Evaluation of an operational malaria outbreak identification and response system in Mpumalanga Province, South Africa
School of Animal, Plant and Environmental Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa; Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, United Kingdom; Medical Research Council, Durban, South Africa; Mpumalanga Department of Health, 66 Anderson Street, Nelspruit, 1200, South Africa; Vector Control Reference Unit, National Institute for Communicable Diseases, National Health Laboratory Service, 1 Modderfontein Road, Sandringham, 2131 Johannesburg, South Africa; Department of Medical Entomology and Vector Control, School of Pathology, University of the Witwatersrand, Johannesburg, South Africa; Hunter New England Population Health, Hunter Medical Research Institute, Locked Bag 10, Wallsend, NSW 2287, Australia
Background and objective. To evaluate the performance of a novel malaria outbreak identification system in the epidemic prone rural area of Mpumalanga Province, South Africa, for timely identification of malaria outbreaks and guiding integrated public health responses. Methods. Using five years of historical notification data, two binomial thresholds were determined for each primary health care facility in the highest malaria risk area of Mpumalanga province. Whenever the thresholds were exceeded at health facility level (tier 1), primary health care staff notified the malaria control programme, which then confirmed adequate stocks of malaria treatment to manage potential increased cases. The cases were followed up at household level to verify the likely source of infection. The binomial thresholds were reviewed at village/town level (tier 2) to determine whether additional response measures were required. In addition, an automated electronic outbreak identification system at town/village level (tier 2) was integrated into the case notification database (tier 3) to ensure that unexpected increases in case notification were not missed. The performance of these binomial outbreak thresholds was evaluated against other currently recommended thresholds using retrospective data. The acceptability of the system at primary health care level was evaluated through structured interviews with health facility staff. Results. Eighty four percent of health facilities reported outbreaks within 24 hours (n = 95), 92% (n = 104) within 48 hours and 100% (n = 113) within 72 hours. Appropriate response to all malaria outbreaks (n = 113, tier 1, n = 46, tier 2) were achieved within 24 hours. The system was positively viewed by all health facility staff. When compared to other epidemiological systems for a specified 12 month outbreak season (June 2003 to July 2004) the binomial exact thresholds produced one false weekly outbreak, the C-sum 12 weekly outbreaks and the mean + 2 SD nine false weekly outbreaks. Exceeding the binomial level 1 threshold triggered an alert four weeks prior to an outbreak, but exceeding the binomial level 2 threshold identified an outbreak as it occurred. Conclusion. The malaria outbreak surveillance system using binomial thresholds achieved its primary goal of identifying outbreaks early facilitating appropriate local public health responses aimed at averting a possible large-scale epidemic in a low, and unstable, malaria transmission setting. © 2008 Coleman et al; licensee BioMed Central Ltd.
Africa; article; binomial distribution; controlled study; education program; evaluation research; follow up; health care facilities and services; health care facility; health survey; high risk population; human; infection control; major clinical study; malaria; medical staff; parasite identification; primary health care; retrospective study; risk factor; urban population; epidemic; evaluation; health survey; malaria; methodology; questionnaire; rural population; season; South Africa; statistical model; Disease Notification; Disease Outbreaks; Humans; Malaria; Models, Statistical; Population Surveillance; Questionnaires; Rural Population; Seasons; South Africa