Digitized smart surveillance and micromanagement using information technology for malaria elimination in Mangaluru, India: an analysis of five-year post-digitization data.

BACKGROUND: Malaria control system (MCS), an Information technology (IT)-driven surveillance and monitoring intervention is being adopted for elimination of malaria in Mangaluru city, Karnataka, India since October 2015. This has facilitated 'smart surveillance' followed by required field response within a timeline. The system facilitated data collection of individual case, data driven mapping and strategies for malaria elimination programme. This paper aims to present the analysis of post-digitization data of 5 years, discuss the current operational functionalities of MCS and its impact on the malaria incidence. METHODS: IT system developed for robust malaria surveillance and field response is being continued in the sixth year. Protocol for surveillance control was followed as per the national programme guidelines mentioned in an earlier publication. Secondary data from the malaria control system was collated and analysed. Incidence of malaria, active surveillance, malariogenic conditions and its management, malariometric indices, shrinking malaria maps were also analysed. RESULTS: Smart surveillance and subsequent response for control was sustained and performance improved in five years with participation of all stakeholders. Overall malaria incidence significantly reduced by 83% at the end of 5 years when compared with year of digitization (DY) (p < 0.001). Early reporting of new cases (within 48 h) was near total followed by complete treatment and vector control. Slide positivity rate (SPR) decreased from 10.36 (DY) to 6.5 (PDY 5). Annual parasite incidence (API) decreased from 16.17 (DY) to 2.64 (PDY 5). There was a negative correlation between contact smears and incidence of malaria. Five-year data analyses indicated declining trends in overall malaria incidence and correlation between closures by 14 days. The best impact on reduction in incidence of malaria was recorded in the pre-monsoon months (~ 85%) compared to lower impact in July-August months (~ 40%). CONCLUSION: MCS helped to micromanage control activities, such as robust reporting, incidence-centric active surveillance, early and complete treatment, documentation of full treatment of each malaria patient, targeted mosquito control measures in houses surrounding reported cases. The learnings and analytical output from the data helped to modify strategies for control of both disease and the vector, heralding the city into the elimination stage.

Tools to accelerate falciparum malaria elimination in Cambodia: a meeting report.

Cambodia targets malaria elimination by 2025. Rapid elimination will depend on successfully identifying and clearing malaria foci linked to forests. Expanding and maintaining universal access to early diagnosis and effective treatment remains the key to malaria control and ultimately malaria elimination in the Greater Mekong Subregion (GMS) in the foreseeable future. Mass Drug Administration (MDA) holds some promise in the rapid reduction of Plasmodium falciparum infections, but requires considerable investment of resources and time to mobilize the target communities. Furthermore, the most practical drug regimen for MDA in the GMS-three rounds of DHA/piperaquine-has lost some of its efficacy. Mass screening and treatment benefits asymptomatic P. falciparum carriers by clearing chronic infections, but in its current form holds little promise for malaria elimination. Hopes that "highly sensitive" diagnostic tests would provide substantial advances in screen and treat programmes have been shown to be misplaced. To reduce the burden on P. falciparum and Plasmodium vivax infections in people working in forested areas novel approaches to the use of malaria prophylaxis in forest workers should be explored. During an October 2019 workshop in Phnom Penh researchers and policymakers reviewed evidence of acceptability, feasibility and effectiveness of interventions to target malaria foci and interrupt P. falciparum transmission and discussed operational requirements and conditions for programmatic implementation.

Indigenously developed digital handheld Android-based Geographic Information System (GIS)-tagged tablets (TABs) in malaria elimination programme in Mangaluru city, Karnataka, India.

