A description of malaria sentinel surveillance: a case study in Oromia Regional State, Ethiopia

What incentives encourage local communities to collect and upload mosquito sound data by using smartphones? A mixed methods study in Tanzania

BACKGROUND

To detect and identify mosquitoes using their characteristic high-pitched sound, we have developed a smartphone application, known as the 'HumBug sensor', that records the acoustic signature of this sound, along with the time and location. This data is then sent remotely to a server where algorithms identify the species according to their distinctive acoustic signature. Whilst this system works well, a key question that remains is what mechanisms will lead to effective uptake and use of this mosquito survey tool? We addressed this question by working with local communities in rural Tanzania and providing three alternative incentives: money only, short message service (SMS) reminders and money, and SMS reminders only. We also had a control group with no incentive.

METHODS

A multi-site, quantitative empirical study was conducted in four villages in Tanzania from April to August 2021. Consenting participants (n = 148) were recruited and placed into one of the three intervention arms: monetary incentives only; SMS reminders with monetary incentives; and SMS reminders only. There was also a control group (no intervention). To test effectiveness of the mechanisms, the number of audio uploads to the server of the four trial groups on their specific dates were compared. Qualitative focus group discussions and feedback surveys were also conducted to explore participants' perspectives on their participation in the study and to capture their experiences of using the HumBug sensor.

RESULTS

Qualitative data analysis revealed that for many participants (37 out of 81), the main motivation expressed was to learn more about the types of mosquitoes present in their houses. Results from the quantitative empirical study indicate that the participants in the 'control' group switched on their HumBug sensors more over the 14-week period (8 out of 14 weeks) when compared to those belonging to the 'SMS reminders and monetary incentives' trial group. These findings are statistically significant (p < 0.05 or p > 0.95 under a two-sided z-test), revealing that the provision of monetary incentives and sending SMS reminders did not appear to encourage greater number of audio uploads when compared to the control.

CONCLUSIONS

Knowledge on the presence of harmful mosquitoes was the strongest motive for local communities to collect and upload mosquito sound data via the HumBug sensor in rural Tanzania. This finding suggests that most efforts should be made to improve flow of real-time information back to the communities on types and risks associated with mosquitoes present in their houses.

Criteria for selecting sentinel unit locations in a surveillance system for vector-borne disease: A decision tool

Objectives

With vector-borne diseases emerging across the globe, precipitated by climate change and other anthropogenic changes, it is critical for public health authorities to have well-designed surveillance strategies in place. Sentinel surveillance has been proposed as a cost-effective approach to surveillance in this context. However, spatial design of sentinel surveillance system has important impacts on surveillance outcomes, and careful selection of sentinel unit locations is therefore an essential component of planning.

Methods

A review of the available literature, based on the realist approach, was used to identify key decision issues for sentinel surveillance planning. Outcomes of the review were used to develop a decision tool, which was subsequently validated by experts in the field.

Results

The resulting decision tool provides a list of criteria which can be used to select sentinel unit locations. We illustrate its application using the case example of designing a national sentinel surveillance system for Lyme disease in Canada.

Conclusions

The decision tool provides researchers and public health authorities with a systematic, evidence-based approach for planning the spatial design of sentinel surveillance systems, taking into account the aims of the surveillance system and disease and/or context-specific considerations.

Assessment of health staff's proficiency and quality of key malaria indicators in rural district of Ghana

BACKGROUND

Routine Health Information Systems (RHIS) are important for not just sure enough control of malaria, but its elimination as well. If these systems are working, they can extensively provide accurate data on reported malaria cases instead of presenting modelled approximations of malaria burden. Queries are raised on both the quality and use of generated malaria data. Some issues of concern include inaccurate reporting of malaria cases as well as treatment plans, wrongly categorizing malaria cases in registers used to collate data and misplacing data or registers for reporting. This study analyses data quality concerning health staff's proficiency, timeliness, availability and data accuracy in the Sissala East Municipal Health Directorate (MHD).

METHODS

A cross-sectional design was used to collect data from 15 facilities and 50 health staff members who offered clinical related care for malaria cases in the Sissala East MHD from 24th August 2020 to 17th September 2020. Fifteen health facilities were randomly selected from the 56 health facilities in the municipality that were implementing the malarial control programme, and they were included in the study.

