In response to the December 2004 tsunami, Kaiser Permanente (KP) sent physician teams and supplies to Sri Lanka and Indonesia. I spent a month in Banda Aceh, Indonesia as the Clinical Director of the Malaria Emergency Technical and Operational Response (MENTOR) Initiative Aceh emergency team. KP provided the entire medical contingent for this MENTOR activity, nine doctors total, who either were Infectious Disease specialists or had experience in malaria treatment and abatement. This program is a United Kingdom-based nonprofit; its goal is to strengthen existing structures within countries that support malaria prevention and treatment. MENTOR provides the necessary support for: health care delivery, public health infrastructure, surveillance systems, funding for medications or pesticides, and for training. In the long term, the MENTOR goal is to have successfully supported a country's health care providers and governmental structures to enable them to continue the programs after MENTOR personnel have left, thus the double significance of the name "MENTOR."

Malaria--A Major Killer

The impact of malaria may exceed that of all other infectious diseases, far surpassing even HIV.¹ The morbidity and mortality still exceeds all other infectious diseases except HIV.¹ Controlling this disease can be more effective and less costly than efforts directed at other diseases.

The MENTOR Initiative has successfully intervened during its short existence in several African countries, most notably Liberia, where after long-term political disruption some stability has been established. In cooperation with the existing governmental health care structure, a malaria prevention program was instituted and in three short years malaria has gone from the leading cause of death by disease to the ninth most frequent cause of death by disease in Liberia.

The tsunami in Indonesia led to the MENTOR Initiative's first efforts outside of Africa and to the organization's first emergency relief effort. The dramatic changes in the geography of Aceh, associated with the tsunami, created a public health emergency that would have compounded the devastation that this large area of Sumatra had already experienced.

After the tsunami, there were many factors that placed the population at great risk of severe malaria epidemic: extensive areas of standing salty water--a perfect environment for mosquito breeding; population displacements placed many people with active malaria in proximity to those uninfected and in the midst of the mosquito bloom; public health efforts had been impaired during the civil conflict in Aceh and were now devastated by the tsunami; clinics, hospitals, labs and pharmaceutical stores were all devastated and the numbers of personnel killed were staggering; and over seven hundred people from the Ministry of Health were killed by the tsunami in Aceh province.

Although malaria has been endemic in Sumatra, the prevalence has been moderate. Although the most common type of malaria is falciparum, and the most lethal type, the mosquitoes that carry this agent there do not bite humans as their first choice.² This is in contrast to Africa, where the human preference is one of the reasons the disease is so catastrophic. Infected mosquitoes always have as their next meal another human, rapidly amplifying the infection prevalence. In addition, in Indonesia, malaria is seasonal, limiting amplification of infection and terminating outbreaks. On the other hand, malaria in this area is highly resistant to antimalarials (Ferdinand Laihad, MD, personal communication, 2005).^a

Artemisinin-based Combination Treatment (ACT) from
MENTOR Initiative. Photo by D Scott Smith, MD.

Our Role in Malaria Prevention and Treatment

MENTOR provided a prevention program that had two main parts. The first and most important was "Interior Residual Spraying." Since the malarial vector, Anopheles sundaicus, only travels a small distance after feeding on an infected person and then rests for a day, spraying the walls of dwellings with a pesticide that has residual activity will break the chain of transmission. It requires approximately 85% of the dwellings to be sprayed to be successful. This technique for pesticide application also limits exposure of the environment to the pesticides. We provided pesticide and "spraymen" as well as sprayers. MENTOR had 181 sprayers who were trained in the safe and effective use of the pesticides employed. These teams sprayed all structures in Banda Aceh (a city the size of Oakland, California) by the second week of February and areas with outbreaks of malaria outside of Banda Aceh as they were identified. These efforts also helped provide a small element of economic recovery for the 200 or so Indonesians employed by the effort. We also trained military personnel from the German and Australian armies as well as local citizens provided by local municipalities or NGOs. We supplied them with sprayers and pesticide as well.

We also provided 37,000 Insecticide Treated Plastic Sheets to use as tenting in the homeless camps, which had a benefit similar to the interior spraying of houses.

The necessity for training in the use of these medications was a priority since inappropriate use would select for drug resistance. As part of the relief effort, the MENTOR Initiative shipped and distributed 275,000 treatment courses of effective malaria medications. The training needed was developed and provided to all personnel in the region who might be involved in clinical care or public health. We also developed a curriculum that the MOH can continue to use and provided equipment for their future training sessions.

Malaria Plasmodium falciparum Rapid Diagnostic Test
by Orchid. Photo for MENTOR Initiative by D Scott Smith, MD.

The New Malaria Rapid Test Kit

A new testing capability for maaria has recently been developed, which is superior to the long-standing diagnosis by microscopy. The new Rapid Test Kit is similar to the rapid pregnancy tests available in this country and has a high sensitivity and specificity rate for falciparum malaria. It permitted deployment of the new effective medicine regimens only to proven cases of malaria and thus prevented inappropriate use. MENTOR provided 500,000 of these kits and trained those receiving them.

The Busy Team

One impressive aspect of this effort was how compact the organization was. KP provided the entire medical contingent for this effort by the MENTOR Initiative. There were three teams of three physicians each working in Banda Aceh for about a month. Since the total expatriate MENTOR team was only ten people, including the KP physicians, we worked long days. Physicians were able to fill broad task capabilities. We could wrap boxes of medications for delivery from a helicopter, substitute for the entomologist in supervising the spraying efforts, and could review a failing case of falciparum malaria. The initial team worked 18-hour days for virtually the entire month. As the weeks passed, the workload eased a bit, although the jobs changed somewhat to meet the evolving needs of the relief efforts.

Closing

The MENTOR activities in Aceh were self-limited by design. A three-month grant might be extended to six months, but the goal was to have established a viable malaria program in the area by this time. So far there has been limited malaria in Aceh, probably less than that of a normal year. There is hope that these successes will provide the basis for extending the program to other areas of Indonesia. The MENTOR Initiative can take significant credit for this. All the donors who contributed, as well as the MOH who will direct and operate all malaria programs in the future in Indonesia, must take great pride in the joint efforts.

^a Malaria Subdirectorate, Directorate General of Communicable Diseases Control, Ministry of Health, Jakarta, Indonesia.

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