Category Archives: Surveillance

The feasibility of achieving and sustaining “malaria-free zones” in southern Zambia

World Malaria Day 2014 was observed at the Johns Hopkins Bloomberg School of Public Health on Friday 25 April. 21 posters were presented. Below is the abstract of a poster presented William Moss and colleagues from the Southern Africa International Centers of Excellence for Malaria Research.

miam_handbook_articleimageThe Government of Zambia is committed to creating “malaria-free zones” in southern Zambia. Through passive case detection at health care facilities and active case detection through community-based surveys, we have documented a dramatic decline in the burden of malaria in the catchment area of Macha Hospital, Choma District, Southern Province, Zambia from 2008 through 2013.

Macha Hospital: https://www.flickr.com/photos/inmed/sets/72157625850417125/

Macha Hospital: https://www.flickr.com/photos/inmed/sets/72157625850417125/

However, residual foci of transmission exist and the potential for repeated importation remains. We identified individuals with subpatent parasitemia and gametocytemia who may be responsible for sustained, low-level transmission and evaluated reactive case detection strategies to identify and treat these individuals using simulation models.

Factors associated with sustained insecticide-treated bed net use were evaluated in light of the declining burden of malaria. Parasite bar coding of 24 SNPs should permit the identification of imported parasites.

Results of a longitudinal analysis of changes in antibody responses to 500 Plasmodium falciparum antigens using a protein microarray should allow detection of residual transmission and document loss of humoral immunity in the absence of exposure.

iPhones for household malaria surveys in Sierra Leone

World Malaria Day 2014 was observed at the Johns Hopkins Bloomberg School of Public Health on Friday 25 April. 21 posters were presented. Below is the abstract of a poster presented by Suzanne Van Hull of Catholic Relief Services.iForm Builder picture on iPhone

Catholic Relief Services (CRS) and the Ministry of Health and Sanitation (MoHS) of Sierra Leone (SL) are co-implementing nationwide malaria prevention and treatment activities funded by the Global Fund to fight AIDS, Tuberculosis and Malaria. In order to track progress and impact, CRS and partners led the implementation of a malaria indicator survey (MIS) in early 2013 covering a nationally-representative sample of 6,720 households, inclusive of blood testing to determine prevalence of anemia and malaria. In early 2012, CRS also had the experience of using mobile technology for a Knowledge Attitude and Practices (KAP) study.

Fieldworkers used Apple 3GS iPhones for both surveys to collect data via the iFormBuilder platform, a web-based, software-as-services application with a companion app for the mobile devices allowing for timely data collection, monitoring, and analysis.

This was the first time that iPhones were used for a MIS, and lessons learned include: allowing at least four months to transform paper-based questionnaires into electronic format, giving the program enough time for pre-testing the tool and training data collectors/biomarkers/laboratory technicians, and involving key malaria stakeholders to ensure a nationally-led survey. Global Positioning Systems enabled the MoHS to make in-depth analyses on malaria trends based on geographic locations.

KAP survey on iPhoneOverall the benefits of an electronic versus a paper-based MIS questionnaire outweighed the challenges. The iPhone technology eliminated the need for paper transcribing, allowing for quicker data tabulation, real-time identification of mistakes, faster interviewing through skip patterns, and a close-to-clean dataset by the end of data collection saving time and money.

Survey results will be used to set evidence-based targets for all partners’ future malaria activities, especially the next 3 years of GF-supported malaria grants

World Malaria Report 2013: Surveillance and Monitoring, Getting to the Heart of the Matter

Although “Malaria surveillance, monitoring and evaluation” is the seventh of eight chapters in the 2013 World Malaria Report (WMR), it is in fact the heart of the matter.  Progress on goals, finance, vector control, preventive therapies, diagnosis and treatment and of course impact (chapters 2-6 and 8) could not be produced without the documentation processes discussed in Chapter Seven. So what does WMR 2013 tell us about the status of malaria surveillance?

