The accuracy of clinical malaria case reporting at primary health care facilities in Honiara, Solomon Islands

Evaluation of the malaria reporting system supported by the District Health Information System 2 in Solomon Islands

Background

District Health Information Systems 2 (DHIS2) is used for supporting health information management in 67 countries, including Solomon Islands. However, there have been few published evaluations of the performance of DHIS2-enhanced disease reporting systems, in particular for monitoring infectious diseases such as malaria. The aim of this study was to evaluate DHIS2 supported malaria reporting in Solomon Islands and to develop recommendations for improving the system.

Methods

The evaluation was conducted in three administrative areas of Solomon Islands: Honoria City Council, and Malaita and Guadalcanal Provinces. Records of nine malaria indicators including report submission date, total malaria cases, Plasmodium falciparum case record, Plasmodium vivax case record, clinical malaria, malaria diagnosed with microscopy, malaria diagnosed with (rapid diagnostic test) (RDT), record of drug stocks and records of RDT stocks from 1st January to 31st December 2016 were extracted from the DHIS2 database. The indicators permitted assessment in four core areas: availability, completeness, timeliness and reliability. To explore perceptions and point of view of the stakeholders on the performance of the malaria case reporting system, focus group discussions were conducted with health centre nurses, whilst in-depth interviews were conducted with stakeholder representatives from government (province and national) staff and World Health Organization officials who were users of DHIS2.

Results

Data were extracted from nine health centres in Honoria City Council and 64 health centres in Malaita Province. The completeness and timeliness from the two provinces of all nine indicators were 28.2% and 5.1%, respectively. The most reliable indicator in DHIS2 was ‘clinical malaria’ (i.e. numbers of clinically diagnosed malaria cases) with 62.4% reliability. Challenges to completeness were a lack of supervision, limited feedback, high workload, and a lack of training and refresher courses. Health centres located in geographically remote areas, a lack of regular transport, high workload and too many variables in the reporting forms led to delays in timely reporting. Reliability of reports was impacted by a lack of technical professionals such as statisticians and unavailability of tally sheets and reporting forms.

Conclusion

The availability, completeness, timeliness and reliability of nine malaria indicators collected in DHIS2 were variable within the study area, but generally low. Continued onsite support, supervision, feedback and additional enhancements, such as electronic reporting will be required to further improve the malaria reporting system.

Molecular epidemiology of residual Plasmodium vivax transmission in a paediatric cohort in Solomon Islands

Background

Following the scale-up of intervention efforts, malaria burden has decreased dramatically in Solomon Islands (SI). Submicroscopic and asymptomatic Plasmodium vivax infections are now the major challenge for malaria elimination in this country. Since children have higher risk of contracting malaria, this study investigated the dynamics of Plasmodium spp. infections among children including the associated risk factors of residual P. vivax burden.

Methods

An observational cohort study was conducted among 860 children aged 0.5–12 years in Ngella (Central Islands Province, SI). Children were monitored by active and passive surveillances for Plasmodium spp. infections and illness. Parasites were detected by quantitative real-time PCR (qPCR) and genotyped. Comprehensive statistical analyses of P. vivax infection prevalence, molecular force of blood stage infection (_molFOB) and infection density were conducted.

Results

Plasmodium vivax infections were common (overall prevalence: 11.9%), whereas Plasmodium falciparum infections were rare (0.3%) but persistent. Although children acquire an average of 1.1 genetically distinct P. vivax blood-stage infections per year, there was significant geographic heterogeneity in the risks of P. vivax infections across Ngella (prevalence: 1.2–47.4%, p < 0.01; _molFOB: 0.05–4.6/year, p < 0.01). Malaria incidence was low (IR: 0.05 episodes/year-at-risk). Age and measures of high exposure were the key risk factors for P. vivax infections and disease. Malaria incidence and infection density decreased with age, indicating significant acquisition of immunity. G6PD deficient children (10.8%) that did not receive primaquine treatment had a significantly higher prevalence (_aOR: 1.77, p = 0.01) and increased risk of acquiring new bloodstage infections (_molFOB _aIRR: 1.51, p = 0.03), underscoring the importance of anti-relapse treatment.

Conclusion

Residual malaria transmission in Ngella exhibits strong heterogeneity and is characterized by a high proportion of submicroscopic and asymptomatic P. vivax infections, alongside sporadic P. falciparum infections. Implementing an appropriate primaquine treatment policy to prevent P. vivax relapses and specific targeting of control interventions to high risk areas will be required to accelerate ongoing control and elimination activities.

Electronic supplementary material

The online version of this article (10.1186/s12936-019-2727-9) contains supplementary material, which is available to authorized users.

