Routine Malaria Surveillance System Yemen experience in implementation Dr Mohammad Ali Khalifa Medic

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Routine Malaria Surveillance SystemYemen
experience in implementationDr Mohammad Ali
KhalifaMedical Officer MalariologistWHO Office
in YemenLuxor, 5-9 December 2004
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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

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• 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

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• 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.

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Principles

• The important principles that were considered
  while establishing the surveillance system in
  Yemen

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• 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.

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• 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.

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• 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.

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• 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?

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• 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.

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• 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.

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• 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.

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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.

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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.

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• 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.

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• 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.

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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.

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• Simple data collection, compilation and analysis
• Vs
• GIS

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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

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Examples from the field
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• 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.

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• 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.

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2- Example from Socotra IslandThe
epidemiological, entomological and rainfall charts
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• 3- Monitoring the efficacy of AMDs in the
  sentinel sites

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Harad 04 ACPR 100 (S/P)
Bajil 02/03 ACPR 58 Failures 42 (CQ)
Al Odein 03 ACPR 61 Failures
39 (CQ) 04 100 ACPR of (S/P) Currently (AQ-AS
)
Brom 04
W.Al Mesemeer 02/03 ACPR 43, Failures
57 (CQ) Currently S/P AQ-AS
Madarba 04
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Key components while developing a surveillance
system

• Training (written and handy guidelines SOPs)
• Remuneration - motivation
• Supervision monitoring
• Quality control
• Feedback
• Evaluation

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• A new malaria case notification form in Socotra
  island

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• 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.

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• Epidemiological Investigation

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• Entomological Surveillance

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Mapping of Anopheline Mosquitoes
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Joint vector control operations at the Yemeni
Saudi border area
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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

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• 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.

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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

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• 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-Chwatts Essential Malariology, third
  edition

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THANK YOU