BACKGROUND: Under-reporting, delayed diagnosis, incomplete treatment and inadequate vector management are few among many factors responsible for uninterrupted transmission of malaria in India. Information technology (IT) and mobile apps can be utilized effectively to overcome these hurdles. Indigenously developed digital handheld geographic information system (GIS)-tagged Android-based tablets (TABs) has been designed especially for implementation of digitization protocol. This has changed the effectiveness of malaria surveillance and intervention strategies in a malaria endemic area of Mangaluru city, Karnataka, India. METHODS: A software was developed and implemented for control measures to create a digital database of each malaria case. Secondary data analyses were carried out to determine and compare differences in malariometric indices between pre- and post-digitization years. With the introduction of this software active surveillance, information education and communication (IEC), and anti-vector measures were made 'incidence-centric'. This means that the entire control measures were carried out in the houses where the malaria cases (index cases) were reported and also in surrounding houses. RESULTS: Annual blood examination rate (ABER) increased from 13.82 to 32.8%. Prompt reporting of new cases had improved (36% within 24 h and 80% within 72 h). Complete treatment and parasite clearance time were documented in 98% of cases. In the second post-digitization year untraceable cases reduced from 11.3 to 2.7%; contact blood smears collection also increased significantly (p < 0.001); Slide Positivity Rate (SPR) decreased from 15.5 to 10.48%; malaria cases reduced by 30%. CONCLUSIONS: IT is very useful in translation of digitized surveillance to core interventions thereby effectively reduce incidence of malaria. This technology can be used effectively to translate smart surveillance to core interventions following the '1-3-7-14' strategy.

Genetic diversity and drug resistance surveillance of Plasmodium falciparum for malaria elimination: is there an ideal tool for resource-limited sub-Saharan Africa?

The intensification of malaria control interventions has resulted in its global decline, but it remains a significant public health burden especially in sub-Saharan Africa (sSA). Knowledge on the parasite diversity, its transmission dynamics, mechanisms of adaptation to environmental and interventional pressures could help refine or develop new control and elimination strategies. Critical to this is the accurate assessment of the parasite's genetic diversity and monitoring of genetic markers of anti-malarial resistance across all susceptible populations. Such wide molecular surveillance will require selected tools and approaches from a variety of ever evolving advancements in technology and the changing epidemiology of malaria. The choice of an effective approach for specific endemic settings remains challenging, particularly for countries in sSA with limited access to advanced technologies. This article examines the current strategies and tools for Plasmodium falciparum genetic diversity typing and resistance monitoring and proposes how the different tools could be employed in resource-poor settings. Advanced approaches enabling targeted deep sequencing is valued as a sensitive method for assessing drug resistance and parasite diversity but remains out of the reach of most laboratories in sSA due to the high cost of development and maintenance. It is, however, feasible to equip a limited number of laboratories as Centres of Excellence in Africa (CEA), which will receive and process samples from a network of peripheral laboratories in the continent. Cheaper, sensitive and portable real-time PCR methods can be used in peripheral laboratories to pre-screen and select samples for targeted deep sequence or genome wide analyses at these CEAs.

Hepatitis C Virus Diagnosis and the Holy Grail.

The world has embraced the call for global elimination of hepatitis C virus by 2030. The unprecedented speed of therapeutic development and increased access to direct-acting antivirals has made elimination a possibility. We must screen hundreds of millions of people to diagnose and treat those currently infected. Global access to hepatitis C virus diagnostics will be a keystone to success. Key challenges must be overcome and systems optimized to ensure widespread access to existing diagnostics. Although promising technologies may soon transform the landscape, innovative strategies are needed to stimulate investment and accelerate the development of point-of-care hepatitis C virus diagnostics.

Trends in spatio-temporal dynamics of visceral leishmaniasis cases in a highly-endemic focus of Bihar, India: an investigation based on GIS tools.

BACKGROUND: Visceral leishmaniasis (VL) in Bihar State (India) continues to be endemic, despite the existence of effective treatment and a vector control program to control disease morbidity. A clear understanding of spatio-temporal distribution of VL may improve surveillance and control implementation. This study explored the trends in spatio-temporal dynamics of VL endemicity at a meso-scale level in Vaishali District, based on geographical information systems (GIS) tools and spatial statistical analysis. METHODS: A GIS database was used to integrate the VL case data from the study area between 2009 and 2014. All cases were spatially linked at a meso-scale level. Geospatial techniques, such as GIS-layer overlaying and mapping, were employed to visualize and detect the spatio-temporal patterns of a VL endemic outbreak across the district. The spatial statistic Moran's I Index (Moran's I) was used to simultaneously evaluate spatial-correlation between endemic villages and the spatial distribution patterns based on both the village location and the case incidence rate (CIR). Descriptive statistics such as mean, standard error, confidence intervals and percentages were used to summarize the VL case data. RESULTS: There were 624 endemic villages with 2719 (average 906 cases/year) VL cases during 2012-2014. The Moran's I revealed a cluster pattern (P < 0.05) of CIR distribution at the meso-scale level. On average, 68 villages were newly-endemic each year. Of which 93.1% of villages' endemicity were found to have occurred on the peripheries of the previous year endemic villages. The mean CIR of the endemic villages that were peripheral to the following year newly-endemic villages, compared to all endemic villages of the same year, was higher (P < 0.05). CONCLUSION: The results show that the VL endemicity of new villages tends to occur on the periphery of villages endemic in the previous year. High-CIR plays a major role in the spatial dispersion of the VL cases between non-endemic and endemic villages. This information can help achieve VL elimination throughout the Indian subcontinent by improving vector control design and implementation in highly-endemic district.