DSCN1496The global press has been taken by World Health Organization estimates that deaths from malaria world-wide have reduced by fifty percent since 2000.[i] These claims have been made despite the note in WMR 2013 that, “In 2012, in 62 countries of 103 that had ongoing malaria transmission in 2000, reporting was considered to be sufficiently consistent to make a reliable judgment about malaria trends for 2000–2012. In the 41 remaining countries, which account for 80% of estimated cases, it is not possible to reliably assess malaria trends using the data submitted to WHO. Information systems are weakest, and the challenges for strengthening systems are greatest, where the malaria burden is greatest.”[ii]

WHO explains that, “Improved surveillance for malaria cases and deaths will help ministries to determine which areas or population groups are most affected and help to target resources to communities most in need.”  WHO suggests that the design of malaria surveillance systems focuses on two fundamental factors. First, the level of malaria transmission should be ascertained, and the resources available to conduct surveillance must be made available. WHO has released two manuals to strengthen malaria surveillance depending on whether the country is high burden and still at the level of “Malaria Control,”[iii] or the country is approaching “Malaria Elimination.”[iv]

3T BrocheureThe World Health Organization has issued a series of documents focusing on “Test. Treat. Track.” or ‘3T’.  In short these documents support malaria-endemic countries in their efforts to achieve universal coverage with 1) diagnostic testing, 2) antimalarial treatment, and 3) strengthening their malaria surveillance systems to track the disease.[v]

WHO notes that in elimination settings, surveillance systems should seek to identify and immediately provide notification of all malaria infections, whether they are symptomatic or not. A summary of WHO’s recommendations for the “Track” or surveillance aspect of 3T follow:

  1. Individual cases should be registered at health facility level. This allows for the recording of suspected cases, diagnostic test results, and treatments administered
  2. In the malaria control phase, countries should report suspected, presumed and confirmed cases separately, and summarize aggregate data on cases and deaths on a monthly basis
  3. Countries in elimination phase should undertake a full investigation of each malaria case.

Some country examples of surveillance efforts in the move toward malaria elimination will be featured in the upcoming January 2014 issue of Africa Health. Watch for it at: http://www.africa-health.com/


[i] Pizzi M. WHO: Malaria deaths of young children cut by half, but gains ‘fragile’. Aljazeera America. December 11, 2013. http://america.aljazeera.com/articles/2013/12/11/who-malaria-battlehalfwaywon.html

[ii] WHO GLOBAL MALARIA PROGRAMME. World Malaria Report: 2013. World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland, 2013. http://www.who.int/malaria/publications/world_malaria_report_2013/en/index.html

[iii] World Health Organization. Disease surveillance for malaria control. World Health Organization, Geneva, 2012.

[iv] World Health Organization. Disease surveillance for malaria elimination: an operational manual. World Health Organization, Geneva, 2012.

[v] World Health Organization. Test. Treat. Track. Scaling up diagnostic testing, treatment and surveillance for malaria. World Health Organization, Geneva, 2012.

Malaria Highlights at TropMed2013 Saturday 16th November

Below please find a brief list of some of the presentations coming up today at the American Society of Tropical Medicine 62nd Annual Conference in Washington DC. Click links to view abstracts.

AnnualMeetinggraphic

Rapid clearance of parasitemia by the novel spiroindolone KAE609 in a phase 2 open-label study of adults with acute, uncomplicated Plasmodium falciparum or vivax malaria mono-infection by Nicholas White et al.

In summary, when administered 30 mg daily for 3 days, KAE609 was well tolerated and achieved rapid parasite clearance in adult patients with uncomplicated P. vivax or P. falciparum malaria infection.

Symposium on Implementation of Mass Drug Administration for Malaria Control and Elimination. Symposium Organizer: Roly Gosling, Global Health Group, University of California, San Francisco, San Francisco

With the recognition that a large proportion of malaria infections are low density, below the level of detection by microscopy or Rapid Diagnostic Test, MDA is coming back into favor. The speakers will explore the drug choices available for MDA in different settings; for example, for P. falciparum settings in Haiti, The Gambia and the Artemsisinin Resistance Containment zone, and for P. vivax in Asia and the Pacific.

