Phase II (Survey II) Report Child and Adult Surveys
Resolving the Critical Challenges Now Facing the Global Programme to Eliminate
Lymphatic Filariasis
Research Questions:
1. To determine whether elimination program for lymphatic filariasis in three endemic districts of Sabah, Malaysia can be stopped or should be continued.
2. To test the usefulness of the newly developed WHO sampling and decision making method for stopping MDA (Transmission Assessment Surveyor TAS).
3. To compare the results of Survey I and Survey II
MALAYSIA Timeframe of on-site activities of the field survey: 23th April - 13rd May 2012
Universiti Sains Malaysia
Rahmah Noordin, Ph.D. Muhammad Hafiznur Yunus
26th June 2012 Table of Contents
Table of Contents ...... i List of Tables ...... iii List of Figures ...... iv 1.0 INTRODUCTION ...... 5 2.0 OBJECTIVES OF THE STUDy ...... 10 3.0 RESEARCH TEAM ...... 10 4.0 METHODOLOGY ...... 11 4.1. Child Surveys ...... 12 4.1.1. Study Evaluation Unit (EU) ...... 12 4.1.2. Survey Design ...... 12 4.1.3. Diagnostics Test and Sample Processing ...... 14 4.2. Adult Survey ...... 17 4.3. Survey Timeframe ...... 17 4.4. Limitations ...... 17 4.5. Data Analysis ...... 17 4.6. Ethical Consideration ...... 17 5.0 RESULTS ...... 19 5.1. Core Survey ...... 19 5.1.1. Overview ...... 19 5.1.2. Demographics ...... 20 5.1.3. Test Results ...... 21 5.1.3.1. Number and percent of Brugia Rapid (+) and Mf (+) ...... 21
5.1.3.2. Discordant Test Results ...... 22
5.1.3.3. Microfilaria (Mf) Density ...... 23
5.1.3.4. Comparison of Survey I and Survey II ...... 23
5.1.3.4.1. Statistical Analysis ...... 24
5.2. Adult Survey ...... 25 5.2.1. Demographic information ...... 25 5.2.2. Test Results ...... 25 5.2.2.1. Number and percent of Brugia Rapid (+) and Mf (+) ...... 25 5.2.2.2. Discordant Test Results ...... 26
5.2.2.3. Microfilaria (Mf) Density ...... 27
5.2.2.4. Comparison of Survey I and Survey II ...... 28
5.2.2.4.1. Statistical analysis ...... 28
6.0 DiSCUSSiON ...... 29 7.0 RECOMMENDATIONS ...... 35 8.0 CONCLUSIONS ...... 35 Appendix 1 List of Participants in Phase Ii Survey 11...... 37 Appendix 2 Training Agenda at Marudu Inn, Kota Marudu, Sabah ...... 39 Appendix 3 Planned Activities of Phase II, Survey II ...... 40 Appendix 4 Result sheet from Survey Sample Builder 1.3 for sample size determination ...... 42 Appendix 5 Timeline for Phase II, Survey II (2012) ...... 43 Appendix 6 Data on individuals with positive Brugia Rapid test and/or positive Mf results among school children ...... 44 Appendix 7 Data on individuals with positive Brugia Rapid test and/or positive Mf results among adults ...... 49 Appendix 8 Excerpts of Activities in Phase II, Survey 11...... 54
ii List of Tables
Table 1: Endemic Districts in Sabah, IUs and MDA information, 2004-2008 ...... 7
Table 2: Endemic districts and IUs which received the 6th MDA, 2010-2011 ...... 9
Table 3: Demographic Data in Proposed EU Survey Area ...... 13
Table 4: Sample Size Overview ...... 19
Table 5: Absentee estimation of core survey population ...... 20
Table 6: Demographic information of core survey population ...... 20
Table 7 : Result of all tests performed on core survey population ...... 21
Table 8: Brugia Rapid results classified by IU ...... 21
Table 9: Brugia Rapid results classified by gender...... 22
Table 10: Discordant test results in core survey population ...... 22
Table 11: Number of children with various microfilaria (Mf) densities ...... 23
Table 12: Comparison of Survey I and II for school children ...... 23
Table 13: Demographic information of adult population ...... 25
Table 14: Result of all test performed in adult population ...... 25
Table 15: Brugia Rapid results stratified by IU ...... 26
Table 16: Brugia Rapid results stratified by gender...... 26
Table 17: Discordant test results in adult population ...... 26
Table 18: Number of adults with various microfilaria (Mf) densities ...... 27
Table 19: Comparison of Survey I and II for adult study ...... 28
iii List of Figures
Figure 1: Lymphatic filariasis endemic districts in the state of Sabah, Malaysia ...... 6
Figure 2: Lymphatic Filariasis endemic IUs in Beluran, Sabah ...... 8
Figure 3: Flow chart of the sampling and testing processes of school children ...... 16
Figure 4: Flow chart of the sampling and testing processes of adults ...... 18
iv 1.0 INTRODUCTION
The National Programme for Elimination of Lymphatic Filariasis (PELF) in Malaysia was
launched in October 2003. The Malaysian state of Sabah is a lymphatic filariasis (LF) endemic
area, with 17 IUs in six districts identified as "red", and encompassing a total population of 108,281.
The Programme in these areas began in year 2004, and by year 2008, five cycles of mass-drug
administration (MDA, single dose of DEC combined with albendazole) had been completed. Figure
1 shows a map of the LF endemic districts in Sabah.
In Dec 2007, we have performed Phase I of the study in the IU of Tangkarason located in
the district of Beluran. Out of 1,212 night samples obtained, 32 were found to be Mf+ (2.64%). All
these individuals were subsequently given the full course of DEC treatment. In year 2008, after the
5th MDA cycle, the Sabah Health Office reported that the Mf rate was 0%.
In planning the Phase II study, the areas were selected based on the guidelines provided by
the Task Force. One of them is that the IUs or EUs chosen preferably should have carried out the
5th MDA cycle more than 9 months before the start of the study. Table 1 shows the MDA
completion dates and coverage of IUs in the endemic districts in Sabah. Based on MDA data and
accessibility of the areas, the districts of Beluran, Pitas and Kota Marudu were chosen for the Phase
II study, and these three districts were considered as one Evaluation Unit (EU). Figure 2 shows the
endemic IUs of Beluran, which is the biggest district in this study.
In April 2010, Phase II, Survey I of the study was successfully carried out in the districts of
Beluran, Pitas and Kota Marudu involving 9 endemic IUs. The critical cut-off level of antibody
positives (using PanLF Rapid) among core survey group (children) was 16. Out of 1434 samples
collected, samples from 90 children were found to be PanLF Rapid positive, which greatly exceeded
the cut-off level. This showed that there was still a significant rate of infected children in the area
and that LF transmission has not ceased, thus MDA in the EU should be continued.
Based on the results of the Phase II Survey 1 study, a decision was made by Ministry of
Health Malaysia and Sabah Health Office to carry out two more MDA cycles in the EU in 2010 and
2011. However due to problems of DEC supply, only one MDA was administered to 8 IUs and no
MDA was given in 1 IU. Table 2 shows the IUs and the time of the 6th MDA cycle.
