1. Unit 5 Surveillance from Control to Elimination tools and procedures to get information about malaria Part 5C
Dr Bayo S. Fatunmbi
[Technical Officer, Monitoring & Evaluation, ERAR GMS]
Training course on Elimination
Chiang Mai, Thailand
10-21 August 2015

2. Case detection Case definition in elimination: Case detection:
a person in whom, regardless of the presence or absence of clinical symptoms, malaria parasites have been confirmed by quality assured confirmatory diagnosis.
Case detection:
Passive case detection: potential foci are identified using data reported by public and private sector health facilities.
Active case detection: Searching for cases in communities where populations have limited access to facilities, or in particularly high risk areas.
House-to-house
Field investigation – village, community or district level
Focus investigation – detailed investigation of a particular case
NB: Passive case detection is generally the preferred method for detecting malaria cases while active case detection should only be used to fill gaps in the passive case detection system.

3. Why active case detection
Malaria at low endemic/ pre-elimination levels is highly clustered.
Clustered geographically in hotspots
Clustered demographically in hot-populations, hot-pops
Infections asymptomatic and low density
Courtesy: Roly Gosling

4. Hot pops - high risk groups
Courtesy: Roly Gosling

5. Reactive Case Detection
Courtesy: Roly Gosling
What should the radius around an index house be?
What is the effective coverage?

6. Asymptomatic and low density infections
Old dogma
Low transmission
Few asymptomatic cases
Less low density infections
New dogma
Many asymptomatic cases (> 50%)
Proportionately MORE low density infections (> 50%)
Courtesy: Roly Gosling
Okell, Nature Comm, 2012

7. Potential solutions Asymptomatic infections Low density infections
Test everyone
Low density infections
Use more sensitive tests
Treat everyone
Operational challenges
Resource intensive and high coverage needed
Reduce radius/ area to screen/treat
Additional measures to take
Vector control, community, etc.
Hot-pops- Not all clusters of infection are geographically clustered
Interventions must target high risk groups

8. Active Case Detection: Tools
Legislation supporting the identification and notification of all malaria cases,
irrespective of their place of residence, or
their first point of contact with public/private health services;
Active case detection though house-to-house visits during the transmission season;
Epidemiological investigation of every confirmed case;
Parasite genotyping and isolate banks;
National malaria case register;
Continuing education and quality control for all public and private clinical services that diagnose and/or treat malaria;
Quality control of all laboratory services that diagnose malaria;
Use of microscopy only (i.e. not RDT) from the pre-elimination program onwards, for species identification, detection of gametocytes and determination of parasite densities.

9. Case classification Imported cases: Local or "autochthonous" cases:
Imported from outside the country
domestically imported (list examples of these imported cases by country)
Local or "autochthonous" cases:
All cases caused by local transmission (a local mosquito bite)
Introduced case - contracted locally from an imported case (first generation from an imported case
indicates "active" ongoing transmission
Indigenous case - contracted locally from any other category of case, including introduced case
Relapsing case - contracted locally before cessation of local transmission including from
hypnozoites of vivax or ovale malaria;
Recrudescent falciparum or malariae malaria;
Undetected long incubating vivax or ovale
Induced - a congenital infection or a case induced by contamination with infected blood.

10. Exercises and 5.6.8
5.6.5: describes a real life situation in an Indian district (pp 112)
Questions:
To which category do the cases belong?
To which category of foci do the three villages belong?
Is the area around Lakdya Hanuman a focus of malaria?
What was the source of infection in this case?
5.6.8: describes an event that took place in Hanoi, Vietnam (p116)
Classify patient A and B’s malaria cases. Discuss and justify the classifications.
Is there a malaria focus in Ngoc Thien? If yes, how should it be classified?
Were the measures taken in Ngoc Thien adequate?
Remember that in 2000 there was no elimination program in Vietnam. If it is assumed that these events took place under an elimination program, would the recommended measures be any different?

