USAID Okoa Maisha Dhibiti Malaria (OMDM) Activity

USAID Okoa Maisha Dhibiti Malaria (OMDM) Activity QUARTERLY PERFORMANCE REPORT: YEAR 2, QUARTER 2

Submitted: April 30, 2020 This report was made possible by the generous support of the American people through the United States Agency for International Development (USAID) and the U.S. President’s Malaria Initiative (PMI). It was prepared by RTI International for the USAID | Okoa Maisha Dhibiti Malaria Activity.

USAID Okoa Maisha Dhibiti Malaria (OMDM) Activity

QUARTERLY PERFORMANCE REPORT January 1–March 31, 2020

Cooperative Agreement Number: 72062118CA-00002 Contractual Period: August 7, 2018–August 6, 2023

Prepared for:

USAID | Tanzania U.S. Agency for International Development Office of Acquisition and Assistance 686 Old Bagamoyo Rd, Msasani P.O. Box 9130 Dar es Salaam, Tanzania Telephone: 255-22-229-4490

Prepared by

RTI International 3040 Cornwallis Road P.O. Box 12194 Research Triangle Park, NC 22709-2194

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The contents of this report are the responsibility of RTI International and do not necessarily reflect the views of USAID/PMI or the United States Government.

USAID Okoa Maisha Dhibiti Malaria (OMDM) Activity, Year 2, Quarter 2 Performance Report iii

Table of Contents 1. PROGRAM OVERVIEW ...........................................................................................................................1

1.1 Program Description ..........................................................................................................................1

1.2 Y2, Q2 Achievements ........................................................................................................................2

2. ACTIVITY IMPLEMENTATION PROGRESS ...........................................................................................7

2.1 Result 1: Malaria surveillance is improved .........................................................................................7

2.1.1 Activity 1A.1: Provide technical support to the SME community ..........................................7

2.1.2 Activity 1A.2: Support HMIS/DHIS2, eIDSR, and malaria surveillance implementation ....................................................................................................................8

2.1.3 Activity 1A.3: Strengthen MoHCDGEC and NMCP outbreak response capacity ............... 19

2.1.4 Activity 1B.1: Support ZAMEP to update and implement the malaria surveillance strategy .............................................................................................................................. 21

2.1.5 Activity 1B.2: Develop interoperability between key HIS .................................................... 21

2.1.6 Activity 1B.3: Enhance and strengthen MCN ICT architecture and sustainability ............... 23

2.1.7 Activity 1B.4: Support MCN implementation ...................................................................... 24

2.1.8 Activity 1B.5: Refine operational thresholds and triggers as MCN data are analyzed ............................................................................................................................ 26

2.1.9 Activity 1B.6: Develop strategy and implementation plan to minimize malaria importation ......................................................................................................................... 27

2.2 Result 2: Entomological monitoring is improved ............................................................................... 28

2.2.1 Activity 2.1: Compile and review entomological monitoring data ........................................ 28

2.2.2 Activity 2.2: Conduct entomological monitoring planning and implementation ................... 30

2.2.3 Activity 2.4: Provide equipment and supplies for entomological monitoring ....................... 34

2.2.4 Activity 2.5: Entomological investigation and response in hot spot areas/active foci (Zanzibar only) ............................................................................................................ 35

2.2.5 Activity 2.6: Capacity building of new entomological field team in new emerging hot spots (Zanzibar only) ................................................................................................... 35

2.2.6 Activity 2.7: Strengthen national malaria vector control strategies, policies, and guidelines .......................................................................................................................... 35

2.3 Result 3: Drug efficacy monitoring is improved ................................................................................ 36

2.3.1 Activity 3.2: Plan, monitor, and implement TES ................................................................. 36

2.3.2 Activity 3.3: Provide equipment and supplies for TES ........................................................ 39

2.3.3 Activity 3.5: Strengthen national malaria case management strategies, policies, and guidelines ................................................................................................................... 39

2.4 Result 4: GOT’s evidence-based decision making is improved ........................................................ 40

2.4.1 Activity 4.1: Strengthen Tanzania’s capacity for state-of-the-art (SOTA) analysis and interpretation of surveillance, entomological, and drug efficacy data .......................... 40

2.4.2 Activity 4.2: Conduct SOTA analysis and interpretation of surveillance, entomological, and drug efficacy data ............................................................................... 41

2.4.3 Activity 4.3: Disseminate OMDM results through various channels ................................... 41

2.4.4 Activity 4.4: Implement Learning Agenda .......................................................................... 43

3. IMPLEMENTATION CHALLENGES ...................................................................................................... 44

4. GENDER CONSIDERATIONS ............................................................................................................... 44

5. ENVIRONMENTAL COMPLIANCE ........................................................................................................ 45

6. MEL PLAN: PROGRESS ON OMDM PERFORMANCE INDICATORS ................................................. 45

7. MANAGEMENT ...................................................................................................................................... 45

7.1 Collaboration with OMDM partners and stakeholders ...................................................................... 45

iv USAID Okoa Maisha Dhibiti Malaria (OMDM) Activity, Year 2, Quarter 2 Performance Report

7.2 List of all documents submitted to the Development Experience Clearinghouse (DEC) .................. 46

7.3 Certification that all participant training information has been entered in the TraiNet database .......................................................................................................................................... 46

8. UPCOMING EVENTS ............................................................................................................................. 46

ANNEX 1. PERFORMANCE INDICATOR SUMMARY TABLE .................................................................... 47

ANNEX 2. ZAMEP QUARTERLY REPORT (JANUARY 2020–MARCH 2020) ............................................ 54

List of Figures

Figure 1. OMDM Results Framework ........................................................................................................1

Figure 2. Number of weekly cases reported in eIDSR, 2019 .....................................................................9

Figure 3. Health facilities in Mpwapwa DC reporting 1234 clinical malaria cases .....................................9

Figure 4. Monthly overall malaria testing and OPD visit ratio, 2018 and 2019 ........................................ 11

Figure 5. Monthly overall antimalarial dispensing ratio, 2018 and 2019 .................................................. 11

Figure 6. IPTp3 uptake by quarter for the period of 2019 ....................................................................... 13

Figure 7. Malaria register template used for data collection .................................................................... 20

Figure 8. Screenshot of DHIS2 interactive dashboard in live DHIS2 visualizing malaria data from Coconut ................................................................................................................................... 22

List of Tables Table 1. Summary of progress during OMDM’s Y2, Q2 ............................................................................2

Table 2. DHIS2 Version 2 Malaria Dashboard issues raised with UDSM ................................................ 10

Table 3. Recommendations, follow-up, and way forward February 2020 ................................................ 12

Table 4. Recommendations, follow-up, and way forward March 2020 .................................................... 13

Table 5. Issues raised during Malaria Zonal Meetings ............................................................................ 15

Table 6. MOHZ and ZAMEP trainees ...................................................................................................... 23

Table 7. MCN detection challenges ........................................................................................................ 24

Table 8. Monthly data review meeting, March 13, 2020 .......................................................................... 25

Table 9. Results on species identification by PCR and sporozoite ELISA results in sprayed and nonsprayed districts ......................................................................................................................... 32

Table 10. TES 2020 study initiation sites and dates ................................................................................ 36

Table 11. Parasitological and clinical outcomes of enrolled patients ....................................................... 37

Table 12. Adverse events reported ......................................................................................................... 38

Table 13. OMDM implementation challenges .......................................................................................... 44

Table 14. OMDM Q2 collaboration with partners and stakeholders ........................................................ 45

Table 15. Upcoming events .................................................................................................................... 46

USAID Okoa Maisha Dhibiti Malaria (OMDM) Activity, Year 2, Quarter 2 Performance Report v

Abbreviations and Acronyms

ACD active case detection

ACPR adequate clinical and parasitological response

ALu artemether lumefantrine

ANC antenatal care

AOR Agreement Officer’s Representative

API application programming interface

App mobile application

ASTMH American Society of Tropical Medicine and Hygiene

Bti Bacillus thuringiensis var. israelensis

CBR CDC light traps with collection bottle rotators

CBS case-based surveillance

CD continuous distribution

CDC U.S. Centers for Disease Control and Prevention

CHMT Council Health Management Team

CHW community health worker

CLA Collaborating, Learning, and Adapting

CMSO Council Malaria Surveillance Officer

CRT Council Response Teams

CUHAS Catholic University of Health and Allied Sciences

DC district council

DDT dichloro-diplenyl-trichloroethane

DEC Development Experience Clearinghouse

DHIS2 District Health Information System 2

dLAB Tanzania Data Lab

DQA data quality analysis

eIDSR electronic Integrated Disease Surveillance and Response

EIR entomological inoculation rate

eLMIS electronic Logistics Management Information System

ETF early treatment failure

FAA fixed amount award

FBO faith-based organization

FELTP Field Epidemiology and Laboratory Training Program

FY fiscal year

vi USAID Okoa Maisha Dhibiti Malaria (OMDM) Activity, Year 2, Quarter 2 Performance Report

GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria

GOT Government of Tanzania

HBHI high burden to high impact

HC health center

HFR health facility register

HIS health information system

HLC human landing catch

HMIS health management information system

ICT information and communication technology

IHI Ifakara Health Institute

IMVC Integrated Malaria Vector Control Unit

ITN insecticide-treated nets

IPD inpatient department

IPTp3 intermittent preventive treatment in pregnancy 3

IRS indoor residual spraying

KCMC Kilimanjaro Christian Medical Centre

LLIN long-lasting insecticidal net

LCF late clinical failure

LPF late parasitological failure

LSM larval source management

LTC CDC-light trap collection

MCM Malaria Case Management

MDA mass drug administration

M&E monitoring and evaluation

MCN malaria case notification

MEEDS Malaria Epidemic Early Detecting System

MEL monitoring, evaluation, and learning

MERLA monitoring, evaluation, research, learning, and adapting

MOHZ Ministry of Health (Zanzibar)

MoHCDGEC Ministry of Health, Community Development, Gender, Elderly and Children

MPR malaria programme review

MRC mass replacement campaign

mRDT malaria rapid diagnostic test

MSD medical store department

USAID Okoa Maisha Dhibiti Malaria (OMDM) Activity, Year 2, Quarter 2 Performance Report vii

MSDQI malaria services and data quality improvement

MSP malaria strategic plan

MTR Malaria Mid-term Review

MUHAS Muhimbili University of Health and Allied Sciences

MVS malaria vector surveillance

MVES malaria vector entomological surveillance

NIMR National Institute for Medical Research

NMCP National Malaria Control Program

OAA Office of Assistance and Acquisition

ODK open data kit

OMDM Okoa Maisha Dhibiti Malaria Activity (Save Lives, End Malaria)

OPD outpatient department

OR operational research

PBO piperonyl butoxide

PCR polymerase chain reaction

PMI U.S. President’s Malaria Initiative

PO-RALG President’s Office—Regional Administration and Local Government

PSC pyrethrum spray catch

PTC pit trap catch

Q1/2/3/4 quarter 1/2/3/4

QA quality assurance

QC quality control

RBM VCWG Roll Back Malaria Vector Control Working Group

RCH reproductive and child health

RDT rapid diagnostic test

RHMT Regional Health Management Team

SBCC social behavior change communication

s.l. sensu lato

SME surveillance, monitoring, and evaluation

SMPNS School Malaria Parasitemia and Nutrition Survey

SMSP Supplemental Malaria Strategic Plan

SNP School Net Program

SOP standard operating procedure

SOTA state of the art

viii USAID Okoa Maisha Dhibiti Malaria (OMDM) Activity, Year 2, Quarter 2 Performance Report

s.s. sensu stricto

STTA short-term technical assistance

Swiss TPH Swiss Tropical and Public Health Institute

TA technical assistance

TBD to be determined

TES therapeutic efficacy studies

ToC theory of change

ToR terms of reference

TWG technical working group

UDSM University of Dar es Salaam

USAID U.S. Agency for International Development

WHO World Health Organization

Y1/2/3/4 Year 1/2/3/4

ZAMEP Zanzibar Malaria Elimination Program

ZILS Zanzibar Integrated Logistic System

USAID Okoa Maisha Dhibiti Malaria (OMDM) Activity, Year 2, Quarter 2 Performance Report 1

States

USAID Okoa Maisha Dhibiti Malaria (OMDM) Activity

1. Program Overview

Program Name: Okoa Maisha Dhibiti Malaria (OMDM) Activity

Activity Start and End Dates: August 7, 2018 to August 6, 2023

Prime Implementing Partner: RTI International

Cooperative Agreement Number: 72062118CA00002

Geographic Coverage: Mainland Tanzania and Zanzibar

Reporting Period: Year 2, Quarter 2: January 1–March 31, 2020

1.1 Program Description As part of the United

continued commitment to reduce the burden of malaria in Tanzania, the U.S. Agency for International Development (USAID) awarded RTI International a five-year cooperative agreement aimed at supporting the Government of Tanzania (GOT) in strengthening malaria surveillance and monitoring and moving the country toward malaria elimination. USAID’s Okoa Maisha Dhibiti Malaria (OMDM; Save Lives, End Malaria) Activity seeks to institutionalize malaria surveillance and monitoring at all government levels, maximizing the epidemiological impact of implemented malaria interventions by improving the targeting and implementation of interventions, refining approaches to manage transmission foci and respond to outbreaks, and providing key data to the GOT and stakeholders for policy development and programmatic decision making. Figure 1 shows OMDM’s results framework underpinning the Activity’s programs.

OMDM’s Year (Y)2 work plan, partially approved in December 2019, was developed in coordination with mainland Tanzania’s National Malaria Control Programme (NMCP) and the Zanzibar Malaria Elimination Programme (ZAMEP). This quarterly performance report focuses on Y2 quarter (Q)2 OMDM activities conducted between January 1 and March 31, 2020.

Figure 1. OMDM Results Framework

2 USAID Okoa Maisha Dhibiti Malaria (OMDM) Activity, Year 2, Quarter 2 Performance Report

1.2 Y2, Q2 Achievements Table 1 summarizes OMDM’s progress toward achieving results during Q2. Please see Section 2 and Annex 1 for additional detailed information regarding progress under each activity.

Table 1. Summary of progress during OMDM’s Y2, Q2

OMDM result areas Y2, Q2 achievements Result 1: Malaria surveillance is improved MAINLAND TANZANIA Activity 1A.1: Provide technical support to Surveillance, Monitoring, and Evaluation (SME) community

• OMDM provided technical input to revise draft terms of reference (ToR) for the SME Technical Working Group (TWG). The draft was shared with the NMCP for input before being further disseminated.

• From March 2–6, 2020, OMDM participated in a malaria programme review (MPR) workshop in Dodoma to evaluate the status of previous policies, strategies, interventions, and targets before launching development of a new Malaria Strategic Plan (MSP) 2021–2025 aligned with World Health Organization (WHO) guidelines. OMDM was represented by , who conducted a field verification visit in the Kigoma region. Results from the MPR workshop and the field visits were presented to the Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) management prior to the development of the MSP 2021–2025.

Activity 1A.2: Support Health Information Management System (HMIS)/District Health Information System 2 (DHIS2), electronic Integrated Disease Surveillance and Response (eIDSR), and malaria surveillance implementation

• OMDM informed the Information Communication Technology (ICT) and Epidemiology Units of the MoHCDGEC about an eIDSR system problem whereby inaccurate clinical malaria cases from some health facilities during weekly transmission of reports via mobile phones were reported. The Activity is working with both Units to rectify the problem.

• OMDM continued to engage with the NMCP and President’s Office– Regional Administration and Local Government (PO-RALG) through data review meetings. In Q2, the Activity facilitated two review meetings in Dodoma using primarily data from DHIS2 Version 2 Malaria Dashboard. The first meeting comprising 18 participants was held on January 31, 2020; the second meeting of 14 participants was held from March 2–3, 2020.

• From February 25–28, 2020, OMDM’s Surveillance and Monitoring, Evaluation, Research, Learning, and Adapting (MERLA) Director—travelled to Dodoma to provide further onsite coaching and mentoring support to the SME Unit. This is part of OMDM’s commitment to an increased presence in Dodoma to work with the NMCP in person.

• In Q2, OMDM participated in Malaria Zonal Meetings. The Activity participated in two (Dar es Salaam and Mwanza) of the five zonal sessions organized by the NMCP and PO-RALG, comprising regional and district malaria focal persons and other partners for the respective regions and councils. The Dar es Salaam Zonal Meeting was held from January 15–16, 2020, including Regional Health Management Teams (RHMT) and Council Health Management Teams (CHMT) from the Dar es Salaam, Lindi, Pwani, and Mtwara regions. The Mwanza Zonal Meeting was held from January 27–28, 2020, including RHMTs and CHMTs from Mwanza, Geita, Mara, and Kagera regions.

• USAID Boresha Afya Southern Zone requested OMDM facilitate DHIS2 training for regional and council health teams in four regions (Lindi, Morogoro, Mtwara, Ruvuma). However, due to GOT-imposed restrictions on travel due to COVID-19, OMDM was only able to facilitate training in the Morogoro Region.

• OMDM’s —was in Dodoma from January 8–13, 2020, to support the NMCP in data cleaning for the latest round of the School Malaria Parasitemia and Nutrition Survey (SMPNS). The 2019 survey collected data from 68,172 public school pupils aged 5–16 years


OMDM result areas Y2, Q2 achievements from 700 schools, sampled across 184 councils in 26 regions of Mainland

Tanzania. • OMDM developed an Excel-based template that focused on illustrating the

Data Quality Audit (DQA) sections of the outpatient department (OPD), Severe Malaria and antenatal care (ANC) malaria services and data quality improvement (MSDQI) modules. The template is built like a dashboard that allows users to select regions and districts through filters to provide results on how well each section is performing in reporting performance, DQA readiness, DQA data consistency, and accuracy based on assigned scores.

Activity 1A.3: Strengthen MoHCDGEC and NMCP outbreak response capacity

• OMDM is currently working on two publications about the eIDSR. The first reviews the history and scale-up of the eIDSR and will be a separate manuscript. The second publication continues OMDM’s work from Y1, reviewing the reporting and case comparison between the eIDSR and DHIS2 at different strata.

• In Q2, OMDM continued to support the NMCP in case-based surveillance (CBS) activities following a workshop which introduced CBS conducted in Moshi in Q1. As a follow-on, NMCP invited OMDM and other partners to Morogoro to continue with phase two of CBS preparations. From January 7–17, 2020, the Activity participated in cleaning and entry of case-based data collected between November and December 2019 from the Arusha, Kilimanjaro, and Manyara regions.

ZANZIBAR Activity 1B.1: Support ZAMEP to update and implement malaria surveillance strategy

• Please see Annex 2 to review Q2 updates from ZAMEP.

