Rti coconut surveillance_2015_05
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Coconut Surveillance is a mobile disease surveillance and rapid response system. It has been used for more than two years by the Zanzibar Malaria Elimination Programme. This presentation provides a brief overview of the system, results, and potential for scale up.
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Rti coconut surveillance_2015_05
- 1. www.rti.orgRTI International is a registered trademark and a trade name of Research Triangle Institute. Coconut Surveillance Improving Surveillance and Response for Malaria Elimination
- 2. Malaria Is a Global Killer 1. Source: World Health Organization, Global Health Observatory Data Repository2
- 3. But Malaria Is Preventable, Curable Malaria-Free, Eliminating, and Controlling Countries, 20121 1. Source: UCSF Global Health Group, Malaria Elimination Group 3
- 4. The Case of Zanzibar 4 East Africa 2 large islands (Unguja, Pemba) A semi-autonomous part of the United Republic of Tanzania
- 5. Malaria Control Phases in Zanzibar Health facility trends: Malaria confirmed cases and positivity rate, 1999–2014 0 500 1000 1500 2000 2500 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0 Jan-99 Jul-99 Jan-00 Jul-00 Jan-01 Jul-01 Jan-02 Jul-02 Jan-03 Jul-03 Jan-04 Jul-04 Jan-05 Jul-05 Jan-06 Jul-06 Jan-07 Jul-07 Jan-08 Jul-08 Jan-09 Jul-09 Jan-10 Jul-10 Jan-11 Jul-11 Jan-12 Jul-12 Jan-13 Jul-13 Jan-14 Jul-14 #ofpositives Positivityrate(%) Positive slides Positivity rate Gain after ACT introduction and before scale-up of mosquito control Gain before ACT introduction Zanzibar Is Nearing Elimination 1. Source: Zanzibar Malaria Elimination Program – for the Third Time 5
- 6. But There Are Challenges 6 Decreasing effectiveness of mosquito control Population resistance to behavior change Case importation from mainland Tanzania An effective surveillance and rapid response system is essential Using dwindling resources more effectively
- 7. A Proven Mobile Malaria Surveillance and Rapid Response System 7
- 8. 8 Collecting Data at the Facility
- 9. 9 Collecting Data at the Household
- 10. Testing and Treating Household Members 10
- 11. Monitoring the Process and Targeting Resources 11 1,328 new cases, including asymptomatic cases, detected and treated Rapid diagnostic tests administered and data collected from more than 22,350 household members Used to respond to more than 5,132 new malaria case reports All 20 district malaria surveillance officers use Coconut Surveillance All 154 government primary care units use the case alert system 78% of private clinics use the case alert system
- 12. Social Impact 12 584,000 people died of malaria in 2013 500,000 died in Africa 400,000 were children under 5 years old Nearly half the world’s population are at risk1 It costs Africa $12 billion each year2 1. World Health Organization, World Malaria Report 2014. 2. Gallup JL, Sachs JD, 2001. The economic burden of malaria. AJTMH 64 (Suppl 1–2): 85–962. 3. World Health Organization, Malaria Fact sheet No94, April 2015. Stronger malaria surveillance systems are urgently needed3
- 13. Scaling Up 13 Unique Free and open source $350 / year for cloud hosting $510 / year for each mobile user $10,200 / year total for 20 users Easy to adopt Adaptable and Scalable
- 14. 2014 – World Health Organization establishes vision for “A world free of malaria” Scaling Up 14 35 countries are pursuing malaria elimination 2005 – U.S. President’s Malaria Initiative launches $1.265 billion expansion to reduce malaria in Africa 2013 – U.S. $2.7 billion funding for malaria control and elimination 2014 – Bill & Melinda Gates Foundation sets goal of eradicating malaria by mid-21st century and boosts anti-malaria funding by 30 percent.
- 15. Questions – ict@rti.org 15 “We must remain committed to the eradication of malaria. Small steps won’t get the job done.” – Bill Gates
Notes de l'éditeur
- Are presenters are: Gordon Cressman, Senior Director of the Information and Communication Technology Program at RTI International Dr. Hugh Sturrock, Assistant Professor of Epidemiology and Biostatistics, Malaria Elimination Initiative, Global Health Group, School of Medicine, University of California, San Francisco Allison Lieber, Program Manager, Google Earth Outreach & Earth Engine at Google Inc. Our team members are based in the US, Zanzibar, and mainland Tanzania. We are specialists in malaria, epidemiology, integrated disease surveillance the response, information technology, and international development. This project is a collaboration between: RTI International, a not-for-profit research organization dedicated to improving the human condition by turning knowledge into practice. The University of California, San Francisco, Global Health Group, which through its Malaria Elimination Initiative supports countries pursuing a goal of malaria elimination. Google Earth Engine, which brings together 40 years of the world's satellite imagery and makes it available online to scientists, independent researchers, and nations. The Zanzibar Malaria Elimination Programme (ZAMEP), the Government of Zanzibar agency dedicated to eliminating malaria in Zanzibar.
