Search

Testing and treating asymptomatic populations has the potential to reduce the population’s parasite reservoir and reduce malaria transmission. Zanzibar’s electronic malaria case notification (MCN) platform collects detailed socio-demographic and epidemiological data from all confirmed malaria cases to inform programmatic decision-making. This Field Action Report describes the design and operationalization process of the platform, as well as other malaria surveillance resources that are enabling Zanzibar to progress toward malaria elimination.The MCN platform consists of an interactive short message service (SMS) system for case notification, a software application for Android mobile devices, a visual question set and workflow manager, a back-end database server, and a web browser-based application for data analytics, configuration, and management. Malaria case data were collected from August 2012 to December 2021 and reported via SMS from all public and private health facilities to a central database, and then to District Malaria Surveillance Officers’ mobile devices. Data included patient names, shehia and date of diagnosis, which enabled the officers to track patients, ideally within 24 hours of reporting. Patients’ household members were tested for malaria using conventional rapid diagnostic tests (RDTs). Treatment using artemisinin-based combination therapy was provided for persons testing positive.Between 2012 and 2021, a total of 48,899 index malaria cases were confirmed at health facilities, 22,152 (45.3%) of whom within 24 hours of reporting; 41,886 (85.7%) cases were fully investigated and followed up to household level. A total of 111,811 additional household members were tested with RDTs, of whom 10,602 (9.5%) were malaria positive.The MCN platform reports malaria case data in near real-time, enabling prompt testing and treatment of members in index case households. Along with routine testing and treatment and other preventive interventions, combined with comprehensive reactive-case detection efforts, the continued use of the MCN platform is likely to reduce malaria transmission and malaria morbidity even further, thereby enhancing malaria elimination in Zanzibar.

BACKGROUND While high-quality primary healthcare services provided can meet 80-90% of health needs over a person’s lifetime, this potential is severely hindered in many low-resource countries by a constrained health care system. There is a growing consensus that effectively designed, resourced and managed Community Health Worker (CHW) programs are a critical component of a well-functioning primary health system, and digital technology is recognized as an important enabler of health systems transformation. OBJECTIVE In this implementation report we describe the design and roll-out of Zanzibar’s national, digitally enabled community health program. METHODS Since 2010, D-tree International has partnered with the Zanzibar Ministry of Health to pilot and generate evidence for a digitally enabled community health program, which was formally adopted and scaled nationally by the government in 2018. Community Health Workers use a mobile app which guides service delivery and data collection for home-based health services, resulting in comprehensive service delivery, access to real-time data, efficient management of resources and continuous quality improvement. RESULTS The Zanzibar government has documented increases in health facility deliveries among pregnant women and reductions in stunting among children under-five since the community health program has scaled. Key success factors included starting with the health challenge and local context, rather than the technology; utilization of data for decision-making; and extensive collaboration with local and global partners and funders. Long-term sustainability has been a key focus of the program since its inception, and the Zanzibar government and D-tree are currently implementing a transition plan to enable full government ownership and financing by 2026. CONCLUSIONS Jamii ni Afya represents one of the world’s first examples of a nationally scaled digitally enabled community health program. This article outlines key successes and lessons learned which may have applicability to other governments and partners working to sustainably strengthen primary health systems.

Background Malaria remains a major public health problem in sub-Saharan Africa. The 2021 World Health Organization (WHO) World Malaria Report indicates a slowing in the decline of malaria incidence since 2015. Malaria prevalence in Zanzibar has been maintained at less than 1% since 2010, however from 2018 to 2021, the annual number of reported malaria cases has gradually increased from 4106 to 9290. Community engagement has been emphasized by the WHO for reducing malaria transmission. To better understand the potential for a door-to-door approach for malaria, a three-month pilot programme was carried out. This qualitative study aimed at understanding stakeholder experiences with the pilot programme and considerations for its implementation. Methods Through multistage sampling, four shehias (wards—the lowest administrative structure) with comparatively high (> 1.9 per 1000) and four with low ( Results Most community members reported high levels of acceptance of door-to-door interventions. Some factors that might affect implementation of door-to-door include, low risk perception of the disease, local beliefs and practice, lack of initiative from the programme level to involve communities, and political instability during the election period. All Community Health Volunteers (CHVs) recommended this approach for community engagement, however, ensuring adequate resources was identified as a key factor for ensuring its sustainability. Conclusion The door-to-door intervention was perceived as helpful for promoting community engagement. There are several factors to consider including ensuring that CHVs are provided with adequate education, regular supervision, and have access to essential resources. Community leaders should be fully involved in choosing CHVs that are acceptable to the community. To ensure sustainability, the government should allocate sufficient resources and improve coordination systems.

