E-361 Eritrea: HAMSET Disease Control Project Environmental Evaluation Environmental Evaluation Eritrea Malaria, HIV/AIDS. STD and TB Project Maw 10. 200 PreCpared by Andrew A. Arata Executive Summary: This Environmental Evaluation (EE) was undertaken to review those components of the malaria control program in Eritrea that might possibly have deleterious environmental side-effects unless properly planned and managed. The major concern is in the continued use of the insecticide DDT. This evaluation finds that as proposed, the use of DDT in this program is consistant with WHO guidelines for use: a) when effective, and b) used in high risk areas to prevent epidemic conditions. However, plans to phase out DDT should be developed and alternate, replacement insecticides tested. This EE recommends such alternate insecticides. The EE also makes recommendations on how to improve other components (environmental management = source reduction, larviciding, indoor house spraying, and especiaDy impregnated bed nets) of the national program that will make them more effective and provide additional information for evaluating their individual and combined efficacy. All of these are made to enhance the effectiveness of the use of insecticides employed in the program. The overall use of insecticides is relatively smaLL and only three compounds are employed (DDT; temphos, a larvicide;permethrin, a pyrethroid). Each of these compounds is approved by NVHO Pesticide Evaluation Scheme (WHOPES) for use as employed in this project. Further recommendations are made on the need to improve surveillance and monitoring of malaria trends to improve efficiency and more effective use of the vector control methods employed. It is also recommended that an entomology laboratory, and a field station, be developed as part of this program, and that adequate funds be provided for training exitomologists and research activities to improve the current vector control methodologies. I Background: Entrea is one of the poorest countries in the world (GPD/capita US$ 190) and it is in the early stages of development, having obtained independence in 1993. Eritrea's health indicators are among the lowest in the world. Life expectancy is 53 years, infant and child mortality are * respectively 72 and 135/1000, and maternal mortality is 1000/100,000. Over 50% of the population are children and nearly 70% is composed of children and women in child-bearing age. Malaria is one of the primary causes of child morbidity and mortality, along with diarrhea and respiratory infections. Although this proposed World Bank Project (Annex 1) will assist the Entrean Ministry of Health (MOUIGOE) strengthen their existing efforts to control and reduce the incidences of malai, l-IIV/ADS, and tuberculosis (Tb), this Environmental Evaluation (EE) will deal only wvirh the malaria component. Although all health conditions have some environmental interactions, the need to control malaria transmission by reducincg the man-vector contact by environmental management (e.g., draining or filling vector breeding sites) or the use of chernical insecticides requires scrutiny and evaluation of potential deleterious environmental impacts.. whethe. the insecticide application is to breeding sites, by house spraying or impregnating bed-nets o. other materalas. Conversely, narural environmental conditions (altitude, rainfa11, temperature, etc.) influence vector populations and thus may have a very strong impact on the rate of malaria transmission. Man- made environmental paramneters such as housing conditions, land and water use and the agricultural use of the same or sirrmlar insecticides in malarious areas often influence the distribution and intensity of malaria transmission. During the transmission season, malaria accounts for over 30% of the total outpatient morbidity. It occurs over about 75% of the country's surface are, and approximately two-thirds of the population live in malaria endemic areas. The predominant forms of rnalaria in the country are -caused by the parasites Plasmodiumfalciparum and P. vivar. In the 1970's, falciparum and Viva.x xalarias nad a relative frequency of 60 and 40% respectively: however, by 1996, tc date, faicipaurm malaria has increased to over 90% of the malaria cases reported. The primary mosquito vector is Anopheles gambiae s.L, with several secondary vectors in different ecoloaical -ones. The number of malaria cases reported treated by health facilities and community malaria agents has increased from 141,213 in 1994, to 466.016 in 1998, and 293,671 in 1999.... despite the control efforLs described below. Approximately 90% of the malaria cases are reported from three Rezions (Gash-Barka, Anseba and Debub), with 60 % of the national populatiorn Malaria is most prevalent in September, October and November, foUowing the distinct rainy seasons in the highlands (July - August) and the coastal areas (February - April). The data used for reviewing these envirornmental interactions were provided by various GOE ministries and offices: the quality of the data may not always be equal, and/or uniformly as aiiable by reions, sub-regions and the central headquarters. And, as will be noted in the body of the text, other agencies, bilateral and multilateral donors are active in assisting the malaria program, so that various admiristrative, training, and information management needs menrtioned in this report are beLng planned outside of this project. These are discussed in the appropriate sections of this report and in the recommendations for W;B coordination with other malaria-related support activities in the country. However, it should be noted that this Environmental Evaluation report is not meant to be a review or evaluation of the malaria control program, per se, as observations have been restricted to the vector control operations with environmental implications and not to areas such as diagnosis and treatment. 2. Description of ongoinz malana vector control actiYitigs ( 994-1999 data and 2000 plans): 2 1 The current malaria control program was derived from the Ethiopian program after independence in 1993. It took several years to get started, but figures are available from 1994 - 1999, demonstrating the integrated approach towarTds vector control that the Ministry of Health has adopted. In part, this is consistent with the overall national emphasis on community participation in health and other endeavors as well as self-reliance. The malaria control staff in the MOH includes: the Program Manager, and three sections (Operations, Entomology, and Epidemiology) with offices in Asmara and a staff of 6-8. In each of the six Regions (Zobas) there is a malaria coordinator with 3-5 inspectors who work in the sub- zobas. In all there are -30 full-time malaria staff. Day laborers are hired and trained annually for spraying: comnmunity malaria agents (volunteers) assist in virtually all villages. This evaluation was conducted over a three week period (April - May, 2000): field visits to the three most rnalarious zones (Anseba, Gash-Barka and Debub), and contact was made with health and other pertinent personnel both in Asmara and the Regions visited (Annex 2). The statistics provided by the MOH (CDC Division which compiles the Malaria statistics) show that malaria affects over 67% ( or 1.8 million) of the estimated 2.7 million population of the country. MaLaria cases are reported by both. a) the Hospitals/ Health Facilities, (HHF) and b) the Community Health Agent(CHA). Table l.Reported number of treated cases, 1993-99 are as follows: Source 10993 1994 1995 1996 1997 .22k 1999 HHF 85,743 88,280 116,671 129,908 171,245 273,319 179,501 CHA n/a 52,933 221,881 76,735 81,476 192,697 114,170 Total (85,743) 141,213 338,552 206,643 252,721 466,016 293.671 Transmission occurs in parts of all six Regions (Zobas), and is distributed over about 75% of the surface of the country. The disease is not only endemic in the lowland areas (<500 m) but in the midlands (5OOm - 1500m): even the highlands up to 2200m are subject to periodic outbreal;s under the most favorable epidemiologic conditions. Heavy rains in 1998 probably contributed to increased transmission, enhanced by population movements resulting from military action on the borders (also see Section 6.2). In Eritrea, nine demonstrated or suspect anopheline vectors occur, although their distribution, behavior and vector status are poorly known. Ongoing studies funded by USAID's Environmental Health Project are will clarify some of these issues. Note Because of the long, ongoing militay conflict on its borders, it is difficult to estimate the national population and, consequently, the numbers of people affected by malaria. There are large * returnee populations in the most malarious areas, and these people dwell in marginal habitatiods, often near vector breeding sites: there are Eritrean retumees from neighboring countries, and others who have been displaced wvithin their Regions, fleeing the border conflict. According to the World Bank- office in Asmara, the Bank and other international agencies estimate the population to be- 3.5 million, although malaria figures place the population at 2.7 raillion. The integrated anti-vector measures carried out by the rnalaria control program (and in the order listed by the Program) are as follows 2.2 Environmental vector control (= source reduction, elimination of vector breeding sites): This consists of flling and/or draining standing or slowly running sites of water that may serve as anopheline breeding sites. The malaria coordinators in the Regions and the village znalaria agents are responsiole for identifying and coordinating this work, on a weekl-y basis during the breeding season. Tris type of activity is especially effective in arid regions where breeding sites can be identified, especially where water leak-s around wells or from irrigation dams. Rivers that run only during the rainy season and course through the many villages, are especially important breeding sites, when water "puddles"along the drying beds. There arc numerous dams, both from pnvate and public enterprises, in the most heavily malarious areas (Gash-Barka, Dabub and Anseba) that are essential for agriculture, but around which, vector breeding may occur, Generally the water reservoirs are not the major problems (except along the shallow shores during the dry season), but leakage to the rivers and/or irrigation chanLnels frequently produce major vector breeding problems. Through the collaborative efforts mentioned above, during 1999 (January - November) a total of 3 1,953 mosquito-breeding sites were filled or drained: an estimated 37,000 people participated. This estimate lunps together all breeding sites eliminated, from bucket size through efforts with land-moving equipment, and sites that are weekly disposed of to those that provide a more permanent solution. Co Mments As successful as environmental control is, it requires good surveillance for identifying breeding sites within mosquito flight range of human dwellings, monitoring and follow-up. It is impossible to imnplement without the support and understanding of the local administrations and the communities in affected areas. In particular, environmental management calls for collaboration with other sectors, especially agriculture and public works. In addition, the develop,ment of programs (IEC) for community education and training, in relation not only to malaria, but to health and water use in general is essential, These are area that will require stren2zhenling to support the integrated vector control measures proposed. Environmnental managcment, as conducted in this program, poses no direct environmental threat, The vast majority of the breeding sites are small water bodies in and about villages, and represent only a fraction of similar sites distant from human habitation. Many of the most important vector breeding sites are man-made (overflow from wells, dams, irTigation canals site, etc.) Yexy few will have permanent fauna, and no endangered species are known in the areas likely to by drained or filled. Caution should be taken in carrying out source reduction operations so that areas likely to be used by people (collection of water, washing clothes, etc.). 