Routine Malaria Surveillance
Yemen experience in implementation
Dr Mohammad Ali Khalifa
Medical Officer Malariologist
WHO Office in Yemen
Luxor, 5-9 December 2004
Surveillance is the ongoing systematic collection,
analysis and interpretation of health data
essential to the planning, implementation and
evaluation of public health practice, closely
integrated with the timely dissemination of
these data to those who need to know.
The final link in the surveillance chain is the
application of these data to prevention and
control or better delivery of service.
Epidemiology, Biostatistics, and Preventive Medicine, Second Edition, By:
James F. Jekel, David L. Katz and Joann G.Elmore
Epidemiology is essentially an
empirical subject, and training
should take this into account;
theory should only be
introduced where necessary.
World Health Forum
Volume 16, Number 3, 1995
Paralysis by Analysis !!!
A clear example:
Being aware that malaria is a major health
problem, lack of information on specific
incidence rates or others where they are not
available must not delay the development of
The important principles that were
considered while establishing the
surveillance system in Yemen:
■ The development of a surveillance system
• clear objectives regarding NMCP (SMART)
• the purposes for which the surveillance is to be
done, e.g. to monitor the effectiveness of a
■ To enable the development of standardized
reporting procedures and reporting forms, the
criteria for defining a case of malaria must be
The case definition is usually based on clinical
findings, laboratory results, and epidemiologic
data concerning the time, place, and persons
■ The intensity of the planned surveillance (active
versus passive) and the duration of the
surveillance (ongoing versus time-limited) must
be known in advance.
■ The selection of sentinel clinicians or
institutions for regular reporting should be
considered. These were selected during the
training activities, the series of clinical meetings
which were conducted and the studies of
monitoring the efficacy of AMDs.
■ The items of data to be collected and the
manner in which each item will be used in the
analysis must be carefully determined.
■ The kinds of analyses needed (e.g., analyses of
incidence, prevalence, case fatality ratios, years
of potential life lost [YPLL], quality-adjusted life
years [QALY], costs, etc.) should be stated in
■ In addition, there should be plans for
dissemination of findings. Whom to share with?
■ The above objectives and methods should be
developed with the aid of those who will collect,
report, and use the data. This ensures
■ A pilot test should be performed and evaluated
in the field, perhaps in one or a few
demonstration areas, before the full system is
■ When the full system is operational, it too
should be subjected to continual evaluation.
■ Information is the lifeblood of the planning
To be successful, planning needs a combination
of a ‘rational’ process and political analysis. Both
of these strands need to be based on
■ ‘Information is power’.
A planner with a confident grasp of information
is in a strong position to convince others of
■ Much of the information needed is not reducible
to a statistical format.
E.g. in planning there is a great need for a political
perspective, and information relating to this is rarely
quantifiable, and as such may often not even be viewed
Hard information and Soft information are both
Beware of the ‘measurable driving out the intangible’.
The adoption of IT-based management information
systems (MIS) may carry with it the danger of an
unwarrantable overemphasis on measurable
Level of aggregation of information
Collecting, analyzing and presenting information all have
attendant costs, yet much information is processed
without any end-use.
Not only is the processing of unnecessary information
costly, but it may also lead to inaccuracies, as the staff
involved see little purpose in their work.
An efficient information system should routinely collect
only that information for which there is use, and the
cost of which is outweighed by the benefits seen in
Accuracy of information
Major constraints and problems:
- Lack of diagnostic tools
- Lack of skills
- Lack of knowledge
- The level of motivation of the staff involved ?
Who will collect the information?
Much of the information collected depends heavily
on both the skills of the ‘collector’ and how
s/he ‘views’ or interprets reality.
In designing an information system, it is advisable
to obtain only the minimum level of accuracy
required, in order to reduce the attendant costs
of the information system and to maintain the
interest of staff.
Trade-offs are therefore needed between the level
of accuracy and the cost of obtaining it.
Remember the famous saying:
The information you have is not what you want.
The information you want is not what you need.
The information you need is not what you can get.
So the requirements should be very carefully
determined in advance.
