Five steps to wrap technology and optimize impact: community malaria surveillance for elimination in Zambia

Five steps to wrap technology and optimize impact: community malaria surveillance for elimination in Zambia

By Anna Winters on December 5, 2018 in Malaria, News

Image caption: Community health workers (CHWs) provide malaria testing and treatment; line-lists in paper registers and aggregated by “data” CHWs and submitted to the DHIS2. Malaria data are mapped to both CHW posts and health facilities.

Akros supports countries and their partners to design, test, and deploy interventions to scale for impact. Often this involves supporting governments to transition from paper-based to digital data collection and reporting. Below is a case study which outlines our approach of applying simple technology that is wrapped in the necessary processes, protocols, and trainings to deliver quality data and build intervention impact that scales.

Component D was initially implemented in districts of Southern, Central, and Western Province, Zambia. Now multiple partners are supporting the rapid scale up of Component D across Zambia, improving malaria surveillance data, while also expanding access to care across the country. Thanks to PATH-MACEPA for this map.

The Government of Zambia (GRZ) has an ambitious goal of malaria elimination by 2021. One approach to achieve this goal is to improve malaria surveillance at the community level. Akros worked alongside the National Malaria Elimination Program and PATH-MACEPA to develop a community-based malaria surveillance system called “Component D.” The goal of Component D is to build community structures that will increase access to malaria testing and treating, identify and eliminate parasite reservoirs, and understand where (within health facility catchments) malaria transmission is happening. Effectively: to better understand and respond to the “needle in the haystack” which malaria can often be.

To assist the GRZ, Akros applied its five-part approach of “wrapping” technology with the processes, protocols, and training that ensure the technology contributes to impact and is able to scale:

  1. Discover and assess—we explored the systems that were already in place in Zambia, evaluated the data needs, and identified the change agents that needed to understand and action information.
  2. Build a “prototype design”—we leveraged simple technology (java feature phones and open data kit software) and documented and developed the processes, protocols, training materials, and supervision needed to support that technology and make it sustainable. We built feedback loops to assist programs to respond to those data.
  3. Work with country governments and partners to test the design through small-scale implementation—we implemented Component D in Southern, Central, and Lusaka Province, Zambia.
  4. Wrap that implementation with research to understand cost efficiency and disease impact—we learned that Component D was one of the primary drivers expanding access to care and treating reservoirs of parasite infection.
  5. Work with our host governments and partners to iterate and smartly scale—from its initial small-scale implementation, Component D has become country policy. Since then, numerous partners and GRZ have now expanded to 36 districts in Zambia.

Did the country switch over to the new system en masse or was there a pilot area / time period? How was this decided? Discovery and assessment processes began in 2009, leading to implementation throughout several districts in Southern, Central, and Lusaka Province over a period of three years. These districts were determined based upon their malaria burden and their existing leadership being open to leveraging community health worker (CHW) activity to better understand the malaria burden at local levels. Component D has now become the GRZ policy for malaria surveillance in malaria elimination districts. Isdell Flowers, PATH-MACEPA, the Global Fund, USAID PMI, and others are leveraging their resources to assist GRZ to continue to expand and improve Component D.

Was there duplicative reporting on the legacy system during the transition period? Component D brought more rigorous “structure” to existing CHW registers, but still relied on the familiarity of these registers while also introducing simple aggregation processes for digital reporting of data.

What measures did you use (or are you using) to validate that data in the new system is adequately high quality in order to build confidence in the new system’s data and switch off the legacy system? Data validation includes periodic record reviews validating CHW registers with aggregated figures, locations and stock use, and in-built validations within the DHIS2.

What resources (e.g., licensing costs, technical support, new printed training materials) were required in order to make the transition? Resources required to transition toward digital data have been the greatest up front, including technical support to prototype and implement, cascade training costs, and initial “supervision visits” to support system continuity and health. As the system has become embedded in the GRZ, external supervision visits have reduced, while internal GRZ supervision has increased.

What have been some of the impacts of this system?

  • The proportion of children with fever to malaria testing increased from only 9% prior to CHW scale-up to 81% by 2017.
  • Parasite prevalence fell from the normal range of ~30% down to 4% by 2016 and remained stable.
  • Access to care doubled.
  • Community malaria data became available at central and district levels, which was not previously available. These data guide health facility stocking and intervention prioritization and planning.
  • Sub-health facility malaria data now available and mapped within DHIS2.
Component D utilizes a reactive case detection approach to follow-up with malaria cases (index cases) identified at clinics or community health worker posts by testing and treating neighbors of that index case. Figure from: https://www.ncbi.nlm.nih.gov/pubmed/26586264.