2 3 L.arvicidine Breeding sites that cannot be eliminated by enviromnental management and are found positive for anopheline larvae are treated with larvicide ( Abate is a trade name = temphos, generic) or used motor oil. During the 1999 campaimn, 9888 ml. oftemphos were applied to 1086 breeding sites: in 1997, some 50,740 rnl were applied to over 3200 breeding sites, As indicated below, ternphos is recommended by WHOIWHOPES (WHO Pesticide Evaluation Scheme) for larviciding and can even be placed in drinking water. It has wide global use, not only for malaria, but dengue and blackfly control, and has little impact on non-target fauna. The programn employs used motor oil as an inexpensive larvicide in poEuted waters or other breeding sites in that are unlikely to be used by man or animals. The use of motor oil should be discouraged as the oil takes a long time to evaporate and contributes to pollution. There are other more volatile oils that can be employed. Commentc Larviciding, lik-e source reduction mentioned above, requires good surveillance, monitoiinsz and community and multi-sector involvement. As is recommended in the conclusion, larvicidin- is an areas in which other control agents...,such as biological control with Bacillus thuringen.is i.-raelensis (Bti) or B. sphaericus (Rs) could be tested and employed as alternates to temphos. An entomolo,7 laboratory with colonies of principal vector species would facilitate the testing of these bio-control agents es alternatives to the currently used chemicals. However, it should be noted that bio-control with bacterial compounds (all of which are larvicides) is currently more expensive than environmentally sound chemicals such as temnphos: this includes the cost of the materials and the frecuency of application required. Pilot tials with biological control compounds and calculation of the possible cost differential should be carried out under local conditions before deciding to employ them on a broad scale. 2.3 Insecticide treated bed nets, Use of insecticide impregnated bed nets began in 1995 (Gash-Barka) and 1997 (Anseba). During 1999 a total of 91,772 nets were distributed, bringing the national total to 164,700 family and double-size bed nets sent to the zones for distribution to date. An additional 95,000 are in the warehouse in Asmuara, awaiting shipment to the zones in May- June, 2000. The method of distribution is through the Regional (Zoba) Malaria Coordinator, to the sub-zoba, and then in the communities. Distribution is through the local autboriies and malaria personnel in zones considered high risk. The price is fixed at 30 Nakfa (approx. USS 3.0 ) per net for those who can afford to pay: those wbo can afford the nets but do not have cash, can purchase ther on credit. Those families which are unable to pay will receive nets at no charge. Nets are distributed at no cost to displaced persons. Reimpregnation will be carried out at no cost to the population (although the insecticide used will cost -US 30 cents per reimpregnation). All funds collected through sale of nets goes into a rotating fund to support the bed net distribution and re- impregnation activities. All nets, regardless of original purchasing agency (e.g., WB, Save the Children, etc.) are distnxbuted through the MOH malaria program as descnbed above. Education on the use of nets is currently provided to the communities by the Zoba, sub-zoba and villaze malaria workers: these same groups are responsible for reimpregnation. The insecticide employed for impregnation is the pyrethroid perrnethrin (see next section). Although over 91 thousand nets were distributed in ] 999, only 12,860 (14%) were reported to have been retmpregnated. No figures were available for the reimpregnation rates for nets prior to 1999. T he amount of permethrin reported used in 1999 (2832 liters diluted at 1:70) would be suicient to reimpregnate almost 200,000 nets, more than have been distributed in the country to date. Comments The impregnated bed net program has problems similar to that of other countries: i.e., starting broad distribution prior to having systems established for community education, monitoring the appropnate use of the nets, a reimpregnation system, and collection of malaria epidemiological data 50om cormunities (or sub- groups) that have or do not have nets. Biological data (now being collected by the USAD/EHP project on vector distribution and behavior (indoor vs. outdoor biting, biting times, etc.) are essential for proper application of all vector control activities .similarly, social data, KAP studies and development of "bottom-up" cormnunity based programs are essential as well. if proper information is not collected from the bezinning of such programs it will be difficult, if not impossible to deterrnine cost-effectiveness, and the appropriate role of this control method in an integrated program. From the envi.onmental standpoint, non-impregnated bed nets, per se ,are neutral: however, with the use of pyrethroids there are some additional considerations. Whereas pyrethroids have very low mammalian and avian toxicity, they are very toxic to aquatic organisms... .fish, insects, crustaceans, etc. Therefore. the proper washing and reimpregnation of bed nets, disposal of any waste or washing of containers, gloves, etc., most be a part of the community education component of any bed net program. And, as attitudes and habits concerning the use of bed nets may differ from one community or group to another, it is important to have a social science input into the desian and operation of bed net programs to prevent malaria transmiission. This is especiallv imDortant in Eritrea where bed nets, along with environmental management are very important elements of an integrated vector control initiative. 2.4 Biolocical Control: Larvivirous fish represent one of the oldest known forms of biological control for mosquitos. Efforts are being made to evaluate this method of control with Aphanius dispar, a top-feeding predator of mosquito larvae and pupae. Trials are underway, both on mass production of A. ispar and efficacy in controlling mosquito larvae. The work is being done on a small scale in both the Northem and Southern Red Sea Zobas. C.omments: Use of larvivorous fish, of various species, has been evaluated in many localities around the wc ,d over the years. The most successful operations have been to control mosquitos in man- made habitats such as_concrete or stone water tanks, especially in and zones such as the Red Sea coast of Eritrea. Studies elsewhere in natural habitats show fish to be less successful in conirolling vectors where there are other sources of food and where they may have a negative impact on other aquatic fauna. However, if they can be successfilly and economically rered and maintain their populations ini man-made habitats in arid areas, they pose no environmental hazard and have a role to play in the most arid zones. 2.5 Residual house/wall sprayng: By MOH policy, this control measure is only conducted in areas subject to malaria epidemics and !n resettlenent zones. However, it is this method of vector control which is most controversial and a rmnajor subject of this evaluation as the insecticide employed is DDT. Details about DDT, WHO's position on its continued usc (especially in Africa) are given in Section 3 of this report. Since the establishrrent of the Eritrean malaria control program, DDT has mainly been used in Gash-Barka, Anseba and Dabub. From a very low level of application in 1996, larger amounts of DDT have been used to in an effort to stem the increasing number of reported malaria cases. Table 2. Reported spray coverage (by villages, houses and population benefflted). quantities of DDT used, and total (CHA +ERF) reported number of cases of malaria. The 352 villages reported sprayed in 1999 represent only 17% of the villages termed "malarious". Description 1994 1995 1996 1997 1998 1999 Villa=es .praved 19 13 2 18 148 352 Houses spraved 9272 13742 600 12385 49482 113789 People benef1tted 41403 3868 2400 30035 166244 225857 Total malaria reported 141,213 338,552 306,643 252,721 466,016 293,671 Kgs. DDT 7S-%WDP 1981 2748 120 3272 14112 21886 Some of these figures are not consistent: for example the number of people shown to have bencfitted in 1995 is much lower than in 1994, even though many more houses were sprayed in 1995. CIormmnts: The house spray component of the Eritrean malaria control program is not extensive. For example, of the 2,089 malarious villages (out of a total of 2,564) only 352 (17%) were sprayed with DDT in 1999. In Gash- Barka, all 784 villages are considered malarious, but only 128 (16%) were sprayed; in Dabub, 579 of 884 villages are considered to be rnalarious, yet only 38% were sprayed with DDT. It is also the stated policy of the MOH to: 1) reduce household spraying further and rely more of environmental management and impregnated bed nets when malaria rates are reduced and; 2) initiate search for altermate compound(s) to replace DDT if house spraying is needed when economic and epidemiologic data indicate that this is feasible. As in the use of bed nets, it is difficult to evaluate the effectiveness of residual spraying. One possibility is to compare the number of new cases of malaria (and mosquito densities, biting rates or inoculation rates) between villages that have or have not been sprayed. At least three successive years are required to determnine if a correlation exists. If some level of residual house spraying is to be retained in the Eritreai rnalaria control, steps sbould be tak-en to select an alternate insecticide to' replace DDT Most likely this would be a pyrethroid.... lambdacyhalothrin, deltamethrin or cypermethrin. A laboratory should be made available to test resistance/susceptibility status of these compounds to An. gambiae and other vector species, followed by pilot trials to test efficacy under field conditions. Using the guidelines and recommendations of WHO regarding the use of DDT in Africa for malaria control (A nnex 3), and as stated by the Mfinister of Health (Annex 4 ), there can be no objection to the manner and quantity used in the current Eritrean program - the GOE regulates the use of DDT only for malaiia control, - there is no recorded vector resistance to DDT in Eritrea (although systematic testing is needed), - application is based on epidemiological evidence in malarious, high-risk areas, - applicators (sprayrnen) are either MOH employees or local hires trained by MOH, - steps will be tak-en under this project to test alternate compounds to replace DDT when epidemiologically and economically feasible 3. Chemical compounds a=plied for vector control and possible alternatives (seeWHO Data Sheets (Annex 5). 