Activity 1B.2: Develop interoperability between key health information systems (HIS)

• In Q2, OMDM continued with the integration between Coconut and DHIS2. The integration is completed for about 90%. Dashboards have been created in DHIS2 and data from MCN from April 2019 to April 2020 is now visible in DHIS2.

Activity 1B.3: Enhance and strengthen malaria case notification (MCN) information and ICT architecture and sustainability

• On March 6, 2020, four participants from the ICT/HMIS Units of the Ministry of Health Zanzibar (MOHZ) and one from ZAMEP’s ICT Unit were enrolled in online courses on MCN systems training. The five trainees—all of whom have backgrounds in software programming—were enrolled in the following courses via UDEMY.com: Linux Mastery, Understanding CouchDB, Backbone JavaScript, and Coffee Script.

• MCN training materials have been finalized, including the manual used for refresher training of ZAMEP SME staff and Council Malaria Surveillance Officers (CMSO).

Activity 1B.4: Support MCN implementation

• OMDM continued engaging with ZAMEP and CMSOs to ensure MCN was functional. Data generated by MCN is reviewed weekly by OMDM and analysis shared with ZAMEP management.

Activity 1B.5: Refine operational thresholds and triggers as MCN data are analyzed

• In Q2, OMDM prepared a comprehensive Excel-based data dashboard that collates information from secondary cases that were followed up between January 2018 and January 2020. The data is disaggregated by district and shehias and can be viewed at annual, monthly, and weekly frequencies. The aim was to understand how many additional secondary cases were identified for each index case followed up to household level.

Activity 1B.6: Develop strategy and implementation plan to minimize malaria importation

• With support from RTI’s Epidemiologist and Modeler OMDM began to analyze travel-related malaria in Zanzibar. Data from January 2015 to January 2020—over 19,500 index cases—was extracted from MCN for secondary analysis. For each index case, sex, age, village coordinates, and travel history outside or within Zanzibar during the previous month were recorded. Spatio-temporal analysis was performed to identify the spatial heterogeneity of case reporting during transmission seasons and its correlation with rainfall from 2015 to 2020. Once the analysis is complete, OMDM will disseminate findings to ZAMEP and the U.S. President’s Malaria Initiative (PMI).


OMDM result areas Y2, Q2 achievements Result 2: Entomological monitoring is improved Activity 2.1: Compile and review entomological monitoring data

• During this implementation period, OMDM compiled the annual entomological surveillance report from Zanzibar and mainland Tanzania into one comprehensive report, submitted to USAID/PMI in March 2020.

• While participating in the ZAMEP’s malaria Mid-Term Review (MTR) from January 13–18, 2020, OMDM also supported ZAMEP’s Entomology Unit finalizing their annual entomological surveillance report.

• On March 3, 2020, OMDM supported ZAMEP review of the compiled entomological surveillance data report. This final report is being converted into a publishable article and will be ready for review in Q3.

• Also on March 3, 2020, OMDM supported ZAMEP to develop abstracts for the upcoming annual meeting of the American Society of Tropical Medicine and Hygiene (ASTMH). Two entomology abstracts were developed.

• OMDM facilitated an NMCP-led Vector Control TWG meeting from February 13–14, 2020. Key issues discussed in the meeting included the following: − Update of entomological monitoring activities supported by OMDM in

Tanzania including insecticide resistance monitoring. − Update on malaria vector entomological surveillance (MVES) activity

in 62 districts. This activity is financially supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and PMI; OMDM provides technical support.

− Update on vector control interventions in Tanzania including indoor residual spraying (IRS), long-lasting insecticide nets (LLIN) distribution through different channels, and larval source management (LSM).

− Update on the drafted LSM monitoring and evaluation framework. The draft document was presented and input provided by meeting participants.

− Updates on vector control database and analytical plan. The task force, led by OMDM, presented the progress reached in the development of entomological indicators for inclusion in the composite database. It was proposed that the task force review the PMI and WHO indicators for inclusion in the country composite database. To accelerate its inclusion, OMDM is liaising with the WHO about the possibility of using the already-developed DHIS2 platform to process and develop the data. OMDM had an in-person meeting with the contact person managing the entomological database from the WHO on February 5, 2010, in Geneva while attending the Roll Back Malaria Vector Control Working Group (RBM VCWG) meeting. OMDM will continue to follow up on this while also working with the task force to finalize the set of indicators.

• During Q2, OMDM continued to engage the National Institute for Medical Research (NIMR) Mwanza, NIMR Amani, ZAMEP, NMCP, PMI, and the Centers for Disease Control and Prevention (CDC) to review the sentinel sites for entomological monitoring to align with the current malaria situation as well the existing vector control interventions. The proposed expansion of sites to include entomological monitoring in regions where piperonyl butoxide (PBO)-LLINs have been distributed but not previously monitored due to lack of funds. Instead, NIMR Amani was asked to drop dichloro- diphenyl-trichloroethane (DDT) from the list of insecticides to be tested in 2020 and to increase the number of sites, to include monitoring of the performance of PBO-LLINs using WHO papers. Entomological monitoring continued in all routine sites agreed upon earlier in 2019.

• In Q2, OMDM continued developing a protocol to assess the impact of IRS in Tanzania’s Lake Zone and Zanzibar initiated in Q1. The protocol will be finalized in Q3 and submitted to the NMCP and ZAMEP for approval.


OMDM result areas Y2, Q2 achievements Activity 2.2: Conduct entomological monitoring planning and implementation

• OMDM continued to support NIMR Amani, NIMR Mwanza, and ZAMEP to conduct entomological monitoring in Mainland Tanzania and Zanzibar.

• NIMR Amani: In Q2, OMDM continued to support NIMR Amani complete preparatory activities for insecticide resistance monitoring in 2020. The planned refresher training for laboratory, scientific, and vector control staff, involving insecticide resistance monitoring activities, has been postponed to Q3 due to the COVID-19 outbreak. NIMR Amani decided to forego classroom training; instead, they will orient field data collectors onsite to reduce the number of people gathering at the same time.

• ZAMEP: OMDM continued to support Zanzibar conduct malaria entomological monitoring and determine the residual efficacy of insecticide post-IRS.

• NIMR Mwanza: In Q2, OMDM continued supporting NIMR Mwanza to conduct entomological monitoring in ten sites; six are located in the districts where IRS is being conducted while four are in districts where IRS is not taking place (control sites). One village was randomly selected in each of the districts; in each village, two households were selected for monthly mosquito collection. Mosquito collections were conducted using CDC light traps, clay pots, Prokopack aspirators, and CDC light traps with collection bottle rotators (CBR) in all selected villages and households. A total of 15,045 female Anopheles mosquitoes were collected between January 2020 and March 2020. Of these, 13,310 (88.47%) were morphologically identified as An. gambiae s.l. and 1,735 (11.53%) as An. funestus s.l.. An. gambiae s.l. was the abundant vector species sampled by all collection methods in each IRS district. Identification of species by polymerase chain reaction (PCR)-based methods showed the local vector population across sites to be predominantly An. arabiensis (38.7%), An. gambiae s.s. (36.2%), An. funestus (18.7%), and An. parensis (0.4%). Sporozoite rates were found to vary across the sites ranging from 0% to 2.6% in sprayed sites and 0% to 9.4% in unsprayed sites. Generally, there was a decrease in indoor biting rates in all sprayed sentinel sites. As expected, unsprayed sentinel sites had the highest number of mosquitoes (An. gambiae s.l. and An. funestus s.l.) resting indoors unlike the sprayed sites.

• IRS Residual Efficacy: In Q2, OMDM continued supporting NIMR Mwanza to determine the residual efficacy of the insecticides sprayed on different wall surfaces inside houses. NIMR Mwanza conducted wall cone bioassays of the clothianidin sprayed during the IRS campaign in Biharamuro, Bukombe, and Ukerewe. Similar bioassays were conducted in Kibondo, Kakonko, and Kasulu districts that were sprayed with pirimiphos methyl (Actellic® 300CS) during IRS operations. The aim of this activity was to determine the residual efficacy of the insecticides sprayed on different wall surfaces inside houses. WHO wall cone bioassays were conducted monthly with laboratory-susceptible An. gambiae s.s. (Kisumu strain) on different wall types sprayed with either pirimiphos-methyl or clothianidin. Five months post-IRS using clothianidin in Biharamulo and Actellic® 300CS in Kakonko, Kibondo, and Kasulu DC, all surfaces retained effective insecticide residual efficacy. One month post-IRS with clothianidin in Bukombe and Ukerewe, all surfaces retained the insecticide quite effectively.

• ZAMEP continued maintaining their An. gambiae s.s. colonies (Kisumu strain) in Q2. Production of adult mosquitoes continued to be maintained to meet the required demands for IRS quality assessments and residual efficacy testing.

Activity 2.4: Provide equipment and supplies for entomological monitoring

• In Q2, OMDM continued to facilitate the procurement, shipment, and custom clearance of the procured materials and supplies needed by NIMR Mwanza, NIMR Amani, NIMR Tanga, and ZAMEP for Y2 activities. The shipment has been delayed due to COVID-19.


OMDM result areas Y2, Q2 achievements Activity 2.5: Entomological investigation and response in hot spot areas/active foci (Zanzibar only)

• Please see Annex 2 to review Q2 updates from ZAMEP.

Activity 2.6: Capacity building of new entomological field team in new emerging hot spot (Zanzibar only)

• No activities were conducted during the reporting period.

Activity 2.7: Strengthen national malaria vector control strategies, policies, and guidelines

• In Q2, OMDM hosted the vector control TWG meeting from February 13– 14, 2020, as described in section 2.1 above. OMDM also initiated discussions with ZAMEP to create a vector control TWG in Zanzibar in Q2.

• From January 13–18, 2020, OMDM supported ZAMEP in the MTR of the current MSP; OMDM supported the NMCP in its MPR from March 2–20, 2020. Both MTR and MPR comprehensively analyzed the malaria situation in Tanzania and NMCP/ZAMEP performance against the strategic plan. Findings from the reviews and lessons learnt were used in the revision of the strategic plans to maximize successes, leverage missed opportunities, and set goals for phase two of the MSP for Zanzibar and for the development of a new strategic plan in the mainland. Additionally, the MTR and MPR were used to inform the government, development partners, and stakeholders on the progress made in implementing the strategic plans and to help set and/or reset the malaria agenda in the short, medium, and long term.

• The LSM operational tool was finalized but not presented to ZAMEP management due to logistical challenges.

Result 3: Drug efficacy monitoring is improved Activity 3.2: Plan, monitor, and implement therapeutic efficacy studies (TES)

• In Q2, OMDM finalized the fixed amount award (FAA) with the Catholic University of Health and Allied Sciences (CUHAS) and supported them to initiate TES 2020, including the review of standard operating procedures (SOP), logs, and other study documents, and the signing of subagreements with TES implementing institutions including Ifakara Health Institute (IHI), NIMR Tanga, Kilimanjaro Christina Medical Centre (KCMC) and Muhimbili University of Health and Allied Sciences (MUHAS).

• OMDM supported CUHAS conduct a planning meeting on March 5, 2020, to update participating institutions on the preparation for TES 2020 activities and to discuss the implementation plan. Training and site initiation is tentatively scheduled for April 18, 2020, in Mlimba. However, this will only happen if the COVID-19 situation normalizes.

• In Q2, OMDM continued to support MUHAS to conduct data analysis and interpret and disseminate results from TES 2019. MUHAS presented the results to malaria control stakeholders during a meeting on March 4, 2020. During this dissemination meeting, MUHAS also formally handed over the coordination of TES 2020 to CUHAS.

• MUHAS presented the 2019 TES implementation report summarized under Result 3 of this quarterly report.

Activity 3.3: Provide equipment and supplies for TES

• In Q2, OMDM continued to facilitate the procurement of reagents and supplies for NIMR Tanga’s molecular analysis activities, including samples from TES 2018, 2019, and 2020. The arrival of the materials and supplies to NIMR Tanga has been delayed due to the COVID-19 pandemic.

Activity 3.5: Strengthen national malaria case management strategies, policies, and guidelines

• In Q2, OMDM supported the TES TWG meeting held from March 4 to 5, 2020, during which 2019 TES results were disseminated and 2020 TES planned. The meeting brought together representatives from OMDM, NMCP, MUHAS, IHI, NIMR Tanga, CUHAS, KCMC, PMI/USAID, and CDC/PMI. The detail of this activity is described under activity 3.2.

• OMDM continued to support NIMR Tanga conduct molecular analysis of 2018 and 2019 samples. The molecular laboratory analysis has stopped due to delayed arrival of reagents and supplies as a result of the COVID- 19 pandemic.

Result 4: GOT’s evidence-based decision making is improved


OMDM result areas Y2, Q2 achievements Activity 4.1: Strengthen Tanzania’s capacity for state- of-the-art (SOTA) analysis and interpretation of surveillance, entomological, and drug efficacy data

• The Swiss Tropical and Public Health Institute (Swiss TPH) malaria course originally scheduled for April and the Field Epidemiology and Laboratory Training Program (FELTP) training scheduled for the first week of March were both postponed due to COVID-19 restrictions; participants identified to attend the FELTP training will join another cohort when announced later in the year.

Activity 4.2: Conduct SOTA analysis and interpretation of surveillance, entomological, and drug efficacy data

• OMDM, with the NMCP, developed the 2019 Annual Malaria Bulletin, Issue 9, working directly with the SME unit in Dodoma on the data analysis and to prepare the relevant charts, tables, maps, and draft sections of the Bulletin.

• With ZAMEP, OMDM worked on secondary analysis of malaria cases and incidence at the shehia level between 2015-2019. The analysis is ongoing, and the first draft will be shared with PMI and the program in Q3.

Activity 4.3: Disseminate OMDM results through various channels

• OMDM worked with NMCP, NIMR Amani, NIMR Mwanza and ZAMEP to prepare abstracts to be submitted to the ASTMH conference taking place later this year. A total of nine abstracts detailed in sections below were finalized in April and eight of them received approval for submission to ASTMH,

Activity 4.5: Implement Learning Agenda

• On March 27, 2020, the OMDM field and home office teams met virtually for their quarterly Pause and Reflect session.

led the session with and (who recently joined RTI’s Global Health Division

as the ). The goal of this session was to walk through the Activity’s Learning Agenda and review the Operations Research (OR) studies recently sent to PMI for review.

2. Activity Implementation Progress 2.1 Result 1: Malaria surveillance is improved MAINLAND TANZANIA

2.1.1 Activity 1A.1: Provide technical support to the SME community Serve as members of and participate in relevant HMIS/DHIS2 coordinating bodies Progress in Y2, Q2

OMDM provided technical input to revise the draft ToR for the SME TWG. The draft was shared with the NMCP’s

for further review and comments by his team before it is further disseminated to key partners for their input.

Planned for Q3

OMDM awaits NMCP feedback before engaging the wider team to move this activity forward.

Support the NMCP in future review and updates of health sector strategic, policy, and technical documents Progress in Y2, Q2

From March 2–6, 2020, OMDM participated in the NMCP’s MPR workshop in Dodoma as an initial step towards writing a new MSP 2021–2025. The objective of the workshop was to review the status of the current strategic plan and effectiveness of previous policies, strategies, interventions, and targets prior to developing the new plan. The MPR was


Participants during the MPR session in Dodoma. Photo credit by: OMDM Activity, RTI International.

facilitated using WHO guidelines by consultant field visits were also conducted.

Specific groups within the NMCP discussed in detail included the Integrated Malaria Vector Control (IMVC) Unit, Malaria Case Management (MCM) Unit, SBCC Unit, SME Unit, Finance team, and the NMCP’s Programme Management Unit. OMDM staff participated in the groups focusing on the IMVC, SME, and Programme Management Units. The OMDM team also developed a checklist used during field visits conducted during the MPR workshop between March 9–13, 2020.

Planned for Q3

Following the MPR, the NMCP is leading development of the new strategic plan and using it to subsequently develop Tanzania’s concept note for submission to GFATM for the period 2021–2023. OMDM continues to provide support to develop the new MSP 2021–2025 and writing of the concept note to the GFATM.

2.1.2 Activity 1A.2: Support HMIS/DHIS2, eIDSR, and malaria surveillance implementation

Continuously engage with MoHCDGEC, NMCP, and other stakeholders to ensure that HMIS/DHIS2 and eIDSR are functional and that data flow is adhered to in terms of timely collection and transfer of data, data completeness, and quality Progress in Y2, Q2

eIDSR Data

OMDM periodically updates malaria data from the eIDSR dashboard within DHIS2. In Q2, as the team was updating its eIDSR dataset, it found that week 36 of 2019 reported a higher than usual number of clinical cases (Figure 2). Upon further review, the abnormal reporting


was noted to be due to a system error whereby it was capturing 1234—the password for eIDSR—as the number of clinical malaria cases instead of the actual number reported by health facilities submitting the weekly data. This is highlighted in Figure 3, an example from the Mpwapwa district council of the Dodoma region. Other district councils that faced a similar problem included Kilwa, Kibiti, and Moshi.

Figure 2. Number of weekly cases reported in eIDSR, 2019

Figure 3. Health facilities in Mpwapwa DC reporting 1234 clinical malaria cases

OMDM reported this problem to the MoHCDGEC’s ICT and Epidemiology Units. It was determined that this system glitch will need to be fixed; once complete, the health facilities that reported inaccurate numbers will be required to re-update their weekly reports.

DHIS2 system upgrades

As a follow-on activity from Q1, OMDM’s , continued providing support to the NMCP to upgrade the DHIS2 system. In Q2, the OMDM team focused on improving the DHIS2 Version 2 Malaria Dashboard. During the Case Management TWG meeting held in Dodoma from February 17 to 18, 2020, the University of Dar es Salaam (UDSM) was invited to orient the NMCP and implementing partners on the new Malaria


Dashboard and respond to challenges observed by partners. Participants reviewed the charts and tables in detail. While doing so, UDSM agreed to correct any issues identified; for example, some facilities that reported were not reflected on the Malaria Dashboard. A task force comprising staff from the NMCP, UDSM, and Jhpiego was formed to identify missing facilities for UDSM to work with to capture and include their data. OMDM continues to engage UDSM to fix other glitches identified in version 2 of DHIS2 (Table 2).

Table 2. DHIS2 Version 2 Malaria Dashboard issues raised with UDSM

Category Section Chart name Issue

OPD module Malaria diagnosis by age group (<5 and >5)

Number of malaria cases disaggregated by age group by subunit

The filter used to choose the type of health facility only allows selection of public health facilities—private health facilities are missing. To resolve: add private health facilities to the filter.