5 SAMH MAP:LYMPHATtCFItAIUASIS ENCl_ DlSTMCTS
NItA,
Figure 1: Lymphatic filariasis endemic districts in the state of Sabah, Malaysia
6 Table 1: Endemic Districts in Sabah, IUs and MDA information, 2004-2008
?;;";';;~~~(irj';,;{·N: ;:;; c,;~: ':"~;"':"'i:MD~:coverage(~l"" ...... ,'\ ....•... ,; Date ofMDA t';' :;';!;:?,{.·\'<~·;;i~i;'.:.(:;> ... ,·!;~l;,·· '~ .. " ",'" ~-:': -)~,:,,!' "~'"' ,"'j..,.";;:~:,,.,,;"'; -, ',";; ;;r;::,;~=~~tJ!~7~;> ,.'" ~~~jJTI~,< ,.....• '2'aQ42;"2Cl05~~:, ."2P0620Q7· 02()(lSr ;~~:qmpJetion, i§! ;;S~;;.}!;;;~;J; "0;; ..... ;',:: .,i·;;";" :;;),;,'1,7.;':;.::, '';;:;;';'';.;'~''f;'''<; ;'i::.. ;";',';... Ii . ,;c'.:"', ~";;:?:':;":':).,; !-c<-'·,'t::,':' s;;;,·">'·"',,;.:,·,-,/ Kudat Bangi 92.80 95.89 97.95 98.87 99.20 14.05.2007 Kota Marudu Talantang 98.72 99.15 93.63 81.40 83.80 01.04.2008 Pitas Pitas 86.00 93.00 87.00 91.00 91.54 11.12.2008 Beluran 81.57 85.48 86.04 94.79 93.40 06.06.2008 Kuala Sa pi 77.82 90.76 96.23 95.37 98.50 28.06.2008 Jambongan 90.20 91.79 93.82 89.33 95.80 12.04.2008 Beluran Tangkara- 89.90 95.71 98.62 97.76 96.40 29.05.2008 son Pamol 87.54 93.64 98.28 98.57 99.50 19.06.2008 Sungai- 88.72 94.68 99.40 99.20 96.40 29.05.2008 Sungai Ulu Liwagu 79.76 85.35 80.43 86.71 99.07 27.05.2008 Kinabatangan Sukau 18.40 83.90 86.30 73.00 75.30 01.11.2008 Limbawang 97.41 86.58 85.56 84.56 84.60 13.07.2007 Kota Klias 96.85 89.39 86.22 85.39 85.40 31.07.2007 Beaufort Weston 98.35 88.13 92.81 95.64 95.60 30.08.2007 Gadong 96.08 85.56 89.60 89.43 89.40 08.05.2007 Padas Damit 99.14 91.73 93.41 92.36 92.40 21.06.2007 Bangkalalak 99.73 95.14 98.25 97.55 97.60 12.06.2007
7 KEYS:
1. Beluran 6. Sungai-Sungai
2. Kuala Sa pi 7. Ulu Liwagu
3. Jambongan 8. Liwagu
4. Tangkarason 9. Tetabuan
5. Pamol 10. Kaingaran
Figure 2: Lymphatic Filariasis endemic IUs in Beluran, Sabah
8 Table 2: Endemic districts and IUs which received the 6th MDA, 2010-2011
Kota Marudu Talantang None Pitas Pantai Sept - Oct 2010 86 Beluran March-April 2011 92 Kuala Sapi March-July 2011 96 Jambongan March 2011 88 Beluran Tangkarason March-June 2011 92 Pamol April-May 2011 95 Sungai-Sungai March-May 2011 93 Ulu Liwagu March 2011 88
9 2.0 OBJECTIVES OF THE STUDY
There were two main objectives of the Phase II, Survey II of the study:
1. To determine whether elimination program in lymphatic filariasis in three endemic districts
(Beluran, Pitas, and Kota Marudu) of Sabah, Malaysia can be stopped or should be continued.
2. To test the usefulness of the newly developed WHO sampling and decision making method for
stopping MDA (Transmission Assessment Surveyor TAS).
3. To compare the results of Survey I and Survey II
3.0 RESEARCH TEAM
The lead researchers were as follows:
1. Prof. Dr. Rahmah Noordin- Universiti Sains Malaysia (principal investigator)
2. Dr. Jenarun Jelip-Sabah Health Office
3. Dr. Rose Faiza Hanim Bt Mohamad Soyoti -Ministry of Health Malaysia
4. Dr.Lokman Hakim- Ministry of Health Malaysia
5. Brian Chu -Task Force for Global Health, Atlanta, USA
6. Alex Pavluck- Task Force for Global Health, Atlanta, USA
7. Muhammad Hafiznur Yunus - Universiti Sains Malaysia
8. Zulkarnain Md. Idris - Universiti Kebangsaan Malaysia
In addition there was 33 staff from Health Offices from various districts (inclusive of 9 drivers). They
comprised people from various backgrounds- public health assistants, environmental health
assistants, medical laboratory technologists, and general workers. The research teams were divided
into five field teams. A foreign research student from USA under the supervision of Prof. Rahmah,
Julie Olson, also accompanied the team to help out and to gain experience in LF field research. The
details of each participant and team members are provided in the Appendix 1.
10 The Sabah Health Offices provided eight 4-wheel drive vehicles and four small engine powered boats,
these vehicles were indispensable for this study since most of the locations were logistically
challenging.
4.0 METHODOLOGY
The field study began by a two day training and workshop session on 23rd and 24th April, 2012 at Kota
Marudu Inn, by Mr. Alex Pavluck, Mr. Brian Chu and Prof. Rahmah Noordin. Lectures and hand-on
sessions covered topics such as background and objectives of the study, study protocols, how to
perform and interpret the Brugia Rapids, how to make the three line blood smears, how to spot and
dry the blood on the filter papers, the use of the smartphones, scanners, labels. Many topics and
issues related to the conduct of the study and troubleshooting strategies were also discussed.
Appendix 2 shows the agenda of the two day training and workshop.
The day-to-day plan of activities of the study is shown in Appendix 3. Various field laboratories (base
camps) were set up during the study period, which comprised a government house, designated areas
in motels and a health centre.
11 4.1. Child Surveys
4.1.1. Study Evaluation Unit (EU)
Table 3 shows the demographic data from the six endemic districts. The endemic IUs of
Beluran, Pitas, and Kota Marudu have a total population of 89,855, 4,179, and 4,663
respectively, and all these IUs was considered as one EU in this study with a total population of
98,697.
4.1.2. Survey Design
The survey design was based on the antigenemia survey guidelines manual provided by
Centers for Disease Control and Prevention (CDC). This manual provides an algorithm for
deciding if mass drug administrations (MDAs) can be stopped. To simplify the manual, a
computer program called Sample Builder (SSB) version 1.3 was developed by The Task Force
for Global Health (Lymphatic Filariasis Support Center), which automatically provides sample
sizes as shown in Appendix 4.
In this study, all nine endemic IUs in Beluran, Pitas and Kota Marudu were considered as one
EU. Primary schooling in Malaysia began at 7 years old and attendance is mandatory, thus the
net primary enrollment rate can be assumed to be almost 100%. There were 62 primary
schools in the EU, and the total population of 1st and 2nd grade school children in the EU was
3,396. Since there were sufficient number of schools and children in years 1 and 2, school
based cluster sampling was justified.