3 1 Temphos (= Abate): This organochlorine insecticide has been widely used globally as a mosquito and black-fly larvicide for over 25 years, because of its efficacy and low mammalian and avian toxicity. Various formulations are available (liquid,- grarular for slow release, etc.) and are recornmend¢d by WHOIWHOPES. In this program fewer than 10 liters (active ingredient) are used in most years: the maximum was -51 liters (a.i.) in 1998. Mammalian Toxicity (LD50) is: Dermal (rat) >4000 mg/kg Oral (rat) 8600 mglkg WHO Classification by Hazard: Class IV "unlikely to present acute hazard in normal use". 3.2 Permethriri This pyrethroid insecticide is one of the earliest, having been used for approximately 30 years as a residual spray, a repellent, and more recently in Eritrea and elsewhere for impregnation of bed nets. It is used by a number of military groups for impregnation of clothes as a repellent and durability even after repeated washings. It is produced in numerous formulations, and approved by WHO6/WHOPES. In this program 2832 liters of pernethrin were used in 1999 to impregnate bed nets. Mammalian Toxicity (LD50) is: Dermal (rat) 2500 mg/kg Oral (rat) 500 mg/kg WHO Classification by Hazard is: Class II "moderately hazardous" .depending on formulation and concentration used. This is the same Classification as for other pyrethroid insecticides: this based on the toxicity of the active ingredient, although operationally they are used at much lo-wer concentrations (e.g. 0.20 - 0.50 g/m2 on nets) than organochlorine or organophosphate compounds. 3.3 DDT At the recent (February 2000) WHO conference on DDT held in Harare, Zimbabwe, WHO noted that the Intl. Action on Certain Persistent Organic Pollutants (POPS) granted a general exemnrion on DDT production and use limited to vector control (the fill Delegates' Report is at'ached as Annex ). WHO fully supports the use of DDT, under certain conditions of use, especially in African countries where it is still effective . The conditions of use in this project are presented in Section 2 (above), justifying its contirrued use in the Eritrean malaria control campaign. Mammalian Toxicity (LD5O) is: Dermal (rat) 250-500 mg/kg (in oil) Oral (rat) 113 mg/kg 3000 mg/kg (powder) WHO Classification by Hazard is: Class II "moderately hazardous"... .depending on formulation. In this program the formulation used is 75% Water Dispersable Powder (WPD). 3.4 Possible Altemative Insecticides: At present the malaria control program uses only the three insecticides described above: (temphos for larviciding; DDT for house/ wall spraying, and permethrin for impregnating bed nets). All are performing well at present, but possible alternates should be tested in the event resistance is developed by the malaria vectors to either of the compounds currently in use. Example of possible altematives are: - Temphos may be replaced by, or alternated with, Bacillus thuringensis israelensis (Bti) a biocontrol agent effective as a larvicide against anophelines. The active ingredient is an endotoxin produced by this spore-forming bacterium: the toxin: when ingested in the gut of the mosquito larvae the toxin destroys the endothelium, killing the larvae. The toxin of Bti is effective only acainst dipteran insects (flies, gnats, mosquitos, etc.). The commercial products (e.g., Vectobac ) are available as powders, granules and "blocks" for slow release. The potential drawbacks are the shorter period of effectiveness ('30-40 days depending on water temperature, acidity. etc ..... whereas temphos may last up to 90+ days, and the cost (both of the material and the increased application required. - Perrnethrin may be replaced by a number of other pyrethroid.s, including cypermethnin, lamnbdacyhalothrin, cyfluthrin and deltamethrin. All are approved by WHO for impregnating bed nets, all are risk classified as Class H as "moderately hazardous"...depending on formulation and concentration used (the same as permethrin). Only the pyrethroids have the necessary plTysical characteristics (high vapor pressure) and low toxicity (at the concentrations used) suitable for bed net impregnation. - DIDT, over the years in many countries, has been replaced by organophosphate compounds oftern of greater acute toxicity, requiring more extensive worker safety training and monitoring (for cholinesterase depression). With the advent of the pyrethroids mentioned above, these compounds have become the most common replacements for DDT. They are more expensive (for the active ingredient), but the dilutions are great, reducing the cost. In addition- transport costs are reduced because of reduction of bulk and most are packaged in "sachets" or plastic or foil packages for individual pump charges reducing handling and worker exposure to the insecticide. Because insecticide prices vary considerably depending on quantity purchased, shipping requirements, etc., it is important that a detailed local costing be made, alone with trials for eficacy, in comparng the alternative materials to be used as DDT is phased out. Note that one should not use the same pyrethroid insecticide for both indoor spraying nd impregnation nets as this may enhance the development of resistance. 4. Insecticides used for crop protecon: In a country where agricultural insecticides are used in both the public and private sector, it is difficult to estimate the total quantities. This is especially true in countries that are subject to desert locust outbreaks, during which intensive application of insecticides is required. The Mi'istry of Agriculture (MOA/GOE)' has provided a list of insecticides used by the Plant Protection Service during 1998 (Annex 6 ). This list includes a large number of both I organochionne and organophosphate compounds, six and nine, respectively. These accounted for over 4l tonnes in 1998. Cypermethrin is the only pyrethroid recorded on the MOA list, 'with 278 liters used in Dabub in 1997 and 1998. However, we have no national statistics on the private sector usage of insecticides in commercial agriculture. An example was obtained during a visit to a large (4000 ha. ) cotton plantation near Tessene (Gash-Barka). Aerial spraying is conducted five times per season wvith 3500 liters of several insecticides including organophosphates and the OC Ensosulfan. It is safe to say that the agricultural use of insecticides, both in quantity and diversity of types is far greater than the limited use of three compounds in public health... .but we do not know howr much greater. It should be noted that the MOA has an active program of Integrated Pest Management (IPM) in its crop protection section. The entomological expertise developed in agriculture will have a healthy influence on the public health sector in developing similar programs, 5, Tnsec+;cide resistance: A properly functioning vector control program that utilizes insecticides must have the capability to test the efficacy of the insecticides employed. Insecticide resistance should be checked regularly in all irnportant vector species in areas of insecticide application for vector control and in areas where insecticides are used for crop protection. To date, resistance testing of the principal malaria vector, Anopheles gambiae, has been very limited: the secondary anophel ne vectors have not been studied to date. One cycle of testing DDT and malathion (by conventional W'HO resistancecsusceptibility test kits, using insecticide impregnated filter papers) was conducted during 1998 and 1999 in three Regions (Zobas). In addition, the pyrethroid perrnethrin has been tested once by bioassay for efficacy against An. gambiae exposing the vectors (under a plastic cone) to swaths of bed-netting material impregnated with this insecticide. The results were as follows: - in five locations (two in Gash -Barka, Sept.- Oct., 1998; two in Debub, Oct.- Nov., 1998; one in Anseba, Oct. 1999), 100 adult female An. gmnbiae were tested with WT{O test kits using 4% DDT impregnated test filter papers: in all trials, observed mortality was 100% in all replicates. - in the same localities, at the same time, female Atn gambiae wre tested with WHO test kits using 5% malathion impregnated test filter papers: observed mortality ranged from 100% in Debub, to 83-98% in Gash Bark, and 95% in Anseba. - 100% mortality of An. gambiae was obtained in bioassay trials with permethrin- impregnated bednet material. Obser-vations: Testing for insecticide resistance is important, not only to detenmine the efficacy of the compounds in use, but also in the selection of alternative compounds should there be t need to replace the currently used compound(s). And, because insecticides are expensive, it is essential to select those that may be effective over a long period of time. Furthermore, economic studies have shown that malaria control programs which rely largely on insecticide application, may use as much as 75% of their budget on the purchase of insecticides, equipment for application, salaries for applicators. etc. The Eritrean malaria control program, as described above, is developing an integrated vector control (=nanagement) approach, not solely dependent on insecticides, but chemical control will be a part of this integrated control effort for the foreseeable future. Therefore for economic and operational reasons it is important that the resistance patterns of all important vectors be known from the different ecological zones in the country. The Geographic Information System (G(S) techniques that the USAID/Environmental Health Project is introducing into Eritrea for mapping vector distribution and behavior can be used equally to plot geographic areas of pesticide usage and sites of testing for insecticide resistance. Although vector resistance can be determined in the field, it is easier and more efficient to have a laboratory devoted to this activity, especially for screening new insecticides. At present there are no colonies of insecticide susceptible vector species that are needed for baseline studies. In addition there are no laboratories for insecticide residue analysis (which could be shared with the agricultural authorities). Such a lab is needed to analyse, after spraying, the precise amount of insecticide "active ingredient" (a.i ) that is on the wall or bednet after treatment. Overall, the development of a capability for testing insecticide resistance is essential for evaluating ongoing control programs, selection of alternative compounds when needed, and operational quality control of ongoing insecticide application activities. 