STEP 3 - MALARIA ELIMINATION Malaria Active Infection Detection for enhanced surveillance at the community level CHW Training Materials 2012

Overview of the two-day training: Day 1  Background of malaria control and elimination in Zambia  Steps towards malaria elimination  Step 2&3 protocol  Step 2&3 workflow  Register records  RDT training

Overview of the two-day training: Day 2  Recap of Step 2&3 protocol  Field exercise  Final discussion

BACKGROUND / REFRESHER

Definition for malaria Suspected Tested Clinical Suspected, but not tested “Confirmed” Positive Negative Test result negative Calculation: Tested minus confirmed Calculation: Tested + Clinical (Not tested) Test result positive (RDT / Microscopy)

Towards malaria elimination in Zambia Malaria parasite prevalence among children by province and year, Southern province has made considerable progress in reducing malaria burden

Malaria reported case rates by district and case counts by facility 2011

1-2-3 Step towards malaria elimination  Ministry of Health Strategic Plan has the goal of creating 5 malaria-free areas in Zambia  It is likely Southern Province has areas that have the potential to be included in these malaria-free zones  MoH has adopted a step plan to eliminate malaria in in the selected areas: Step 1: Rapid Reporting Step 2: Mass test and treat Step 3: Surveillance for elimination

STEP 1 – RAPID REPORTING SYSTEM Data Reporting Step STEP 2 – MASS SCREEN AND TREAT Positive Malaria Case STEP 3 – ONGOING ACTIVE SURVEILLANCE COMMUNITY MASS TEST AND TREAT CAMPAIGNS: A.CHWs test all individuals in their catchment areas B.CHWs test all individuals in villages with passively detected cases PASSIVE: PATIENT IN COMMUNITY CHW tests individual seeking care

STEP 2 (A&B) PROTOCOL Mass screen and treat campaigns

1-2-3 Step towards malaria elimination  Step 2 involves mass testing and treating of facility catchment areas for malaria  Some catchment areas have very high levels of malaria, some have lower levels of malaria It is a waste of resource to screen areas with no malaria Must collect information about where malaria cases originate  Community (CHW-level) surveillance necessary to understand which parts of the facility catchment are necessary to screen and treat

1-2-3 Step towards malaria elimination  Step 2A = testing everyone in the catchment  Step 2B = testing everyone in only those villages in catchments with passive malaria cases detected

Participating Health Facility Catchment Area = household + + = health facility

Participating Health Facility Catchment Area = household + + = health facility Village a Village b Village d Village c Village eVillage f

Participating Health Facility Catchment Area = household + + = health facility Village a Village b Village d Village c Village eVillage f = CHW abcdef

= household + = health facility= CHW Participating Health Facility Catchment Area + Village a Village b Village d Village c Village eVillage f c de Field work STEP 2 A&B Catchment Team with facility staff chooses catchment area starting point (X) Working in Testing Pairs from the starting point, Catchment Team moves together house- to-house through whole catchment area ONE household is visited by only ONE Testing Pair = enumerator a 1 + b 2 + f 3 + X X = starting point

= household + = health facility= CHW Participating Health Facility Catchment Area + Village a Village b Village d Village c Village eVillage f c de = enumerator a 1 + b 2 + f 3 + = starting point = tested / completed household DAY 1 X Catchment Team will work with additional CHWs not participating in the training while in their respective areas Scheduling household visits may be necessary Important to test as many household members as possible Revisit households for additional testing only on the same day as other household members tested Daily target = 10 households tested per testing pair X Field work STEP 2A

= household + = health facility= CHW Participating Health Facility Catchment Area + Village a Village b Village d Village c Village eVillage f c de = enumerator a 1 + b 2 + f 3 + = starting point = tested / completed household DAY 2 X Catchment Team will work with additional CHWs not participating in the training while in their respective areas Scheduling household visits may be necessary Important to test as many household members as possible Revisit households for additional testing only on the same day as other household members tested Daily target = 10 households tested per testing pair X Field work STEP 2A

= household + = health facility= CHW Participating Health Facility Catchment Area + Village a Village b Village d Village c Village eVillage f cde = enumerator a 1 + b 2 + f 3 + = starting point = tested / completed household DAY 3 X Catchment Team will work with additional CHWs not participating in the training while in their respective areas Scheduling household visits may be necessary Important to test as many household members as possible Revisit households for additional testing only on the same day as other household members tested Daily target = 10 households tested per testing pair X Field work STEP 2A