RESULTS

On the question of when did staff receive any training on malaria-related health information management in the past six months prior to the survey, as minimal as 13 out of 50(26%) claimed to have been trained, whereas the majority 37 out of 50 (74%) had no training. In terms of proficiency in malaria indicators (MI), the majority (68% - 82%) of the respondents could not demonstrate the correct calculations of the indicators. Nevertheless, the MHD recorded monthly average timeliness of the 5th day [range: 4.7-5.7] within the reporting year. However, the MHD had a worse average performance of 5.4th and 5.7th days in July and September respectively. Furthermore, results indicated that 14 out of 15(93.3%) facilities exceeded the target to accomplish report availability (> = 90%) and data completeness (> = 90%). However, the verification factor (VF) of the overall malaria indicator showed that the MHD neither over-reported nor under-reported actual cases, with the corresponding level of data quality as Good (+/-5%).

CONCLUSIONS

The Majority of staff had not received any training on malaria-related RHIS. Some staff members did not know the correct definitions of some of MI used in the malaria programme, while the majority of them could not demonstrate the correct calculations of MI. Timeliness of reporting was below the target, nevertheless, copies of data that were submitted were available and completed. There should be training, supervision and monitoring to enhance staff proficiency and improve the quality of MI.

Malaria diagnostic methods with the elimination goal in view

Malaria control measures have been in use for years but have not completely curbed the spread of infection. Ultimately, global elimination is the goal. A major playmaker in the various approaches to reaching the goal is the issue of proper diagnosis. Various diagnostic techniques were adopted in different regions and geographical locations over the decades, and these have invariably produced diverse outcomes. In this review, we looked at the various approaches used in malaria diagnostics with a focus on methods favorably used during pre-elimination and elimination phases as well as in endemic regions. Microscopy, rapid diagnostic testing (RDT), loop-mediated isothermal amplification (LAMP), and polymerase chain reaction (PCR) are common methods applied depending on prevailing factors, each with its strengths and limitations. As the drive toward the elimination goal intensifies, the search for ideal, simple, fast, and reliable point-of-care diagnostic tools is needed more than ever before to be used in conjunction with a functional surveillance system supported by the ideal vaccine.

Improved kala-azar case management through implementation of health facility-based sentinel sites surveillance system in Bihar, India

Background

Visceral leishmaniasis (VL), also known as kala-azar (KA), is a neglected vector-borne disease, targeted for elimination, but several affected blocks of Bihar are posing challenges with the high incidence of cases, and moreover, the disease is spreading in newer areas. High-quality kala-azar surveillance in India, always pose great concern. The complete and accurate patient level data is critical for the current kala-azar management information system (KMIS). On the other side, no accurate data on the burden of post kala-azar dermal leishmaniasis (PKDL) and co-infections are available under the current surveillance system, which might emerge as a serious concern. Additionally, in low case scenario, sentinel surveillance may be useful in addressing post-elimination activities and sustaining kala-azar (KA) elimination. Health facility-based sentinel site surveillance system has been proposed, first time to do a proper accounting of KA, PKDL and co-infection morbidity, mortality, diagnosis, case management, hotspot identification and monitoring the impact of elimination interventions.

Methodology/principal findings

Kala-azar sentinel site surveillance was established and activated in thirteen health facilities of Bihar, India, using stratified sampling technique during 2011 to 2014. Data were collected through specially designed performa from all patients attending the outpatient departments of sentinel sites. Among 20968 symptomatic cases attended sentinel sites, 2996 cases of KA and 53 cases of PKDL were registered from 889 endemic villages. Symptomatic cases meant a person with fever of more than 15 days, weight loss, fatigue, anemia, and substantial swelling of the liver and spleen (enlargement of spleen and liver).The proportion of new and old cases was 86.1% and 13.9% respectively. A statistically significant difference was observed for reduction in KA incidence from 4.13/10000 in 2011 to 1.75/10000 in 2014 (p<0.001). There were significant increase (0.08, 0.10 per 10 000 population) in the incidences of PKDL and co-infection respectively in the year 2014 as compared to that of 2011 (0.03, 0.06 per 10 000 population). The proportion of HIV-VL co-infection was significantly higher (1.6%; p<0.05) as compared to other co-infections. Proportions of male in all age groups were higher and found statistically significant (Chi-square test = 7.6; P = 0.026). Utilization of laboratory services was greatly improved. Friedman test showed statistically significant difference between response of different anti kala-azar drugs (F = 25.0, P = 0.004).The initial and final cure rate of AmBisome was found excellent (100%). The results of the signed rank sum test showed significant symmetry of unresponsiveness rate (P = 0.03). Similarly, relapse rate of sodium antimony gluconate (SAG) was also found significantly higher as compared to other drugs (95%CI 0.2165 to 19.7035; P = 0.03). A statistically significant difference was found (p<0.001) between villages having 1–2 cases (74%) and villages with 3–5 cases (15%). Significantly higher proportion (95%) of cases were captured by existing Govt. surveillance system (KMIS) (p<0.001), as compared to private providers (5%).