Innovative Field Tools for Detecting Counterfeit Medicines – The Case Study of Anti-Malarials. Symposium Organizer: JOEL BREMAN, FOGARTY INTERNATIONAL CENTER, NATIONAL INSTITUTES OF HEALTH

The need for innovative field tools for the detection of spurious/falsely-labelled/falsified/counterfeit medicines is becoming increasingly important, particularly in low-resource settings. A global public health crisis is looming, especially in malaria treatment and prevention, where up to 90 percent of antimalarials in surveys done in Asia and Africa are reported to be falsified or substandard.

Session: Malaria Epidemiology – Tracking Trends and Finding Foci, Village-level characteristics associated with spatial distributions of malaria-infected individuals in an area of Southern Zambia receiving mass screening and treatment by David A Larson et al.

Varying spatial distributions of malaria-infected individuals appear to be driven by vector abundance and gametocyte prevalence in the population. The ability to clearly delineate village malaria prevalence may assist in developing mechanisms for focused interventions to optimize their effectiveness.

Session: Malaria Epidemiology – Tracking Trends and Finding Foci. Reservoirs of asymptomatic malaria in Malawi: results of two cross-sectional studies by Jenny A. Walldorf et al.

In Malawi and potentially in other endemic settings, school age children represent important reservoirs of asymptomatic infection and should be targeted for interventions to interrupt transmission.

Session: Malaria Epidemiology – Tracking Trends and Finding Foci. Sustained Declining Burden of Malaria at Community level in Northeastern Tanzania. by Acleus S. Rutta et al.

The reported decline of malaria in most parts of Tanzania has some implication on accuracy of malaria diagnosis and management. The current remarkable and sustained decline in malaria suggests that these areas might be moving from control to pre-elimination levels.

Eliminate Malaria, Not Malaria Funding

As countries begin to see the benefits of sustained malaria intervention, they worry that they may be punished by donor agencies for their success. For example, The Tanzania Daily News reports that, “HEALTH officials in Zanzibar have said that the Islands are likely to experience problems in the fight against Malaria should major donors, including Global Fund and the United States government pull out from financing the project.”

dscn9801a.jpgZanzibar is nearing pre-elimintion malaria transmission levels but is dependent on donor funding to maintain progress. The Daily News specifies that, “The US through its President’s Malaria Initiatives (PMI) remains the leading financier with 56 per cent of the funds received for the malaria campaign. Global Fund is 40 per cent, WHO and UNICEF two per cent; other donors 1.97 per cent; and Zanzibar government is 0.03 per cent.”

Health officials did clarify the actual situation by saying that, “We are happy that PMI has not shown any indication to pull out, but we must prepare ourselves and look for alternative financiers should the US stop supporting Malaria programme.” A look at the latest grant progress report for Zanzibar at the Global Fund website had only a report from August 2012 for Round 8 Malaria Grant that was made near the end of Phase 1 of the grant.

It is not clear if Phase 2 of the Global Fund grant has been or will be funded, but we know that the GFATM has been going through financial difficulties and changes.  This is likely why Zanzibar health managers are worried. The last grant rating was files back in 2011 and gave the program a ‘B2’ rating which is cause for caution and possibly hints at reasons why Phase 2 is in limbo.

PMI reports that donor support and Zanzibari leadership, “has resulted in a dramatic decrease in malaria prevalence in Zanzibar. However, persistence of malaria transmission in surrounding areas (Tanzania mainland and Kenya) leaves the island vulnerable to sudden outbreaks and the re-establishment of ongoing, perennial malaria transmission.” Even though Zanzibar is an island, it is still vulnerable, and any withdrawal of support would negate and reverse gains made. For example, PMI explains that Zanzibar is a place where “Malaria Early Epidemic Detection System (MEEDS) … an innovative mHealth system” is being tested.

Pre-elimination not only requires sustaining existing interventions, but also implementing new ones like MEEDS in order to maintain necessary surveillance that will ultimately document whether malaria elimination has succeeded. As PMI notes, “MEEDS and Coconut Surveillance are helping Zanzibar to identify and treat many otherwise undiagnosed malaria cases, identifying hot spots and transmission patterns, and responding rapidly to new outbreaks. These mHealth applications are helping Zanzibar to sustain the remarkable gains it has made against this dangerous and debilitating disease.”

