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India to use mobile phones to track millions of immunizations

Child being given vaccination. Photo Credit: getty images

India’s health minister announced earlier this month a new initiative designed to boost the country’s rate of immunizing newborns by collecting mobile phone numbers of all pregnant mothers to monitor their babies’ vaccinations over time.

Ghulam Nabi Azad, the health minister, told a World Health Organization meeting in New Delhi that his ministry has been supervising the collection of about 26 million mobile numbers of pregnant women in India since January and plans to finish the job by December.

The women whose numbers are collected will be tracked via the mobile phones in the future by the Indian government to ensure the women’s babies receive the proper immunizations at the proper times. Babies in India are supposed to be immunized against tuberculosis, polio, diphtheria, tetanus, whopping cough and measles, health experts say.

According to Mr. Azad, the campaign will “enable us to monitor our immunization service at a national level. In addition, the central government will be able to check on the accuracy of data collected locally, which is often in doubt.”

The impetus for this program manifested due to a decentralized and deficient public health system, poor monitoring methods and sub standard vaccination coverage.

Photo Credit: wisdomblog.com

In 2010, only 72% of Indian babies received the three doses of the DPT vaccine against diphtheria, tetanus and whooping cough, an accepted indicator of a successful vaccination program, according to a joint estimate United Nations Children’s Fund and the WHO. That compares poorly with Bangladesh at 95% and Indonesia at 83%, according to the same joint estimate.

An inherent problem with the monitoring of vaccinations in India is that once babies are vaccinated, there tends to be no physical record of that baby being vaccinated. It is up to the guardians of the child to remember which vaccination was administered at which time. Also, the district levels governments may report erroneous numbers when reporting on the number of children vaccinated.

This initiative will give the central government the ability to contact the new mothers to confirm their babies’ immunization. “We’ll know the capacity of each state so they can’t fool us,” said Mr. Azad, reflecting widespread frustration.

Such an encompassing initiative is bound to face obstacles. Mr. Azad already encountered problems when he tried calling ten numbers from a list gathered back in February. “In front of all of the ministers, I picked up the phone and dialed the first 10 numbers. Only six of them were accurate numbers. Knowing we were going to be checking these numbers, our health workers still collected 40% faulty numbers—that is very bad” he said.

Mr. Azad declined to detail the cost of the program or how many numbers have been entered into the government’s system so far. But he said that tracking 26 million babies “is not an easy job.”

This is an ambitious project to say the least. Mobile phones after all aren’t permanent tools. A family could potentially report one number and procure a new phone with a new number. Also keep in mind, the Indian government is talking about a series of vaccinations that will span over a number of years for families living in rural areas. There could be a high turnover issue of mobile numbers. Families could also report a false phone number for fear of government intrusion – there is no way of double checking for that. Don’t forget, not all mothers will have a mobile phone to begin with.

The list of possible impediments could go on, but the bottom line is that attaining 26 million accurate and functional mobile numbers is idealistic at best. Nonetheless, this is a good start for the central government – it shows they are paying attention to the issue.

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Tanzania tracks malaria prevention with mobile phones

Photo Credit: medatanzania.org

In Tanzania, a new voucher program started in late July that provides discounted insecticide treated bed nets for pregnant women and children. This program also takes advantage of mobile technology as retailers can inform local clinics when their shops are getting low on life saving supplies by text messaging.

The program which is being overseen by MEDA, a Canadian organization, integrates health clinics, wholesalers, retailers and bed net manufacturers. Pregnant women and families with children in rural areas are eligible to receive a voucher from health clinics to get discounted insecticide treated bed nets from health supply retailers at 500 Tanzania shillings (about $0.35).

Once a woman takes a voucher to a retailer and pays a discounted price, she receives a bed net in return. The retailer then uses his or her cell to send a text message back to MEDA, which helps run the program. That SMS provides crucial monitoring data that includes the number of bed nets provided to the community and how many are needed in their next shipment.

The use of mobile technology to monitor bed net stocks and shipments is the feature that set this bed net initiative apart from others.

Each shipment contains a predetermined number of bed nets for a specific region based on their unique needs. Once the bed nets are delivered and the vouchers are collected, the retailers receive monetary compensation.