12 Table 3: Demographic Data in Proposed EU Survey Area
;,,~~~~~,t :rs'Qlio{ijrs;1Ul.IU''i7)!2IT~2: ; .' :"~ '\,,?:::~~':'- :S,'.) ~\:~,«;}~~:, ,'~~; '>; ':,' 2 264 Pitas 39,128 Pantai 4,179 2 294 Beluran 23,432 13 886 Kuala Sapi 11,370 8 304 Jambongan 3,237 3 76 Beluran 113,023 T angkarason 11,476 15 360 Pamol 10,962 6 300 Sungai-Sungai 14,870 7 560 Ulu Liwagu 14,508 6 352 TOTAL EU 232,690 9 endemic IUs 98,697 62 3,396 13 According to the SSB calculation, the required sample size for school-based cluster design was 1,368 children, and the minimum number of schools that should be sampled was 33. In comparison, 30 schools were sampled during Survey I in 2010. Using the computer program, the 33 schools were randomly selected from the total of 62 schools. Based on the manual, the critical cut-off for Survey II was 16, this is thus the maximum number of antibody positives (Brugia Rapid test results) 'allowable' for the EU. Thus if the number of school children with positive Brugia Rapid results were 16 or below, then the MDA in the EU can be stopped. On the other hand if the number of children with positive Brugia Rapid results were more than 16, then MDA should be continued. In addition, the survey also included adults numbering between 914 and 1514 (aged 16-45 years) who resided in the communities around the selected schools. We have selected a sample number of 1000 for this population based on the manual. Thus the total number of samples for children and adults planned for Survey II was 2368. 4.1.3. Diagnostics Test and Sample Processing All the tests used in this study were performed according to the standard operating procedures (SOP) provided. A custom-made bar coding system and electronic data collection was used to reduce human error, allowed good traceability and daily data analyses. Figure 3 shows the flow chart of the sampling and testing processes of the school children which constituted the core survey group. Several weeks before the actual field survey, the staff of the Sabah Health Office went to the selected schools and explained to the head of school and teachers on the objective and conduct of the survey, as well as the requirements of the study i.e. student list, desks/tables, chairs, area for sampling and area for performing the 14 Brugia Rapid test. On the day of sampling, first the team leader went to see the school head who then mobilized the teachers to help with setting up of the sampling and the testing area, as well as queuing up of the students for the sampling. From each student, approximately 100 IJL of finger-prick blood were collected in EDTA-coated microtubes. After all the students have been sampled, the team sat down in the deSignated area and performed the Brugia Rapid tests. The test used 35 IJL of the whole blood. The results of the test were then written on the cassette with a marker pen. If time permitted, data entry into the smartphone was performed on site, if not this was performed when the team returned to the field laboratory (base camp). The house addresses of the children with the positive Brugia Rapid test results were then obtained from school head/teacher to enable the team to return to their homes at night to collect night finger-prick blood samples. During the night sampling, about 100 IJL of blood was obtained from each student in EDTA coated microtubes. Next day in the field laboratory, 60 IJL of each blood sample was used to make three-line blood smear. The blood smears were air-dried overnight and then stained with Giemsa as per the SOP provided. Due to the lack of experienced microscopist among the field teams, all stained blood smears were brought back to the Institute for Research in Molecular Medicine (INFORMM) at USM where a senior and experienced microscopist carefully examined all the slides, followed by data entry. As a token of appreciation, the children who provided the blood samples were each given a "goody bag" containing sweets and chips. 15 Enter basic personal and epidemiological information from study subjects into smartphone 1 I Finger-prick of subjects and transfer into an EDTA-coated tube I ! Perform Brugia Rapid test ! Data entry 1 1 1 Negative result Positive result ! Data entry Obtain 100 III of night blood into EDTA-coated tubes. Place in cool box. Next day, make thick blood smears with 60 III of blood. Air dry, stain slide with Giemsa stain (Microscopic examination performed at USM) Data entry Figure 3: Flow chart of the sampling and testing processes of school children 16 4.2. Adult Survey The target sample number of adults (16-45 years old) to be sampled was1,000. About 30-40 adults were randomly selected from the adults who lived around the vicinity of each school. House to house sampling was performed. Most of the Brugia Rapid tests were performed in the field laboratory. The rest of the procedure was as described for the children core survey. Figure 4 shows the flow chart of the sampling and testing processes of the adults. 4.3. Survey Timeframe Timeline of Survey II of the study is shown in the Appendix 5. 4.4. Limitations Limitations are described in Discussion part of the report. 4.5. Data Analysis An Android phone based on Open Data Kit (ODK) was used for data collection for the operational study for Survey II. Six smartphones were provided for 5 field teams and 1 lab team. All collected data were then downloaded into website database. The final complete dataset were downloaded from the website to be analyzed using Microsoft Excel software. 4.6. Ethical Consideration Ethical approvals were obtained from both Universiti Sains Malaysia and Ministry of Health Malaysia. 17 Enter basic personal and epidemiological information from study subjects (16-45 years old) into smartphone 1 Finger-prick of subjects and transfer into an EDTA-coated tube ! Perform Brugia Rapid test 1 Data entry 1 ! 1 Negative result Positive result ! Data entry Obtain 100 III of night blood into EDTA-coated tubes. Place in cool box. Next day, make thick blood smears with 60 III of blood. Air dry, stain slide with Giemsa stain (Microscopic examination performed at USM) Data entry Figure 4: Flow chart of the sampling and testing processes of adults 18 5.0 RESULTS 5.1. Core Survey 5.1.1. Overview Table 4: Sample Size Overview Pitas Pantai SK. Kanibungon 141 139 Kota Marudu Talantang SK. Talantang 120 115 SK. Sg. Napas 46 46 SK. Sg. Nangka 45 45 SK. Balaban Jaya 51 51 Beluran SK. Pekan 213 212 SK. Ulu Muanad 49 49 SK Lungmanis 53 53 SK Labuk Subur 31 31 SK. Pekan Telupid 178 178 Ulu Liwagu SK. Batu 4 49 48 SK Miruru 49 49 SK. Tagas-Tagas 20 20 SK. Sabapalm 30 30 SK. Ulu Sa pi 107 107 Kuala Sa pi Sk. Sualok 34 33 Sk. Lidong 17 17 Beluran SK. Perancangan 22 22 SK. Nangoh 63 63 Pamol SK. Pamol 65 65 SK. Binsulung 36 36 SK. Lingkabau 15 15 Sungai-Sungai SK. Sungai-sungai 45 44 SK Pantai Boring 13 13 SK. Terusan Sugut 8 8 SK. Simpangan 47 47 SK Lubang Buaya 13 13 Tangkarason SKMaidan 5 5 SKGolong 26 26 SK Kabuluh 53 53 SK Jambongan 13 13 Jambongan SK. Malalin 17 17 SKObah 21 21 Total (n=) 1695 1684 * Invalid tests, samples not tested, individuals registered but not sampled and three children (two 9 years old male and one 11 years old female) are excluded in this table and omitted in all analysis involve in the study. 