Also, “maintaining and continuing to reduce malaria transmission will require ongoing education for both health care providers and residents to reinforce the importance of using preventive measures,” as the public and health workers perceive the drop in prevalence according to Bauch and colleagues. Malaria prevalence in Zanzibar has been less that 1% for over 6 years, and we need to continue to reduce it.

Interventions in the final phases of malaria elimination may not be as dramatic or visible as distributing millions of insecticide treated bednets, but they are just as essential.  We need to maintain support in all endemic countries until we see malaria elimination through to its conclusion. Otherwise years of intervention will be wasted, and new lives will be lost.

Addressing the Barriers of a Malaria Implementation Program in Jacmel, Haiti

Mary E. Schmidt, M.D. has studied the malaria situation in Haiti for her MPH capstone project at the Johns Hopkins Bloomberg School of Public Health. She has shared the abstract of the project with us here.

pf_class_2010_htism.jpgBackground:  Hispaniola is the only Caribbean island still endemic for malaria.  While the Dominican Republic continues to see improvement in the use of prevention measures and malaria rates, Haiti has been unable to organize, operate and fund a sustainable program.  The city of Jacmel in the South East District has the capacity to create a successful program.

Materials and Methods:  A literature review was performed of population based surveillance studies to understand the epidemiology of malaria in Haiti and the South East District. Individuals were interviewed to understand the Minister of Public Health and Population (MSPP) malaria policy and the current epidemiologic practices.  Haitian physicians and CBO workers were observed and interviewed to understand how malaria is diagnosed and treated, how patients are educated and the current community malaria prevention programs.

A literature review was performed of  materials from malaria experts, the World Health Organization (WHO), Pan American Health Organization (PAHO) and The Global Fund to better understand the components of a successful malaria elimination program.

Results:  This review focused on the current barriers of a malaria implementation program in Jacmel and the national system that would prevent a successful program.   The review led to the creation of a malaria elimination framework for Jacmel and the South East District.

The framework emphasizes a strong management and operations component.  The MSPP office communicates with finance, surveillance, the district health officer, and the operations team.  For a functional system, operations and management communicates with the MSPP oversight team and receives input from finance and surveillance in order to manage training, deployment, communications and local surveillance.

Monitoring and Evaluation is done on a district level and reported to district operations to help with managing the program and to the surveillance team.  Recommendations for policy development include focus on diagnostics, specific treatment, vector control, education and monitoring.  Barriers include funding and implementing an adequate operation and deployment team.

Conclusion:  The implementation of an effective malaria elimination program in Haiti will require MSPP leadership oversight and a strong operations and management team in each district.  The city of Jacmel in the South East District has the  interest and support from local CBOs and business leaders that make it the ideal location to implement the framework and create a sustainable program.

Malaria Vector Bionomics During the Dry Season in Nchelenge District, Zambia

Smita Das and Douglas E Norris of the Johns Hopkins Bloomberg School of Public Health Department of Molecular Microbiology and Immunology and Johns Hopkins Malaria Research Institute have written our guest blog posting based on a poster they presented at the recent JHU Global Health Day.

picture1-smita-das-and-douglas-norris-jhmri-sm.jpgAs part of the International Centers of Excellence in Malaria Research (ICEMR) in Southern Africa project, mosquito collections are being conducted in Nchelenge District in Luapula Province, Zambia. Nchelenge experiences hyperendemic malaria despite continued implementation of indoor residual spraying (IRS) and long-lasting insecticide nets (LLINs) as control measures.

Center for Disease Control light trap (CDC LT) and pyrethroid spray catch (PSC) collections performed during the wet season in April 2012 revealed the presence of both Anopheles gambiae s.s. and An. funestus s.s. Both species were highly anthropophilic and the Plasmodium falciparum sporozoite infection rate in An. funestus was higher compared to An. gambiae.

In the dry season collections, An. funestus continued to be the dominant species with even fewer An. gambiae caught compared to the wet season.  Due to the abundance of An. funestus and high human malaria infection rates in Nchelenge, it is predicted that the human blood index and entomological inoculation rate for An. funestus is higher than that of An. gambiae in both seasons.

The multiple blood feeding behavior and insecticide resistance status of both malaria vectors will also be explored as this can give us an idea of estimating the transmission potential of these mosquitoes. The vector data in Nchelenge present unique opportunities to further our understanding of malaria transmission and the implications for malaria control in high-risk areas.

