Coconut Surveillance™ has been used for more than 3 years in Zanzibar, where the software is often referred to as the malaria case notification system.
Controlling Malaria
RTI began supporting IRS in mainland Tanzania in 2007 to assist the Ministry of Health and Social Welfare in controlling malaria outbreaks in targeted unstable malaria transmission areas of Karagwe and Muleba districts in Kagera region (approximately 130,000 structures cumulatively). In 2009, operations were scaled up to spray the remaining stable- and high-transmission areas in the two original districts and also in five other districts of Kagera region—Biharamuro, Bukoba, Rural, Chato, Misenyi, and Ngara—for a cumulative total of 413,000 structures.
In 2006 RTI began helping the Zanzibar Malaria Control Program (ZMCP) with its Indoor Residual Spraying (IRS) program, contributing to a substantial drop in new malaria infections.
Developing an Early Warning System
In 2008 RTI helped the ZMCP to establish the malaria epidemic early detection system (MEEDS). MEEDS broke ground in mHealth systems. Health facility officers in clinics used simple cell phone handsets to submit weekly aggregated case data. This enabled Zanzibar to detect new epidemic outbreaks within two weeks of onset.
MEEDS uses Unstructured Supplementary Service Data (USSD) technology to display a simple form on any mobile phone handset and to transmit data to a central database. A web interface enables ZMCP to monitor the data in real time and to quickly detect outbreaks. This was a breakthrough for the ZMCP.
MEEDS was deployed to 10 sites in 2008, 52 more sites in 2009, and 90 more sites in 2010. MEEDS is now used by all public healthcare facilities in Zanzibar and has also been deployed to all private healthcare facilities.
Moving from Control to Elimination
Control programs proved effective, and Zanzibar changed status from malaria control to malaria elimination. The new Zanzibar Malaria Elimination Program (ZAMEP) knew that weekly aggregate reporting from MEEDS could not provide them the data needed to help eliminate all local malaria transmission and to prevent outbreaks from imported cases. ZAMEP needed to be able to respond quickly and contain outbreaks effectively, and to target limited resources for maximum impact.
As malaria burden continues to decrease in countries and these countries move toward pre-elimination, there will be an increasing need to track and follow up individual malaria cases to limit onward transmission that could lead to outbreaks or broader resurgence.
- US President’s Malaria Initiative Strategy, 2015-2020
Adding Individual Case Followup
In 2012 MEEDS was modified to support individual case reporting. Each District Malaria Surveillance Officer (DMSO) was equipped with a tablet computer running Coconut Surveillance, a mobile application developed by RTI in collaboration with ZAMEP.
Coconut Surveillance receives case alerts from MEEDS automatically. Once a DMSO is alerted of a new case, he or she is guided through an active case response protocol by Coconut Surveillance. Additional case data are entered into the tablet at the facility and the household. Coconut Surveillance uses the Geographical Positioning System (GPS) capability of the tablet to record the location of the household. Each household member is tested, and new cases are treated immediately. The data are synchronized at least daily with a shared cloud database.
A web-based dashboard enables near real-time monitoring of active follow-up. An automated notification system helps to alert officials to system errors and problems with case follow-up. Officials use real-time maps and reports to quickly identify hot-spots and transmission patterns. Coconut Surveillance provides Zanzibar with near real-time case identification, geo-located data for finely targeting interventions, and management information about field staff progress.
Scaling, Sustaining, and Enhancing the Tool
MEEDS and Coconut Surveillance have been deployed to all public and private healthcare facilities in Zanzibar. In collaboration with ZAMEP, RTI has improved mobile decision support, enhanced risk stratification, refined alert thresholds and the alert systems, and has added and refined analytical displays. Since 2012, Coconut Surveillance has helped malaria surveillance officers in Zanzibar respond to more than 9,500 reported cases of malaria, complete nearly 10,500 household visits, test more than 40,000 household members, and identify and treat 2,100 previously unknown cases.
Data from Coconut Surveillance are used to monitor and significantly improve the timeliness and completeness of case follow-up. Data from Coconut Surveillance are also being used to identify imported cases and foci (hotspots), suspected outdoor transmission, and to help target interventions. Continuous enhancement has added intelligence and automation to improve data quality, detect outbreaks, and alert decision makers via SMS text messaging and email.
The integrated MEEDS and Coconut Surveillance system in Zanzibar has been recognized as one of the most advanced in the world.