In-patient department (IPD) module

Severe malaria burden

Severe malaria burden map

The map title was not displayed. To resolve: add map title.

Accountability Tool Artemether lumefantine (ALu)

Ratio ALu dispensed: Malaria confirmed cases

There were two tables showing the same information. To resolve: 1) data should be displayed as graphs instead of tables; 2) first graph should show overall trends from the last 5 years; 3) second chart should be disaggregated by subunit, showing data for last year (2019).

Malaria rapid diagnostic test (mRDT)

mRDT electronic logistics management information system (eLMIS) consumption (estimated)/mRDT testing

Data for this section could not be displayed. Also, instead of showing the data in tabular format, it was recommended to display it as a chart. To resolve: 1) enable data to be displayed; 2) change the format from table to chart.

Planned for Q3

OMDM will continue to support the NMCP by working with the ICT and Epidemiology Units and UDSM on DHIS2 system maintenance and additional enhancement features, such as rectification of eIDSR data, Version 2 Malaria Dashboard, and others. Using the Malaria Dashboard, OMDM will also continue to monitor monthly DHIS2 data after reports have been submitted to monitor trends on key indicators and communicate with the NMCP in case further action or follow-up is required.

Facilitate monthly MoHCDGEC/NMCP data use workshops to review, analyze, and interpret epidemiological and programmatic data reported through the HMIS/DHIS2 and eIDSR, including pause and reflect sessions to identify trends, bottlenecks, and action items Progress in Y2, Q2

Data review meetings

OMDM continued to engage with the NMCP and PO-RALG through two data review meetings held in Dodoma in Q2, primarily using data from the DHIS2 Version 2 Malaria Dashboard. The first meeting was held on January 31, 2020, for 18 participants from the


NMCP and PO-RALG’s SME, Vector Control, and Case Management Units. During this meeting, two indicators were reviewed in-depth: 1) the ratio of malaria tests (laboratory) and OPD visits (Figure 4) and 2) the ratio of confirmed malaria cases and ALu dispensed (Figure 5). Participants used the Malaria Dashboard to discuss the national-, regional-, district-, and facility-level data for the selected indicators, assess their performance, identify areas and possible reasons for low performance, and develop strategies for their mitigation (Table 3).

Figure 4. Monthly overall malaria testing and OPD visit ratio, 2018 and 2019

Figure 5. Monthly overall antimalarial dispensing ratio, 2018 and 2019


Participants discussing action points during data review. Photo credit by: OMDM Activity, RTI International.

Table 3. Recommendations, follow-up, and way forward February 2020

Area Action to be taken Responsible person

Time frame

Malaria testing Investigate reasons for low malaria testing ratio in regions within low and very low malaria endemicity

NMCP, PO-RALG, and partners

TBD

Review data on testing ratio, identify facilities contributing to low and/or abnormal performance, and take appropriate actions

Share updates with NMCP on the actions taken

Boresha Afya, Association of Private Hospitals Tanzania (APHTA), RHMT, and CHMT

March 30, 2020

Testing ratio as an indicator should be reviewed— ANC visits should be included in the denominator as well since they are part of the numerator in the dashboard calculations

NMCP and partners

TBD

Malaria commodities

Review data on ALu dispensing ratio, identify facilities that are under- and over dispensing and take appropriate action

Share updates with NMCP on the action taken

NMCP and partners

TBD

The second data review meeting was held from March 2 to 3, 2020, in Dodoma for 14 participants from the NMCP and PO-RALG. During this meeting, participants reviewed intermittent preventative treatment in pregnancy (IPTp) indicators across national, regional, district, and facility levels (Figure 6) to assess their performance, identify areas and possible reasons for low performance, and develop strategies for their mitigation (Table 4).


Figure 6. IPTp3 uptake by quarter for the period of 2019

Table 4. Recommendations, follow-up, and way forward March 2020

Area Action to be taken Responsible person

Time frame

IPTp3 Use ongoing quarterly supervision platforms to follow up to the least- IPTp3-performing regions; insist council conducts MSDQI supervision

NMCP, PO- RALG, and

partners

Not specified

Share 2019 Sulpfadoxine Pyrimethamine (SP) stock-out report NMCP Case Management

Unit

Not specified

Follow up with health facilities to understand SP status and share report

NMCP Case Management

Unit

March 16, 2020

Follow up with the Medical Store Department (MSD) to understand amount of money received for SP and general progress

NMCP Case Management

Unit

March 9, 2020

IPTp 2/3 denominator should be tabled in the SME technical working group for further review

SME TWG Not specified

To review the calculation of the IPTp3 indicator during the SME technical working group

NMCP, PO- RALG, and

partners

TBD


Support to NMCP’s SME staff

From February 25–28, 2020, , OMDM’s Director, traveled to Dodoma to provide further onsite support and mentoring to SME Unit staff as part OMDM’s commitment to an increased presence in Dodoma to work with the team in person. The Activity has been allocated an office space in Dodoma, which allows the team to work comfortably. During this short-term technical assistance visit (STTA), worked with the team to brainstorm ideas for abstracts to be developed and submitted to different meetings and conferences including the upcoming ASTMH, including a review of previous abstracts drafted in the last Scientific Writing Workshop conducted in 2019 and other ideas identified through data sources including the MSDQI. OMDM additionally oriented

SME team member from the NMCP, to manipulate pivot tables and to use Excel for calculations within the same field list. The NMCP appreciated the STTA provided and remarked that this coaching and mentoring was extremely useful to build the capacity of staff in various areas of data management.

Planned for Q3

OMDM will continue supporting the NMCP conduct data review meetings in Q3 and will continue STTA trips to Dodoma. Additionally, the OMDM Senior Management Team is actively discussing plans to permanently co-locate an Activity member with the NMCP in Dodoma. Development of a job description for this position is underway and discussions planned with USAID.

Maximize the use of the malaria interactive dashboard within DHIS2 and promote its use at all levels Progress in Y2, Q2

In Q2, OMDM participated in two of five Malaria Zonal Meetings organized by the NMCP and PO-RALG, including regional and district malaria focal persons and other partners from the respective regions and councils.

Participants going through IPTp3 data during the review session. Photo credit by OMDM Activity, RTI International.


The Dar es Salaam Zonal Meeting was held from January 15–16, 2020, including RHMTs and CHMTs from Dar es Salaam, Lindi, Pwani, and Mtwara. The Mwanza Zonal Meeting was held from January 27–28, 2020, including RHMTs and CHMTs from Mwanza, Geita, Mara, and Kagera. The objectives of the Malaria Zonal Meetings include the following:

• Provide updates on the malaria situation and its control in Tanzania

• Review the Supplementary Malaria Strategic Plan (SMSP) 2018–2020

• Share NMCP updates across specific thematic areas e.g case management, surveillance, vector control

• Review implementation progress across malaria control interventions

• Review the main malaria programmatic indicators in the respective regions and councils

• Allow participants to exchange experiences, best practices, and challenges

• Identify implementation priorities across malaria control interventions in the respective region and councils

• Set targets for the next implementation period

OMDM noted the key issues raised during both Zonal sessions of Dar es Salaam and Mwanza (Table 5).

Table 5. Issues raised during Malaria Zonal Meetings

Topic Key points from presentations

Questions/Issues raised Response

SMSP 2018–2020 including objectives and interventions by thematic area

• Need for SMSP • Malaria stratification • Supplementary

Strategic Plan • Malaria targeted

intervention packages

• Outline of SMSP • Strategic

components • Strategic objectives • Specific objectives

and outcomes

Can data and stratification maps for malaria endemicity address the council wards to view heterogenicity in district councils?

The stratification maps are currently covering regional and district endemicity level. Plans are underway to cover lower levels.

IMVC interventions • Entomological

surveillance and insecticide resistance monitoring

• LSM • LLIN Mass

Replacement Campaign (MRC)

Concern: • Budget for bio-

larviciding is not adequate to cover all identified breeding sites.

• Regions should collaborate with stakeholders and the community to enable adequate coverage.

It was noted that PBO nets will be distributed in eight regions.

In malaria intervention, why is mosquito repellant not included as one of the core or supplementary interventions?

• Currently, mosquito repellant is not among interventions that are recommended by the WHO. As a result, NMCP is concentrating on LLIN, IRS, and




larviciding as core interventions.

It was noted that some of the councils did not submit entomological surveillance reports on time and others not at all.

Malaria case management

Why is there no system to follow index malaria cases in the community?

NMCP is in process to start CBS in areas with very low malaria transmission like the Kilimanjaro, Arusha, and Manyara regions. The pilot has been completed; the report is being prepared.

Why are we limited to IPTp3 while IPTp4 is present in Mfumo wa Taarifa za Uendeshaji wa Huduma za Afya (MTUHA) form #6 and other countries are now at IPTp5?

It was noted that IPTp4 is being practiced in the facilities, but it is not entered into HMIS to reduce system burden. Previous data on IPTp4 had shown it did not perform well, hence NMCP has opted to concentrate on improving IPTp3.

What is the progress in developing a malaria vaccine?

The development of a malaria vaccine is still in progress. Unfortunately, Tanzania is not directly involved. Three countries have started piloting on the malaria vaccine: Malawi, Kenya, and Ghana.

Are there plans for cross- border interventions?

The Great Lake initiative is one of the cross-border malaria intervention efforts; Tanzania is one of the member states.

Who is responsible for distribution of subsidized ALu drugs?

MSD is responsible for the distribution of subsidized ALu drugs; however, the drugs have been scarce due to shipment delays such that by the time the supply arrives, the demand is high. Also problematic is that some private health facilities tend to give drugs without a positive diagnosis.

Why in some private facilities is SP still being used for treatment of malaria and not for prevention of malaria?

• CHMT, RHMT, and TMDA should ensure that SP are used for prevention of malaria in pregnancy and not




for treatment of malaria.

• CHMTs should ensure availability of SP in their facilities.

• NMCP and TMDA should write a letter directing the private sector to stop using SP for treatment of malaria.

• Malaria SME implementation updates

• Tanzania malaria scorecard

• Overview of version 2 Malaria Dashboard

It was noted that the malaria scorecard will be introduced to selected regions with high malaria burden.

Concern: It was noted that nationwide MSDQI supervision is at an unsatisfactory level of 11%. Suggestion: It was advised that the RHMT and CHMT should budget for implementation of MSDQI supportive supervision using domestic funds to achieve sustainability.

• Composite malaria database

• Introduction to CBS

• Malaria SBCC updates

• SBCC and advocacy

• “Zero Malaria Starts with Me” campaign

It was noted that the SBCC is faced with two challenges: • Limited SBCC

community mobilization in regions without implementing partners

• Misconceptions in LLIN use

All malaria interventions are being done by service providers; can we empower the community to participate in the interventions?

Yes, the CHMTs should engage the health facility governing committee and come up with a plan on how to engage the community in the interventions.

Malaria Program Management Implementation Updates • Programmatic

audit findings (Controller and Auditor General (CAG), Local funding Agent (LFA), and Office of Inspector General (OIG))

• Regional Review Meeting feedback

• MSDQI and entomological surveillance fund

• Management status 2018/2019, challenges and way forward

No issues raised


DHIS2 Orientation

USAID Boresha Afya Southern Zone requested OMDM facilitate DHIS2 trainings for regional and council health teams from Lindi, Morogoro, Mtwara, and Ruvuma to enhance their capacity to access and use the system and review malaria data through DHIS2 Version 2 Malaria Dashboards. By capacitating them to utilize the platform, RHMTs and CHMTs can improve their monitoring of malaria data and increase their use of data for better decision making within their councils and regions. The original plan was to initiate training in Morogoro during the third week of March, then move to remaining regions. However, due to government-imposed restrictions on travel due to COVID-19, OMDM was only able to conduct the Morogoro training. This two-day training was held at the Edema Conference Centre in Morogoro Municipal Council. OMDM’s led the sessions, with eight RHMTs and 28 CHMTs being trained on the DHIS2 platform receiving an overview of the Version 2 Malaria Dashboards and learning how to install the MSDQI Mobile Application (DHIS2 Touch) on their Android devices.

During the training, eight participants were newly assigned to their roles and did not have access to DHIS2. It was agreed that the regional malaria focal person would request that they be provided user accounts through the HMIS Unit at the MoHCDGEC.

RHMTs and CHMTs were urged to review malaria data frequently and formalize a process of conducting regular data review meetings within their regions and councils so as to increase data use as part of improving data quality and help with decision making.

2019 SMPNS data cleaning

, OMDM , was in Dodoma from

January 8–13, 2020, to support the NMCP in data cleaning from the latest round of SMPNS. The 2019 survey collected data from

68,172 public school pupils aged 5–16 years from 700 schools, sampled across 184 councils in 26 regions of Mainland Tanzania. Survey data were collected using Open Data Kit (ODK) software through four different data collection sections including Individual Pupil’s Interview, Malaria Parasite Test Results, Household (10% of selected pupils), and School Information Summary.

From January 8 to 10, 2020, OMDM participated in the cleaning of Individual Pupils’ Interview data for Iringa, Simiyu, Kagera, Geita, Singida, and Katavi. This exercise focused on checking and ensuring that the pupil identification number (ID) and school IDs were in the correct format (Region/District/School ID/Pupil ID). One of the challenges observed was that most of the pupils’ records did not match the IDs. Hard copies of individual pupils’ data were pulled for verification and cleaning.

In the remaining three days of exercises, OMDM supported the data management of household data (6,749 respondents) by generating STATA commands. This exercise

xxxxxxxxxxxx leading a session in Morogoro. Photo credit by OMDM Activity, RTI International


focused on regrouping responses from the open-ended questions, converting string values to numeric responses, and generating new variables for indicator computation. One challenge observed during this exercise was inconsistencies in skipped questions, indicating that the data collectors were not well oriented in completing the interview forms.

As a future recommendation, additional time should be allocated to train data collectors to use the interview tools and to pretest them before the actual survey.

Planned for Q3

In Q3, OMDM will continue to engage with the NMCP and relevant stakeholders to build capacity around using DHIS2 to institutionalize data review and use by key staff.

Support the NMCP and other stakeholders in the implementation of the MSDQI framework by facilitating the interpretation and utilization of the outcomes of the routine supportive supervision activities Progress in Y2, Q2

In this quarter, OMDM developed an Excel-based template focused on illustrating the DQA sections of the OPD, Severe Malaria, and ANC MSDQI modules. The template is built like a dashboard, allowing users to select regions and districts through filters thus providing them results on how well each section is performing in reporting performance, DQA readiness, DQA data consistency, and accuracy based on assigned scores. The template was shared with PMI for review and feedback. It has proven useful in providing detailed information without the need to log in to MSDQI. The template will prove useful in future data review meetings during which MSDQI results will be discussed by the NMCP and partners.

Planned for Q3

OMDM will continue updating and sharing these results as part of data use and decision making with PMI and respective partners, like Boresha Afya, as well as the NMCP and PO- RALG. With current GOT restrictions due to COVID-19, OMDM is exploring other avenues to engage with the NMCP and partners, including using Zoom to conduct data review meetings, keeping in touch with the SME Unit via phone and Skype, and providing as much support as possible remotely.

2.1.3 Activity 1A.3: Strengthen MoHCDGEC and NMCP outbreak response capacity

Support the MoHCDGEC/NMCP to define thresholds and triggers indicating malaria outbreak, including implementing them as predictors and automated notifications in eIDSR and DHIS2 and continuously monitoring and analyzing malaria data in the national DHIS2 system Progress in Y2, Q2

OMDM is currently working on two publications focused on eIDSR. The first examines the history and scale-up of eIDSR and will be developed into its own manuscript. The second is a continuation from an assessment conducted in Y1, reviewing the reporting and case comparison between eIDSR and DHIS2 at different strata. An initial draft sent to PMI was reviewed and feedback received in March 2020 for consideration to improve the draft. OMDM is working to incorporate these recommendations and finalize the publication.

CBS

OMDM continued to support the NMCP with CBS activities. CBS will be implemented in areas with very low malaria endemicity as a strategy towards malaria elimination. Seventeen


councils from Arusha, Manyara, and Kilimanjaro regions will be involved in phase one implementation; other immediate regions include Njombe and Songwe. A workshop introducing CBS was conducted in Moshi in Q1. As a follow-on in Q2, the NMCP invited OMDM and other partners to Morogoro to continue with phase two of CBS preparations. From January 7–17, 2020, the Activity participated in the cleaning and entry of case-based data collected between November and December 2019, from the pilot regions of Arusha, Kilimanjaro, and Manyara. This pilot was initiated by the NMCP as part of gathering baseline data of malaria-positive cases diagnosed in the health facilities across the three regions, along with other characteristics such as age, location (ward, village, hamlet), and gender. Data were collected using specific malaria registers (Figure 7) introduced by the NMCP in those health facilities. After collecting the paper-based data, NMCP, with support from OMDM and other partners, initiated data entry and cleaning using a specifically designed Excel template.

Figure 7. Malaria register template used for data collection

Participants were divided into teams and each one assigned one region for data entry and cleaning. A major challenge was identifying hamlets and villages, as workers did not clearly capture this information, and it therefore took longer to verify some of the locations. Other observations were as follows:

• In some forms, a few parameters, such as location or name of health facility, were incomplete or missing entirely.

• Some paper-based forms listed new health facilities that had not been updated in DHIS2.

• Naming of the health facilities was incomplete and inconsistent; for example, it was difficult to determine whether what was written indicated the Leguruki Dispensary or Leguruki Lutheran Dispensary.

• Checking the type of malaria species (Pf and Pan) was confusing; some facilities checked both sections for a single patient outcome.

• Some villages within the catchment area did not include population data.

• Some forms mistakenly exchanged village and ward names.

• There was a lack of facility ownership in some of the health facilities; it was unknown whether they were government, faith-based organizations (FBO), or private facilities.

• Some health facilities did not provide ward information.

• Names of some villages or wards were not present in the National Bureau of Statistics Census list. Teams were unsure if they were newly identified wards and/or villages.


Following the data cleaning and entry exercise, gaps remain requiring follow-up with health facilities by the NMCP. Once complete, the NMCP will provide next steps to continue with this activity.

Planned for Q3

OMDM will continue to advance the eIDSR manuscripts and provide technical support to the NMCP on protocol development and other CBS-related activities.

ZANZIBAR

2.1.4 Activity 1B.1: Support ZAMEP to update and implement the malaria surveillance strategy

Coordinate malaria surveillance and response system strengthening efforts through the Malaria Surveillance TWG Progress in Y2, Q2

In Q2 ZAMEP focus was mainly in addressing the spike in malaria prevalence and the development of the GF concept note which was preceded by MTR hence it was not possible to have the surveillance TWG initiated. OMDM has already held discussions with ZAMEP management to highlight the importance of this TWG and will work to revive these meetings in Q3.

