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Development and Evaluation of a Spatial Decision Support System for Malaria Elimination in Bhutan Kinley Wangdi1,2* , Cathy Banwell1, Michelle L

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Development and Evaluation of a Spatial Decision Support System for Malaria Elimination in Bhutan Kinley Wangdi1,2* , Cathy Banwell1, Michelle L Wangdi et al. Malar J (2016) 15:180 DOI 10.1186/s12936-016-1235-4 Malaria Journal RESEARCH Open Access Development and evaluation of a spatial decision support system for malaria elimination in Bhutan Kinley Wangdi1,2* , Cathy Banwell1, Michelle L. Gatton3, Gerard C. Kelly1, Rinzin Namgay4 and Archie CA Clements1 Abstract Background: Bhutan has reduced its malaria incidence significantly in the last 5 years, and is aiming for malaria elimi- nation by 2016. To assist with the management of the Bhutanese malaria elimination programme a spatial decision support system (SDSS) was developed. The current study aims to describe SDSS development and evaluate SDSS utility and acceptability through informant interviews. Methods: The SDSS was developed based on the open-source Quantum geographical information system (QGIS) and piloted to support the distribution of long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS) in the two sub-districts of Samdrup Jongkhar District. It was subsequently used to support reactive case detection (RACD) in the two sub-districts of Samdrup Jongkhar and two additional sub-districts in Sarpang District. Interviews were con- ducted to ascertain perceptions on utility and acceptability of 11 informants using the SDSS, including programme and district managers, and field workers. Results: A total of 1502 households with a population of 7165 were enumerated in the four sub-districts, and a total of 3491 LLINs were distributed with one LLIN per 1.7 persons. A total of 279 households representing 728 residents were involved with RACD. Informants considered that the SDSS was an improvement on previous methods for organ- izing LLIN distribution, IRS and RACD, and could be easily integrated into routine malaria and other vector-borne disease surveillance systems. Informants identified some challenges at the programme and field level, including the need for more skilled personnel to manage the SDSS, and more training to improve the effectiveness of SDSS imple- mentation and use of hardware. Conclusions: The SDSS was well accepted and informants expected its use to be extended to other malaria report- ing districts and other vector-borne diseases. Challenges associated with efficient SDSS use included adequate skills and knowledge, access to training and support, and availability of hardware including computers and global position- ing system receivers. Keywords: Bhutan, Spatial decision support system, Long-lasting insecticidal nets, Key informants Background five deaths in 2004 to 42 cases and no deaths in 2014 Bhutan has shown considerable success in control- [1]. Malaria elimination is now Bhutan’s goal, with the ling malaria, having achieved substantial reductions in aim to be malaria-free by the year 2016 [2, 3]. Malaria malaria morbidity and mortality from 2670 cases and elimination needs a relentless focus on surveillance and response. In many other countries entering the pre-elimi- *Correspondence: [email protected] nation phase, initial efforts have focussed on creating line 1 Research School of Population Health, College of Medicine, Biology listings of confirmed cases at the district level and case and Environment, The Australian National University, Canberra, ACT, mapping by village, which constitutes an elementary form Australia Full list of author information is available at the end of the article of malaria focus delineation [2]. However, as elimination © 2016 Wangdi et al. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Wangdi et al. Malar J (2016) 15:180 Page 2 of 13 activities intensify and the malaria incidence approaches 12–16] (Fig. 1). Such tools have been successfully used zero, higher-resolution mapping at the household level to support malaria elimination in a variety of countries may be required in residual areas of transmission. The [7, 13]. However, limited rigorous evaluation of these need for modernized, high-resolution mapping to sup- tools has been done. These tools require an investment port the operational management of scaled-up interven- in financial and human resources to develop and imple- tions is increasingly being recognized [4]. ment [17] and considerable effort to maintain. Whilst Paper-based maps have been used for planning it appears intuitive that such systems will improve the malaria interventions since the