Mapping a Plasmodium transmission spatial suitability index in Solomon Islands: a malaria monitoring and control tool

BACKGROUND

Malaria remains a challenge in Solomon Islands, despite government efforts to implement a coordinated control programme. This programme resulted in a dramatic decrease in the number of cases and mortality however, malaria incidence remains high in the three most populated provinces. Anopheles farauti is the primary malaria vector and a better understanding of the spatial patterns parasite transmission is required in order to implement effective control measures. Previous entomological studies provide information on the ecological preferences of An. farauti but this information has never before been gathered and "translated" in useful tools as maps that provide information at both the national level and at the scale of villages, thus enabling local targeted control measures.

METHODS

A literature review and consultation with entomology experts were used to determine and select environmental preferences of An. farauti. Remote sensing images were processed to translate these preferences into geolocated information to allow them to be used as the basis for a Transmission Suitability Index (TSI). Validation was developed from independent previous entomological studies with georeferenced locations of An. farauti. Then, TSI was autoscaled to ten classes for mapping.

RESULTS

Key environmental preferences for the An. farauti were: distance to coastline, elevation, and availability of water sources. Based on these variables, a model was developed to provide a TSI. This TSI was developed using GIS and remote sensing image processing, resulting in maps and GIS raster layer for all the eight provinces and Honiara City at a 250 m spatial resolution. For a TSI ranging from 0 as not suitable to 13 as most suitable, all the previous collections of An. farauti had mean TSI value between 9 and 11 and were significantly higher than where the vector was searched for and absent. Resulting maps were provided after autoscaling the TSI into ten classes from 0 to 9 for visual clarity.

CONCLUSIONS

The TSI model developed here provides useful predictions of likely malaria transmission larval sources based on the environmental preferences of the mosquito, An. farauti. These predictions can provide sufficient lead-time for agencies to target malaria prevention and control measures and can assist with effective deployment of limited resources. As the model is built on the known environmental preferences of An. farauti, the model should be completed and updated as soon as new information is available. Because the model did not include any other malaria transmission factors such as care availability, diagnostic time, treatment, prevention, and entomological parameters other than the ecological preferences neither, our suitability mapping represents the upper bound of transmission areas. The results of this study can now being used as the basis of a malaria monitoring system which has been jointly implemented by the Solomon Islands National Vector Borne Disease Control Programme, the Solomon Islands Meteorological Services and the Australian Bureau of Meteorology. The TSI model development method can be applied to other regions of the world where this mosquito occurs and could be adapted for other species.

Utility of passive malaria surveillance in hospitals as a surrogate to community infection transmission dynamics in western Kenya

Background

Malaria continued to be the major public health concern in sub-Sahara Africa, thus for better planning of control activities, periodic surveillance of both clinical and asymptomatic cases remains important. However, the usability of routinely collected malaria data in Kenyan hospitals as a predictor of the asymptomatic malaria infection in the community amidst rapid infection resurgence or reduction in different areas of disease endemicities remains widely unstudied. This study was therefore aimed to evaluate the utility of passive surveillance of malaria in health facilities as a proxy of infection transmission of the surrounding community in different transmission intensities.

Methods

Prospective multiple cross-sectional surveys were done in three villages in western Kenya. Monthly asymptomatic malaria positivity among school children, number of outpatient (OPD) confirmed malaria cases and abundancy of indoor resting malaria vectors were surveyed from June 2015 to August 2016. Community surveys on antimalarial drug use among adults and children were also done. Detection of malaria parasitaemia was done using thick and thin Giemsa stained blood slide microscopy for both clinical and school participants. A questionnaire was used to collect information on self-use of antimalarial drugs from randomly selected households.

Results

The overall OPD blood slide positivity from all study sites was 26.6% (95%CI 26.2–27.0) and highest being among the 5–14 years (41.2% (95% CI 40.1–42.3). Asymptomatic malaria positivity among the school children were 6.4% (95%CI 5.3–7.5) and 38.3% (95%CI 36.1–40.5) in low and high transmission settings respectively. A strong correlation between overall monthly OPD positivity and the school age children positivity was evident at Marani (low transmission) (rho = 0.78, p = 0.001) and at Iguhu (Moderate transmission) (rho = 0.61, p = 0.02). The high transmission setting (Kombewa) showed no significant correlation (rho = − 0.039, p = 0.89).

Conclusion

Hospital malaria data from low and moderate malaria transmission predicted the infection transmission dynamics of the surrounding community. In endemic sites, hospital based passive surveillance didn’t predict the asymptomatic infection dynamics in the respective community.

Electronic supplementary material

The online version of this article (10.1186/s13690-018-0288-y) contains supplementary material, which is available to authorized users.

