Summary of Malaria Assessment Visit to Dili, East Timor

REPORT OF PRELIMINARY MALARIA ASSESSMENT MISSION TO DILI, EAST TIMOR

October 26-28 1999

Report prepared by:

Dr Nick Anstey Tropical Medicine and International Health Unit Menzies School of Health Research (MSHR) and Territory Health Services (THS) Darwin, Northern Territory, Australia and Member of RBM Complex Emergencies Network

The mission was conducted by Dr Anstey as part of 4 member team of experts from Territory Health Services, Darwin, Northern Territory, Australia who assessed malaria, TB and laboratory services in East Timor at the request of WHO. PRELIMINARY MALARIA ASSESSMENT MISSION TO DILI, EAST TIMOR

I. Aim

To undertake a preliminary malaria situation analysis as part of an initial communicable diseases assessment by Territory Health Services

II. Situation Analysis, Dili, East Timor

1. Geography of East Timor

East Timor is 14,609 sq km, approximately 80% hills/mountains, 20% lowland. The highest mountain, Gunung Tata Mai Lau, is 2,963m and directly south of Dili. Of the 75 rivers in East Timor only 5 are described as having water in them by the end of the dry season. The wet season is from November-April. Under Indonesian administration, the province was divided into 13 districts, and 62 sub-districts, including 442 villages (East Timor Provincial Health Office 1993 report).

Dili on the north coast follows the coastal strip and is limited on all sides by hilly ranges, with a relatively steep and constant slope down to the sea. Full details of climate, topography and agriculture are found in “East Timor’s Potential Profile” by the Regional Investment Coordinating Board 1991.

2. Population

Pre-referendum population of East Timor estimated at 875,989, with an IMR of 70/1000 (1998 Indonesian Government data on file at RBM).

The population of Dili in the last week of October 1999 is estimated by Dili WHO staff at approximately 80,000 people. There is continuing spontaneous and structured movement of displaced people back to Dili. These include Dili residents and those from other cities and villages throughout East Timor. Many (but not all) of these are then moving back to regional towns and villages of origin. Despite widespread destruction of housing and public buildings there are no refugee camps within Dili, and none are planned. Returnees are living in the minority of houses that escaped destruction, or alternatively in partially-repaired houses. Economic activity is restarting, with increasing numbers of street vendors.

3. Malaria epidemiology

Existing data suggests mesoendemicity in at least 4 districts of East Timor (see below), with lower rates seen at higher altitudes.

3.1 Background malaria epidemiology based on past Indonesian Ministry of Health data

3.1.1 1993 report by Provincial Health Office Malaria Control Unit (Dr Alex Un Usfinit): Malaria second commonest cause of disease according to government primary health care clinic data. Both species found in all 13 administrative districts (relative proportions not reported). Parasite rate in 0-9 years averaged 8% province-wide in 1992. Parasite rate in 0-9 years reported as >10 % in 4 districts of East Timor: Dili, Bomonaro, Baucau and Manufahi. Two peaks in Anopheles vector density in East Timor reported in June/July and December/January.

3.1.2 Ministry of Health 1998 Health Profile (on file in Dili WHO Office): Malaria is listed as second or third commonest cause of disease in all age groups. This is based on a clinical rather than laboratory diagnosis in most cases, and in view of high rates of clinical malaria reported in the 0-28 day and >60 years age groups (which do not usually have high rates of clinical malaria), these are likely overestimates. Malaria and dengue haemorrhagic fever were each reported to account for 11.1% of East Timor hospital inpatient deaths in 1998.

3.1.3 Ministry of Health slide positivity rates (year not reported) in WHO databases (Sept 1999 RBM report) were reported as being10% in Ermera, 55% in Dili (?whether sampled from rural or urban areas of Dili district) and 73% in Manufahi, averaging 49% province-wide.

