Now if the same consortia can somehow figure out a surveillance program of bureaucratic inefficiencies, then the relevant governments of these countries may actually be able to respond well and respond fast, given that identification is just one component to controlling epidemics. Increasing the efficiency with which epidemics are identified is a step forward, but what comes after–implementation of crowd control, region-wide communications, and swift deployment of medical personnel–is the real test.

The Real-Time Biosurveillance Program (RTBP) pilot, during the first week of April, interviewed health workers and health officials in Kurunegala District to study the notification and response policy and procedures. These interviews revealed that in some occasions by the time health officials receive the notification to inspect the patient, with the infectious disease, at the patient’s residence, the patient had already died; health workers literally pull their hair trying to decipher the illegible handwriting on the paper forms; they also mentioned that they have to travel long distance from their villages to the Medical Officer of Health (MOH) office to pickup the paper forms with the patient’s information. These inefficiencies and excessive costs can be drastically reduced with ICT; with a technique as simple as a communicating the information via SMS text messages that costs Rupees 0.50 (fifty cents).

We asked health workers as to how they came to know of any adverse health events (i.e. rise in cases of a disease or an outbreak) either in their own or neighboring jurisdictions. Most of them replied “through word-of-mouth” while some said they came to know through the main stream media (TV, Radio, News Papers). Ideally they should be receiving first hand information from the health system itself.

A summary of the RTBP conducted assessments are documented: field report for India and field report for Sri Lanka.

An ICT system for alerting and situational awareness, is what the RTBP is introducing to the health system in India and Sri Lanka. RTBP adopts a global standard called Common Alerting Protocol (CAP) for issuing standardized alerts and situational awareness messages. Besides structuring complete all-media all-hazards messages, CAP provides grounds for interoperability. The CAP guidelines and preliminary design was adopted from the USA Center for Disease Control Public Health Information Network CAP Guide.

The RTBP introduced technology and procedures are a paradigm shift from the present day surveillance and notification system. The new paradigm introduces situational awareness and alerting, giving the health officials advance notice to decide on the actions that would make a difference, opposed to an unproductive set of formalities that are not aimed towards saving lives but just for pushing statistics up the chain.

In the RTBP, when a health event of interest such as an increased number of common syndromes or diseases are identified through the T-Cube Web Interface, authorized health officials issue a message to the restricted recipients (i.e. health workers) in the effected as well as surrounding areas. Then health workers will be aware of the present danger and can mobilize to respond immediately or chose to be vigilant and observe the situation. For example, a health worker in the effected area would know that he/she needs to investigate the cases in their jurisdiction; while health workers in other neighboring areas may conduct awareness campaigns to educate the public.

The CAP messages designed for health alerts and situational awareness are delivered via SMS, Email, and Web. The single input multiple output software system was developed by Respere Lanka and is embedded in to the Sahana Messaging and Alerting Module. Sahana is a Free and Open Source Software specifically designed for managing disasters.

These health workers (few of them are in the photo with their backs to you) were given training and mobilized with the mHealthSurvey, mobile phone application, for submitting patient disease/syndrome data for the surveillance of epidemiological events. Data that used to take over 15 days to relay up to the paper chain, but was not subject to any detection analysis (i.e. just reporting), now takes several seconds. Moreover, the RTBP collects all communicable and non-communicable diseases along witht their syndrome opposed to a handful of diseases (i.e. Integrated Disease Surveillance Program S and P list of diseases). Each Primary Health Center sends over 100 patient records (probable, suspected, and confirmed cases) a day that is now subject to, RTBP introduced, real-time health event detection analysis. Although there were some errors due to misspelling at the begining, once they were asked to be cautious and were made aware of the consequences of the errors resulting in false statistics that may lead to false alarms of disease outbreaks, they have reduced the error rates to almost zero.

Dr. Ganesan M., (Senior Program Officer, RTBI – extreme left seated at head table, facing you, talking the Health Workers in the photo), present the paper titled: “Real-Time Bio-surveillance Program: Field Experience from Tamil Nadu, India” at the 7th Indian Association for Social Sciences and Health (IASSH) conference on Health, Poverty and Human Development held at Banaras Hindu University, Varanasi from 5th to 7th March 2010. Dr. Ganesan is part of the research team at the Indian Institute of Technology – Madras’s Rural Technology and Business Incubator (RTBI) conducting the RTBP action research in the state of Tamil Nadu, India.