Planned for Q3

Work with the ZAMEP to finalize the TORs and initiate meeting the first meeting virtually upon agreement with the program

Strengthen public and private sector facility malaria diagnosis and treatment capacity Progress in Y2, Q2

Please see Annex 2 to review Q2 updates from ZAMEP.

Strengthen health facility and community-level SBCC capacity

Progress in Y2, Q2

Please see Annex 2 to review Q2 updates from ZAMEP

2.1.5 Activity 1B.2: Develop interoperability between key HIS Complete ongoing electronic interoperability efforts between MCN and DHIS2 to enable ZAMEP to compare, analyze, and visualize data from multiple sources in DHIS2, including the ability to automatically generate necessary program and data elements in DHIS2 Progress in Y2, Q2

The ongoing integration between Coconut and DHIS2 is 90% complete. Key tasks completed in Q2 include the following:

• harmonization of the shehias in DHIS2 and Coconut;

• development of indicators in DHIS2 and linked in Coconut;

• configuration of scripts in Coconut to push data to DHIS2;

• migration of data from Coconut to DHIS2 using a web-based application programming interface (API);

• creation of dashboard in DHIS2 to visualize the data; and,


• testing of the integration process and replication to the live DHIS2 system.

All these tasks have been completed and data from Coconut successfully migrated from DHIS2 to the live system between April 2019 and April 8, 2020. The team continues to migrate data for previous years.

On March 13, 2020, OMDM presented the integration progress to ZAMEP’s management team by providing an explanation of the selected indicators, the flexibility the system offers to add indicators, and how to visualize data in DHIS2 for its use in decision making (Figure 8). ZAMEP was happy and suggested additional improvements to the indicators and requested access for its staff to begin regularly using the system.

Figure 8. Screenshot of DHIS2 interactive dashboard in live DHIS2 visualizing

malaria data from Coconut

Planned for Q3

In Q3 OMDM will continue with the process of migrating data from Coconut to DHIS2 and continue to improve the visualization in DHIS2. OMDM will also orient the ZAMEP SME team on how to use the dashboard.

Link Zanzibar’s Integrated Logistic System (ZILS) to DHIS2 to improve ZAMEP’s ability to monitor and manage the supply of antimalarial drugs, RDTs and insecticide- treated nets (ITNs) to health care facilities and districts Progress in Y2, Q2

No activities were conducted during the January–March 2020 reporting period.

Planned for Q3

In Q3, OMDM will work with ZAMEP’s HMIS and ICT Units to better understand the underlying database used by ZILS to track relevant indicators and explore how it may best be integrated within the DHIS2. OMDM will also explore the use of existing Malaria Dashboards developed using MCN data to house commodities and stock data.


2.1.6 Activity 1B.3: Enhance and strengthen MCN ICT architecture and sustainability

Improve MCN documentation for technical support and SOPs, transfer routine MCN technology support responsibilities to ZAMEP through mentoring, develop local MCN software development and support capacity, and transfer Tier 1 MCN software development and support responsibility to an identity identified by ZAMEP Progress in Y2, Q2

On March 6, 2020, four participants from the ICT and HMIS Units of MOHZ and one from ZAMEP’s ICT Unit were enrolled in online training courses on the MCN system. The five trainees (Table 6)—all who have a background in software programming—were enrolled in the following courses on UDEMY.com: Linux Mastery, Understanding CouchDB, Backbone JavaScript, and Coffee Script. These courses are useful to enhance their skills to understand and troubleshoot the backend of the MCN system.

Table 6. MOHZ and ZAMEP trainees

Participant Position ICT Unit, MOHZ HMIS Unit, MOHZ ICT Unit, MOHZ ICT Unit, MOHZ ICT Unit, ZAMEP

Participants are expected to complete the online courses by the end of Q3. and

, RTI’s Mobile Applications Developers also engage with participants weekly via Skype Group Chat. Trainees are assigned activities and exercises specifically related to improving their MCN knowledge and to practice their skills in managing the system to equip them with adequate skills to maintain, troubleshoot, and enhance key features as they progress through their training.

Additionally, MCN training materials have been finalized, including the MCN manual and others to be used in refresher trainings for CMSOs. Prior to orienting the CMSOs, OMDM will conduct MCN overview training for ZAMEP SME staff and the five participants listed in Table 6. Due to current GOT advisories on COVID-19 limiting travel and large gatherings, OMDM is exploring other avenues including conducting some of the trainings online.

Planned for Q3

Online MCN systems training will continue in Q3. OMDM will work with ZAMEP to identify the best way to conduct other MCN trainings for the SME Unit and CMSOs.

Add threshold settings and associated data visualizations and alerts to the MCN and new focal area screen-and-treat data collection forms and reports to improve ZAMEP’s ability to implement, monitor, and adjust this protocol Progress in Y2, Q2

In Q2, OMDM introduced a feature in the MCN system that automatically detects an abnormal increase in malaria cases at the health facility, district, and shehia levels based on existing threshold values set by ZAMEP. OMDM intends to engage with ZAMEP to understand if the current threshold settings still hold meaning or require updates.


Table 7. MCN detection

e

Planned for Q3

OMDM will work with ZAMEP to obtain feedback on threshold settings and determine who should receive notifications when an alarm is detected.

Continue to adapt and enhance MCN reports and data visualizations to meet emerging ZAMEP needs Progress in Y2, Q2

This is an ongoing activity; in Q2, OMDM continued adapting and enhancing MCN reports and data visualizations to meet emerging ZAMEP needs.

Planned for Q3

OMDM will continue this activity in Q3.

2.1.7 Activity 1B.4: Support MCN implementation Provide software technology and equipment support to CMSO Progress in Y2, Q2

This is an ongoing activity; in Q2, OMDM continued providing support to the MCN system and its software as required.

Planned for Q3

OMDM will continue this activity in Q3.

Continuously engage with ZAMEP and CMSOs to ensure that MCN is functional and data flow is adhered to in terms of timely collection and transfer of data, data completeness, and quality, and that reactive case follow-up occurs within stipulated time windows Progress in Y2, Q2

In Q2, OMDM continued engaging with ZAMEP and CMSOs to ensure MCN was functional. Data generated by MCN is reviewed at least weekly—if not daily—by OMDM. Anomalies observed in the data are raised with ZAMEP, and any action required to correct the data or the procedures for collection are discussed and implemented.

The various teams within ZAMEP also regularly check their data for issues. For example, a recent check in Pemba identified 16 duplicates. Initially, OMDM thought that this may be a problem with the Malaria Epidemic Early Detecting System (MEEDS) reporting duplicate cases and the MCN not detecting them. Upon further analysis, however, OMDM identified that the problem was caused by health facilities notifying the same case more than once. This is a known problem, and the MCN has code to automatically detect duplicates; however, it can only detect duplicates if the same name is used for the notification and if the notifications happen within 1 hour of each other. Upon investigation, it was identified that the reported duplicates were primarily different versions of the same name as shown in Table 7.

Name 1 vs. Name 2 Different spellings of the same name


When surveillance officers follow up on the case, they determine that these are duplicates.

OMDM has identified the following action items as a result of investigations into duplicates:

1) Discuss with health facilities that they should not resend notifications when a mistake is made with the patient's name; corrections can be made during follow-up by surveillance officers.

2) Notifications are sometimes submitted twice, as MEEDS does not always provide a timely confirmation. OMDM has continued to follow up with Selcom to try and identify the source of the problem. Selcom is still working on this.

3) Expand duplicate detection to 24 hours. 4) Create a new feature in MCN to mark cases as duplicates; this is in progress.

Other issues that OMDM has been assisting with:

• Tablets run out of disk space and cause the application to lose data. This issue is rectified by regular syncing and by limiting non-MCN activities on the tablet. The software team is looking at other ways to detect and avoid this problem.

• OMDM has made significant progress in updating and synchronizing organization unit names between MCN and DHIS2; however, there are still some issues with cases being assigned to the wrong surveillance officer due to these updates.

• Some cases are missing geocoordinate data; this is still being investigated.

• OMDM is investigating a report that the offline mode is not working for some surveillance officers.

• Questions were updated to make wording more precise (e.g., treatment -> prescription), to include additional options, and to update skip logic.

Planned for Q3

OMDM will continue providing support to ZAMEP via daily follow-up of MCN data and through ensuring system performance remains stable to facilitate data management.

Facilitate data use workshops to review, analyze, and interpret epidemiological and programmatic data reported through DHIS2 and MCN Progress in Y2, Q2

OMDM conducted a monthly data review meeting with the ZAMEP-SME team on March 13, 2020, in Zanzibar to review, analyze, and interpret programmatic data, specifically discussing updates on the comparison between MEEDS and MCN data, reviewing facility and household follow-up data collected in Q2, and discussing challenges faced by district malaria surveillance officers (DMSO) in the field (Table 8).

Table 8. Monthly data review meeting, March 13, 2020

Topic Key points/issues raised Actions Updates on data comparison (MEEDs vs MCN)

MEEDS and MCN data are not comparable because the MCN data use diagnosis data to allocate cases in their respective weeks while MEEDS data use the date of notification.

It was advised to use MCN as the main source of surveillance data and rely on MEEDS data only if MCN is not working.

Review on health facility and household follow-up data

• Facility and household follow- up data covering the period of

It was agreed that OMDM and the ZAMEP- SME team should meet with DMSOs to discuss and identify the causes of the low


Topic Key points/issues raised Actions January–March 2020 was

reviewed. • It was noted that 34%

(1,679/4,946) of the cases had not been followed up at the facility level and 56% (2,779/4,946) had not been followed up at the household level.

• In Unguja, Urban district had the highest number of cases 45% (834/1,858) that were not followed up at the facility level and 73% (1,357/1,858) were not followed up at the household level.

• In Pemba, Micheweni district had the highest number of cases 63% (199/317) that were not followed up at the facility level and 78% (246/317) were not followed up at the household level

follow-up rate, particularly in these two districts.

Challenges faced by DMSOs

• DMSOs faced difficulties when synchronizing their tablets.

• The tablets tend to be stuck when navigating from one questionnaire to the other.

• Some of the households were missing geo-coordinates

• A skip logic question regarding treatment on the household members questionnaire is not working properly in DMSOs’ tablets.

• This problem was due to low disk space in tablets; DMSOs were advised to remove all unnecessary programs from the tablets.

• This problem can be resolved by reinstalling the Coconut software in the tablets; by doing that all the data that had been entered will be discarded.

• All the households with missing geo- coordinates should be identified so that DMSOs can revisit the respective households.

• The skip logic question should be revisited, and any bugs should be identified.

• These two issues should be listed in the GitHub application and individuals assigned to follow up on the progress.

Planned for Q3

OMDM will schedule and conduct a monthly data review meeting with ZAMEP in Q3 using the Zoom application.

2.1.8 Activity 1B.5: Refine operational thresholds and triggers as MCN data are analyzed

Use MERLA approach to continuously support ZAMEP to assess sensitivity and specificity of thresholds and triggers, that change and adapt, as appropriate, to further increase interventions’ programmatic effectiveness Progress in Y2, Q2



Planned for Q3

No activities are planned for Q3.

Collaborate with ZAMEP, PMI, and stakeholders to update, as necessary, guidance and intervention strategies to prevent and respond to the emergency of case clusters at village or Shehia level Progress in Y2, Q2

In Q2, OMDM prepared a comprehensive Excel-based data dashboard that collates information from secondary cases followed up between January 2018 and January 2020. The data are disaggregated by district and shehias and can be viewed at annual, monthly, and weekly frequencies. The dashboard can be used to understand how many additional secondary cases were identified for each index case followed up at the household level. OMDM reviewed the data with PMI to understand whether the current reactive active case detection (ACD) done by CMSOs is sufficient or whether it warrants a widely targeted Pro- ACD that ZAMEP undertook in November 2019 following an abnormal increase of cases in some shehias of Unguja and Pemba. Pro-ACDs are resource intensive; if the additional cases found in the community are around the same level as routine active case detection, then it should not be considered a priority. For example, Kikwajuni Bondeni in Urban district was one of the targeted shehia in 2019 for pro-ACD because it reported a higher number of cases than in previous years. Of the 2,649 targeted, only 629 were tested for malaria, of which 16 (2.5%) were found malaria positive. In contrast, 58 index cases were followed up in the same shehia by the CMSO and 162 additional household members tested, of whom 8 (4.9%) were found positive. Even with a 70% follow-up rate of index cases by CMSOs in the Urban district, the additional secondary cases found positive in relation to those tested yielded higher malaria positivity compared with pro-ACD. Such information can prove useful for ZAMEP to decide on the best course of action.

Planned for Q3

OMDM will continue working on the analysis and inform ZAMEP how best to proceed when thinking of various approaches for ACD.

Conduct ACD and foci investigation Please see Annex 2 to review Q2 updates from ZAMEP.

2.1.9 Activity 1B.6: Develop strategy and implementation plan to minimize malaria importation

Continuously monitor and assess proportion of reported cases with a history of travel through the MCN system Progress in Y2, Q2

In Q2, OMDM worked alongside RTI’s Epidemiologist and Modeler, to analyze travel-related malaria data extracted from MCN for over 19,500 index cases in Zanzibar between January 2015 and January 2020. For each index case, sex, age, village coordinates, and travel history outside or within Zanzibar during the previous month were recorded. Spatio-temporal analysis was performed to identify the spatial heterogeneity of case reporting during transmission seasons and its correlation with rainfall from 2015 to 2020, while also investigating if the data indicated an increase of autochthonous cases.


Planned for Q3

The majority of the analysis is complete; in Q3, OMDM staff will continue finalizing the results. Once complete, OMDM will disseminate findings to ZAMEP and PMI.

Support the development of a strategy and implementation plan with PMI and other stakeholders that outlines approaches to target travelers leaving and returning to Zanzibar Progress in Y2, Q2


Planned for Q3

Activities will be initiated in Q4.

Implement selected approaches of the strategy and implementation plan as operational research (OR) studies Progress in Y2, Q2


Planned for Q3

Activities will be initiated in Q4.

2.2 Result 2: Entomological monitoring is improved 2.2.1 Activity 2.1: Compile and review entomological monitoring data Carry out a desk-based review of all entomological monitoring efforts in the past decade in Tanzania Progress in Y2, Q2

During this implementation period, OMDM compiled the Annual Entomological Surveillance Report for Zanzibar and the Mainland into one comprehensive report, submitted to USAID and PMI in March 2020.

OMDM initiated a desk-based review of entomological monitoring efforts in the Mainland and Zanzibar in Y1; these efforts continue in Y2. While supporting ZAMEP’s MTR from January 13 to 18, 2020, OMDM helped ZAMEP’s Entomology Unit finalize its annual entomological surveillance report. During a follow-up visit to ZAMEP on March 3, 2020, OMDM reviewed the compiled entomological surveillance data and helped the team develop two entomology- focused abstracts for the 2020 ASTMH annual meeting. The final compiled entomological surveillance data report is being converted into a publishable article and will be ready for USAID and PMI review in Q3.

OMDM hosted a meeting of the vector control TWG in the mainland from February 13 to 14, 2020. The key issues discussed in the meeting included the following:

• Update of entomological monitoring activities supported by OMDM including insecticide resistance monitoring.

• Update on MVES in 62 districts: This activity is financially supported by GFATM and PMI; OMDM provides technical support. The need to call a task force to review the data from the NMCP and NIMR Amani was once again raised in the discussion. OMDM will work with the NMCP and NIMR Amani to support the triangulation and analysis of the data and to write a comprehensive report of findings. Additionally, the


NMCP was advised to involve other available stakeholders to strengthen supportive supervision to districts undertaking this surveillance to ensure quality data.

• Update on vector control interventions in Tanzania such as IRS, reproductive and child health, school net program, long lasting insecticide nets and Larval source management (RCH)/MRC/SNP, LLIN distribution, and LSM.)

• Update on the drafted LSM monitoring and evaluation framework: The draft document was presented and input provided by the meeting participants. A task force was established to finalize the document under the leadership of the NMCP.

• Update on vector control database and analytical plan: The task force, led by OMDM, presented the progress in the development of entomological indicators for inclusion in a composite database, including a proposal to review PMI and WHO indicators for inclusion. To accelerate this activity, OMDM is liaising with the WHO’s headquarters (HQ) to explore the possibility of using the already-developed DHIS2 platform. OMDM had an in-person discussion with the WHO lead while in Geneva attending the RBM VCWG meeting on February 5, 2010. Communication with WHO HQ proceeded smoothly until COVID-19 swept through Europe. OMDM will continue to explore this option with WHO HQ while also working with the task force to finalize the set of indicators proposed during the vector control TWG meeting.

Planned for Q3

In Q3, OMDM will continue working with ZAMEP to develop a publishable article based on compiled entomological surveillance data. Additionally, OMDM will continue supporting the NMCP to finalize the entomological indicators for inclusion in the composite database based on recommendations from the vector control TWG and finalizing uploading entomology data into DHIS2.

Review entomological monitoring sites and their current operational and analytical capacity to successfully conduct entomological monitoring Progress in Y2, Q2

In Q2, OMDM continued to engage with NIMR Mwanza, NIMR Amani, ZAMEP, NMCP, and PMI/CDC to review the sentinel sites for entomological monitoring to align with the current malaria situation in Tanzania as well the existing vector control interventions. NIMR Amani was asked to drop DDT in the list of insecticides to be tested in 2020 and to increase the number of sites to include monitoring the performance of PBO-LLINs using WHO papers. Entomological monitoring continued in all routine sites that were agreed to early in 2019. The current entomological monitoring sites in the mainland were endorsed by the vector control TWG.

Planned for Q3

In Q3, OMDM will support orientation of ZAMEP’s entomologists to use MCN, including training on data collection forms. Conduct an IRS impact evaluation study Progress in Y2, Q2

During this implementation period, OMDM continued to develop the protocol to conduct an impact analysis of IRS in Tanzania’s Lake Zone and Zanzibar initiated in Q1.


Planned for Q3

In Q3, OMDM will finalize the IRS impact analysis protocol and present it to the NMCP and ZAMEP for approval. Once approved, OMDM will lead data collection activities aligned with the protocol and will present initial findings from the IRS impact analysis to the NMCP and ZAMEP vector control TWGs for feedback.

Provide TA to NMCP for entomological monitoring and data analysis Progress in Y2, Q2

In Q2, OMDM discussed with the NMCP and in the vector control TWG the modalities to review, triangulate, and analyze GFATM’s MVES data.