Investing in Foresight, not Just Hindsight for Malaria Elimination

wmd2013logo-sm.jpgThe 2015 Millennium Development Goals milestone of reducing malaria morbidity and mortality is sometimes hard to see from here because of the many carts that got ahead of the horses and clogged the road.  We discussed earlier this week about the big push for universal coverage with long lasting insecticide-treated nets that got ahead of thoughts and plans for disposing the net packaging as well as old nets in an environmentally sound way.

Only a few efforts are underway to find a solution to old net disposal. In fact the need to replace LLINs much sooner than expected because of less than desired durability in real life field settings was another cart that surprised some horses and may lead to stock-outs in the next few years as financial sources for nets are not as certain as before.

A classic example ‘carthorsology’ is the roll out of artemisinin-based combination therapy medicines long before appropriate, easy to use diagnostic procedures were in place. Certainly we needed to save lives, but while most endemic African countries replaced first line drugs to which parasites had developed resistance with ACTs between 2005 and 2008, there was no alternative to clinical diagnosis in place.

Hopes that net use and other preventive measures would bring down the demand for ACTs were thwarted when health workers had to rely on their clinical judgment and continued to prescribe the more expensive ACTs presumptively just as they had done for the cheaper chloroquine and sulphadoxine-pyrimethamine. When RDTs finally became more common, there was an uphill battle to convince health workers that their clinical diagnosis was no longer acceptable.

In actuality, RDT supplies are still not matching need – i.e. enough to test all fevers and suspected cases of malaria. So in hindsight we are rushing to invest more heavily in RDTs and health worker diagnostic training and trying to find ways to safely dispose old nets.

roadmaps2012.pngProcesses like RoapMap planning sponsored by RBM and WHO are certainly moving us in the right direction that views holistically the totality of the malaria intervention package intervention. One wonders though if any other carts lie unforeseen ahead to block our horses.

One example of needed foresight is the development of appropriate strategies for end game pre-elimination and elimination.  In particular are appropriate surveillance systems in place?

Donors, especially the Global Fund seem reluctant to support the challenges of pre-elimination in countries like Swaziland, Namibia, Solomon Islands and others who are on the frontline of the elimination effort.  Fortunately the Clinton Health Initiative is one of those with foresight.  Hopefully we can keep investing in the forward march without additional unforeseen diversions in the RoadMaps.

Household Survey Used to Study Human Population Movement on Malaria Transmission in Southern Zambia

Karen E. Kirk, a MSPH-Internal Health Candidate at the Johns Hopkins Bloomberg School of Public Health has written this guest posting based on a poster she presented at the School’s Global Health Day earlier this month.

The inability to eliminate malaria in low endemic settings due to importation by infected individuals is considered a potential barrier in the fight to eradicate malaria worldwide.  Individuals living in the rural Choma District, Southern Province, Zambia have seen a dramatic decline in malaria since 2007 with the implementation of malaria control programs that include active case detection; mass distribution of insecticidal treated nets (ITNs); and widespread use of indoor residual spraying (IRS).  However, malaria elimination has still not been achieved in this region of the country.

blog-kirk-field-staff-collecting-blood-samples-2.jpgThe first photo shows field staff collecting blood samples from household members to test for malaria parasitemia in Choma District

A household survey was conducted in the Choma District to assess human population movement (HPM) and its association with confirmed or suspected malaria cases of individuals living in the district. The survey looked at travel history of 196 individuals from 42 randomly selected households between December 2012 and March 2013.  It collected data on travel patterns of individuals from the previous 4 weeks who stayed overnight for at least one night outside of their village. In addition, it collected blood sample for the testing of malaria parasitemia.  This survey was included in both the longitudinal and cross-sectional household surveys being conducted by the International Centers of Excellence in Malaria Research (ICEMR).

blog-kirk-community-survey-2.jpgThe second photo shows Field staff conducting malaria community health and HPM survey with mother in Choma District

Of the 196 individuals surveyed there were 97 (49.5%) adults (ages >17), and 99 (51.5%) children (<17).  There were a total of 34 trips taken by 31 (15.8%) individuals, 18 adults and 13 children. The majority of these individuals (59.3%) traveled for 7 days or less and 27 (87.1%) individuals traveled within the Choma District.  No malaria cases were detected in this study and therefore the results of this preliminary data were not able to show an association between HPM and malaria incidence rates.  However, with an increase in data collected over time, trends could be ascertained to determine seasonal patterns with HPM and its impact on malaria incidence rates in this hypoendemic setting.  The hope is that with adequate funding in malaria research with HPM, these types of studies can contribute important information on malaria transmission and help achieve the goal of regional elimination and ultimately eradication of this harmful disease.

