title: The usefulness of school-based syndromic surveillance for detecting malaria epidemics: experiences from a pilot project in Ethiopia.
abstract: BACKGROUND
  Syndromic surveillance is a supplementary approach to routine surveillance, using pre-diagnostic and non-clinical surrogate data to identify possible infectious disease outbreaks. To date, syndromic surveillance has primarily been used in high-income countries for diseases such as influenza--however, the approach may also be relevant to resource-poor settings. This study investigated the potential for monitoring school absenteeism and febrile illness, as part of a school-based surveillance system to identify localised malaria epidemics in Ethiopia.
  
  
  METHODS
  Repeated cross-sectional school- and community-based surveys were conducted in six epidemic-prone districts in southern Ethiopia during the 2012 minor malaria transmission season to characterise prospective surrogate and syndromic indicators of malaria burden. Changes in these indicators over the transmission season were compared to standard indicators of malaria (clinical and confirmed cases) at proximal health facilities. Subsequently, two pilot surveillance systems were implemented, each at ten sites throughout the peak transmission season. Indicators piloted were school attendance recorded by teachers, or child-reported recent absenteeism from school and reported febrile illness.
  
  
  RESULTS
  Lack of seasonal increase in malaria burden limited the ability to evaluate sensitivity of the piloted syndromic surveillance systems compared to existing surveillance at health facilities. Weekly absenteeism was easily calculated by school staff using existing attendance registers, while syndromic indicators were more challenging to collect weekly from schoolchildren. In this setting, enrolment of school-aged children was found to be low, at 54%. Non-enrolment was associated with low household wealth, lack of parental education, household size, and distance from school.
  
  
  CONCLUSIONS
  School absenteeism is a plausible simple indicator of unusual health events within a community, such as malaria epidemics, but the sensitivity of an absenteeism-based surveillance system to detect epidemics could not be rigorously evaluated in this study. Further piloting during a demonstrated increase in malaria transmission within a community is recommended.
authors.affiliation: Malaria Consortium, London, UK. rashton@tulane.edu.|Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK. rashton@tulane.edu.
authors.forename: Ruth A
authors.initials: RA
authors.lastname: Ashton
authors.affiliation: Malaria Consortium Ethiopia, Addis Ababa, Ethiopia. t.kefyalew@malariaconsortium.org.
authors.forename: Takele
authors.initials: T
authors.lastname: Kefyalew
authors.affiliation: Malaria Consortium Southern Nations, Nationalities and People's Regional State sub-office, Hawassa, Ethiopia. e.batisso@malariaconsortium.org.
authors.forename: Esey
authors.initials: E
authors.lastname: Batisso
authors.affiliation: Malaria Consortium Southern Nations, Nationalities and People's Regional State sub-office, Hawassa, Ethiopia. t.awano@malariaconsortium.org.
authors.forename: Tessema
authors.initials: T
authors.lastname: Awano
authors.affiliation: Malaria Consortium Ethiopia, Addis Ababa, Ethiopia. z.kebede@malariaconsortium.org.
authors.forename: Zelalem
authors.initials: Z
authors.lastname: Kebede
authors.affiliation: Malaria Consortium Ethiopia, Addis Ababa, Ethiopia. g_tesfaye@yahoo.com.
authors.forename: Gezahegn
authors.initials: G
authors.lastname: Tesfaye
authors.affiliation: Southern Nations, Nationalities and People's Regional State Health Bureau, Hawassa, Ethiopia. tamex23@yahoo.com.
authors.forename: Tamiru
authors.initials: T
authors.lastname: Mesele
authors.affiliation: President's Malaria Initiative, U.S. Agency for International Development, Addis Ababa, Ethiopia. schibsa@usaid.gov.
authors.forename: Sheleme
authors.initials: S
authors.lastname: Chibsa
authors.affiliation: Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK. rreithinger@yahoo.co.uk.|RTI International, Washington, DC, USA. rreithinger@yahoo.co.uk.
authors.forename: Richard
authors.initials: R
authors.lastname: Reithinger
authors.affiliation: Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK. simon.brooker@lshtm.ac.uk.
authors.forename: Simon J
authors.initials: SJ
authors.lastname: Brooker
mesh_terms: D000041:Absenteeism; D000293:Adolescent; D002648:Child; D003430:Cross-Sectional Studies; D004196:Disease Outbreaks; D058872:Epidemics; D005002:Ethiopia / Q000453:epidemiology; D005260:Female; D005334:Fever / Q000453:epidemiology; D006268:Health Facilities; D006801:Humans; D007251:Influenza, Human / Q000453:epidemiology; D008288:Malaria / Q000453:epidemiology*; D008297:Male; D010865:Pilot Projects; D011159:Population Surveillance / Q000379:methods*; D011446:Prospective Studies; D012574:Schools