Planned for Q3

OMDM will provide TA to the NMCP to perform MVES data triangulation, analysis, and report writing.

2.2.2 Activity 2.2: Conduct entomological monitoring planning and implementation

Entomological surveillance, including Anopheles mosquito vector distribution, density, seasonality, biting behavior, human blood index, sporozoite rate, and entomological inoculation rate (EIR) Progress in Y2, Q2

OMDM continued to help NIMR Mwanza and ZAMEP conduct entomological monitoring in mainland Tanzania and Zanzibar. Summary data for Y2, Q2 is reported below.

NIMR MWANZA

In Q2, NIMR Mwanza continued entomological monitoring activities across ten sites; six of them are located in districts where IRS is being conducted, while four are in districts where IRS is not taking place (control sites). One village in each district was randomly selected, and two households within the village were selected for monthly mosquito collection. Monthly mosquito collections were conducted using CDC light traps, clay pots, Prokopack aspirators, and CBR in all selected villages and households.

A total of 15,045 female Anopheles mosquitoes were collected by all collection methods outlined above between January and March 2020 in the six IRS and four unsprayed districts. Of these, 13,310 (88.47%) were morphologically identified as An. gambiae s.l. and 1,735 (11.53%) as An. funestus s.l. A total of 7,787 (51.8%) female Anopheles mosquitoes were collected using CDC light traps, 3,551 (23.6%) by CBR, 2,200 (14.6%) by Prokopack aspirator, and 1,507 (10.0%) by clay pots. An. gambiae s.l. was the abundant vector species sampled by all collection methods in each IRS district.

Identification of species by PCR showed the local vector population across sites to be predominantly An. arabiensis (38.7%), An. gambiae s.s. (36.2%), An. funestus (18.7%), and An. parensis (0.4%). Of the PCR-processed samples, 6% were not amplified using An. gambiae s.l. and An. funestus s.l. primers (Table 9). An. arabiensis was identified as the abundant species in most IRS districts except in Kibondo DC, Kasulu TC, Ukerewe DC, and Muleba DC. There was a higher abundance of An. funestus s.s. in Muleba, an unsprayed site. An. parensis was found in Geita DC and Muleba.

Sporozoite rates varied across the sites ranging from 0% to 2.6% in sprayed sites and 0% to 9.4% in unsprayed sites. Sprayed site Kasulu DC registered the highest sporozoite rate (2.6%). The unsprayed site Geita DC recorded the highest sporozoite rate of 9.4%.


Generally, there was a decrease in indoor biting rates in all sprayed sentinel sites. Higher mean bites per person per night with An. funestus s.l. were detected pre-IRS despite the imperceptible differences in number of indoors and outdoors An. gambiae s.l. and An. funestus s.l. in sprayed districts.

As expected, unsprayed sentinel sites recorded the highest number of mosquitoes (An. gambiae s.l. and An. funestus s.l.) resting indoors when compared with the sprayed sites. An. gambiae s.l. dominated both sprayed and unsprayed sites.

Higher mean bites per person per night with An. funestus s.l. pre-IRS was noted despite unnoticeable differences in number of indoors and outdoors An. gambiae s.l. and An. funestus s.l. before and after IRS in sprayed districts. Among the four previously sprayed districts—Kakonko, Kibondo, Kasulu DC, and Biharamulo—it was recorded that five months post-IRS, indoor resting density decreased in all districts with the exception of Kakonko. There were higher observed trends of indoor resting density in non-IRS districts with Muleba as the lead during the monitoring period.


Table 9. Results on species identification by PCR and sporozoite ELISA results in sprayed and nonsprayed districts

SPECIES ID BY PCR ELISA

DISTRICT Number (N) tested

An. gambiae s.s. (%)

An. arabiensis (%) An. funestus (%) An. parensis

(%) Negative (%) Total tested

Number positive

Sporozoite rate (%)

SPRAYED SITES

Biharamulo 97 30 (30.9)

45 (46.4)

16 (16.5)

3 (3.1)

3 (3.1) 97 0 0

Kasulu DC 39 1 (2.6)

31 (79.5)

5 (12.8)

0 (0)

2 (5.1) 39 1 2.6

Kibondo 122 68 (55.7)

31 (25.4)

12 (9.8)

0 (0)

11 (9) 122 0 0

Kakonko 454 64 (14.1)

271 (59.7)

54 (11.9)

10 (2.2)

55 (12.1) 454 0 0

Total (Sprayed sites) 712 163

(22.9) 378

(53.1) 87

(12.2) 13

(1.8) 71

(10) 712 1 0.1

UNSPRAYED SITES

Bunda 513 151 (29.4)

325 (63.4)

1 (0.2)

0 (0)

36 (7) 651 0 0

Muleba 848 385 (45.4)

38 (4.5)

408 (48.1)

0 (0)

17 (2) 938 20 2.1

Geita 64 8 (12.5)

16 (25)

28 (43.8)

1 (1.6)

11 (17.2) 64 6 9.4

Kasulu TC 292 171 (58.6)

94 (32.2)

20 (6.8)

0 (0)

7 (2.4) 292 8 2.7

Bukombe 281 4 (1.4)

254 (90.4)

22 (7.8)

0 (0)

1 (0.4) 281 0 0

Ukerewe 456 263 (57.7)

120 (26.3)

25 (5.5)

0 (0)

48 (10.5) 582 3 0.5

Total (Unsprayed sites) 2,454 982 (40)

847 (35.5)

504 (20.5)

1 (0)

120 (4.9) 2,808 37 1.3

Total (All sites) 3,166 1,145

(36.2) 1,225 (38.7)

591 (18.7)

14 (0.4)

191 (6) 3,520 38 1.1

USAID Okoa Maisha Dhibiti Malaria (OMDM) Activity, Year 2, Quarter 2 Performance Report

33

33

ZAMEP

In Q2, ZAMEP continued routine entomological monitoring in ten sentinel sites in Zanzibar. The detailed outcome of this activity is included in Annex 2.

Planned for Q3

The following entomological activities will continue in Q3:

• Continue observing indoor biting rates using CDC light traps through the collection of mosquitoes for 14 nights during 2 consecutive weeks each month. NIMR Mwanza and ZAMEP will survey two different houses per night.

• NIMR Mwanza will continue monitoring outdoor biting rates using CBR, including sampling on nights near the new moon.

• NIMR Mwanza and ZAMEP will continue monitoring malaria vector feeding time and location using CBR/HLC, with mosquitoes collected on 10 days of the lunar month.

• On a monthly basis, continue determining mosquito indoor and outdoor resting densities using Prokopack aspiration (NIMR Mwanza) or PSC (ZAMEP).

• NIMR Mwanza and ZAMEP will continue Identifying species of mosquitoes via laboratory analysis, including determining sporozoite rates and blood meal type.

• NIMR Mwanza and ZAMEP will continue conducting periodic quality assurance (QA) checks for species identification.

• NIMR Mwanza will conduct molecular sequencing on unidentified mosquitoes for species determination.

QA and insecticide residual efficacy monitoring following IRS Progress in Y2, Q2

NIMR MWANZA

In Q2, NIMR Mwanza conducted cone bioassays to determine the residual efficacy of the insecticides sprayed on different wall surfaces inside houses in Biharamuro, Bukombe, and Ukerewe following the IRS campaign using Clothianidin; similar bioassays were conducted in Kibondo, Kakonko, and Kasulu, which were sprayed with pirimiphos methyl (Actellic® 300CS). WHO wall cone bioassays were conducted monthly with laboratory susceptible An. gambiae s.s. (Kisumu strain) on different wall surfaces reflecting those most typically found in the communities surveyed—mud oil- or water-painted, lime-washed, unplastered cement blocks, stock blocks—sprayed with either pirimiphos-methyl or clothianidin. Five months after spraying with Clothianidin (in Biharamulo) and Actellic® 300CS (in Kakonko, Kibondo, and Kasulu DC), all surfaces retained effective insecticide residual efficacy. One month after spraying Clothianidin in Bukombe and Ukerewe, all surfaces also effectively retained the insecticide.

ZAMEP

In Q2, wall cone bioassays were conducted in shehias in IRS districts in Zanzibar. The detailed outcome of this activity is included in Annex 2.

Planned for Q3

In Q3, NIMR Mwanza and ZAMEP will continue performing cone bioassays to evaluate spray quality and monitor insecticide decay rates for all IRS-treated sites.


Insecticide resistance testing Progress in Y2, Q2

During this implementation period, OMDM continued helping NIMR Amani complete preparatory activities for insecticide resistance monitoring in 2020. OMDM worked with NIMR Amani to finalize the procurement of field and laboratory entomological equipment and supplies required for the activity.

The planned refresher training for laboratory, scientific, and vector control staff involved in insecticide resistance monitoring activities has been rescheduled to May due to COVID-19.

Planned for Q3

In Q3, OMDM will support NIMR Amani to conduct refresher trainings for laboratory, scientific, and vector control staff involved in insecticide resistance monitoring activities and to undertake insecticide resistance monitoring in the field. NIMR Amani is expected to conduct this via TOT and cascade training.

Species identification using PCR Progress in Y2, Q2

This activity was not planned for this quarter.

Planned for Q3

Molecular analysis of mosquito samples using PCR follows the completion of field insecticide resistance testing. This activity for NIMR Amani is expected to start in Q3. Maintain Anopheles colony in NIMR Mwanza and ZAMEP insectaries Progress in Y2, Q2

Both NIMR Mwanza and ZAMEP continued maintaining their An. gambiae s.s. colonies (Kisumu strain) in Q2. Production of adult mosquitoes continued to be maintained to meet the required demands for IRS quality assessment and residual efficacy testing.

Planned for Q3

In Q3, NIMR Mwanza and ZAMEP will continue maintaining their insectaries.

2.2.3 Activity 2.4: Provide equipment and supplies for entomological monitoring

Progress in Y2, Q2

Throughout Q2, OMDM continued working with vendors and freight forwarders to ship entomological monitoring equipment, supplies, and reagents to NIMR Mwanza, NIMR Amani, and ZAMEP. Most of the items procured on behalf of subrecipients have been shipped and received by each partner; the few outstanding items continue to be delayed due to the impact of COVID-19 on international shipping.

Planned for Q3

In Q3, OMDM will continue working with RTI’s home office logistics team to coordinate shipment of the final materials and supplies to partners in Tanzania.


2.2.4 Activity 2.5: Entomological investigation and response in hot spot areas/active foci (Zanzibar only)

Progress in Y2, Q2

Details related to ZAMEP’s entomological investigations and responses in hot spot and active foci areas can be found in Annex 2.

2.2.5 Activity 2.6: Capacity building of new entomological field team in new emerging hot spots (Zanzibar only)

Progress in Y2, Q2

No activities were conducted during this reporting period.

Planned for Q3

Hands-on training of the entomological field staff on foci/hot spot investigation is planned for Q3 if COVID19 restrictions are lifted.

2.2.6 Activity 2.7: Strengthen national malaria vector control strategies, policies, and guidelines

Engage with the respective subcommittees and TWGs Progress in Y2, Q2

OMDM hosted the vector control TWG meeting in the mainland on February 13–14, 2020, as described in section 2.2.1 in key achievements table. Additionally, OMDM initiated discussions with ZAMEP to create a vector control TWG in Zanzibar.

Planned for Q3

In Q3, OMDM will support NMCP’s vector control TWG meeting in addition to working with ZAMEP to develop the ToR for a vector control TWG for Zanzibar.

Review and update relevant policy and technical guidelines Progress in Y2, Q2

The MPR field validation team in the Kigoma region. Photo credit by OMDM Activity, RTI International.

In Q2, OMDM helped both the NMCP and ZAMEP review progress against their current MSPs. The NMCP’s MPR was conducted from March 2– 20, 2020; ZAMEP’s MTR was conducted from January 13–18, 2020. Both events comprehensively analyzed the malaria situation and program performance against indicators approved in the strategic plan. Findings from both reviews and lessons learnt were used to

suggest revisions to the strategic plans to maximize successes, leverage missed opportunities, and establish goals for future implementation in Zanzibar and develop a new


strategic plan in the mainland. Once complete, MTR and MPR will be used to inform GOT, development partners, and stakeholders on implementation progress and help to set or reset the malaria agenda in the short, medium, and long term.

Planned for Q3

In Q3, OMDM will continue supporting both the NMCP and ZAMEP in the revisions to and development of their national MSPs. Technical assistance (TA) will continue to be provided to the NMCP to develop their concept note to the GFATM using the revised strategic plan. Additionally, OMDM will present the finalized LSM operational tool to ZAMEP’s management team for feedback.

Provide financial and logistic support to disseminate updated guidance documents Progress in Y2, Q2


Planned for Q3

The NMCP High Burden to High Impact (HBHI) report was scheduled to be launched in Q3 alongside new NMCP MSP 2021–2023 during World Malaria Day. The official launch was postponed due to COVID19 restrictions.

2.3 Result 3: Drug efficacy monitoring is improved

2.3.1 Activity 3.2: Plan, monitor, and implement TES Mainland Tanzania: Plan, monitor, and implement TES Progress in Y2, Q2

TES 2020

During this implementation period, OMDM finalized the FAA with CUHAS and helped it initiate TES 2020, including the review of SOPs and other study documents and signing of subagreements with TES implementing institutions including IHI, NIMR Tanga, KCMC, and MUHAS. On March 5, 2020, CUHAS conducted a planning meeting to update participating institutions on TES 2020 preparation and to discuss implementation plans. Training and site initiation is tentatively scheduled for April 18, 2020, in Mlimba; subsequent study initiation dates are indicated in Table 10. However, TES 2020 will only be initiated when the COVID- 19 situation normalizes.

Table 10. TES 2020 study initiation sites and dates

Site name Mlimba Yombo Mkuzi Ujiji Tentative site initiation and training dates

18/4/2020– 24/4/2020

26/4/2020– 2/5/2020

9/5/2020– 15/5/2020

23/5/2020– 29/5/2020

OMDM also continued to support MUHAS conduct data analysis, interpretation, and dissemination of TES 2019 results in Q2. MUHAS analyzed TES data and disseminated the results to malaria control stakeholders on March 4, 2020, in addition to formally handing over the coordination of TES 2020 to CUHAS.


TES 2019

In 2019, TES was implemented in four outpatient health facilities, as follows—Ipinda (Mbeya region), Igombe (Mwanza region), Nagaga (Mtwara region), and Simbo (Tabora region). The aim of TES 2019 activities was to assess the efficacy and safety of ALu, the first line ACT for uncomplicated malaria in Tanzania. In 2019, children aged 6 months to 10 years with microscopy-confirmed uncomplicated P. falciparum malaria who met the inclusion criteria** based on the WHO protocol were recruited at four health facilities. Children were treated with ALu twice daily for 3 days and followed up on days 3, 7, 14, 21, 28, and on any day of recurrent illness for clinical and parasitological assessments. Blood was also collected on Whatman filter paper on day 0 and at the time of recurrent infection for PCR analysis. The primary outcome measure was PCR-corrected ACPR on day 28.

A total of 628 children were screened; of these, 349 (55.6%) were enrolled, and 343 (98.3%) completed 28 days of follow-up and/or attained the treatment outcomes according to the protocol. The 2019 study results show that there was no early treatment failure. However, LCF occurred in 20 (5.7%) patients, and late parasitological failure occurred in 34 (9.7%) patients. The day 28 PCR-uncorrected ACPR ranged from 73.9% at Igombe (Mwanza) to 90.9% at Ipinda (Mbeya). PCR-corrected cure rates were high (>98%) at all four sites. There were 54 (15.5%) recurrent infections, with the majority (72.2%) occurring in Igombe (Mwanza) and Simbo (Tabora) located in zones with high malaria burden (Table 11). The drug was well tolerated, and no serious adverse events were reported. The most commonly reported adverse event was cough, experienced by 7% of enrolled patients (Table 12).

These findings suggest that ALu is still highly efficacious and well tolerated with minimal adverse events in Tanzania. Recurrent malaria infections were more common in areas located in regions with higher prevalence.

Table 11. Parasitological and clinical outcomes of enrolled patients

Outcomes Karume (n = 88)

Simbo (n = 88)

Ipinda (n = 88)

Nagaga (n = 85)

Total (n = 349)

PCR Uncorrected ACPR 65

(73.9) 67

(76.1) 80

(90.9) 77

(90.6) 289

(82.8) LCF 10

(11.3) 6

(6.8) 2

(2.3) 2

(2.3) 20

(5.7)

Official handing over of TES coordination from MUHAS to CUHAS (left) being witnessed by WHO, PMI/USAID and NMCP officials and a group photograph (right) of all TES principal investigators from KCMC, IHI, NIMR Tanga, CUHAS, and MUHAS in the presence of NMCP, WHO, and PMI/USAID officials. Photo credit by OMDM Activity, RTI International.


Outcomes Karume (n = 88)

Simbo (n = 88)

Ipinda (n = 88)

Nagaga (n = 85)

Total (n = 349)

Late parasitological response (LPF)

13 (14.8)

10 (11.4)

5 (5.7)

6 (7.1)

34 (9.7)

Lost to follow-up - 3 (3.4)

- - 3 (0.9)

Withdrawn - 2 (2.3)

1 (1.1)

- 3 (0.9)

PCR corrected ACPR 65

(98.5) 67

(98.5) 80

(98.7) 77

(98.7) 189

(98.3) LCF 1

(1.1) 0

(0) 0

(0) 0

(0) 1

(0.3) LPF 0

(0) 1

(1.2) 1

(1.2) 1

(1.2) 3

(0.9) Total analyzed 66 68 81 78 293 New infection 21

(91.3) 15

(93.7) 5

(71.4) 7

(87.5) 48

(88.9) Nondeterminant 1

(1.1) 0

(0) 1

(1.2) - 2

(0.6) Table 12. Adverse events reported

Adverse event Frequencies Percent Cough 24 52.2 Anemia 11 23.9 Abdominal pain 2 4.3 Pain micturition 2 4.3 Allergic dermatitis 1 2.2 Difficulty breathing 1 2.2 Itchy genital area 1 2.2 Rectal prolapse 1 2.2 Urinary tract infection 1 2.2 Vomiting 1 2.2 Chest wound 1 2.2 Total 46 100

** Inclusion criteria included: mono-infection of P. falciparum detected by microscopy, parasitaemia between 250 and 200,000 P. falciparum asexual forms/µl of blood, history of fever during the past 24 hours or fever at presentation (axillary temperature ≥ 37.5 0C), ability to swallow oral medications, and willingness to attend scheduled follow-up visits.

