Expert Q&A: Innovations and challenges in malaria surveillance

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Monitoring, evaluation and surveillance techniques are central to Malaria Consortium’s work to improve overall performance and maximise the delivery of disease control interventions. Malaria Consortium consistently engages in monitoring and evaluation activities, using the results to guide the design of malaria surveillance systems and implementation of malaria control programmes.

In June 2017, the School of Public Health at the University of Ghana, in collaboration with MEASURE Evaluation, hosted the 7th Annual Workshop on Monitoring and Evaluation of Malaria Control Programmes (http://bit.ly/2s0gIWj). The aim of the workshop was to provide professionals with the skills in fundamental concepts, surveillance, and practical approaches to monitoring and evaluation of malaria programmes in sub-Saharan Africa.

The event was co-facilitated by Malaria Consortium’s Head of Monitoring and Evaluation, Dr Arantxa Roca-Feltrer. In this Q&A, Arantxa discusses the importance of surveillance activities, innovations in surveillance processes and the challenges encountered by surveillance practitioners in the control and elimination of malaria.

What is malaria surveillance?

Malaria surveillance is the systematic and regular collection of information on the occurrence, distribution and trends of malaria with sufficient accuracy and completeness to inform decision-making. The latest World Health Organization (WHO) Global Technical Strategy (GTS) identifies malaria surveillance as an intervention that encompasses the tracking of diseases (including malaria), programmatic responses, and taking action based upon the received data.

Is surveillance done differently in Asia and Africa?

Malaria surveillance is not intended to be implemented differently in Asia or Africa. The difference in the surveillance process depends on where the country lies in relation to the elimination spectrum. In countries with a high malaria burden aiming to control the disease, surveillance is focused on collecting aggregated data for use in planning, implementation and evaluation of public health practices. Surveillance in malaria eliminating countries, on the other hand, is focused on gathering individual level data, where programmes implement activities related to the identification, investigation and elimination of continuing transmission, the prevention and cure of infections, and the final proof of claimed elimination.

Why should we monitor and evaluate surveillance systems?

Monitoring and evaluating a country’s existing surveillance system is important for several reasons. Firstly, there is a need to ensure that the surveillance system follows national malaria control or elimination priorities. Secondly, we need to document the effectiveness of the surveillance system as well as its linkages with existing health information systems such as the national health management information system. Finally, monitoring and evaluation allows government teams to introduce new surveillance methods or techniques that might strengthen the system once proven evidence has been gathered through small scale pilot evaluations, such as reactive case detection or cross border surveillance techniques.

How can we monitor and evaluate what makes a good surveillance system?

The World Health Organization considers several quality criteria:

  • Simplicity
  • Adaptability and flexibility
  • Acceptability
  • Performance (sensitivity, specificity, predictive positive value, predictive negative value)
  • Representativeness
  • Ability to respond and identify actions

One example of a good surveillance system can be seen in Southeast Asia, where Malaria Consortium has been supporting strategies for rapid malaria elimination through cross-border surveillance in areas with high levels of artemisinin resistance. In Uganda and Ethiopia, we have been monitoring the changes in the epidemiology of malaria and the effectiveness of interventions through our Beyond Garki project.

What were the key lessons learnt from the MEASURE workshop on malaria surveillance?

The workshop highlighted that malaria surveillance activities should be adequately budgeted and resourced to enable the effective implementation of case notification and investigation activities. Also, the use, interpretation and feedback of data are key for a successful malaria surveillance system, and this requires proper training and a cultural move towards ‘using data for action’.

Are there any novel or innovative approaches to surveillance?

The WHO GTS Framework for Malaria Elimination emphasises the importance of research and innovation for malaria elimination. This document states that ‘investment in basic science and product development must be sustained to create new tools and strategies for malaria elimination and its eventual global eradication’. It goes on to say that the ‘operational feasibility, safety and cost-effectiveness of new tools and strategies should be evaluated by context-adapted operational research as a basis for reliable policy recommendations by national policy-makers and WHO’.

The operational research agenda within the WHO GTS Framework, which covers a range of topics, is currently exploring the use of digital strategies to improve the rapid reporting of malaria cases. It also looks at other participatory surveillance approaches that include and deliver interventions to groups at the greatest risk. With over seven years of experience in mobile health (mHealth) and health systems strengthening, Malaria Consortium believes that effective digital health strategies can help governments manage malaria and disease control programmes better. In the countries we work in, we have explored how digital strategies can play an important role, particularly to improve the motivation and supervision of community health workers, to provide effective diagnostic tools, and to strengthen surveillance and data management.

Given that the new WHO elimination strategy incorporates malaria surveillance, how can we prioritise surveillance and what challenges might we face?

Strengthening surveillance is crucial for implementing country-wide malaria elimination activities. Malaria surveillance systems require new functionalities which facilitate/incorporate surveillance, such as data visualisation, and new data quality features for the effective implementation of surveillance activities, such as timeliness and comprehensiveness. Other priority areas include product development of medicines, diagnostics, vector control methods and vaccines.

However, countries also face specific challenges that are unique to their context. These require careful attention – particularly at the community level – in order to ensure feasibility, user acceptability at various health levels, sustainability and long-term system flexibility. Therefore, it is important to stress that a ‘one-size-fits-all’ approach does not apply to malaria surveillance and information systems, and that contextual factors must be taken into consideration when strengthening malaria surveillance activities.