Conclusions/significance

Establishment of a sentinel site based kala-azar surveillance system in Bihar, India effectively detected the rising trend of PKDL and co-infections and captured complete and accurate patient level data. Further, this system may provide a model for improving laboratory services, KA, PKDL and co-infection case management in other health facilities of Bihar without further referral. Program managers may use these results for evaluating program’s effectiveness. It may provide an example for changing the practices of health care workers in Bihar and set a benchmark of high quality surveillance data in a resource limited setting. However, the generalizability of this sentinel surveillance finding to other context remains a major limitation of this study. The justifications for this; the sentinel sites were made in the traditionally high endemic PHC’s. The other conditions were Program commitment for diagnostic (rk-39) and the first line anti kala-azar drug i.e. miltefosine throughout the study period in the sentinel sites. In addition, there were clause of fulfillment of readiness criteria at each sentinel site (already described in the line no 171 to 180 at page no-8, 181–189 at page no-9 and 192–212 at page no-10). Rigorous efforts were taken to improve all the sentinel sites to meet the readiness criteria and research activities started only after meeting readiness criteria at the site. Therefore sentinel site surveillance described under the present study cannot be integrated into other set up (medium and low endemic areas). However, it can be integrated into highly endemic areas with program commitment and fulfillment of readiness criteria.

Visceral leishmaniasis is a neglected vector-borne disease, and one of the major public health problems of Bihar. The disease has been targeted for elimination by 2020. Bihar still posing challenge i.e. incidence is much high in a number of affected blocks, and even the disease is spreading in newer areas. None availability of an accurate data on the burden of post kala-azar dermal leishmaniasis (PKDL) and co-infections under the current surveillance system may emerge as a serious concern. Therefore, health facility-based sentinel site surveillance system has been attempted for the first time in Bihar for proper accounting of KA, PKDL and co-infection morbidity, mortality, diagnosis, case management, hotspot identification and monitoring the impact of elimination interventions. A system for capturing regional transmission is essential that can target focal areas of infection to monitor progress towards kala-azar elimination. Kala-azar sentinel site surveillance was established and activated in thirteen health facilities of Bihar during 2011 to 2014. The results showed a significant increase in PKDL and co-infection in 2014 when compared to 2011. Findings further revealed that utilization of laboratory services and case management were greatly improved, as majority of patients with KA, PKDL & co-infections were managed by the sentinel sites itself. The final cure rate of AmBisome was found excellent (100%). These observations may be useful to provide the basis for the design, refinement and resource allocation of the kala-azar control program. This system may also be useful in measuring impact of elimination interventions, their effectiveness and finally help in improving program management. It may further be used as an example for changing the practices of health care workers in Bihar and a lesson how to achieve high quality surveillance data in a resource limited setting. Standardization of sentinel site surveillance in terms of improved procedure, training, logistics, etc may further increase the effectiveness of this system. It may possibly be used as a cost-effective approach for capturing real-time kala-azar data under national kala-azar elimination programme.

A Portrait of Sentinel Surveillance Networks for Vector-Borne Diseases: A Scoping Review Supporting Sentinel Network Design

Vector-borne diseases (VBDs) are continuing to emerge globally, requiring new surveillance systems to follow increasing VBD risk for human populations. Sentinel surveillance is an approach that allows tracking of disease risk through time using limited resources. However, there is no consensus on how best to design a sentinel surveillance network in the context of VBDs. We conducted a scoping review to compare VBD sentinel surveillance systems worldwide with the aim of identifying key design features associated with effective networks. Overall, VBD surveillance networks were used most commonly for malaria, West Nile virus, and lymphatic filariasis. A total of 45 criteria for the selection of sentinel unit location were identified. Risk-based criteria were the most often used, and logistic regression showed that using risk-based criteria dependent on host animals is particularly correlated with surveillance system sensitivity (p < 0.018). We identify tools that could prove valuable for sentinel surveillance network design, including a standardized approach for evaluating surveillance systems and a tool to prioritize criteria for selecting optimal geographic locations for spatial sentinel units.

