A workshop on malaria surveillance, monitoring and evaluation was held on 13-15 March 2019 in Gurugram, Haryana, India; following the meeting of the national malaria programme managers of the SEAR on operationalizing the Ministerial Declaration on Accelerating and Sustaining Malaria Elimination in the South-East Asia Region on 11-12 March 2019.
General objective
To strengthen collaboration and capacities to accelerate elimination of malaria towards a malaria-free South-East Asia Region by or before 2030.
Specific objectives
- To strengthen and expand knowledge among national malaria programme managers and surveillance focal persons on malaria surveillance including surveillance systems, monitoring & evaluation (based on the new WHO surveillance reference manual); and
- To discuss the modalities of establishing the SEA regional malaria database.
The participants included: Programme managers and surveillance focal points from National Malaria Programmes from 11 Member States, MEOC Focal person for SEAR E2020 countries & individual experts, WHO technical & support staff from the South-East Asia Regional Office, Country Offices (SEAR), Western Pacific Regional Office, HQ and partners [APLMA, RBM Partnership to End Malaria, National Institute of Malaria Research, India (WHO CC) and select NGOs (BRAC-Bangladesh, Save the Children-Nepal)].
On Day 1, the workshop started with opening remarks and details of the objectives by Dr. Neena Valecha, RA-Malaria, SEARO. She mentioned that transforming surveillance into a core intervention was one of the pillars of the Global Technical Strategy for Malaria 2016-2030 (GTS). The WHO therefore urges endemic countries and those that have achieved elimination to strengthen their disease surveillance, health information and vital registration systems. Effective surveillance of malaria cases and deaths as well as key entomological and efficacy indicators are essential for identifying the areas or population groups that are at risk of and most affected by malaria and are vulnerable to reduced efficacy of interventions. This in turn, allows for effective programme planning including informing decisions on targeting resources for interventions including response to epidemics and intensification of control, when necessary, towards maximum impact. In 2018, the WHO released a reference manual on malaria surveillance, monitoring and evaluation that provides guidance on global surveillance standards and guides countries in their efforts to strengthen surveillance systems and use their own data to make evidence-informed decisions. The aim of this manual is to align with the concept of transmission continuum in the GTS and the elimination framework and to bring together epidemiological, entomological and efficacy surveillance in one reference guideline for staff in ministries of health, national malaria programmes and health information systems, and partners involved in malaria surveillance as well as WHO staff who advise countries on malaria surveillance.
Following self-introduction of participants and observers and nomination of chairs, co-chairs and rapporteurs, the first technical session was held on: surveillance on the pathway to elimination. The presentations & discussion included: the framework for malaria elimination; an overview of surveillance strategies and characteristics including case detection, case notification, investigation and classification, foci investigation and classification, foci response, and entomological surveillance and vector control monitoring and evaluation. The next session was on: IT based surveillance platforms that included presentations & discussion on: DHIS2 for malaria surveillance in burden reduction and elimination settings followed by Bhutan malaria surveillance using the DHIS2, and 2019 World Malaria Report with emphasis on DHIS2, data collection tool and the processes. Sri Lanka also shared their experience on surveillance and response to the first introduced case following malaria elimination.
On Day 2, the session on components of malaria surveillance included presentations & discussion on: surveillance of antimalarial drug efficacy and drug resistance; iDES in Thailand; quality diagnosis for improving surveillance; Mekong Malaria Elimination Programme and the role of WHO; and detection and response to malaria outbreaks. A session on surveillance in countries targeting elimination was held with presentations & discussion on: malaria surveillance to accelerate towards elimination by Myanmar followed by group work.
On Day 3, a presentation & discussion was held on: examples of best practice from GMS by Mekong Malaria Elimination programme. Thereafter, a session on technical updates on monitoring and evaluation was held with presentations & discussion on: monitoring and evaluation of national programmes; subnational elimination verification: country plans and experience; and establishing the SEA regional malaria data repository. Later, a group work was held on: World Malaria Report 2018.
The closing session included concluding remarks by Dr. Neena Valecha, RA-Malaria, SEARO. Salient recommendations were drafted with consensus by the Member States:
- For countries:
- Elimination is not the end of game because of receptivity & vulnerability and prevention of reintroduction is critical. Countries & even the donors like the Global Fund & others need to learn & recognize the potentials for transmission and act accordingly
- WHO Surveillance and Monitoring & Evaluation Manuals is not prescriptive but provide guidance to countries. The countries need to adopt & adapt relative to specific country context
- Countries need to establish surveillance systems for burden reduction and elimination settings. In former settings, aggregated data may be sufficient, however, in elimination settings, data from case/focus investigations are needed
- Countries need to take up parasitological and entomological investigations & ensure appropriate skill sets are available
- Countries need to adopt appropriate combination of approaches for vector control and judicious use
- Countries need to ensure quality assured diagnostic tools (RDT, microscopy). PCR and other resource intensive tools are not requirements in all settings
- Countries need to ensure national accredited & certification scheme with WHO support. Whilst the WHO facilitates ECA, countries need to progressively build in-country capacities following ECA of certain facilitators. In large countries, ECA with external facilitators can be held in parallel with in-country trainings using standard reference materials
- Existing reference laboratory may be utilized for RDT lot testing and slide bank by the region with facilitation by the WHO. Capacities of few other institutions may also be built
- G6PD test for P. vivax radical treatment is the best practice recommended by the WHO. However, in elimination settings where the number of cases are very low, this test may be done in all cases
- Countries need to adopt web based system like DHIS 2 and or customize own systems to capture all relevant data and progressively move towards capturing real time data. In elimination settings, real time data availability and analysis is mandatory
- Private sector data is crucial especially in low & elimination settings. Private sector disease notification needs to be enforced
- Countries need to diligently use the WMR formats for correct representation of data
- Local health facilities should be the first port to detect & respond to epidemics and not district & national levels, where aggregated data is transmitted. Countries may use 2-year rather than 5-year data base for analysis
- For WHO:
- A regional approach to malaria elimination is critical & not piecemeal approach. There is risk of reintroduction till whole region eliminates malaria. A regional mechanism for oversight should be established
- Periodic independent evaluation of malaria programmes with facilitation by WHO should be encouraged. Follow up with countries on implementation of recommendations should be done
- Advocacy support to countries should continue for operationalizing ministerial declaration & follow up should be done
- Establishment of SEA regional malaria database should be initiated