 

Links to more information:

https://www.nmec.org.zm/enhanced-surveillance

https://www.ncbi.nlm.nih.gov/pubmed/26586264

https://akros.com/malaria-prevention/community-surveillance/

About Anna Winters, PhD

Anna Winters founded and serves as the CEO of Akros. Winters holds a PhD and MS in epidemiology coupled with extensive field experience leading the development and implementation of community-wide surveillance systems in sub-saharan Africa aimed at targeting health interventions to maximize impact. Through Akros and previously with the Centers for Disease Control and Prevention, Dr. Winters works directly with host country governments to ensure viability and integration of health innovations. Contact her at awinters@akros.com

Prioritizing Interventions – Targeting IRS to Maximize Effectiveness

Prioritizing Interventions – Targeting IRS to Maximize Effectiveness

By Annie Martin on October 30, 2018 in Malaria, News

A team of IRS spray operators prepare for the 2017 spraying season.

Malaria kills a staggering number of people every year — nearly half a million. That number is unacceptable given malaria is both preventable and treatable and somewhat surprising given donors and governments spend hundreds of millions of dollars each year attempting to control malaria.

So why is that number still so high? Well, first of all, malaria is primarily in countries with largely rural and hard to reach populations. Getting to those populations is logistically complicated and costly. Secondly, the mosquitos that transmit malaria quickly adapt to resist insecticides and to evade interventions. Thirdly, the scale of the problem is massive. While there are half a million deaths and over 200 million cases annually, the population at risk is even larger – half of the global population. Half of seven billion people are at risk for malaria.

With this context, hundreds of millions of dollars in control efforts begins to sound like a drop in the bucket. In order to make the most of the resources at hand, we must maximize the impact of each dollar spent. For example, interventions like indoor residual spraying (IRS) – where spray operators move household to household spraying the walls of homes with insecticide in order to kill the malaria transmitting mosquitoes – are very effective at killing mosquitoes and reducing malaria. However, IRS is expensive. We need to ensure we are distributing IRS resources in the most strategic and likely most impactful way.

In 2017, Akros worked with the Zambia National Malaria Elimination Centre (NMEC), the Africa Indoor Residual Spray (AIRS) Project implemented by Abt Associates, and the U.S. President’s Malaria Initiative (PMI) to conduct a comparison control trial of IRS prioritization strategies. The question was simple: If we do not have enough resources to spray every house, where should we spray to see the greatest decreases in malaria incidence? Should we spray one condensed geographic area? Should we spray the areas near the health centers with the highest burden of malaria? Or, should we spray the areas predicted to have the most mosquitoes? Each of these questions defined an arm of the study; one arm targeted IRS by concentrating it in one geographic area, one arm targeted IRS by prioritizing its delivery by health facility-measured malaria burden, and one arm targeted IRS by prioritizing its delivery by predicted mosquito density due to ecological factors. The NMEC implemented each arm in two districts of Eastern Province during the 2017 IRS operations.

Finding a village never before visited by IRS

Finding a village never before visited by IRS

By Ernest Mulenga on March 8, 2018 in Malaria, News

Background

The mSpray tool is more than just a mobile data collection tool that improves data quality and timeliness. The mSpray tool provides spray teams with maps to navigate to areas that might otherwise be difficult to find. These maps are highly accurate and complete, made through our satellite enumeration process. The district mop-up teams are especially reliant on these maps. Mop-up teams, are teams designated by the district with the specific task of revisiting areas that were not sprayed well during an initial visit or areas that were missed completely.

Unsurprisingly, mop-up teams help more areas reach the coverage goal of 90% sprayed and these teams visit some of the most remote villages, some of which have never been visited before. Ernest Mulenga, an Akros Surveillance Officer, documents the Chadiza’s mop-up team visit to a village; because the the team relies heavily on maps to navigate, they adopt vernacular of mapping and navigation, referring to the villages by the codes assigned to the “polygon” shapes appearing on the maps.

