Vector Control - BVS

Vector Control

2016 Annual Report

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TABLE OF CONTENTS

List of Abbreviations ...................................................................................................................................................... 3

Acknowledgements ........................................................................................................ Error! Bookmark not defined.

1. Introduction ............................................................................................................................................................... 4

Background ............................................................................................................................................................ 4

Vision, Mission and Objectives .............................................................................................................................. 4

Situational analysis ................................................................................................................................................ 4

2. Operational Overview ................................................................................................................................................ 8

Key Achievements ................................................................................................................................................. 8

Major Activities and outputs ................................................................................................................................. 8

Workshops Attended/Facilitated .......................................................................................................................... 9

Major Challenges ................................................................................................................................................... 9

3. Statistical Analysis .................................................................................................................................................... 10

4. Financial Analysis ..................................................................................................................................................... 14

5. SWOT analaysis ........................................................................................................................................................ 15

Strengths .............................................................................................................................................................. 15

Weaknesses ......................................................................................................................................................... 15

Opportunities ....................................................................................................................................................... 15

Threats ................................................................................................................................................................. 16

6. Recommendations ................................................................................................................................................... 17

7. Conclusion ............................................................................................................................................................... 19

8. Appendices .............................................................................................................................................................. 20

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LIST OF ABBREVIATIONS

All acronyms and abbreviations that appear in the report should be listed here, particularly jargon related to the

relevant technical area/health region/facility. Sample below:

ULV Ultra Low Volume

IRS Indoor Residual Spraying

E.U. European Union

EMMIE Elimination of Malaria in Meso America and the Island of Hispaniola

AMI/RAVREDA Amazon Malaria Initiative

USAID United States Agency for International Development

NHI National Health Insurance

PAHO Pan American Health Organization

CHW Community Health Worker

VC Voluntary Collaborator

ABER Annual Blood Examination Rate

API Annual Parasitic Index

WHO World Health Organization

COMBI Communication for Behavioral Impact

IEC Information, Education and Communication

BTB Belize Tourist Board

BTIA Belize Tourism Industry Association

DFID Department for International Development

INDRE Institute for Epidemiologic Diagnosis and Reference (Mexico)

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1. INTRODUCTION

BACKGROUND

Under the Environmental Health Unit, the Vector Control Program has the responsibility for implementing

surveillance, prevention and control measures to protect the population against vector borne diseases, particularly

Malaria, Dengue, Chikungunya, Zika and Chagas. It executes, on an ongoing basis, a series of Malaria and Dengue

control activities such as: active and passive case detection; presumptive and radical case treatment with a 14-day

treatment scheme; adult mosquito control via indoor house spraying (using Deltamethrin 5% WP and Lambda

Cyhalothrin 2.5 EC for thermal fogging) and spatial Ultra Low Volume (ULV) spraying using Malathion 96%; chemical

larvae control with Temephos in granular and liquid formulations; and health education in schools. The Ministry in

its effort to carry out an integrated approach to vector control also uses Natular DT (spinosad) as a biological larvicide

for containerized water; likewise, Altosid (methoprene) is being utilized for larvae control in drains and larger

breeding sites. The use of long lasting insecticide treated bednets in Malaria high risk communities is also part of our

integrated strategy. Dissemination of IEC materials and the use of COMBI – communication for behavioral impact is

also used which focuses on behavioral change to address habits which contribute disease transmission.

VISION, MISSION AND OBJECTIVES

To reduce the social and economic effects of vector borne diseases in Belize by implementing prevention and control

measures based on the principles of integrated vector management

Objectives:

To conduct active and passive surveillance of vector borne diseases

To conduct Public Awareness and Education of major vector borne diseases

To achieve a 20% reduction in the incidence of Dengue by 2020

To eliminate autochthonous transmission of Malaria by 2020

SITUATIONAL ANALYSIS

MALARIA SITUATION

Belize is poised to eliminate malaria by the year 2020, a goal set and affirmed by all countries of Mesoamerica and

the Island of Hispaniola in the 2013 Meeting of the Council of Ministers of Health of Central America and Dominican

Republic (COMISCA). Nine countries, seven from Central America and two from the Island of Hispaniola, are part of

the Global Fund financed “Elimination of Malaria in Mesoamerica and the Island of Hispaniola” (EMMIE). The project

aims to accelerate the efforts to eliminate malaria, urging all countries to reach zero autochthonous malaria cases

by the year 2020. Belize’s commitment to malaria elimination is reflected in their National Malaria Elimination Plan

