Mass Screening and Treatment on the Basis of Results of a Plasmodium falciparum-Specific Rapid Diagnostic Test Did Not Reduce Malaria Incidence in Zanzibar

Background. 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. Methods. 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. Results. 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. Conclusions. 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 phas

Operational coverage and timeliness of reactive case detection for malaria elimination in Zanzibar, Tanzania

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

Socio-demographic trends in malaria knowledge and implications for behaviour change interventions in Zanzibar

Abstract Background Zanzibar is among the few places within East Africa that have documented a significant reduction of malaria morbidity and mortality. Despite tremendous gains over the past decade, malaria transmission still persists in Zanzibar. This study aimed at understanding levels of malaria knowledge to provide recommendations that can be used to reinforce and scale up targeted malaria social and behaviour change interventions. Methods A descriptive cross-sectional survey was conducted through an administered questionnaire to 431 households selected randomly. The interviewees were the heads of household or representative adults above 18 years. This study investigated the levels of knowledge about the causes, symptoms, and prevention of malaria in areas with high (> 1.9 per 1000) and low (< 1 per 1000) incidence of local malaria cases. The Principal Component Analysis (PCA) was used to compute the composite variable of each category. Descriptive statistics were calculated to understand variables of interest between low and high transmission areas. Multinomial logistic regression model was used to compare knowledge on malaria based on key variables. Results A total of 431 heads of households were interviewed. Respondent age, education level, and wealth status were significantly associated with variations in level of malaria knowledge. Old age was found to be significantly associated with low knowledge of malaria (P < 0.001). The majority of study participants who had secondary and higher education levels had good knowledge of malaria (P < 0.006). Participants characterized as middle-income had good knowledge compared to those characterized as low-income (P < 0.001). Conclusion The study identified existing gaps in malaria knowledge in low and high transmission areas. Low levels of malaria knowledge were documented among elderly and populations with lower education and income levels. There is a need to extend mobilization, advocacy, and expand channels of communication to reach all community members. The reported gaps in knowledge are important to consider when designing strategies to engage communities in malaria elimination in Zanzibar. Tailored social and behavioural change interventions aiming to increase malaria knowledge could enhance the uptake of malaria prevention services in the community

Using Mobile Technology to Facilitate Reactive Case Detection of Malaria

ObjectiveThis presentation will share findings from more than three years ofusing mobile technology for reactive case detection (RACD) to helpeliminate malaria in a well-defined geographic area. It will reviewthe concepts of RACD, the application of mobile technology, lessonslearned from more than three years of application, and considerationsin applying this technology in other malaria elimination contexts.IntroductionZanzibar is comprised primarily of two large islands with apopulation 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 Malariaprevalence from 39% in 2005 to less than 1% in 2011-2012. Asmalaria burden decreases, there is an increasing need to track andfollow up individual cases to contain transmission that could lead toresurgence. One method being used to achieve these aims is reactivecase detection (RACD).RACD is generally understood to be triggered whenever a case isidentified by passive case detection. The response involves visiting thehousehold of the newly reported case and screening family members.Depending on program protocol, it may also involve screeningneighbors within a defined radius. RACD has been used or testedin Cambodia, China, India, Peru, Senegal, Swaziland, Tanzania,and Zambia. RACD can be resource intensive. Several studies raisequestions concerning whether and how RACD can be prioritized andtargeted effectively as case numbers continue to decline.MethodsSince September 2012 Zanzibar Malaria Elimination Programme(ZAMEP) has used RACD to limit onward transmission, reduce thelocal parasite reservoir, and gather data needed improve programeffectiveness. Zanzibar is one of very few malaria eliminationcontexts using a mobile technology system to support RACD.1Thissystem, called the Malaria Case Notification system (MCN) usesmobile software called Coconut Surveillance.Coconut Surveillance is free and open source software designed formalaria elimination. It includes an interactive SMS system for casenotification, a mobile software application designed to guide mobilecase workers through RACD, and an analytics software applicationdesigned for surveillance and response program managers.Data were collected in the Coconut Surveillance database formore than three years, beginning in September 2012. Reports weremonitored in real time and periodically to assess RACD responsetimes against protocol targets, case trends, case locations, and otherdata. Geographical Information System (GIS) software was usedto produce detailed maps of case households. Three independentassessments were conducted of various aspects of the malariasurveillance system.ResultsFrom September 2012 to December 2015, Coconut Surveillancehas helped malaria surveillance officers in Zanzibar respond tomore than 8,617 (84%) reported cases of malaria, complete nearly10,245 household visits, test more than 36,185 household members,and identify and treat 2,032 previously unknown cases. The averagenumber of RACD activities occurring within 48 hours increased from72% in 2013 to 89% in 2015. The number of household membersscreened during RACD also increased from 7,589 in 2013 to 14,987in 2015. Challenges included incomplete registers at health carefacilities, lack of transport, inadequate training for clinicians andsurveillance officers, and insufficient communication to the affectedcommunities.ConclusionsIn Zanzibar twenty malaria surveillance officers equipped withinexpensive Android tablets and motorbikes are keeping malariaprevalence at less than 1%. The effectiveness of the system mightbe enhanced by improving training for clinicians and surveillanceofficers, ensuring the availability of transportation for surveillanceofficers, and improving communications to the affected communities.These results suggest key considerations for applying this and similarsystems in other malaria elimination contexts

The Journey of Zanzibar’s Digitally Enabled Community Health Program to National Scale: Implementation Report