= household + = health facility= CHW Catchment Team will work with additional CHWs not participating in the training while in their respective areas Scheduling household visits may be necessary Important to test as many household members as possible Revisit households for additional testing only on the same day as other household members tested Daily target = 10 households tested per testing pair = enumerator = starting point = tested / completed household DAY 4 and so on…. X Participating Health Facility Catchment Area + Village a Village b Village d Village c Village eVillage f c de a 1 + b 2 + f 3 + X Field work STEP 2A

= household + = health facility= CHW= enumerator a 1 + b 2 + f 3 + = starting point = tested / completed household DAY X = DONE!! Participating Health Facility Catchment Area + Village a Village b Village d Village c Village eVillage f c de X Catchment Team will work with additional CHWs not participating in the training while in their respective areas Scheduling household visits may be necessary Important to test as many household members as possible Revisit households for additional testing only on the same day as other household members tested Daily target = 10 households tested per testing pair X Field work STEP 2A

= household + = health facility= CHW Participating Health Facility Catchment Area + Village a Village b Village d Village c Village eVillage f cde Field work STEP 2B CHWs from catchment review 2 months of data from their registers. Make a list of villages with passive cases reported. For example, Villages A,B,D and E had cases. Villages C and F did not have cases so will not be screened. = enumerator a 1 + b 2 + f 3 + X X = starting point

= household + = health facility= CHW= enumerator a 1 + b 2 + f 3 + = starting point = tested / completed household DAY X = DONE!! Participating Health Facility Catchment Area + Village a Village b Village d Village c Village eVillage f cde X Follows the same process as Step 2A but only include required villages. X Field work STEP 2B

STEP 1 – RAPID REPORTING SYSTEM STEP 3 – ONGOING ACTIVE SURVEILLANCE Data Reporting HEALTH FACILITY PASSIVE: PATIENT AT CLINIC Staff test individual Step STEP 2 – MASS SCREEN AND TREAT Positive Malaria Case COMMUNITY ACTIVE: TEST AND TREAT CHW tests all individuals living around the positive case PASSIVE: PATIENT IN COMMUNITY CHW tests individual

1-2-3 Steps for malaria elimination  All clinics have implemented Step 1  Due to very low malaria burden in the district, Step 2 is not necessary  Hence, Step 3 is being introduced in the district

STEP 3 PROTOCOL

Definitions  Passive Someone is sick (Symptomatic) They come to the clinic / CHW for testing / treatment You are already doing this in your clinic / community  Active People who live close to someone with malaria are tested They may have NO symptoms of malaria (Asymptomatic) This is a NEW activity in the community  Household Single family group under a single household head

COMMUNITY HEALTH FACILITY MOBILE PHONE REPORTING CHW INDICATORS CLINIC INDICATORS PASSIVE: PATIENT SEEKS OUT CLINIC Symptomatic individuals tested at the clinic Record: Name, Age, Sex, Address, Purpose, Comment*, Result Treatment ACTIVE: CHW CONDUCTS TEST AND TREAT Test as many individuals living around the positive case as possible (1 day / 2 boxes) Record : Name, Age, Sex, Address, Symptoms, Travel, Result, Treatment PASSIVE: PATIENT SEEKS OUT CHW Symptomatic individuals tested by CHW Record: Name, Age, Sex, Address, Purpose, Comment*, Result Treatment Step 3 – Malaria Surveillance for Elimination EHT Data CHW POSITIVE * - Travel History

Questions  What do we mean by the term “Passive”? Where can “Passive” activities take place?  What do we mean by the term “Active”? Where can “Active” activities take place?  What do we mean by the terms: “Asymptomatic”? “Symptomatic”?  What do we mean by the term household?

Active response in the community  Notification of household of malaria patient  Locate patient household (House 1)  Explain purpose to household members  RDT test all consenting household members  Record details in CHW register (ACTIVE)  Treat all positives  Move on to next household NEXT HOUSEHOLD

Test malaria patient’s family and their neighbours  Start at malaria patients house and test and treat their family  Identify immediate neighbors around the malaria patient  Test (and treat if necessary) neighbors around malaria patient house.