2015-2020 which is guided by the following global and regional plans:

WHO - Global Technical Strategy for Malaria - 2016 – 2030

PAHO - Plan of Action for Malaria Elimination 2016-2020

AMEXCID - MesoAmerican Master Plan for Malaria Elimination

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Strategic Plan for Malaria Elimination in Central America and the Island of Hispaniola - 2015 - 2020

Between 2000 and 2016 the country achieved a 99.7% reduction in cases from 1,486 cases to 5 in 2016. Malaria

continues to be concentrated mostly in the Southern and Northern districts and likewise cases are now concentrated

in a few communities. Of the 5 cases in 2016, there were 2 imported from Nicaragua and Guatemala. In 2016

indigenous transmission occurred in Trio Village alone but there are several localities at risk or with recent

transmission – therefore we have 27 foci (areas with various level or risk for transmission) under close surveillance.

All cases were investigated, classified, and had various levels of supervised treatment based on patient

access/availability. Data reported for 2015 and part of 2016 was verified in the external validation process carried

out independently by the Global Fund and PAHO from the 24th October to 1st November 2016.

The period between 2014 and 2015 which saw the introduction of a grants by the EU and the Global Fund (EMMIE),

both contributed significantly in achieving a 50% reduction in cases when comparing is to the 2013 baseline of 26

cases. Important to note is that of the 13 cases reported in 2015, investigations revealed 9 were local and 4

imported. During the execution of EMMIE activities which ran from August 2014 to July 2016, the country went from

19 cases in 2014 to 3 cases at the closing period. The EMMIE start up phase closed the program saw:

procurement of various equipment were procured to strengthen the GIS component of the program, this

included the purchasing of desktop computers, GPS devices, printers etc.

diagnosis improved through the procurement of microscopes and some lab furniture

Health Education and Community Participation Bureau (HECOPAB) greatly improved by supplying all 8

offices country wide with mobile education kits which included with tents, tables, chairs, and projector

screens

Improved entomological surveillance of the program with the procurement of equipment for mosquito

trapping and rearing to support the monitoring of insecticide resistance and vector identification

development of various IEC materials

procurement of 3 pickup trucks – 2 in Stann Creek and in 2016 the procurement of 1 for San Ignacio. This

resulted in improved active surveillance, timely interventions, widened coverage of spraying operations and

supervised treatment for patients.

Apart from the EMMIE project there was also:

Completion of the first National Malaria Guidelines (including treatment protocol)

Indoor Residual Spraying of over 8,000 homes in 56 localities, and protecting a population of just over

30,000

Distribution of approximately 4,000 bed nets

Distribution of over 400 kits to Malaria voluntary collaborators and community health workers to equip

them to take blood smears for malaria testing

The current focus is on border areas and communities with highly mobile populations, especially to endemic regions.

This includes workers in the sugar cane, citrus, banana and tourism industries which not only have a high population

of immigrant workers, but a mobile one as well.

Plasmodium vivax account for 100% of detected cases, as p. falciparum was eliminated in 2006. Long Lasting

Insecticide Treated Bed nets (LLIN’s) are now used in combination with IRS in areas with transmission, this

combination of interventions along with supervision of treatment has produced great results. In 2017 the plan is to

improve on both passive and active surveillance, re-distribute bed nets, cut down on the turn around time from the

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time a slide is taken to treatment administered, treatment supervision, and classification of foci to determine

necessary actions.

DENGUE AND OTHER EMERGING VECTOR BORNE DISEASES

Since the introduction of Dengue in Belize in 1978, the disease have changed its characteristics of being an urban

disease to now affecting many rural communities on an annual basis during the rainy season which runs from June

to November. There are a relatively low number of cases during the dry season which is from January to end of May;

this is followed by a sharp increase in the middle of June extending to the middle of October. Between October and

December, there is a gradual decrease in the number of cases.

Over time many rural communities have grown significantly and can be classified as being “urban like”, meaning that

many of the contributing factors which exit in an urban setting also exits in the rural setting. Factors such as poor

garbage disposal, drainage, tire shops/disposal of tires and storage of water exist in both settings. Over the past

three years we have seen the introduction of two new diseases transmitted by the same aedes vectors affect the

same communities which are traditional hot spots for dengue outbreaks.

