Enhanced surveillance and data feedback loop associated with improved malaria data in Lusaka, Zambia

Abstract

Background: Accurate and timely malaria data are crucial to monitor the progress towards and attainment of elimination. Lusaka, the capital city of Zambia, has reported very low malaria prevalence in Malaria Indicator Surveys. Issues of low malaria testing rates, high numbers of unconfirmed malaria cases and over consumption of anti-malarials were common at clinics within Lusaka, however. The Government of Zambia (GRZ) and its partners sought to address these issues through an enhanced surveillance and feedback programme at clinic level.

Methods: The enhanced malaria surveillance programme began in 2011 to verify trends in reported malaria, as well as to implement a data feedback loop to improve data uptake, use, and quality. A process of monthly data collection and provision of feedback was implemented within all GRZ health clinics in Lusaka District. During clinic visits, clinic registers were accessed to record the number of reported malaria cases, malaria test positivity rate, malaria testing rate, and proportion of total suspected malaria that was confirmed with a diagnostic test.

Results and discussion: Following the enhanced surveillance programme, the odds of receiving a diagnostic test for a suspected malaria case increased (OR = 1.54, 95 % CI = 0.96-2.49) followed by an upward monthly trend (OR = 1.05, 95 % CI = 1.01-1.09). The odds of a reported malaria case being diagnostically confirmed also increased monthly (1.09, 95 % CI 1.04-1.15). After an initial 140 % increase (95 % CI = 91-183 %), costs fell by 11 % each month (95 % CI = 5.7-10.9 %). Although the mean testing rate increased from 18.9 to 64.4 % over the time period, the proportion of reported malaria unconfirmed by diagnostic remained high at 76 %.

Conclusions: Enhanced surveillance and implementation of a data feedback loop have substantially increased malaria testing rates and decreased the number of unconfirmed malaria cases and courses of ACT consumed in Lusaka District within just two years. Continued support of enhanced surveillance in Lusaka as well as national scale-up of the system is recommended to reinforce good case management and to ensure timely, reliable data are available to guide targeting of limited malaria prevention and control resources in Zambia.

Fig. 1

Range of malaria test positivity by month from 2009 to 2012 at all health facilities in Lusaka, Zambia. There were no differences in malaria test positivity by year

Fig. 2

Clockwise from top left: a malaria testing rate, b proportion of reported malaria cases unconfirmed by microscopy or RDT, c proportion of total OPD that was reported as malaria, and d mean cost in ACT courses dispensed at each public clinic within Lusaka District from 2009 to 2012. Price of ACT in USD by pack size: 6′s = $0.36; 12′s = $0.72; 18′s = $1.08; 24′s = $1.30 (Medicine for Malaria Venture, USAID|Deliver, Zambia)

Fig. 3

Comparison of total malaria cases reported through standard HMIS versus data collected through monthly supervision and review of clinic registers during the enhanced surveillance system (ES). Graph includes data from before and after the implementation of monthly enhanced surveillance system visits in 2011. Prior to the start of enhanced surveillance system, HMIS, and enhanced surveillance data were only moderately correlated compared to after, where correlation increased significantly