View the conference presentation slides

Read a brief on the conference participation

These concluding remarks are from the paper titled- “Real-TIme Biosurveillance Pilot in India and Sri Lanka“, which I shall be presenting at the e-Asia 2009 Conference to be held December 02 – 04, 2009 in Colombo, Sri Lanka.

For the Slides Click Here

m-HealthSurvey is a mobile application developed by indian Institute of technology Madras’s Rural Technology and Business Incubator (RTBI) for collecting near real-time patient disease, syndrome, and demographic data for rapid detection of disease outbreaks. It is a J2ME midlet that allows users to select categorical data as well as type information to generate patient clinical records to be submitted via GPRS to a central database. The pilot is going on in India and Sri Lanka now.

Observations from the exercise revealed a disparity in the usage and adoption between the age groups of the health workers using the m-HealthSurvey for RTBP data submission – younger Sarvodaya Suwadana Center health workers, between the age of 18 – 35 in Sri Lanka, were able to complete the exercise easily in the allotted time by themselves without any help. While the older Tamil Nadu Health Department Village Health Nurses, between the age of 30 – 50, but with 10 – 20 years field experience, were unable to complete the exercise in time and, except for one or two of them, all others required guidance and assistance. This, adoption and usability, disparity of mobile phone applications between older and younger generations is also evident from LIRNEasia’s BOP findings; where “youngsters are more likely than older to adopt mobile phones beyond voice” (De Silva et al, 2009).

The health workers in Sivagangai and Kurunegala began using the m-HealthSurvey mobile application immediately after the training in June 2009; see blogs -  Village Health Nurse training and Suwadana Center Health Worker training.

View link for field report -

Sivagangai District Field report by Dr. Ganesan Muthaiya (India)

Kurunegala District Field report by Ms. Pubuduni Weerakoon (Sri Lanka)

Village Health Nurses in Tamil Nadu examine at most 70 patients a week. Ninety percent of the Village Health Nurses opt to jot down the records on paper and later enter them leisurely after the day’s work is complete. Therefore, they can easily use a mobile phone for data entry. However, the same solution cannot be applied to Primary Health Centers (Clinics) or Hospitals because they cater to as much as 200 patients a day within a span of 5 hours (8am – 1pm), giving the Medical Officers just about 90 seconds to examine each patient. Although the m-HealthSurvey mobile application offers the users to mostly select data opposed to typing, some editing of symptoms and signs are required. Hence, it is near impossible to request that the Medical Officers enter each patient record in real-time while they are overwhelmed with caring of patients.

Medical Officers are still required to pencil the patient’s health ID, age, gender, and diagnosis in the OPD registry. The present day protocols require that the Hospital and Clinic staff extract the OPD data for weekly reports that are propagated up through the District to State/Province and finally to the National level. The extra steps of aggregating and consolidating records manually at each level can be eliminated and delays that are as long as 30 days can be minimized to real-time, if the health records are digitized at the point of care.

At present the RTBP has recruited staff to digitize that data using the m-HealthSurvey for the purpose of the pilot. The RTBP research has realized two options for digitizing health records at the point of care: 1) recruit additional staff to enter health records (similar to what is being done now in the pilot) or 2) develop a mobile handheld device with touch screen and handwritting recogniztion for Medical Officers. Option 1) is costly since it involves additional human resources. Option 2) is ideal, if a handheld devices, similar to the mobile wireless medical tablet, can be developed for aound US$100, the same price as the mobile phones used in the RTBP field work at present.

1) Sahana biosurveillance module (database and desktop web application)

2) Mobile J2ME application (data collection)

3) T-Cube web interface (analysis and event detection)

4) Sahana Common Alerting Protocol Messaging Module (publishing SMS/Email/Web alerts)

During a recent workshop, in Tamil Nadu, a discussion around the accountability of submitting data revealed that the VHN sometimes cheat on the statistics they tediously record on large volumes of paper forms. At times if a certain disease count, during a given visitation to a village is, let’s say 6, they may record 2. This is to avoid additional work imposed on them by the Deputy Director of Health Service office. If the count is above a certain threshold, let’s say 4, then they must immediately notify the Sector Health Nurse (SHN) resident at the Public Health Center (PHC) in that VHN’s jurisdiction. The VHN are provided with mobile phones by the state to communicate such incidents. The RTBP will complement the present State of Tamil Nadu health data collection system by introducing the, RTBP developed, m-Health application, termed as the m-HealthSurvey.