11. Jun Cao, Hugh J. W. Sturrock, Chris Cotter, etc
Jun Cao, Hugh J. W. Sturrock, Chris Cotter, etc. Communicating and Monitoring Surveillance and Response Activities for Malaria Elimination: China’s ‘‘1-3-7’’ Strategy. PLoS Med. 11:e

12. See short video on: Active Case Detection, Focus identification, Investigation & Response

13. Case Recording and Reporting (1)
Community based:
Health facility:
case detection;
record of each suspected case (line list) is kept
Field level:
case investigation form is completed for each confirmed case
focus investigation
Case Recording:
District level:
Monthly reports – summaries of all cases detected, inv.,
Register of health programs and resources incl. HR
Malaria case notifications
Malaria case investigation forms
Focus investigation forms
List of foci
Databases – case and entomological
Annual and periodic reports
Maps

14. Case Recording and Reporting (2)
National level:
A compilation of malaria elimination programs to inform decisions and as a stockpile of all malaria information (reference)
Contains:
Cases and foci (National Register; focus investigation data, list of foci with changes, etc.
Health services: Resources, Laboratory data, Reports of activities
Vector surveillance data
Surveillance reports (districts  national levels)
Annual reports over past five years; feedback records to lower levels, etc.

15. Case Recording and Reporting (3)
Immediate: notification of detected cases and investigations to the national level through electronic communication within 24 hours.
Monthly: summaries of tested, confirmed, investigated, updated foci, etc. ref data flow chart
Annual: Report should compare previous years’ data, do trend analysis and use findings for program decisions

16. Monitoring & Evaluation in Malaria Elimination
Emphasis is on:
Program operational aspects – input, process, output, outcome and impact
Epidemiological changes resulting from implementation
Interpreting results and informing program decisions
Documentation and sharing of progress

17. Malariometric indicators in advanced control / pre-elimination
Indicators based on microscopy:
Prevalence of malaria among persons examined (SPR or TPR) by specie
Parasite incidence (Annual Parasite Incidence)
Coverage of case detection (Annual Blood Examination Rate)
PI = TPR*ABER
Proportion of confirmed cases by species
Indicators based on other criteria:
Malaria detected by RDT
Incidence of clinical malaria
Fever rate and incidence of suspected malaria

18. Malaria Elimination indicators (1):
Target or Norm
Data Source
Impact:
Number and incidence rate of confirmed malaria cases by classification, sex, age group, risk group (e.g. schoolchildren, migrant workers)
Number of foci by classification
Quantity and quality of surveillance:
Annual blood examination rate by district and focus detected passively and actively
Indicative target in endemic, residual active, new active and residual non-active foci: 8% of population in focus
Indicative target in cleared up and new potential foci: 1–3% of population in focus
District monthly and annual reports database

19. Malaria Elimination indicators (2):
Target or Norm
Data Source
Quantity and quality of surveillance:
% of expected monthly reports received from health facilities and laboratories (with number of patients tested for malaria and number positive)
Target: 100%
District monthly reports database
% of confirmed cases fully investigated (including case investigation form, focus investigation form and active case detection)
Malaria case investigation database
% of foci fully investigated (malaria focus investigation form completed, including data from an entomological investigation) and registered (on register, with maps of each focus)
Malaria focus database

20. Malaria Elimination indicators (3):
Target or Norm
Data Source
Quantity and quality of surveillance:
Time from first symptom (fever) to first contact with the health system
Norm: within 48 h
Malaria case investigation database
Time from first contact to testing
Norm: within 24 h
Time from positive test result to start of treatment
Norm: same day
Time from positive test result to notification of the national malaria programme (to district or intermediate level, with copy to central level)

21. Malaria Elimination indicators (4):
Target or Norm
Data Source
Quantity and quality of surveillance:
Percentage of malaria testing laboratories participating in quality management system (all positive slides and 10% of negatives sent for retesting and the blind proficiency test completed each year)
Target: 100%
External quality assurance database
Percentage of past 5 years with national annual malaria programme report

22. Establish a surveillance system

23. Moving to Malaria Elimination: A functional Surveillance System is mandatory
Transform malaria surveillance into a core intervention
Pillar 3 of Global Technical Strategy ( )
Malaria Case and Entomological Surveillance
Key intervention 3 of GMS Malaria Elimination Strategy ( )

