STEP 3 - MALARIA ELIMINATION
Malaria Active Infection Detection for enhanced surveillance at the
community level
CHW Training Materials
2012
Overview of the two-day training: Day 1
 Background of malaria control and elimination in
Zambia
 1-2-3 Steps towards malaria elimination
 Step 2&3 protocol
 Step 2&3 workflow
 Register records
 RDT training
Overview of the two-day training: Day 2
 Recap of Step 2&3 protocol
 Field exercise
 Final discussion
BACKGROUND / REFRESHER
Definition for malaria
Suspected
Calculation: Tested + Clinical (Not tested)
Clinical
Tested
Suspected, but not tested
“Confirmed ”
Positive
Test result positive
(RDT / Microscopy)
Negative
Test result negative
Calculation:
Tested minus confirmed
Towards malaria elimination in Zambia
Malaria parasite prevalence among children by province and year, 2006-2010
• Southern province has made considerable progress in reducing
malaria burden
Malaria reported case rates by district
and case counts by facility 2011
Malaria reported case rates by district
and case counts by facility 2011
1-2-3 Step towards malaria elimination
 Ministry of Health Strategic Plan 2011-2015 has the goal
of creating 5 malaria-free areas in Zambia
 It is likely Southern Province has areas that have the
potential to be included in these malaria-free zones
 MoH has adopted a 1-2-3 step plan to eliminate malaria
in in the selected areas:
• Step 1: Rapid Reporting
• Step 2: Mass test and treat
• Step 3: Surveillance for elimination
Step 1-2-3
STEP 1 – RAPID REPORTING SYSTEM
STEP 2 – MASS SCREEN AND TREAT
COMMUNITY
MASS TEST AND TREAT CAMPAIGNS:
A. CHWs test all individuals in their
catchment areas
B. CHWs test all individuals in villages
with passively detected cases
PASSIVE: PATIENT IN
COMMUNITY
CHW tests individual seeking
care
STEP 3 – ONGOING ACTIVE SURVEILLANCE
Data Reporting
Positive Malaria Case
STEP 2 (A&B) PROTOCOL
Mass screen and treat campaigns
1-2-3 Step towards malaria elimination
 Step 2 involves mass testing and treating of facility
catchment areas for malaria
 Some catchment areas have very high levels of malaria,
some have lower levels of malaria
• It is a waste of resource to screen areas with no malaria
• Must collect information about where malaria cases originate
 Community (CHW-level) surveillance necessary to
understand which parts of the facility catchment are
necessary to screen and treat
1-2-3 Step towards malaria elimination
 Step 2A = testing everyone in the catchment
 Step 2B = testing everyone in only those villages in
catchments with passive malaria cases detected
Participating Health Facility Catchment Area
+
= household
+
= health facility
Participating Health Facility Catchment Area
+
Village a
Village d
= household
+
= health facility
Village b
Village c
Village e
Village f
Participating Health Facility Catchment Area
a
b
+
Village a
e
Village d
= household
Village c
Village b
d
Village e
+
c
= health facility
= CHW
f
Village f
Participating Health Facility Catchment Area
c
Village a
d
X
a
+
1
b
+
2
f
+
3
+
Village b
e
Village d
= household
Village c
Village e
+
= health facility
Field work STEP 2 A&B
• Catchment Team with
facility staff chooses
catchment area starting point
(X)
•Working in Testing Pairs from
the starting point, Catchment
Team moves together houseto-house through whole
catchment area
•ONE household is visited by
only ONE Testing Pair
Village f
= CHW
= enumerator
X = starting point
Participating Health Facility Catchment Area
c
Village a
d
a
+
Village b
Village c
e
+
1
X
b
+
2
+
f
3d
Village
Village e
Village f
DAY 1
Field work STEP 2A
• Catchment Team will work
with additional CHWs not
participating in the training
while in their respective areas
•Scheduling household visits
may be necessary
•Important to test as many
household members as
possible
•Revisit households for
additional testing only on the
same day as other household
members tested
•Daily target = 10 households
tested per testing pair
= tested / completed household
= household
+
= health facility
= CHW
= enumerator
X = starting point
Participating Health Facility Catchment Area
c
+
Village a
a
+
1
b
d
+
2
f
Village b
Village c
e
+
3
X
Village d
Village e
Village f
DAY 2
Field work STEP 2A
• Catchment Team will work
with additional CHWs not
participating in the training
while in their respective areas
•Scheduling household visits
may be necessary
•Important to test as many
household members as
possible
•Revisit households for
additional testing only on the
same day as other household
members tested
•Daily target = 10 households
tested per testing pair
= tested / completed household
= household
+
= health facility
= CHW
= enumerator
X = starting point
Participating Health Facility Catchment Area
f
+
3
a
+
1
c
+
2
b
Village a
d
+
Village b
Village c
e
X
Village d
Village e
Village f
DAY 3
Field work STEP 2A
• Catchment Team will work
with additional CHWs not
participating in the training
while in their respective areas
•Scheduling household visits
may be necessary
•Important to test as many
household members as
possible
•Revisit households for
additional testing only on the
same day as other household
members tested
•Daily target = 10 households
tested per testing pair
= tested / completed household
= household
+
= health facility
= CHW
= enumerator
X = starting point
Participating Health Facility Catchment Area
a
f
b
Village a
d
+
+
1
c
+
3
+
2
Village b
Village c
e
X
Village d
Village e
Village f
DAY 4 and so on….