19 Table 5: Absentee estimation of core survey population Kota Marudu Talantang 135 120 15 11.1 Pitas Pantai 161 139 22 13.7 Jambongan 60 51 9 15.0 Tangkarason 215 144 71 33.0 Sungai-sungai 227 117 110 48.5 Beluran Ulu Liwagu 302 275 27 8.9 Pamol 154 128 26 16.9 Beluran 610 488 122 20.0 Kuala Sapi 261 230 31 11.9 Total (n=) 2125 1692 433 20.4 *8ased on info from school registration **Inclusive of children who were absent from school and those who refused to be sampled 5.1.2. Demographics Table 6: Demographic information of core survey population 6 1 0 1 (0.1%) 7 415 403 818 (48.3%) 8 409 464 873 (51.6%) Total (n=) 825 (48.8%) 867 (51.2%) 1692 20 5.1.3. Test Results 5.1.3.1. Number and percent of Brugia Rapid (+) and Mf (+) Table 7 : Result of all tests performed on core survey population Positive 73/1692 (4.3%) 15/61 (24.6%) Negative 1611/1692 (95.2%) 46/61 (75.4%) Invalid 0/1692 (0.0%) 0/61 % (0.0%) Not tested* 8/1692 (0.5%) 0/61 (0.0%) Total 1692 61** *Reasons for not tested: 2 - No consent 3 - Refused 2 - Insufficient blood 1 - Blood clotted ** 12 children were 'missing' due to difficulties to trace the locations of their homes Table 8: Brugia Rapid results classified by IU ;-r!~t'~~~M\~ .• ;.,,:.'t{~~~,ii,~~l';' Tangkarason 34/144 (23.6%) 110/144 (76.4%) 0/144 (0.0%) Kuala Sa pi 15/230 (6.5%) 214/230 (93.0%) 1/230 (0.4%) Pantai 6/139 (4.3%) 133/139 (95.7%) 0/139 (0.0%) Jambongan 2/51 (3.9%) 49/51 (96.1 %) 0/51 (0.0%) Talantang 2/120 (1.7%) 113/120 (94.2%) 5/120 (4.2%) Beluran 8/488 (1.6%) 479/488 (98.2%) 1/488 (0.2%) Ulu Liwagu 4/275 (1.5%) 271/275 (98.5%) 0/275 (0.0%) Sungai-sungai 1/117 (0.9%) 115/117 (98.3%) 1/117 (0.9%) Pamol 1/128 (0.8%) 127/128 (99.2%) 0/128 (0.0%) Total 73/1692 (4.3%) 1611/1692 (95.2%) 8/1692 (0.5%) 21 Table 9: Brugia Rapid results classified by gender Positive 34/825 (4.1 %) 39/867 (4.5%) Negative 790/825 (95.8%) 821/867 (94.7%) Not tested 1/825 (0.1 %) 7/867 (0.8%) Total 825 867 5.1.3.2. Discordant Test Results Table 10: Discordant test results in core survey population 1 Positive Negative 46 2 Positive Not tested o Total Discordant Results (n=) 46 22 5.1.3.3. Microfilaria (Mf) Density Table 11: Number of children with various microfilaria (Mf) densities 1-10 12 11-20 1 21-40 0 41-60 2 TOTAL 15 5.1.3.4. Comparison of Survey I and Survey II Table 12: Comparison of Survey I and II for school children Ab (PanLF/BmR1) Target sample size 1368 1368 Critical cutoff 16 16 Schools surveyed 32 33 Actual sample (n) 1434 1692 Positive 90/1434 (6.3%) 73/1692 (4.3%) Negative 1339/1434 (93.2%) 1611/1692 (95.2%) Invalid 1/1434 (0.1 %) 0/1692 (0.0%) Not tested 4/1434 (0.3%) 8/1692 (0.5%) Mf (Blood smear) n 87 61 Positive 31/87 (35.6%) 15/61 (24.6%) Negative 56/87 (64.4%) 46/61 (75.4%) Invalid 0/87 (0.0%) 0/61 (0.0%) Not tested 0/87 (0.0%) 0/61 (0.0%) Mf(PCR) n 87 Positive 46/87 (52.9%) NO Negative 40/87 (46.0%) NO Invalid 0/87 (0.0%) NO Not tested 1187 (1.1%) NO NO: not done 23 5.1.3.4.1. Statistical Analysis Using Chi Square test (SPSS version 20.0): 1. Comparison of difference in IgG4 antibody prevalence between Survey I and Survey II was found to be significant, p= 0.014 2. Comparison of difference in Mf prevalence between Survey I and Survey II was found to be not significant, p=0.1S3 24 5.2. Adult Survey 5.2.1. Demographic information Table 13: Demographic information of adult population 16-20 79 101 180 (17.3%) 21-25 79 82 161 (15.5%) 26-30 93 102 195 (18.8%) 31-35 73 108 181 (17.4%) 36-40 71 84 155 (14.9%) 41-45 75 91 166 (16.0%) Total (n=) 470 (45.3%) 568 (54.7%) 1038 5.2.2. Test Results 5.2.2.1. Number and percent of Brugia Rapid (+) and Mf (+) Table 14: Result of all test performed in adult population Positive 77/1038 (7.4%) 17/73 (23.4%) Negative 960/1038 (92.5%) 56/73 (76.7%) Invalid & Not tested 1/1038 (0.1%) 0173 (%) Total (n=) 1038 73 * i) Invalid = 0 ii) Not tested =1 (Clotted blood) 25 Table 15: Brugia Rapid results stratified by IU ,,()\~C~Fi';::: :,'~1-:;~?~ .', ,{>~;~;A~~;:/~.~;/l~:;l.:'::, Pantai 2/33 (6.1%) 0/33 (0.0%) Talantang 0/30 (0.0%) 29/30 (96.7%) 1/30 (3.3%) Beluran 6/241 (2.5%) 235/241 (97.5%) 0/241 (0.0%) Ulu Liwagu 1/96 (1.0%) 95/96 (99.0%) 0/96 (0.0%) Kuala Sa pi 16/184 (8.7%) 168/184 (91.3%) 0/184 (0.0%) Pamol 1/67 (1.5%) 66/67 (98.5%) 0/67 (0.0%) Sungai-sungai 9/150 (6.0%) 141/150 (94.0%) 0/150 (0.0%) Tangkarason 40/158 (25.3%) 118/158 (74.7%) 0/158 (0.0%) Jambongan 2/79 (2.5%) 77179 (97.5%) 0179 (0.0%) Total 77/1038 (7.4%) 960/1038 (92.5%) 1/1038 (0.1%) Table 16: Brugia Rapid results stratified by gender Positive 49/470 (10.4%) 28/568 (4.9%) Negative 421/470 (89.6%) 539/568 (94.9%) Not tested 0/470 (0.0%) 1/568 (0.2%) Total 470 568 5.2.2.2. Discordant Test Results Table 17: Discordant test results in adult population 1 Positive Negative 56 2 Positive Not tested o Total Discordant Results (n=) 56 26 5.2.2.3. Microfilaria (Mf) Density Table 18: Number of adults with various microfilaria (Mf) densities 1-10 13 11-20 1 21-40 1 41-60 1 61-80 0 81-90 0 91-100 0 >100 1 TOTAL 17 27 5.2.2.4. Comparison of Survey I and Survey II Table 19: Comparison of Survey I and II for adult study Ab (PanLF/BmR1) Target sample size 1000 1000 Adult surveyed, n 1007 1038 Positive 132/1007 (13.1%) 77/1038 (7.4%) Negative 874/1007 (86.8%) 960/1038 (92.5%) Invalid 010 (0.0%) 0/1038 (0.0%) Not tested 1/1007 (0.1%) 1/1038 (0.1%) Mf (Blood smear) n 128 73 Positive 29/128 (22.7%) 17173 (23.4%) Negative 99/128 (77.3%) 56/73 (76.7%) Invalid 0/128 (0.0%) 0173 (0.0%) Not tested 0/128 (0.0%) 0173 (0.0%) Mf (PCR) n 128 Positive 37/128 (28.9%) Negative 88/128 (68.8%) Invalid 0/128 (0.0%) Not tested 3/128 (2.3%) 5.2.2.4.1. Statistical analysis Using Chi Square test (SPSS version 20.0): 1. Comparison of difference in IgG4 antibody prevalence between Survey I and Survey II was found to be significant, p= 0.001 2. Comparison of difference in Mf prevalence between Survey I and Survey lI·was found to be not significant, p= 0.916 Appendices 6 and 7 show data of individuals with positive Brugia Rapid test andlor positive Mf results among school children and adults respectively. Appendix 8 shows some pictures of the activities at various stages of the survey. 28 6.0 DISCUSSION Sabah is an exclusively brugian filariasis area (Brugia malaY/), thus the first line diagnostic tool used in this study to assess the prevalence of lymphatic filariasis was a lateral flow cassette test called Brugia Rapid. It is an IgG4-based assay using filarial recombinant antigen (BmR1), and detects infection by both B. malayi and B. timori. The sensitivity and specificity of the test have been previously shown to be 94-100% and 99-100% respectively. In addition, thick blood smears from positive Brugia Rapid individuals using night-blood were also performed in order to determine the presence (and density) of the microfilariae. Surveys I and II were conducted in the same EU, and were performed in the same manner except for the following: 1. Brugia Rapid test was used in Survey II while panLF Rapid test was used in Survey I. This is not an issue since results of Phase I study (2007) showed that the two tests performed equally well in brugian filariasis endemic areas. 2. PDA system was used in Survey I while smartphone was used in Survey II. The latter was definitely superior in terms of field-friendliness and efficiency. 