The country has two main vectors, with the aedes aegypti as the primary vector and aedes albopictus as a secondary

vector. The latter is found predominantly in rural communities and in limited distribution as opposed to the primary

vector which is found in most areas. 2016 saw field officers conduct approximately 100,000 inspections of homes

and establishments and reported as high as 9% being positive for aedes larvae. Positive container index was reported

as high as 13% in some areas and the Breteau index which shows the correlation between the number of positive

containers to houses inspected being as high as 10%. For the most part hot spots have remained constant but these

are areas with wither significant soci-economic conditions, poor drainage, and cultural habits which significantly

impact transmission. These traditional indicators which vector control program use are often debated, as numerous

studies have demonstrated outbreaks in areas with these indices below what is considered low risk or even 1%.

A study published in journal Emerging Infectious Diseases entitled Aedes aegypti Larval Indices and Risk for Dengue

Epidemics highlighted “The house index (HI, percentage of houses positive for larvae) and the Breteau index (BI,

number of positive containers per 100 houses) have become the most widely used indices, but their critical threshold

has never been determined for dengue fever transmission. Since HI≤1% or BI≤5 was proposed to prevent yellow

fever transmission, these values have also been applied to dengue transmission but without much evidence. The

Pan American Health Organization described 3 levels of risk for dengue transmission: low (HI<0.1%), medium (HI

0.1%–5%), and high (HI>5%), but these values need to be verified. The vector density, below which dengue

transmission does not occur, continues to be a topic of much debate and conflicting empiric evidence. For example,

dengue outbreaks occurred in Singapore when the national overall HI was <1%. In contrast, researchers from

Fortaleza, Brazil, found that dengue outbreaks never occurred when HI was <1%.”

In 2014 Belize reported its first case of Chikungunya but for the most part this is a disease which is either being under

reported or have not established itself after the first wave of cases in small pockets in most districts. Despite the

challenges with the reliability of testing kits available on the market the ministry have been able to conduct some

testing for Chikungunya in country but most testing being done in Trinidad at CARPHA or in Chetumal Mexico. In

2016 of the several hundred blood samples tested for the three major arboviruses, there was only 1 positive for

Chikungunya coming from the Corozal District.

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There were 237 laboratory confirmed dengue cases in 2016 along with 385 clinically diagnosed, and some 4,709

tests ordered. The majority of cases occurred in the productive age group of 15 – 55 and as such dengue continues

to have a great economic impact on the country due to loss of productivity time. The distribution among sexes was

fairly even with 109 males and 128 females being confirmed as positive by lab test. Belize City which in recent years

accounted for approximately 70% of the total cases in country have made significant advancements through

improved supervision, investment in transportation and equipment, hiring of seasonal workers to compliment

larviciding program during the rainy season, increase public awareness and increased clean up campaigns in

collaboration with stakeholders including the private sector. There is much work to be done in the Corozal, Orange

Walk and Cayo districts which account for 26%, 18% and 29% of total lab confirmed cases respectively.

Zika which took the entire region of the Caribbean and Americas by storm was detected in April 2016. The ministry

immediately developed and rolled out a preparedness and response plan which included the procurement of

equipment and supplies, development of IEC materials, sensitization of healthcare workers, and preventative

measures to high risk groups, particularly pregnant women and those in their reproductive age. Much support was

received from WHO/PAHO, DFID, CARPHA, INDRE, Gorgas Institute, Ministry of Health Brazil, UNICIEF, BTB/BTIA and

local municipalities. The response was commendable and at the end of 2016 we had 889 persons either clinically

diagnoses or had a test ordered of which we confirmed by lab 73 cases. Majority of cases came from the Belize and

Cayo districts.

The impact and the distribution of Zika on the population is difficult to tell at this time as some districts such as Stann

Creek, Toledo and Orange Walk have reported very few suspected cases. This combined with a supposed 80%

asymptomatic rate make it a complexed and challenging scenario. At the close of 2016 the Ministry entered into an

agreement with the Secretary of Health in Mexico to support an arbovirus study to look at the distribution of Dengue,

Chikungunya and Zika in Belize. This commenced in December 2016 and will run for a duration of six months. Initial

results are very much in line with results from CARPHA which indicate that over 90% of cases tested are negative for

all three arboviruses, which has left not only the Ministry but indeed ministries throughout the region longing for

answers. In the meantime the ministry continues to educate the public, sensitize healthcare workers and take

preventative measure with pregnant women to prevent infection and possible Zika congenital syndrome to child.

During 2016 the ministry procured over 7,000 bottles of insect repellent and distributed approximately 4,000

insecticide treated bed nets, with pregnant women being offered a package of repellent and bed net.