6 0 Other Enviroruneital and Safetv Issues 6.1 Safe uce procedures: A s this evaluation took place before the spraying season,, it was not possible to review the training of day-laborers who are hired annually to do house spraying. However, the Zoba malaria coordinators are very experienced men. Regardless, it would be good to have an annual review of'training procedures prior to the start of spraying, and to assure that protective clothing, boots, ,gloves and dust masks are available for all work-ers in each zone. The temperatures are hot, but not oppressive, especially in the arezs above 1000 m, and protective clothing should be wom when spraying DDT, It was noted that equipment such as spray tanks were carefully cleaned and stored before the spraying season: equal attention should be paid to cleaning equipment in the field, and disposing of excess insecticide so as not to contaminate animal and/or human water sources. The malaria field personnel have had years of experience with spraying: on the other hand imnpregnation of bed nets is a relatively new procedure, and various approaches ( impregnation by MOH, NGOs, community action, individual, etc.) are being used in different countries. Ir? order to effectively and safely apply the insecticide being used, the procedure for 1) educating the comrnmunity about malaria and mosquitos; 2) distributing the nets and their effective use, and: 3) reimpregnation and care of the nets, should all form one " packet" and the IEC and malaria staff need to develop this in the local context. This will require the addition of social scientists to the "malaria team" to conduct KAP or related studies and baseline data in all areas (entomological, epidemiological and socio-economic). The very low reimpregnation noted in this campaign is an indication that this has not been done and the people have not understood, or accepted, the concept of impregnated nets. As the use of impregnated nets is one of the major components of the integrated control concept, this could present a real problem. No large numbers of nets should be distributed a better system is in place. What has been said above is general for the education needed by the general population... especially when developing and integrated program with large emphasis on methods ..ch as bed nets and environmental management (source reduction). The malaria staff is too small, and otherwise occupied, to do this along with its other duties. Because this review was made before the spraying season, the whole process of handing storage and transport of insecticides was not seen. Although the three insecticides being used in this program do not present major risks, standard warehousing and handling procedures should be followed. Insecticides are reported to be moved (after delivery) quicldy from the central stores to the Rev,ions, and then to the subregions before spraying. The central warehouse in Asmara is adequate for short time storage (1-2 months for powdered insecticide formulations) but not for long periods. Transport to the Regional stores is by commercially rented (not central government ) vehicles. It is not known whether the commercially hired truckers and laborers were faniliar with, or trained in handling insecticides, or used any protective clothing. The only Regional (Dabub) warehouse visited was suitable only for short- term (1-2 months) storage. 6.2 Other FEnvirornental Consideraiions - There is no question that broad climatic changes that produce high, or even excessive, rainfall or drought weill have local effects on malanra transrnission. The same can be said of large population movements caused, as in Eritrea, by persons displaced by military conflicts. However, to understand these pattems and chanrges, baseline and systematic data over a period of time are necessary: some of these data are just being collected in Eritrea. Some of the data collected by the Zones (e.g. Anseba) indicates that although there was an big increase in rnalaria (epidemic) in 1998, the increase occurred in almost all of the known malarious areas in the zone (albeit not at the same rate), but it did not indicate that it was localized or caused by mass movements of people (Annex 7 ). - Although we have a tendency in an EE such as this to review the potential deleterious impacts that malaia control programs, especially by the use of insecticides, may have on components of the natural environment, we seldom consider the impact, both social and economic, that malaria itself has on the human ecology. For example, in 1998, there were over 466 thousand cases df malaria reported in Eritrea: assuming that each case debilitates a person for 10 days (a conservative estimate), we can calculate a loss of almost 13 thousand person-years: if we calculate the lost number of working days in a year, the loss is IS thousand person-years. This is a serious loss in an agricultural/pastoral society (and to children at school). 7.0 Donors/Coilaborators A number of agencies, international and bilateral, as well as PVOs are working with the malaria control program in Eritrea. Assistance may range from training, to vector control, or provision of drugs. In August 1999 the MOH produced a Plan of Action in the context of Roll Back Malaria (RBM). From that document and others the following list of donors/collaborators is taken. WORLD BANK UNDP USALD WHO/PHARPE SAVE THE CHLDREN WHO UNICEF ITALIAN COOPERATION and other partners 8 0 Development of an inteerated malaria vector control a-proach: The vector control component of malaria control program in the Eritrean MOH is an integrated effort. As mentioned in this document, there are elements of environmental management (=source reduction), larviciding, use of imnpregnated bed nets, biological control and residual spraying in houses in high risk areas. What must be addressed is: - need for more research and training, more community participation; - need for collection of baseline data (biological, socio-economic); = development of methods to measure efficacy of the integrated components, together and individually; - understanding the economics of Integrated Vector Management (IPM); programs for continual adaptation and improvement. 9 0 Environmental guidelines of WB and GQ_F. According to the terms of reference of this EE it is to reflect both IDA's and the GOE's environmental policies with priority given to the national. According to the draft (unofficial) National (GOE) Environmental Assessment Procedures and Guidelines, page 12, the project under consideration was registered for screening (Annex 8) would best be categorized as Category B, i.e. "because of their type, size. location and/or mode of operation: could lead to significant negative impacts if not carefully planned". And (Chapter 4, page 14, same document) "the potential environmental impacts associated with the project type are, - predictable on the basis of prior experience; - capable of avoidance or mitigation through design and management, - overall enNironmental impacts should be relatively small-scale if the project is well designed. Public Health projects are not listed among the Proposed Environmentally Sensitive Areas ir! the above mentioned document, and the available MLWE questionnaires (mostly dealing with agricultural use of insecticides) were not applicable to this project. Therefore, in the absence of a formal NLWE questionnaire pertaining to the scope of this project, a draft questionnaire (applicable to this project and other insect-borne disease control activities) was drafted and completed in cooperation with the Department of the Environment of the MLWE (Annex 9). * This EE has artempted to answer the relevant issues regarding pesticide usage, including that of DDT (the major environmental issue associated with this project), and development of proper information gathering, analysis and training to reduce insecticide usage to a inimnmum as part of an integrated vector control program. Regarding insecticide usage this EE draws upon the published approvals of WHO for public health (specifically malaria) use. At the initiation, and later at the conclusion of this work the author discussed the above points and the findings of this environmental evaluation vwith representatives of both the MOH and the Ministry of Land, Water and Environment (MLWE), 10. Conclusions and Recommendations In drafLing these recommendations, the author recognizes that the project being evaluated is much larger than those components (insecticide usage) which are the primary focus of the ER. Also, the parts of what normally would be a management or mitigation plan, are necessarily parts of a much larger national malaria control effort. Therefore, these conclusions and recomunendations are offered, to be included into the broader project and to assist in the improvement of the vector control elements of the ongoing national malaria control program. Such issues as surveillance. improved data collection and measuring eEcacy of control methodologies are not "stand alone" issues, but are to be included in the project both to reduce reliance upon and safe use of insecticides as major components of other the total project. 1. The continued use of DDT for malaria control is supported, subject to annual testing for efticacy (susceptibility of target vectors) and monitoring for potentially negative environmental impacts in the ecologically diverse malaria transmission zones of the country Studies are to be initiated to test the suitability of alternate insecticides (pyrethroids) to replace DDT when economicaly and biologicallv feasible. All DDT, and other insecticides purchased must meet WHO specifications. 2. Funds should be reserved for establishment of an entomology laboratory to monitor insecticide resistance in mralaia vectors, testing altemate compounds (including biological control) and carry out insecticide residue studies (possibly share the latter with Mi. of Agriculture as there is no such lab in the country). 3. Reorganize the distribution of insecticide impregnated bed nets so that there is a system by which communities are instructed in malaria-mosquito relations, reimpregnation of nets, proper use and care of nets, and a monitoring system for efficacy is in place. This will involve the social sciences in gathering KAP like studies and other appropriate baseline data.. 4. The procedures for selection of houses for spraying with DDT (or its replacement compodnd) should be standardized and quantified if possible. 5. The strong efforts being made in environmental management (= source reduction) could be strengthened by better collaboration with agriculture, public works and other sectors, by increasing surveillance, monitoring and elimination of breeding sites in and around communities. 6. Continue the studies initiated by USADDIFEH? on vector distribution and behavior, expand the technology to other areas (surveillance, plotting use of spraying, source reduction, bed nets, etc. The work should be incorporated into the structure of the Division of Malaria Control and will serve as a base for in-country training of entomologists. 7. Initiate studies to deterniine the efficacy of spraying, bed nets and envirormnental management as described in text: these should include analysis of malaria incidence in sprayed vs. non-sprayed communities(or parts thereof, or communities with and without nets. 8, Use of used motor oil is to be discouraged, after introduction and trials with more biodegradable "mosquito " oils and monomolecular layer oils. 9. As the use and reimpregnation of bed nets increases, greater efforts will have to be made to assure that net washing and disposal of reimpregnation waste insecticide does not come in contact with natural aquatic habitats because of the toxicity of pyrethroids to aquatic organisms. 