"Every day they keep adding new tools but they don't take any away": Producing indicators for intermittent preventive treatment for malaria in pregnancy (IPTp) from routine data in Kenya

BACKGROUND

Intermittent preventive treatment for malaria in pregnancy (IPTp) is part of a multi-pronged strategy aimed at preventing malaria in pregnancy in areas of moderate to high transmission in sub-Saharan Africa. Despite being formally adopted as a malaria prevention policy over a decade ago, IPTp coverage has remained low. Recent demands for action have incorporated calls to strengthen IPTp monitoring and evaluation systems, including the use of routine data, to measure coverage, track implementation and identify roadblocks to improving uptake. Concerns about the quality of malaria indicators reported through routine information systems are well recognized, but there are few data on the realities of IPTp recording practices in frontline facilities or their entry into District Health Information Software (DHIS2).

METHODS

Drawing on fieldwork conducted in two malaria endemic sub-counties in Kenya, we explore how local adaptations and innovations employed by health workers and sub-country managers to cope with a range of health system constraints, shape recording practices and in turn, the measurement of IPTp. Data were collected through observations, interviews, and document reviews. Data analysis and interpretation was guided by thematic analysis approach.

RESULTS

Measurement of IPTp was undermined by health system constraints such as stock-out of drugs and human resource shortages. Coping strategies adopted by health workers to address these challenges ensured continuity in service delivery and IPTp data generation but had variable consequences on IPTp data quality. Unclear recording and reporting instructions also led to lack of standardization in IPTp data generation. The use of redundant tools created significant data burdens which undermined service delivery in general.

CONCLUSIONS

There is need to integrate monthly reporting forms so as to remove redundancies which exacerbates workload for health workers and disrupts service delivery. Similarly, data collection instructions in registers and reporting forms need to be clarified to standardize IPTp data generation across health facilities. There is also need to address broader contextual factors such as stock-out of commodities and human resource shortages which undermine IPTp data generation process.

Data reporting constraints for the lymphatic filariasis mass drug administration activities in two districts in Ghana: A qualitative study

OBJECTIVES

Timely and accurate health data are important for objective decision making and policy formulation. However, little evidence exists to explain why poor quality routine health data persist. This study examined the constraints to data reporting for the lymphatic filariasis mass drug administration programme in two districts in Ghana. This qualitative study focused on timeliness and accuracy of mass drug administration reports submitted by community health volunteers.

METHODS

The study is nested within a larger study focusing on the feasibility of mobile phone technology for the lymphatic filariasis programme. Using an exploratory study design, data were obtained through in-depth interviews (n = 7) with programme supervisors and focus group discussions (n = 4) with community health volunteers. Results were analysed using thematic content analysis.

RESULTS

Reasons for delays in reporting were attributed to poor numeracy skills among community health volunteers, difficult physical access to communities, high supervisor workload, poor adherence reporting deadlines, difficulty in reaching communities within allocated time and untimely release of programme funds. Poor accuracy of data was mainly attributed to inadequate motivation for community health volunteers and difficulty calculating summaries.

CONCLUSION

This study has shown that there are relevant issues that need to be addressed in order to improve the quality of lymphatic filariasis treatment coverage reports. Some of the factors identified are problems within the health system; others are specific to the community health volunteers and the lymphatic filariasis programme. Steps such as training on data reporting should be intensified for community health volunteers, allowances for community health volunteers should be re-evaluated and other non-monetary incentives should be provided for community health volunteers.

Comparison of routine health management information system versus enhanced inpatient malaria surveillance for estimating the burden of malaria among children admitted to four hospitals in Uganda

The primary source of malaria surveillance data in Uganda is the Health Management Information System (HMIS), which does not require laboratory confirmation of reported malaria cases. To improve data quality, an enhanced inpatient malaria surveillance system (EIMSS) was implemented with emphasis on malaria testing of all children admitted in select hospitals. Data were compared between the HMIS and the EIMSS at four hospitals over a period of 12 months. After the implementation of the EIMSS, over 96% of admitted children under 5 years of age underwent laboratory testing for malaria. The HMIS significantly overreported the proportion of children under 5 years of age admitted with malaria (average absolute difference = 19%, range = 8-27% across the four hospitals) compared with the EIMSS. To improve the quality of the HMIS data for malaria surveillance, the National Malaria Control Program should, in addition to increasing malaria testing rates, focus on linking laboratory test results to reported malaria cases.

A marked decline in the incidence of malaria in a remote region of Malaita, Solomon Islands, 2008 to 2013

SETTING

Atoifi Adventist Hospital (AAH), Solomon Islands, the only hospital in the East Kwaio region.

OBJECTIVE

To use routine surveillance data to assess the trends in malaria from 2008 to 2013.

DESIGN

Descriptive study of records from (1) AAH laboratory malaria records; (2) admissions to AAH for malaria; and (3) malaria treatments from outpatient records.

