MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies

TABLE 7: PRE-ELIMINATION AND ELIMINATION INDICATORS
Epidemiology Foci
Investigation
Activity Indicator Target (targets
between brackets are
not WHO defined)
# Active foci reported
per year
Proportion of reported
foci fully investigated
# cases within a focus
Total population at risk
within a focus
When moving towards elimination, M&E objectives do not change.
The phase specific activities will still need to be monitored and
evaluated, but they shift from a “population” level approach to a
“foci” or even an “individual case” type of approach. The former
looks at coverage of malaria control intervention and prevalence of
malaria in the general population, while the latter evaluates every
single case. In terms of service coverage monitoring, outcome
and process indicators need to be adapted to the activities they
are supposed to evaluate, but in essence the methodologies are
no different from those used in a control program. However,
demonstrating the interruption of local transmission will require
different methods for data collection and will also require proof
that any potential case, even if non-symptomatic, would have
been detected.
The drafts of the M&E Plan and the Early Detection and Response
Plan (2008-2012) of the ZMCP specify the goals and objectives
of malaria-related M&E and discuss the different data sources
-
(100%)
Surveillance NMSS Completeness (100%)
Case
Management
Vector
Control
Entomological
Surveillance
Tracking
Burden
Timeliness Decrease in time
between diagnosis,
reporting and
investigation
# cases reported per
year
Proportion of cases fully
investigated
Diagnosis Total population at risk
Proportion of
case confirmed by
microscopy
Microscopy QA/QC
in place
Treatment Proportion of cases
treated according to the
guidelines
IRS Number and proportion
of at-risk households
that have been sprayed
Larval
Control
(Adapted from WHO, 2007)
Number and proportion
of reported active foci
that were sprayed
Proportion o fknown/
potential breeding sites
treated with chemicals/
fish
Larviciding Proportion of breeding
sites positive for
mosquito larvae
-
-
-
(100%)
-
(100%)
-
(100%)
> 90% (but numbers
of at-risk households
decreases over time
> 90%
> 90%
< 5%
2 | Operational Feasibility
used and variables collected. Although elimination is mentioned,
the currently proposed M&E plan focuses on malaria prevention
and control. However, recognizing the potential implications of
the recently observed low prevalence, the plan also extensively
discusses the need for a routine malaria early detection and
response system.
When moving towards elimination, some of the proposed
indicators and the methods to collect them in the current
M&E plan will need to be adapted or changed. Based on the
WHO recommendations, necessary changes to the M&E plan if
Zanzibar decides to pursue elimination are explored here.
DATA SOURCES AND INDICATORS FOR MALARIA
ELIMINATION
M&E Routine Data Collection
Malaria-related M&E data are collected both through routine
reporting and periodic surveys. The routine systems in place
are the national Health Management and Information System
(HMIS), the health facility-based sentinel surveillance system
(HFBSS), and the ZMCP’s malaria diagnosis quality assurance
program.
When moving towards elimination, the M&E system will need
to demonstrate that all cases have been reported and that the
necessary action has been taken to prevent onward transmission.
This requirement means that the current system of sentinel
surveillance through the 6 HFBSS sites, representing only a
sample of facilities and areas, will need to eventually be abandoned.
All health facilities will need to comply with the standards
currently only applicable to the sentinel sites. In addition, during
elimination and maintenance, the malaria burden will no longer
be evaluated based on the results of surveys (prevalence), but
rather on the number of cases reported from facilities (incidence).
The M&E system will need to collect relevant data in order to
assess whether incidence is being appropriately measured. Key
indicators and data to be collected have been discussed in the
surveillance chapter and some practical recommendations are
given below (programmatic monitoring).
Data Management
The data management will need to be evaluated for completeness,
speed, and accuracy in order to prove beyond doubt that all cases
have been detected and documented. In addition, all cases will
need to be notified as soon as possible to allow for rapid response.
Specific indicators will need to be established to evaluate the
timelines of the reporting system at all levels of the reporting
chain. Potential indicators in this area could include:
�� Time between positive diagnosis at the facility level and
reception of the notification at the ZMCP
�� Time between reception of the malaria case notification and
the arrival of the case investigation team at the health facility
�� Time between the arrival at the health facility and the start of
the preventive measure in the foci
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