The control of aedes vectors remain the single biggest challenge for the program, particularly because the

responsibility of reducing risk factors lie across various stakeholders including government ministries, private sector

and the householder. The dependency syndrome particularly upon a small government program such as the vector

control program to provide a long term solution is unrealistic and will result in minimal gains being achieved on a

yearly basis. The opportunity presented by Zika to bring some stakeholders to the table came about in 2016 but this

window of opportunity appears to be closing rather quickly. A multi-disciplinary and sectorial group to address the

problem at hand the only long term solution and this must be based on the Integrated Management Strategy model

which involves epidemiology, lab, environment, integrated vector management, patient care, and social

communication. The vector control program specifically must continue to be guided by the framework integrated

vector management which is described as the optimal use of resources for vector control. The approach seeks to

improve the efficacy, cost-effectiveness, ecological soundness and sustainability of disease-vector control.

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2. OPERATIONAL OVERVIEW

KEY ACHIEVEMENTS

1. 61.5% case reduction between 2015 (13 cases)- 2016 (5 cases)

2. The first comprehensive National Malaria Guidelines completed

3. Development of new malaria case reporting form

4. Development of malaria foci classification form

5. Malaria project entitled “Elimination of Malaria in Mesoamerica and the Island of Hispaniola” being funded by

the Global Fund phase 1 completion with 91% execution of funds

6. External validation of cases and assessment of program completed with a score of 66% compliance with all

recommendations fulfilled and criteria met for elimination. Target of 25% case reduction exceeded and criteria

fulfilled for cash reward component of Global fund grant.

7. 65% reduction in laboratory confirmed dengue cases

8. Development of Zika preparedness as response plan

9. Procurement of additional vehicle for San Ignacio

10. Procurement of printers, projectors, screens, tables, chairs, tents, laptops, desktops, GPS, office furniture and

entomology equipment etc. for vector control and HECOPAB

11. Completion of Zoning exercise w/ GIS Technician to streamline reporting on aedes inspections and to conduct

risk stratification for optimal use of resources

12. Ovti Trap training for w/ Mexican counterparts as part of Insecticide Resistance Monitoring Program

MAJOR ACTIVITIES AND OUTPUTS

Implementation of best practices for Malaria elimination including the use of IRS, bed nets, and supervised

treatment resulting in a 61.5% reduction in cases between 2015 (13 cases) and 2016 (5 cases). The target of a

25% reduction set out at the start of 2016 was surpassed. Malaria is at its lowest transmission level since 1963

when the country reported 8 cases.

Countrywide there was a 65% reduction in laboratory confirmed cases of Dengue. A 70% reduction in clinical

diagnosis and 20% increase in testing. The program surpassed its target of a 10% reduction in laboratory

confirmed cases. Significant gains were made even in the most endemic areas in Belize City and Cayo district.

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WORKSHOPS ATTENDED/FACILITATED

Workshop Venue Date Sponsor Participants

INT5155 - Meeting on Aedes

Mosquito Population Control

Using an Integrated Vector

Management Approach with

SIT (sterile insect technique)

Component

Brazilia, Brazil 24-26 February 2016 IAEA Kim Bautista

3era Reunión EMMIE

Panama March 14th – 16th, 2016 COMISCA Aldo Sosa

Orlando Chan

Kim Bautista

Zika Virus Epidemic:

Challenges and the Road

Ahead

Rio de Janeiro,

Brazil

13 – 15 April, 2016 IDB CEO – Dr. Ramon

Figueroa

Kim Bautista

XV Annual Evaluation

Meeting of AMI/RAVREDA

Bogota, Colombia 3 – 5 May, 2016 PAHO Kim Bautista

Dr. Gerhaldine

Morazan Hidalgo

MAJOR CHALLENGES

The following are the major challenges for the reporting period:

1. Limited staff to adequately address dengue/chik-v and malaria surveillance and prevention measures

2. Poor supervision and accountability for field officers – poor productivity is a major issue crippling the

program

3. Urgent need to fill critical vacancies in 2 district supervisors in Orange Walk and Belize districts.

4. Appointment of officers who have been performing exceptionally well for over 15 to 20 years. Many of

officers are demoralized with numerous personnel only recently hired having been appointed

5. Regional management teams continue take away transportation from the program, thereby limiting

response time and mobility of officers. Commitment from the regions seem to come in a responsive manner

as opposed to being proactive.