[Bill Moss of JHSPH served as Principal Investor of this project]

Malaria Funding from the Perspective of International Donors

The recently released 2012 World Malaria Report (WMR) brought in to focus both malaria progress as well as the charges in malaria funding for the 104 malaria-endemic countries. Increased rates of coverage with vector control and malaria case management measures has mean that 274 million cases and 1.1 million deaths have been averted between 2001 and 2010. Unfortunately, The WMR observes that, “The enormous progress achieved appears to have slowed recently. International funding for malaria control has leveled off, and is projected to remain substantially below” projected needs.

We are not talking about small amounts of money or minor contributions to date. The WRM reports that, “The past decade has witnessed tremendous expansion in the financing and implementation of malaria control programmes. International disbursements for malaria control rose steeply from less than US$ 100 million in 2000 to US$ 1.71 billion in 2010 and were estimated to be US$ 1.66 billion in 2011 and US$ 1.84 billion in 2012.” This must be put in context with amounts estimated to be needed to achieve universal coverage (including use) of the major prevention and treatment interventions.

The WMR explains that “The enormous progress achieved appears to have slowed recently.” As noted above international funding for malaria control has leveled off, and “is projected to remain substantially below the US$ 5.1 billion” annually required to achieve and maintain universal coverage of malaria interventions. The Roll Back Malaria Partnership has estimated a higher projected annual need. “Resource requirements for global malaria prevention, control and elimination were estimated in the GMAP (Global Malaria Action Plan) to amount to some US$6.1 billion annually between 2012 and 2015.” This figure includes both program management costs as well as research needed to develop new tools.

The link between funding and coverage is clear in the WMR. The number of ITNs procured in 2012 (66 million) is far lower than in 2011 (92 million) and 2010 (145 million). “With the average useful life of ITNs estimated to be 2 to3 years, ITN coverage is expected to decrease if ITNs are not replaced in 2013.” Recent reports from a regional malaria elimination meeting in Kigali show that replacement time may be even shorter, possibly every 18-24 months based on local use and environmental conditions.

When identifying what is happening in malaria financing, it is important to recognize that there are relatively few direct donors. Major international malaria funders accounting for over 90% of donor financing are Global Fund, US President’s Malaria Initiative (PMI), Department for International Development (DfID), World Bank, and AusAid. Others include bilateral assistance, corporate donors and foundations.

international-funding-sm.jpgThe Global Fund as an entity and as the sum of its country contributors shocked the malaria and global health communities in 2011 when it announced the cancellation of its Round 11 of annual funding. The situation was complex and reflected weak financial pledging and inputs as well as internal management issues. The new funding approach was discussed in the WMR.  There are some uncertainties causing concern for the malaria community.

According to the 2012 WMR, “countries will be grouped by the Global Fund into Country Bands based upon a composite score which is a combination of a country’s GNI and its disease burden. Then there will be a “global disease split (i.e. 52% for HIV, 32% for malaria and16% for TB), until a new formula is determined, the Board,” that will be combined with a split according to Bands.  Finally actual allocation decisions will be made by the country coordination mechanisms (CCMs).  Malaria appears to be in greater direct competition with the other two diseases than what obtained in the past.  How other donors will compensate for any country shortfalls is unknown at present.

One possible implication of bands is that there may be less focus on lower burden countries that are heading toward malaria elimination.  Just because disease burden is low, or becomes low due to effective intervention does not mean that funding is not needed. Continued surveillance and case containment activities are not cheap, and require constant vigilance and sustained efforts since not all of one’s neighboring countries are at the same stage of malaria elimination.