SENTINEL SURVEILLANCE OF MALARIA MORBIDITY AND MORTALITY
Objective 1: To strengthen and maintain an out-patient-based sentinel site surveillance system for monitoring indicators of uncomplicated malaria morbidity
UMSP has successfully maintained an out-patient based malaria surveillance at 6 health facilities; Aduku and Nagongera (high transmission), Walukuba and Kasambya (medium transmission), Kihihi and Kamwezi (Low transmission). The surveillance is ongoing with systematic data collection using a standardized individual patient record form completed for all the patients attending the OPD clinic. The health facilities’ leadership and staff have continued to be in full support and conduct their work in awareness of the quality needs for sentinel surveillance. Data entry is still done at the sites by a dedicated data officer hired by UMSP. The UMSP data officer works in collaboration with the facility health records officers to produce site data reports. UMSP has routinely supported the sites with the necessary utilities including stationery, patient record forms on top of laboratory necessities like malaria reagents, lancets, and gloves among others. In addition, UMSP has ensured that site equipment (solar panels/inverters, microscopes and computers) are regularly serviced to provide quality outputs in the lab and ensure timeliness and efficiency in the data management sections. Monthly data quality reports on completeness and consistency are sent to the data officers who ensure that these reports are displayed at the facility notice boards and that they are also discussed in the health facility meetings. In January, UMSP conducted a data accuracy evaluation assessing accuracy of the data entry process by comparing the database to the data on the CRF. Results showed minimal data entry errors at all the sites. Malaria testing rates among the malaria suspected patients have also been maintained at over 97% at all the sites. Summarized below is the data collected between Sep 2011 and Aug 2012 at the outpatient sentinel sites.
Table 1: Summary of the outpatient sentinel sites data collected between Sep 2011 and Aug 2012
District Site Total number of patients seen Malaria suspected Patients sent to the laboratory Laboratory confirmed malaria
Over 150,000 patients were seen between Sep 2011 and Aug 2012 with children under 5 years of age contributing 16% to 33% of patients seen. Over 89,000 patients were suspected to have malaria in this period and 98% of these were referred for a lab confirmatory test. Overall, test positivity rate ranged from 24% (Aduku) to 38% (Kihihi).
Objective 2: To strengthen and maintain an in-patient-based sentinel site surveillance system for monitoring indicators of severe malaria morbidity and malaria mortality
As planned, by June 2011, malaria surveillance had been established at all the six inpatient sites; Tororo District and Apac hospitals (high transmission), Mubende and Jinja hospitals (medium transmission) and Kabale and Kambuga hospitals (low transmission). Prior to the start of the surveillance, at each site, UMSP conducted a workshop where all the hospital staff were sensitized and introduced to the program. In addition, UMSP provided power back up systems to enable uninterrupted power supply to the laboratory and data office where new computers were installed for on-site data entry. UMSP supplemented the site labs with microscopes, hemocues and continues to provide malaria lab regents and stationery regularly. UMSP hired a site data officer responsible for site data management and administration. Data is collected using a standardised case record form(CRF) designed to capture patient demographics including area of residence, history taking, admission diagnosis, admission treatment, final diagnosis and outcome. Starting Jan, 2012, the CRF was revised to capture additional information on reasons for hospitalising children with un-complicated and specifying complicated malaria criteria. Furthermore, the CRF was modified to capture data on treatment administered and not just treatment prescribed. The site leaders and staff are fully sensitized about the programme and the CRF has been adopted in the paediatric wards. Health workers at all the sites were trained prior to the introduction of the revised CRF. The proportion of children admitted that are tested for malaria has been consistently high (over 95%) throughout the year.
Table 2. Absolute numbers of children hospitalized at the in-patients sites (Sep 2011 – Aug 2012)
Between September 2011 and August 2012, a total of 22,180 children were hospitalized, 20,237 (85%) were below five years of age. Over 97% of these were tested for malaria. The proportion of children under five with malaria parasitemia was highest in Tororo (60%) and Apac (48%) followed by Jinja (46%) and Mubende (41%) and lowest in Kambuga (25%) and Kabale (6%). The proportion of children with complicated malaria ranged from 47% (Tororo) to 5% (Kabale) while the proportion of those who died with a positive malaria test was relatively low (<2%).
Sentinel sites laboratory quality assessment
Starting January 2012, UMSP embarked on a rigorous assessment of the quality and validity of the malaria slides stained and read at the sites. The process started with a shift of the malaria staining technique from Field stain to Giemsa stain ‘WHO recommend stain for malaria microscopy’ at all surveillance sites. Microscopists were trained on the Giemsa staining technique, mounting slides with cover slips and labelling of slides. Microscopists (WHO defines a microscopist as anybody reading blood smears for malaria parasites) were also instructed to keep all the slides read in the month. At the end of the month, slides for each individual microscopist and copies of the results as documented in the facility lab register were sent to the UMSP central lab. 50 slides were randomly selected for each of the microscopist and re-read by the UMSP central lab technicians. If a microscopist read less than 50 slides in a month, all slides were re-read. Both the first (site microscopist) and second (UMSP central lab tech) reader results were double entered in a database and compared. Discrepant results were generated for third reading. Slides qualifying for third reading were independently re-read by a tie breaker. Sensitivity, specificity and the percentage level of agreement between the first reader and the final result were computed for each microscopist and those scoring sensitivity and/or specificity below 85% were re-trained. The overall performance was good at all sites with majority scoring above 85% for sensitivity and specificity. Specificity scores were generally higher than sensitivity scores at all sites for most of the months. Comparisons between and within sites were limited by variation in the number of slides (positives and negatives) read by individual lab techs.
Objective 3: To strengthen data management to ensure timely data analysis and the provision of reports on key malaria indicators to the Ministry of Health NMCP
Data dissemination to stakeholders and policy makers for planning and decision making is a key component of any surveillance program. Since September 2008, monthly data from each of the sites is uploaded into a central database in Kampala for cleaning and report generation. To date we have successfully implemented a system where data from all the sites is sent to Kampala (the center) within 10 days after the end of each month. UMSP has utilised a number of avenues to disseminate the data and information generated at the sentinel sites. Firstly, UMSP manages a public website where data and automated reports can freely and easily be accessed by anyone with internet connection. UMSP has also continued to provide the monthly data reports to key stakeholders and policy makers. The UMSP team further works with NMCP to address findings in these monthly reports. For example NMCP and UMSP held a meeting with the Mubende Hospital at the beginning of this financial year to address the relatively high mortality rate noted at the hospital. Furthermore, basing on monthly surveillance reports, NMCP and WHO were recently in Kabale district to investigate and respond to the malaria upsurge in the area. UMSP plans to continue frequent interaction with the districts, NMCP and MOH to ensure that our work remains relevant to malaria control efforts.