RESULTS

AAH examined 35 608 blood films and diagnosed malaria in 4443 samples comprised of 2667 Plasmodium falciparum (Pf) and 1776 Plasmodium vivax (Pv). Between 2008 and 2013 the total number of malaria cases detected annually decreased by 86.5%, Pf by 96.7% and Pv by 65.3%. The ratio of Pf to Pv reversed in 2010 from 2.06 in 2008 to 0.19 in 2013. For 2013, Pf showed a seasonal pattern with no cases diagnosed in four months. From 2008 to 2013 admissions in AAH for malaria declined by 90.8%, and malaria mortality fell from 54 per 100 000 to zero. The annual parasite index (API) for 2008 and 2013 was 195 and 24, respectively. Village API has identified a group of villages with higher malaria incidence rates.

CONCLUSION

The decline in malaria cases in the AAH catchment area has been spectacular, particularly for Pf. This was supported by three sources of hospital surveillance data (laboratory, admissions and treatment records). The decline was associated with the use of artemisinin-based combined therapy and improved vertical social capital between the AAH and the local communities. Calculating village-specific API has highlighted which villages need to be targeted by the AAH malaria control team.

Theoretical investigation of malaria prevalence in two Indian cities using the response surface method

Background

Elucidation of the relationships between malaria incidence and climatic and non-climatic factors in a region is of utmost importance in understanding the causative factors of disease spread and design of control strategies. Very often malaria prevalence data is restricted to short time scales (months to few years). This demands application of rigorous statistical modelling techniques for analysis and prediction. The monthly malaria prevalence data for three to five years from two cities in southern India, situated in two different climatic zones, are studied to capture their dependence on climatic factors.

Methods

The statistical technique of response surface method (RSM) is applied for the first time to study any epidemiological data. A new step-by-step model reduction technique is proposed to refine the initial model obtained from RSM. This provides a simpler structure and gives better fit. This combined approach is applied to two types of epidemiological data (Slide Positivity Rates values and Total Malaria cases), for two cities in India with varying strengths of disease prevalence and environmental conditions.

Results

The study on these data sets reveals that RSM can be used successfully to elucidate the important environmental factors influencing the transmission of the disease by analysing short epidemiological time series. The proposed approach has high predictive ability over relatively long time horizons.

Conclusions

This method promises to provide reliable forecast of malaria incidence across varying environmental conditions, which may help in designing useful control programmes for malaria.

Estimating the global clinical burden of Plasmodium falciparum malaria in 2007

BACKGROUND

The epidemiology of malaria makes surveillance-based methods of estimating its disease burden problematic. Cartographic approaches have provided alternative malaria burden estimates, but there remains widespread misunderstanding about their derivation and fidelity. The aims of this study are to present a new cartographic technique and its application for deriving global clinical burden estimates of Plasmodium falciparum malaria for 2007, and to compare these estimates and their likely precision with those derived under existing surveillance-based approaches.

METHODS AND FINDINGS

In seven of the 87 countries endemic for P. falciparum malaria, the health reporting infrastructure was deemed sufficiently rigorous for case reports to be used verbatim. In the remaining countries, the mapped extent of unstable and stable P. falciparum malaria transmission was first determined. Estimates of the plausible incidence range of clinical cases were then calculated within the spatial limits of unstable transmission. A modelled relationship between clinical incidence and prevalence was used, together with new maps of P. falciparum malaria endemicity, to estimate incidence in areas of stable transmission, and geostatistical joint simulation was used to quantify uncertainty in these estimates at national, regional, and global scales. Combining these estimates for all areas of transmission risk resulted in 451 million (95% credible interval 349-552 million) clinical cases of P. falciparum malaria in 2007. Almost all of this burden of morbidity occurred in areas of stable transmission. More than half of all estimated P. falciparum clinical cases and associated uncertainty occurred in India, Nigeria, the Democratic Republic of the Congo (DRC), and Myanmar (Burma), where 1.405 billion people are at risk. Recent surveillance-based methods of burden estimation were then reviewed and discrepancies in national estimates explored. When these cartographically derived national estimates were ranked according to their relative uncertainty and replaced by surveillance-based estimates in the least certain half, 98% of the global clinical burden continued to be estimated by cartographic techniques.

CONCLUSIONS AND SIGNIFICANCE

Cartographic approaches to burden estimation provide a globally consistent measure of malaria morbidity of known fidelity, and they represent the only plausible method in those malaria-endemic countries with nonfunctional national surveillance. Unacceptable uncertainty in the clinical burden of malaria in only four countries confounds our ability to evaluate needs and monitor progress toward international targets for malaria control at the global scale. National prevalence surveys in each nation would reduce this uncertainty profoundly. Opportunities for further reducing uncertainty in clinical burden estimates by hybridizing alternative burden estimation procedures are also evaluated.