Household follow-up

How much work?  Test all households within 140m (one and a half football field length)  Up to a MAXIMUM of 40 people per active response  Include houses hidden by obstacles e.g. trees Walk around to familiarise yourself with the area Ask the community for help to find other households  If very few houses close to House 1 you can test further away from House 1

Explain purpose “An individual from your household / neighbourhood has been found positive for malaria. I am a community health worker and am here to help prevent further cases of malaria. I would like to test each member of your household for malaria using a small kit called a rapid diagnostic test. To do so, I will need to take a small drop of blood from your finger. If you have malaria I will provide free antimalarials as necessary. I would also like to record the results of the malaria test.” Turn to your neighbour and explain the procedure (any language) Turn to your neighbour and explain the procedure (any language)

DATA RECORDING

Travel History  To assess travel history, ask the person: “ Have you traveled outside the district within the last month?”  If they say yes, then ask: “Did you spend at least one night there?”  If yes, record ‘Travelled to ……’ e.g. Travelled to Livingstone.  If they say no then record ‘No Travel’ Why is it important to know someone’s travel history?

Passive Register ACTIVE RESPONSE POSITIVE 16/2/12Timothy Banda 5MSimangoHeadacheNo TravelNegativeNo Treatment DateNameAgeSexAddressPurposeCommentResultTreatment 14/2/12Juliet Mbewe 32FSimangoVomittingTravelled to Eastern Province NegativeNo Treatment 16/2/12Simon Kataya 28MSimangoVomittingNo TravelPositive1 x 24 Pack ACT

Active Register DateNameAgeSexAddressSymptomsTravelResultTreatment 16/2/12Inonge Kataya 26FSimangoFeverNo TravelNegativeNo Treatment 16/2/12Chilufya Kataya 8MSimangoNo symptomsNo TravelNegativeNo Treatment House 1 17/2/12Michael Lupiya 4MSimangoHeadacheNo TravelPositive1 x 12 Pack ACT 17/2/12Florence Lupiya 2FSimangoNo symptomsTravelled to Livingstone NegativeNo Treatment House 2

DATA REPORTING

Passive Register – Monday TOTALS TOTALS 16/2/12Timothy Banda 5MSimangoHeadacheNo TravelNegativeNo Treatment DateNameAgeSexAddressPurposeCommentResultTreatment 14/2/12Juliet Mbewe 32FSimangoVomittingTravelled to Eastern Province NegativeNo Treatment 16/2/12Simon Kataya 28MSimangoVomittingNo TravelPositive1 x 24 Pack ACT 20/2/12Travelled – 1 Not Travelled - 2 Total Tested – 3 Positive - 1 Treated – 1 Not treated - 2 TOTALS

Active Register – Monday TOTALS TOTALS DateNameAgeSexAddressSymptomsTravelResultTreatment 16/2/12Inonge Kataya 26FSimangoFeverNo TravelNegativeNo Treatment 16/2/12Chilufya Kataya 8MSimangoNo symptomsNo TravelNegativeNo Treatment House 1 17/2/12Michael Lupiya 4MSimangoHeadacheNo TravelPositive1 x 12 Pack ACT 17/2/12Florence Lupia 2FSimangoNo symptomsTravelled to Livingstone NegativeNo Treatment House 2 20/2/12Travelled – 1 Not Travelled - 3 Total Tested – 4 Positive – 1 Treated – 1 Not treated - 3 TOTALS House - 2

Reporting  CHW must add up the TOTALS every MONDAY!  TOTALS are given to the data CHW every MONTH  Important: Separate passive cases from active cases Break into groups and review each CHW register Practice drawing out register to include all indicators Break into groups and review each CHW register Practice drawing out register to include all indicators

OWNERSHIP

Clinic Attachments  REQUIRED for all untrained CHWs  No Step 3 until attachment is completed No RDT Testing No prescription of ACT  Minimum attachment (or until competent): 14 days for untrained 7 days for trained Talk to your clinics to arrange when this can happen

An Incentive to Work  Each CHW will receive 5,000 ZMK Airtime per week  If you don’t have a phone / want a phone Each week will count towards a new phone 10 weeks of reports and we will provide a phone for you  No report = NO AIRTIME / PHONE  No Data CHW report = NO AIRTIME / PHONE for ANYONE