3. Blood spots for peR test was prepared in Survey I but not in Survey II. 4. The number of schools in Survey II was one more than in Survey I. 5. There were eight schools sampled in Survey II which were not sampled in Survey I. On the other hand there were seven schools sampled in Survey I which were not sampled in Survey II. For each Survey I and II, different versions of the "Sample Survey Builder" was used. In addition, in Survey II the percentage of expected absentee was factored in the sample calculation. These were the reasons for the differences described in no. 4 and 5 above. 29 The experience gathered during Survey I has enabled Survey II to be more organized and efficient. For example, a better approach of getting parental consent was introduced in Survey II, thus we did not face much problems with getting good cooperation from children and parents. The use of smartphone instead of PDA in this survey was very much welcomed by the research team. It was certainly a big improvement over the PDA used in Survey I. The data entry in Survey II was much smoother and more 'enjoyable' with the smartphone system. However there was one limitation of the smartphone which is described below. A total of 1692 of school children were sampled which comprised 0.1 % of 6-year-olds, 48.3% of 7-year-olds and 51.6% of 8-year-olds. There were almost equal percentages of participation from both genders. The actual percentage of children who were absent or refused consent was similar to the initial projected percentage of absentees used in the Survey Sample Builder i.e. -20%. Among the school children population, 4.3% (73/1692) tested positive by Brugia Rapid, with almost equal percentages of both genders. Thus this greatly exceeded the critical cut-off level of 16 Brugia Rapid positive individuals. Thus there was still a significant rate of Brugia Rapid positive children in the EU, indicating that active disease transmission was still occurring. Similar to the results of Survey I, the IU of Tangkarason, Kuala Sa pi and Pantai were among those with the high percentages of positive Brugia Rapid results. However the IU of Jambongan and Ulu Liwagu recorded 3.9 % and 1.5% prevalence rates in Survey II as compared to 0% in Survey I; and Sungai-sungai reported a decrease from 4.5% in Survey I to 0.9% in Survey II. Out of the 73 positive Brugia Rapid children, 61 night blood samples were available for blood smear examination. The results showed that 15/61 (24.6%) of the children who were IgG4 antibody positive were also Mf positive. The rather high number (n=12) of children without night 30 blood samples was due to the difficulty in locating their homes since they live far from the school which they attended. There were 258 more children sampled in Survey II as compared to Survey I. Also in Survey II, 324 more children than the targeted sample size were sampled. The increase in the number of children sampled in Survey II was due to two reasons: i. As compared to Survey 1, there was one more school sampled in Survey II ii. For some schools, the numbers of students reported by the State Education Department were less than the number actually recorded in the school registration books. Thus in the middle of the study, there were shortages of some supplies (blood collection tube, lancet and Brugia Rapid kits) and we had to arrange an emergency purchase of these supplies to be sent to the field. Fortunately the Malaysian scientific companies had ex-stocks of these items for urgent delivery to the study area. Brugia Rapid detects IgG4 antibodies to Mf and adult worms while blood smears detects the presence of the larvae. When comparing results of Survey I and II, there was a significant reduction in the number of IgG4 antibody positive children, thus this shows that additional MDA received by the population was able to significantly reduce the number of infected children in the EU. However, it is interesting to note that the reduction in Mf prevalence in the IgG4 antibody positive children was not significantly different. It is not clear how this may be interpreted. Some relevant points to consider are: 1. The number of Brugia Rapid positives examined for presence of Mf is not large enough to be used to compare between Survey I and II. In addition, there were unequal total number of Brugia Rapid positive tests between the two surveys, with Survey II having 16 less individuals who were positive. 31 2. After Survey I, only Mf+ positive children were treated and Mf- children with IgG4 positive results were not treated. Could this be a factor that leads to this result? It is also notable that the Mf density of the positive children in Survey" was generally lower than in Survey J. In Survey II, most children had Mf density of 1-10 Mf/smear and only two children had the highest level of 41-60 Mf/smear. In contrast Survey I showed that most children had larvae density 1-15 Mf/smear and there were 10 children with larvae density of more than 50 Mf/smear (inclusive of 7 children with >100 Mf/smear). Thus the extra MDA performed after Survey I seemed to have an impact on the Mf density among the core group. In the survey on adults, a total of 1038 individuals ages 16 to 46 years old were sampled; and 7.4% (77/1038) were positive by Brugia Rapid. There was almost twice the rate of positive males as compared to females, although there was 100 more females than males who participated in the study. This may reflect the greater amount of time spent in outdoor activities by adult males as compared to females. The pattern of prevalence according to IUs was the same as that observed in the core group (children). A total 73 adults who were positive Brugia Rapid positive samples were available for night sampling for blood smear. The results showed that 17/73 (23.4%) of the adults were also positive for Mf. Similar to what was seen in the core group (children), there was a significant decrease in Brugia Rapid positive results from Survey I to Survey II, but no significant difference in Mf positive results between the two surveys. It is also interesting to note that the percentages of Mf positive in children (core group) and adults are similar. With regard to Mf density, there were only two individuals with larvae density of >50 Mf/smear in Survey II, as compared to 12 adults in Survey I, with 4 adults >1 OOMf/smear in the latter. Thus many aspects of the adult data seemed to be consistent with the core group. One exception was that the adults in IU of 32 Talantang had no Brugia Rapid positive in Survey II despite not receiving the 6th MDA. On the other hand, in the core group (children) there was an increase in prevalence from 0.75% (1/113) in Survey I to 1.7% (2/120) in Survey II. After Survey I, efforts had been made to increase MDA coverage and improve drug compliance; however the results of Survey II showed that transmission in the EU has not stopped. This could be due to the fact that only one MDA (instead of the required two MDAs) was given in the EU after Survey I due to the DEC supply problem. In addition, more 'drastic' measures may be needed to address this persistent endemic situation. Since anti-filarial IgG4 has been shown to be a marker of infection especially in children, perhaps all children with Brugia Rapid positive results (Mf+ or Mf-) should receive the full course of DEC treatment. Similarly, it may also be useful to provide the full DEC treatment course to all adults with Brugia Rapid positive results. Limitations of the study There were several limitations of Survey II, and many were similar as those reported in Survey I: (i) Challenges due to the logistics of the schools and villages. This is particularly felt during mobilization of team members and research supplies as well as setting up of field laboratories (base camps) and sampling activities. Most of the sampling sites were situated in remote rural areas with long hours of driving, rough terrains, and many areas with accessibility problems The various types of terrains included swamps, hilly areas, logging areas, palm oil plantations, and islands accessible by boats through rivers and open seas. Some of the rivers harbored crocodiles. The challenges were more acute during night sampling and on rainy days. (ii) There was an unexpected special school holidays (cuti peristiwa) in some schools, which affected some days of the sampling schedule. 