Using Triangulation Methodology to Evaluate Reported Malaria Trends in the Urban Clinic of Maevatanana, Madagascar 2005-2010
Bove, Joanna Marie
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The impact of malaria control programs has been widely investigated in recent years following the implementation of multifaceted control programs in many low-income countries. Some clinical studies show few signs of decreasing malaria incidence after the distribution of long-lasting insecticide treated nets (LLINs), the adoption of artemisinin-based combination therapy (ACT), and other malaria case-management strategies. In Madagascar, routine data collection has shown inconsistent results of malaria control interventions in some regions, such as the region of Betsiboka in northwest Madagascar, where different data sources show increasing and decreasing trends in malaria incidence less than two years after the first distribution of LLINs and the introduction of ACT and rapid diagnostic tests (RDTs). In this study, hypotheses regarding the trends seen in the Health Management Information System (HMIS) and Sentinel Site data sources from a large clinic in the Betsiboka region, the CSBU in Maevatanana district, were evaluated using triangulation methodology. This study showed that the main reason for decreasing malaria trends seen in the HMIS data was the change in case definition for malaria after the introduction of RDTs. For the Sentinel Site data source, increases in the number of RDT+ malaria cases as well as the percentage of RDT+ malaria cases of all patient consults at the CSBU contradict what was expected after the implementation of malaria control interventions in 2007. The effects of malaria control interventions may be attenuated by changes in human behavior, such as increased fever consults at the CSBU and the improved capture ability of RDTs. However, increases in the proportion of malaria cases of all patient consults at the CSBU may suggest a true increase in malaria incidence. Furthermore, increases in reported malaria cases in the Sentinel Site data also corresponds to increases in ACT stock-out in Maevatanana, ambient temperature, as well as the presence of resistance to pyrethroids and quinolines. By collecting and comparing different data sources of different measurements, this study was able to make conclusions about the decreasing malaria trends in the HMIS data. However, the study showed inconclusive results regarding the increasing trends seen in the Sentinel Site data, and further investigation is needed.
- Global health