3.2 Malaria epidemiology in post-referendum evacuees to Darwin from Dili (including those seeking refuge in the UNAMET compound) in September 1999:

In the first group of 347 evacuees (UNAMET employees and families from Dili), all patients were screened for malaria by thick and thin film: only 3/347 (0.9%) were thick film-positive (0/31 children <5 years, 0/65 children 5-14 years, 3/220 adults > 14 years), with one each of P. falciparum, P. vivax and P. malariae. In the second group of 1517 evacuees (Refugees who had taken refuge in the UNAMET compound, including 16.8% children <5 years) thick films were only done in the 175 with a fever or a history of fever in the preceding one week: only 11/175 were positive, for a slide positivity rate (SPR) of 6.3%. Age-specific SPRs were 14.3% (3/21) <5 years, 14.3% (5/35) 5-14 years, and 3.4% (4/119) >14 years, with 5 having P. vivax, 4 P. falciparum and 2 P. malariae. Tuberculosis was the major problem seen in these evacuees (see report by Dr Vicki Krause).

NB 2 of the 14 Timorese evacuee malaria cases above were found to be G6PD deficient.

3.3 Current malaria epidemiology in Timorese, October 1999

3.3.1 French Clinic in Don Bosco area of Dili: Includes Timorese residents in Don Bosco area but also those from a variety of areas returning to Dili from the adjacent hills/rural areas. Malaria microscopy was performed by Professor Pierre Claude of the French clinic in the 75 patients who had fever or history of fever to October 28, with or without splenomegaly, with no other cause evident clinically. Parasitemia was reported in both children and adults, with a slide positivity rate of 32% (24/75). 13 (54%) had P. falciparum and 11 (46%) P. vivax. SPR was higher early in October than at the end of the month. One child with a parasitemia of 5% had had confusion, but there had been no other cases of severe malaria or malaria deaths. There had been two patients (one Timorese, one soldier) with a clinical suspicion of dengue, both awaiting serological results.

3.3.2 ICRC Hospital (former Dili General Hospital):

Parasitological data from ICRC hospital unavailable. There have been one or possibly two cases of severe malaria since the post-referendum reopening, but these were not confirmed. Hospital staff believe that malaria morbidity has so far been no higher than before the referendum. However referral of severe malaria cases to and within Dili will have been even more difficult than usual over recent months, and consequently out-of-hospital malaria deaths will not have been quantitated. 3.3.3 Weekly Morbidity data from NGO clinics to WHO (including data from Dili, Baucau, Los Palos, Manatuto and Viqueque):

Best estimates for malaria morbidity have been based on fever with no other explanation, however case definitions have not been standardised, and reporting has been incomplete. Reporting fell in the second half of October, making data reliability and interpretation of trends difficult. Presumed malaria has comprised approximately 15-20% of reported morbidity, a proportion that has remained stable during October.

3.4 Risk of malaria morbidity and mortality with coming of the wet season: factors that may increase morbidity and mortality risk with the rainy season compared with previous years include: a. Reduced access to primary health facilities for early diagnosis and treatment through transportation difficulties, destruction of facilities and microscopes, and reduced numbers of health workers. b. Reduced access to referral centres for management of severe malaria. c. Lesser ability to return to health facility if first line antimalarial therapy fails. d. Lack of vector control activities with the economic crisis followed by the civil unrest over the last year. e. Return of refugees from low transmission mountainous areas to higher transmission coastal areas. f. Displacement of refugees with some immunity to parasite strains found in their usual locality to different endemic areas with different strains to which they have less immunity. g. Effects of undernutrition and increased co-morbidities.