Elimination of schistosomiasis: the tools required.

BACKGROUND: Historically, the target in the schistosomiasis control has shifted from infection to morbidity, then back to infection, but now as a public health problem, before moving on to transmission control. Currently, all endemic countries are encouraged to increase control efforts and move towards elimination as required by the World Health Organization (WHO) roadmap for the global control of the neglected tropical diseases (NTDs) and the WHA65.21 resolution issued by the World Health Assembly. However, schistosomiasis prevalence is still alarmingly high and the global number of disability-adjusted life years (DALYs) due to this infection has in fact increased due to inclusion of some 'subtle' clinical symptoms not previously counted. MAIN BODY: There is a need to restart and improve efforts to reach the elimination goal. To that end, the first conference of the Global Schistosomiasis Alliance (GSA) Research Working Group was held in mid-June 2016 in Shanghai, People's Republic of China. It reviewed current progress in schistosomiasis control and elimination, identified pressing operational research gaps that need to be addressed and discussed new tools and strategies required to make elimination a reality. The articles emanating from the lectures and discussions during this meeting, together with some additional invited papers, have been collected as a special issue of the 'Infectious Diseases of Poverty' entitled 'Schistosomiasis Research: Providing the Tools Needed for Elimination', consisting of 26 papers in all. This paper refers to these papers and discusses critical questions arising at the conference related to elimination of schistosomiasis. CONCLUSION: The currently most burning questions are the following: Can schistosomiasis be eliminated? Does it require better, more highly sensitive diagnostics? What is the role of preventive chemotherapy at the elimination stage? Is praziquantel sufficient or do we need new drugs? Contemplating these questions, it is felt that the heterogeneity of the endemic areas in the world requires WHO policies to be upgraded instituting new, differentiated guidelines.

Current and future tools for global canine rabies elimination.

Even though rabies is almost uniformly fatal, it is readily preventable with currently available tools. Vaccination is highly efficacious for the pre-exposure prophylaxis (PrEP) of rabies in humans and animals, and prompt postexposure prophylaxis (PEP) with vaccine and rabies immune globulin (RIG) can reliably prevent disease in humans. However, access to these tools and knowledge of their proper use are often limited, especially in impoverished, rabies-enzootic countries with the highest disease burden. In the absence of reliable diagnostic capacity and risk assessments, vaccines and RIG are often administered inappropriately, leading to chronic supply shortages and otherwise preventable deaths. Rather than focusing solely on human prophylaxis, it is more cost-effective over the long term to eliminate canine rabies in its natural terrestrial reservoirs. Because more than 99% of human rabies deaths result from dog bites, prevention efforts should focus on dogs. A versatile "One Health" strategy for canine rabies elimination should aim to create sustainable herd immunity in dogs, using proven vaccination strategies at the local level, coupled with community education and humane population management. Such strategies have succeeded in both developed and developing countries, and can be adapted to any locality. Numerous examples in Africa, Asia, and Latin America have shown that community-based, locally guided vaccination and education programs, based on a shared vision and long-term commitment, can eliminate canine rabies. Such programs should have specific goals and measurable outcomes, and should be conducted under the guidance of supportive governments, in collaboration with international partners and nongovernmental organizations. In addition to currently available tools, rabies prevention can be augmented by new dose-sparing human vaccine schedules, alternative routes of vaccine administration, monoclonal antibodies as an alternative to RIG, sensitive and specific point-of-care diagnostics and the development of canine immunocontraceptive methods. Accurate risk assessments of potential human exposures and support for decentralized laboratory capacity will be essential to ensure the most effective utilization of vaccines and RIG until canine rabies has been eliminated.