Background Reactive case detection (RCD) is a commonly used strategy for malaria surveillance and response in elimination settings. Many approaches to RCD assume detectable infections are clustered within and around homes of passively detected cases (index households), which has been evaluated in a number of settings with disparate results. Methods Household questionnaires and diagnostic testing were conducted following RCD investigations in Zanzibar, Tanzania, including the index household and up to 9 additional neighboring households. Results Of 12,487 participants tested by malaria rapid diagnostic test (RDT), 3·2% of those residing in index households and 0·4% of those residing in non-index households tested positive (OR = 8·4; 95%CI: 5·7, 12·5). Of 6,281 participants tested by quantitative polymerase chain reaction (qPCR), 8·4% of those residing in index households and 1·3% of those residing in non-index households tested positive (OR = 7·1; 95%CI: 6·1, 10·9). Within households of index cases defined as imported, odds of qPCR-positivity amongst members reporting recent travel were 1·4 times higher than among those without travel history (95%CI: 0·2, 4·4). Amongst non-index households, odds of qPCR-detectable infection were no different between households located within 50 m of the index household as compared with those located farther away (OR = 0·8, 95%CI: 0·5, 1·4). Sensitivity of RDT to detect qPCR-detectable infections was 34% (95%CI: 26·4, 42·3). Conclusions Malaria prevalence in index households in Zanzibar is much higher than in non-index households, in which prevalence is very low. Travelers represent a high-risk population. Low sensitivity of RDTs due to a high prevalence of low-density infections results in an RCD system missing a large proportion of the parasite reservoir.

BackgroundDespite the continued high coverage of malaria interventions, malaria elimination in Zanzibar remains elusive, with the annual number of cases increasing gradually over the last 3 years. The aims of the analyses presented here were to (i) assess the spatio-temporal dynamics of malaria in Zanzibar between 2015 and 2020, and (ii) identify malaria hotspots that would allow Zanzibar to develop an epidemiological stratification for more effective and granular intervention targeting, thereby allowing for more effective programmatic resource allocations.MethodsData routinely collected by Zanzibar’s Malaria Case Notification (MCN) system were analyzed. The system collects detailed socio-demographic and epidemiological data from all malaria cases who are passively detected and reported at the islands’ 313 public and private health facilities (defined as primary index cases), as well as through case follow-up and reactive case detection (defined as secondary cases). Using these data, spatio-temporal analyses were performed to identify the spatial heterogeneity of case reporting at shehia (ward) level during transmission seasons and its correlation with 2015–2020 rainfall.ResultsFrom January 1, 2015, to April 30, 2020, 22,686 index cases were notified by health facilities and reported through the MCN system. Number of cases reported showed declining trends from 2015 to 2017, followed by an increase from 2018 to 2020. More than 40% of cases had a travel history outside Zanzibar in the month prior to testing positive for malaria. The proportion of followed-up index cases was approximately 70% for all years. Change point analysis identified 10 distinct periods of malaria transmission across the study period, and the seasonality of reported index cases was significantly correlated to the amount of precipitation that occurred during the previous rainy season. Out of Zanzibar’s 388 shehias, 79 (20.3%) were identified as malaria hotspots in any given year between 2015 and 2020; these hotspots reported 52% of all index cases during the study period. Of the 79 shehias identified as hotspots, 12 (3% of all shehias) were hotspots in more than four years, i.e., considered temporally stable, reporting 14.5% of all index cases.ConclusionsOur findings confirm that the scale-up of malaria interventions has greatly reduced malaria transmission in Zanzibar since 2006, with mean annual shehia incidence being 3.8 cases per 1,000 over the 2015–2020 study period. Spatio-temporal analyses identified hotspots, some of which were stable across multiple years. From a programmatic perspective, malaria efforts should progress from an approach that is based on universal coverage of interventions to an approach that is more tailored and nuanced, with resources prioritized and allocated to a select number of hotspot shehias.

