SURVEYS IN MALARIA CONTROL PROGRAMS

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SURVEYS IN MALARIA CONTROL PROGRAMS

• Malaria Monitoring and Evaluation Workshop,
  Luxur, Egypt
• 5 9 December 2004
• M. Naeem Durrani
• WHO Temporary Advisor
• Technical Advisor, HealthNet International

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Survey a Source of Data Collection

• Why Malaria Surveys are selected as data
  collection Tool
• Types of Surveys and information collected by a
  Survey
• DHS, Demographic and Health Survey (DHS)
• Multiple Indicator cluster survey (MICS)
• Household Surveys, Coverage surveys
• Parasite Surveys (slides, RDTs)
• Serological Surveys, laboratory tests
• Entomological Surveys
• Health Facility Surveys
• Characteristics of a Survey
• Planning Process (18 Major Steps)
• Selection of Samples
• Experience From Countries ( Kenya, Eritrea,
  Afghanistan, Pakistan)

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Surveys as Data Collection Tool

• What is Survey?
• Collection of data/information from all
  individuals or sample of individuals chosen to be
  representative of the population form which they
  are drawn.
• Why and When to Undertake a Survey ?
• When accurate population based data are needed to
  determine the magnitude of the problem
• When more detailed or recent information is
  needed than is available from record review or
  surveillance (demography, examination,
  Laboratory)
• When information is needed on health problems
  that may not routinely be seen by health
  providers
• When information is needed on health behaviours,
  knowledge and attitude, and this information is
  not routinely available through existing
  mechanisms.

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Types of Information Collected by a Survey

• Morbidity Prevalence (parasitological Surveys in
  Malaria
• Morbidity Incidence (generally collected by
  inquiring about events that have occurred some
  time in the past)
• Mortality (also generally collected by inquiring
  about deaths that have occurred some time in the
  past)
• Detailed risk factors or behavioural information
• Knowledge, attitude and practices
• Physical Signs (paralysis, splenomegaly,
  malnutrition)
• Serological or laboratory tests
• Entomological Surveys while planning/designing
  vector control interventions or assessing its
  impact
• Coverage of Interventions. Eg. ITN coverage,
  usage, re-impregnation rates, drug usage etc.

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Characteristics of a Survey

• Representative if the sample is chosen correctly.
• Single point in time snapshot
• Provide more in-depth information than
  surveillance or record reviews
• Usually performed by a limited number of
  personnel specially trained to perform surveys.
• Can some time be expensive, time consuming to
  perform
• Cannot be used to monitor change unless repeated
  at a later time may therefore be suitable for
  situation analysis than for ongoing monitoring of
  a current problem or a programme.

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Process (Major Steps)Cost
each phase

• Preparation
• Determine the objectives of Survey
• Determine outcome indicators/ variables
• Develop preliminary tables, forms etc (practice)
• Sampling
• Determine the study subjects, methods and sample
  size required
• Establish a sampling plan
• Forms/Questionnaire
• Design forms/questionnaire
• Field test forms/ questionnaire in the population

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Process (Major Steps)
Continued..

• Logistics
• Determine personnel needs
• Develop instruction manuals
• Select and train the personnel to be used to
  conduct survey
• Develop a checklist of logistics
• Field Work
• Conduct Survey/ Collect data
• Edit data
• Analysis
• Analyse the data
• Interpret your data
• Reporting
• Write up the results NOW and disseminate them to
  the appropriate people

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Selection Of Samples

• Types of Sampling most frequently used in health
  Surveys
• Complete or Comprehensive Survey Each unit of
  the population is surveyed, this may be used if
  the total number of individuals is small
  (patients in a hospital with a given diagnosis).
• Probability Sample Survey Samples are taken from
  representative units selected from the
  population.
• Most Commonly used in developing Countries
• Systemic sampling Often review of clinic records
  or surveys of health care workers
• Cluster sampling Frequently used in surveys of
  widely dispersed populations.
• If it is important to have precise estimate of a
  value for different sub groups with in a
  population, the sample size will need to take
  this into account ( This is Called STRATIFIED
  SAMPLING)

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Experience From CountriesAFGHANISTAN (HealthNet
International, MOH,WHO)

• Cross-Sectional Malaria Prevalence Surveys were
  conducted in Afghanistan to
• Identify areas with Malaria, its type and
  intensity in transmission
• Monitor annual trends of disease pattern
• Plan for expansion of control to high prevalent
  areas
• Monitor the impact of interventions
• Methodology
• Two representative villages were surveyed in each
  district with a random samples of 150 individuals
  of 6-10 years age (school/Madrassa) and 150
  individuals of all ages. (household)
• One sample was taken from population while the
  second one from school children (absent children
  followed for slide collection)

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Experience From CountriesAFGHANISTAN (HealthNet
International and MOH)

• Methodology
• This target population was selected because
• The prevalence of disease is likely to be more in
  children and hence represent the local
  transmission as opposed to adults who may perhaps
  reflect imported disease more
• Easy to access children as compared to adults,
  particularly adult females who were extremely
  difficult to access under the given conditions in
  Afghanistan.
• School survey generally allowed for a wide
  coverage, as children in a given school may come
  from several localities at reasonable distance
  from schools.