6. Regional teams must involve stakeholders in the public and private sector, particularly for dengue

prevention – the Ministry of Health cannot do it alone but the regions must convince stakeholders of the

vital role they play

3. STATISTICAL ANALYSIS

2014 Malaria by District and Species



District SPECIES

District SPECIES

District SPECIES

FALCIP VIVAX MIXED Total



Corozal 0 6 0 6

Corozal 0 5 0 5

Corozal 0 0 0 0

Orange Walk 0 1 0 1

Orange Walk 0 4 0 4

Orange Walk 0 0 0 0

Belize 0 0 0 0

Belize 0 1 0 1

Belize 0 0 0 0

Cayo 0 0 0 0

Cayo 0 1 0 1

Cayo 0 0 0 0

Stann Creek 0 12 0 12

Stann Creek 0 2 0 2

Stann Creek 0 4 0 4

Toledo 0 0 0 0

Toledo 0 0 0 0

Toledo 0 1 0 1

Total 0 19 0 19

Total 0 13 0 13

Total 0 5 0 5

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DISTRICT

# # #

Cases Slides Pop API ABER Cases Slides Pop API ABER Cases Slides Pop API ABER

Corozal 6 5866 44613 0.13 13.1 5 6053 44613 0.11 13.6 0 3839 46472 0.00 8.3

Orange

Walk 1 4823 48744 0.02 9.9 4 5145 48744 0.08 10.6 0 4246 50208 0.00 8.5

Belize 0 6321 107494 0.00 5.9 1 5544 107494 0.01 5.2 0 5591 113878 0.00 4.9

Cayo 0 3002 85243 0.00 3.5 1 3529 85243 0.01 4.1 0 1585 90579 0.00 1.7

Stann

Creek 12 1799 38728 0.31 4.6 2 3758 38728 0.05 9.7 4 2915 41032 0.10 7.1

Toledo 0 2311 34077 0.00 6.8 0 2338 34077 0.00 6.9 1 2760 35800 0.03 7.7

Country

Total 19 24122 358899 0.05 6.7 13 26367 358899 0.04 7.3 5 20936 377968 0.01 5.5

ABER 6.7 7.3 5.5

YEAR 2014 YEAR 2015 YEAR 2016

2016 Indoor Residual Spraying

# of communities

sprayed

# houses sprayed By IRS

Population Protected By IRS

Corozal 9 2673 10,140

Orange Walk 12 2293 8,981

Belize 0 0 0

Cayo 5 1772 6,860

Stann Creek 6 840 3801

Toledo 20 1175 5,482

Total 52 8753 35,264

2016 Active and Passive Case Detection

Active Passive Total

Corozal 3171 668 3839

Orange Walk 3790 456 4246

Belize 296 5295 5591

Cayo 414 1171 1585

Stann Creek 993 1922 2915

Toledo 770 1990 2760

Total 9434 11502 20936

2016 Local Cases (4):

• Stann Creek District –

– Trio Village – 3 cases

• Toledo District –

– Conejo Creek Village – 1 case

Imported Cases (1):

Stann Creek – 1 case from Puerto Cabezas - Nicaragua

2016 Cases – 2 cases in Trio Village – Stann Creek

---------------------------------------------------------------------------------------------------------------------------- --------------------

