F1000Research 2018, 7:1986 Last updated: 06 JAN 2020 RESEARCH ARTICLE Two parallel reporting systems for malaria surveillance in Pakistan, 2013–17: is exact burden reflected? [version 1; peer review: 2 approved with reservations] Hammad Habib 1, Razia Fatima 2, Abdul Baseer Achakzai1, Ahmad Wali3, Aashifa Yaqoob2, Hina Najmi4, Mahboob Ul Haq 2, Abdul Majeed1 1Directorate of Malaria Control (DOMC), Ministry of National Health Services, Regulations and Coordination, Islamabad, Pakistan 2National TB Control Program, Ministry of National Health Services Regulations and Coordination, Islamabad, Pakistan 3Provincial TB Control Program, Provincial Department of Health, Quetta, Balochistan, Pakistan 4Sukh Initiative, Aman Foundation-Aman Health Care services, Karachi, Sindh, Pakistan First published: 28 Dec 2018, 7:1986 ( Open Peer Review v1 https://doi.org/10.12688/f1000research.17202.1) Latest published: 28 Dec 2018, 7:1986 ( https://doi.org/10.12688/f1000research.17202.1) Reviewer Status Abstract Invited Reviewers Background: Pakistan is facing challenges regarding the availability of 1 2 reliable data for malaria surveillance. These include lack of coordination between different reporting systems and fragmented information system. version 1 This study aimed to compare the reporting of malaria surveillance systems published report report in Pakistan. 28 Dec 2018 Methods: There are two parallel reporting systems for malaria surveillance in Pakistan, the District Health Information System (DHIS) and Malaria Information System (MIS). DHIS reports on all morbidity at health facility 1 Lindsey Wu, London School of Hygiene & level, while MIS is only used for malaria surveillance in the donor supported Tropical Medicine (LSHTM), London, UK districts. A cross sectional study was conducted between July-September Chris J. Drakeley , London School of 2018 by using the retrospective records of DHIS and MIS data reported to Hygiene & Tropical Medicine (LSHTM), London, the Directorate of Malaria Control (DOMC) Islamabad during 2013-17. Descriptive and inferential analysis was performed to compare the UK coverage, outcome and impact indicators. 2 Mrigendra P Singh , ICMR-National Results: During 2013-17, all districts (n=145, 100%) across Pakistan reported on the DHIS. The MIS reporting coverage has gradually increased Institute of Malaria Research, Jabalpur, India from 21 (14.5%) to 72 (49.7%) districts. Reported number of suspected Any reports and responses or comments on the screened and confirmed malaria cases were compared. MIS reported twice article can be found at the end of the article. the number of suspects screened for malaria (100.5%) and confirmed malaria cases (124.4%) as compared to the DHIS. The difference in the reported average annual blood examination rate (ABER) was 3.8, test positivity rate (TPR) was -0.9 and the annual parasite incidence (API) was 4.9/1000 population over five years between two systems. DHIS reported only half the ABER and API as compared to MIS. Conclusion: There is huge under-reporting of suspected and confirmed malaria cases in the DHIS as compared to MIS. Urgent attention is needed to address this, as it is vital to have uniform reporting of true disease burden across the country. An integrated disease surveillance system, improved data validation systems, and use of the online DHIS-2 are potential options for better integrity and coherence of reported data. Keywords Page 1 of 13 F1000Research 2018, 7:1986 Last updated: 06 JAN 2020 Keywords Malaria surveillance, comparison, operational research, DHIS, Pakistan, reporting system This article is included in the TDR gateway. Corresponding author: Hammad Habib ([email protected]) Author roles: Habib H: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Validation, Writing – Original Draft Preparation, Writing – Review & Editing; Fatima R: Funding Acquisition, Methodology, Project Administration, Software, Supervision, Writing – Review & Editing; Achakzai AB: Conceptualization, Project Administration, Resources, Supervision; Wali A: Formal Analysis, Methodology, Resources, Software, Validation, Writing – Review & Editing; Yaqoob A: Data Curation, Formal Analysis, Investigation, Methodology, Software, Validation, Writing – Original Draft Preparation, Writing – Review & Editing; Najmi H: Methodology, Validation, Writing – Original Draft Preparation, Writing – Review & Editing; Haq MU: Methodology, Resources, Software, Writing – Review & Editing; Majeed A: Conceptualization, Methodology, Resources, Supervision, Writing – Original Draft Preparation Competing