The search for polygon 01-455

It was the 9th of November 2017 when the mop-up team left Chadiza IRS base in search of Polygon 01-455 under Mtaya catchment area, which is located to eastern side of Chadiza district about 45 km from the district main post office.

Passing through Ngala area under Miti catchment, the team made a first stop at polygon 01-457 around 11:00 before proceeding to 01-455. The team used the GPS locator on the mSpray application, to navigate to a road that would lead to the village. Discovering the road to be impassable due to flooding from the heavy rain the team was re-directed by locals to a path that went through the mountain, and was said to be passable with a vehicle.

The Mtaya catchment area. The spray team was progressing through this area when they found polygon 01-455, which had never before been visited by a spray team.

The journey through the mountain started off well. After climbing some distance, however, the path became too filled with potholes for the Land Cruiser to continue. The team was left with no choice but to complete the journey on foot. At this point the team felt that they had covered a considerable distance with the Cruiser and that the polygon must not be far off. Thus, the team began to move with the aid of a GPS on the tablet. Once the direction of walking was set, the tablet was switched off for fear of using too much battery power.

USAID Awards Global Contract to PSI and Partners to Advance Malaria Service Delivery in 28 Countries

USAID Awards Global Contract to PSI and Partners to Advance Malaria Service Delivery in 28 Countries

By Akros Media on February 26, 2018 in Malaria, News

We are excited to announce that PSI has been successfully awarded a new contract by USAID to support the President’s Malaria Initiative (PMI) to Advance the Progress of Malaria Service Delivery (APMSD) in 28 malaria-affected countries and selected Akros as an implementing partner. The project, worth over $160 million USD over five years, will be delivered by a consortium of core partners, led by PSI and including JHPIEGO, Medical Care Development International (MCDI) and University of California-San Francisco.

The project will focus on supporting national malaria control programs in USAID-supported Malaria Endemic countries including 25 in Africa and three in Asia. The interventions aim to improve quality of and access to malaria case management and malaria in pregnancy interventions. They will also improve quality of and access to other malaria drug-based approaches and provide support to pilot/scale-up newer malaria drug-based approaches. Global technical leadership, support for operational research, and advances in program learning are priorities as well. In addition to the core team, private sector partner Akros and University of Oslo and Medicines for Malaria Venture will support.

Akros will lean into its experience working with national ministries by leading efforts on strengthening capacity building of Ministries of Health (MoHs) for HMIS and executing a central strategic plan around data use within the MoHs and communities.

Globally, the world has made remarkable progress in controlling malaria; halving the burden of disease between 2000 and 2015, but progress is stalling. The WHO’s most recent World Malaria Report highlights the current state of case management of children under five years and delivery of intermittent presumptive treatment for pregnant women as major concerns.

The President’s Malaria Initiative, led by USAID and implemented with the U.S. Centers for Disease Control and Prevention, is the U.S. Government’s primary vehicle for assisting malaria affected countries to scale up proven malaria control and elimination interventions.

The PMI Strategy for 2015-2020 accounts for much progress over the past decade and offers a strategy for new and emerging challenges. Malaria prevention and control remains a major U.S. foreign assistance objective and PMI’s strategy fully aligns with the U.S. Government’s vision of ending preventable child and maternal deaths and protecting communities from infectious diseases. By working with PMI-supported countries and partners, the U.S. Government aims to further reduce malaria deaths and substantially decrease malaria morbidity, towards the long-term goal of elimination.

This new contract comes as PSI launches its new global strategy for consumer-powered healthcare. APMSD will innovate ways to bring healthcare closer to the consumer in developing countries. PSI is proud to be associated with USAID and its partners to achieve this goal.

Akros featured in recent reports

Akros featured in recent reports

By Akros Media on August 28, 2017 in Capacity Building, Health Data Systems, Malaria, News, Uncategorized, Water and Sanitation Health

We strive to be consistently on the cutting edge of the development and technology sector. And the cutting edge does not form without a stalwart commitment to research and a collecting of best practices. We are excited to have been mentioned in several recent pieces of independent research as having implemented technologies and systems that are furthering development work around the world.