DENGUE

2015

Clinical

2016

Clinical

2015 #

Persons

Tested

2016 #

Persons

TestedCorozal 138 18 463 781

Orange Walk 42 24 164 322

Belize 113 36 1143 1562

Cayo 931 281 850 1304


Toledo 30 13 496 325

Total 1277 385 3407 4709

Confirmed Probable Suspected (Clinical) Suspected(by Test) Grand Total

<1 4 1 4 111 120

1-4 1 4 9 397 411

5 -9 5 8 20 299 332

10-14 12 4 32 293 341

15-19 10 15 40 391 456

20-24 18 13 57 406 494

25-29 11 9 50 445 515

30-34 19 10 47 423 499

35-39 5 12 25 312 354

40-44 15 10 27 280 332

45-49 7 9 27 240 283

50-54 4 8 24 179 215

55-59 4 6 12 104 126

60-64 3 4 4 75 86

65+ 3 3 7 136 149

Dk/Ns 0 0 0 0 0

Total 121 116 385 4091 4713

Confirmed Probable Suspected (Clinical) Suspected(by Test) Grand Total

Female 64 64 202 2278 2608

Male 57 52 183 1813 2105

Indeterminant 0 0 0 0 0

Total 121 116 385 4091 4713

SexClassification

Classification

Age-group

2013

Lab

Positive

2014

Lab

Positive

2015

Lab

Positive

2016

Lab

Positive

% Difference

2015 - 2016

Corozal 35 151 184 62 -66.3

Orange Walk 87 28 37 43 16.2

Belize 189 345 92 41 -55.4

Cayo 200 90 242 68 -71.9

Stann Creek 38 48 22 20 -9.1

Toledo 12 21 101 3 -97.0

Total 561 683 679 237 -65.1

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ZIKA

ConfirmedSuspected

(Clinical)Suspected(by Test) Grand Total

Corozal 13 47 66 126

Orange Walk 2 19 15 36

Belize 30 143 176 349

Cayo 22 77 92 191


Toledo 8 99 26 133

Unknown 1 1 0 2

Total 81 404 418 903

ConfirmedSuspected


<1 2 14 16 32

1-4 1 20 30 51

5 -9 7 17 19 43

10-14 4 7 36 47

15-19 11 69 45 125

20-24 15 87 54 156

25-29 7 66 55 128

30-34 10 46 47 103

35-39 8 31 56 95

40-44 5 22 16 43

45-49 2 4 26 32

50-54 4 10 8 22

55-59 1 4 5 10

60-64 0 3 2 5

65+ 4 3 3 10

Dk/Ns 0 1 0 1

Total 81 404 418 903

ConfirmedSuspected


Female 61 328 276 665

Male 20 76 142 238

Total 81 404 418 903

Sex

ZIKA Classification

ZIKA Classification

District

ZIKA Classification

Age-group

4. FINANCIAL ANALYSIS

The budget approved for the fiscal period 2016/2017 is $792,121 of which 46% has been executed through the end of 2016. There are still payments to be made

for the most costly inputs, particularly pesticides procured through tender which is paid under Materials and Supplies. There is a significant sum of unspent funds

under travel and subsistence as the rates had changed and these funds are used mostly for temporary hired workers conducting indoor residual spraying. After

payments for fuel, tender supplies, and purchase of additional spares are done we should have an execution of approximately 80%.

Additional funds spent through 2016:

Global Fund – EMMIE Grant – BZD $103,153.92

Item Description Approved Adjusted Budget

Release Encumbrance Expense Available Reserved Unspent % Spent

230 Personal Emoluments

$159,955 $159,955 $133,290 $0 $102,281 $31,009 $26,665 $55,674 64%

231 Travel & Subsistence

$132,840 $132,840 $132,840 $0 $44,404 $66,296 $22,140 $88,436 33%

340

Material & Supplies

$359,766 $359,766 $359,766 $12,197 $137,437 $150,156 $59,976 $222,329 42%

341 Operating Cost $122,510 $122,510 $122,510 $1,700 $52,556 $47,834 $20,420 $69,954 44%

342 Maintenance Costs

$13,050 $13,050 $13,050 $1,307 $7,091 $2,482 $2,170 $5,959 64%

343 Training $4,000 $4,000 $4,000 $0 $1,592 $1,738 $670 42,408 40%

Total $792,121 $792,121 $710,853 $15,204 $345,361 $299,515 $132,041 $446,760 46%

5. SWOT ANALAYSIS

STRENGTHS

The strength of the vector control program, specifically Malaria, is the network of voluntary collaborators and community health workers. This network is the backbone of the passive surveillance system and has been responsible for over 90% of positive Malaria cases detected.

The vector control program, although understaffed, has a number of dedicated, the majority of which have received the necessary training to carry out core functions required.

The program has significant assets at its disposal with respect to a fleet of reliable vehicles, equipment and all the necessary inputs – this has allowed district program to respond timely and appropriately to outbreaks.

The program is supported technically by regional experts in the area of Malaria, Dengue, Chikungunya, and Zika. This has allowed us to keep up to date with best practices and technology in vector control.

WEAKNESSES

The human resources issue needs to be addressed as the staffing profile has not grown over the years to keep

up with a booming population. 62 officers are responsible for the prevention and control of Chagas, Malaria,

Dengue, Chikungunya, and Zika. As a result, majority of time and resources are now spent on aedes aegypti

control.

Low productivity by field officers in the regions has led to dismal results for aedes control and regional

management teams must ensure the performance appraisal reporting mechanism in place is utilized if we are

to see any improvements

Lack of adequate transportation for some district health teams have resulted in a constant struggle for access to vector control owned vehicles which result in slow response and demoralized officers.

