The use of schools for malaria surveillance and programme evaluation in Africa

Abstract

Effective malaria control requires information on both the geographical distribution of malaria risk and the effectiveness of malaria interventions. The current standard for estimating malaria infection and impact indicators are household cluster surveys, but their complexity and expense preclude frequent and decentralized monitoring. This paper reviews the historical experience and current rationale for the use of schools and school children as a complementary, inexpensive framework for planning, monitoring and evaluating malaria control in Africa. Consideration is given to (i) the selection of schools; (ii) diagnosis of infection in schools; (iii) the representativeness of schools as a proxy of the communities they serve; and (iv) the increasing need to evaluate interventions delivered through schools. Finally, areas requiring further investigation are highlighted.

Figure 1

Historical recommendations for planning and conducting school malaria parasite surveys [26].

Figure 2

The relationship between age and Plasmodium falciparum parasite rate (PfPR) [Adapted from data provided in ref [9]]. Each line represents the age profile for population living in varying transmission settings: South and Central Somalia (PfPR among 5-14 year olds (PfPR_5-14) = 24.6%) [74]; Kilifi, coastal Kenya (PfPR_5-14 = 37.5%) [75]; Navrongo, Ghana (PfPR_5-14 = 66.9%) [76] and Kilombero, Tanzania (PfPR_5-14 = 83.7%) [77]. Shaded box indicates typical age range of Primary school children in Africa (5-14 years).

Figure 3

Developing a national school-based malaria information system in Kenya, 2009. (A) geographical location of the 416 sentinel schools in a national school malaria survey and all Government of Kenya (GoK) primary schools; and (B) the estimated personal, laboratory consumable, data management and logistics costs to implement a national school malaria survey in Kenya. (C) Geographical location of sampled 197 clusters in the 2007 Kenya Malaria Indicator Survey and all communities in Kenya; and (D) MIS costs, excluding training and piloting and technical support.

Figure 4

Representativeness of school children for malaria surveillance in Africa. (a) enrollment and (b) completion rates by country. Countries shaded grey indicate an absence of malaria transmission: Algeria, Egypt, Lesotho, Libya, Morocco, Tunisia and Western Sahara. Net enrollment ratio is the ratio of children of official school age who are enrolled in school to the population of the corresponding official school age. Primary completion rate is the percentage of students completing the last year of primary school. It is calculated by taking the total number of students in the last grade of primary school, minus the number of repeaters in that grade, divided by the total number of children of official graduation age. Data source: World Development Indicators [60]. (c) Geographical distribution of malaria survey data (n = 5307) currently included in the Malaria Atlas Project [63].