BackgroundWhile high-quality primary health care services 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 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. ObjectiveIn this implementation report, we describe the design and rollout of Zanzibar’s national, digitally enabled community health program–Jamii ni Afya. MethodsSince 2010, D-tree International has partnered with the Ministry of Health Zanzibar 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 that 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. ResultsThe Zanzibar government has documented increases in the delivery of health facilities among pregnant women and reductions in stunting among children younger than 5 years since the community health program has scaled. Key success factors included starting with the health challenge and local context rather than the technology, usage of data for decision-making, and extensive collaboration with local and global partners and funders. Lessons learned include the significant time it takes to scale and institutionalize a digital health systems innovation due to the time to generate evidence, change opinions, and build capacity. ConclusionsJamii ni Afya represents one of the world’s first examples of a nationally scaled digitally enabled community health program. This implementation report outlines key successes and lessons learned, which may have applicability to other governments and partners working to sustainably strengthen primary health systems

Using Mobile Technology to Facilitate Reactive Case Detection of Malaria

ObjectiveThis presentation will share findings from more than three years ofusing mobile technology for reactive case detection (RACD) to helpeliminate malaria in a well-defined geographic area. It will reviewthe concepts of RACD, the application of mobile technology, lessonslearned from more than three years of application, and considerationsin applying this technology in other malaria elimination contexts.IntroductionZanzibar is comprised primarily of two large islands with apopulation 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 Malariaprevalence from 39% in 2005 to less than 1% in 2011-2012. Asmalaria burden decreases, there is an increasing need to track andfollow up individual cases to contain transmission that could lead toresurgence. One method being used to achieve these aims is reactivecase detection (RACD).RACD is generally understood to be triggered whenever a case isidentified by passive case detection. The response involves visiting thehousehold of the newly reported case and screening family members.Depending on program protocol, it may also involve screeningneighbors within a defined radius. RACD has been used or testedin Cambodia, China, India, Peru, Senegal, Swaziland, Tanzania,and Zambia. RACD can be resource intensive. Several studies raisequestions concerning whether and how RACD can be prioritized andtargeted effectively as case numbers continue to decline.MethodsSince September 2012 Zanzibar Malaria Elimination Programme(ZAMEP) has used RACD to limit onward transmission, reduce thelocal parasite reservoir, and gather data needed improve programeffectiveness. Zanzibar is one of very few malaria eliminationcontexts using a mobile technology system to support RACD.1Thissystem, called the Malaria Case Notification system (MCN) usesmobile software called Coconut Surveillance.Coconut Surveillance is free and open source software designed formalaria elimination. It includes an interactive SMS system for casenotification, a mobile software application designed to guide mobilecase workers through RACD, and an analytics software applicationdesigned for surveillance and response program managers.Data were collected in the Coconut Surveillance database formore than three years, beginning in September 2012. Reports weremonitored in real time and periodically to assess RACD responsetimes against protocol targets, case trends, case locations, and otherdata. Geographical Information System (GIS) software was usedto produce detailed maps of case households. Three independentassessments were conducted of various aspects of the malariasurveillance system.ResultsFrom September 2012 to December 2015, Coconut Surveillancehas helped malaria surveillance officers in Zanzibar respond tomore than 8,617 (84%) reported cases of malaria, complete nearly10,245 household visits, test more than 36,185 household members,and identify and treat 2,032 previously unknown cases. The averagenumber of RACD activities occurring within 48 hours increased from72% in 2013 to 89% in 2015. The number of household membersscreened during RACD also increased from 7,589 in 2013 to 14,987in 2015. Challenges included incomplete registers at health carefacilities, lack of transport, inadequate training for clinicians andsurveillance officers, and insufficient communication to the affectedcommunities.ConclusionsIn Zanzibar twenty malaria surveillance officers equipped withinexpensive Android tablets and motorbikes are keeping malariaprevalence at less than 1%. The effectiveness of the system mightbe enhanced by improving training for clinicians and surveillanceofficers, ensuring the availability of transportation for surveillanceofficers, and improving communications to the affected communities.These results suggest key considerations for applying this and similarsystems in other malaria elimination contexts

Using Mobile Technology to Help Eliminate Malaria in Zanzibar

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

Mass screening and treatment on the basis of results of a Plasmodium falciparum-specific rapid diagnostic test did not reduce malaria incidence in Zanzibar

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

Multiplexed ddPCR-amplicon sequencing reveals isolated Plasmodium falciparum populations amenable to local elimination in Zanzibar, Tanzania

Abstract Zanzibar has made significant progress toward malaria elimination, but recent stagnation requires novel approaches. We developed a highly multiplexed droplet digital PCR (ddPCR)-based amplicon sequencing method targeting 35 microhaplotypes and drug-resistance loci, and successfully sequenced 290 samples from five districts covering both main islands. Here, we elucidate fine-scale Plasmodium falciparum population structure and infer relatedness and connectivity of infections using an identity-by-descent (IBD) approach. Despite high genetic diversity, we observe pronounced fine-scale spatial and temporal parasite genetic structure. Clusters of near-clonal infections on Pemba indicate persistent local transmission with limited parasite importation, presenting an opportunity for local elimination efforts. Furthermore, we observe an admixed parasite population on Unguja and detect a substantial fraction (2.9%) of significantly related infection pairs between Zanzibar and the mainland, suggesting recent importation. Our study provides a high-resolution view of parasite genetic structure across the Zanzibar archipelago and provides actionable insights for prioritizing malaria elimination efforts

Malaria infection prevalence and sensitivity of reactive case detection in Zanzibar

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.; Household questionnaires and diagnostic testing were conducted following RCD investigations in Zanzibar, Tanzania, including the index household and up to 9 additional neighboring households.; 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).; 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