Feasibility of Malaria Elimination in Ethiopia

Background

The problem of malaria is very severe in Ethiopia where it has been the major cause of illness and death for many years. The purpose of this review article is to assess the feasibility of malaria elimination in Ethiopia

Method

To compile this review article, different relevant research articles related to the topic from open access journals were searched using different searching engines such as Google scholar, Science direct, and Pub Med using different key words and phrases

Result

Based on review of the literature, Ethiopia has been trying to control and eliminate malaria for more than 60 years. To assess feasibility of malaria elimination, the WHO assessment tools/recommendations for elimination of malaria were used. Based on WHO parameters, the country has achieved remarkable progress on the fight against malaria during the most recent decades. Malaria morbidity and mortality have been reduced dramatically with intensive use of insecticide residual spray, long lasting insecticide treated nets, chemotherapies, improved diagnosis and case management, improved quality of laboratories, continued support from malaria partners, and political commitment of the Ethiopian government towards malaria prevention and control. Hence, the past achievements and current activities, have led to consider the possibility of malaria elimination in Ethiopia at least by 2030 or beyond

Conclusion

Considering the triumphs achieved so far and the current undertaking efforts, malaria could possibly be eliminated from Ethiopia once and for all

Leveraging phone-based mobile technology to improve data quality at health facilities in rural Malawi: a best practice project

BACKGROUND

To further reduce malaria burden, identification of areas with highest burden for targeted interventions needs to occur. Routine health information has the potential to indicate where and when clinical malaria occurs the most. Developing countries mostly use paper-based data systems however they are error-prone as they require manual aggregation, tallying and transferring of data. Piloting was done using electronic data capture (EDC) with a cheap and user friendly software in rural Malawian primary healthcare setting to improve the quality of health records.

METHODS

Audit and feedback tools from the Joanna Briggs Institute (Practical Application of Clinical Evidence System and Getting Research into Practice) were used in four primary healthcare facilities. Using this approach, the best available evidence for a malaria information system (MIS) was identified. Baseline audit of the existing MIS was conducted in the facilities based on available best practice for MIS; this included ensuring data consistency and completeness in MIS by sampling 25 random records of malaria positive cases. Implementation of an adapted evidence-based EDC system using tablets on an OpenDataKit platform was done. An end line audit following implementation was then conducted. Users had interviews on experiences and challenges concerning EDC at the beginning and end of the survey.

RESULTS

The existing MIS was paper-based, occupied huge storage space, had some data losses due to torn out papers and were illegible in some facilities. The existing MIS did not have documentation of necessary parameters, such as malaria deaths and treatment within 14 days. Training manuals and modules were absent. One health centre solely had data completeness and consistency at 100% of the malaria-positive sampled records. Data completeness and consistency rose to 100% with readily available records containing information on recent malaria treatment. Interview findings at the end of the survey showed that EDC was acceptable among users and they agreed that the tablets and the OpenDataKit were easy to use, improved productivity and quality of care.

CONCLUSIONS

Improvement of data quality and use in the Malawian rural facilities was achieved through the introduction of EDC using OpenDataKit. Health workers in the facilities showed satisfaction with the use of EDC.

The DIOS framework for optimizing infectious disease surveillance: Numerical methods for simulation and multi-objective optimization of surveillance network architectures

Infectious disease surveillance systems provide vital data for guiding disease prevention and control policies, yet the formalization of methods to optimize surveillance networks has largely been overlooked. Decisions surrounding surveillance design parameters-such as the number and placement of surveillance sites, target populations, and case definitions-are often determined by expert opinion or deference to operational considerations, without formal analysis of the influence of design parameters on surveillance objectives. Here we propose a simulation framework to guide evidence-based surveillance network design to better achieve specific surveillance goals with limited resources. We define evidence-based surveillance design as an optimization problem, acknowledging the many operational constraints under which surveillance systems operate, the many dimensions of surveillance system design, the multiple and competing goals of surveillance, and the complex and dynamic nature of disease systems. We describe an analytical framework-the Disease Surveillance Informatics Optimization and Simulation (DIOS) framework-for the identification of optimal surveillance designs through mathematical representations of disease and surveillance processes, definition of objective functions, and numerical optimization. We then apply the framework to the problem of selecting candidate sites to expand an existing surveillance network under alternative objectives of: (1) improving spatial prediction of disease prevalence at unmonitored sites; or (2) estimating the observed effect of a risk factor on disease. Results of this demonstration illustrate how optimal designs are sensitive to both surveillance goals and the underlying spatial pattern of the target disease. The findings affirm the value of designing surveillance systems through quantitative and adaptive analysis of network characteristics and performance. The framework can be applied to the design of surveillance systems tailored to setting-specific disease transmission dynamics and surveillance needs, and can yield improved understanding of tradeoffs between network architectures.

Implementation of a malaria sentinel surveillance system in Togo: a pilot study

Background

In Togo, the National Malaria Control Programme, in collaboration with the Global Fund to Fight AIDS, Tuberculosis and Malaria, has implemented a pilot study for malaria sentinel surveillance since 2017, which consists of collecting information in real time and analysing this information for decision-making. The first 20 months of malaria morbidity and mortality trends, and malaria case management in health facilities included in the surveillance were assessed.

