title: Enhanced surveillance and data feedback loop associated with improved malaria data in Lusaka, Zambia.
abstract: BACKGROUND
  Accurate and timely malaria data are crucial to monitor the progress towards and attainment of elimination. Lusaka, the capital city of Zambia, has reported very low malaria prevalence in Malaria Indicator Surveys. Issues of low malaria testing rates, high numbers of unconfirmed malaria cases and over consumption of anti-malarials were common at clinics within Lusaka, however. The Government of Zambia (GRZ) and its partners sought to address these issues through an enhanced surveillance and feedback programme at clinic level.
  
  
  METHODS
  The enhanced malaria surveillance programme began in 2011 to verify trends in reported malaria, as well as to implement a data feedback loop to improve data uptake, use, and quality. A process of monthly data collection and provision of feedback was implemented within all GRZ health clinics in Lusaka District. During clinic visits, clinic registers were accessed to record the number of reported malaria cases, malaria test positivity rate, malaria testing rate, and proportion of total suspected malaria that was confirmed with a diagnostic test.
  
  
  CONCLUSIONS
  Following the enhanced surveillance programme, the odds of receiving a diagnostic test for a suspected malaria case increased (OR = 1.54, 95 % CI = 0.96-2.49) followed by an upward monthly trend (OR = 1.05, 95 % CI = 1.01-1.09). The odds of a reported malaria case being diagnostically confirmed also increased monthly (1.09, 95 % CI 1.04-1.15). After an initial 140 % increase (95 % CI = 91-183 %), costs fell by 11 % each month (95 % CI = 5.7-10.9 %). Although the mean testing rate increased from 18.9 to 64.4 % over the time period, the proportion of reported malaria unconfirmed by diagnostic remained high at 76 %.
  
  
  CONCLUSIONS
  Enhanced surveillance and implementation of a data feedback loop have substantially increased malaria testing rates and decreased the number of unconfirmed malaria cases and courses of ACT consumed in Lusaka District within just two years. Continued support of enhanced surveillance in Lusaka as well as national scale-up of the system is recommended to reinforce good case management and to ensure timely, reliable data are available to guide targeting of limited malaria prevention and control resources in Zambia.
authors.affiliation: Akros, Cresta Golfview Grounds, Great East Road, Unit 5, Lusaka, Zambia. zchisha@akros.com.
authors.forename: Zunda
authors.initials: Z
authors.lastname: Chisha
authors.affiliation: Akros, Cresta Golfview Grounds, Great East Road, Unit 5, Lusaka, Zambia. dlarsen@akros.com.|Department of Public Health, Food Studies and Nutrition, Syracuse University, Syracuse, NY, USA. dlarsen@akros.com.
authors.forename: David A
authors.initials: DA
authors.lastname: Larsen
authors.affiliation: Akros, Cresta Golfview Grounds, Great East Road, Unit 5, Lusaka, Zambia. matt.r.burns75@gmail.com.
authors.forename: Matthew
authors.initials: M
authors.lastname: Burns
authors.affiliation: PATH Malaria Control and Elimination Partnership in Africa (MACEPA), National Malaria Control Centre, Chainama Hospital College Grounds, Great East Road, Lusaka, Zambia. jmiller@path.org.
authors.forename: John M
authors.initials: JM
authors.lastname: Miller
authors.affiliation: Department of Public Health and Research, National Malaria Control Centre, Ministry of Health, P.O. Box 32509, Lusaka, Zambia. jack.chirwa@gmail.com.
authors.forename: Jacob
authors.initials: J
authors.lastname: Chirwa
authors.affiliation: Lusaka District Health Management Team, Ministry of Health, Lusaka, Zambia. cmbwili@yahoo.com.
authors.forename: Clara
authors.initials: C
authors.lastname: Mbwili
authors.affiliation: Akros, Cresta Golfview Grounds, Great East Road, Unit 5, Lusaka, Zambia. dbridges@akros.com.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Bridges
authors.affiliation: Department of Public Health and Research, National Malaria Control Centre, Ministry of Health, P.O. Box 32509, Lusaka, Zambia. mkamuliwo@yahoo.com.
authors.forename: Mulakwa
authors.initials: M
authors.lastname: Kamuliwo
authors.affiliation: Department of Public Health and Research, National Malaria Control Centre, Ministry of Health, P.O. Box 32509, Lusaka, Zambia. mhawela@yahoo.com.
authors.forename: Moonga
authors.initials: M
authors.lastname: Hawela
authors.affiliation: Malaria Branch and US President's Malaria Initiative, Centers for Disease Control and Prevention, Atlanta, GA, USA. ktan@cdc.gov.
authors.forename: Kathrine R
authors.initials: KR
authors.lastname: Tan
authors.affiliation: Malaria Branch and US President's Malaria Initiative, Centers for Disease Control and Prevention, Atlanta, GA, USA. acraig@cdc.gov.
authors.forename: Allen S
authors.initials: AS
authors.lastname: Craig
authors.affiliation: Akros, Cresta Golfview Grounds, Great East Road, Unit 5, Lusaka, Zambia. awinters@akros.com.|University of Montana School of Public and Community Health Sciences, Missoula, MO, USA. awinters@akros.com.
authors.forename: Anna M
authors.initials: AM
authors.lastname: Winters
mesh_terms: D002675:Child, Preschool; D003955:Diagnostic Tests, Routine / Q000706:statistics & numerical data; D062665:Epidemiological Monitoring; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008288:Malaria / Q000175:diagnosis / Q000453:epidemiology* / Q000469:parasitology; D015995:Prevalence; D062486:Public Health Surveillance / Q000379:methods*; D015024:Zambia / Q000453:epidemiology