10. The Integrated Vector Control (1CV) program being developed for malaria control requires more personnel and expertise than a program based only on spraying (for exarnple. Therefore, increased staff; at the central level, and at least one field research station are required to carry out the R&D needed by such a program. Funds should be set aside for increased transport and field work as these ICV components are measured in the field for efficacy. 11. A task force (malaria staf, epidermiologists and statisticians) should be assembled to review the current malaria information system, Zoba by Zoba, and the indicators that are being used, or need to be developed, to determine the efficacy and cost effectiveness of the various components of the IVC program 11. Management Plan: The above recommendations made during this environmental evaluation are broad, as would be expected, considering that insecticides are used as larvicides, household spraying (with DDT), and for impregnating bed nets. As with any integrated program there will be overlap in activities required to assure the efficacy, safety and economy of vector control operations. Accordingly, the management plan recommended below consists of four (4) major activities, each containing elements of more than one of the above recornmendations. Activity A - Testing efficacy of DDT and alternative insecticide compounds and initiation of a phase-ouT schedule for use of DDT (Recommendations 1 and 2). Annual testing (during years 1-5) of susceptibility of vectors in the field to DDT should be conducted using the WHO test kit methodology described in Section 5 of this report. In addition, testing of pyrethroids (cyfluthrin, alpha-cypermethrin, deltamethrin, lambda-cyhalothrin , and others as available, in different formulations should be carried out in years 2 - 3. Those selected as most suitable (based on efficacy, safety and economy) should be pilot- tested against DDT in years 3-5, ro begin phasing-out DDT by the fifth year. Establishment of an entomology laboratory, preferably in one of zone offices (Anseba or Bebub, and training (see next Activity) should be planned during year I and initiated during year 2, to be operational during years 3-5. Estimated cost =US5 300 thousand! 5 yrs.: primary responsibility with MOH through National Malaria Control Program (NMCP) Activity B. - Capacity buildine and strengthening the infrastructure of the National Malaria Control Program (Recommendations 2. 6 and 10). This activity should focus on entomology training and collection of baseline biological data to support the implementation and monitoring all of the integrated vector control components of the national malaria program. It should extend and build upon the USAID/Environmental Health Project's activities including contacts with the International Center for Insect Physiology and Ecology (ICIPE) in Nairobi for training entomology professionals and technicians. The activities should make use of the entomology laboratory (Activity A. above) to be established: a detailed plan should be developed in year 1 for the full 5 year period of the project, identifying nationals to be trained. either at ICIPE, elsewhere, or in-country with consultants. in vector taxonomy, ecology/behavior, mapping and monitoring of vector control activities. Estimated cost = US$ 250 thousand/ 5 yrs.: primarv responsibility with MOH through National Malaria Control Program. Activitv C. - Develop IEC strategy for cornmunitv-based implementation and maintenance of insecticide impregnated bed nets (Recommendations 3 and 9). The low percentage of bed nets reported reimnpregnated is an indication of a lack of understanding by the general population on the advantages of an insecticide impregnated bed net as opposed to a plain, unimpregnated bld net. MOH's IEC group should work with the NMCP to develop a local system for distribution and community participation in understanding the mosquito-malaria relationship, proper use and care of the nets and reimpregrnation (Recommendation 3). The system should be based on understanding of local knowledge and practices (KA? studies) and adapted to community organization and experiences with otherjoint community activities. The system should be developed in year 1, field tested in years 2 and 3, and fully operational by the end of the project in all regions. The MOHIIEC section should work jointly with NMCP (Central, regional and sub-regional) and external consultants. As a guide, there is a large WHO and Roll Back Malaria (RBM) literature on such distribution and reimpregnation systems tested in other African countries, and also are available from USAID/EHP and the LTK Maaria Consortium (London School of Hygiene and Tropical Medicine). As the use of impregnated bed nets is planned as one of the major vector control activities to reduce the transmission of malaria (and the use of DDT in spraying houses) and is one of the most costly components of the program, it is essential that the IEC-NMCP initiative to develop a national system be initiated as soon as possible in year I before further large numbers of bed nets are distibuted. As noted in Recommendation 9, the pyrethroid insecticides used for impregnating bed nets are toxic to most aquatic animals (insects, fish, crustacea, etc.) and it is imperative that users understand this and do not dispose of insecticides or wash impregnated (- treated) nets in natural aquatic habitats wvith such a fauna. The user communities, if properly instructed. wvill serve as both the best prevention and best monitoring systems, by seeing that insecticides are not used in/by natural habitats or, if so, wvhether unusual numbers of dead animals occur in such localities near the villages. These concepts should be incorporated in the national system developed to rnstruct the local communities in the proper use and care of treated bed nets. Coordination of the MIOH's IEC group, the NMCP and the Department of the Environment (Ministry of Land, Water and Environment) is essential. Estimated cost = USS 350 thousand/5 yrs.: Primary responsibility the MOH.._.both IEC and NMCP (including malaria coordinators of the zones and sub-zones), cooperation with MLWE and external consultants are recommended. Activity D: Improved collection and analvsis of data leading to cost-effectiveness information on different (intearated) mcthods of malaria vector control. A national malaria task force (Recommendation I 1) should be established. Its taskl will be to review the currently employed criteria to determine which of the integrated malaria vector control methods (spraying, bed nets, larviciding, cnviroarnental management, etc.) will bc used, and where, determine their cost and effectiveness, modify their application if warranted, and monitor the results (Recommendations 4, 5, 6 and 7). This must be done seasonally over the 5 year life of the project. MOH cpiderniologists, statisticians and NMCP staff including regional malaria coordinators (w7ith data at regional, sub=regional and xillage levels) should participate. Cooperation of other ministries (e.g. Agriculture and Environment) should be sought. An economnist from the governrnent or the universitv should be included. The task force should assist the NMCP in making annual plahs and reviewing the progress in testing alternative insecticides to eventually replace DDT, and see that safe practices are continually employed where and when insecticides are employed. Estimated cost = US$ 200 thousand/5 yrs. MOH/NMCP should coordinate, others as mentioned above: an external consultant would be initially desirable,....activitics to respond to these recommendations should continue duing the life of the project. Note The costs estimated for the above activities are those required to improve the efficiency and safety of the methods used for vector control (i.e. to reduce malaria transmission by reducing the "man-vector" contact, and to mitigate any potential negative environmental impact that the insecticides or other control methods employed might produce. These are not the estimated cost of the malaria control program in Eritrea, and do not include estimates for operational costs, including personnel, materals, insecticides, bed nets, transport surveillance, etc. List of Annexes: Annex 1 Project Description: Eritrea Malaria-EWY/ATDS/STDs-TB Program Annex 2 Persons Contacted -nnex 3 Delegates' Report: Regional Consulation to Prepare African Countries Towards Reduction of Reliance on DDT for Malaria Control (WHO, Harare, Feb. 2000) Annex 4 Statement by Minister of Health (March 24, 2000) regarding use of DDT in the national malaria control program Annex 5 WHO Pesticide Data Sheets: - DDT - Temphos - Perrnethrin Annex 6 Examples of pesticides used in 1998 by Plant Protection Service (Min. of Agr.) Annex 7 Yearly Malaria Prevalence (1996 - l 999): Anseba Zone Annex 8 Screening decision registration at Department of Envirornent Annex 9 Environmental Evaluation Questionnaire for Vector-Bome Disease Control Projects (prepared for this project with Ministry of Land, Water and Environment) *.'-' r....9.Eritrea ~. ttcregrared M.aIZ-isLEalVIAMDS1STDSJTB Program lFroject Description 1.0 Proposed Project: Eritrea Malania-HIV/AIDS/STDs-TB Progamm 2.0 ExecutiL, .AgenciS: Ministry of Heilth supporEod by the following ministries: Ministry of Education Ministry of Labor and Human Welfare Ministry pf Agriculture, Ministry of Fisherics Ministry of Informraion Ministry of Defense Ministry of Local Government Ministry of Tourism Ministy of Land and Water Ministry of Transport 3.0 Implernenvarion period: five years (2000 - 2005) 4.0 Conrext annd Justificatiort: Eritrea is once - the poorcst countr-ics in the wvorld (GDP/capita USS 190); 80'Qe of the population reside-4-i rural areas. In the eight years since independence. the GoCaertnrent of Eri:rc; (GOE) has madc z-cat stridcs to support development and irnpro'c thc living c&ndirions of its population. Basic sociaf tnfrasr-ucturc has been rchabilitated and expanded. Despite a significant overall reducLion ot monalilty and morbidity. the health indicators are among Lhe lowest in'the wvorld: lite expectancy is 51 ye4rs (LIC 63). infant monalitv is 7211000 (SSA 72) lite births. under 5 rnornaiirv is estimated at 13511000 (SSA 93), and maiernal mortality is estimated at 1000100/00.0 (SSA 500/100.000) Ilifc births. The primary rauscs ol morbidiry and nortnality among children under five'are ARI. Malhina. and Diarrhea. I n gencr.l population, 62% of the burdcn of disease (SOD)' caused by perinatal/rnaterLa1Mauscs, Malaria. Diarrhea, ARI and Tuberculosis. In 1997 td 1998 above average raintall r ered a Malaria epidemic making this condition the lead riTtcausc of mortality and morbidirv acrcJs ages. Available data indicate that malaria accounts lor 3 % of total outpabient morbidity and 28% of all admissions. It has been estimated that ab6.t iO work days is lost per cpisode of malaria. This is scrious since malaria incidcnce is highest during planting and harvesting seasons. The main causes of maternal mortaliry are: obstrucLtive lab r, complications lrom unsafe aborty, hemorrhage, and Malaria; anemia being the main underE Iing cause for the last rwo conditions/,J Thc rcproductive health situation is very poor. first pregnancy occurs at an carly age (21% of 17 ycars old and over 50% at 19th). fertiliry ratc is high (5.6) and female genital mucilation (forbidden by la%v) is a common practice in certain regions. Thlis situation is compounded by an increase otCSTDs, and the emcrgcncc of HIVIAIDS (3.2% adult population). While the estimated current HVWAIDS prevalcnce rate among adults is relatively low, this tnfection ratc could rise cxponentialiv ..AlDS is 99% fatal. strikes the most productive segments of thc population causing 'vdrce pQrsonnl loss. disruption ofsocial strcutures and exabertaes povcrry. Prevcnting 9 . , .r,3iWa:noeen s4own Lo oc rALK14y cosL _.S .,; r t~n. SD 20-lOo per casewhile treatmntcanc __ Bir_sinds of dollars in ~~I~totheincome and personal losses incunscd bj ies.' Ihe Govemment is strongly committcd to addrcss M;laxia, HIV/AlDS, and TB through an ~.snUxflctoral and decencralized approach. Draft action plans;ffd-long term stategics for thc three .