4. Vectors in East Timor and malaria control activities:

4.1 Vectors. For a detailed description and review refer to “Mosquito Survey of Dili, 1991” prepared by Peter Whelan of Territory Health Services following a site visit to Dili and Hera in 1991. In summary, the major vectors of malaria in East Timor are thought to be Anopheles barbirostris, An. sundaicus, and An. subpictus. An. subpictus tolerates high salinity levels and breeds in coastal swamps and pools. It has been thought to be the major vector around Dili. An. barbirostris is a swamp breeder, which tolerates high pollution levels, usually rests outside houses in the day, and feeds on people indoors. It is also the only known vector of Brugia timori. An. sundaicus breeds in coastal brackish water, and high concentrations were found in tidal pools in Hera in 1991. Adults rest both indoors and outdoors during the day and readily enter houses to feed on people.

A limited dry-season mosquito trapping survey at 4 sites in Dili on 15 October1999 by M. Connolly and P. Whelan revealed relatively few numbers of most mosquito species, with the exception of the nuisance species Mansonia uniformis and Culex quinquefasciatus from the swamp near the UN compound. See attached 1999 summary and report by P. Whelan. Mosquito trapping in September 1991 found An. subpictus and Aedes aegypti around the Governor’s Residence in Kampong Alor on the outskirts of Dili and Kai Koli respectively (see Mosquito Survey of Dili, 1991). There were no Anopheles or Aedes aegypti found in the limited October1999 survey above, however it was thought that malaria and dengue potential will increase significantly from the start of the wet season. A visit by Peter Whelan with repeat trapping is thus planned for early December 1999.

4.2 Vector Control activities. Past vector control measures by the Ministry of Health have included house spraying (DDT 1982-1991 and Bendiocarb 80% since 1992). Refusal of house spraying by householders was documented at 15% in 1993. Chemical and biological larviciding, and source reduction activities were undertaken on a very limited scale in the past, but have been severely hampered over the last 2 years by the economic crisis.

It was observed on 26.10.99 that fogging was being undertaken at night along the Dili foreshore. No house spraying was observed during the assessment.

4.3 Potential breeding sites- limited assessment 26.10.99: There is evidence of the two “Clean-up days” coordinated by INTERFET troops, in that the streets and some buildings/housing have been cleared of debris. Much debris remains in destroyed/gutted housing including many small receptacles and lesser numbers of tyres, all of which will be suitable breeding sites for Aedes aegypti with the coming of the rains in November/December. Dili has an open drainage system. Many were still clogged with debris and others with vegetation, with pooling and stagnation of polluted water. While these themselves are not potential breeding sites for Anopheles mosquitoes, with the coming of the rains clogged drains will mean poorer drainage of surrounding fields/swampy areas, increased Anopheles breeding in these latter sites, and increased malaria potential. The major river through Dili was dry. Some drain outlets into the sea were blocked by sand banks with terminal pooling of polluted water.

Outside of Dili, areas that may have high malaria potential are irrigated wet rice fields around Baucau, Manatuto, Same, Manufahi and in Ocussi. These were not inspected on this visit.

4.4 Bed nets. Although used in the past this does not appear to have been widespread. Compliance/uptake data is not available. International Rescue Commission is planning to distribute 75,000 impregnated bed nets by the end of November (with a policy of two per family), and subject to funding through the UN Appeal, 200,000 by June 2000. UNICEF plans an additional 60,000 nets for returnees from West Timor. IRC informs us that bednets will come with instructions and education in Tetum.

5. Available resources and logistics

5.1 Hospitals: Health facilities, staff and supplies are available at the ICRC Hospital in Dili (formerly Dili General Hospital) for diagnosing and treating severe malaria, as the hospital and laboratory remains intact. ICRC quinine and other antimalarial drug supplies are not listed in the SUMA centralised register of drugs, and quantities of antimalarial drugs stocked by the hospital will need clarification. The hospital currently has sufficient nursing staff, but is operating under its 240-bed capacity (with approximately 60-80 inpatients at the time of the visit). In addition to expatriate ICRC staff, there were 2 Timorese doctors working at the hospital, 4 laboratory technicians (with the expatriate laboratory scientist with predominantly TB expertise having left the day of the visit). Two microscopes and the necessary reagents for malaria and TB microscopy were present in the Hospital laboratory.