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Experience From CountriesAFGHANISTAN (HealthNet
International and MOH)

• Results
• Overall Prevalence Came out to be 5.2 (PF 2.7
  and PV 2.5) with considerable fluctuation in
  prevalence between different clusters, prevalence
  in a cluster was as high as 38.
• Prevalence in different regions
• Central Region 0.9
• East 10.5
• North 5.3
• South 2.4
• West 2.8

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Experience From CountriesAFGHANISTAN (HealthNet
International and MOH)

• Conclusion The information provided by the
  survey is quite useful in
• Information on disease trends
• Identified areas with high prevalence
• Demonstration of high prevalence in female
  children
• Baseline for need based implementation of control
  measures
• Information on bednet use in different parts of
  the country
• Realizing the need for improvement in the survey
  methodology to obtain quality information

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Experience From CountriesAFGHANISTAN (HealthNet
International and MOH)

• Limitation Of The Survey
• Sampling disproportion among different regions in
  the country. The information has to be
  interpreted in the context of this specific
  constraint.
• The Survey instruments need to be further
  improved and standardized and make it more robust
  enough to collect useful data.
• Security resulted in low levels of supervision.
• Local workers need to be properly trained for
  surveys in areas un-accessible to staff from
  centre.
• Involvement of other partner organizations/ CBOs
  was felt to be important.
• WAY FORWARD IN COMPLEX EMERGENCIES
• RISK MAPPING

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Pakistan Experience, 2004Cross-Sectional Survey
(Household), systemic sampling
3 Districts (GFATM) Programme In 2 of the 4
Provinces
District A
District C
District B
12 Villages, 3 TH
12 Villages, 4 TH
12 Villages, 7 TH

• 15 Random Houses/per village Parasite Survey
• 10 villages for Entomological Survey

15 Random Houses/per village Parasite Survey 10
villages for Entomological Survey

• 15 Random Houses/per village Parasite Survey
• 10 villages for Entomological Survey

Prev 3.76 (0-10)
Prev 0.6 (0-2)
Prev 4 (0-18)
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Outcome

• Baseline on disease prevalence and entomological
  profile was obtained.
• Highly endemic areas were identified for timely
  intervention.
• Staff of the National Programme in target
  district Trained on survey methodologies.
• Malaria came out to be an important public health
  problem in the target areas.
• Both public and private sectors were involved in
  malaria control in epidemic prone areas through
  improved case detection and treatment.

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Experience From CountriesKENYA (WHO 2001)

• Home Treatment Of Children With Fever, BedNet Use
  and Attendance at Antenatal Clinics
• Method Cluster Sample Household Survey to
  investigate home management of febrile children,
  use of bednets and attendance at antenatal
  clinics.
• Important Findings Female carers provided
  information on 314 recently febrile children
  under 5 years of age.
• 43 received care at health facility
• 47 received antimalarial drugs at home
• 25 received neither

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Experience From CountriesKENYA (Continued..)

• Of the treatment given at home, 91 were started
  by the second day of fever and 92 according to
  the national treatment guidelines (CQ 25mg/kg)
• Dosages given at home were lower when syrup was
  administered than when tablets were used.
• Only 5 of children under 5 years of age slept
  under a bednet.
• No bedNets had been treated with insecticide
  since last purchased.
• At least 2 antenatal visits were made by 91 of
  pregnant women.
• Conclusions Carers are major and prompt
  providers of antimalarial treatment, home
  treatment should be strengthened when prompt
  treatment at health facility is not possible.
• Administration of incorrect dosages, which proved
  common with CQ may occur less frequently with SP
  as the dosage is simpler.
• High levels of antenatal clinics afford the
  opportunity to achieve good coverage with IPT and
  to reach goal of wide spread use of treated nets
  by pregnant women and children by distributing
  nets during antenatal visits.

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Experience From CountriesTHE STATE OF ERITREA
(EHP 2000-1)

• NATIONAL MALARIA PREVALENCE SURVEYS
• Malaria is an important public health problem and
  a major cause of morbidity and mortality Eritrea.
  Malaria transmission is seasonal, PF accounts for
  gt90 of all cases.
• Before implementation of a new 5 years RBM plan,
  the NMCP conducted a series of studies including
  national survey of vector distribution, vector
  ecology, biting behaviour and Prevalence of the
  Disease (Malaria)
• Country 6 Administrative Zones, 56 sub zones,
  1500 villages, total population 3.5 million.

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Experience From CountriesTHE STATE OF ERITREA
(Continued.)

• Objective of the Survey
• To stratify the Prevalence of Malaria in various
  zones of the country
• To determine the distribution of P.falciparum and
  Vivax in the country
• To identified risk factors associated with
  malaria prevalence.
• Methods
• The number of samples collected from each zone
  was proportional to population size and density
• Using ecological maps, villages in zones were
  stratified into sub zones.
• More villages were sampled from sub zones showing
  greater ecological diversity.
• A set of villages were selected from each zone,
  20 households were randomly sampled from each
  village for parasite surveys using OptiMal
• 15 Villages were selected for Entomological
  Surveys

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Experience From CountriesTHE STATE OF ERITREA
(Continued.)

• Results
• Data on Household composition, sex ratios,
  Average family size, literacy and important
  wealth indicators was obtained during surveys
• Malaria Prevalence
• 13279 individuals screened and overall prevalence
  came out to be 2.15 (ranging between 0.13
  6.98 in different zones) with PF above 90 in 4
  zones and 100 in 1 zone
• In sub zones, Prevalence was ranging between 0.12
  20.19
• Distribution of anti-malarial drug use among
  respondents in one Zone
• CQ 87
• CQSP 1
• SP 1.3
• Traditional 3
• Did not know 7.6

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Experience From CountriesTHE STATE OF ERITREA
(Continued.)

• Two third of the households reported having at
  least 1 mosquito net in one zone, re-treatment of
  nets varied in different zones (Range 18 - 74)
• Recommendations after Surveys
• Improvement in the timing of the Survey
• Education on the anti-malaria drug use and
  strengthened self treatment.
• More studies on anti-malarial drugs distribution
  and prescribtion practices
• Awareness for re-impregnation of ITNs
• Need for more focused questionnaire for more
  specific information collection

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