There is an urgent need for adequate storage facilities for equipment and pesticides, currently being housed

inside some offices which is a serious health risk.

OPPORTUNITIES

With the emergence of Zika bringing to the forefront the urgent need for aedes control, the opportunity must

be seized to build relationships with stakeholder government ministries and the private sector. The importance

of fighting this vector collectively must be sold and there must be persistent follow up.

Establish a National Technical Group for Dengue to ensure an integrated approach to vector control is being

implemented and to Integrated Vector Management committee with stakeholders such as other government

ministries responsible for drainage and infrastructure, housing, sanitation, and waste disposal, to address some

of the contributing factors to the spread of dengue and chikungunya

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The relationship with the Belize Vector and Ecology Center in Orange Walk and the University of Notre Dame

professors who manage this institution must be further exploited in conducting critical operational research

including susceptibility testing in areas where IRS is conducted and insecticide resistance testing.

Look at new technology beyond malaria microscopy, in order to be able to detect “sub microscopic” parasite

levels and to support screening of asymptomatic patients in serologic surveys. Such tools are necessary for

countries going through the pre-elimination phase and gearing towards elimination. This may be possible

through USAID LAC Malaria Program.

The cash on delivery component of the EMMIE grant should bring much needed finances into the program which can be used to improve the staffing situation and diagnostic limitations which will impact the program right across the board.

There is a need to train more vector control personnel in the core concepts of field epidemiology. The opportunity is there with the FETP program but this must be prioritized by the ministry to ensure this critical group is included.

THREATS

The addition of Zika to the portfolio of the program and the far reaching implications of this disease have resulted in the program having to be selective in its strategies and at the same time limited to the extent of the various interventions necessary. The current financial climate in country will bring about additional challenges in the coming months.

There must be a human resource succession plan to ensure that the retirement of experienced officers in critical roles do not leave the program at a disadvantage. It is critical to ensure district programs are led by well-rounded persons in all aspects of vector control.

Natural disasters for the most part results in the outbreaks of mosquito vector borne diseases and that was the case in 2016 with Hurricane Earl. Post Earl saw outbreaks of Zika in the Cayo district and in a short period there were pockets of cases in most areas. As a program we need to be prepared annually for such eventuality as external assistance is extremely slow to come or non existent.

6. RECOMMENDATIONS

LOGICAL FRAMEWORK

Intervention logic Objectively verifiable indicators of achievement

Sources and means of verification

Assumptions

Overall objectives Belize elimination of autochthonous transmission of Malaria by 2020 Reduction of 30% in Dengue cases by 2020 Reduce the incidence of Zika and Chikunguna

To reduce the social and economic impacts of major vector borne diseases

% reduction of laboratory confirmed cases vs. 2016 baseline

BHIS Reports

Adequate funding for execution of planned activities No unforeseen natural disaster

Specific objective 20% reduction in Malaria cases 10% reduction in dengue cases 10% reduction in Zika cases

Global Fund/Elimination Target Strategic Plan Target

Baseline of 5 in 2016 Baseline of 237 laboratory cases in 2016

BHIS Reports

Adequate funding for execution of planned activities No unforeseen natural disaster

There are several areas which are priority for Malaria at this time, including the following:

Creating the post of district supervisor for Orange Walk

Creating the post of microscopist for Orange Walk as there is only 1 microscopist in Corozal servicing both

districts and this officer is pulling double duty

Hiring of additional staff Malaria surveillance for the Independence catchment area

Maintain minimum of 80% coverage for villages selected for bed net distribution

Monitor the quality and use of bed nets distributed

Maintain minimum of 80% coverage for Indoor Residual Spraying (IRS) spraying in localities which have

produced malaria over the past 3 years.

Ensure that 100% of malaria cases are treated and 100% supervised treatment

Ensure malaria evaluators visit CHW’s and VC’s on a weekly basis, as recent checks have malaria slides

remain for weeks at a time and are not picked up. VC’s and CHW’s also need to be more active.

Development of a work plan for execution of cash reward component of Global Fund project

Adherence of National Malaria Guidelines

There are several areas which are priority for Dengue/Chikungunya/Zika at this time, including the following:

Review of capacity of vector control district programs to adequately implement dengue prevention and

control activities within their region. Some regions appear to be severely understaffed to conduct Malaria,

Dengue and Chikungunya activities.