Hospital facilities for the diagnosis and treatment of uncomplicated and severe malaria are also available at the French Military Clinic and Hospital and at the Australia-Singapore Military Hospital. At this stage these facilities are considered relatively short-term, with the French Hospital likely to revert to a school within 6 months.

5.2 Primary health care facilities are more limited. It is thought that all existing Government primary health care centres (Puskesmas) have been destroyed. Microscopes and other supplies may have been hidden/protected during this period, but the extent of this is not yet known. NGOs and church-affiliated clinics in regional centres of East Timor are establishing primary health care services.

5.3 Human Resources. The number of and skills of remaining and returning health workers are currently being collated by the East Timor Health Professionals Work Group (see also 4.4). The nursing school and provincial reference laboratory remain intact. 5.4 Microscopes and Microscopists. Microscopes and other supplies from destroyed primary health care centres may have been hidden/protected during this period, but the extent of this is not yet known. The former Provincial Reference Laboratory currently has 12 functional microscopes and 26 trained laboratory technicians including 3 designated as parasitologists. The Reference Laboratory estimated that Dili had approximately 70 laboratory technicians, with perhaps 100 in the whole of East Timor. It is not yet known how many microscopists have returned. Professor Pierre Claude at the French Clinic was supportive of his laboratory being involved in refreshing/retraining of local Timorese microscopists.

5.5 Drugs. Antimalarial drug supplies stocked by NGOs East Timor-wide on 25.10.99 and listed in the SUMA database were as follows: chloroquine tablets (150 mg): 1,180,000 chloroquine syrup: full details not included in printout supplied primaquine (7.5 mg): 25,000 quinine (300 mg/ml) 300 ampoules; (60 mg/ml) 2,000 ampoules quinine tablets (300 mg) sulphadoxine/pyrimethamine (500 mg/25 mg): 28,900 tablets

UNICEF emergency kits do not contain sulphadoxine/pyrimethamine (Sam Hari, personal communication).

Caritas and other NGO essential drug lists are based on WHO lists and do contain sulphadoxine/pyrimethamine

5.6 Funds from UN Appeals are thought by WHO Darwin and Dili staff to be likely available in early December.

III. Site planning There is continuing spontaneous and structured movement of displaced people back to Dili and beyond, but no camps are planned/thought needed at present. IV. Disease management and drug resistance data

1. Diagnosis: As in most of Eastern Indonesia, almost all malaria under Indonesian administration was diagnosed clinically, because of limited access to limited numbers of trained microscopists and microscopes.

2. Treatment: Under Indonesian administration malaria was treated using standard Ministry of Health protocols for eastern Indonesia, as follows:

First line therapy for uncomplicated malaria: Uncomplicated falciparum malaria: 3 days chloroquine plus single dose primaquine Uncomplicated vivax malaria: 3 days chloroquine plus 5 days primaquine Uncomplicated clinical malaria without microscopic confirmation: 3 days chloroquine plus single dose primaquine

Second line therapy for uncomplicated malaria (failing to respond or relapse): Sulphadoxine/pyrimethamine stat dose

Severe malaria: standard WHO protocols using intravenous then oral quinine.

Current Caritas and other printed NGO protocols use chloroquine as first line treatment for uncomplicated malaria.

WHO protocols/publications for severe and uncomplicated malaria are available in the Dili WHO office, but do not appear to be widely available within NGOs clinics and centres outside Dili.

3. Prophylaxis:

Malaria prophylaxis in Timorese during pregnancy not routinely undertaken at present.

Military personnel are taking antimalarial prophylaxis. eg. Australian military are taking doxycycline.

Not all NGO staff are currently taking effective antimalarial prophylaxis, and malaria cases can be expected particularly during the upcoming wet season. Evacuation of expatriate personnel with severe malaria will be expensive, and will use NGO resources that can be better used.