Long lasting insecticide treated bed nets. Photo Credit: medatanzania.org

In the “fight” against malaria, insecticide treated bed nets are a cost effective and proven weapon, especially for families in rural communities. According to the Global Fund, more than 300 million bed nets have been distributed in Sub-Saharan Africa since 2008. Moreover, Tanzania is a hard hit country as 2 million out of the 44 million people are affected by malaria.

Distributing vouchers for discounted bed nets is not a new method of tackling malaria. However, this approach produces a different sentiment amongst bed net owners than simply passing out bed nets to families for free.

Health workers have found that when a family makes a small investment in the net, it becomes a more valued commodity. Initiatives that pass out bed nets for free sometimes fail because families adopt the mentality that bed nets are valueless and easily replaceable.

This program distributes paper vouchers to the women that visit health clinics. Paper vouchers can easily be lost or ruined altogether. Therefore, keeping track of paper vouchers is often an obstacle. The next step is eliminating paper vouchers and developing text message based vouchers to make the process more efficient.

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Study shows importance of evaluating mHealth programs

One the biggest issues in mHealth and mobile campaigning in the developing world is the lack of evaluation. Well, the Lancet published an article last week that measured the effectiveness of mobile phone text message reminders on Kenyan health workers’ adherence to malaria treatment guidelines.

What the study found was that text messages can be a cost effective way to improve the care for malaria treatment in African children. Even though the study focused on malaria treatment, the results of the study suggest that using text messages can be an effective weapon to fight many different health burdens with.

According to the study, half of children received the correct treatment at the end of the study, more than double the starting figure. At the beginning of the study, 20.5% of children were correctly managed, this increased to 49.6% after the six month study.

The effect appeared to persist after the texts stopped. Six months after the trial ended, 51.4% of children were receiving the correct treatment due to the text messaging.

Professor Bob Snow, who headed the research group, said, “The role of the mobile phone in improving health providers’ performance, health service management and patient adherence to new medicines across much of Africa has a huge potential.”

Despite the positive numbers, the authors acknowledge that “we do not fully understand why the intervention was successful”. They speculate that the presence of the texts themselves serve as a reminder and reinforce the importance of the message itself.

One of the conclusions in the study is that “text-message reminders should be used to complement existing interventions—which themselves should be qualitatively improved—to target weak points” in health management practices.

The study however, sheds light on the importance of evaluating an mHealth campaign. Through evaluations, stakeholders can figure out whether a program is meeting its goals and how much of an impact it is making on the health issue it was designed for.

Currently in the developing world, numerous mHealth programs are being implemented on a small scale basis without monitoring and evaluation components. This not only leaves the project unfinished, but it is irresponsible as well. If a given program is appropriate to scale up to a wider population, we would never have the statistics to prove it. Then again, that hasn’t stopped NGO’s and governments before.

Evaluating mHealth programs is not a complicated task. Perhaps stakeholders are afraid to discover that their programs are not actually producing the impact they envisioned in the board room. This study has shown that positive results can indeed manifest from text messaging campaigns, and it is worthwhile to evaluate such campaigns.

The world needs to know what works and what doesn’t for the sake of the populations that are supposed to be the beneficiaries of the programs they are involuntarily thrown into. Otherwise, stakeholders are shooting in the dark with the well-being of innocent people.

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New app gives Thailand’s healthcare chance to go paperless

A doctor using the Family Folder Collector app on an Android pad, collecting information on a member patient. Photo Credit: bangkokpost.com

Thailand’s public health system has developed a mobile app for Android enabled tablet PC’s to monitor and collect household information on patients. The app, called Family Folder Collector (FFC), was developed by a research team at the National Electronics and Computer Technology Centre (Nectec).

Nectec researcher Watcharakon Noothong said the application comprises three major programs, including a walking map, genogram (a pictorial display of a patient’s health and family relationships) and Java Health Center Information System (JHCIS) synchronization.

FFC is designed to make life easier for public health workers who collect data on patients and for patients who are on time sensitive treatment schedules and cannot travel to health stations at any given moment for treatment.

The app is free. The only cost to utilize the service is paying for the tablet PC’s which is being covered by the province’s public health office.