- 3.3 billion people, roughly half the world’s population, is at risk of infection with malaria. 1.2 billion of these people are at high risk of contracting the disease. In 2013, the most recent year for which global statistics are available, the World Health Organization estimates that there were 198 million cases. These resulted in 584,000 deaths. 90% of those deaths were in Africa 78% were children less than 5 years old And people sick with Malaria miss work and school The impact on lives and developing economies is enormous
- But malaria is preventable and curable. And it can be eliminated. Malaria elimination means interrupting local mosquito-borne malaria transmission, i.e. zero incidence of locally contracted cases. Malaria has been eliminated in many countries. Malaria was eliminated in most of Western Europe by the mid-1930s; the United States achieved elimination of the disease in 1951. The most recent additions are the United Arab Emirates (2007), Morocco (2010), Turkmenistan (2010) and Armenia (2011). 35 of the 97 countries with active transmission are pursuing elimination. Elimination is a realistic but challenging goal. It requires sustained commitment, resources, and large field programs over 8-10 years. Tragically, some countries have shifted resources to other health priorities, only to see malaria rebound. Without effective surveillance and rapid response systems, it can rebound in a single rainy season. If it does, millions of dollars invested in elimination efforts have achieve nothing.
- Zanzibar is a case in point. Zanzibar is a semi-autonomous part of the United Republic of Tanzania It consists largely of two large islands (Ugunja, Pemba) with a total population of 1.3 million (2012 census, National Bureau of Statistics, United Republic of Tanzania) It is 15 minutes by air and 1.5-2 hours by ferry from Dar es Salaam. The constant traffic between Zanzibar and the mainland includes private boats.
- This graph shows the dramatic decrease of malaria in Zanzibar. The blue bars show the number of confirmed cases. The brown line shows the positivity rate. This is a commonly used indicator of the incidence of malaria. As we can see, this was has been reduced from more than 40% in 1999 to less than 1% in 2014. The red line at 5% is the threshold used by the World Health Organization to classify a country as being in the pre-elimination phase. The shaded rectangle shows the gain or reduction before the introduction of Artemisinin Combination Therapy (ACT), the recommended combination for malaria in Africa. The green shaded rectangle shows the gain after the introduction of this treatment, and before the scale-up of mosquito control programs. Mosquito control programs include spraying the inside of buildings with long-lasting insecticide, distributing bed nets treated with long-lasting insecticide, treating standing water to kill mosquito larva, and, where possible, eliminating standing water where mosquitos breed. The shaded rectangle in the lower right corner shows that malaria has nearly been eliminated; then we begin to see repeated seasonal spikes during the rainy season. This is the third time that Zanzibar has nearly eliminated malaria. They are very close to achieving their goal.
- But there are challenges to eliminating malaria. Mosquitos can develop resistance to insecticides. Insecticide-treated bed nets don’t last as long as intended. People are sometimes reluctant to change habits that expose them to mosquitos. Malaria can rebound quickly, even in a single rainy season. A study in 2012 (J M Cohen) reviewed 75 malaria resurgence events in 61 countries, from the 1930s through the 2000s. Almost all resurgence events (91%) were attributed at least in part to the weakening of malaria control programs for a variety of reasons, of which resource constraints were the most common (57%). Zanzibar needs a system that can help them quickly detect and respond to new cases to stop the chain of transmission. A system that helps them target their limited resources precisely at high risk areas in real time. A system that could automatically alert high risk communities to take preventive measures. Such a system could be extended to diagnose and treat travelers before they board ferries from the mainland. It could also be used in other countries. They are almost there.
- RTI has worked closely with the Zanzibar Malaria Elimination Programme (ZAMEP) to create a unique malaria case notification and mobile rapid response system. It has been used for more than two years. Let’s see how it works. It’s Wednesday, and feeling awful, Siti and her mom decide to head to the doctor. It’s at Charawe Heath Facility that Siti first will learn that she has malaria. From the health facility, Siti receives ACT, the recommended treatment for P. falciparum malaria. She is instructed to take the medicine for three days. A clinician at the health facility enters basic information about this new case by responding to an interactive SMS text messaging system. This enters the case alert into the system. Shabani Khamis is one of 20 District Malaria Surveillance Officers serving Zanzibar’s 10 health districts. Instantly, Shabani receives an SMS notification on his phone that a new malaria case has been identified in Central District, where he serves. He opens the Coconut Surveillance application on his Android tablet to retrieve and view the new case record. Shabani will be the first to respond to Siti’s malaria case. On his motorbike, Shabani rides off with a backpack containing medical supplies. He also has the Coconut Surveillance mobile application on his tablet. He will use this to collect data as he follows up on this new case.
- First, Shabani visits the Charawe Health Facility, where he verifies the reported case and gathers additional information. A medical provider gives Shabani additional patient information for Siti, including a phone number and address where he can reach her. He enters the information collected into the Coconut Surveillance application on his tablet.