BackgroundDespite high coverage of malaria interventions, malaria elimination in Zanzibar remains elusive, with the annual number of cases increasing gradually over the last 3 years.ObjectiveThe aims of the study were to (1) assess the spatiotemporal dynamics of malaria in Zanzibar between 2015 and 2020 and (2) identify malaria hotspots that would allow Zanzibar to develop an epidemiological stratification for more effective and granular intervention targeting.MethodsIn this study, we analysed data routinely collected by Zanzibar’s Malaria Case Notification (MCN) system. The system collects sociodemographic and epidemiological data from all malaria cases. Cases are passively detected at health facilities (ie, primary index cases) and through case follow-up and reactive case detection (ie, secondary cases). Analyses were performed to identify the spatial heterogeneity of case reporting at shehia (ward) level during transmission seasons.ResultsFrom 1 January 2015 to 30 April 2020, the MCN system reported 22 686 index cases. Number of cases reported showed a declining trends from 2015 to 2016, followed by an increase from 2017 to 2020. More than 40% of cases had a travel history outside Zanzibar in the month prior to testing positive for malaria. The proportion of followed up index cases was approximately 70% for all years. Out of 387 shehias, 79 (20.4%) were identified as malaria hotspots in any given year; these hotspots reported 52% of all index cases during the study period. Of the 79 hotspot shehias, 12 were hotspots in more than 4 years, that is, considered temporally stable, reporting 14.5% of all index cases.ConclusionsOur findings confirm that the scale-up of malaria interventions has greatly reduced malaria transmission in Zanzibar since 2006. Analyses identified hotspots, some of which were stable across multiple years. Malaria efforts should progress from a universal intervention coverage approach to an approach that is more tailored to a select number of hotspot shehias.

Since 2012, the Zanzibar Malaria Elimination Program has been implementing reactive case detection (RACD). Health facility (HF) staff send individual malaria case notifications by using mobile phones, triggering a review of HF records and malaria testing and treatment at the household level by a district malaria surveillance officer. We assessed the completeness and timeliness of this system, from case notification to household-level response. We reviewed two years (2015–2016) of primary register information in 40 randomly selected HFs on Zanzibar’s two islands Unguja and Pemba and database records of case notifications from all registered HFs for the period 2013–16. The operational coverage of the system was calculated as proportion of HF-registered cases that were successfully reviewed and followed up at their household. Timeliness was defined as completion of each step within 1 day. Public HFs notified almost all registered cases (91% in Unguja and 87% in Pemba), and 74% of cases registered at public HFs were successfully followed up at their household in Unguja and 79% in Pemba. Timely operational coverage (defined as each step, diagnosis to notification, notification to review, and review to household-level response, completed within 1 day) was achieved for only 25% of registered cases in Unguja and 30% in Pemba. Records and data from private HFs on Unguja indicated poor notification performance in the private sector. Although the RACD system in Zanzibar achieved high operational coverage, timeliness was suboptimal. Patients diagnosed with malaria at private HFs and hospitals appeared to be largely missed by the RACD system.

Background Impact evaluations allow countries to assess public health gains achieved through malaria investments. This study uses routine health management information system (HMIS) data from Zanzibar to describe changes in confirmed malaria incidence and impact of case management and vector control interventions during 2000–2015. Methods HMIS data from 129 (82%) public outpatient facilities were analyzed using interrupted time series models to estimate the impact of artemisinin-based combination therapy (ACT), indoor residual spray, and long-lasting insecticidal nets. Evaluation periods were defined as pre-intervention (January 2000 to August 2003), ACT-only (September 2003 to December 2005) and ACT plus vector control (2006–2015). Findings After accounting for climate, seasonality, diagnostic testing rates, and outpatient attendance, average monthly incidence of confirmed malaria showed no trend over the pre-intervention period 2000–2003 (incidence rate ratio (IRR) 0.998, 95% CI 0.995–1.000). During the ACT-only period (2003–2005), the average monthly malaria incidence rate declined compared to the pre-intervention period, showing an overall declining trend during the ACT-only period (IRR 0.984, 95% CI 0.978–0.990). There was no intercept change at the start of the ACT-only period (IRR 1.081, 95% CI 0.968–1.208), but a drop in intercept was identified at the start of the ACT plus vector control period (IRR 0.683, 95% CI 0.597–0.780). During the ACT plus vector control period (2006–2015), the rate of decline in average monthly malaria incidence slowed compared to the ACT-only period, but the incidence rate continued to show an overall slight declining trend during 2006–2015 (IRR 0.993, 95% CI 0.992–0.994). Interpretation This study presents a rigorous approach to the use of HMIS data in evaluating the impact of malaria control interventions. Evidence is presented for a rapid decline in malaria incidence during the period of ACT roll out compared to pre-intervention, with a rapid drop in malaria incidence following introduction of vector control and a slower declining incidence trend thereafter., Highlights • Health Information Management System (HMIS) data can be used successfully in rigorous impact evaluation analyses. • An interrupted time series model identified a rapid decline in malaria incidence in Zanzibar after introduction of ACT. • The low incidence was sustained with both ACT and vector control, with continued slight declining trend during 2006-2015.