-diseascs have becn devcloped. With support of the USAfDl-finded Envirrnmeital Health Project. *studiesin:mbeing under.ken to hclp guide the Malaria CAi&iLPrSram (MCP) and, social mackcting of condoms is being implemented. Iralian Cooicraiion, through WHO, assisEs in the desigznand implementation of an integmated disease survelilance'system. 5.0 Project Obtictive. To enable the population to adopt hcalthy practices and use quality, effectivc health care, thereby reducing the transmission and prevalence of malaria and HIV/A1DSrTDS/TlB. 6.0 Program Target. The program is nationwide in scope. Thc priority target groups for HIV/AIDS/SI7DsIB are womcn, adQlescents, and soldiers; specific intcrventions will be geared. towards high risk groups such as prostitutes and migrant labor. In general, the priority target groups for malaria are children uider five years of age, pregnant and laCtating womcn, and immune populations although in epidemic situations, it would be the general population. 7.0 Project Components ard Propsed Activities The project has fGve main components: (a) Human resource development: (b) - Strengthening the Health Care System, (c) [EC and Advocacy, (d) Monitoring and'Evaluation, and (e) Research. 8.0 Projecr Nlanagement and Irlplkncntation. The overall framcwvork- for projcct managemcnt and implemcnmafion is as lollows. a. A Ccncral Policy Commiree %vill be responsible for policy decisions on project activities. This will be chaired by the Ministry of Hcalth, with members including the Ministres ot- Education, Labor and Human Wllt'are, Agriculture, Fisherics, Defense, and niforrmation, and Tourism. b. The project will be execLnedch*ough the existing, well-functioning PMU based at the , ( M191 that is managing the curren1hFjiih project. The financial arrangements and capacity ofri.'. * PMiU was cvaluated during the jafl i4ission. As reflectcd in the last Aidc-memoire the r 17 arrangements are fully satisfacto r~Iarrd the PMU is ablc to implement the LAC[ system. IY Howevcr, another accountant will )c lired to tke on the additional load from this proposed project. In addition, an MIS officdr will be added to the team to handle the increased reponint and data gathering and analysis nceds,- The PMU has becn assessed by the mission as i procurement-capable under LACI re4uirements and already include two procurement experienced staff (a civil engineer nd a procurcment officer) presently undertaking advancedI procuremenr courses at [LO (procit'rement ofcivil works) and Mombasa (procurement of good:). c. Thne actual implemcntation at zonal and sub-zonal level will be camed our through the Zonal and sub-Zonal Administration. Depcnding on capacity, scrvice delivery will be contracted out ro extcmal agencics and NGOs or delcgated to diffcrent govcrnment aSgencics and depanments. I 0 I ANNEX 2 Persons Contacted! World Bank (Wash. D.C.) Dr. Montserrat Meiro-Lorenzo- Team Leader Dr. Magda Lara-Resende - Environmental Planner Dr. Peter D&wees- Environmental Economist World Bank (Asmaran Mr. Emmanual Ablo - Resident Representative Dr. Eyob Teckde - Project Managemet Unit (PMU)/ Head Mr. Hebte - PMU/ Finance-Administraion Minista of Health (Asmara) Dr. Saleh Meky - Minister of Health Dr. Nadia Al-Alawi - Assistant to Minister Dr. Mfsmay Hiwet- Director, Primary Health Care Dr. Tewolde G/Meskel - Manager, National Malaria Control (NMC) Mr. Asmelasb - Operations Chief; NMC Mr. Fessehale - Entomology Chief, NMC Mr. Mehari Zerom - USAID/EHP Coordinator, Malaria Project Mr. Solomon - USAID/EHP Lab. Tech., Malaria Project Mr. Embaye - CDC Statistician Mr. Berhe Habte Michael - Head Sanitaiari Envirornental Health Umit(B Mr. Fitwi - Sanitarian, EHU vMinist of Health (in Regi6nq=7obas) Dr. Berhane Bebru - Medical Director, Anseba Zone Mr. Kiros Sereke - Malaria Coordinator, Anseba Zone Mr. Afeworki Araya - Malaria Coordinator, Gash-Barka Zone Mr. Ali Gidir - Nurse Assistant, Tessene Clinic, Gash-Barka Zone Mr. Solomon Negusse - Malaria Coordinator, Debub Zone Mr. Tajedin Abdeloziz - Health Administrator, tebub Zone Mnistry of Land Water and Environment (MlWE'- Mr. Teldeab Mesghena - Director-General, Department of Environment Mr. Beyene Mesgena - Director, Ernvironmental Assessment and Information Mr. Teclemariam Berhane - Department of Environment Dr. Rita Mazzocchi - Lawyer, MLWE Mfinis=r of Agriculture Mr. Mehari Tesfayohannes Other Mr. Mussie Yohannes - Private Sector, Insecticide Bednet Distributor Mr. Woldu Tekiegiorgis - Private Sector, Local Insect Control Consultant REGIONA LUNbULJLAIIUN 1UW ~A*.rL wS~ '- ., _..i ANNEX 3 DELEGATES- REPORT REGIONAL CONSULTATION TO PREPARE AFRJCAN COUNTRIES rOWARDS REOUCTIOAJ OF RELIANCE ON DDT FOR MALARIA CONTROL Harare, Zimbabwe 8-10 February 2000 STATEMENT OF THE DELEGATES We, the Delegates to the Regional consultation to prepare African countries towards reduction of reliance on DOT for malaria control having considered; 1. reports of the Intergovernmental Ne6otiabng Committee (INC) for an International Legally Binding Instrurnent for Implementing Intemational Action on Certain Persistent Organic Pollutants (POPs), 2. World Health Assembly Resolution (WHA5O.13) on the Promotion of chemical safety, with special attention to persistent organic pollutants, 3. the Statement of African Ministers of Health at the Regional Committee for Africa. 49th Session, 4. the Draft WHO action plan for the reduction of reliance on DDT use for public health purposes, and, 5. the programmatic experience and current use of DDT for malaria vector control in our countries, rnake the foilowing observations: 1. Present Use of DDT for Malaria Vector Control In our countries malaria is a significant cause of morbidity and mortality and an impediment to economic development Indoor residual spraying of DDT continues to be an important tool in efforts to control malaria in areas of unstable transmission and to prevent or respond to epidemics. Documented programmatic experience in Africa with proposed altematives does not, at present, indicate a potenfal for rapid elimination of reliance on DDT for rmalaria vector control. 2. DDT and tfie POPs Negotiations- We note the presence of a general exemption on DDT production and use limited to vector control in the present draft convention text included in the report of INC-3 and unanimously support the inclusion of this exemption in the future Treaty. We further support proposed mechanisms within the Treaty (i.e. Articles J and K) to assure that technical assistance and adequate financial resources are available to countries for action to reduce and/or eliminate reliance on DOT. We support the elimination of DDT for agrcultural uses as specified in Annex A of the Treaty. ACTIONS TO LIMIT DDT TO PUBLUC HiEALTH USE AND REDUCE RELIANCE ON DDT FOR MALARIA VECTOR CONTROL REQUIRES: 1. Improving Current Public Health Use of CDT: * Countries currently using DDT for malaria vector control must establish and maintain a regulatory basis to assure that DDT is used for public health purposes only. Countries will further need to strengthen capacity to monitor and enforce compliance with these regulations * Technical assistance and capacity building is needed for strengthening countries' abilities to develop surveillance systems for epidemiological monitoring, epidemic forecasting, and detection of insecticide resistance so as to target and selectively apply insecticides for indoor residual spraying purposes. - Countries need reliable access to quality DDT and altemative insecticides and mechanisms for quality assurance. http://ww.who.itit/rbrn/DDT/ddt_zimbabwe.htm 4/11/00 * When DDT is replaced by an altemate insecticide, re-introduction of DDT should remain an opton if vector resistance to the altemative occurs. 2. Reducing Reliance on DOT for Malaria Vector Control: aCountries recognize that reducing reliance on DDT involves a complex set of activties over a potentially long t'me frame. Strategies and interventions must be developed andlor adapted to country specific scenarios and will require sustained mobilization of financial and technical resources. 2.1. Evidence Base for Decision Maklng and Planning: * Evidence is needed on the environmental and health impacts associated with current use of DDT for malaria control in African countries. * Evidence is also needed on the environmental and health impacts associated with DDT alternatives for malaria control in African countries. •Decisions to replace DOT with potantial altematives should be based on a complete assessment of the costs, effectiveness, feasibility, and environmental and health impacts of DDT and alternatves under local conditions. . A priority research agenda must be developed to address information needs of malaria control programmes. • More investment in research for the development of effective and affordable altematives to DDT is urgently needed. * The involvement of industry is necessary to facilitate the development of safe and low-cost altemative insecticides. •Field-based research and careful monitoring and evaluation of altematives are essential in order to evaluate cost-effectiveness and safety under operational conditions. 2.2 Characteristics of Altematives and Conditions for Implementation . Viable alternatives to DDT should pose less risk to the enyironment and human health and be equally or more cost effective for malaria vector control. •Evaluation of alternatives to DDT must include assessment of technical characteristics, acceptability by communities and health workers, potential sustainablity in terms of cost, effectiveness and the potential for resistance development (e.g. extent of concomitant use in agriculture), availability, environmental impact and human safety. * Altematives to DOT should be introduced gradually into' Malaria Control Programmes.after investigation of insecticide resistance, status and prospects. *Monitoring and management of insecticide resistance should be strengthened and coordinated at national and regional levels. *Insecticide policy, legislation and inter-sectoral collaboration should en7nrce protection of altemative insecticides. 