33 (iii) There were several challenges faced at Paitan in the district of Beluran. One was shortage of water supply, but it was not a very acute problem in Survey" since it rained at intervals and rain water is the main source of water supply. In some areas there was neither gas station for refueling the petrol/diesel nor repair shop for minor repairs of the four wheel drive vehicles. (iv) Two of the six vehicles used for the entire study were rather old, and often broke down. Most of the tarred and dirt roads in the EU were littered with pot holes and bumps, thus it is understandable why vehicles in the area need regular servicing and repairs. In future, perhaps more research funds should be allocated for servicing and minor repairs of vehicles. (v) Rest periods were quite limited. Since the sampling activities at school started at 8am, sampling teams had to leave the base camp very early, and if there were positive results, they had to return at night. In areas which were far from the base camp, they had to wait in the village until night time to do the night sampling. (vi) Many areas had no mobile phone coverage. Thus it was difficult to communicate among sampling teams to update each other the ongoing situations and to get information. (vii) There were two issues faced with regard to the smartphone: a) One of the smartphone malfunctioned during one of the sampling days, thus manual recording of the data had to be performed. However, on that night at the base camp, one of the team members managed to make the smartphone work again, but it was unclear what the actual problem was. b) Some processes in the data entry were rather inefficient and redundant as some data fields need to be entered repeatedly. For instance, information such as team number, district, IU, school name had to be entered for each child from the same school. Thus for a school of 40 children, the same information has to be entered 34 40 times. This process is rather tiresome and may lead to errors. It would better if the repetitive information can be entered just once for each school. 7.0 RECOMMENDATIONS 1. MDA in the EU should be continued since prevalence of the IgG4 antibody test in the core group (children) exceeded the critical cut-off level of 16. In addition Mf prevalence of both core group and adults was not significantly different from Survey I performed two years ago. 2. Consideration should be made to treat children who were Brugia Rapid positive but Mf negative. 3. It may also be useful to treat adults who were Brugia Rapid positive but Mf negative. 4. There is room for improvement (as explained above) of the smartphone to increase the efficiency of data entry in schools. 8.0 CONCLUSIONS The WHO Transmission Assessment Survey (TAS) seemed to be very useful in assessing the status of the LF transmission in the EU in Sabah, Malaysia. The results of Survey II shows that LF transmission in the EU of Kota Marudu, Pitas and Beluran is still ongoing and thus further MDA cycles are necessary. Nevertheless the level of infection seemed to have decreased since Survey I in 2010, since Survey II showed significant decrease in Brugia Rapid positives in both the core group (children) and adults. Moreover the density of Mf in the thick blood smears in both children and adults also decreased in Survey II as compared to Survey I. 9.0 Acknowledgements This study was funded by a research grant from the Bill & Melinda Gates Foundation, obtained through the LF Support Centre at the Task Force for Child Survival & Development, Atlanta, 35 Georgia, USA. Our outmost gratitude goes to the Director of Sabah Health Office, all personnel from the various Sabah Health Offices and the populations at the districts of Beluran, Pitas and Kota Marudu. We would also to thank Zulkarnain Md. Idris for performing the statistical analysis. 36 Appendix 1 List of Participants in Phase II Survey II Assistant Director 28 Senior Principal Assistant Health Department Director 29 Assit Environmental Health Officer 37 Appendix 2 Training Agenda at Marudu Inn, Kota Marudu, Sabah M on d ay, 23rd A~pn "' , 2012 Time Activity 12.00 pm Check-in 12.30 - 2.00 pm Lunch 3.00 - 3.30 pm Tea 7.00 pm Dinner 8.00-8.30 pm Registration 8.30 -10.30 pm Welcoming speech & briefing on study by_ Prof. Rahmah Noordin 10.30 pm Supper Tuesday, 24th April,2012 Time Activity 7.00 am Breakfast 8.30-9.00 am Speech by Dr. Jenarun Jelip 9.00-10.00 am Briefing on sampling strategy by Alex PavlucklBrian 10.00-10.30 am Tea break 10.30am -12.00 pm Smartphone system training by Alex PavlucklBrian -Introduction of the system -Practical - entering data into the system 12.00 -12.30 pm Rapid test (Brugia Rapid) by Prof. Rahmah Noordin -principle of test 12.30 -2.00 pm Lunch 2.00 pm - 3.00 pm Diagnostic test training i) Blood collection -labeling -practical training on use of lancet and EDTA tube provided ii) Rapid test -labeling -training on performing and interpretation of test -data input into Smartphone 3.00-3.30pm Tea break 3.30-S.00pm .. cont. on rapid test training iii) Three line thick blood smear -performing the smear -labeling -data input into Smartphone iv) Blood spot training -labeling -spotting 5.00-6.00pm Adding GPS data into the Smart~hone idemo outsidEtl. 6.00-S.00pm Rest and dinner 8.00-10.30 pm Review/retrain as needed 10.30pm Supper th W e d nes d ay, 25 A~prl "' , 2012 Time Activity 7.00 am Breakfast 8.30-10.00 am Review/retrain as needed 10.00-10.30 am Tea break 10.30am -12.00 pm Review study implementation plan by Hafiznur 12.00 -12.30 pm Packing (Beluran & Pitas Team) 12.30-2.00 pm Lunch 2.00 pm End of training Check out & depart to Paitan (Beluran & Pitas team) 39 Appendix 3 Planned Activities of Phase II, Survey II DATE ACTIVITY Apr23,2012 Check in at Marudu Inn, Kota Marudu Apr24,2012 Training Apr 25,2012 Training (half day) PITAS STATION ( 1 team) - Check out from Marudu Inn and move to Pitas. TEAM FROM BELURAN ( 3 teams) - All 3 teams will move to Paitan. - They will prepare and clean the government quarters and arrange the research equipments (field lab). Apr 26,2012 PITAS STATION ( 1 team) - Sampling at SK Kanibongan (1 school) and communities surrounding the school area. - Rapid test positive individual will be followed-up by night blood sampling. The blood sample will then be taken to Paitan for staining and microscopy examination. - 1 night stay at Pitas. KOTA MARUDU STATION (1 team) - Sampling at SK Talantang (1 school) and communities surrounding the school area. - Rapid test positive individual will be followed-up night blood sampling. The blood sample will then carry to Paitan for staining and microscopy examination. PAITAN STATION (3 teams) - Sampling activities for schools and communities in 3 IUs: a. IV Jambongan: 3 school SK. Jambongan SK. Malalin SK.Obah Apr 27,2012 PAITAN STATION (5 teams) Apr 28,2012 a. Sampling IV Tangkarason: 5 schools Apr 29,2012 SK. Simpangan SK. Lubang Buaya Apr 30,2012 SK. Maidan May 1, 2012 SK. Golong SK. Kabuluh b. IV Sungai-sungai: 5 schools - SK. Sungai-sungai - SK. Binsulung - SK. Tampat - SK. Lingkabau ii. Sampling arrangement will be decided by local coordinators iii. Phase I Follow-up sampling activities during weekend. 