Planned for Q3

OMDM will continue to support CUHAS and other implementing partners with TES 2020 activities throughout Q3.

Enter all historical and future clinical data in a DHIS2 database Progress in Y2, Q2

Current and historical TES data has been entered into a composite database. Dashboards have been developed and are awaiting approval from MoHCDGEC’s ICT Unit; they will then


be linked with the DHIS2 database. This was further discussed in the TES taskforce meeting; the NMCP agreed to follow up on the outstanding approval from the ICT Unit.

Planned for Q3

OMDM will continue working with the NMCP to seek approval from MoHCDGEC’s ICT Unit; once received, OMDM will begin linking the TES composite database and all dashboards with DHIS2.

Review TES sites and their current operational and analytical capacity to successfully conduct TES Progress in Y2, Q2

TES 2020 is underway in the Mlimba, Ujiji, Mkuzi, and Yombo sites.

Planned for Q3

Continue with implementation of TES 2020 and molecular analysis of TES 2018 and 2019 samples upon arrival of reagents.

2.3.2 Activity 3.3: Provide equipment and supplies for TES Enter all historical and future clinical data in a DHIS2 database Progress in Y2, Q2

In Q2, OMDM continued to facilitate the procurement of reagents and supplies for NIMR Tanga’s molecular analysis of samples from TES 2018, 2019, and 2020. Unfortunately, due to the COVID-19 pandemic, the shipping of materials and supplies to NIMR Tanga is delayed.

Planned for Q3

OMDM will continue working with RTI’s shipping and logistics department to push to get the supplies to NIMR Tanga as soon as possible.

2.3.3 Activity 3.5: Strengthen national malaria case management strategies, policies, and guidelines

Engage with the respective subcommittees and TWGs Progress in Y2, Q2

OMDM supported the TES TWG meeting held from March 4 to 5, 2020, including participants and stakeholders from OMDM, NMCP, MUHAS, IHI, NIMR Tanga, KCMC, PMI, USAID, and CDC. Over the course of the 2 days, participants were informed of the results from the TES 2019 and worked together to plan for the TES 2020 implementation. Additional details are described in section 2.3.1.

OMDM also continued to help NIMR Tanga conduct molecular analysis of TES 2018 and 2019 samples. Unfortunately, this analysis has been delayed as reagents and supplies have not yet arrived due to shipping disruptions caused by the COVID-19 pandemic.

Planned for Q3

In Q3, OMDM will continue working with RTI’s shipping and logistics department to push to get the reagents and supplies to NIMR Tanga to finalize molecular analysis of samples from TES 2018 and 2019. Additionally, OMDM will help NIMR Tanga conduct training on molecular analysis of samples for technical staff from TES partner institutions.


2.4 Result 4: GOT’s evidence-based decision making is improved 2.4.1 Activity 4.1: Strengthen Tanzania’s capacity for state-of-the-art (SOTA)

analysis and interpretation of surveillance, entomological, and drug efficacy data

Provide and/or support attendance of short courses Progress in Y2, Q2

The Activity has identified potential short courses for interested applicants from the NMCP and ZAMEP. The Swiss Tropical and Public Health Institute (Swiss TPH) malaria course originally scheduled for April and the Field Epidemiology and Laboratory Training Program (FELTP) training scheduled for the first week of March were both postponed due to COVID- 19 restrictions; OMDM will continue to track the timeline of both trainings for interested participants.

Planned for Q3

The NMCP has been asked to select one person to participate in the Ghana Measure Evaluation SME course at the end of June or early July in anticipation that travel restrictions will have been lifted.

Support for FELTP trainees Progress in Y2, Q2

No activities were conducted during the January–March 2020 reporting period as the FELTP course has been delayed due to the COVID-19 pandemic.

Planned for Q3

OMDM will support FELTP trainees as the training is reinitiated once COVID-19 restrictions have been lifted.

Hold scientific stature/data analysis workshops Progress in Y2, Q2

No activities were conducted during the January–March 2020 reporting period due to the COVID-19 pandemic.

Planned for Q3

OMDM will reinitiate scientific stature and data analyses workshops in Q3 once COVID-19 restrictions have been lifted.

Mentor and coach MoHCDGEC/NMCP and MOHZ/ZAMEP staff Progress in Y2, Q2

As highlighted under result areas 1 and 2, OMDM staff continuously engage with the NMCP and ZAMEP through the mentoring, coaching, and one-on-one engagement of team members, staff secondment in Zanzibar, regular OMDM staff presence in the NMCP’s offices, and TA in various TWGs and meetings.

Planned for Q3

OMDM will continue mentoring and coaching activities for NMCP and ZAMEP staff. In Q3, OMDM is actively pursuing the placement of a full-time staff position with the NMCP in Dodoma. A job description is under development and will be discussed further with the NMCP, USAID, and PMI stakeholders.


2.4.2 Activity 4.2: Conduct SOTA analysis and interpretation of surveillance, entomological, and drug efficacy data

Progress in Y2, Q2

Working with the NMCP and ZAMEP, OMDM continues to identify various areas for further analysis and interpretation of epidemiological and entomological data. In Q2, OMDM continued to support data management and analysis. Examples follow:

• Working with the NMCP, OMDM jointly prepared for a data review meeting by downloading and reviewing the indicators before the meeting with the larger team.

• OMDM provided PMI with a monthly summary of the malaria situation in the regions and councils of mainland Tanzania.

• OMDM, with the NMCP, developed the 2019 Annual Malaria Bulletin, Issue 9, working directly with the SME unit in Dodoma on the data analysis and to prepare the relevant charts, tables, maps, and draft sections of the Bulletin.

• With ZAMEP, OMDM worked on secondary analysis of malaria cases and incidence at the shehia level.

Planned for Q3

• Continue working with NMCP to conduct data review meetings

• Continue working with ZAMEP on secondary analysis of malaria cases

2.4.3 Activity 4.3: Disseminate OMDM results through various channels Provide regular updates on SOTA analyses Progress in Y2, Q2

OMDM, in collaboration with the NMCP, conducted two data review meetings as highlighted under result area 1. OMDM also supported the NMCP finalize and disseminate the 2019 Annual Malaria Bulletin, Issue 9 on February 21, 2020. OMDM supported ZAMEP with key data analysis following reports of abnormal increases in 2019 malaria cases, particularly between January to March 2020 period. Data was analyzed from MEEDS and MCN to review trends over the last three years. OMDM also acquired weekly rainfall data and plotted it against malaria cases to help ZAMEP understand how rainfall patterns impacted changes in malaria transmission. Shehia-level analysis also showed different patterns—especially for the Urban district—over the last three years. Other information from MCN, such as self- reported use of LLINs, history of IRS, and case management, was also analyzed. Findings were disseminated by ZAMEP to PMI and partners in a meeting on January 31, 2020, to help identify response strategies.

Planned for Q3

In partnership with the NMCP and ZAMEP, OMDM will continue to provide support in the analysis of routine malaria data, including entomological data.

Support drafting and disseminating programmatic updates Progress in Y2, Q2

OMDM supported the NMCP, ZAMEP, and NIMR Amani develop abstracts for the 2020 ASTMH conference. Through this international forum, the programs will be able to disseminate malaria control and elimination activities to a wider audience. The list of abstracts follows:


1) Trends of Insecticide Resistance and Its Implications on Malaria Control in Tanzania,

2) Continued Efficacy of Primiphos-Methyl (Actellic 300CS) for Indoor Residual

Spraying in Areas with High Malaria Vector Resistance to Pyrethroids in Zanzibar,

3) Surveillance of Efficacy and Safety of Artemether-Lumefantrine for the Treatment of Uncomplicated Falciparum Malaria in Mainland Tanzania,

4) Assessment of the residual effectiveness of resistant malaria vectors in North-Western

5) Factors associated with clustering of malaria cases within the index case households and neighborhood households in Zanzibar.

6) Improving malaria data quality for programquality audits in Mainland Tanzania, 2019.

7) Factors Associated with Long-Lasting Insecticidal Detected Malaria Cases in Zanzibar, 2012-20

Planned for Q3

OMDM’s Communications Plan was approved by USAID in Q2; in Q3, OMDM will begin implementing activities specified in the plan.

Develop policy and advocacy briefs No activities are planned for Y2.

Attend national, regional, and international conferences and workshops Progress in Y2, Q2

In Q2, OMDM attended the 15th Annual Meeting of the RBM VCWG meeting in Geneva, Switzerland, from February 3 to 5, 2020. This working group promotes research and development of new tools and the translation of vector control priorities into OR, combining inputs from its constituency of national and international academia, research, and private- sector development partners. It provides a forum where all the constituencies can come together to build consensus on the challenges, gaps, and opportunities in vector control. In


the February 2020 meeting, presented a poster entitled “Increasing Insecticide Resistance in Malaria Vectors of the An. gambiae Complex in Tanzania.”

Planned for Q3

As noted above, OMDM provided technical support to key implementing partners to develop abstracts for submission to ASTMH’s annual meeting. In Q3, OMDM will work with USAID and PMI to obtain abstract approval and ensure submission for consideration by ASTMH’s planning committee.

Manuscript submitted for peer review Progress in Y2, Q2

In Q2, OMDM developed a plan of action for proposed manuscripts. With support from RTI’s HQ and the MERLA team, OMDM developed a list of titles, estimated timelines for their publication, and lead authors who will coordinate writing; this plan was shared with PMI. OMDM also created a SharePoint site so that all authors and contributors are kept up to date and have access to required resources. OMDM has conducted Skype calls every two weeks with and to keep the team focused on ensuring we are working towards stated timelines to finalize the manuscripts.

Planned for Q3

OMDM will continue collaborating with RTI’s key technical experts to continue manuscript development in Q3.

Success stories Progress in Y2, Q2

In this quarter, OMDM identified a success story through the data review meetings with the NMCP and PO-RALG, which have proven to be successful and appreciated by all participants. The draft success story is currently under development.

Planned for Q3

OMDM will finalize and submit the draft success story on the data review meetings with the NMCP and PO-RALG in Q3. OMDM will continue to identify additional success stories to further publicize OMDM successes, aligned with the goals of the Activity’s Communications Plan.

2.4.4 Activity 4.4: Implement Learning Agenda Progress in Y2, Q2

On March 27, 2020, the OMDM field and home office teams met virtually for the quarterly Pause and Reflect session. , led the session attended by who recently joined RTI’s Global Health Division as the Infectious Disease Director). The goal of this session was to review the Activity’s Learning Agenda and proposed OR studies recently sent to PMI for review. The following are general highlights from the internal discussion:

• The team discussed the unfolding COVID-19 crisis and OMDM’s close work with RTI to ensure business continuity and plan for changes to the workplan; monitoring, evaluation, and learning (MEL) plan; and other operations.

• There was no time to review the theory of change (ToC) and Results Framework during this session, but the OMDM team plans to hold an external Pause and Reflect


session with USAID, NMCP, ZAMEP, and other partners and stakeholders at the earliest possible date once COVID-19 restrictions have been lifted.

• reviewed the MEL plan to discuss potential effects of COVID-19 and the effect on staff and partners’ ability to travel and work together in person. They will work on revising indicators and targets as needed to present to USAID.

• Analyses and Assessments: 1) eIDSR analysis: draft currently under development with Jeremiah Ngondi; 2) Mortality Rate Study: met with FELTP, PMI, and NMCP on March 27 to go through desk review; 3) Patterns of Case Notification: Shabbir is working on a manuscript from the ASTMH presentation; 4) Spatial Epidemiology: currently underway, led by ; 5) Community Engagement: OMDM is providing support to (ZAMEP).

• Potential OR studies: OMDM reviewed three potential OR studies sent to PMI earlier in fiscal year (FY)20: 1) RDT sensitivity, 2) mass drug administration (MDA) efficacy, and 3) travel between Zanzibar and the mainland. is revising the Activity’s concept note, combining 1 and 2. OMDM will recirculate revised OR studies to PMI on 27th April 2020

Planned for Q3

In Q3, OMDM will continue implementing the Activity’s Learning Agenda and focus on revising the OR concept note in addition to continuing work on the analysis and assessments described above.

3. Implementation Challenges OMDM’s implementation activities experienced minimal challenges in Y2, Q2, as detailed in Table 13.

Table 13. OMDM implementation challenges

Implementation challenge

Context

COVID-19 The COVID-19 pandemic has impacted implementation of OMDM activities as described throughout the narrative. OMDM staff members are working from home to respect social distancing guidelines and maintain the health and safety of the team. GOT restrictions on the size of gatherings have impacted events and trainings planned by OMDM staff and partners. Domestic and international travel restrictions have limited movement within and to/from Tanzania. Insecticides resistance monitoring data collectors training had to be rescheduled and modalities of training changed. Shipping of entomological and TES materials and supplies are significantly delayed due to international flight cancellations and restrictions in other countries where items are manufactured. OMDM continues to monitor the situation closely and remains committed to working closely with USAID and RTI’s home office if further impacts to implementation are realized.

4. Gender Considerations OMDM ensured gender integration in implementation of all activities during the reporting period. Please see Annex 1 to review OMDM’s progress on the performance indicators specified in the MEL plan.


5. Environmental Compliance TES continues at four study sites (health facilities) as detailed under Result 3. Teams observe the personal protective equipment (e.g., laboratory coats and gloves) and use of sharps and biological sample waste bins for disposal of needles, test kits, and slides during supervision visits to TES sites as per MoHCDGEC medical waste disposal procedures. Site supervision checklists include components for monitoring waste disposal procedures.

6. MEL Plan: Progress on OMDM Performance Indicators OMDM’s Performance Indicator Summary Table is attached as Annex 1. The table includes reporting on indicators for which quarterly updates are required. Annual and periodic indicators will be updated as proposed in OMDM’s MEL plan.

7. Management 7.1 Collaboration with OMDM partners and stakeholders Substantial collaboration occurred among OMDM’s partners and stakeholders throughout this reporting period in support of technical activities. OMDM staff members have contributed to, and participated in, the partners’ and stakeholders’ meetings and events detailed in Table 14.

Table 14. OMDM Q2 collaboration with partners and stakeholders

Event Participants FY2020 Q2 dates Cleaning and data entry of case- based data collected between November and December 2019

OMDM January 7–17, 2020

SMPNS data cleaning NMCP, OMDM, IHI January 8–13, 2020 ZAMEP MTR ZAMEP stakeholders including PMI IPs,

WHO January 13–18, 2020

Dar es Salaam Malaria Zonal Meeting

RHMT, CHMTs, NMCP, PORALG, OMDM

January 15–16, 2020

Mwanza Malaria Zonal Meeting NMCP, RHMTs, CHMTs January 27–28, 2020

NMCP data review meeting NMCP, JHPIEGO, OMDM, PORALG January 31, 2020 Vector control TWG meeting NMCP, NIMR Amani, NIMR Mwanza,

VectorLinks, OMDM, MSF, UNHCR, WHO, IHI, KCMC,

February 13–14, 2020

Case management TWG workshop NMCP, JHPIEGO, FHI 360, Deloitte; PORALG, OMDM

February 17–18, 2020

OMDM onsite coaching and mentoring of SME Unit

OMDM February 25–28, 2020

NMCP data review meeting OMDM, PORALG, JHPIEGO, OMDM March 2–3, 2020 NMCP MPR workshop NMCP, OMDM, March 2–20, 2020 TES TWG meeting CUHAS, MUHAS, USAID, PMI, OMDM,

IHI, NIMR Tanga, NMCP March 4–5, 2020

NMCP MRP field site visits OMDM, NMCP, WHO, PMI IPs March 9–13, 2020 Internal OMDM Pause and Reflect session

OMDM March 27, 2020


7.2 List of all documents submitted to the Development Experience Clearinghouse (DEC) Work continued in Q2 to ensure that performance reports to date meet 508 compliance requirements in terms of redaction and readability to allow posting to DEC. All Y1 reports have been posted; OMDM’s Y2 Q1 Report is being made 508 compliant and will be posted to DEC in Q3.

7.3 Certification that all participant training information has been entered in the TraiNet database No participant training sessions were conducted in Y2, Q2. OMDM will ensure timely updates to the TraiNet database as training sessions occur throughout the life of the Activity.

8. Upcoming Events Table 15 highlights planned events involving OMDM and key implementing partners in Y2, Q2.

Table 15. Upcoming events

Event Lead FY2020, Q4 dates NMCP Global Fund Concept Note Development Meetings

NMCP Between 19th April - 20th May 2020

Data Review Meeting NMCP OMDM TBD Data Review Meeting ZAMEP OMDM TBD ZAMEP stakeholders Meeting ZAMEP 30th April 2020 NMCP stakeholders meeting NMCP TBD


Annex 1. Performance Indicator Summary Table Annual and periodic indicators presented below have been shaded grey as quarterly updates are not applicable. Indicators with annual reporting frequency are presented in the Y1 column; indicators requiring periodic frequency will be updated on an ad-hoc basis.

