real-time biosurveillance program

I was invited to share my research with Stockholm Environment Institute Asia office in Bangkok. The intention was for SEI-Asia Researchers to possibly identify any areas for collaboration. I themed my talk on “ICT4D action research in Early Warning Systems”. It has been 10 years since I first began my research work in December of 2005. It was important to first establish an abstract definition of an EWS.
“Often, most cases are suspected cases, with fewer confirmed cases. Patients with symptoms are asked to go for further tests, and this takes time. By the time a good number of confirmed cases are collected, the disease has spread rapidly. From a public health perspective, this is just not good enough. We need to catch it at the out-patient care level, restrict spread to clusters and deliver a cure before it grows into a wider geographical spread.
I had the opportunity attend the discussion by Tim Berners-Lee and Gordon Brown in Geneva, speak on the “future of the web“, a public lecture hosted by the Université de Genève, April 06, 2011. The two discussants didn’t have anything new to share; they were talking the same language of tapping in to the untapped through mobile phones; nothing new to LIRNEasia (see our Teleuse at the Bottom of the Pyramid studies). The WWW Foundation has realized the reach of the mobile phone to deliver the web to those 80% that have not yet been exposed. What we were more eager to hear was the defense on the claim that the “web is dead, long live the internet“. In defense – “No the web isn’t dead” with the success story pointing to the Wikipedia.
Those who know graphs theory are familiar with the “four color theorem“; an example being the world map (relaxed as a planar graph) can be colored with a minimum of four colors such that two countries sharing a border do not share the same color. Researchers at Queen Mary University of London use this theorem to color code cellular network base stations. The base stations are in abstract sense regarded as message Brokers (also termed as “Publisher Subscriber Message Oriented Middleware” – PSMOM) that channel the published message (SMS, Email, Voice packet, data packets, etc) to the Subscriber (or message recipient). Sometimes a subscriber and a publisher can be directly linked through a single broker or they may be linked through several intermediary brokers. The role of the Sahana Alerting Broker, essentially, is similar to that of a cellular base station; where decision-maker or decision-system published risk information is disseminated to the subscribers of the response systems in the form of public warnings or restricted and private alerts (also known as closed user group alerts typically applicable to first responders).
Fidelity of digitized data in the Real-Time Biosurveillance Program (RTBP) was not promising; especially with the personnel in Sri Lanka with no medical knowledge but technically capable were producing up to 45% noisy data (second stacked graph). On the contrary the medically trained but less fluent in mobile phone usage Indian nurses were less prone to producing noisy data. The Indian health workers had an incentive because the erroneous data would produce false alarms, and they would need to respond to these false alarms or it would portray a bad image of the health situation in their area; while the Sri Lanka data digitizing personnel had no incentive besides picking up a paycheck for the data entry work they did. The data was submitted through the mHealthSurvey mobile software that works on less expensive Java-enabled hand-helds. The RTBP envisions that hospital data is submitted each day; thus, the real-time expectations.
I just received my copy of the book: Biosruveillance methods and case studies edited by Taha Kass-Hout and Xiaohui Zhang. I first met Taha in cyberspace when he was with InSTEDD, we had started a Google group: Biosurveillance, which we use as a knowledge-base. Their approach to disease surveillance was through “event-based surveillance” and our approach was through “indicator-based surveillance” but both converging at finding signals for timely public health alerts that would advocate early control measures. We had contributed three chapters in the context of the Real-Time Biosurveillance Program pilot (RTBP) – Chapter 9: “The role of Data Aggregation in Public Health and Food Safety Surveillance” – Artur Dubrawski Chapter 13: “User Requirements towards a Real-Time Biosurveillance Program” – Nuwan Waidyanatha and Suma Prashant Chapter 14: “Using Common Alerting Protocol to Support a Real-Time Biosurveillance Program in India and Sri Lanka” – Gordon A. Gow and Nuwan Waidyanatha.
Findings from the Real-Time Biosurveillance Program was presented in the poster session at the mHealth Summit 2010 (Fig 1). Our partners from Auton Lab were creative in affixing an iPad to the poster to show a video of the working solution. Thanks to the marketing abilities of our friends from Auton Lab, our work caught the special attention of delegates from the Bill & Melinda Gates Foundation, Rockefeller Foundation, UN Foundation and several other global development agencies. The Gates Foundation’s video crew made an exclusive appearance to capture our poster content and interviewed Prof. Arutur Dubrawski, which made all others presenting their work a bit jealous.
