Report of malaria external review team. Part I : surveillance of malaria, chemotherapy of malaria

Special evaluation is based on document review, site visits, and interviews with project implementors and beneficiaries. Regarding surveillance, the lack of reliable epidemiologic data to guide operations is hampering MCP effectiveness. Although laboratories function well and health facility utilization is high, 70-80% of cases are not being detected, primarily due to lack of coordination with other health programs. Mortality data and data on patients' age/sex distribution in particular are lacking. Rates and indices (e.g., the annual parasite index and the slide positivity rate) are not computed for all administrative levels (especially villages), nor are these indicators used to plan vector control or drug intervention; attention to entomologic data has also been insufficient. Laboratory backup in most instances is good, despite extremely limited supplies and failure to provide training and materials for slide collection to health facilities. The understaffed and inefficiently operated active case detection home visit program is overburdened with the impossible task of detecting, monthly, all fever cases in a population of 12-30,000, as well as such duties as geographical reconnaissance, activated passive case detection, treatment, overseeing of spraymen, and coordination of supplies. Dissemination of malaria data should not be limited to annual reports and community participation in malaria control should be promoted. Realistic and objective MCP targets must be set. Regarding chemotherapy, a variety of drugs and treatment schedules are used in different areas, both for presumptive and radical therapy, creating confusion and uncertainty as to whether patients are properly treated. Chloroquine is the drug of choice. MCP use of drugs containing pyrimethamine is inappropriate because resistance develops rapidly and could extend to other drugs; the problem is particularly serious in Punjab and Sind where P. falciparum is gaining strength (fortunately only 2 cases of suspected chloroquine resistance have been found). In some areas, mass drug administration is being given without epidemiological justification. Detailed recommendations are made.