4. Drug resistance data:

To our knowledge, no in vivo drug resistance studies have been carried out in East Timor in recent years. In vitro drug resistance to chloroquine and sulphadoxine/pyrimethamine is reported in WHO data on file from the Indonesian Ministry of Health.

A recent collaborative study between the National Institute of Health Research and Development in Jakarta and Menzies School of Health Research in Darwin (see attached abstract by Tjitra, et al) examined therapeutic efficacy of current first [chloroquine (CQ)] and second-line [sulphadoxine-pyrimethamine (SP)] antimalarials in the island of Sumba which lies to the west of Timor island in Nusa Tenggara Timur Province. Therapeutic efficacy was assessed in patients unwell with uncomplicated falciparum malaria using modified 1996 WHO guidelines in Radamata Primary Health Centre, a hypoendemic area of West Sumba from February-May 1998. Patients were treated with CQ or SP and followed for 28 days. All doses were supervised and microscopy read and cross-checked by experienced parasitologists. 9% of 66 CQ-treated patients had Early Treatment Failure (ETF [5 R3 and 1 R2]), 56% (2 R2, 5 early R1, 30 late R1) Late Treatment Failure (LTF), and 35% (23/66) Adequate Clinical Response (ACR). Of concern only 30.4% ACR (7/23) had hemoglobin (Hb) on D28 > Hb on D0. In summary only 7/66 (11%) of patients treated with chloroquine had an adequate clinical response with any degree of haematological recovery. 36 of the 37 LTF were retreated with SP, and only 32 cases could be followed for another 28 days, with a cure rate of 100%; 81.2% (26/32) had a haematological recovery with HbD28>HbD0.

V. Recommendations

Most parts of East Timor appear to be in the post-emergency phase, however with the upcoming wet season, malaria morbidity and mortality may increase more than in previous years, for reasons outlined in section I 3.4. The following are recommended:

1. Vector control activities/Prevention:

1.1 Vector control interventions in Dili before the onset of the November-December wet season: 1.1.1 Clear urban drains, to improve drainage of surrounding fields/swamps. 1.1.2 Create a landfill site for receptacles found in debris within burnt houses that are suitable for Aedes aegypti breeding. 1.1.3 Create a centralised stockpile of all tyres, which can be sprayed as one if Aedes breeding becomes a problem in the wet season. 1.1.4 Distribution of water containers to Dili residents with an attached lid

These issues were discussed briefly with INTERFET commander Major-General Peter Cosgrove who agreed to explore the possibility of further military assistance with such measures. It would be ideal if these measures could also be undertaken by NGOs involved in environmental health activities, perhaps through mobilising local Dili residents.

1.1.5 Review the need for current outdoor fogging activities. Such fogging usually has little impact on disease-causing and pest mosquito numbers, and unless it can be demonstrated to be effective, the resources are likely to be better utilised elsewhere eg larval surveys and targeted BTI larviciding. If such larval surveys or larviciding are planned by the military or NGOs it would be of great benefit if any Timorese vector control personnel could be identified to assist with these activities as part of capacity building for the future.

1.2 Vector control activities after the start of the wet season will be guided by the results of an entomological assessment to be performed by Peter Whelan of THS in early December and similar ongoing assessments by the Military authorities. This assessment will aim to assess sites in both Dili and Baucau, and ideally wet rice growing areas around Baucau, and will make recommendations based on vector activity identified and in the light of consultations with Military and Timorese vector control personnel. This assessment will also aim to review current Timorese vector control human resources, and identify opportunities for capacity building in the short, medium and long term. Because of the feeding and resting habits of the local Anopheles mosquitoes, it is thought likely that residual house spraying will be of only limited benefit, and that where possible, targeted larviciding guided by larval surveys will be of greater benefit.

1.3 The IRC and UNICEF plans for the early distribution of impregnated bed nets are fully supported. Followup of uptake and usage are recommended as resources allow. Plans for re- impregnation will need to be made.