Indicators Data source Disaggregation Reporting

frequency Domain Baseline Q1 Q2 Q3 Q4 Y2

1a

# of malaria- related deaths per year

HMIS/ DHIS2

Gender/district/ regions/Mainland

Tanzania and Zanzibar

Annually

Mainland Tanzania

4,294 (2017)

1b Zanzibar 1

(2017/2018)

2a # of malaria cases

HMIS/ DHIS2



Annually

Mainland Tanzania

5,593,544 (2017)

2b Zanzibar 4,190 (2017)

3a Malaria prevalence rate among children aged 6‒59 months

Demogra- phic and Health Survey/

MIS



Periodically

Mainland Tanzania

7.5% (2017)

3b

Zanzibar

0.2% (2017)

4a Malaria prevalence in pregnant women attending antenatal clinics

ANC malaria testing reports



Periodically

Mainland Tanzania

6.7% (2017)

4b

Zanzibar 0.3%, N = 383

(2017/2018)

RESULT 1: MALARIA SURVEILLANCE IS IMPROVED

1.1a # of national meetings (TWGs, etc.) conducted with policy and decision makers

Reports

Mainland Tanzania and Zanzibar

Quarterly

Mainland Tanzania

2 (2017) 0 2

1.1b

Zanzibar 0

(2017/18)

0

2

1.2a

# of districts implementing regular data review meetings

Reports

District/Mainland Tanzania and

Zanzibar

Quarterly

Mainland

TBD

8, Dodoma;

6, Njombe;

8, Mwanza;

6, Shinyanga


Indicators Data

source Disaggregation Reporting frequency Domain Baseline Q1 Q2 Q3 Q4 Y2

for data analysis as a basis for sound planning

5, Iringa; 7, Mbeya;

9, Morogoro

; 7, Arusha; 5,

Dar es Salaam; 7,

Mbeya

1.2b Zanzibar 0 (2017/2018)

0 2 (national level)

1.3

% of districts that conducted MSDQI supervision in the Mainland and supportive SME supervision in Zanzibar

Activity records

District/Mainland Tanzania and

Zanzibar

Quarterly

Mainland Tanzania

Not applicable (NA)

25% (46/184)

41.3% (76/184)

Zanzibar

NA

100%

100%

1.4

% of districts using malaria dashboard based on DHIS2 and other local systems

Activity records

District/Mainland


Quarterly

Mainland Tanzania

76.34 % (2018) 80% 80%

Zanzibar

NA

NA

NA

1.5

# of data use, Pause and Reflect meetings under NMCP/ZAMEP’s leadership with meeting minutes distributed

Activity records


Annually

Mainland Tanzania NA

Zanzibar

NA

1.6

# of GOT staff trained in HMIS/DHIS2 and MCN (cumulative)

Activity records

Gender/Mainland


Annually

Mainland Tanzania

NA

Zanzibar

1.7

# of GOT staff trained in data analysis and

Activity records

Gender/Mainland Tanzania and

Zanzibar

Annually

Mainland Tanzania

NA

Zanzibar


Indicators Data


scientific stature (cumulative)

1.8a

% of outbreaks detected and investigated

Epidemi- ological records

Districts/Regions/M ainland Tanzania

and Zanzibar

Upon every

outbreak

Mainland Tanzania NA NA NA

1.8b Zanzibar 100% (N = 8)a (2018/2019)

39.5% (15/38)

17.5% (7/40)

1.9a % of malaria outbreaks responded to by district councils within 2 weeks of onset

NMCP/ ZAMEP Activity reports


and Zanzibar

Annually


1.9b

Zanzibar

100% (N = 8)a (2018/2019)

39.5% (15/38)

17.5% (7/40)

1.10a # of rapid response guidelines and protocols

Draft guidelines/

SME records

Mainland Tanzania

and Zanzibar

Periodically


1.10b Zanzibar 1 (2017/2018)

1.11 % of eIDSR reports submitted

Electronic reports/

case registers


Monthly/ Quarterly/ Annually

Mainland Tanzania

51.3%

(Aug 2018)

81.4%

90.6%

1.12

% of MEEDS (SMS) reports submitted

Electronic reports/

case registers

Districts/Regions/

Zanzibar

Monthly (Weekly in

surveillance system)

Zanzibar

23.8%

(2017/2018)

97.4%

98.6% (3,046/ 3,094)

1.13a

% of facilities reporting complete and accurate routine malaria indicators quarterly1 and within a prescribed time period

HMIS/ DHIS2/

Electronic reports/

case registers

Districts/Regions/ Mainland Tanzania

and Zanzibar

Monthly/ Quarterly/ Annually

Mainland Tanzania

98% (2017)

ANC: 99.8% OPD: 99% IPD:

98.6%

ANC: 99.8% OPD: 99.1% IPD: 99%

1.13b

Zanzibar 47%

(2017/2018) ANC: 100%

ANC: 97.3%

1 Monthly data for DHIS2 is also available


Indicators Data


OPD: 89.7% IPD: 83.3%

OPD: 84.2% IPD: 77.4%

1.14a % of health facilities conducting data quality assessments

DQA

Districts/regions/


Annually


1.14b

Zanzibar

55%

1.15

% of health facilities submitting eIDSR reports on time

Electronic and

supervision records

Districts/regions/

Mainland Tanzania

Weekly/ monthly/ quarterly/ annually

Mainland Tanzania

40.9%

(Sept 2018)

68.6%

73.6%

1.16

% of health facilities submitting MEEDS (SMS) reports on time

Electronic and

Supervision Records

Districts/regions/ Zanzibar

Monthly (weekly in

surveillance system)

Zanzibar

80%

(2018/19)

91.0%

88.6%

1.17a

# of positive cases reported and investigated/ confirmed from health facilities

MCN analysis

dashboard

Gender/district/ regions/ Mainland


Monthly/ quarterly/ annually

Mainland Tanzania NA 2,944

cases notified; 1,712 cases

investigate 58.2%

5,504 cases

notified; 2,927 cases

investigate 53.2%

1.17b

Zanzibar

4,106 cases notified; 2,997

cases investigated (2017/2018)

1.18a

% of districts conducting active CBS

Reports

Districts/Mainland


Upon case detection


1.18b Zanzibar 100%

(2017/2018) 100%

100% (11/11)

1.19a % of notified cases that were fully investigated within specified time

MCN

analysis dashboard

Districts/Mainland


Upon case detection


1.19b

Zanzibar 30%

(2016/2017) 56% (965/

41.3% (1,209/


Indicators Data


1,712) 2,927)

RESULT 2: ENTOMOLOGICAL MONITORING IS IMPROVED

2.1a % of entomological surveillance sites reporting timely on expected parameters

Entomol-

ogical monitoring

reports

Mainland Tanzania and Zanzibar, by

site

Periodically/ annually

Mainland Tanzania

61% (2017)

2.1b

Zanzibar

100% (2017/2018)

2.2a # of entomological monitoring plans developed and adopted

Entomol- ogical

monitoring reports

Mainland Tanzania

and Zanzibar

Annually

Mainland Tanzania

1 (2014)

2.2b

Zanzibar

0

2.3a Vector susceptibility (% mortality of vector population)

Entomol- ogical

monitoring reports


site, by insecticide

Annually

Mainland Tanzania Various

2.3b

Zanzibar

Various

2.4a Resistance among malaria mosquito hosts to current, recently used, and new insecticides for IRS and insecticide- treated nets

Entomol- ogical

monitoring reports


site

Annually


2.4b

Zanzibar

Various

2.5a # of sentinel sites established for monitoring insecticide resistance

Activity reports


site

Annually

Mainland Tanzania

28 (2017)

2.5b

Zanzibar

10 (2017/2018)

2.6a Malaria vector abundance and morphological characterization

National malaria vector

Mainland and

Zanzibar, by site

Annually


2.6b Zanzibar TBD


Indicators Data


by species in selected sentinel sites

surveillance (MVS) sites

2.7a

Sporozoite rate among Anopheles spp

National

MVS Sites


site

Annually

Mainland Tanzania

1.8% (2017)

2.7b Zanzibar 0

(2017/2018)

RESULT 3: DRUG EFFICACY MONITORING IS IMPROVED

3.1a % of patients with an absence of parasitemia on day 28 (day 42)

TES

reports

Gender/age, by

TES site

Semi-

annually

Mainland Tanzania

>95% (2017/2018)

3.1b Zanzibar 100%

(2017/2018)

3.2a Therapeutic efficacy of the first-line and alternate ACT nominated by NMCP/ZAMEP for consideration

TES reports

District/regions/ Mainland Tanzania

and Zanzibar

Annually for 4 out of 8

established sites

Mainland Tanzania TBD

3.2b

Zanzibar

97%

(2017)

3.3a # of patients enrolled in TES

TES

reports

Gender/age, by

TES site

Annually


3.3b Zanzibar 146

(2017)

RESULT 4: GOT’S EVIDENCE-BASED DECISION MAKING IS IMPROVED

4.1

# of GOT staff trained in data analysis and scientific stature

Activity records

Gender/Mainland Tanzania and

Zanzibar

Annually

Mainland Tanzania

NA

Zanzibar

4.2

National malaria strategies, policies, and guidelines reviewed,

Activity records

Mainland Tanzania

and Zanzibar

Annually

NA

0


Indicators Data


renewed, or updated

4.3

# of OR studies conducted with GOT collaboration

Activity records

Mainland Tanzania

and Zanzibar

Annually

NA

0

4.6

# of presentations on OR study results given in partnership with GOT

Activity records

TWGs/conferences

Annually

NA

0

4.7

# of peer- reviewed manuscripts published with NMCP/ZAMEP collaboration

Activity records


Annually

NA

0

4.8

# of success stories and blog entries written in partnership with NMCP/ZAMEP

Activity records

Mainland Tanzania

and Zanzibar

Quarterly

NA

0

1

0


Annex 2. ZAMEP Quarterly Report (January 2020–March 2020)


Zanzibar Malaria Elimination Programme (ZAMEP) QUARTERLY PERFORMANCE REPORT: YEAR 2, QUARTER 2

Submitted: April 30, 2020

This report was made possible by the generous support of the American people through the United States Agency for International Development (USAID) and the U.S. President’s Malaria Initiative (PMI). It was prepared by RTI International for the USAID | Okoa Maisha Dhibiti Malaria Activity.

Zanzibar Malaria Elimination Programme (ZAMEP)

QUARTERLY PERFORMANCE REPORT January 1–March 31, 2020

Cooperative Agreement Number: 72062118CA-00002 Contractual Period: August 7, 2018–August 6, 2023

Prepared for:

USAID | Tanzania U.S. Agency for International Development Office of Acquisition and Assistance 686 Old Bagamoyo Rd, Msasani P.O. Box 9130 Dar es Salaam, Tanzania Telephone: 255-22-229-4490

Prepared by

Ministry of Health Zanzibar PO Box: 236 Mnazi Mmoja Zanzibar Tanzania

Phone: +255 24 2231614 Fax: +255 24 2231613

Email: [email protected] www.mohz.go.tz

RTI International is one of the world’s leading research institutes, dedicated to improving the human condition by turning knowledge into practice. Our staff of more than 3,700 provides research and technical services to governments and businesses in more than 75 countries in the areas of health and pharmaceuticals, education and training, surveys and statistics, advanced technology, international development, economic and social policy, energy and the environment, and laboratory testing and chemical analysis.

RTI International is a registered trademark and a trade name of Research Triangle Institute.

The contents of this report are the responsibility of RTI International and do not necessarily reflect the views of USAID/PMI or the United States Government.

USAID Zanzibar Malaria Elimination Programme (ZAMEP), Quarterly Report iii

Acknowledgment The Zanzibar Malaria Elimination Program (ZAMEP) is indebted to the US President’s Malaria Initiative (PMI) and US Agency for International Development (USAID) for the continued and extended financial and technical support targeting malaria intervention activities including Surveillance, Vector Control, Diagnosis and Case Management in Zanzibar. We extend our special appreciation to health workers, Council Health Management Teams (CHMT) and community leaders who are working hand-in-hand with the Programme to ensure services are effectively used by the beneficiaries at the delivery points. Special thanks are extended to the community for complying with and accepting the services.

iv USAID Zanzibar Malaria Elimination Programme (ZAMEP), Quarterly Report

Table of Contents EXECUTIVE SUMMARY .................................................................................................................................1

1. DIAGNOSTIC UNIT ..................................................................................................................................2

1.1 Malaria microscopy supervision and quality control ...........................................................................2

1.2 Quarterly supportive supervision on malaria rapid diagnostic test (mRDT) QA/QC in public health facilities (HF) ...........................................................................................................................3

2. SOCIAL BEHAVIOR CHANGE COMMUNICATION (SBCC) ..................................................................4

2.1 Mass media SBCC activities, live radio and TV programmes ............................................................4

2.2 Community meetings .........................................................................................................................4

2.3 Community sensitization through theatre groups ...............................................................................4

2.4 Monitoring and supervision of SBCC activities at the shehia and community levels ..........................5

2.5 SBCC to support the 2020 IRS campaign ..........................................................................................5

2.6 Technical meeting to design malaria SBCC materials .......................................................................5

2.7 Monitoring and supervision of continuous distribution (CD) scheme..................................................5

2.8 LLIN redistribution ..............................................................................................................................5

2.9 Preparation for min mass LLINs distribution ......................................................................................5

2.10 Coupon status ....................................................................................................................................5

3. ENTOMOLOGY AND VECTOR CONTROL .............................................................................................6

3.1 Entomological foci investigation and response ..................................................................................6

3.2 Foci investigation results and responses ...........................................................................................6

3.3 QA and monitoring of insecticide decaying rate following 2020 IRS campaign ..................................7

3.4 Efficacy residue of Clothianidin 50 WG results in Zanzibar ................................................................8

3.5 Entomological monitoring in ten sentinel sites ...................................................................................9

4. SURVEILLANCE, MONITORING AND EVALUATION (SME) UNIT ...................................................... 10

4.1 Improve MEEDS reporting timeliness .............................................................................................. 10

4.2 District Malaria Surveillance Officer (DMSO) feedback meeting ...................................................... 10

4.3 CMSO supervision ........................................................................................................................... 11

4.4 Support data auditing and cleaning .................................................................................................. 11

5. CASE MANAGEMENT ........................................................................................................................... 12

5.1 Training on revised malaria diagnosis and treatment guidelines ...................................................... 12

List of Figures Figure 1. mRDT Quality Control Results ...................................................................................................3

Figure 2. Different wall surfaces used for bioassay testing .......................................................................8

List of Tables Table 1. QA/QC results .............................................................................................................................2

Table 2. PT results ....................................................................................................................................2

Table 3. Clothianidin efficacy residue, one-month post-IRS—Unguja, March 2020 ..................................8

USAID Zanzibar Malaria Elimination Programme (ZAMEP), Quarterly Report v

Table 4. Clothianidin efficacy residue, one-month post-IRS—Pemba, March 2020 ..................................9

Table 5. Malaria vectors collected by method, January–March 2020........................................................9

Table 6. Issues raised during CMSO feedback meetings ....................................................................... 10

vi USAID Zanzibar Malaria Elimination Programme (ZAMEP), Quarterly Report

Abbreviations and Acronyms

CD continuous distribution

CHMT Council Health Management Team

HF health facility

HLC human landing catch

IEC information, education, communication

IPC intermittent parasite clearance

IRS indoor residual spraying

LLIN long-lasting insecticide net

LTC light trap collection

MCN malaria case notification

MEEDS Malaria Early Epidemic Detection System

MOHZ Ministry of Health Zanzibar

MIS malaria information system

mRDT malaria rapid diagnostic tests

OPD outpatient department

PMI US President’s Malaria Initiative

PSC pyrethrum spray collection

PTC pit trap collection

SBCC social behavior change communication

SME Surveillance Monitoring and Evaluation Unit

USAID US Agency for International Development

WHO World Health Organization

ZAMEP Zanzibar Malaria Elimination Program

USAID Zanzibar Malaria Elimination Programme (ZAMEP), Quarterly Report 1

Executive Summary This quarterly report summarizes the major findings and achievements for the activities conducted between January and March 2020 by ZAMEP per thematic area.

Routine vector collection at ten monitoring sites indicates the dramatic rise of the mosquito population in Zanzibar, particularly outdoor host-seeking Anopheles, increasing the probability of increased malaria transmission in outbreak areas and beyond. Foci investigations indicated low coverage and utilization of long-lasting insecticide nets (LLIN). However, other operational villages reported over 100% universal coverage, though the majority are still in their original bags.

Slide cross-checking through quality assurance (QA) and quality control (QC) revealed 97.4% Plasmodium falciparum, 2.3% Plasmodium malaria, and 0.4% Plasmodium ovale with sensitivity and specificity between 98.9% and 100%, respectively.

Malaria data cleaning and auditing from three sources (Malaria Early Epidemic Detection System [MEEDS] booklets, malaria case registers [MCR], and the health management information system [HMIS] outpatient registers) were compared to confirm agreement between the data. Results indicated agreement of 97% in positive cases and 95% agreement between MEEDS and HMIS for the negative cases. The agreement for MEEDS and HMIS for outpatient department (OPD) visits was 96%.

Many social behavioural activities were conducted during this reporting period, including live radio and TV programmes, community meetings, monitoring and supervision. Activities aimed at increasing awareness and community understanding on key malaria prevention messages towards elimination, including LLIN usage, indoor residual spraying (IRS) and case management.

ZAMEP is planning to conduct distribution of LLINs in fifty-two shehia following an abnormal increase in cases associated with poor coverage within the population.

2 USAID Zanzibar Malaria Elimination Programme (ZAMEP), Quarterly Report

1. Diagnostic unit Key activities implementing during the reporting period include the following:

1.1 Malaria microscopy supervision and quality control A total of 96 (100%) health facilities were involved in malaria microscopy QA/QC. All health facilities were supervised to ensure the timely, accurate and consistent quality of results (Table 1). Supervision aimed to improve the quality of malaria testing standards in accordance with malaria microscopy guidelines.

Table 1. QA/QC results

DISTRICT

Health facilities results

Malaria Microscope Quality assurance quality control results ( Slide cross check)

Total Examined Under five years Examined Positive Negative Slides

Examined F

M

Pos

F

M

Exd

F

M

POS

F

M

R1

R2

R1

R2

Mkoani 1,214 675 539 23 6 17 305 160 145 - - - 23 23 120 120

Chakechake 1,245 720 525 23 13 10 284 142 142 5 2 3 23 23 131 131

Wete 1,285 744 541 79 36 43 214 91 123 8 3 5 79 79 119 119

Micheweni 1,197 774 423 65 32 33 403 238 165 8 5 3 65 65 127 127

Kusini 673 378 295 2 1 1 207 99 108 - - - 2 2 68 68

Kati 984 624 360 12 7 5 159 69 90 - - - 12 12 98 98

Mjini 5,088 2,627 2,461 33 17 16 1,928 1,008 920 6 3 3 33 31 506 506

Kaskazini “A” 338 166 172 5 3 2 79 40 39 - - - 5 5 34 34

Kaskazini “B” 392 251 141 8 4 4 124 69 55 - - - 8 8 41 41

Magharibi ‘A’ 2,473 1,423 1,050 23 9 14 866 507 359 5 2 3 23 22 324 324

Total 14,889 8,382 6,507 273 128 145 4,569 2,423 2,146 32 15 17 273 270 1,568 1,568

Through the slide cross-check, sensitivity was 98.9%; specificity was 100%. The malaria speciation revealed 97.4% Plasmodium falciparum, 2.3% Plasmodium malaria, and 0.4% Plasmodium ovale.

During supervision, ZAMEP staff reviewed the quality of slide preparation, including preparation, staining and reading of blood films. These activities aim to ensure quality and accurate results by ensuring all blood films are fully labeled, without blue coloration, using the correct film size and volume of blood, the blood is uniformly spread, and is pink or light purple in color. It was observed that 90% of slides met these criteria.

Sixteen health facilities in Unguja were given proficiency tests (PT) during this reporting period to assess the capacity of individual laboratory technicians to prepare blood slides (Table 2).