Methods

Since July 2017, 16 health facilities called sentinel sites, 4 hospitals and 12 peripheral care units located in 2 epidemiologically different health regions, have provided weekly data on malaria morbidity and mortality for the following 3 target groups: < 5-years-old children, ≥ 5-years-old children and adults, and pregnant women. Data from week 29 in 2017 to week 13 in 2019 were analysed.

Results

Each sentinel site provided complete data and the median time to data entry was 4 days. The number of confirmed malaria cases increased during the rainy seasons both in children under 5 years old and in children over 5 years old and adults. Malaria-related deaths occurred mainly in children under 5 years old and increased during the rainy seasons. The mean percentage of tested cases for malaria among suspected malaria cases was 99.0%. The mean percentage of uncomplicated malaria cases handled in accordance with national guidelines was 99.4%. The mean percentage of severe malaria cases detected in peripheral care units that were referred to a hospital was 100.0%. Rapid diagnostic tests and artemisinin-based combination therapies were out of stock several times, mainly at the beginning and end of the year. No hospital was out of stock of injectable artesunate or injectable artemether.

Conclusions

These indicators showed good management of malaria cases in the sentinel sites. Real-time availability of data requires a good follow-up of data entry on the online platform. The management of input stocks and the promptness of data need to be improved to meet the objectives of this malaria sentinel surveillance system.

Operational Coverage and Timeliness of Reactive Case Detection for Malaria Elimination in Zanzibar, Tanzania

Since 2012, the Zanzibar Malaria Elimination Program has been implementing reactive case detection (RACD). Health facility (HF) staff send individual malaria case notifications by using mobile phones, triggering a review of HF records and malaria testing and treatment at the household level by a district malaria surveillance officer. We assessed the completeness and timeliness of this system, from case notification to household-level response. We reviewed two years (2015-2016) of primary register information in 40 randomly selected HFs on Zanzibar's two islands Unguja and Pemba and database records of case notifications from all registered HFs for the period 2013-16. The operational coverage of the system was calculated as proportion of HF-registered cases that were successfully reviewed and followed up at their household. Timeliness was defined as completion of each step within 1 day. Public HFs notified almost all registered cases (91% in Unguja and 87% in Pemba), and 74% of cases registered at public HFs were successfully followed up at their household in Unguja and 79% in Pemba. Timely operational coverage (defined as each step, diagnosis to notification, notification to review, and review to household-level response, completed within 1 day) was achieved for only 25% of registered cases in Unguja and 30% in Pemba. Records and data from private HFs on Unguja indicated poor notification performance in the private sector. Although the RACD system in Zanzibar achieved high operational coverage, timeliness was suboptimal. Patients diagnosed with malaria at private HFs and hospitals appeared to be largely missed by the RACD system.

The potential of pregnant women as a sentinel population for malaria surveillance

Background

With increasing spatial heterogeneity of malaria transmission and a shift of the disease burden towards older children and adults, pregnant women attending antenatal care (ANC) have been proposed as a pragmatic sentinel population for malaria surveillance. However, the representativeness of routine ANC malaria test-positivity and its relationship with prevalence in other population subgroups are yet to be investigated.

Methods

Monthly ANC malaria test-positivity data from all Tanzanian health facilities for January 2014 to May 2016 was compared to prevalence data from the School Malaria Parasitaemia Survey 2015, the Malaria Indicator Survey (MIS) 2015/16, the Malaria Atlas Project 2015, and a Bayesian model fitted to MIS data. Linear regression was used to describe the difference between malaria test-positivity in pregnant women and respective comparison groups as a function of ANC test-positivity and potential covariates.

Results

The relationship between ANC test-positivity and survey prevalence in children follows spatially and biologically meaningful patterns. However, the uncertainty of the relationship was substantial, particularly in areas with high or perennial transmission. In comparison, modelled data estimated higher prevalence in children at low transmission intensities and lower prevalence at higher transmission intensities.

Conclusions

Pregnant women attending ANC are a pragmatic sentinel population to assess heterogeneity and trends in malaria prevalence in Tanzania. Yet, since ANC malaria test-positivity cannot be used to directly predict the prevalence in other population subgroups, complementary community-level measurements remain highly relevant.

Quantifying malaria endemicity in Ethiopia through combined application of classical methods and enzyme-linked immunosorbent assay: an initial step for countries with low transmission initiating elimination programme

Background

In the context of reduced transmission of malaria, it is essential to re-evaluate and determine the level of transmission as it guides re-orientation of control measures which is appropriate to local disease epidemiology. However, little is known about level of malaria transmission in Ethiopia. The present study aimed to investigate the level of malaria transmission through combined application of classical methods and enzyme-linked immunosorbent assay (EIA) in low transmission settings of Ethiopia.