1.4 In the medium term integrate malaria control activities with dengue and filariasis control activities

2. Malaria Disease Surveillance. This is a high priority. Malaria morbidity and mortality surveillance using RBM Complex Emergency Guidelines should be promoted. Current morbidity data for presumed malaria used by WHO Dili suffer from a lack of standardisation of case definitions for presumed malaria and incomplete reporting. It is recommended that at least initially, the case definition should be fever or history of fever in the preceding 48 hours, in the absence of evidence of an alternative diagnosis, that every effort be made to ensure complete reporting and that in the regional NGO clinics that this is supported by microscopy whenever possible for case management as well as surveillance purposes. When microscopy is not possible in every febrile attendee in a busy clinic, microscopy in all patients meeting the case definition seen in a representative time period (eg 4 hour period) on a given day each week could be used to provide a relatively reliable slide positivity rate to compare longitudinally.

In addition to regional NGO clinic reporting of morbidity and mortality, it is recommended that microscopy be done in all febrile patients admitted to the ICRC Hospital, that malaria morbidity, severe malarial morbidity and malaria mortality data is reported to WHO Dili and followed longitudinally.

3. Diagnosis.

Because of limited access to primary health care facilities and to microscopy services, in the short term diagnosis is likely to continue to be based on clinical grounds followed by empirical therapy. It is recommended that microscopic diagnosis be introduced as soon as feasible in regional city NGO and other clinics as above for the purposes of accurate diagnosis for case management but also accurate morbidity/mortality surveillance (as above). Retraining/refreshing of local Timorese microscopists by currently available expatriate microscopists (eg Military Hospitals, AMI) and Central laboratory microscopists, where possible, in both malaria and TB microscopy will assist in capacity building and could be coordinated by the East Timor Health Professionals Work Group. Refreshing/retraining in both malaria and TB microscopy and re-establishment of a quality assurance system with the Central Laboratory is recommended in association with 2 full time expert malaria and TB microscopists funded by the UN appeal from December (see also Central Laboratory Assessment).

An inventory of functioning microscopes salvaged from destroyed health centres in Dili and regional towns should be made prior to the UN appeal funds being made available, to guide decisions on purchasing microscopes to replace those lost/destroyed.

It is suggested that a stock of rapid antigen tests for both P. falciparum and P. vivax (recognising the limitations of immunochromatographic tests for vivax malaria) should be kept for use if there is a sudden surge in fever cases seen in a given NGO clinic and when microscopy services are overwhelmed or unavailable, to help in rapid and accurate confirmation of a malaria epidemic, and rapid implementation of control/case-management strategies as per WHO RBM guidelines.

4. Treatment.

Although no in vivo data from East Timor are available, available chloroquine efficacy data from surrounding islands suggest that chloroquine is no longer likely to be optimal for the first line monotherapy of uncomplicated falciparum malaria. Moreover, for the reasons outlined in I 3.4 above, potentially impaired immunity and reduced ability to return for second line therapy in the event of treatment failure would make increased risk of morbidity and mortality more likely if chloroquine monotherapy is retained as the first line antimalarial for uncomplicated falciparum malaria.

4.1 Recommendation:

Option 1. Switch to Sulphadoxine/pyrimethamine (SP) single dose on day 1 PLUS chloroquine daily for 3 days for all cases of falciparum malaria or when the species is not known. The addition of chloroquine to SP (as has been done in coastal Kenya and Madang, PNG) is preferred by patients as it results in more rapid resolution of fever than with SP alone, and may also delay the development of resistance to SP over time (pending adoption of relatively cheap artesunate- based combination therapies once the current WHO/TDR multicentre combination artesunate drug trials are finished and new WHO combination drug recommendations are announced in 1-3 years ). Undertake chloroquine and SP efficacy studies to determine which drug will be suitable to combine with artesunate in 1-3 years’ time.