2.3 Enhancing Availability and Affordability of DDT and Altematives * All strategies with the potential for sustaining reductions in cost and enhancing the availability of malaria and vector conbol tools should be, evaluated and promoted. These sb'ategies include, but are not tp://www_who.int/rbrnmDDT/ddt zimbabwe.htm 4/11/00 limited to, the reduction or elimination of taxes and tarffs on pubUlc health commodities. and the transfer of technology to pronote development of endemic country andl/or regional production of these tools. 3. Strengthening Health Systems Al activities to reduce reliance on DDT for malaria vector control (including planning, operational research, implementation, monitoring and evaluation) as well as national efFrts to strengthen malaria control and health systems should be an integral component of health systems developrnent Strengthening intygrated epidemiological survewilance systems is essential to any process of assessment and implementation of altematives to DDT. - Comprehensive "Country Needs Assessments' that describe the current epidemiological situation, disease control and health care practices and the national health infrastructure are required for planning and strengthening malaria controi activities. 4. Cross-Sectoral and Cross-Border Strategies . Inter-sectoral and regional collaboration should strengthen surveillance, research and planning activities and linkages should be established between health, environment, agriculture, and other sectors. Advocacy • Political commitment and community participation, mobilized through advocacy and awareness raising. is necessary to implement an integrated strategy for malaria control that reduces refiance on DDT. 6. Resource Requirements i Country activities related to needs assessment, planning, research and evaluation of potendal alternatives to DDT require the immediate mobiRisation of significant external resources. * The global community, through both existing mechanisms and new mechanisms to be established under a future POPs treaty, should ensure that financial and technical assistance required to reduce reliance on DDT without compromising effective malaria control is available to countries for imrnediate and longer term action. CMMENDATOrS TO COUNTRIES:. * Countries currently using DDT for malaria vector control must estabiish and maintain a regulatory basis to ensure that DOT is used for public health purposes only. Countries will further need to strengthen capacity to monitor and enforce compliance with these regulations. * All strategies with the potential for sustaining reductions in cost and enhancing the availability of malaria and vector control tools should be evaluated and promoted. * Altematives to DDT should be introduced gradually into Malaria Control Programmes after investigation of insecticide resistance, status and prospects. * Monitoring and management of insecticide resistance should be strengthened and coordinated at national and regional levels. * Insecticide policy, legislation and inter-sectoral collaboration should enforce protection of alternative insectcides. a Inter-sectoral and regional collaboration should strengthen surveillance, research and planning activities ittp://www.who.intlrbmnlDDT/ddt zimbabwc.htm 4/11/00 and linkages should be established between health, environment, agriculture, and other sectors. * Delegates to this consultative meeting should inform the INC negotiators of their respective countries participatin in the next INC meetings of the technical, economic, health and environmental issues in the use of 1DT and potential altematives for malaria control in preparation for the forthcoming INC meetings. RECOMMENDATIONS TO WHlO WHO should advocate and highlight, at any relevant and appropriate forum, the deep concems of the participating member states on the possible economic and health implications of any restriction made on DOT use for malaria control. WHO, in collaboration with partners, should ensure that the necessary technical and financial support is available to member states for implementation of integrated, evidence based and cost effecve vector control programrs to ensure sustamnable reduction of malaria burden. WVHO, with its partners, should support investments in research to develop new affordable, cost- effective and sustainable vector control methods including effective and affordable altemative insectcides. WHO should commission a consolidated review of potential economic, environrnental and health consequences for African countries of replacing DDT with altemative insecticides for vector control. rtp://Hwww.who.int/rbrn/DDT/ddt-zinbabwe.htm 4/11/00 The State of Eritrea ANNE 4 M1iRSY OF HEALTH March 24. 2000 * To Whom It May Concer: (r;-y X Lod . . As a policy, the Ministry of Health (MoH) is very committed to the environment in all of its projects. The Integrated Malaria-HVIAJADS/STlDs-TB Progam is to be no exccption. -TheMol plans-to use dichlorodiphenyltrichlor ctlilEii'(DDT)'in this'prsp'ective project. We will deal extremely cautiously with DDT, as shown by the following m;asure to be taken during its use: a it wvill be used in limited and selective pockets of malaria-infested areas, mainly during epidemic outbreaks, and only if deemcd necessary * it wvill be sprayed using manual hnndpumps only * it will be used strictly witilin DoE guidelines * it-%Vill not be used in environmentally sensitive arcas (suclh as ncar water sources or agriculture) D DDT use wvill be plhased out during the course of the project and replacod wi.th morc ccologically safe methods (c.,. fish ponds) The 4oli plans to takc every prccMution witlh lhuman safety measurcs, incLuding: * training sprayers on the hazards,during focal spraying, safety procedures to bc used during handling and storave, and dangers of inappropriate use and application - providing timely and rclovant ikYformation and education to the inhiabitants of applicable areas Attached please find a brief project description, as well as the data safety shect ror DDT. Sincerely, S AM! R F!li Y '7TSTF- OF PEALTt .__ L.iTcl. 120297 4-h IFax 291 - I- 122X99 T%%-%- YTlA%V ..U T. T L NV Zi 117549 1:4.r.O.rsox 212 %s El% Pesticide Properties by Common DDT pesticide Type Insecdcidde 5 Chemical Group Orgnochlorine QCr' FaormouIationS Dusablc pododr (ID) WHOlES Paued T-micl WHOPES Paud WjwardLa wsibi*p-der WHoPES Paued Rcomineended Use rarger ardwop.d AMadt ofAppanecw Dwetq.n o DeffeC semiu Mosb4quiCo* l. idua alptying 1.0-2-0 6If2 6 vasu or smo Pmiabotoine sandfliz Reddualyia8 smyj 1OK-10 VM 6 m aoba or woa Selected Propertics PhyiCal Propealles redmli DOT is afvuabla co.pskcu and way st of 11c nom D om ds ovif h whi pp'isomw rfDDT ce libe" 63-'77% tb-e QpV mr 3.12% aadtbe *o'-Isomer 0.1 -1.0%. Pure pp'DDT is a whk. cry =Ifis solid ofmakingpois lOs.5 - 1090C. Theuidical nrAiaLholwevfa takA the foam ofa whil or aum colowud waxy solid or ammpaus powder ofiadatinke mdtigpoinL Salability Praed=lly inoluble iw twr.Molutcly soluble in hydozyllc aId polar solvas and in pdolam oils Rcily soluble im OS aroma sAd chlariszd tdovAtL SLablity Driclorinsai aittmpcrm jkbo%c km mcibcpokei t a nor-incaciddal izhykne daivaiv, a rmi Iysco dyaa by fktric and aluminium cdloidc aed byUV li;At in solutica k is rmdily drdrodilarikumad by lkala or orguile Fesa, othawjis it is sable, a it is aa--akmd by adid and aeAline pmgas awd by aquos *sds A alkalis& Wrthecdnial DDT ddiy*oioaiai mypr--d at t8pcouu as low 05 300C Vapour Prcuum pp'V9isoo 1.x 10x.7 mmHgat 201C SheL tLUe 2 yc Toxicolo Absoapda Rode. Aaorbed lothc groidstogin al ree tad by 6alation. It may also b-ebsoi bythe htaeL skin wda in oily solutim Mode of AcUon DDT is L QOAI nCrVouA stan inxanLspro&inyepraaivicky andtmoor, covulWou my Oor ha erelc com than wii ctir orpneloriancpeaddcdL Manm Ual Toxicity Oal. r: 113 mg*kg (Oral Deran LDSO) Daml. r 250-500 mnlcg in oi 3000 magkgaspc pwd Toxiity to Nox- flrmbfial Mwnnmali Sped" Birftl%(ddamly toxic OdiwqspeciaJ lrento beon WHO Recmumada Clau IL "Modaaaly h2admou, (Eial dagilcatoni dqmns cam tbe fo mzIiau) CefcUnby Hazard, boed an Tccmical eorted ResiStaDnC Spwcct Par Cazgei a C.mN Bedbup Cim; leaularius Urulm"rad Cotiches BLnellas iurepd ) ~~~~~~~~~~PoripLins a mtden Uldeq s Thurrsday, M,ay 25, 2 Warld Heat Organisdion p I o10 a Mdddo Evalution Scheme P ° J u 1-4 I WJ | - *r * &M * D _.-q-- - Pesticide Properties by Common DDT Pcra bnmnu Widpread B. aimulis Csldovk Guan Fles (Cat md dogZ Cmaocpbiaidas >fli Calmabil Dainurk tUSA C. udacta USSR FEd= (HB man fI) P. Irsitaa1 Drailu. * . ~~~~~~~~~~~~~~~~~Czacuslowaki Pcru S3~yltatonqeciE Mdap r Turkey RFles(od^1e) Sivaiu o "au Wid~rcd - S~~~~~>nopsyllu'i, adaca ~~~~~~~~~Epiyada... Mya Phhpmes M--d Tanzania Thailand Vufzdam X eIWt bidia Myw X brmliaues Tanznia Flies Chysona proria Widespread HMalwaobia k&rniui nAlnlia L $Micat KUwuiw TnIMiA, CapruikA Widcnand N4L,ca doman VWiand Iraapaniralinwmovae USSR S. eoubra santipwli WurJpreud S. aquamowam Widetiread SiumWiim dauusum 3 a n C&*e svoise Mali TOq Simuliun aokii .Jpan Simuliuni an= Japan stonoxys ca)ckaas Oennavy Fu0nia c2XijAris Jaopan uesday. May 3.2m) World Health Organion Page 2of 10 Pestidde Evaluation Schdne Pesticide Properties by Common DDT MpaE USA UK F. 1fla USA 7q.oo' If~ USAK 4 mNma armp ni S. %,ud% CanadI USA S. D~ icS n S. hlarpvl flurkta F - : Ethi9ia Pnnc kdm Syraa uMcisia Pem Rrnanunu Tudx Turicy UM& W5 Afici Yi0doIis P. qa Ca:adn r~~r Iradcoo Impa' USA^- Moaqua AD aa* V.Id srnrd MD. ,Jbopidpa CamGbQis Sinppot- uesday May Z3. - Worki Heal Orguniadon Paw 30fio Peadle Evaluaton Sduem Pesticide Properties by Common DDT a lmiL,nd Am. dcadsals Vridm-d As nWILiM VSA AhL pmuddpea c5i A& molliwa USA Actoo KM A.M. pabidopwaszauiI Ao aoU~ CS Ato Ria4 Cesizi"ica p Doniini Repi. El Salvador Hait HTonduras Paaa An. ahftwsi fka2 CoIonibNa An. anulas Bangiades kidia Parkw Th.aiand An. amabiaua E*aicpi;L MAMS 8'^ At alrqlaTVIM .wLilan Rmennia Spai UK USSR Am. b*broti India SAi Laka An. mu*mai t esday, May;>. 2t World tealth Organkliotn PeSIcide Evaluadon Scheme P1ge440(10 Pesticide Properties by Common DDT Sa"di Abia An. aICO" sA~ai Ianusia &1ff NUA M9uncro Ah1 dthaN brm M. dsrI~ Cal A.i* 1w. f1u"iat~Ws ACLaiashn Tanzani BursicEa Faso C'bmi AcnR' Liaiat Mali Am byrcenum AfdTanimnia Tyaurk Pay USSR Ao.jmuui ~ ~ oud c An. kaz4ari Vidftrmad TUiA An. maaiu*wmis I*spria -ogo RoIndia Ttdagky USSR An. bn uidflpria ,)say.Aft _2_2_ World Health Organisaton " f1 Pestkicde Evaluation Schuas agSf1 * .) .-.*- Pesticide Properties by-Common DDT TAR Rmndia An. pIarm SAudi Aa& AL niu* Sb'hu - ' P ~~~~~~EP wapia USA An. padnisi Widra ArL ancharmi BuSlpran IrafLt M - n Ckgamsia UJSA AD. ,bodwaai Widesprad .],;|. rebaswi ~us4sit AzL aidW- Chn~pa frann VSSRt A ;am~ Egp Japa Nq3 An0 .hau_ . Paki*a. ' Saudi Arabia UA5 YCQ An. aubpiua Afd-ita Myaaa .~~~~~~~~~~~~~~~~~~~~~~~~~~~Btds .. Tuesday, May 23. 2 World HIfi Organisation PAe 6 of 10 PeaXicide Evaluation Schwm Pesticide Properties by Common DDT Vadnm 8d Mailmd- victnu N-pa SriLanka Anrig subalbau JaPaa cuiiada jluaaasa USA Cx annulzim Wd Cz. ecusba OL PUdua SnJdh India T'hafland Cx nilnpaJpu USA Cx. p4pipica ' Cx pmaIeua AWLnia Bulpriu nre Korea Izwak tiebanu) MArcow Syria Cx. Paz. USA Cx psriuzx.U Ouin QL pipioup 'M Cx. qtnefaacLinm wiepad Cx. trman SA Ox. ia,uaiu USA C.td±*acMiwbyab~iuX a5a ucaday, May 23, MM Wold Halwi OrganisuUon Page 7 of 10 Podde Ev.