Methods

This study was conducted in June 2016 on 763 apparently healthy children 2–9 years of age. Children were recruited from ten sites representing different malaria transmission settings in Ethiopia. Splenomegaly rate, infection rate and EIA antibody test were used to determine endemicity. The data were analysed using SPSS 21.0 and Stata 12.0.

Results

The overall prevalence of malaria parasitaemia was 2.49% (95% CI 1.38–3.59) and 2.36% (95% CI 1.28–3.44) as detected using rapid diagnostic test and microscopy, respectively. Plasmodium falciparum accounted for 62.63% of the infections. The prevalence of parasitaemia significantly varied by altitude and localities; the highest (5.8%) in areas below 1500 m above sea level. Overall, splenomegaly rate was 1.70% (95% CI 0.78–0.2.66%), making the overall malaria transmission hypoendemic. Infection rate was higher among males (2.7%), but rate of splenomegaly was higher in females. Incongruent with spleen rate and parasitaemia, EIA showed a higher level of cumulative exposure to malaria with spatially localized and highly heterogeneous transmission. Overall, 126 (18.75%, 95% CI 15.79–21.71) of the children were positive for total malaria antibodies with significant variations with altitude, age and sex; the higher in areas of < 1500 m asl (25.8%), children ≥ 5 years (22.1%) and among males (20.9%).

Conclusions

Splenomegaly and parasitaemia are not good measures to show variations in the levels of malaria transmission in reduced and/or low endemic settings. The malaria antibody (i.e. serological) test seems to be a good measure of malaria endemicity showing greater degree of heterogeneity and localized risk of transmission. Thus, malaria elimination efforts need to be supported with serological indicators to identify patterns of foci of transmission to set priorities for interventions.

Use of epidemiological and entomological tools in the control and elimination of malaria in Ethiopia

Malaria is the leading public health problem in Ethiopia where over 75% of the land surface is at risk with varying intensities depending on altitude and season. Although the mortality because of malaria infection has declined much during the last 15–20 years, some researchers worry that this success story may not be sustainable. Past notable achievements in the reduction of malaria disease burden could be reversed in the future. To interrupt, or even to eliminate malaria transmission in Ethiopia, there is a need to implement a wide range of interventions that include insecticide-treated bed nets, indoor residual spraying, improved control of residual malaria transmission, and improved diagnostics, enhanced surveillance, and methods to deal with the emergence of resistance both to drugs and to insecticides. Developments during the past years with increasing awareness about the role of very low levels of malaria prevalence can sustain infections, may also demand that tools not used in the routine control efforts to reduce or eliminate malaria, should now be made available in places where malaria transmission occurs.

Caretakers' understanding of malaria, use of insecticide treated net and care seeking-behavior for febrile illness of their children in Ethiopia

Background

Local understandings of malaria and use of preventive measures-are critical factors in sustained control of malaria. This study assessed caretakers’ knowledge on malaria, use of Long Lasting Insecticide Treated Nets (LLINs) and care-seeking behavior for their children’s illness in different malaria transmission settings of Ethiopia.

Methods

Data were collected from 709 caretakers of children of 2–9 years of age during in 2016. A standard questionnaire was used to assess caretakers’ perceptions of malaria, use of LLIN and care seeking behavior for febrile illness of children aged 2–9 years.

Results

The caretakers recognized malaria mostly by chills (70.4%, 499/709), fever (45.7%, 324/709) and headache (39.8%, 282/709). Overall, only 66.4% (471) of the caretakers knew that mosquito bite caused malaria and that it was quite heterogeneous by localities (ranging from 26.1% to 89.4%) and altitude (p < 0.05). Majority, 72.2% (512), of the caretakers knew that sleeping under LLIN could prevent malaria. Overall knowledge on malaria (mean = 51.2%) was very low with significant variations by localities, altitude and levels of malaria transmission, being low in high altitude and low in transmission areas (p < 0.05). Four hundred ninety-one (69.3%, 491/709) of the children slept under LLIN in the previous night. Of malaria related knowledge items, only knowledge of LLIN was associated with net use; non-use of LLN was higher among caretakers who did not know the role of LLIN (AOR = 0.47, 95%CI: 0.28–0.77, p = 0.003). Of course, attributing causation of malaria to stagnant water discouraged use of net (p = 0.021). Of febrile children (n = 122), only 50 (41.0%) sought care with only 17 (34.0%) seeking the care promptly. There was no significant link between knowledge of malaria and care seeking behavior (p > 0.05). However, knowledge of malaria had some level of influence on treatment source preference where caretakers with greater knowledge preferred pharmacy as source of care.