24. Functional Surveillance as a core intervention
Malaria case surveillance in the elimination phase aims at:
detecting and notifying on all malaria infections;
early treatment, to prevent secondary cases;
investigating each malaria case and classify if locally acquired or imported should be completed within 1–3 days.
focus investigation; and
appropriate intervention (response) put in place promptly
Entomological surveillance to inform choice of VC

25. Design of a Surveillance System for Malaria Elimination (1)
Elimination phase
Purpose
To discover any evidence of the continuation or resumption of transmission; detect local and imported cases as early as possible; investigate and classify each case and focus of malaria; provide a rapid and adequate response; and monitor progress towards malaria elimination
Data reporting, recording and indicators used
Malaria is a notifiable disease
Private sector must report every case by law
Number of local and imported cases, and residual or new active and potential foci of malaria
Detection method
PCD at all levels of health system
ACD to fill gaps in PCD system, in order to detect infections as early as possible, with particular focus on high-risk groups
Reactive ACD in case investigation and clearing of foci
Case and foci identification, investigation and classification
Yes
E.g. Decentralized authority to make appropriate legislation e.g. Pailin

26. Design of a Surveillance System for Malaria Elimination (2)
Elimination phase
Technology, monitoring and evaluation
Adequate case- and foci-based malaria surveillance fully functional across the entire territory of a country
National computerized malaria elimination database or register established
National malaria elimination monitoring committee set up
Data elements
Case based, foci (starting from control phase)
Case definition
Any malaria infection (symptomatic and asymptomatic)
Case investigation
All cases
Timescale
Immediate notification

27. Steps in Establishing a Surveillance System for Malaria Elimination (1)
Describe current malaria situation
including the current macro-stratification
Situation analysis of surveillance system
Including the Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis
Design a suitable Surveillance System for elimination program phase (differentiated by stratum)
Develop a workplan with detailed activities to operationalise the surveillance system (‘make it real’)

28. Steps in Establishing a Surveillance System for Malaria Elimination (2)
Identify operational targets, milestones and realistic timelines
stating the challenges, risks, assumptions, practical solutions and alternate interventions (Plan B)
Cost estimation (Detailed budgeting) and resource mobilization strategies
Prepare draft SOPs for appropriate thematic areas for malaria and health workers at different levels
Develop monitoring framework to monitor the surveillance system performance
Each case is referred to HF

29. Areas to consider when assessing the Surveillance System for Malaria Elimination
Malaria context
Organizational structure and human resources
Stratification and targeting
Passive case detection and reporting
Reporting, data management including analysis
Case Notification, case and focus investigation
Response mechanisms
Cross border activities and coordination
Operational research
Others

30. Key recommendations from recent SME Assessment in the GMS (2014)
Develop adequate and up-to-date guidelines and policy documentation at country and regional level
Improve case-based automated data management
Strengthening linkages with the private sector
Harmonize elimination and resistance SM&E indicators
Strengthen SME capacity at all levels of NMCP
Avoid multiple reporting systems and transition to case-based reporting and investigation systems only where viable
Country SME report has specific findings and recommendations – please use

31. Malaria Surveillance System: The tools
report forms,
tally sheets,
registers,
patient cards,
computer hardware and software,
communication (mobile phones, SMS), documentation and training materials,
Other logistics

32. Malaria Surveillance System: Procedures
case definitions
reporting frequency
pathways of information flow
data quality checks
incentive schemes
data analysis
mechanisms for review of performance
methods for disseminating results,
using data for making decisions
supervision and planning.

33. Malaria Surveillance System: The People
Decision-makers:
both inside and outside the health service who use data from surveillance systems,
Health staff:
who collect, collate, analyse, store or use the data
Community:
whose details are registered.
Other stakeholders:
Partners, NGOs, etc. who facilitate and support the system

34. Malaria Surveillance System: Structure
The ways staff are organized to manage, develop and use the system e.g. 1) Organogram, 2) Data flow charts: data flow, use, and feedback
Data flow chart of one country

35. Malaria Surveillance - operational manuals for adaptation to local context (e.g. SOPs)

36. Exercise 5.7
Develop a plan for establishing a surveillance system for a particular country, to which one or several members of the group belong. Discuss it at the plenary.
Note that this may be the main course exercise to be continued through following Learning Units.