As countries transition toward malaria elimination, malaria programs rely on surveillance–response systems, which are often supported by web- and mobile phone–based reporting tools. Such surveillance–response systems are interventions for elimination, making it important to determine if they are operating optimally. A metric to measure this by is timeliness. This study used a mixed-methods approach to investigate the response time of Zanzibar’s malaria elimination surveillance–response system, Malaria Case Notification (MCN). MCN conducts both passive and reactive case detection, supported by a mobile phone–based reporting tool called Coconut Surveillance. Using data obtained from RTI International and the Zanzibar Malaria Elimination Program (ZAMEP), analysis of summary statistics was conducted to investigate the association of response time with geography, and time series techniques were used to investigate trends in response time and its association with the number of reported cases. Results indicated that response time varied by the district in Zanzibar (0.6–6.05 days) and that it was not associated with calendar time or the number of reported cases. Survey responses and focus groups with a cadre of health workers, district malaria surveillance officers, shed light on operational challenges faced during case investigation, such as incomplete health records and transportation issues, which stem from deficiencies in aspects of ZAMEP’s program management. These findings illustrate that timely response for malaria elimination depends on effective program management, despite the automation of web-based or mobile phone–based tools. For surveillance–response systems to work optimally, malaria programs should ensure that optimal management practices are in place.

Introduction: To achieve malaria elimination, understanding of the individual risk factors for malaria infection is critical to inform strategic planning and implementation. To address this, a community-based individual risk-factor study was conducted in Unguja Island Zanzibar.Methods: A matched case control study with a sample size of 103 cases and 309 controls was conducted in Unguja Island. Malaria cases from health facilities were reported via Unstructured Supplementary Service Data (USSD) mobile phones to a central database, after which an SMS alert was sent to the District Malaria Surveillance Officer’s (DMSO) mobile phone. DMSO followed up index cases up to household level and performed malaria test on all household members using rapid diagnostic tests (mRDT). Family members tested negative were considered as controls. Both cases and controls were interviewed with the same questionnaire. Data were analyzed using Epi-info version 3.5.1 using conditional logistic regression model. Results: The findings revealed that chance of malaria infection was higher among individuals who travelled outside Zanzibar [AOR = 60.47, 95% CI 15.73 - 232.44], who spend their time in outdoor activities during the night [AOR = 8.53, 95% CI 1.96 - 37.11], whose rooms were not sprayed with indoor residual spray (IRS) [AOR= 29.60, 95% CI 2.68 - 326.49] and those who did not have a bed net [AOR=16.25, 95% CI 3.32 - 79.50].Conclusion: Travel outside Zanzibar, outdoors activities during the night, lack of access to malaria interventions (IRS or bed nets) were the risk factors for malaria infection in Unguja. Ministry of Health should set a mechanism of encouraging people who travel to malaria endemic areas to attend the nearby health facility for malaria screening. Sensitizing people on using protective gear during the night and ensuring good coverage of malaria interventions would reduce the risk of malaria in Unguja Zanzibar.

Background Mass drug administration (MDA) appears to be effective in reducing the risk of malaria parasitaemia. This study reports on programmatic coverage and compliance of MDA using artemisinin-based combination therapy (ACT) in four shehias (smallest administration unit) that had been identified as hotspots through Zanzibar’s malaria case notification surveillance system. Methods Mass drug administration was done in four shehias selected on the basis of: being an established malaria hot spot; having had mass screening and treatment (MSaT) 2–6 weeks previously; and exceeding the epidemic alert threshold of 5 cases within a week even after MSaT. Communities were sensitized and MDA was conducted using a house-to-house approach. All household members, except pregnant women and children aged less than 2 months, were provided with ACT medicine. Two weeks after the MDA campaign, a survey was undertaken to investigate completion of ACT doses. Results A total of 8816 [97.1% of eligible; 95% confidence interval (CI) 96.8–97.5] people received ACT. During post MDA surveys, 2009 people were interviewed: 90.2% reported having completed MDA doses; 1.9% started treatment but did not complete dosage; 4.7% did not take treatment; 2.0% were absent during MDA and 1.2% were ineligible (i.e. infants