San Pedro does not have any officers and we need to establish a minimum of 2 officers fulltime on the

island

Ensure the use of COMBI – communication for behavioral impact as a tool to address behaviors which are

risk factors that increase the probability for dengue transmission/outbreaks

Supervision at the level of district supervisor is weak and must improve. Vector control officers are

entrusted to work mostly unsupervised and this leads to poor execution of duties.

Administration at the regions, starting the with deputy and regional health managers need to ensure there

is better execution of vector control programs, starting with proper reporting, planning sessions, and

regular meetings to update on the progress of work plans. Operational plans are developed but not

followed and there is little to no periodic update and review of these plans. SLA’s are reported on but these

are limited indicators and will not reflect the limitations on the ground level

Need to strengthen the epidemiological surveillance system through refresher/sensitization sessions for

clinicians to enable early detection of dengue and chikungunya cases. This should allow for rapid

implementation of control measures to break transmission and prevent the occurrence of epidemics.

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7. CONCLUSION

It is clear that the primary objectives set out for the Malaria program were met and the necessary steps have been

taken to strengthen the gaps identified in the program. Malaria was kept in the spotlight even in light of the

introduction of Zika, in fact, the country continued to achieve significant success. The drastic reduction in malaria

cases should not be reason for complacency. Frequent traveling of Belizean nationals to malaria endemic areas as

well as the constant increase of immigrant workers in the agriculture and tourism industry pose a constant threat

for the reintroduction of the plasmodium parasite into malaria free areas. The expansion of the sugar cane industry

into the Cayo district is a primary example of the potential for reintroduction into malaria free areas. The influx of

workers from neighbouring Guatemala into this newly established industry in the Cayo district which have not

reported a local case of Malaria for the past 4 years is a cause for concern. Another key concern is the re-emergence

of Malaria in a few localities in the Corozal and Orange Walk districts, particularly communities in close proximity to

the Mexican villages on their side of the Rio Hondo where there is active transmission. The program continues to go

through a process of re-orientation whereby plans and strategies must shift from the mind-set of controlling malaria

to eliminating malaria. This in itself will be a major challenge and will continue to be part of the discussion in 2017

during the roll out of the new National Malaria Guidelines which was developed, the implementation of the National

Malaria Elimination Action Plan 2015 – 2020 and another phase of the Global Fund grant. It is also expected that

support both technically and financially will continue from USAID funded Amazon Malaria Initiative now being called

USAID LAC (Latin America and the Caribbean) Regional Malaria Program. The USAID funded program is in the process

of finalizing its strategic framework for the period 2017 – 2021. Over the next fiscal year Belize’s national program

will focus on improving surveillance, diagnosis, treatment/follow up, and prevention of malaria based on

recommendations made during the 2016 Global Fund/PAHO assessment.

With respect to vector borne diseases transmitted by the aedes aegypti and aedes albopictus, there are so many

external factors which contribute to transmission and in this aspect it is critical that regional management teams

forge the relationships necessary to reduce their incidence and impact. 2016 saw involvement from the various

municipalities and organizations such as UNICIEF, PAHO, Red Cross, BTB/BTIA among others. It will take a concerted

effort to make successful, meaningful gains in controlling the aedes vector. These efforts, together with other actions

based on the principles of integrated vector control is the new path which the program must undertake.

The training of volunteers and community health workers in core competencies of vector control and surveillance

at the community level which was done in 2015 is a step in the direction we need to go. The inputs in terms of

capacity building and investment in assets over the past two years have resulted in a reduction of Dengue and

Chikungunya. Some strategies which commenced in 2015 will require more time, particularly COMBI –

communication for behavioral impact, which is geared at targeting behaviors which are risk factors or which

contribute to disease transmission. Vector control and some public health officers have been trained in this

technique which must be implemented based on the contributing factors to the transmission of vector borne

diseases in their respective districts. The program must be a critical part of all district vector control plans and

enforced by regional management teams.

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8. APPENDICES

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PARTICIPATION IN REGIONAL AND LOCAL EVENTS TO SENSITIZE PUBLIC ON VECTOR BORNE DISEASES

TRAINING W/ MEXICAN COUNTERPARTS ON OVI TRAP FOR AEDES SURVEILLANCE AND ROLE IN INSECTICIDE RESISTANCE MONITORING

EQUIPPING ALL MALARIA VOLUNTARY COLLABORATORS AND COMMUNITY HEALTH WORKERS TO AID IN THE PASSIVE SURVEILLANCE SYSTEM FOR MALARIA

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GLOBAL FUND/PAHO MALARIA PROGRAM EXTERNAL VALIDATION

Vector Control - BVS

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