Drug-resistant malaria has become the core focus of malaria activities in Cambodia, leading to nation-wide elimination efforts and collaboration across a vast range of actors, including the national program, donors, implementers, researchers and critically, public health providers. A key to combatting the spread of the drug-resistant form is early detection, strong surveillance and patient follow up. To strengthen malaria data collection and the quality of data, PSI and partners have developed the PSK Malaria Case Surveillance Tool, an app that providers can use in the field to report positive cases. We recently sat down with Malaria Technical Advisor for PSI Cambodia Abigail Pratt and Program Manager for Technology Integration Graham T. Smith to get their insights on the app’s innovation and impact on malaria surveillance in Cambodia.
mHealth apps are growing increasing popular in the field, what makes the PSK Malaria Case Surveillance app an innovation in global health?
Graham Smith: The PSK Malaria Case Surveillance tool is a simple and elegant mobile application designed to report positive cases of malaria detected throughout Cambodia in near real-time. The tool is user-friendly and requires little to no technological knowledge. By collecting very basic data points, such as geographic location, type of malaria detected and age of the client, PSI and our partners will be able to track malaria cases, identify outbreaks and re-direct resources to where they are most needed. Rather than relying on maps with old or out-of-date data, PSI will be able to make informed decisions with real-time information collected by providers in the field.
Can you describe what Malaria looks like in Cambodia? Who is most at risk and what are some of the characteristics of transmission in the country?
Abigail Pratt: With over 50,000 cases of reported in 2014, malaria remains a concern in Cambodia, both in terms of public health and economic burden. Twenty-one of 25 provinces are considered endemic, putting nearly 8 million people at risk of the disease. Forest villagers in the eastern and northern provinces are at high risk of malaria, with all age groups suffering infection. Children under the age of five years are at highest risk of severe disease due to their lack of immunity. Elsewhere, malaria is an occupational disease with specific high-risk groups, and it’s a key contributor to anaemia, complications during pregnancy, low-birth weight and poor child growth.
Adult men experience the highest malaria prevalence rates, reflecting the increased occupational risk associated with forest goers. Malaria transmission risk is seasonal and associated with the rainy season, with peaks generally around August/September. Around 63% of confirmed cases are Plasmodium falciparum (Pf) and 37% Plasmodium vivax (Pv) malaria.
What was the need for the PSK Malaria Case Surveillance app? What problems did it seek to address?
AP: The application was built to overcome a number of serious issues surrounding data collection and flow. Currently, PSK is using a standard yet antiquated system of paper reporting forms, printed in carbon copy triplicates. Providers are meant to fill in the detailed form for each patient seen; a process that is both time consuming and prone to error. Often, the provider waits for the monthly supportive supervision visit to fill in the form, leading to even greater likelihood of recall error. The provider holds on to the original copy, but the two other forms are brought to the Operational District level, and to PSK where the data is manually entered into respective MIS systems. Within this flow, there are countless points for errors to occur. Finally, reports are collected, collated and entered into PSI’s open source database using the DHIS2 platform up to two months after the case was identified. This delay makes it nearly impossible to identify foci or investigate providers with anomalous caseloads with sufficient time to respond.
With the new phone application, the Surveillance team is able to immediately identify hot spots, liaising with the National Malaria Control Program and Provincial Health Departments to determine the appropriate course of action. With a simple interface, pictorial prompts and clear response options, the app should improve the quality of data received. The data collected will be validated by comparing each individual entry with used Rapid Diagnostic Test cassettes, allowing supervisors to ensure that providers are reporting accurately.
How will the app use open data to help curb the rate of malaria related deaths in Cambodia?
AP: Fortunately for Cambodia, malaria mortality rates have plummeted dramatically over the last 20 years. In 2014, malaria related deaths dropped to just 18, out of an estimated population of 15 million. However, there is a far greater threat associated with the malaria parasites that are endemic across the Greater Mekong Sub-region, and that threat is the emergence of antimalarial drug resistance. The parasites in the GMS have once again developed the ability to survive attack from the global first-line treatment, artemisinin-based combination therapies. Should this resistant parasite follow the historical spread of earlier drug resistant parasites, the consequences for sub-Saharan Africa and the rest of the globe could be dire. This application will play a small role in ameliorating this threat by improving the speed and quality of data collected. The app will allow immediate identification of a positive case, and it will enable the ability to track patients over the course of treatment to ensure that a cure has been achieved, and that the patient isn’t harboring, and potentially transmitting, drug resistant parasites.
Can you talk a little about who is building the app and the partners involved?
AP: This project was funded initially by USAID’s President’s Malaria Initiative, but the concept has catalyzed other donors like the Global Fund under the New Funding Model and the Regional Artemisinin Initiative, which will allow for expanded coverage. The National Malaria Control Program has led the charge for improved reporting, and there are a number of other partners working on similar tools with different end goals, such as referral tracking and stock management. URC, MORU, Malaria Consortium and CHADA are all partners working to improve data collection and use, and partners capitalize on Surveillance Technical Working Group meetings to coordinate approaches for different sectors.
GS: The development of this application in particular is being led by collaborators at PSK, including the Global Business Systems team, the Evidence for Implementation team and PSI’s graphic designer Sophie Greenbaum. These teams are responsible for the conceptual and functional design of the application.
Now that the app is in pilot stages, what are the hopes for the application’s impact in the future?
GS: If the pilot is successful, this technology could be used throughout the region and among other malaria endemic countries to help combat the spread of malaria and reach elimination. The application is also highly flexible. It could very easily be tailored to collect real-time data across other health areas as well, such as HIV or TB.
Looking towards the future, however, this application could go beyond simply collecting real-time information. Eventually, we may be able to combine this data with other sources, such as weather patterns and predictions, to create predictive analytics for use in decision making.
Preview the app below and check out the Pulse Report: