Strengthening eHealth Systems to Support Universal Health Coverage in sub-Saharan Africa.

The aim of universal health coverage (UHC) is to ensure that all individuals in a country have access to quality healthcare services and do not suffer financial hardship in using these services. However, progress toward attaining UHC has been slow, particularly in sub-Saharan Africa. The use of information and communication technologies for healthcare, known as eHealth, can facilitate access to quality healthcare at minimal cost. eHealth systems also provide the information needed to monitor progress toward UHC. However, in most countries, eHealth systems are sometimes non-functional and do not serve programmatic purposes. Therefore, it is crucial to implement strategies to strengthen eHealth systems to support UHC. This perspective piece proposes a conceptual framework for strengthening eHealth systems to attain UHC goals and to help guide UHC and eHealth strategy development.

Implementing Impact Evaluations of Malaria Control Interventions: Process, Lessons Learned, and Recommendations.

As funding for malaria control increased considerably over the past 10 years resulting in the expanded coverage of malaria control interventions, so did the need to measure the impact of these investments on malaria morbidity and mortality. Members of the Roll Back Malaria (RBM) Partnership undertook impact evaluations of malaria control programs at a time when there was little guidance in terms of the process for conducting an impact evaluation of a national-level malaria control program. The President's Malaria Initiative (PMI), as a member of the RBM Partnership, has provided financial and technical support for impact evaluations in 13 countries to date. On the basis of these experiences, PMI and its partners have developed a streamlined process for conducting the evaluations with a set of lessons learned and recommendations. Chief among these are: to ensure country ownership and involvement in the evaluations; to engage stakeholders throughout the process; to coordinate evaluations among interested partners to avoid duplication of efforts; to tailor the evaluation to the particular country context; to develop a standard methodology for the evaluations and a streamlined process for completion within a reasonable time; and to develop tailored dissemination products on the evaluation for a broad range of stakeholders. These key lessons learned and resulting recommendations will guide future impact evaluations of malaria control programs and other health programs.

Anti-malarial prescription practices among children admitted to six public hospitals in Uganda from 2011 to 2013.

BACKGROUND: In 2011, Uganda's Ministry of Health switched policy from presumptive treatment of malaria to recommending parasitological diagnosis prior to treatment, resulting in an expansion of diagnostic services at all levels of public health facilities including hospitals. Despite this change, anti-malarial drugs are often prescribed even when test results are negative. Presented is data on anti-malarial prescription practices among hospitalized children who underwent diagnostic testing after adoption of new treatment guidelines. METHODS: Anti-malarial prescription practices were collected as part of an inpatient malaria surveillance program generating high quality data among children admitted for any reason at government hospitals in six districts. A standardized medical record form was used to collect detailed patient information including presenting symptoms and signs, laboratory test results, admission and final diagnoses, treatments administered, and final outcome upon discharge. RESULTS: Between July 2011 and December 2013, 58,095 children were admitted to the six hospitals (hospital range 3294-20,426).A total of 56,282 (96.9 %) patients were tested for malaria, of which 26,072 (46.3 %) tested positive (hospital range 5.9-57.3 %). Among those testing positive, only 84 (0.3 %) were first tested after admission and 295 of 30,389 (1.0 %) patients who tested negative at admission later tested positive. Of 30,210 children with only negative test results, 11,977 (39.6 %) were prescribed an anti-malarial (hospital range 14.5-53.6 %). The proportion of children with a negative test result who were prescribed an anti-malarial fluctuated over time and did not show a significant trend at any site with the exception of one hospital where a steady decline was observed. Among those with only negative test results, children 6-12 months of age (aOR 3.78; p < 0.001) and those greater than 12 months of age (aOR 4.89; p < 0.001) were more likely to be prescribed an anti-malarial compared to children less than 6 months of age. Children with findings suggestive of severe malaria were also more likely to be prescribed an anti-malarial after a negative test result (aOR 1.98; p < 0.001). CONCLUSIONS: Despite high testing rates for malaria at all sites, prescription of anti-malarials to patients with negative test results remained high, with the exception of one site where a steady decline occurred.

Prevalence and Factors Associated with Anemia Among Children Under 5 Years of Age--Uganda, 2009.

Anemia in children under 5 years of age, defined by the World Health Organization as a hemoglobin concentration < 11 g/dL, is a global public health problem. According to the 2006 Demographic Health Survey, the prevalence of anemia among children under five in Uganda was 72% in 2006. The 2009 Uganda Malaria Indicator Survey was conducted in late 2009 and revealed that over 60% of children less than 5 years of age were anemic and that over half of children tested positive for malaria via a rapid diagnostic test. Children with concomitant malaria infection, and in households without any type of mosquito net were more likely to be anemic, confirming that children under 5 years, are vulnerable to both the threat of malaria and anemia and the beneficial effect of malaria prevention tools. However, prevention and treatment of other factors associated with the etiology of anemia (e.g., iron deficiency) are likely necessary to combat the toll of anemia in Uganda.

Comparison of routine health management information system versus enhanced inpatient malaria surveillance for estimating the burden of malaria among children admitted to four hospitals in Uganda.

The primary source of malaria surveillance data in Uganda is the Health Management Information System (HMIS), which does not require laboratory confirmation of reported malaria cases. To improve data quality, an enhanced inpatient malaria surveillance system (EIMSS) was implemented with emphasis on malaria testing of all children admitted in select hospitals. Data were compared between the HMIS and the EIMSS at four hospitals over a period of 12 months. After the implementation of the EIMSS, over 96% of admitted children under 5 years of age underwent laboratory testing for malaria. The HMIS significantly overreported the proportion of children under 5 years of age admitted with malaria (average absolute difference = 19%, range = 8-27% across the four hospitals) compared with the EIMSS. To improve the quality of the HMIS data for malaria surveillance, the National Malaria Control Program should, in addition to increasing malaria testing rates, focus on linking laboratory test results to reported malaria cases.

Evaluation of a universal coverage bed net distribution campaign in four districts in Sofala Province, Mozambique.

BACKGROUND: Malaria is the leading cause of death in Mozambique in children under five years old. In 2009, Mozambique developed a novel bed net distribution model to increase coverage, based on assumptions about sleeping patterns. The coverage and impact of a bed net distribution campaign using this model in four districts in Sofala Province, Mozambique was evaluated. METHODS: Paired household, cross-sectional surveys were conducted one month after the 2010 distribution of 140,000 bed nets and again 14 months after the campaign in 2011. During household visits, malaria blood smears were performed and haemoglobin levels were assessed on children under five and data on bed net ownership, access and use were collected; these indicators were analysed at individual, household and community levels. Logistic regression was used to evaluate predictors of malaria infection and anaemia. RESULTS: The campaign reached 98% (95% CI: 97-99%) of households registered during the precampaign listing, with 81% (95% CI: 77-85%) of sleeping spaces covered by campaign bed nets and 85% (95% CI: 81-88%) of the population sleeping in a sleeping space with a campaign bed net designated for the sleeping space. One year after the campaign, 65% (95% CI: 57-72%) of sleeping spaces were observed to have hanging bed nets. The proportion of sleeping spaces for which bed nets were reported used four or more times per week was 65% (95% CI: 56-74%) in the wet season and 60% (95% CI: 52-68%) in the dry season. Malaria parasitaemia prevalence in children under five years old was 47% (95% CI: 40-54%) in 2010 and 36% (95% CI: 27-45%) in 2011. Individual-level malaria infection and anaemia were significantly associated with community-level use of bed nets. CONCLUSIONS: The campaign using the novel distribution model achieved high coverage, although usage was not uniformly high. A significant decrease in malaria parasitaemia prevalence a year after the campaign was not observed, but community-level use of bed nets was significantly associated with a reduced risk for malaria infection and anaemia in children under five.

Caution is required when using health facility-based data to evaluate the health impact of malaria control efforts in Africa.

The global health community is interested in the health impact of the billions of dollars invested to fight malaria in Africa. A recent publication used trends in malaria cases and deaths based on health facility records to evaluate the impact of malaria control efforts in Rwanda and Ethiopia. Although the authors demonstrate the use of facility-based data to estimate the impact of malaria control efforts, they also illustrate several pitfalls of such analyses that should be avoided, minimized, or actively acknowledged. A critique of this analysis is presented because many country programmes and donors are interested in evaluating programmatic impact with facility-based data. Key concerns related to: 1) clarifying the objective of the analysis; 2) data validity; 3) data representativeness; 4) the exploration of trends in factors that could influence malaria rates and thus confound the relationship between intervention scale-up and the observed changes in malaria outcomes; 5) the analytic approaches, including small numbers of patient outcomes, selective reporting of results, and choice of statistical and modeling methods; and 6) internal inconsistency on the strength and interpretation of the data. In conclusion, evaluations of malaria burden reduction using facility-based data could be very helpful, but those data should be collected, analysed, and interpreted with care, transparency, and a full recognition of their limitations.

Fatal infectious disease surveillance in a medical examiner database.

Increasing infectious disease deaths, the emergence of new infections, and bioterrorism have made surveillance for infectious diseases a public health concern. Medical examiners and coroners certify approximately 20% of all deaths that occur within the United States and can be a key source of information regarding infectious disease deaths. We hypothesized that a computer-assisted search tool (algorithm) could detect infectious disease deaths from a medical examiner database, thereby reducing the time and resources required to perform such surveillance manually. We developed two algorithms, applied them to a medical examiner database, and verified the cases identified against the opinion of a panel of experts. The algorithms detected deaths with infectious components with sensitivities from 67% to 94%, and predictive value positives ranging from 8% to 49%. Algorithms can be useful for surveillance in medical examiner offices that have limited resources or for conducting surveillance across medical examiner jurisdictions.

Theoretical risk for occupational blood-borne infections in forensic pathologists.

Using a cumulative probability analysis and published data, we calculated the theoretical career risk of occupational HIV (2.4%) and HCV (39%; possible range, 13% to 94%) infections for forensic pathologists. Serologic studies of these physicians are needed to clarify occupational exposure and infection risks. Autopsy personnel should wear cut-resistant undergloves to decrease percutaneous injuries.