Mobile Solutions for Malaria Elimination Surveillance Systems: A Roadmap

The first is in a report titled “Mobile Solutions for Malaria Elimination Surveillance Systems: A Roadmap” funded by the Gates Foundation and carried out by Vital Wave. The study was done to “develop key recommendations regarding appropriate, scalable strategies to promote further innovation and coordination among technology partners” and to “Develop specific recommendations for a coherent and effective Foundation strategy for strengthening data collection systems and associated platforms.” Our mSpray system was featured as a highlight of the geolocation category for the way it increases the efficiency and effectiveness of indoor residual spraying (IRS) campaigns (page 48 of the report).

In its conclusions and recommendations, the report points out that “many of the key elements needed to improve the development and implementation of robust mobile tools for malaria surveillance already exist.” It also says that coordination among malaria program implementers will be key to success and will help keep current the list of necessary features within these digital tools.

The Elimination 8 Regional Surveillance Database (ERSD)

The Elimination 8 Regional Surveillance Database (ERSD)

By Annie Martin on May 8, 2017 in Capacity Building, Health Data Systems, Malaria, News

To achieve malaria elimination, an understanding of neighboring country malaria situations is critical for the prevention of introduction of parasites. Malaria parasites don’t stop at country borders, so effective elimination strategies shouldn’t either. That is why the Elimination 8 (E8), in its strategy on cross-border collaboration, identified Akros to support the development of the E8 Regional Surveillance Database System (ERSD) for the eight member states constituting the E8: Botswana, Namibia, South Africa, Swaziland, Angola, Mozambique, Zambia, and Zimbabwe. This innovative approach is a means to level the playing field and conduct malaria surveillance at a regional scale.

Figure 1. Cross-border incidence* in districts in Zambia, Mozambique, and Zimbabwe: Having access to several countries in one database allows these kinds of visualizations, which may highlight transmission patterns that occur between countries, which in turn supports decisions to invest in control methods in border areas.
*All data shown is used purely for illustrative purposes and do not reflect current or historic epidemiological status of countries. Current data can be accessed in the database itself by those granted authority.

Malaria is hardly an emerging disease, and though the interventions of preventing, treating, and monitoring malaria are somewhat standardized, each country has slight permutations of their approach to doing so. Indicators may differ slightly, investment in one prevention method versus another likely differs too, and policies surrounding implementation certainly are not identical.

Akros-led consortium to develop Elimination 8 regional malaria database

Akros-led consortium to develop Elimination 8 regional malaria database

By Akros Media on August 19, 2016 in Malaria, News

We are excited to announce that an Akros-led consortium has been selected to develop a regional malaria surveillance platform for a coordinated, eight-country effort to achieve the historic goal of eliminating malaria in eight southern African countries. The Southern African Malaria Elimination 8 (E8) is a partnership between Botswana, Namibia, South Africa, Swaziland, Angola, Mozambique, Zambia, and Zimbabwe. The first four of these countries (frontline countries) have an elimination goal of 2020, and the later four (second line countries) hold a goal of elimination by 2030. Consortium members working with Akros include HISP-SA and Compre Health.

E8 countries reported a tremendous reduction of malaria cases of more than 50% since 2004. However, the closer we get to elimination, the better surveillance we must have. Malaria does not respect borders, meaning the four eliminating countries cannot eliminate as long as high transmission remains within the region, and human migratory patterns facilitate parasite movement from more highly endemic countries. Therefore, new regional strategies are needed to support the surveillance and control efforts by the second line countries in order to reduce the reservoir of malaria parasites which have a potential for cross border spread of infections that could re-establish infection in the frontline four countries. As frontline countries progress towards malaria elimination, second-line countries are intensifying their malaria control efforts in order to achieve pre-elimination status.

The knowledge of malaria trends between countries will be one of the main factors influencing the success of malaria elimination. To facilitate the ease of information sharing, the E8 working with the consortium have developed a regional database, which will sit within the District Health Information System (DHIS 2), a system already familiar to many of the 8 countries. The regional database will not be a parallel system — no new malaria data elements or indicators will be collected. Rather several malaria data indicators already captured in countries will be shared amongst countries via the regional database. This is in-line with E8 country-level commitments to malaria data sharing in efforts to eliminate the disease. The more data we have consistently and accurately, the better we can plan and target relevant interventions that will drive the malaria burden in southern Africa down to zero.

