Although RBM reports that MEWS generally are performing well in southern Africa and programs have started in Ethiopia, Kenya, Uganda, Tanzania, and Sudan (WHO/UNICEF, 2003), a recent failure to detect epidemics in Kenya is revealing. In summer 2002, early warning based on district-level rainfall estimates had the potential to detect two epidemics in four highland districts in southwestern Kenya. District-specific warnings could have given 4 weeks notice of possible emergency conditions. In this case, not only did the early warning system fail, early detection based on outpatient surveillance also was delayed because reporting was only being performed monthly. The authors of a retrospective analysis of the 2002 Kenya experience advocate better planning based on known seasonal epidemiologic risks (Hay et al., 2003).
A timely and effective response to a possible malaria epidemic typically requires the deployment of additional drug stocks, use of highly effective treatments, and vector control, in particular, widespread IRS (Luxemburger et al., 1998; Rowland and Nosten, 2001). Early diagnosis also is important during rapid refugee influx; rapid diagnostic tests have proved very useful in such situations (Nosten et al., 1998). In addition, drug treatment policies that take into account the immune status of victims are needed. Artemisinin-based combinations are particularly attractive during epidemics because of their clinical efficacy and independent effects on gametocyte carriage (which, in turn, reduces transmission). Since epidemics frequently involve a high proportion of the population for a relatively short period, one or more rounds of mass drug administration (MDA) along with other control measures is another option for rapidly terminating an outbreak (von Seidlein and Greenwood, 2003). If MDA is chosen, the drug selected needs to kill gametocytes. It also should be given as promptly as possible, which poses a major logistical challenge.
Malaria control cannot be a campaign; it should be a policy, a long-term programme. It cannot be accomplished by spasmodic effort. It requires the adoption of a practical programme … that will be sustained for a long time.