 

Links to the projects as stated above:

  1. UpSCALE: http://www.malariaconsortium.org/inscale/pages/about-upscale
  2. inSCALE: http://www.malariaconsortium.org/inscale/pages/inscale-project
  3. IMMERSE: http://www.malariaconsortium.org/pages/immerse_project.htm
  4. Trans-border malaria: Mapping high-risk populations and targeting hotspots with novel intervention packages, Cambodia and Thailand: www.malariaconsortium.org/resources/publications/743/
  5. Targeting malaria infection and artemisinin resistance in formal/ informal border points, Cambodia-Laos border: www.malariaconsortium.org/resources/publications/620/
  6. Innovative Malaria M&E Research and Surveillance towards Elimination (MESA), Cambodia, Myanmar, Thailand: www.malariaconsortium.org/resources/publications/262/
  7. Moving towards malaria elimination: developing innovative tools for malaria surveillance, Cambodia: www.malariaconsortium.org/resources/publications/257/
  8. Transitional, Enhanced, Accessible Malaria Surveillance (TEAMS), Myanmar: www.malariaconsortium.org/resources/publications/975/
  9. Pioneer project 2009-2014: A holistic systems strengthening approach towards malaria control in mid-western Uganda: www.malariaconsortium.org/resources/publications/408/
  10. Beyond Garki: http://www.malariaconsortium.org/beyondgarki/

 

Related Links (journals and learning papers):

Expert Q&A: No one size fits all in the pursuit of the best pneumonia diagnostic aids

Malaria Consortium Senior Project Officer, Charlotte Ward, speaks about pneumonia as a global priority issue, how we are attempting to tackle the disease and explore the future of diagnostic devices.

Pneumonia is an acute respiratory infection that affects the lungs and is responsible for 16 percent[1] of deaths of all children under five. This proportion is much higher in low-resource countries where access to healthcare is limited, particularly in South Asia and sub-Saharan Africa.

Yet despite being the single largest infectious cause of death in children worldwide, pneumonia can be diagnosed and treated with low-cost and simple interventions and medication.

 

What are the current challenges in diagnosing and treating pneumonia?

Diagnosis of pneumonia by community health workers (CHWs) is commonly based on counting the number of breaths in 60 seconds in children under five to assess whether the respiratory rate (RR) is higher than the normal parameters for a child of that age. However, manually counting RR can be challenging due to the difficulties in observing and counting chest movements for a full minute and keeping the child calm during this period. Therefore, misclassification of observed rate is common, leading to incorrect diagnosis and consequently inappropriate antibiotic treatment, contributing to the spread of antibiotic resistance.

 What different types of devices are currently being used?

Non-automated devices, assisted RR counting devices and pulse oximeters are currently being used. Non-automated devices are the lowest cost and most commonly used tools. They support manual counting of chest movements by indicating when to start and stop counting. Assisted counting RR devices automate the counting process thus negating the need for manual counting. An example is a mobile RR smartphone app that works by counting the number of times the CHW taps the screen for each chest movement. Pulse oximeters work by measuring the blood oxygen saturation levels in the patient. Three types of pulse oximeters exist: handheld, mobile and finger-tip pulse oximeters.

How do we evaluate the best devices?

Formative research to understand the best class of devices is critical before designing and implementing a device field trial. An example of formative research is pile sorting and accompanying focus group discussions with key stakeholders. Pile sorting is when you ask key stakeholders to sort word, item or picture cards into piles that classify a range of opinions or categories of interest and then capture and explore participants’ decision-making rationale for their sorting using a focus group discussion. In this case, stakeholders including representatives of national and regional Ministry of Health (MoH), regional health bureaus, multilateral organisations such as UNICEF, and relevant NGO staff, would be demonstrated device types and asked to place cards with various device names into different piles according to their perceived usability, and again for their perceived scalability. Devices are then scored based on how they are sorted and those with the highest scores may be carried forward for field testing.

 What challenges will there be in designing appropriate diagnostic aids?

A major challenge is designing appropriate diagnostic aids that appeal to a wide range of stakeholders with differing views and priorities. CHWs and national and regional stakeholders prioritise different characteristics when rating the potential scalability of aids. For example, CHWs emphasise the importance of aids being acceptable to CHWs, parents and caregivers more than national stakeholders who prioritise the need for cost-effectiveness and sustainability. Practical usability is also heavily prioritised by CHWs whereas NGO and MoH stakeholders are strongly invested in ensuring the supply and distribution processes are uncomplicated and inexpensive. Further considerations are whether the device can be used in remote areas with unreliable electricity source, how much training is required to use the device and how durable the device is.

 What are future directions?

Device development is a complex process and the challenges in appealing to a wide range of stakeholders mean that a ‘one size fits all’ approach is unfeasible. However, there is global momentum towards developing automated devices that count RR without the need for human intervention. It is hoped that such devices will offer improved accuracy and effectiveness compared to current practice for classifying the symptoms of pneumonia, therefore improving the treatment of patients at community level. Furthermore, automated devices have the potential to increase caregiver and patient confidence in CHWs, thus strengthening programmes of integrated management of new-born and child health at community level in low-resource settings.

Projects that Malaria Consortium has undertaken on pneumonia

 Related resources:

Charlotte Ward is a Senior Project Officer here at Malaria Consortium. She is currently focussed on the ARIDA project, which is working to bring automated respiratory rate counting aids to wide-scale use by frontline health care workers in resource limited community settings.

 

[1] http://www.who.int/mediacentre/factsheets/fs331/en/