title: A comprehensive assessment of the malaria microscopy system of Aceh, Indonesia, in preparation for malaria elimination.
abstract: BACKGROUND
  The Health Office of Aceh aims to eliminate malaria from Aceh Province, Indonesia by 2015. Malaria was formerly common in Aceh (population 4.5 million), but has declined dramatically in recent years consequent to post-tsunami control efforts. Successful elimination will depend upon rapid and accurate diagnosis and case follow-up at community level. A prerequisite to this is widespread coverage of high quality malaria diagnosis. This study describes the results of a comprehensive assessment of the malaria diagnostic capacity in Aceh as the province moves towards malaria elimination.
  
  
  METHODS
  The study was conducted in 23 districts in Aceh from October 2010 to July 2011. Six types of questionnaires were used to collect data on competency of microscopists and laboratory capacity. Standardized slides were used to evaluate the proficiency of all microscopists. In addition, site visits to 17 primary health centres (PHC) assessed diagnostic practice and logistics capacity.
  
  
  RESULTS
  Five hundred and seventy four malaria microscopists have been officially registered and assigned to duty in the 23 districts in Aceh Province. They work in 345 laboratories, predominantly in PHCs (69 %) and hospitals (25 %). Three laboratories were evaluated as adequate for all 30 elements, while 29 laboratories were adequate for less than five of 30 elements. Standardized proficiency tests showed that 413 microscopists were at basic (in training) level, with 10 advanced and 9 reference level. No microscopist achieved expert level. Neither the province nor any of Aceh's districts has a standardized inventory and logistics database for malaria diagnostics, nor did any of the surveyed laboratories operate a quality assurance programme for either microscopy or rapid diagnostic tests.
  
  
  CONCLUSIONS
  The study highlights the importance of careful assessment of diagnostic capacity when embarking upon a large-scale malaria elimination programme. Aceh's laboratories have minimal infrastructure with nearly all microscopists still in training. On the positive side, a large workforce of microscopists has been assigned to laboratories with the needed equipment. Aceh will need to embark on a large-scale comprehensive quality assurance scheme if it is to achieve malaria elimination.
authors.affiliation: Paritrana Asia Foundation, Jalan Utama 113, 12640, Jakarta, Indonesia. lenny.ekawati@gmail.com.|Eijkman-Oxford Clinical Research Unit, Jalan Diponegoro 69, 10430, Jakarta, Indonesia. lenny.ekawati@gmail.com.
authors.forename: Lenny L
authors.initials: LL
authors.lastname: Ekawati
authors.affiliation: United Nation Children's Fund Banda Aceh Zone Office, Jalan Mesjid Shadaqah 2, Lamlagang, 23243, Banda Aceh, Indonesia. hherdiana@unicef.org.
authors.forename: Herdiana
authors.initials: H
authors.lastname: Herdiana
authors.affiliation: United Nation Children's Fund Indonesia, Jalan Jenderal Sudirman Kavling 31, 12920, Jakarta, Indonesia. esumiwi@gmail.com.
authors.forename: Maria E
authors.initials: ME
authors.lastname: Sumiwi
authors.affiliation: Aceh Provincial Health Office, Jalan Teungku Syech Mudawali 6, 23242, Banda Aceh, Indonesia. cutbarussanah@yahoo.co.id.
authors.forename: Cut
authors.initials: C
authors.lastname: Barussanah
authors.affiliation: Aceh Provincial Health Laboratory, Jalan Teungku Muhammad Daud Beureuh 168, 23242, Banda Aceh, Indonesia. cut.ainun01@gmail.com.
authors.forename: Cut
authors.initials: C
authors.lastname: Ainun
authors.affiliation: Aceh Provincial Health Laboratory, Jalan Teungku Muhammad Daud Beureuh 168, 23242, Banda Aceh, Indonesia. labkes_aceh@yahoo.com.
authors.forename: Sabri
authors.initials: S
authors.lastname: Sabri
authors.affiliation: Aceh Provincial Health Office, Jalan Teungku Syech Mudawali 6, 23242, Banda Aceh, Indonesia. tkmaulana@yahoo.com.
authors.forename: Teuku
authors.initials: T
authors.lastname: Maulana
authors.affiliation: Aceh Provincial Health Office, Jalan Teungku Syech Mudawali 6, 23242, Banda Aceh, Indonesia. rahmadyani93@yahoo.com.
authors.forename: Rahmadyani
authors.initials: R
authors.lastname: Rahmadyani
authors.affiliation: Aceh Provincial Health Laboratory, Jalan Teungku Muhammad Daud Beureuh 168, 23242, Banda Aceh, Indonesia. cutmaneh@gmail.com.
authors.forename: Cut
authors.initials: C
authors.lastname: Maneh
authors.affiliation: Aceh Provincial Health Office, Jalan Teungku Syech Mudawali 6, 23242, Banda Aceh, Indonesia. m_yani61@yahoo.com.
authors.forename: Muhammad
authors.initials: M
authors.lastname: Yani
authors.affiliation: United Nation Children's Fund Banda Aceh Zone Office, Jalan Mesjid Shadaqah 2, Lamlagang, 23243, Banda Aceh, Indonesia. Valentipaola59@gmail.com.
authors.forename: Paola
authors.initials: P
authors.lastname: Valenti
authors.affiliation: Eijkman-Oxford Clinical Research Unit, Jalan Diponegoro 69, 10430, Jakarta, Indonesia. iqbal.elyazar@gmail.com.
authors.forename: Iqbal R F
authors.initials: IR
authors.lastname: Elyazar
authors.affiliation: United Nation Children's Fund Indonesia, Jalan Jenderal Sudirman Kavling 31, 12920, Jakarta, Indonesia. whawley@unicef.org.
authors.forename: William A
authors.initials: WA
authors.lastname: Hawley
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D007214:Indonesia; D059232:Laboratory Personnel / Q000706:statistics & numerical data; D008288:Malaria / Q000175:diagnosis* / Q000517:prevention & control; D008297:Male; D008853:Microscopy / Q000592:standards* / Q000706:statistics & numerical data; D008875:Middle Aged; D011795:Surveys and Questionnaires; D055815:Young Adult