Another interesting aspect revealed during the meeting was that almost one member from each household was working abroad. They label them as visitors. As a result the VHNs attending to the patients wished to distinguish between resident patients and visitor patients. If the patient was a visitor the VHN would record additional information such as the patient’s overseas address. This was one of the elements that the RTBP had addressed in the proposal; i.e. the fear of locals working overseas carrying diseases back to the home land and the need to detect such cases well in advance; as it is the case with the swine-flu alert these days.

The workshop was organized by the Rural Technology and Business Incubator research team, partners of the RTBP carrying out the field work with resepect to the Inian case study. The meeting took place in Karriakudi, Sivaganga District, May 4th and 5th, 2009 (see workshop program).

Click to view workshop report

ICTD2009 highlights new developments in technology for developing countries

“Dr. Artur Dubrawski, Director of the AutonLab at Carnegie Mellon University and Mr. Nuwan Waidyanatha, Senior Researcher and Project Director of LIRNEasia in Sri Lanka, are presenting their collaborative project using mobile telephony. The project uses the T-Cube Web Interface, a tool developed by Carnegie Mellon University to visualize and manipulate large scale multivariate time series datasets, to support real-time bio-surveillance.  “Health workers in the field will input patient and symptom data into a form on their mobile phones, which will immediately update a central database. The database will be available to central health organizations, and is designed to support rapid detection and mitigation of bio-medical threats in developing countries by improving the response time to analyzing the data.” The program is currently in pilot in Sri Lanka and India.  “We see many different applications for this type of program across other areas,” comments Dr. Dubrawaki.  “We look forward to meeting the other delegates at the conference and presenting our program, with the intention to expand our own project to other fields as well as to learn about their technologies”.

Remember in Star Trek Dr. Leonard McCoy, nicknamed Bones, would use a handheld device (shaped like a mobile phone) to scan the vital signs report of a patient; the little screen on the device would make some electronic noises and display some random illuminated pixels, which he would interpret to diagnose the condition of the patient; thereafter, he would use the same device or the wrist device to call “Sick Bay” tell them what to do with patient diagnosed outside of the facility. He would even transfer the diagnostic report to Sick-Bay for the on duty staff to pickup to get ready before the patient arrived.

A team of researchers at the University of California, Berkley are using mobile phones that display faint blue dots on the screen received through a text message to diagnose signatures of Malaria. The Science and Technology article of the Economists tells the story about Dr. Fletcher imposing a challenge on to his students to turn a mobile phone in to a microscope.

While the Berkley project uses the mobile for interpreting health related statistics, LIRNEasia intends to field test the use of mobile phones for collecting health related information for disease surveillance and notification. LIRNEasia believes that the biggest challenge is the gathering of health data for any kind of statistical analysis. Indian Institute of Technology – Madras Rural Technology Incubator (IITM-RTBI) will partner in the project to develop an interface for Healthcare Workers in Sri Lanka and the state of Tamil Nadu – India to install on their personal mobile phones to feed health information to the regional epidemiology units. This will speed up the real-time capabilities of performing statistical analysis in order to detect any unusual events in the health records that may trigger early signs of disease outbreaks. The current paper based system does not provide the regional/state disease surveillance facilities with timely data for early detections. IITM has already developed a remote medical diagnostic unit which can gather a patient’s vital signs in a rural village through a computer (without the assistance of a health professional) and transmit the report to a Doctor in a city for diagnosis (no old fashion stethoscope involved here). It want be too long before the same features of the remote medical diagnostic unit will be embedded in a mobile phone.

LIRNEasia and IITM-RTBI will add on to the ongoing work of the open source consortium: openROSA, comprising members of organizations like dimagi, Makerere University, University of Berkley, EpiHandy and EpiSurveyor, who have developed a series of “X Forms” specifically for collecting health related information via mobile phones.

A decade ago, in this region, all that a doctor would have on them is a Stethoscope draped around their neck. Over the past half a decade we noticed doctors carrying a mobile phone along with the Stethoscope. Soon that stethoscope will disappear and the mobile phone will be the “Real McCoy”. I wouldn’t be surprised one day the mobile phone coupled with medical diagnostic tools is all what a doctor would posses.

related link:: Real-Time Biosurveillance for Early Warnings in Sri Lanka, Colloquium.