- Shabani finds Siti and her mom at their home. First, he checks in with Siti to see how she is feeling and to make sure she is taking her prescribed medicine. Then he begins testing all members of the household—as long as they are home—for malaria infection using rapid diagnostic strip tests (RDT). Malaria is transmitted from one infected family member to another as mosquito vectors commonly feed on multiple people within a household. By detecting and treating cases early, Shabani ensures that the disease transmission stops with Siti.
- Pricking the finger of Siti’s mother, Shabani draws a small drop of blood and places it on the rapid diagnostic strip test. He also takes her temperature. If any household members test positive for malaria, Shabani will give them medication (ACT) on the spot. Secondary malaria cases are being detected and treated in record time, often within 48 hours and before clinical symptoms are even presented. Shabani then assesses the household and its surroundings for any environmental and household factors that may be conducive to malaria transmission. He drains any standing water and checks for the presence of window screens and for when the household was last sprayed with residual insecticide (IRS). Before he leaves, Shabani makes sure that Siti’s family has enough long-lasting insecticide-treated bed nets (ITNs) to protect the entire family from mosquitoes and malaria. He pauses outside the house to record the geo-location and wirelessly sends the data collected during his household visit over the mobile network to a cloud database for further analysis and reporting. Recording precise household location is valuable. These data are the difference between only knowing that malaria is in a health facility's catchment area (could be 10 square kilometers) and the location of the household (within 10 square meters). Being able to pinpoint response saves a lot of money. Data collected on the tablet are synchronized over the mobile phone network with a shared cloud database.
- Back at the office, ZAMEP staff are able to access data for Siti and her household as well as any new malaria case data in all of Zanzibar along with the GPS locations for each. Supervisors uses a web dashboard to track the progress of the response to each new case nearly in real time. Managers and supervisors use maps that enable drill-down to individual case data. The maps help managers to identify hot spots and transmission patterns. These examples show the ferry routes and illustrate the high risk of malaria arriving from the mainland. There is also an extensive set of dynamic reports developed in close collaboration with ZAMEP. The data can be exported easily for analysis using other tools. We call the software Coconut Surveillance. It is free and open source. It has been in use for more than two years. The system has been used to follow up over 5,000 new malaria cases and has been used to diagnose and treat over 1,300 secondary cases. It performs basic analysis, including incidence rates and mapping, But it lacks the high-resolution, real-time risk-mapping capability needed to alert communities and improve targeting of limited response resources. No such system exists anywhere in the world. We believe we know how to meet this need.
- What is the possible social impact of eliminating malaria? Near half of the world’s population are at risk of infection with malaria. In 2013 it killed and estimated 584,000 people. Roughly half a million of these died in Africa. 400,000 were children under 5 years of age. Malaria costs Africa an estimated $12 billion each year in health care and lost productivity The only sustainable approach to addressing malaria is eradication of the parasite. But current tools and treatments are insufficient to achieve elimination in many countries. And the cost of maintaining these interventions has reached several billion dollars a year. Donor countries cannot maintain funding of several billion dollars a year forever. A resurgence of malaria could threaten hard-won progress. Without continued surveillance and effective rapid response, it can rebound in a single rainy season. The World Health Organization states that stronger malaria surveillance systems are urgently needed. Currently, no tool enables malaria elimination efforts to warn communities and target interventions precisely in real-time. Coconut Surveillance is part of the solution. RTI is in discussion with partners to fill in the missing piece. This will help to maximize the impact of limited resources, complete the task of eliminating malaria, and prevent its rapid resurgence.
- This innovative disease surveillance and risk-based rapid response system will be unique in malaria elimination. It has several characteristics that make it easy to adopt and scale. First, it is built entirely using free and open source software technology, and will remain free and open source. There are no licensing fees. Second, it is inexpensive to operate and scale. It costs less than $350 each year for cloud hosting for Zanzibar. It costs less than $510 each year per mobile user, and less than $10,200 each year in Zanzibar for 20 users. It is quick and easy to adopt, Adaptable to different case alert systems and to other diseases. And the technology scales easily.
- Scale up will initially depend on the support of the international organizations who are supporting malaria elimination efforts. In 2005 the U.S. President’s Malaria Initiative launched a $1.265 billion expansion to reduce malaria in Africa. By 2013 international organizations were contributing U.S. $2.7 billion towards malaria control and elimination. Last year the World Health Organization declared their vision for “A world free of malaria”. The Bill & Melinda Gates Foundation was more specific, setting the goal of eradicating malaria by mid-21st century and boosting anti-malaria funding by 30 percent. 35 countries are now pursuing malaria elimination. The World Health Organization states that stronger malaria surveillance systems are urgently needed. We will seek the support of these international organizations for scaling up this innovative mobile case response and high-resolution risk-based response system. We have already had several discussions with the Bill & Melinda Gates Foundation.
- As you can tell, we’re very excited about the potential of this innovation. We would like to open it up now to your questions and discussion.