Conclusions

The findings demonstrated that caretakers’ understanding of malaria was unsatisfactory with marked heterogeneity by localities. The present evidence suggests that knowledge is not sufficient enough to drive LLIN use and care seeking. Yet, context-specific health education interventions are important besides ensuring access to necessary preventive tools.

Relationship between exposure to malaria and haemoglobin level of children 2-9 years old in low malaria transmission settings

In the context of reduced transmission of malaria, it is essential to examine the association between exposure to malaria and haemoglobin level. This study measured the Haemoglobin level of children 2-9 years of age and examined its association with malariometric indices. A cross sectional study was conducted, during June 2016, on 763 children 2-9 years old, recruited from ten sites representing different malaria transmission settings in Ethiopia. Haemoglobin concentration was determined using HemoCue analyzer. Malariometric indices (splenomegaly rate, parasite rate and serological marker) were measured. The overall prevalence of anaemia was 17.3% (95% CI: 14.6-19.9) in the study population. Mild, moderate and severe anaemia accounted for 7.3%, 7.2% and 2.8% respectively. Of the children with anaemia (132), only 7 (5.3%) had malaria parasitaemia. The prevalence of malaria parasitaemia was 3.6% (2/56), 9.1% (5/55) and 0.0% (0/21) among children with mild, moderate and severe anaemia, respectively. Malaria reactive antibody and anaemia co-occurred in 3.13% (21/672) of the samples. Seroprevalence and parasitaemia did not have significant association with anaemia (p>0.05). However, splenomegaly was significantly associated with increased risk of anaemia (AOR=14.93; p=0.001). Anaemia was significantly higher among children 2-4 years old (22.2%), and children living in households without any insecticide treated bed net (34.0%). The prevalence of anaemia was lower by 55.0% among children living in households with at least one net (AOR=0.45, 95% CI: 0.21-0.96). Repeated exposure to malaria infections (seropositive) and parasitaemia was less likely to contribute to development of anaemia among children 2-9 years in this study setting. Thus, in low malaria endemic settings, anaemia prevention and control program required to reconsider the historical evidence that suggests malaria is one of the major risk factor for anaemia.

Methodological Considerations for Use of Routine Health Information System Data to Evaluate Malaria Program Impact in an Era of Declining Malaria Transmission

Coverage of malaria control interventions is increasing dramatically across endemic countries. Evaluating the impact of malaria control programs and specific interventions on health indicators is essential to enable countries to select the most effective and appropriate combination of tools to accelerate progress or proceed toward malaria elimination. When key malaria interventions have been proven effective under controlled settings, further evaluations of the impact of the intervention using randomized approaches may not be appropriate or ethical. Alternatives to randomized controlled trials are therefore required for rigorous evaluation under conditions of routine program delivery. Routine health management information system (HMIS) data are a potentially rich source of data for impact evaluation, but have been underused in impact evaluation due to concerns over internal validity, completeness, and potential bias in estimates of program or intervention impact. A range of methodologies were identified that have been used for impact evaluations with malaria outcome indicators generated from HMIS data. Methods used to maximize internal validity of HMIS data are presented, together with recommendations on reducing bias in impact estimates. Interrupted time series and dose-response analyses are proposed as the strongest quasi-experimental impact evaluation designs for analysis of malaria outcome indicators from routine HMIS data. Interrupted time series analysis compares the outcome trend and level before and after the introduction of an intervention, set of interventions or program. The dose-response national platform approach explores associations between intervention coverage or program intensity and the outcome at a subnational (district or health facility catchment) level.

How does the cellular phone help in epidemiological surveillance? A review of the scientific literature

BACKGROUND

In the field of epidemiological surveillance, no systematic literature review appears to exist of implemented projects using cellular phone technology.

METHOD

We performed a systematic literature review using the Pubmed and Scopus databases to retrieve articles published up to December 2015. We analyzed information reported in these publications according to the mobile health (mHealth) evidence reporting and assessment (mERA) checklist, and complemented this work with specific items related to epidemiology, in order to clarify the types of results reported and summarized in this context.

RESULTS

Thirty-three articles were selected and reviewed. Each article was related to a different project. Two mERA items were systematically and fully reported, while two others were never reported. Three projects were deployed in very specific zones. Most of the projects were implemented in Africa. Infectious diseases were the elements most monitored. Most projects were based on daily data collection and SMS transmission. Economic assessment was limited to SMS, mobile phone, and implementation costs.