interests: No competing interests were disclosed. Grant information: This research was conducted through the Structured Operational Research and Training Initiative (SORT IT), a global partnership led by the Special Programme for Research and Training in Tropical Diseases at the World Health Organization (WHO/TDR). The training model is based on a course developed jointly by the International Union Against Tuberculosis and Lung Disease (The Union, Paris, France) and Médecins Sans Frontières (MSF, Geneva, Switzerland). The specific SORT IT programme that resulted in this publication was implemented by the National Tuberculosis Control Programme of Pakistan, through the support of the Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund, Geneva, Switzerland). The publication fee was covered by the Special Programme for Research and Training in Tropical Diseases at the World Health Organization (WHO/TDR). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2018 Habib H et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite this article: Habib H, Fatima R, Achakzai AB et al. Two parallel reporting systems for malaria surveillance in Pakistan, 2013–17: is exact burden reflected? [version 1; peer review: 2 approved with reservations] F1000Research 2018, 7:1986 ( https://doi.org/10.12688/f1000research.17202.1) First published: 28 Dec 2018, 7:1986 (https://doi.org/10.12688/f1000research.17202.1) Page 2 of 13 F1000Research 2018, 7:1986 Last updated: 06 JAN 2020 Introduction It is estimated that due to such challenges, only around 23% Malaria ranks sixth amongst the top ten causes of deaths in low of malaria cases have been captured in Pakistan through various income countries of the world1. In 2016, 91 countries reported surveillance systems during 20162. an increase in malaria cases (216 million) as compared to 2015 (211 million). Around 0.4 million deaths have also been Limited evidence has been found regarding the comparison of reported during the same year. Most cases were reported by the various malaria surveillance systems in Pakistan. This study World Health Organization (WHO) African Region (90%), aims to compare the malaria coverage, screening, cases, out- followed by the South-East Asia Region (7%), and the Eastern come and impact as reported through the MIS and DHIS in high Mediterranean Region (2%)2. The incidence of malaria cases burden sharing districts of Pakistan. varies from low to high in different countries. Countries with low malaria incidence are progressing towards malaria Methods elimination, while others having a high disease burden, including Study design and setting Pakistan, have implemented malaria control programs3. This was a cross sectional retrospective record review of malaria routine surveillance data for the period 2013–17 The World Health Organization (WHO) has emphasized the reported through the DHIS and MIS from donor supported critical need for transforming malaria surveillance as a core districts of Pakistan. The study was conducted from July to intervention in the Global Technical Strategy for Malaria. WHO September 2018 at the Directorate of Malaria Control (DOMC), has further stressed on the importance of prioritizing investments Islamabad which is an attached department of the Ministry of in malaria surveillance system to ensure that reliable data is National Health Services, Regulations and Coordination. DOMC available for decision making4. Effective surveillance of malaria is primarily responsible for malaria surveillance in Pakistan in is essential for identifying and prioritizing the most affected collaboration with the provincial malaria control programs. The areas or population groups5. Moreover, uniformity of the Global Fund (donor) is supporting the malaria control interven- surveillance tools and timeliness of reporting is important in tions in the highest burden sharing stratum-I districts located countries with low disease burden at the malaria control phase6. It mainly in the provinces of Balochistan, Sindh, Khyber has been observed that despite all the efforts and investments, Pakhtunkhwa (KP) and FATA12. malaria surveillance system has many challenges related to the timeliness, representativeness, data quality and reliabil- Malaria surveillance data from the public health facilities is ity in high and low burden countries from the WHO African and reported through two parallel systems, namely the DHIS (intro- Eastern Mediterranean regions7,8. duced in 2008 for all districts) and MIS (only for the Global Fund supported districts). DHIS reports on all morbidity at health Pakistan