Field work STEP 2A
• Catchment Team will work
with additional CHWs not
participating in the training
while in their respective areas
•Scheduling household visits
may be necessary
•Important to test as many
household members as
possible
•Revisit households for
additional testing only on the
same day as other household
members tested
•Daily target = 10 households
tested per testing pair
= tested / completed household
= household
+
= health facility
= CHW
= enumerator
X = starting point
Participating Health Facility Catchment Area
c
Village a
d
+
f
b
+
3
Village b
+
2
a
+
1
Village c
e
X
Village d
Village e
Village f
DAY X = DONE!!
Field work STEP 2A
• Catchment Team will work
with additional CHWs not
participating in the training
while in their respective areas
•Scheduling household visits
may be necessary
•Important to test as many
household members as
possible
•Revisit households for
additional testing only on the
same day as other household
members tested
•Daily target = 10 households
tested per testing pair
= tested / completed household
= household
+
= health facility
= CHW
= enumerator
X = starting point
Participating Health Facility Catchment Area
c
Village a
d
X
a
+
1
b
+
2
f
+
3
+
Village b
e
Village d
= household
Village c
Village e
+
= health facility
Field work STEP 2B
• CHWs from catchment
review 2 months of data from
their registers.
•Make a list of villages with
passive cases reported. For
example, Villages A,B,D and E
had cases.
•Villages C and F did not have
cases so will not be screened.
Village f
= CHW
= enumerator
X = starting point
Participating Health Facility Catchment Area
c
Field work STEP 2B
• Follows the same process as
Step 2A but only include
required villages.
Village a
d
+
f
b
+
3
Village b
+
2
a
+
1
Village c
e
X
Village d
Village e
Village f
DAY X = DONE!!
= tested / completed household
= household
+
= health facility
= CHW
= enumerator
X = starting point
Step 1-2-3
STEP 1 – RAPID REPORTING SYSTEM
STEP 2 – MASS SCREEN AND TREAT
STEP 3 – ONGOING ACTIVE SURVEILLANCE
HEALTH FACILITY
PASSIVE: PATIENT AT
CLINIC
Staff test individual
COMMUNITY
ACTIVE: TEST AND
TREAT
CHW tests all
individuals living
around the positive
case
Data Reporting
PASSIVE: PATIENT IN
COMMUNITY
CHW tests individual
Positive Malaria Case
1-2-3 Steps for malaria elimination
 All clinics have implemented Step 1
 Due to very low malaria burden in the district, Step 2
is not necessary
 Hence, Step 3 is being introduced in the district
STEP 3 PROTOCOL
Definitions
 Passive
• Someone is sick (Symptomatic)
• They come to the clinic / CHW for testing / treatment
• You are already doing this in your clinic / community
 Active
• People who live close to someone with malaria are tested
• They may have NO symptoms of malaria (Asymptomatic)
• This is a NEW activity in the community
 Household
• Single family group under a single household head
Step 3 – Malaria Surveillance for Elimination
HEALTH FACILITY
PASSIVE: PATIENT SEEKS OUT CLINIC
Symptomatic individuals tested at the clinic
Record: Name, Age, Sex, Address, Purpose, Comment*, Result
Treatment
POSITIVE
CLINIC INDICATORS
EHT
COMMUNITY
MOBILE PHONE
REPORTING
ACTIVE: CHW CONDUCTS TEST AND TREAT
Test as many individuals living around the positive case as
possible (1 day / 2 boxes)
Record : Name, Age, Sex, Address, Symptoms, Travel, Result,
Treatment
CHW INDICATORS
POSITIVE
PASSIVE: PATIENT SEEKS OUT CHW
Symptomatic individuals tested by CHW
Record: Name, Age, Sex, Address, Purpose, Comment*, Result
Treatment
Data
CHW
* - Travel History
Questions
 What do we mean by the term “Passive”?
• Where can “Passive” activities take place?
 What do we mean by the term “Active”?
• Where can “Active” activities take place?
 What do we mean by the terms:
• “Asymptomatic”?
• “Symptomatic”?
 What do we mean by the term household?
