Having the people, procedures, and tools in place to be able to track, investigate, and quickly respond to malaria cases can make or break a country’s ability to achieve malaria elimination. As countries move toward elimination and cases decrease, systems must be able to adapt to report individual case data in specific geographic areas in near real time.
Many countries can also face obstacles including insufficient digital infrastructure, increased costs of maintaining a health management information and surveillance system, limited financial and human resources, population mobility, and waning effectiveness of medicines used to treat malaria that can make an effective malaria surveillance response increasingly complex.
With funding from the U.S. President’s Malaria Initiative, we are working alongside the governments of both Thailand and Tanzania to strengthen their surveillance systems and reach their elimination goals by promoting integration and local ownership of data systems.
We sat down with Jui Shah, Chief of Party for the USAID Inform Asia program in Thailand, and Abdul Al Mafazy, Senior Technical Advisor for the USAID Okoa Maisha Dhibiti Malaria (OMDM)—Save Lives, End Malaria project in Tanzania to learn more about successes, challenges, trends, and learnings in malaria surveillance.
Q: Can you describe where your respective countries are in their malaria journeys?
Jui: Thailand is on track to reach its goal of zero local malaria cases by 2024. Last fiscal year, there were just 2,893 cases, down from more than 24,000 cases in 2015. There has been quite a dramatic reduction over time and the proportion of Plasmodium falciparum (Pf) malaria, the deadliest type of malaria, has also dramatically reduced to just 55 cases last year. Nowadays we are focused on Pf malaria elimination, and Thailand is leading the way toward the Mekong region’s goal of zero local Pf cases by 2023.
Abdul: Through USAID OMDM, we partner with two different ministries of health—one on mainland Tanzania and one in Zanzibar, a semi-autonomous archipelago that is part of Tanzania. Zanzibar has reached and maintained malaria levels of less than one percent prevalence since 2008 thanks to a combination of vector control interventions, effective case management, and case-based surveillance. Zanzibar currently has around 6,000 cases, with 2,500 local cases and the remainder associated with travel to the mainland. To reach elimination, we are focused on strengthening the malaria surveillance system to better understand where the transmission hotspots are and how to target the right interventions to these hotspots. As for mainland Tanzania, malaria is still in the control phase, with more than 4.6 million cases. The national goal is to reduce the malaria prevalence in children under five years from 7.5% in 2017 to 3.5% by 2025.
Q: What are the key elements of the malaria surveillance system in your country?
Jui: Malaria Online, Thailand’s main malaria surveillance database, was developed in 2012 to facilitate case-based malaria reporting both offline and online. Under the 1-3-7 strategy, which is a key component of Thailand’s surveillance system, cases are reported within 1 day, investigated within 3 days, and responded to within 7 days. This approach helps ensure that every single malaria case triggers a timely and coordinated response to prevent further spread in communities. Malaria Online also stores data from the integrated drug efficacy surveillance program, which incorporates drug resistance monitoring as part of routine malaria surveillance and response. Thailand is the first country in the Greater Mekong Subregion to pilot and implement this approach. These data allow us to both make sure that every single malaria patient throughout Thailand is getting cured, and track expansion of drug-resistant parasites to ensure that treatments remain effective.
Abdul: The malaria surveillance infrastructure in mainland Tanzania and Zanzibar differs from that of Thailand because both Ministries of Health use the district health information software 2 (DHIS2)-based health management information system for all public health data collection at the national level, which is considered the government standard. However, DHIS2 is not specific to malaria reporting and only reports aggregate monthly malaria data, which limits our ability to respond in a timely manner to outbreaks in communities.
Therefore, in 2008, we supported Zanzibar to create the Malaria Early Epidemic Detection System (MEEDS) to capture new case notifications and weekly summaries of malaria cases at the facility level using mobile phones. Then in 2012, RTI worked with the Zanzibar Malaria Elimination Program (ZAMEP) to develop a complementary case investigation application called Coconut Surveillance. So, we essentially have three separate systems all tracking malaria surveillance data and performing different important functions—DHIS2 at the national and district level, MEEDS at the facility level, and Coconut at the community and household level. Now, through the USAID OMDM program, we are working alongside ZAMEP to streamline the data from these parallel systems into one integrated system that is ultimately owned and managed by the Ministry of Health of Zanzibar. In mainland Tanzania, case-based malaria surveillance has only been introduced in three regions so far since it is still in the control phase.