40 May 2,2012 i. All 5 teams will move to Telupid and check in at Queen Alice Inn. ii. Briefing for the next sampling activities. May 3,2012 TELUPID STATION(5 teams) May 4,2012 i. Sampling activities for schools and communities in 3 IUs: May 5,2012 a. IU Ulu Liwagu: 3 school May 6,2012 - SK. Pekan Telupid - SK. Batu 4 May 7,2012 - SK. Miruru b. IU Pamol: 2 schools - SK. Nangoh - SK. Pamol c. IU Kuala Sap;: 6 schools - SK. Lidong - SK. Ulu Sapi - SK. Sualok - SK. Bintang Mas - SK. Tagas-tagas ii. Sampling arrangement will be decided by local coordinators. May 8,2012 i. Check out from Queen Alice Inn, Telupid. ii. Check in at Legend Motel, Beluran. iii. Briefing for the next sampling activities. May 9,2012 BELURAN STATION(5 teams) May 10, 2012 i. Sampling activities for school and communities in 3 IUs: May 11, 2012 a. IU Beluran: 7 schools - May 12, 2012 - SK. Sg Napas - SK. Sg Nangka - SK. Balaban Jaya - SK. Pekan - SK. Ulu Muanad - SK. Lungmanis - SK. Labuk Sabur ii. Sampling arrangement will be decided by local coordinators. May 13, 2012 i. Check out from Legend Motel and return home. 41 Appendix 4 Result sheet from Survey Sample Builder 1.3 for sample size determination Country: Malaysia Name of EU: Kota Marudu Pitas Beluran Primary Vector: Anopheles or Culex Demographic data on EU (provided by user) Population of 1st and 2nd year primary-school children: 3,396 Total number of schools: 62 Ave. number of 1st and 2nd year primary-school children per school: 55 *Note, if any of the above information is incorrect, return to the "Start Here" tab and click on the 'edit EU information' button Cluster Survey of School Entrants Survey Sampling Methodology (calculated by program) Sample Size for Cluster Design 1,368 Number of Clusters! 33 Sampling Fraction (of children within the schools)! Test all first and second graders Sampling Interval (of children within the schools)! N/A Critical Cut-off (maximum # positive ICT results allowable for country to "Pass") 16 1 Based on a 22.9% absentee rate 42 Appendix 5 Timeline for Phase II, Survey II (2012) 2012 Activitie~ Dec Jan Feb Mar Apr May June Finalized protocol, budget and deliverables I RB approval Sub-contract signed and sent Supplies delivered Funds wired 1. Training. 2. Visits to participants identified for Phase I follow-up Blood collection Blood processing Processing in referral labs Data entry and analysis Conclusions and initial report 43 Appendix 6 Data on individuals with positive Brugia Rapid test and/or positive Mf results among school children Slide (Mf No 10 District IU School Name Name Brugia rapid I Age No) 1 PMY3432 Beluran Kuala Sapi SK. Sua 10k Nikholas jay jasni 17 pas 55 2 I PMY2443 I Beluran I Tangkarason I SK. Golong I Christantiana baramli 18 pas 47 3 I PMY2456 I Beluran I Tangkarason I SK. Golong I Sanlin matajam 18 pas 11 4 PMY2840 Beluran Tan9karason SK. Golong Mohd elfrin nizam japrin 18 pas 8 5 I PMY2465 Beluran Tangkarason SK. Golong Shafik arbob 17 pas 7 6 PMY2454 Beluran Tangkarason SK. Golong I Fredechi asri chu fook sin 18 pas 4 7 I PMY3846 Beluran Beluran SK. Pekan I Auni insyirah aspar 18 pas 4 8 PMY1738 Beluran Beluran SK. S9. Napas I Joeromey turus 17 pas 3 9 I PMY2837 Beluran Kuala Sapi SK. Sualok 1 Heranitta domanik 17 pas 3 10 I PMY2258 I Beluran I Tangkarason I SK. Kabuluh I Juskie juri 18 pas 2 11 I PMY2441 I Beluran I Tangkarason I SK. Golong I Anita eyaco~ 18 pas 2 12 I PMY2448 I Beluran I Tangkarason I SK. Golong I K.fredlee karislin 18 pas 2 13 PMY2453 Beluran Tangkarason SK. Golong Frencilla insik 18 pas 2 14 I PMY2457 Beluran Tangkarason SK. Golong Kartini sandony 17 pas 2 15 1 PMY2434 Beluran Kuala Sapi SK. Sualok 1 Edmaoand mohamad 17 pas 16 I Kota PMY1062 Marudu I Talantana I SK. Talantana I Lvssa vennicia aurut 18 pas • 44 17 PMY1149 Beluran SK. Kabuluh S •• 0 1S I Kota PMY1201 Marudu SK. Talantan Riezan hildebrand herman 0 19 I PMY1375 I Beluran lUlu Liwagu I SK. Sabaealm I Rozalind Binti Jalimin IS 0 20 I PMY1516 I Beluran I Beluran I Jaya I Riana jusli 17 - 0 21 I PMY1533 I Beluran I Kuala Saei I SK. Ulu Saei I Patrisiah ahi Is - 0 22 I PMY1753 I Beluran I Beluran I SK. Sg. Nangka I Mohd khalid al walid 17 - 0 23 I PMY1931 I Beluran lUlu Liwagu I Telueid I Lovelyn irene liverinus Is -__.0 24 I PMY1962 I Beluran lUlu Liwagu I SK. Miruru I Chendeviah Cassius Clay Is 0 25 I PMY1963 I Beluran lUlu Liwagu I SK. Batu 4 I Alwyney jolly 17 - 0 26 ____0 I PMY19S2 I Beluran lUlu Liwagu I SK. Miruru I Clinoxlee yaeicon 17 - 27 I PMY2034 I Beluran I Kuala Sa pi I SK. Sualok I Velantine ramin Is 0 2S PMY2046 Beluran Kuala Sa pi SK. Sualok 1 Bryan owen edwin Is - •• 0 29 I SK. PMY2063 Pitas Pantai Kanibungon 1 Nor nilam sari bt nordin 17 •• 0 30 I SK. PMY2067 Pitas Pantai Kanibungon I Estefenia stecy maining 17 •• 0 31 I SK. PMY210S Pitas Pantai Kanibungon I Shueen liew 17 •• 0 32 I SK. PMY213S Pitas Pantai Kanibungon I Danyol jebson daransang 17 •• 0 33 I PMY220S I Beluran I Tangkarason I SK. Simeangan I Missale adik 17 0 34 PMY2245 I Beluran I Tanakarason I SK. Simoanaan I Wileam henrv 17 - e' 0 45 35 I PMY2345 Pitas Pantai Larina sutail 8 •• a 36 PMY2401 Beluran SK. Sualak 8 •• a 37 PMY2445 Beluran SK. Galan David chresle 'aikal 8 •• a 38 PMY2446 I Beluran I Tangkarasan I SK. Galang Ilgbal khan rashid 18 0 39 PMY2455 Beluran Tangkarasan SK. Galang Felix maikal 18 - •• a 40 I PMY2459 Beluran Tangkarasan SK. Galang Ana mazila anang 17 •• a 41 I PMY2477 I Beluran I Tangkarasan I SK. Kabuluh I Selvixsan kinsarun 18 0 42 I PMY2657 I Beluran lUlu Liwagu I SK. Saba~alm I Sherlin Binti Bujang 18 - 0 43 PMY2829 Beluran Kuala Sapi SK. Sualak Danaven carla danny 18 - •• a 44 I mahamad rafiq haslan bin PMY2845 Beluran Tangkarasan SK.Obah makirim 17 •• a 45 PMY2855 Beluran Tan karasan SK.Obah Nuranizah binti nasran 7 •• a 46 I SK. Lubang PMY2990 Beluran Tan karasan Bua a Raefili rasli a 47 SK. Lubang PMY3037 Beluran Tan karasan Bua a Christine 'uan a 48 PMY3066 Beluran Jeslina bte sabdin a 49 PMY3114 Beluran Mahd. Haikal fadhzil bin sanama 8 •• a 50 PMY3124 Beluran SK. Kabuluh Yerikha butiti 7 •• a 51 I PMY3256 Beluran Siti narshahidah .asmin a 52 PMY3267 I Beluran I Tanakarasan I SK. Kabuluh I Natashikin asmad 18 •• a 46 53 PMY3375 Beluran Tan karason Jessica rechard 0 54 PMY3434 Beluran Kuala Sa i SK. Lidon 0 55 1 PMY3443 1 Beluran 1 Ulu Liwagu 1 SK. Saba~alm Iintan Sakinah 17 0 56 I PMY3466 I Beluran I Kuala Sa~i I SK. Lidong