Routine Malaria Surveillance System by ndy15701

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									Routine Malaria Surveillance
         System

Yemen experience in implementation

       Dr Mohammad Ali Khalifa
       Medical Officer Malariologist
         WHO Office in Yemen
        Luxor, 5-9 December 2004
                 SURVEILLANCE
Definition:
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
  anti-malaria activities.
           Principles


The important principles that were
 considered while establishing the
  surveillance system in Yemen:
■ The development of a surveillance system
  requires:
• clear objectives regarding NMCP (SMART)
• the purposes for which the surveillance is to be
  done, e.g. to monitor the effectiveness of a
  certain intervention.
■ To enable the development of standardized
  reporting procedures and reporting forms, the
  criteria for defining a case of malaria must be
  known.
  The case definition is usually based on clinical
  findings, laboratory results, and epidemiologic
  data concerning the time, place, and persons
  affected.
■ 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
 advance.

■ 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
  sustainability.
■ A pilot test should be performed and evaluated
  in the field, perhaps in one or a few
  demonstration areas, before the full system is
  attempted.
■ When the full system is operational, it too
  should be subjected to continual evaluation.
■ Information is the lifeblood of the planning
  process.
  To be successful, planning needs a combination
  of a ‘rational’ process and political analysis. Both
  of these strands need to be based on
  information.

■ ‘Information is power’.
   A planner with a confident grasp of information
  is in a strong position to convince others of
  her/his case.
■ 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
 as ‘information’.
 Hard information and Soft information are both
 important.
 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
 information.
 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
  improved decision-making.
       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.
Minimum accuracy:
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.
     2- Concise
     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

          Vs

         GIS
GIS – An Invaluable Tool In Disease
       Control Surveillance
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
 control programmes.
      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
  teams.
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
  sites:
                               Harad 04
                              ACPR: 100%
                                 (S/P)


  Bajil 02/03
 ACPR: 58%           Sa'dah




                                                                             h
                                                             t




                                                                          hra
                                                          ou
  Failures:                      Al Jawf




                                                          m




                                                                        Ma
    42%              Amran




                                                       dra
    (CQ)        Hajjah




                                                                       Al
                                                     Ha
                         da




                       Capital Ma'rib
                      day




                      Sana'a
 Al Odein 03            Dhamar        Shabwah
                     u
                 Al H




 ACPR: 61%                   Al Bayda
Failures: 39%            Ibb                                                     N
    (CQ)                  Al Dala
                    Ta'izz          Abyan
      04                    Lahj                                      Brom 04
100% ACPR
   of (S/P)                                  W.Al Mesemeer 02/03
 Currently:                                ACPR: 43%, Failures: 57%
  (AQ-AS)                                           (CQ)
                                                  Currently:
                    Madarba 04                  S/P & AQ-AS

                        400                     0                     400 Kilometers
    Key components while developing a
           surveillance system:
   Training (written and handy guidelines – SOPs)
   Remuneration - motivation
   Supervision – monitoring
   Quality control
   Feedback
   Evaluation
A new malaria case notification form
         in Socotra island
Definition:
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.
Epidemiological Investigation
Entomological Surveillance
     Mapping of
Anopheline Mosquitoes
Joint vector control operations at the Yemeni Saudi
                     border area
             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
    transmission
•   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
  available:
• Experienced professional and technical staff
• Organized teams
• Well equipped: drugs, microscopes, glassware
  and chemicals, RDTs, ITNs, supportive drugs,
  etc.
                  Challenges:
•  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
References:
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

								
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