Option 2. Retain chloroquine as first line therapy (3 day regimen using standard WHO dosing), with SP for treatment failure, but combine CQ with a single dose of SP on day of presentation if the patient will not be able to return in the event of treatment failure. Undertake a chloroquine efficacy study as a matter of urgency (eg starting early December 1999) making a decision to change to SP + CQ as soon as possible if treatment failure is confirmed at >25%.

Option 1 is preferred, but option 2 acceptable if the chloroquine efficacy study is done as a matter of urgency. With either option, more supplies of SP are likely to be required than are currently stocked (10,000 treatment courses).

If resources allow, patients treated with either regimen for uncomplicated malaria at sentinel sites (eg regional NGO clinics) could be followed up on days 3 and/or 7 to assess treatment failure rates.

Other treatment recommendations:

4.2. Chloroquine monotherapy be retained for management of confirmed vivax malaria.

4.3 Once finalised, translate the treatment algorithms into Tetum (and the official language once chosen) and disseminate widely.

4.4 Retain and disseminate widely the existing WHO parenteral quinine protocol and guidelines for management of severe malaria (used previously by the Indonesian Ministry of Health) and the list of danger signs (in Tetum) warranting parenteral quinine.

NB. Two different concentrations of quinine are being stocked by NGOs. It is essential that concentrations and dosages are checked carefully at the time of administration, to avoid inadvertent under/overdosing.

4.5 Avoid 5 or 14 day radical treatment with primaquine. Although documentation of effectiveness is not ideal, single dose primaquine, as recommended routinely throughout eastern Indonesia, may be useful in reducing transmission of falciparum malaria in this transitional situation

5. Prophylaxis.

5.1 NGOs promote prophylaxis and confirm that all their staff are on doxycycline or mefloquine prophylaxis.

5.2 In pregnant women emphasize the importance of early diagnosis and treatment. As antenatal services are re-established, introduce weekly chloroquine prophylaxis when possible and ideally prior to the start of the wet season, for primigravidae and secundi-gravidae. Chloroquine will protect against the recently-identified deleterious effects of vivax malaria in pregnancy. Whilst unlikely to be fully effective against falciparum malaria, it may attenuate the deleterious effects on mother and fetus. If the chloroquine efficacy study shows major chloroquine resistance, a switch to single dose SP given three times in total in the second and third trimesters should be considered in areas found to have high endemicity. Areas where such intermittent therapy may be useful can be identified by documenting the ratio of low birth weight (LBW) in primigravidae vs multigravidae. NGO and other clinics offering antenatal care should prospectively gather this data.

6. Other standard treatment protocols.

In the medium term, standard treatment protocols for all common Timorese illnesses should be developed in Tetum/official language, perhaps modified from similar protocols used in neighbouring countries (eg Indonesia, PNG) and made suitable for use in primary health care clinics by nurses and other health workers.

7. Operational research.

7.1 Resources be made available for a chloroquine efficacy study. This is an urgent priority, as above, for falciparum malaria, and should start no later than December1999/January 2000. Funding should include expert microscopist(s) (who can undertake refreshing/retraining with Timorese Reference Laboratory staff as part of the study), local support/study staff wages, supplies, drugs, transport, accommodation, genotyping of recrudescent isolates, chloroquine levels etc... This in vivo study would be usefully complemented by parallel in vitro resistance studies, genotyping for chloroquine resistance. Efficacy studies of SP for falciparum malaria and chloroquine for vivax malaria are also required but with lesser urgency.

7.2 Bed net, case management and service delivery operational research as outlined in RBM Guidelines.

7.3 Surveillance for other diseases that may cause morbidity in Timor, eg Japanese Encephalitis (many pigs observed in Dili), dengue, other arboviruses, melioidosis and rickettsiae. Pending ethics approval, seroepidemiology of dengue/JE/melioidosis in deidentified sera in evacuees to Darwin would be useful. Use of Ashdown’s selective media in Military hospitals for skin/soft tissue infections and pneumonia in the wet season would also be useful. See TB report for TB operational research priorities.