World Malaria Day 2019: Information Can Help Us Get to Zero Malaria
“Information is a source of learning. But unless it is organized, processed, and available to the right people in a format for decision making, it is a burden, not a benefit.” – William G. Pollard (1911 – 1989), American Physicist
I recently came across this quote. It made me think about how today’s rapidly evolving technology and connectivity often inundates us with information. The amount of data available to us can be overwhelming, but the opportunity to learn from it is powerful. On a daily basis most of us access various types of information to make the best decisions possible — we check reviews before choosing a restaurant or handyman and monitor our bank accounts or our children’s online grade portals. Timely and accurate information are just as essential for good public health decision-making.
A key pillar of the World Health Organization’s (WHO) Global Technical Strategy for Malaria is to “transform malaria surveillance into a core intervention” across the entire spectrum of malaria transmission. In simple terms, this means access to good information is critical and should be used to develop stronger programs to control malaria and other diseases. In areas with higher disease burden/transmission, people with suspected malaria infections need to be tested, and confirmed cases should be recorded across the health system. This includes cases identified through community-based detection strategies and strengthening the quality and timeliness of case/death reporting through training and supervision. The information collected should then be used to target interventions and evaluate their impact. As transmission declines in an area, malaria surveillance systems should provide more detailed information, like a patient’s behavioral risk factors and where the person with malaria has traveled, the latter to support a tailored response to address the illness and also contain any risk for spreading.
With these aims in mind, my colleagues and I at the CDC are working to strengthen data collection for malaria and public health systems. We are doing this in a number of ways, in a number of places:
First, we co-implement the U.S. President’s Malaria Initiative (PMI) with U.S. Agency for International Development (USAID), which helps to reduce death and illness related to malaria by scaling up the delivery of proven interventions in 27 countries in Africa and the greater Mekong sub-region in Southeast Asia. Since the initiative began in 2006, CDC has been leading the evaluation of surveillance systems in several PMI countries. We conduct assessments of data structure, core and support functions, and the quality of both passive (tracking suspected illnesses that are reported) and active (going out to look for those with malaria) case detection systems. We are now developing the tools to help others perform similar assessments so that quality surveillance data can be used to inform and improve malaria programs all over the world.
In western Kenya, CDC colleagues including myself, have collaborated with the Kenya Medical Research Institute (KEMRI) for nearly four decades. Over the years we have invested in multiple efforts to strengthen public health surveillance and adapt it to the changing infrastructure and public health needs. For example, periodic surveys of the community were adequate to evaluate the impact of interventions when malaria transmission in this country was very high. As malaria rates have declined in recent years, we have realized the need to understand not just what malaria rates look like at a specific time point in the year, but how malaria rates change throughout the year in different geographic areas. This will allow us to move from an approach of distributing interventions everywhere we can to an approach that is more targeted, delivering interventions to where they are most needed. We are also digitizing the information that is regularly collected, so that data specific to individual illnesses can be used not just for providing appropriate testing and treatment for that person, but also for evaluating health care system performance and identifying opportunities to improve it. Even the routine systems need to adapt to changing interventions. Diagnosis and treatment for malaria are now available at the smallest health centers and even in the community itself. Expanded access to diagnosis and treatment is very much needed, but it is more challenging to track what is happening across these remote and often resource-challenged settings.
As one county health director stated, “We know we still have many cases in this county. It would be great for us to know which villages have the most cases and when, so we can better focus our efforts.”
In response, CDC staff have been working to adapt reporting forms so that local staff can transmit critical information with just the click of a cell phone photo! This enables the malaria control program to receive information that is more accurate and in almost real time. This use of technology to obtain information leads to faster and better feedback and a stronger program overall.
Soon, as the lead for a consortium of partners evaluating the malaria vaccine implementation pilot program in Kenya, CDC will be assessing the impact of the vaccine to reduce childhood deaths in 8 counties in the region. Doing this effectively will require improving all the forms and systems used to report deaths in the hospital and in the community. This will help ensure that all deaths in the community are captured and require collaboration between CDC program staff, national program staff, county health officials, and community members. Each of these efforts will help strengthen data collection in the region.
We have also been working to improve data collection and use in Nigeria, the country that has the highest burden of malaria in the world. CDC has been working with the National Malaria Elimination Program and partners to improve malaria control and surveillance, use the collected data to identify intervention gaps, and ensure that health care workers responsible for malaria treatment are well supported and trained. Program staff now meet monthly to review the information collected from their clinics to identify problems and work out ways to fix them.
In addition to working in these high burden settings, we are also helping strengthen surveillance in areas close to eliminating malaria, like Haiti. In areas where malaria is already uncommon, it is critical to find each person with malaria and check whether family members or neighbors have malaria. In the town of Ouanaminthe, the CDC has supported house-to-house searches for people with malaria. Ouanaminthe used to be one of the places in Haiti with the highest malaria rates—but now malaria is rare. CDC is leading the Malaria Zero consortium of partners to focus intensely on the remaining areas of Haiti with the highest malaria rates. The consortium partners are employing novel ways of using complex computer models to pinpoint the highest risk areas, and then use a package of interventions to aggressively work to lower the malaria risk in those areas.
Working to eliminate malaria is not new to CDC; the agency actually started as the agency for Malaria Control in War Areas. Our mission was to help eliminate malaria from the U.S. by 1951, particularly in the southeastern U.S. It’s the reason why we are located in Atlanta! Even today, we continue to monitor rates of malaria in the U.S. each year to ensure that it does not resurge. Having eliminated malaria in the U.S. and conducting ongoing surveillance makes us well poised to share our knowledge and experience with others around the world. In addition to assisting Haiti, we recently initiated a partnership with World Health Organization to help train others to assist countries to eliminate malaria. This new effort, called “STOP Malaria”, will be piloted in 5 countries this year.
With all of these efforts underway, I optimistically look to the future, knowing that the chance to end malaria is closer than ever. We have already seen tremendous progress over the last decade–helping to save almost 8 million lives from this serious and often deadly disease. We now have the potential to build upon this success even further by arming ourselves with the best possible information to guide our decisions, and truly begin to make malaria surveillance the core intervention it should be.