Active response in the community







Notification of household of malaria patient
NEXT HOUSEHOLD
Locate patient household (House 1)
Explain purpose to household members
RDT test all consenting household members
Record details in CHW register (ACTIVE)
Treat all positives
Move on to next household
Test malaria patient’s family and their neighbours
 Start at malaria patients house and test and treat
their family
 Identify immediate neighbors around the malaria
patient
 Test (and treat if necessary) neighbors around
malaria patient house.
Household follow-up
How much work?
 Test all households within 140m (one and a half
football field length)
 Up to a MAXIMUM of 40 people per active response
 Include houses hidden by obstacles e.g. trees
• Walk around to familiarise yourself with the area
• Ask the community for help to find other households
 If very few houses close to House 1 you can test
further away from House 1
Explain purpose
“An individual from your household / neighbourhood
has been found positive for malaria. I am a
community health worker and am here to help
prevent further cases of malaria. I would like to test
each member of your household for malaria using a
small kit called a rapid diagnostic test. To do so, I will
need to take a small drop of blood from your finger. If
you have malaria I will provide free antimalarials as
necessary. I would also like to record the results of
the malaria test.”
Turn to your neighbour and explain the procedure
(any language)
DATA RECORDING
Travel History
 To assess travel history, ask the person:
“ Have you traveled outside the district within the last
month?”
 If they say yes, then ask:
“Did you spend at least one night there?”
 If yes, record ‘Travelled to ……’ e.g. Travelled to
Livingstone.
 If they say no then record ‘No Travel’
Why is it important to know someone’s travel
history?
Passive Register
Date
Name
Age
Sex
Address
Purpose
Comment
Result
Treatment
14/2/12
Juliet
Mbewe
32
F
Simango
Vomitting
Travelled to
Eastern Province
Negative
No
Treatment
16/2/12
Timothy
Banda
5
M
Simango
Headache
No Travel
Negative
No
Treatment
16/2/12
Simon
Kataya
28
M
Simango
Vomitting
No Travel
Positive
1 x 24 Pack
ACT
POSITIVE
ACTIVE RESPONSE
Active Register
Date
Name
Age
Sex
Address
Symptoms
Travel
Result
Treatment
16/2/12
Inonge
Kataya
26
F
Simango
Fever
No Travel
Negative
No
Treatment
16/2/12
Chilufya
Kataya
8
M
Simango
No symptoms
No Travel
Negative
No
Treatment
17/2/12
Michael
Lupiya
4
M
Simango
Headache
No Travel
Positive
1 x 12 Pack
ACT
17/2/12
Florence
Lupiya
2
F
Simango
No symptoms
Travelled to
Livingstone
Negative
No
Treatment
House 1
House 2
DATA REPORTING
Passive Register – Monday TOTALS
Date
Name
Age
Sex
Address
Purpose
Comment
Result
Treatment
14/2/12
Juliet
Mbewe
32
F
Simango
Vomitting
Travelled to
Eastern Province
Negative
No
Treatment
16/2/12
Timothy
Banda
5
M
Simango
Headache
No Travel
Negative
No
Treatment
16/2/12
Simon
Kataya
28
M
Simango
Vomitting
No Travel
Positive
1 x 24 Pack
ACT
TOTALS
20/2/12
TOTALS
Travelled – 1
Not Travelled - 2
Total Tested – 3
Positive - 1
Treated – 1
Not treated - 2
Active Register – Monday TOTALS
Date
Name
Age
Sex
Address
Symptoms
Travel
Result
Treatment
16/2/12
Inonge
Kataya
26
F
Simango
Fever
No Travel
Negative
No
Treatment
16/2/12
Chilufya
Kataya
8
M
Simango
No symptoms
No Travel
Negative
No
Treatment
17/2/12
Michael
Lupiya
4
M
Simango
Headache
No Travel
Positive
1 x 12 Pack
ACT
17/2/12
Florence
Lupia
2
F
Simango
No symptoms
Travelled to
Livingstone
Negative
No
Treatment
House 1
House 2
TOTALS
20/2/12
TOTALS
House - 2
Travelled – 1
Not Travelled - 3
Total Tested – 4
Positive – 1
Treated – 1
Not treated - 3
Reporting
 CHW must add up the TOTALS every MONDAY!
 TOTALS are given to the data CHW every MONTH
 Important: Separate passive cases from active cases
Break into groups and review each CHW register
Practice drawing out register to include all indicators
OWNERSHIP
Clinic Attachments
 REQUIRED for all untrained CHWs
 No Step 3 until attachment is completed
• No RDT Testing
• No prescription of ACT
 Minimum attachment (or until competent):
• 14 days for untrained
• 7 days for trained
Talk to your clinics to arrange when this can
happen
An Incentive to Work
 Each CHW will receive 5,000 ZMK Airtime per week
 If you don’t have a phone / want a phone
• Each week will count towards a new phone
• 10 weeks of reports and we will provide a phone for you
 No report = NO AIRTIME / PHONE
 No Data CHW report = NO AIRTIME / PHONE for
ANYONE