DISCUSSION-CONCLUSION

Although suitable for epidemiologic surveillance, the mERA checklist needs further interpretation. The technical and transmission modes of cellular phone use varied greatly from one study to another. No evaluation of the interoperability capabilities of cellular phones with other applications or sub-systems was possible.

An embedded barcode for "connected" malaria rapid diagnostic tests

Many countries are shifting their efforts from malaria control to disease elimination. New technologies will be necessary to meet the more stringent demands of elimination campaigns, including improved quality control of malaria diagnostic tests, as well as an improved means for communicating test results among field healthcare workers, test manufacturers, and national ministries of health. In this report, we describe and evaluate an embedded barcode within standard rapid diagnostic tests as one potential solution. This information-augmented diagnostic test operates on the familiar principles of traditional lateral flow assays and simply replaces the control line with a control grid patterned in the shape of a QR (quick response) code. After the test is processed, the QR code appears on both positive or negative tests. In this report we demonstrate how this multipurpose code can be used not only to fulfill the control line role of test validation, but also to embed test manufacturing details, serve as a trigger for image capture, enable registration for image analysis, and correct for lighting effects. An accompanying mobile phone application automatically captures an image of the test when the QR code is recognized, decodes the QR code, performs image processing to determine the concentration of the malarial biomarker histidine-rich protein 2 at the test line, and transmits the test results and QR code payload to a secure web portal. This approach blends automated, sub-nanomolar biomarker detection, with near real-time reporting to provide quality assurance data that will help to achieve malaria elimination.

Integrating malaria surveillance with climate data for outbreak detection and forecasting: the EPIDEMIA system

Background

Early indication of an emerging malaria epidemic can provide an opportunity for proactive interventions. Challenges to the identification of nascent malaria epidemics include obtaining recent epidemiological surveillance data, spatially and temporally harmonizing this information with timely data on environmental precursors, applying models for early detection and early warning, and communicating results to public health officials. Automated web-based informatics systems can provide a solution to these problems, but their implementation in real-world settings has been limited.

Methods

The Epidemic Prognosis Incorporating Disease and Environmental Monitoring for Integrated Assessment (EPIDEMIA) computer system was designed and implemented to integrate disease surveillance with environmental monitoring in support of operational malaria forecasting in the Amhara region of Ethiopia. A co-design workshop was held with computer scientists, epidemiological modelers, and public health partners to develop an initial list of system requirements. Subsequent updates to the system were based on feedback obtained from system evaluation workshops and assessments conducted by a steering committee of users in the public health sector.

Results

The system integrated epidemiological data uploaded weekly by the Amhara Regional Health Bureau with remotely-sensed environmental data freely available from online archives. Environmental data were acquired and processed automatically by the EASTWeb software program. Additional software was developed to implement a public health interface for data upload and download, harmonize the epidemiological and environmental data into a unified database, automatically update time series forecasting models, and generate formatted reports. Reporting features included district-level control charts and maps summarizing epidemiological indicators of emerging malaria outbreaks, environmental risk factors, and forecasts of future malaria risk.

Conclusions

Successful implementation and use of EPIDEMIA is an important step forward in the use of epidemiological and environmental informatics systems for malaria surveillance. Developing software to automate the workflow steps while remaining robust to continual changes in the input data streams was a key technical challenge. Continual stakeholder involvement throughout design, implementation, and operation has created a strong enabling environment that will facilitate the ongoing development, application, and testing of the system.

Mobile phone imaging and cloud-based analysis for standardized malaria detection and reporting

Rapid diagnostic tests (RDTs) have been widely deployed in low-resource settings. These tests are typically read by visual inspection, and accurate record keeping and data aggregation remains a substantial challenge. A successful malaria elimination campaign will require new strategies that maximize the sensitivity of RDTs, reduce user error, and integrate results reporting tools. In this report, an unmodified mobile phone was used to photograph RDTs, which were subsequently uploaded into a globally accessible database, REDCap, and then analyzed three ways: with an automated image processing program, visual inspection, and a commercial lateral flow reader. The mobile phone image processing detected 20.6 malaria parasites/microliter of blood, compared to the commercial lateral flow reader which detected 64.4 parasites/microliter. Experienced observers visually identified positive malaria cases at 12.5 parasites/microliter, but encountered reporting errors and false negatives. Visual interpretation by inexperienced users resulted in only an 80.2% true negative rate, with substantial disagreement in the lower parasitemia range. We have demonstrated that combining a globally accessible database, such as REDCap, with mobile phone based imaging of RDTs provides objective, secure, automated, data collection and result reporting. This simple combination of existing technologies would appear to be an attractive tool for malaria elimination campaigns.