Table 2. PT results

Health

facilities

# of slide

Agreement Detection Speciation Quantification Total

Score

True Results

False Positive

False Negative

3 Slides 3 Slides (%)

Chukwani 10 8 3 1 0 3 1 80 Mpendae 10 9 4 0 0 3 1 90 Makunduchi 10 7 4 0 0 3 2 70 Kivunge 10 8 4 0 0 0 2 80 Kitope 10 9 4 0 0 0 2 90


Health

facilities

# of slide

Agreement Detection Speciation Quantification Total

Score

True Results

False Positive

False Negative

3 Slides 3 Slides (%)

Mwera 10 10 4 0 0 0 0 100 Muyuni 10 10 4 0 0 0 0 100 Fujoni 10 9 4 0 0 0 2 90 Kidutani 10 9 4 0 0 3 2 90

Mpendae 10 9 4 0 0 3 2 90

Kwamtipura 10 10 4 0 0 3 3 100

SDA 10 10 4 0 0 3 3 100

Kombeni 10 9 4 0 0 3 2 90

Shauri moyo 10 9 4 0 0 2 3 90

Jku Sateni 10 10 4 0 0 3 3 100

Ziwani Police 10 10 4 0 0 3 3 100

Total 160 146 32 1 0 32 31

91.3% of laboratory technicians passed the PT, highlighting an increase in the performance of laboratory technicians, particularly in the areas of parasite detection and speciation. Additional work is required, however, to improve technicians with low scores in the area of parasite quantification.

Supportive supervision, on-the-job training, and refresher trainings are planned to maintain and improve the performance of laboratory technicians in preparing and reading blood slides.

1.2 Quarterly

supportive supervision on malaria rapid diagnostic test (mRDT) QA/QC in public health facilities (HF)

ZAMEP, in collaboration with mRDT district supervisors, conducted supportive supervision activities at 198 testing sites across 163 public HFs to ensure the accuracy and performance of mRDT results across six key factors (Figure 1).

mRDT availability

All 163 HFs across Unguja and Pemba reported a stock out of mRDTs during this reporting period.

Figure 1. mRDT Quality Control Results


HFs

162 of 163 HFs (99%) using mRDTs were visited during this reporting period to assess the number of tested patients, positivity, and species identification. Of the 34,331 tested patients, 699 (2.0%) revealed malaria antigen-positive; of those 67% were revealed to be Plasmodium falciparum, 218 (31.2%) Plasmodium falciparum plus Pan and 7 (1%) Pan.

Collection of mRDT positive slides

Microscopy and mRDTs are the primary tools used for malaria diagnosis in Zanzibar; however, mRDTs are unable to speciate and quantify parasites. Based on the results of microscopy data, other malaria Plasmodium species have been identified in addition to Plasmodium falciparum.

A total of 191 slides were collected from 26 HFs. Of these, 180 (94.74%) revealed a true positive result, 9 (4.7%) revealed negative results, and 1 (1.05%) revealed auto-fixation. For this reporting, only Plasmodium falciparum trophozoite and gametocyte were identified.

2. Social behavior change communication (SBCC) Key activities implementing during the reporting period include the following:

2.1 Mass media SBCC activities, live radio and TV programmes A total of twelve live radio and fifteen television programs were aired through four media outlets in Unguja and Pemba. Each programme was designed to convey appropriate information related to key malaria elimination strategies for the general public; in this quarter, a major task was to draw community attention to the increase in malaria cases in some shehia and community action to be taken. The broadcasts focused on the importance of continuous net use for malaria prevention and community-based case follow-up.

2.2 Community meetings Due to the increase of malaria cases in the Urban West region, implementation of Interpersonal communication (IPC) activities was compulsory as part of ZAMEP’s SBCC response. Twenty-three community meetings were conducted in the ten shehia reporting an increased number of malaria cases within the reporting period. The objective of the meetings was to inform community members on the increased malaria cases and the need to reduce transmission among community members living in the Urban West region. The meetings were also conducted in five schools with boarding camps located in Stone Town, Zanzibar.

2.3 Community sensitization through theatre groups Through support from USAID/PMI, ZAMEP conducted community activities in 109 shehia in Unguja and Pemba to sensitize community members on the importance of practicing key malaria elimination strategies, particularly continuous use of LLINs. The focus on LLIN use was a direct result of 2017 data from the malaria information system (MIS), reporting low usage of LLINs in the Urban West region (59.1%). This campaign utilizing theatre groups was supported by district health promotion officers and district culture officers and implemented by district councils through sheha and their assistants from individually targeted shehia.


2.4 Monitoring and supervision of SBCC activities at the shehia and community levels

Thirty-five HFs and fifteen community health committees were visited to monitor and supervise the implementation of SBCC activities in six districts of Unguja. As part of this activity, ZAMEP’s SBCC Unit interviewed health workers and members of community health committees to assess implementation progress of community mobilization activities to support malaria elimination in Zanzibar, particularly in areas with a recent increase in cases. The community requested additional information, education and communication (IEC) materials and working tools to further support community mobilization activities at the grassroots level.

2.5 SBCC to support the 2020 IRS campaign During this reporting period, ZAMEP’s SBCC Unit coordinated community mobilization activities to support Zanzibar’s 2020 IRS campaign across national, district, and grassroots levels. Four live television and five live radio programs were aired prior to the start of the campaign in addition to house-to-house visits to ensure effective message delivery.

2.6 Technical meeting to design malaria SBCC materials The USAID Tulonge Afya Project in Tanzania supported a three-day meeting to design SBCC materials to be distributed to community members living in malaria hotspot areas and at ports of entry. First drafts of IEC materials designed included radio spots, animations, posters, billboards, poems, leaflets, and factsheets; all will be pre-tested in the first week of April 2020.

2.7 Monitoring and supervision of continuous distribution (CD) scheme

Over six days, monitoring to assess the progress of implementation of the continuous net distribution scheme was completed at HF and community levels in four districts of Zanzibar, two each in Unguja and Pemba. Among the identified challenges were the shortage of LLINs and coupons in some HFs and shehia. The shehia affected were from Central, North A and South district in Unguja and in Wete and Micheweni districts in Pemba.

2.8 LLIN redistribution LLIN redistribution activities were completed in six HFs in North B and Central districts where a net shortage was identified during monitoring and supervision activities related to continuous net distribution. Nets were redistributed to the Kitope, Kivunge, Ghana, Mahonda, and Mkokotoni HFs in Unguja and Fundo and Piki HFs in Pemba to ensure the availability of nets throughout the year.

2.9 Preparation for min mass LLINs distribution Districts West A, West B and Urban reported increased malaria cases between October 2019 and January 2020. In response, ZAMEP collaborated with district councils to initiate preparations for a mass distribution campaign to fifty-shehia within these districts, including registration of households, training of net distributors, and quantification of LLINs. Distribution is expected to occur during the first week of April 2020.

2.10 Coupon status ZAMEP will receive 200,000 coupons from USAID/PMI to support the community based LLIN distribution scheme in 388 shehia across Unguja and Pemba. Coupons will be


distributed to all shehia identified to have a shortage of LLINs; monitoring and supervision in support of the campaign will be conducted between April and June 2020 to assess distribution, including the availability of coupons across HFs and shehia.

3. Entomology and vector control Key activities implementing during the reporting period include the following:

3.1 Entomological foci investigation and response During this reporting period, ZAMEP conducted entomological hotspot investigations at Bandari Kuu, Mgeni Nje and Sijuu villages at Kifundi, Msuka Magharibi and Mihogoni shehia in Pemba and in Kikwajuni Juu, Kikwajuni Bondeni, Mto wa pwani, Miembeni and Shangani in Unbuja following non-stop transmission of local cases. We investigated entomological risk factors that drive residual transmission within villages, including vector control application at the household level, malaria vector characterization, and mosquito breeding sites close to residences. The number of households, LLIN ownership and utilization and demographic information was also captured.

Mosquitoes were collected via human landing catches (HLC) and through the use of Prokopacks. Over a three-night period, HLC were conducted in two houses per village using two indoor and two outdoor baits to collect vectors over a twelve-hour period, between 6:00 p.m. and 6:00 a.m. Over a three-day period, Prokopack aspirators were used to collect mosquitoes in ten houses per village, thirty houses total. Collected mosquitoes were then taken to the laboratory for counting, sorting, and identification before being analyzed for molecular identification and infection rate.

3.2 Foci investigation results and responses The number of households at the village level ranges from fifty to ninety, with a residential population ranging from 303 to 516. Universal coverage of LLINs, targeting one net for every two people, ranges from 28% compliance in Mgeni Nje to 100% in Bandari Kuu in Pemba. The lowest utilization was recorded at Mgeni Nje (28% coverage) and highest use reported at Sijuu, Msuka Magharibi (80% coverage). In Unguja, universal coverage rates ranged from 35% in Kikwajuni Juu to 86% in Kikwajuni Bondeni.

A significant number of Anopheles mosquitoes were collected outdoors at Mgeni Nje villages in Pemba, highlighting the likelihood of current transmission outdoors. All foci had positive breeding sites for both Anopheles and Culex larvae.

Many LLINs were found un-hung and within their original bags in Pemba, indicating low awareness and compliance on net utilization within the villages. In response, ZAMEP’s BCC Unit collaborated with shehia leaders to conduct a house-to-house campaign to convey the importance of hanging and utilizing LLINs.


3.3 QA and monitoring of insecticide decaying rate following 2020 IRS campaign

ZAMEP, in collaboration with the PMI VectorLink project, conducted a targeted IRS campaign in February 2020, covering seventy-one shehia (8 Pemba, 63 Unguja) with Clothianidin (SumiShield 50 WG) insecticide.

Clothianidin is regarded as a slow-acting insecticide; using the World Health Organization’s (WHO) insecticide monitoring protocol ZAMEP’s Entomology Unit observed and recorded mosquito mortality following insecticide application every 24 hours over a one-week period. Given its slow-acting nature, Clothianidin may provide longer-lasting and more effective coverage.

The insecticide decay rate was assessed in six shehias in Unguja and Pemba. Fifteen houses per shehia with wall surfaces reflective of typical household construct—mud, cement, oil paint, water paint, and stone block—were selected to conduct WHO cone bioassays (Figure 2). Three houses representing each wall surface type were tested in each shehia; selected houses were sprayed by different spray operators and supervised by different team leaders to reduce bias in the findings.

Photo credit: ZAMEP. LLIN photo taken from four households during foci investigation, highlighting poor adherence to LLIN campaigns and abnormality in net distribution


Figure 2. Different wall surfaces used for bioassay testing

Water paint

Stone block

Oil paint

Mud

Cement

3.4 Efficacy residue of Clothianidin 50 WG results in Zanzibar Tables 3 and 4 present results from the wall cone bioassay tests. In Pemba, Observed mortality rates ranged from 94% (stone block and water paint surfaces) to 98% (oil paint) on day 1 and 100% mortality across all surfaces from days 2 and 3 post-insecticide exposure. In Unguja, all surfaces displayed 100% mortality of susceptible Anopheles mosquitoes within 24 hours post-insecticide exposure.

Table 3. Clothianidin efficacy residue, one-month post-IRS—Unguja, March 2020

Surface type

Number of

houses tested

Total number of mosquitoes

exposed

Observed mortality % Control

mortality %

24hrs 48hrs 72hrs 96hrs

Mud 9 360 100 100 100 0

Oil paint 9 360 100 100 100 0


Surface type

Number of

houses tested


exposed


mortality %


Cement 9 360 100 100 100 0

Lime wash 9 360 100 100 100 0

Water paint 9 360 100 100 100 0

Table 4. Clothianidin efficacy residue, one-month post-IRS—Pemba, March 2020

Surface type

Number of

houses tested


exposed


mortality %


Mud 9 360 97 100 100 0

Oil paint 9 360 98 100 100 0

Cement 9 360 89 99.6 100 0

Stone block 9 360 94 99.6 100 0

Water paint 9 360 94 95 100 0

3.5 Entomological monitoring in ten sentinel sites ZAMEP’s Entomology Unit routinely conducts entomological monitoring activities in ten sites in Unguja and Pemba to assess the impact of IRS and LLIN coverage. Vector density, infection rate, biting, resting behavior, and species composition were monitored using pit trap collection (PTC), HLC, light trap collection (LTC), and pyrethrum spray collection (PSC) or Prokopack. For this reporting period, only density will be reported, as other parameters were not molecularly investigated.

Compared to last quarter, the density of An. gambiae s.l. collected across the ten monitoring sites was low; however, it reflects a significant increase when comparing data from the same quarter over the past several years. This is likely due to an increase in rainfall recorded for this year. The majority of mosquitoes were observed to bite outdoors all night, indicating a high threat to the population that remain outdoors during the night hours. In many sites, there was no difference in terms of numbers of vectors collected, regardless of the spraying status in 2020. This data insists upon the use of complementary vector control interventions to combat outdoor biting malaria mosquitoes, such as larviciding.

Table 5. Malaria vectors collected by method, January–March 2020

Sentinel site

Vector species

MLC PSC

PTC

LTC Tota

l indoor outdoor Uwandani An. gambiae s.l 0 0 0 25 0 25 Bopwe An. gambiae s.l 3 58 0 6 0 67 Tumbe An. gambiae s.l 4 109 0 4 0 117 Wambaa An. gambiae s.l 3 162 0 2 5 172


Sentinel site

Vector species

MLC PSC

PTC

LTC Tota

l indoor outdoor Stone town An. gambiae s.l. 1 0 0 0 0 1 Donge An. gambiae s.l. 2 3 0 0 0 5 Mwera An. gambiae s.l. 0 0 0 166 0 166 Muyuni An. gambiae s.l. 0 0 0 0 0 0 Bumbwini An. gambiae s.l. 2 1 0 0 0 3 Cheju An. gambiae s.l. 19 22 0 0 0 41 Grand total 34 355 0 203 5 597

4. Surveillance, Monitoring and Evaluation (SME) Unit 4.1 Improve MEEDS reporting timeliness ZAMEP’s SME Unit continues to emphasize the importance of reporting malaria data on time. The SME Unit focuses significant effort on ensuring all facilities and Council Malaria Surveillance Officers (CMSO) submit their reports in a timely fashion, and regularly tracks reporting to increase timeliness across HFs, utilizing different approaches including calls to HFs when data is delayed and/or mismatched and in-person visits to resolve field-level data issues.

Between January and March 2020, 81% of the facilities submitted their reports on time (Monday of each week)—93 facilities for Unguja, 90 health facilities in Pemba. The major challenge to timely reporting was receiving the message notification once health care providers submitted their reports; HFs delayed submission the notification that all data had been received in the system. ZAMEP reported these delays to RTI for additional follow-up and resolution through Selcom.

4.2 Council Malaria Surveillance Officer (CMSO) feedback meeting The SME Unit conducts routine CMSO feedback meetings in Pemba and Unguja to review data reported during case investigation and to share and resolve operational challenges identified in the field, including case duplication and system failure. Between January and March 2020, six meetings were conducted; major issues discussed included delays to increase functionality of options in the Malaria Case Notification (MCN) system menu and increased malaria cases across almost all districts in Unguja and Pemba. Table 6 highlights issues discussed and proposed resolution.

Table 6. Issues raised during CMSO feedback meetings

SN Issue Status Way forward 1 Increased of malaria cases In this quarter 5,281 cases were

reported compared to last quarter (2,942 cases reported). Due to the increased number of cases, only 46% of cases were followed up to the household level.

The program through SME Unit requests CMSOs not to accumulate cases in their tablets.

2 Delayed of some buttons in the menu (Household) and problem of skipping during case follow-up.

This issue was reported by CMSOs of both Unguja and Pemba. During the household visits, when they press the Household button it takes too long to run.

This issue was already reported to programmer; he advised CMSOs to reduce unnecessary programs in their tablets which seemed to slow down operation of their tablets. However, CMSOs were


SN Issue Status Way forward advised to restart their machines

when they face problems of this nature.

3 Overwhelming number of cases for some CMSOs

It was observed that CMSOs have divided themselves into different areas for case follow-up. What happened now is there are some CMSOs that have less cases to make case follow up compared to their fellow ones with in one district. This contributes to low performance for case follow up.

ZAMEP’s SME Unit advised the CMSOs to increase teamwork and make sure all cases notified in their districts are followed up regardless of their distribution of areas for case follow up.

4.3 CMSO supervision Supervision is one of primary monitoring mechanisms which provides the SME Unit an opportunity to track and improve health worker performance to better collect and report quality data to the national level.

In this quarter, supervision was conducted for eighteen CMSOs (ten in Unguja, eight Pemba) to monitor data management performance and to identify and correct implementation challenges from the HF to household level. Sixteen malaria cases (two per DMSO) were supervised, with visited cases reported from ten health facilities—Bwejuu, Kizimkazi Dimbani, Donge Mchangani, Nungwi, Kizimbani and Keimbe Samaki in Unguja and Konde, Abdalla Mzee, Chonga and Jadida in Pemba.

Field results—HF level

• 95% cases were well registered across all three data sources—MCR, MEEDS and HMIS; only one patient was not documented in the MCN.

• All cases (ten total) were followed up to the household level.

• Nine cases were notified within the specified 48-hour timeframe; only one case extended beyond that timeframe.

Field results—household level

• CMSOs delayed following up malaria cases

• Some CMSOs overwhelmed by follow-up cases following redistribution of CMSO district assignments

• Challenges with the household button within the MCN menu on CMSO tablets; takes a long time to complete one case during follow-up

4.4 Support data auditing and cleaning Data auditing and cleaning was conducted by ZAMEP’s SME Unit on both islands to assess and improve data quality. Data from three sources—MEEDS booklets, the MCR, and the HMIS outpatient register—were compared to ensure agreement data agreement. It was observed that 97% of the data matched for positive cases across the MEEDS, MCR and HMIS, 95% matched for negative cases across the MEEDS and HMIS, and 96% matched between the MEEDS, HMIS and OPD visits. These results highlight that the sampled data is


being well managed across HFs, though work will continue to arrive at a 100% match across all three sources.

5. Case management 5.1 Training on revised malaria diagnosis and treatment guidelines Since 2018, ZAMEP’s Case Management Unit has conducted a series of training session for 300 health care providers (120 Pemba, 180 Unguja) on the revised Zanzibar guidelines for malaria diagnosis and treatment and the WHO’s malaria case management recommendations.

In this reporting period, the Unit conducted training for fifty-eight health care providers from the intensive care unit (ICU) and emergency unit at the Mnazi Mmoja Hospital. The training covered seven learning units, including the following:

• Malaria situation in Zanzibar

• Diagnosis and treatment policy

• Malaria epidemiology

• Management of severe and uncomplicated malaria

• Case-based surveillance

• Malaria in pregnancy

• Pharmacovigilance

• Chemoprophylaxis

Documents

USAID Okoa Maisha Dhibiti Malaria (OMDM) Activity