The IEEE-RIVF – Research, Innovation, and Vision for the Future –  International Conference on Computing and Communication Technology took place in Hanoi, Vietnam at the Vietnam National University, Nov 02-04, 2010. The plannery sessions were on applied operations research, software engineering, human machine interface & imaging technology, computational Intelligence, information & knowledge management, communication & networking, and modeling & computer simulations. I presented out paper titled: T-Cube Web Interface as a Tool for detecting disease outbreaks in real-time: a pilot in India and Sri Lanka. This paper discusses the results from the pilot in India and Sri Lanka, namely the Real-Time Biosurveillance Program (RTBP). While may discussed the science behind their solutions, we had surpassed that and were able to discuss the challenges in practically working the solutions in the real world.
Not just eHealth but in any national innovation, finding a champion to own, operate, and promote the new intervention is crucial. We found ours in Sri Lanka to take the Real-Time Biosurveillance Program (RTBP) to the next level; our champion is Dr. R.M.S.
The Real-Time Biosurveillance Program (RTBP) held a news conference in Colombo, Sri Lanka on September 14, 2010 at the Cinnamon Lake Side Hotel. This is list of the articles published in the News papers:
The Director of Carnegie Mellon University’s Auton Lab – Prof Artur Dubrawski – delivered a keynote speech at the Health Informatics Society of Sri Lanka organized eHealth Sri Lanka 2010 conference, 15-16 September, 2010. His talk titled – Detection of Informative Disjunctive Patterns in Support of Clinical Informatics (click to view slides) – has synergies with the Real-Time Biosurveillance Program (RTBP) we are piloting in India and Sri Lanka. RTBP specifically integrates a data mining and probability testing tool called the T-Cube Web Interface. In addition to the keynote, Chamindu Sampath, LIRNEasia Research Assistant, presented a paper titled the “T-Cube web tool for rapid detection of disease outbreaks in India and Sri Lanka” (click to view the slides) and a poster. Several interesting issues regarding data quality needed for event monitoring was discussed by the audience during the session: public health informatics.
The key take home from the workshop were: the Regional Epidemiologist – Dr. P. Hemachandra – stressing the need for Syndromic surveillance; especially, the ability to monitor escalating fever like disease and geographic clusters of increase in common symptoms. Dr. Lakshman Edirisinghe (Deputy Director Planning) emphasized the need for comprehensive patient clinical data for becoming a data driven organization that can optimize the resources opposed to speculative expert opinion.
I was in Lyon, France presenting our mHealth paper – Real-Time Biosurveillance pilot in India and Sri Lanka – at the IEEE-HealthCom conference, which took place 01-03, July 2010 (click to view the slides). I spent an extra day in France to travel down to Grenoble, accompanied by my friend and research partner – Artur Dubrawski – an ex-scholar from Grenoble,  in search of a Joseph Fourier’s statue for a photo opportunity. Why? Jean Baptist Joseph Fourier (21 Mar 1768 to 16 May 1830) was a French mathematician and physicist best known for the “Fourier series” – a way of writing a function as a sum of frequency components; i.e.
The “Evaluating a Real-Time Biosurveillance Program” (RTBP) research team meet in Chennai, July 6 – 7, 2010 to discuss the interim findings of the evaluation work (click to read workshop report) carried out in Tamil Nadu India. In addition to the workshop a news conference was organized to disseminate the pilot project findings. The links below are some of the news prints (click on the thumbnails to view news clippings) :: – Mobiles on Health Calls, The Hindu Business Line, September 13, 2010 – Pilot study in using mobile technology for disease reporting shows promise,, July 07, 2010 – Pilot study on epidemiological early disease warning system,, July 07, 2010 – New tech to keep tab on diseases, timesofindia.
The present day disease surveillance and notification system in Sri Lanka, confined to a handful of diseases, known as Notifiable disease, and reporting large numbers of common cases, is what the British introduced in 1897 as part of the quarantine and prevention of diseases ordinance. This paper based surveillance and reporting system has its shortcomings that the health professionals themselves have voiced. 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.
Recently I presented a paper titled – Robustness of the mHealthSurvey Midlet for a Real-Time Biosurveillance program at the 2010 International Symposium on Medical Informatics and Communications Technology – in Taipei, Taiwan. The main focus was on mobile computing; especially surrounding Body Area Networks (BAN) that is in the working mills of the IEEE 802 standardization process under the auspices of Task Group 6. The present day challenges that countries like Taiwan and Japan face, also propagating in to other Asian countries, are increase in chronic illnesses, aging population, and need for convenience. Within this frame, researchers are realizing the growing need for remote sensing and maintenance of health; such remote maintenance ICT based services would reduce patient admissions (or inward patients), which countries like India, Sri Lanka, Taiwan, etc, fully subsidize and can be drastically reduced. The mHealthSurvey has proven the capability to transport digitized data compressed to ~ 2KB over GPRS-10 and higher networks in rural India and Sri Lanka.