In Cambodia, 2.5 million children under the age of five are at risk of malaria, with an estimated 80,664 cases being reported in 2008. Despite these statistics, the country has set a goal of eliminating malaria by 2025. Malaria Consortium is working in Cambodia as part of a Bill & Melinda Gates Foundation funded project to contain artemisinin resistant malaria along the Thai-Cambodia border. The organisation has been providing overall monitoring and evaluation support and strengthening surveillance. This is achieved through the development of efficient and timely systems for managing information on an on-going basis while also providing feedback.
Certain data is essential in the run up to elimination and if containment of resistance is to be achieved. These are: demographic information of all villages at risk in order to plan appropriate interventions, monthly malaria incidence numbers at village level, real time data about patients who are showing drug tolerance, real time data about malaria outbreaks and real time data about all Plasmodium falciparum and Plasmodium vivax cases.
Malaria Consortium, through a sub-grant from the World Health Organization (WHO), provided assistance in developing innovative tools to improve malaria surveillance as it was clear that existing tools were not able to provide the necessary information for national and district staff to respond to malaria outbreaks and individual cases. One of these innovative tools for real time data collection has been applied through the use of mobile phones.
Mobile phones were being used by an estimated 62 percent of the Cambodian population in 2010 and there are currently 12 mobile operators working in the country. Malaria Consortium has been using this cost-effective resource to better quantify and monitor real time malaria and potential artemisinin resistance occurrence.
"Without doubt, this is an important tool to quickly identify malaria cases and respond effectively," explained Pengby Ngor, data manager for the Malaria Consortium.
The unique SMS system is part of a larger effort to try and track ‘day 3’ positive cases in the community (these are cases where the malaria parasite has not cleared the patient’s blood three days after being given artemisnin combination therapy and is a possible indication of resistance). Village Malaria Workers (VMWs) take slides of blood samples at day 0 and day 3; health facility staff read these and send a simple coded SMS to the open source software. The software links with the Malaria Information System (MIS), a database where incoming information is processed, as well as to Google Maps. The day 3 positive cases are mapped to identify potential hotspots.
A day 0 reporting system is also being implemented, currently operating in four districts and covering 184 VMWs and 17 health centres to report all cases of Plasmodium falciparum malaria. This information system is web-based as it is expected to receive and handle a far larger amount of data than the day 3 system. The software was designed by Malaria Consortium and the Cambodia National Malaria Centre and allows for differing alert rules to reflect different transmission settings; the phones can also support Khmer or English scripts.
The day 0 reporting system is easy to implement as VMWs do not need to take slides and could be scaled up for approximately $100 per user for the equipment which is a basic mobile phone, instructions on sending and receiving SMS, log book to record SMS sent, reminder cards for VMWs and health centre staff on how to format and send SMS and a non-essential solar charger.
Finally, SMS is being used as a pilot for monitoring malaria drug stock outs in a number of health centres; they report the stock levels every two weeks or when levels drop below a set threshold and all participating health centres are displayed on Google Maps and colour coded depending on stock levels. This is an efficient way of enabling national staff to relocate resources where needed.
When setting out to achieve highly ambitious goals such as eliminating malaria and containing the spread of artemisinin resistance it is important to use the most innovative, simple to use and cost effective solutions in order to achieve widespread use and dissemination of efficient information for accurate surveillance.
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