I Noraslianih bte asli 18 - 0 57 PMY3477 Beluran Pamol SK. Nan oh Eisster orra I n ·aman - 0 58 PMY3572 Beluran Tan karason SK. Sim an an Harnitah naroh 0 59 I PMY3623 I Beluran I Beluran I SK. Sg. Nangka I Norshafika bt. Relica 18 0 60 I PMY3731 I Beluran I Beluran I SK. Pekan I S~ahnizam b m. Shahrin 17 - 0 61 I PMY3790 I Beluran I Beluran I SK. Pekan I Mohd aidil s~ahfig kamsan 17 - 0 62 PMY1163 Beluran Tangkarason SK. Kabuluh I Zita asman 18 - 63 I SK. PMY2020 Pitas Pantai Kanibungon 1Velintino manjim 17 64 I PMY2442 I Beluran I Tangkarason I SK. Golong I Biadidi petrus 18 65 PMY2562 I Beluran I Tanakarason I SK. Golono I Nexvico iusoina 18 66 PMY3063 I Beluran I Tanakarason I SK. Kabuluh I Norhaini anit 17 67 1 PMY3196 I Beluran I Tanakarason I SK. Kabuluh I Juralik iefrinus 17 68 PMY3236 I Beluran I Tanokarason I SK. Kabuluh I Nurfaizzatul sarkina berahim 17 69 PMY3249 I Beluran I Tanakarason I SK. Kabuluh I Nur fina wati vona 17 70 PMY3303 I Beluran I Tanakarason I SK. Simoanaan I Christooer suan 17 47 71 PMY3310 Beluran karason I SK. Kabuluh Lukman aziz 8 72 PMY3353 Beluran karason I SK. Kabuluh Mohd. Abdul sah salleh 8 73 PMY3812 Beluran Beluran I SK. Pekan ian a faradona 7 48 Appendix 7 Data on individuals with positive Brugia Rapid test and/or positive Mf results among adults Brugia Slide (Mf No 110 I Shoal I Name I Age NOTES rapid No) 1 I PMY3122 I SK. Maidan I Roniklos bin marandah 16 pos 226 Opposite Sk Kanibongan 2 I PMY2545 I SK. Golong Rozelah maju 18 3 I PMY2037 I SK. Maidan Liprid subambol 23 Shop beside SK Maidan 4 I PMY2531 I SK. Golong Keifli dilu 25 5 I PMY1091 I SK. Lidong Memee bin dairin I 33 6 I PMY2006 I SK. Maidan Lajinai masantap 45 Opposite SK Maidan 7 I PMY2180 I SK. Pantai Boring Awang Radzi Bin Ondang 25 8 I PMY1225 I SK. Sua 10k Jamil pasikin 145 • Rumah kedai 9 I PMY3067 I SK. Maidan Jarryxe lee bin jusli 17 Opposite SK Maidan 10 I PMY2558 I SK. Golong Sulini marbang 34 11 I PMY2547 I SK. Golong Jafrin bubunong 140 12 I PMY1795 I SK. Lidong Latif bin mohamad 123 13 I PMY2039 I SK. Maidan Elvinah jupiel 120 os 2 0195355896 14 I PMY2177 I SK. Pantai Boring Mohd Syukri Bin Budon 20 pos 2 other side of village 15 I PMY2719 I SK. Binsulung Jineoh wot 27 os 2 Opposite school 49 16 I PMY2282 I SK. Pantai Boring Sani Bin Mohd Rady 39 pos 1 in front Sugut River 17 I PMY2674 I SK. Lubang Buaya Resame roslie 18 18 I PMY1012 I SK. Kanibungon Abdullah apok 137 19 I PMY1052 I SK. Kanibungon Rukiah sulangi 33 0 Kg. Sinukab 20 I PMY1215 I SK. Ulu Muanad Haslim bin angkang 26 0 014-8728468 21 I PMY1282 I SK. Sua 10k Stfiona pet 18 0 "se belah sekolah dekat jambatan suolok" 22 I PMY1289 I SK. Sua 10k Rosnani atot 29 0 2 storey house 23 I PMY1291 I SK. Sua 10k Richard mois 38 0 Kuarters 24 I PMY1348 I SK. Nangoh Willie joubin 25 0 Beside school 25 I PMY1484 I SK. Balaban Jaya Andrew petrus 22 26 I PMY1654 I SK. Sabapalm Agus Liano I 18 27 I PMY1671 I SK. Sabapalm Mohd Anuar Bin Awang 24 0 school security guard 28 I PMY1691 I SK. Pekan Juhani bin jeriun 35 29 I PMY1796 I SK. Lidong Maharan bin yussop 145 30 I PMY1996 I SK. Maidan Rosliza severinus 32 0 Kg Maidan 31 I PMY1998 I SK. Maidan Jolita@maria bt angkang 42 0 Opposite SK Maidan 32 PMY2002 SK. Maidan Jutilin rumangi 40 0 Opposite SK Maidan 33 PMY2003 SK. Maidan Lakiam kalumpat 45 0 Blue tank opposite house 50 34 I PMY2028 I SK. Pantai Boring Raman @ Mohamadun bin Mohamad Said I 44 II 0 35 I PMY2036 I SK. Maidan Katrin chong @ nyuk moi 27 0 Opposite SK Maidan 36 I PMY2043 I SK. Maidan I Rafiah maluka 38 0 Kg Maidan 37 I PMY2079 I SK. Maidan I Ailine matsindu 39 0 Opposite SK Maidan 38 I PMY2194 I SK. Perancangan Norliana akok 19 0 39 I PMY2293 I SK. Pantai Boring Mohd Hafizulnizar Bin Abd Kasim I 19 II 0 40 I PMY2340 I SK. Maidan Jarail bin bugong 45 _0 1 Opposite SK Maidan 41 I PMY2398 I SK. Golong Arcob eyacob 1 33 .. 0 42 I PMY2444 I SK. Golong Lilian toisin 123 I. 0 I Lilian toisin 43 I PMY2466 I SK. Golong Daniel jamin 129 • 0 44 I PMY2468 I SK. Golong Wilson ondok I 18 I. 0 45 I PMY2526 I SK. Golong Lina majunja 130 I. 0 46 I PMY2527 I SK. Golong Kunsiah masuka 141 • 0 47 I PMY2528 I SK. Golong Rustia rugia 141 I. 0 48 I PMY2530 I SK. Golong Eliziah sabalah I 22 I. 0 49 I PMY2532 I SK. Golong Minah bt. Jamil I 30 • 0 50 I PMY2540 I SK. Ulu Muanad Alvianah bt awang 122 I. 0 51 I PMY2550 I SK. Golong Rika sabalah 125 I. 0 51 52 I PMY2552 I SK. Golong Hairin bubunong 28 •• 0 53 I PMY2553 I SK. Golong Salleh jurus 29 •• 0 54 I PMY2557 I SK. Golong Baramli tidong 42 •• 0 55 I PMY2698 I SK. Lubang Buaya Rasid bason 43 •• 0 56 I PMY2724 I SK. Tagas-Tagas Marbin benjamin 31 •• 0 57 I PMY2726 I SK. Binsulung Norman mujiri 30 pos 0 Opposite school 58 I PMY2732 I SK. Binsulung I Masdin bin salat 21 pos 0 Opposite school 59 I PMY2765 I SK. Tagas-Tagas Jabir bakri 24 os 0 60 I PMY2769 I SK. Ulu Muanad Mastura anak ambi 31 019-8134074 61 PMY2925 SK. Obah Nurun bin amat 45 62 PMY2989 SK.Lidong Darmatasiah bte sabnih 19 63 I PMY3020 I SK. Maidan Charily bin jutilin 16 pos 0 Opposite SK Maidan 64 I PMY3128 I SK. Maidan Joyner ukung 24 os 0 65 I PMY3148 I SK. Maidan I Noraina bt rahman 19 pos 0 Kg Maidan 66 I PMY3235 I SK. Kabuluh Majid abas 44 os 0 67 I PMY3349 I SK. Simpangan Raman ayu 23 •• 0 68 PMY3396 SK. Ulu Muanad Sharif azmi bin sharif ahmad 34 69 PMY3420 SK. Miruru Timah Alak 27 52 70 I PMY3423 I SK. Simpangan Mazlan bin awang 127 •• a 71 I PMY3426 I SK. Kabuluh Samsurry jiki 130 I. a 72 I PMY3513 I SK. Kabuluh Sabturia limjau 136 I' a 73 I PMY3529 I SK. Perancangan I Jaspar thomas 126 _0 No night 74 I PMY1296 I SK. Sualok I Lee peng hoong 141 blood I {Kuarters}+ve before this No night 75 I PMY1644 I SK. Sabapalm Norizam Bin Ancharuddin 28 blood I teacher No night 76 I PMY2253 I SK. Lingkabau 1 Abd. Hassan rio 33 _blOOd 1 No night 77 I PMY2926 I SK. Obah I Imran bin tingkawon 142 blood 53 Appendix 8 Excerpts of Activities in Phase II, Survey II 1. Training workshop at Marudu Inn, Kota Marudu Fig 1.1 General brifieng of the study by Fig 1.2 Briefing of basic principal of Brugia Mr. Brian Chu Rapid test by Prof. Rahmah Noordin Fig 1.4 Rapid test training Fig 1.5 Participant learning how to use c:"""nnnnn during training session 54 2. Sampling activities at school Fig 2.1 A health worker entering the Fig 2.2 Teachers helping a health worker students demographic data into a during blood collection smartphone 3. Performing rapid test at field lab (school, clinic, etc) Fig 3.1 Rap test being performed in a Fig 3.2 Rapid test being performed along classroom at SK. Talantang a corridor of the classroom at SK. Maidan Fig 3.3 test being performed in a Fig Rapid being performed clinic at Sungai-Sungai directly after blood taking in a classroom at SK. Sabapalm 55 4. Sampling activities for adults in the community Fig 4.1 A health worker collecting blood Fig 4.2 Blood sampling at Sungai-Sungai sample from an adult in the community 5. Sampling activities at night Fig 5.1 Team members preparing the Fig 5.2 Night blood sampling at Paitan for night blood sampling at Tangkarason 6. Example of challenges faced during the sampling journey Fig 6.1 Team"'" members had to collect Fig 6.2 One of the vehicles had to be samples using a small boat in muddy pushed by health workers as the engine water broke down 56 7. Group photo at Marudu Inn, Kota Marudu 57