Reflections on ASTMH Conference 2015

Reflections on ASTMH Conference 2015

By Sandra Chishimba on January 21, 2016 in Capacity Building, Malaria, News

First and foremost, I wish to acknowledge the travel funds from Akros for providing me a great opportunity allowing me to attend the 2015 annual meeting American Society for Tropical Medicine and Hygiene (ASTMH). ASTMH is an interdisciplinary organization for the field of tropical medicine, and the annual meeting is for all scientists whose work is in tropical medicine around the world. The research topics ranged from basic science to clinical research. The conference program was divided into two blocks: oral presentations and poster presentations. Presentations of interest to the general audience were arranged for the morning and afternoon. The poster sessions were scheduled for lunch time.

The meeting began on Sunday evening with the keynote lecture given by an eminent scientist, Rajiv Shah MD who formerly opened the meetings. During this session we also had a moment of silence in honour of the former late president Dr Allan McGill who died suddenly.

The oral presentations were about 15 minutes each. The presenters were clinicians, researchers, PhD students, postdoctoral fellows and some MSc students. The presentations were of high quality cutting edge science research and a broad range of topics were covered. The topics were subdivided into Global health, Clinical, Virology, Molecular, Cellular, and Immunoparasitology research. Much emphasis was made on combating new infections during the global health discussions. This was with reference to the most recent outbreak of Ebola in West Africa. It was clear that the research field, and health systems around the world, need to be strengthened and prepared in the event of a major disease outbreak. Malaria research was a topic not to be missed. New cutting edge techniques on how to investigate ultra-low infections as malaria elimination is being implemented in several countries were presented. Such ideas work to our advantage as we can then interact personally with the researchers by asking questions in person at the meeting and after the meeting in the event that we decide to follow up on the idea for our research.

How Zambia is Tackling Malaria

How Zambia is Tackling Malaria

By Alexis Barnes on December 11, 2015 in Malaria, News

Click here to view original publication in Africa Times.

Five-year-old Melanie lives on the outskirts of Lusaka, Zambia’s capital city in Chainda compound, a settlement that is less than one square kilometer (.24 square mile) yet houses approximately 26,000 people. She spends her days running around the maze of dirt roads and alleyways, playing with the dozen siblings and neighbor children near her brick and mud home.

In late July she tested positive for malaria at Chainda Clinic, her small body exhibiting some of the most common symptoms, fever and chills, of a disease that affects approximately four million and kills 8,000 Zambians annually, according to UNICEF. More than 50 percent of those killed by the disease are children under the age of five.

Her positive malaria test immediately set off a chain of events. A Reactive Case Detection team, including a nurse, environmental health technologist and community health worker, dispatched to Melanie’s neighborhood. Within 90 minutes, the team tested family members and the nearest neighbors. The GPS locations of the homes and the test findings were then entered into a tablet- painting an on the ground real time picture of malaria statistics in that neighborhood of Lusaka.

Chainda Clinic is a part of a community led surveillance initiative, called Step D, taking hold in selected parts of Zambia. The Zambia Ministry of Health and the National Malaria Control Center (NMCC) in partnership with organization, Akros, are working to create five malaria-free zones by 2015, as proposed in the Zambia National Malaria Strategic Plan (2011-2016).

The first of its kind on the African continent, the community health worker malaria surveillance network mixes community mobilization and simple technology to tackle malaria in Zambia.

“In the past we used paper-based forms to collect data from the field and would send them to National Malaria Control Centre physically,” said Mwila Sianankange, an environmental health technologist (EHT) at Chainda Clinic. “This would take a much longer reporting time period.”

Health Worker Continues Commitment to Malaria Elimination Despite Injury

Health Worker Continues Commitment to Malaria Elimination Despite Injury

By Alexis Barnes on September 24, 2015 in Malaria, News

When Cairo Situlo learned of a new surveillance system that mobilizes community members and data, he sprung into action volunteering his time tracking down sources of malaria cases. He volunteers in the Southern Province Zambian city of Zimba to fight malaria in his community.

Mr. Situlo's x-ray, showing his orthopedic surgery.
Mr. Situlo’s x-ray, showing his orthopedic surgery.

When a health facility or post receives a malaria-infected patient, it alerts community health workers (CHWs) near the patient’s household. The CHWs then open a case investigation- testing surrounding households and giving treatment where applicable.

Committed community health workers like Cairo are vital to the system and their work has increased access to care in rural areas of Zambia, stopping transmission of the disease. Nowhere was Mr. Situlo’s commitment more evident than following his accident in late 2014.