-IuUon Sdnme Pesticide Properties by Common DDT OiMa Indi. iapmn Kma haland 6da An aiciwss pln ] aa, An Q=iaw :diaw An d.f.1 'al M Savi Sde~~~Thilnd An farauti Saloamn sad An funr s Sudan An kodu hndbi An kniiamb indwimia AFn nmKuIa Bwlaun India N"l An nmdaniaw Turkay An ninimus Thiland An dkamattu India An phDiippis Mya1+=mar ThApans An puldzonin.s AfrJiakinan Saudi A~i An pundimaala Cokmthis Eaudor Panam An pianan Inamia An splaididus An nadaiacu kdmsi' Thai a uesday, Mq 23, 2= World IHalth Orarisations PacIde Evaluaton Sc Page of10 Pesticide Properties by Common DDT An lUdjtiUAI kmAis Ntal An blW1 B Ucdmo Ac MXalpua USA As s ara is, ~~ P>^ r~~auiy Cs ci oma A. 0jinado P * . - Mvmnia mnulil I'TiLnd M Emi. Thiland Peroph oonlimis USA CZ wabdius USA icd asid Inie Ambly -i hdanebran Soudg Arica D. dClOrUwS Sozuh Afica Zimbabwe B. ni¶iplus ArFgi- Brufi Saudh Afiica vacnwica Hyallmma anatliaun W-idmprcad TrL,mmiiIn buos Triatoma iafana Gtcrn (Oaankal Group) V034ble Ra6ataace uho sfas Kdr, Sy Rsndlinp Trwanp.rtation an Should betnupa ede and rmid in dswIy hclmed rigid lImk-praafaam and a-ay frm sjaimas of fod and Skorage drink.Swne ahluld bcunder ldck and key and xeaue frm ac5 by tdwripaem and childrm. Rwndhing ProtaWiv cMaze should be *am byho hadling o. AdQ*azwaAht2fudhitift should be a-ailablCUM at hand Baia& danking and snoking should be prolibibed during hmndFa5 ad beftm waain4 ASr handling Disperal Co of olapm, a aciad rxpir0an Ahould be rec-himg P"alds a Selected References Dat aa±t co pistiides. No. B. T.uphos. World RHai Ogaiz,aL WHOV9DSWS.2 TIe WHO L,cOrd iAsAcsti, ofpcitadi c by tar 6andiddisato dclaidiaUn5 1996.1997, Gaciv, Wold Heakh Orpoizazia. (Unpubli:hed doenmam WHOMM19cG.3) r OisLe ofvacou and ramwvor of diasa to patici. WHO T.dmimI rq,pit Simt. No. 737, 19S6 Vecor reiumamto peetid5c, WHO Tedmial Ritot Smia No. SII, 1992 camnicul makbods For he uumurol ofvmz.rs amd pas afpubl,ic iwb ipai twoep, wHO/CT KOPE.S3Y hursday, May 25,2= Woid Hernth Orarntion pa 3 or 3 Petcilde Ev*luaion Schbm Pesticide Properties by Common Permethrin Pesticide Type Isecticide Chemical Group Pyrethroid ANNEX 5 (cont'd) _ L)urj'bIcpda*.P) lIzruzIii5abIc, coU nswaiW (EC) WHOMP.SIassed uldiiabk e C) . VWHWOMS Prsd Watcr-diapcailslo3powdor WHOMES Passed Reenmmended gle Z arger 27reopod Mode ofApplicadov Deragarcalfc 2fint .i Dwriuom of efeciv acae Cockroa4ta Amawol 0.25.0.5% Flim Cold aevwol. space pyis S-lO gD Mosuios Cold aertsol. apwnacprayin S Vm Badbug. sDus 0.5% I maIgh Cockroadh - Dust 0.5% 1 month F1ems (Hiiuzn flxa) Dust 0.25% FIc(s(RodaatIfes) DUSt 0.5%4 1 mw Hwuan Uce Dust 0.5% Mn.squitu Tnpraztvion of Labris 0.120.5 Vu2 3-6 motnhs Simufiuln T.arvadi*ne 200 &/ (0.045 Yualocc uivcr di Human ULe Lotion 1.0% ' edbup vrid a l .yine 31 mg/m2 1.5 nmdrh Lockroachd Readduals .wrayg 0.25% 2-6 "wdck Flis Reaidual spmyirt8 0.0625 gtrn2 1-2 woee Muaslitua Residual spraying 0.5 Win2 2-3 wmIia Phlzomincandflies Reaidual .ImyiAe 0.5 /n2 2-3 monuhs T id-s and mixa Residual mprayit 0.25% 1 monh Tnatozminc bug RiziduaI ipr.ys8 0.25-0.5 gJnm2 6 mosths V=inonis inhropods Reiduai spraying ,icus (Cat and dog flea) Shanpoo Human Lici Shapmoo * .. FHa (Cst and dog f115) Spay 3.0% vAnaguhos t'hermal fobggis space spraying 10 SI" telected Proberries Physical ProPWeyU lte pure iomame arceolouuraes c*U atambicK%c Tertun , dclnngtv as dlar,pleyelow. visutas liqwidabavethe ncking poiL of 634651C fur ihc ci i8ouaar and 44-47'C for t(m isamcm Mm boilingpoi is 200C c 0.01 niml(g Thatedmical productis a *xiscnua biwn liquid 4idch may partiaily ctnlhse at ambictwnpaurs and is c tcdyliquid *soim 600C. The tedinicl pmtt hoils tK 210-2200C aL 0.05 zmRg. Tno qPifio pw-ity ir 1.190-1.272 at 201C Solubility At 200C. lcsthin 0.1 mIl wler At3C'C, 0.2 mn'i wale 450.0 El acdmc450.0 ;1T q3lga s.ono 450.0 g/l dhsnol 450.0 S4 tiytmc 450.0 g/i dalorfbrm - It is solublc in or uixable with mou w icsohmats Lxoapt ehykne giycol uesday, May 23,Z Wgrid Hea lt OtganScatlon Page I of S Pisidc[de Evialuation Scharme Pesticide Properties by Common Permethrin _ SbxbWt In xolWWi is *ablb mdezrul and a,idipB skt nLivdy .aacablo it' aWllias nditinS Va~ cure Ai ZO; cis imar 2 x 10G9 kP, u os iasacr I x 10-9 VPa SheV ._ 2 rCU Tosiolxc Aha.Jpdon Rjiuie npmdb2i =u ly a1wbad nfivmi PUnx1-iasmatrac; ni nanIlwmhro9tbc infec ak:, aipcasafy il nO.pohr solvaen nd byi lbaLatis afdudm atd spray inig Aode At euam.r fi k toXa ncuafaloxivdIastdinty nn maibrn. lLpPrOl easodium nip pe bilky datinghe adisy ph& cftha aim pcat ihus cffine rive actiity in ihesmuoty and ,notorpathupy-.cp Tnp prt ons tbncn i agm± M -UUM Tosilcty O, rat4 100 son (Oral DLwr D o) Dacmal., 2500 zmWkg Tosjiey to Nap- FiA, pcF dum islillytnsicto liMLhovwaedrdrikis of dct duation diuto rapid lo" frn wazrby adboptica and Mammaln Spedes dgadxUot Bir4q± Very low zaickyto birk MdN 4panes: Pmrid is todcto beu and aqnat in"" agaceans 3d l1a azzhibiua,4 bo'Au ductothe sact paiumee otpamahrin n wter, zuapulaticass oon rwoo WHO Rec_am dai CLasus I Modwtdlyhawdnue, (fmal laifflcuio dends acthefornuluti) ClaasIflcad bY P-M, based on Tehnial Rexported Resistance Speifi P-a Caq.y Sprcia Ceuay M.aquko Ae- aegypti indenons AzL albiznuus DomW=ic Re. kazadnr An. uliacs tJAE An. culicfat opi Oman AzL pi biae B,nia Burkina Faso C&c d¶vofei Am sacharri Iraq An. rimcAlS Chin Cx quimqudfsaus Sad udrnabiu CodckrAdca Blaila #=Ania Canada Japan USA USSR Ild" (Cat lot dog!f Coocwh1idha 1is . Tanx=a rlau (Rodu Ilea) S3yncsllus&mquamisi' Madagpocar Xainepfylla chdopis . Mt ar Flie faanabib imritan AuaLis USA *LAcicg CiMa RUWAf .uac donmaca An'ria' Caada. May 23,2 Wad Health OrhW(onf Pae 2ofS Pesticide Evalution ShernomS * ~ .,. i,, Jcri'i L4D t-ir>L 4000mg/kg; oral (rat) 8600 mg/kg. Permethrin is classified by WHIO as Class Il "moderately hazardous"...depending on formulation and concentration: mammalian toxicity is: dermal (rat) 2500 mg/kg; oral (rat) 500 mg/kg. DDT is classified by WHO as Class II "moderately hazardous"....depending on formulation and concentration: mammalian toxicity is: dermnal (rat) 250-500 mg/kg (in oil) or 3000 mg/kg ( as powder); oral (rat) 113 mg/kg- 3) How are the iusecticides to be applied? Temephos is used as a larvicide. applied by hand or with a hand/back pack compression sprayer ro small bodies of water that are mosquito brceding sites, these rnay be puddles along strearn beds near villages, leak-age and water accumulation from wells and or dams, ctc. at conccntration of- 1 ppm. The toxicity is sufficiently low so that WHO approves use in drinking water, if necessar. Perrnethrin is used to impregnate mosquito bed nets: nets are dipped in dilute solutions of the insecticide to give a concentration of 0.5 mg/m2 on the net ...... nets are recommended to be reimpregnated at six month intervals. 'DDT is applied with hand/back pack compression sprayers on inside walls of houses at a rate to produce a residue of 2 g/m2. Spraying is done once a year, prior to the mosquito breeding scason. In 1999, only 352 of 2089 (175) were sprayed with DDT because of the high risk of a malaria epidemic. 4) What quantities are proposed for use (per year, cycle, etc.)? In 1998 and 1999 (combined ) 60 liters of Temphos a.i. were diluted and used to treat over 4000 vector breeding sites, mostly small. The quantity wvill vary depending on the number of mosquito nets in active use, but 2800 liters of permethrin are adequate to reimpregnate -200,000 nets. By the end of 2000, - 3000 nets should be used in Eritrea. Depending on the epidemiologic asscssment of the priol year, the rainfall conditions and the nunber of rcfugee camps, 25 tons of 75% DDT water dispersable powder (VDP) will be used. The amounts needed in future years should not excccd this number, with the increase in use of bed nets, source reduction (elimination -of breeding sites), larviciding and biological control increase. 5) Are the insecticides to be used as part of an lntegrated Vector Cootrol (IVC - IPM) program? Yes (see #4 above): the malaria program is well integrated, and more emphasis in future years will be places on environmental management, larviciding, biological control and impregnated bed nets. 6) What is the known effectiveness avainst target vectors? (Is resistance status known?) In 199S and 1999, field trials with WIiO test kits showed that Anopheles ganibiae, the principal vector of malaria in ETitrea is fully susccptible to DDT: tests were done in Ansaba, Debub, and Gash-Barka. Bioassays have shown Ehai nets impregnated wvith pernmethrin are fully effectiv- against the sarne vector. Temphos effectiveness has been noted by monitoring but not, to date, tested. The new project will provide funds to increase the testing annually, and as part of a screening process to identify alternative compounds, especially for DDT. 7) What is the compatibility witll non-target organisms? Temphos has littl4 effect on non-target organisms (aquatic or terrestrial) at the concentrations used in vector control. Perrnethrin, like all pyrethroids, is quite toxic to aquatic organisms (fish, insect larvae, crustaceans, etc.) and for this reason should be kept away from natural water bodies. Since there will bc no broad application of this compound, but restricted use only to reimpregnate nets, the risk to non-targets is considerably reduced. The environmental effects of DDT are well known, but are generally the result of broad scale application. Public Health use, as in this project, will bo vc-ry focused. Oniy the inside ofhouses in high risk areas, as deLermined by epidemniological and entomological monitoring, will be sprayed..-all spraymen will be either MOH employees, or persons trained by MOH. There is only a minor risk of insecticide leakagc from the houses' into the environment 9) What are the conditions of storage and transport, training of applicators and provisions for monitoring? The MOH has a Ccntral warehouse and othcrs in each Zoba: generally insecticides are moved quickly (by truck as Lhe quantities are not too large) to the sub-Zobas where application will take place. There is no long Tcrm storage at either level. ApplicaLors are MOHI staff, supported by local-hire personnel employed over the spraying season: some have workld each season for years. Equipment is well stored and cared for at the Zoba offices. Monitoring the effectiveness of appplication has traditionally been done by recording the nrumber of malaria cases in the villages treated versus those not treated. This project will improve the sensitivity of monitoring by increased work on the distribution and habits of the insect vectors, their responses to the different components of the integrated vector control program being developcd, etc. qA) What is the availability and effectiveness of alternative chemical insecticides or non- chemical control for vector control as proposed in this project? One of the objectives of this project is to improve the malaria vector control in Eritrea. The three insecticides in use will be systematically tested for efficacy and cost -effectiveness, along with the other IVC components. Teniphos might be replaced with Bacillus thuringensis israelensis (Bli) or B. sphaericus, if needed: both have been proven effective elsewhere. DDT can be replaced by a pyrethroid such as lambdacyhaJothrin, deftamnethrin, cyfluthrin ot cypermethrin should rcsistance develop. Perrnethuin, could bc replaced by any of the same pyrethroids mentioned above should 0 resistance to it develop with the net impregnation. Replacement of course will depend on cost- effectiveness and safety.