Objective This presentation will share findings from more than three years of using mobile technology for reactive case detection (RACD) to help eliminate malaria in a well-defined geographic area. It will review the concepts of RACD, the application of mobile technology, lessons learned from more than three years of application, and considerations in applying this technology in other malaria elimination contexts. Introduction Zanzibar is comprised primarily of two large islands with a population of 1.3 million. Indoor Residual Spraying (IRS) campaigns, distribution of long-lasting insecticide treated bed nets (LLINs), and use of Rapid Diagnostic Tests (RDTs) have reduced Malaria prevalence from 39% in 2005 to less than 1% in 2011-2012. As malaria burden decreases, there is an increasing need to track and follow up individual cases to contain transmission that could lead to resurgence. One method being used to achieve these aims is reactive case detection (RACD). RACD is generally understood to be triggered whenever a case is identified by passive case detection. The response involves visiting the household of the newly reported case and screening family members. Depending on program protocol, it may also involve screening neighbors within a defined radius. RACD has been used or tested in Cambodia, China, India, Peru, Senegal, Swaziland, Tanzania, and Zambia. RACD can be resource intensive. Several studies raise questions concerning whether and how RACD can be prioritized and targeted effectively as case numbers continue to decline. Methods Since September 2012 Zanzibar Malaria Elimination Programme (ZAMEP) has used RACD to limit onward transmission, reduce the local parasite reservoir, and gather data needed improve program effectiveness. Zanzibar is one of very few malaria elimination contexts using a mobile technology system to support RACD. 1 This system, called the Malaria Case Notification system (MCN) uses mobile software called Coconut Surveillance. Coconut Surveillance is free and open source software designed for malaria elimination. It includes an interactive SMS system for case notification, a mobile software application designed to guide mobile case workers through RACD, and an analytics software application designed for surveillance and response program managers. Data were collected in the Coconut Surveillance database for more than three years, beginning in September 2012. Reports were monitored in real time and periodically to assess RACD response times against protocol targets, case trends, case locations, and other data. Geographical Information System (GIS) software was used to produce detailed maps of case households. Three independent assessments were conducted of various aspects of the malaria surveillance system. Results From September 2012 to December 2015, Coconut Surveillance has helped malaria surveillance officers in Zanzibar respond to more than 8,617 (84%) reported cases of malaria, complete nearly 10,245 household visits, test more than 36,185 household members, and identify and treat 2,032 previously unknown cases. The average number of RACD activities occurring within 48 hours increased from 72% in 2013 to 89% in 2015. The number of household members screened during RACD also increased from 7,589 in 2013 to 14,987 in 2015. Challenges included incomplete registers at health care facilities, lack of transport, inadequate training for clinicians and surveillance officers, and insufficient communication to the affected communities. Conclusions In Zanzibar twenty malaria surveillance officers equipped with inexpensive Android tablets and motorbikes are keeping malaria prevalence at less than 1%. The effectiveness of the system might be enhanced by improving training for clinicians and surveillance officers, ensuring the availability of transportation for surveillance officers, and improving communications to the affected communities. These results suggest key considerations for applying this and similar systems in other malaria elimination contexts.

Seasonal increases in malaria continue in hot spots in Zanzibar. Mass screening and treatment (MSAT) may help reduce the reservoir of infection; however, it is unclear whether rapid diagnostic tests (RDTs) detect a sufficient proportion of low-density infections to influence subsequent transmission.; Two rounds of MSAT using Plasmodium falciparum-specific RDT were conducted in 5 hot spots (population, 12 000) in Zanzibar in 2012. In parallel, blood samples were collected on filter paper for polymerase chain reaction (PCR) analyses. Data on confirmed malarial parasite infections from health facilities in intervention and hot spot control areas were monitored as proxy for malaria transmission.; Approximately 64% of the population (7859) were screened at least once. P. falciparum prevalence, as measured by RDT, was 0.2% (95% confidence interval [CI], .1%-.3%) in both rounds, compared with PCR measured prevalences (for all species) of 2.5% (95% CI, 2.1%-2.9%) and 3.8% (95% CI, 3.2%-4.4%) in rounds 1 and 2, respectively. Two fifths (40%) of infections detected by PCR included non-falciparum species. Treatment of RDT-positive individuals (4% of the PCR-detected parasite carriers) did not reduce subsequent malaria incidence, compared with control areas.; Highly sensitive point-of-care diagnostic tools for detection of all human malaria species are needed to make MSAT an effective strategy in settings where malaria elimination programs are in the pre-elimination phase.

Decision support systems for malaria elimination must support rapid response to contain outbreaks. The integrated mobile system in Zanzibar has been recognized as one of the most advanced in the world. The system consists of a simple facility-based case notification system that uses common feature phones, and a mobile application for Android tablet computers. The resulting system enables rapid response to new cases, helps to rapidly diagnose and treat secondary case, and provides high-quality data for identifying hot spots, trends, and transmission patterns. This presentation will review the history, technology, results, lessons-learned, and applicability to other contexts.