A balance needs to be sought; and a crude rule is to
attempt to obtain only the minimum level of
information needed at that time for the decision.
Development of surveillance system
Developing tools for data collection
1- Easy to use in the field.
3- Adaptable to local epidemiological situations
4- Covering all the areas of core indicators
5- Computerized for data capture and analysis
6- Divided into main groups according to the level
and the methods of data collection.
7- All the tools should be pre-coded to facilitate the
development of software for analysis.
Simple data collection,
compilation and analysis
GIS – An Invaluable Tool In Disease
Geographical information systems, remote sensing and
linkage with meteorological information systems will
facilitate the targeting of control measures and require
developing within control programmes, particularly for
malaria, to support the mapping of risk areas,
stratification, epidemic forecasting, and monitoring of
Report of the Technical Advisory Group Meeting
Geneva – 26 to 28 February 1997
Examples from the field
1- Example from Tihama:
The office of the NMCP in Tihama, the highest malaria
endemic area in Yemen, used to be almost a malaria
clinic in the nineties and eighties.
In 2000, during the reinvigoration of the NMCP in
Yemen and based on the situation analysis, the
authorities were convinced that the role of the NMCP
office in Tihama is planning, implementing, monitoring
and evaluating the different NMCP activities and
interventions including training and national capacity
building, supervision, quality control, conducting
surveys and ACD through its outreach or mobile
On the other hand PCD in all the health
institutions including health units, health centres
and hospitals should be strengthened and
improved within the context of early and correct
diagnosis and prompt and effective treatment.
Parallel to the above the information system was
introduced using the new forms and the
machinery for data collection and analysis.
2- Example from Socotra Island:
The epidemiological, entomological and rainfall charts
3- Monitoring the efficacy of AMDs in the sentinel
ACPR: 58% Sa'dah
Failures: Al Jawf
Al Odein 03 Dhamar Shabwah
ACPR: 61% Al Bayda
Failures: 39% Ibb N
(CQ) Al Dala
04 Lahj Brom 04
of (S/P) W.Al Mesemeer 02/03
Currently: ACPR: 43%, Failures: 57%
Madarba 04 S/P & AQ-AS
400 0 400 Kilometers
Key components while developing a
Training (written and handy guidelines – SOPs)
Remuneration - motivation
Supervision – monitoring
A new malaria case notification form
in Socotra island
Surveillance is the ongoing systematic collection, analysis
and interpretation of health data essential to the
planning, implementation and evaluation of public
health practice, closely integrated with the timely
dissemination of these data to those who need to
The final link in the surveillance chain is the
application of these data to prevention and control
or better delivery of service.
Joint vector control operations at the Yemeni Saudi
Epidemics of malaria:
How to deal with an outbreak?
• Establishing the diagnosis
• Reporting the epidemic even before confirming it
• Epidemiologic Case Definition
• Determining whether an epidemic exists
• Characterizing the epidemic by Time, Place and Person:
Epidemic Time Curve
• Managing the cases promptly to prevent deaths and interrupt
• Developing hypothesis regarding source, type, route of spread
• Testing the hypothesis
• Initiating control measures
• Following up Surveillance to evaluate the control measures
Stand-by Epidemic preparedness teams are
• Experienced professional and technical staff
• Organized teams
• Well equipped: drugs, microscopes, glassware
and chemicals, RDTs, ITNs, supportive drugs,
• National Capacity Building…. Imperative and crucial
• Commitment: political, staff and community
• Skills of inter-personal communication
• Motivation ?
- Problem of ‘Brain Drain’
- High level of turnovers
• Sustainability ?
• The need for innovative and creative solutions to
strengthen the surveillance system
1- Epidemiology, Biostatistics, and Preventive Medicine, Second
Edition, By: James F. Jekel, David L. Katz and Joann G.Elmore
2- World Health Forum , volume 16, number 3, 1995
3- ROLL BACK MALARIA
Framework for Monitoring Progress & Evaluating Outcomes
and Impact , WHO/CDS/RBM/2000.25
4- Enhancing Health Services Management
by Steve Cropper and Paul Forte
5- Bruce-Chwatt’s Essential Malariology, third edition