding and eliminating the hiding places where mosquitoes could breed.

The blood testing earned many volunteers the nickname “Dracula,” but the dedicated health workers didn’t mind in their pursuit of a lofty goal. “I want malaria to be eliminated from my island,” said Srikayanti, one volunteer. “It’s ridiculous. No one should die from a mosquito bite, especially no child.” This intensive, broad-based effort succeeded. There hasn’t been a single additional case of indigenously transmitted malaria on Sabang since 2012. The lessons learned in Sabang are being applied in seven more districts in Aceh province. 

Inside the 'Living Laboratory'

A 2013 study in Malaria Journal, Progress towards malaria elimination in Sabang Municipality, Aceh, Indonesia, describes the Sabang case study in detail.

A cross sectional census and survey in six villages selected on the basis of their continued malaria endemicity over the three-year period was conducted.

In the context of Indonesia, Sabang District is an appropriate place to pilot malaria elimination by virtue of its geographic position at the western end of the archipelago, its diverse mosquito fauna, the presence of both major malaria parasites, and its strong local government. The rate of importation of malaria into Sabang is likely low, giving hope that the municipality will be able to maintain elimination in the long run. Sabang has, in general outline, followed the recommendations of the WHO for malaria elimination [8], while recognizing the necessity to adapt these guidelines according to circumstances on the ground in Sabang....

To develop the basis for surveillance and rapidly respond to infections, available malaria baseline data at household level were incorporated into a GIS system to support implementation of malaria elimination. Design of the database included wide consultation, including focus group discussions with the District Planning Board, Civil Registration Office, District Health Office, Health Division of the Armed Forces, Center of Data and Information under the Mayor of Sabang, and sub district leaders. Both routine and survey data were incorporated into the database. A cross sectional census and survey in six villages selected on the basis of their continued malaria endemicity over the most recent three-year period was conducted. The survey was carried out from March to June 2009 in the villages of Paya Seunara, Balohan, Jaboi, Batee Shok, Krueng Raya and Keneukai. The questionnaire included demographic data, malaria risk factors and measurement of coverage of IRS and LLINs. All houses in each village were surveyed and mapped with GPS. 

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Mapping Progress on Malaria

At a meeting of the Asia Pacific Malaria Elimination Network in February 2013, Dr. Ali Imran, chief of the municipal health office of Sabang, presented his findings and lessons learned.

Community-based active fever detection  

  • 83 malaria volunteers were recruited by MHA Sabang (for serving 78 sub-villages and 5 military compounds) 
  • They were trained, certified and monitored every three months 

Malaria Endemicity by Village, 2007-2011 (see map below)

Click here to read the full presentation >

 

UNICEF is a founding partner, with the World Health Organization (WHO), the United Nations Development Programme (UNDP), and the World Bank of the Roll Back Malaria (RBM) initiative, a global partnership established in 1998 to catalyze support for malaria control and elimination, and to rally partners around a common plan of action to fight the disease. One of the keys goals of the 2011 revision of RBM's Global Malaria Action Plan is to reduce global malaria deaths to near zero by the end of 2015. 

Learn more about UNICEF's efforts to combat malaria