Abstract
BackgroundSurveillance is a core component of an effective system to support malaria elimination. Poor surveillance data will prevent countries from monitoring progress towards elimination and targeting interventions to the last remaining at-risk places. An evaluation of the performance of surveillance systems in 16 countries was conducted to identify key gaps which could be addressed to build effective systems for malaria elimination.MethodsA standardized surveillance system landscaping was conducted between 2015 and 2017 in collaboration with governmental malaria programmes. Malaria surveillance guidelines from the World Health Organization and other technical bodies were used to identify the characteristics of an optimal surveillance system, against which systems of study countries were compared. Data collection was conducted through review of existing material and datasets, and interviews with key stakeholders, and the outcomes were summarized descriptively. Additionally, the cumulative fraction of incident infections reported through surveillance systems was estimated using surveillance data, government records, survey data, and other scientific sources.ResultsThe landscaping identified common gaps across countries related to the lack of surveillance coverage in remote communities or in the private sector, the lack of adequate health information architecture to capture high quality case-based data, poor integration of data from other sources such as intervention information, poor visualization of generated information, and its lack of availability for making programmatic decisions. The median percentage of symptomatic cases captured by the surveillance systems in the 16 countries was estimated to be 37%, mostly driven by the lack of treatment-seeking in the public health sector (64%) or, in countries with large private sectors, the lack of integration of this sector within the surveillance system.ConclusionsThe landscaping analysis undertaken provides a clear framework through which to identify multiple gaps in current malaria surveillance systems. While perfect systems are not required to eliminate malaria, closing the gaps identified will allow countries to deploy resources more efficiently, track progress, and accelerate towards malaria elimination. Since the landscaping undertaken here, several countries have addressed some of the identified gaps by improving coverage of surveillance, integrating case data with other information, and strengthening visualization and use of data.
Highlights
Surveillance is a core component of an effective system to support malaria elimination
Countries that have successfully eliminated malaria have typically relied on a combination of effective passive case detection (PCD) [8,9,10] and active case detection (ACD) activities [10,11,12,13], with staff dedicated to surveillance at all health system levels [11, 14, 15], and integrated response mechanisms [12, 16, 17]
The 2017 World Health Organization (WHO) Framework for Elimination suggests that achieving malaria elimination requires countries to transition from surveillance systems reporting aggregated case data towards systems that facilitate rapid confirmation, investigation, and reporting of individual cases, and provide enhanced analytic methods to guide decisionmaking related to anti-malaria interventions [18]
Summary
Surveillance is a core component of an effective system to support malaria elimination. WHO’s Global Technical Strategy for Malaria 2016–2030 (GTS) describes the need to transform malaria surveillance into a core intervention allowing the identification, tracking, classification and response for all malaria cases to effectively support case management (i.e. providing diagnosis and treatment at health facility or in the community through community health workers or during active surveillance activities such as reactive case detection) and vector control activities (e.g. Indoor Residual Spraying) [19]. This recommendation is supported by several country case studies in Bhutan, Cape Verde, Malaysia, Mauritius, Philippines, Réunion, Sri Lanka, Tunisia, Turkey and Turkmenistan which found that investment in robust, response-driven surveillance systems is critical for malaria elimination [20]. New guidelines for malaria surveillance appeared in early 2018 [21], reinforcing the GTS and Framework for Elimination principle that surveillance should be a primary intervention
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