eradication efforts in efficiency of malaria elimination interventions through the 1960s [5]. More recently, electronic geographic supporting more effective resource allocation deci- information systems (GIS), which permit input, storage, sions, SDSS uptake depends on establishing acceptabil- manipulation, and output of geographic information, ity and utility. have provided a powerful suite of tools for managing The traditional surveillance system in Bhutan is based data in the context of the prevention and control of on passive reporting of cases and fever surveillance. In malaria. There is a plethora of GIS software packages the traditional reporting system, the location of house- available, with varying capacities for data processing, holds with malaria is not available—data are recorded analysis and display. Spatial analysis in disease manage- at the village level. By contrast, the SDSS maps cases at ment and health planning is now well established [6– the household level and enables the spatial relation of 10]. Spatial decision support systems (SDSS) provide the index case to other households to be mapped. This is enhanced support for decision making and manage- essential for facilitating reactive case detection (RACD) ment, using data that have a geographical component in 1-km buffer zones, which is the main approach to con- [11]. A SDSS is generally based on a database housed taining transmission. within a GIS, with an interactive mapping interface. The aim of the present study was to develop and imple- SDSS can contain modules for planning, monitoring ment a SDSS based on open source GIS (Quantum GIS) and evaluating the delivery and coverage of interven- to aid in the distribution of LLINs, carry out IRS and tions such as indoor residual spraying (IRS) and distri- for RACD as part of the malaria elimination efforts of bution of long-lasting insecticidal nets (LLINs) within Bhutan. Additionally, this study aimed to determine the target populations, and for mapping malaria surveil- acceptability and utility of the SDSS for malaria elimi- lance data, including identifying and classifying active nation in Bhutan using informant interviews with those transmission foci and guiding targeted responses [10, involved in the programme. Fig. 1 Framework of spatial decision support system for malaria control and prevention with potential use in other vector borne diseases. (GIS geo- graphical information system, PDA personnel digital assistant, GPS Global positioning system, SDSS spatial decision support system, GR geographic reconnaissance, LLIN long-lasting insecticidal net, IRS indoor residual spraying, PCD passive case detection, RACD active case detection, JE Japanese Encephalitis) Wangdi et al. Malar J (2016) 15:180 Page 3 of 13 Methods therapy (ACT) [24]. Elimination efforts are further aug- Study area mented with interactive information, education and Malaria in Bhutan is reported in seven districts: Chukha, communication and behavioural change and communi- Dagana, Pemagatshel, Samdrup Jongkhar, Samtse, Sar- cation strategies to enhance utilization of interventions. pang, and Zhemgang [18, 19] (Fig. 2). These districts are Of the seven malaria-endemic districts of Bhutan, located in the foothills of the Himalayas, bordering the Samdrup Jongkhar and Sarpang Districts were selected Indian states of Assam and West Bengal, which report for the current study because these districts persistently some of the highest numbers of malaria cases in India reported the highest incidence of malaria in Bhutan [20–23]. The climatic conditions in these districts are hot over the last 7 years [24]. Further, two sub-districts were and humid during summer months with plenty of rainfall selected from each district on the basis of them having providing a suitable environment for vectors [18, 19]. the highest numbers of malaria cases in their respective Currently, focal IRS is routinely conducted in house- districts. Jomotshangkha basic health unit (BHU) I caters holds in malaria-endemic districts of Bhutan every to Langchenphug sub-district and Samdrupchoeling 6 months, using synthetic pyrethroid. This spraying is BHU I caters to Phuntshothang sub-district in Samdrup carried out prior to and immediately following the mon- Jongkhar District. Chuzergang and Umling BHU II serve soon season, in March and September. LLINs are distrib- Chuzergang and Umling sub-districts in Sarpang Dis- uted by the Vector-borne Disease Control Programme trict, respectively (Fig. 2). (VDCP) of the Department of Public Health (DoPH) within the Ministry of Health (MoH) every 3–4 years. Building the spatial decision support system Malaria technicians at the respective
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