Here are some of the features and capabilities of the FFC app:

  • Google maps shows the exact location and number of households in a given area
  • Genograms can be displayed
  • Chronic disease frequency can be color coded on a house-to-house basis
  • The program can collect and store other vital data, such as a patient’s weight, height, blood pressure and pulse rate, and even calculate a patient’s body mass index (BMI) automatically.
  • The program provides forms for treatment results, initial symptoms, health recommendations, and health behaviors
  • Doctors can schedule future appointments with patients
  • In the near future, the program will also be able to send an SMS to alert patients to get treatment at the health station.

All the collected data is updated and stored on the Android device then synchronized to the JHCIS database server. Public health workers were trained on how to properly input data into the tablet PC’s before pilot testing started. Of a total of 25 districts in the province of Ubon Ratchathani, eight are running the pilot trial of the FFC program, which, in its first phase, covers 123 health stations.

Ubon Ratchathani was chosen as the province since its existing IT infrastructure can accommodate sophisticated ICT’s for healthcare. There are over 1.8 million people in the province, all of whom will be accounted for by health workers using the FFC app.

This do-it-all app is a valuable tool for public health officials and physicians in Thailand. FFC can potentially replace the paper based system of collecting data and monitoring patients in Thailand.

The FFC application can display a genogram, monitor chronic diseases with Google Maps, and locate the house coordinates using a GPS system. Photo Credit: bangkokpost.com

The potential benefits of using this service are bountiful. Patient data will be gathered much easier and will be much harder to lose over time. Doctors can schedule appointments and prescribe treatments without physically seeing patients. Also, analysis of patient data will be faster, more efficient and more accurate.

Thailand may experience a revolution in healthcare if this service lives up to its potential. Currently, each health station has one tablet PC equipped with the program. The FFC application is expected to run throughout the province covering all 346 health stations by 2012.

Furthermore, according to Sinchai Tawwuttanakidgul, director of ICT Centre, Office of the Permanent Secretary, Ministry of Public Health, today there are some 45 provinces that are ready to switch from their paper-based system to the FFC mobile application. It sounds like Thailand is ready to experience that revolution soon.

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To UNICEF and WHO: Don’t forget to monitor your vaccines

Children and women waiting to get diagnosed in clinic. Photo Credit: WHO

In the wake of the drought and famine being experienced in the Horn of Africa, multiple vaccination campaigns have been launched in the region. UNICEF, WHO and Kenya’s Ministry of Health (MOH) are launching a campaign for the children situated in the Dadaab refugee camp in Northern Kenya, which is already triple the amount beyond its refugee capacity. UNICEF is also launching a solo campaign for children in the Horn of Africa, with a particular focus on Somalia.

The UNICEF and WHO-backed campaign in Dadaab will target 202,665 children under five years of age, with measles and polio vaccines, together with Vitamin A and de-worming tablets. The campaign is part of a regional push to ensure all children in drought affected areas are vaccinated against a killer disease like measles which can be deadly for malnourished children, and be protected from polio.

The solo UNICEF campaign for the rest of the Horn of Africa includes a strategy to vaccinate every child in Somalia under the age of 15 against measles which totals over 2.5 million children.

“This is a child survival crisis,” said Elhadj As Sy, UNICEF Regional Director for Eastern and Southern Africa. “Children don’t die just because they don’t have enough food. In various stages of malnutrition, they are more prone to sickness and disease. As big a challenge as the rates of malnutrition pose, the danger for children extends even further.”

“Malnutrition can weaken a child’s immune system, increasing their susceptibility to infectious diseases like measles and polio,” says Ibrahim Conteh, UNICEF Dadaab Emergency Coordinator. “We are acting now because these diseases can spread very quickly in overcrowded conditions like we have now in the camps.”

Measles is a highly contagious disease which can flourish in unsanitary and overcrowded environments like refugee camps. Measles reduces a child’s resistance to illness and makes them more likely to die when they are malnourished and suffering from other diseases.

Launching a vaccination campaign in the Horn of Africa is no simple task, even without a drought crisis to worry about. The region experiences atrocious coverage rates as evidenced by Southern Somalia where vaccination coverage is just 26%, one of the lowest in the world.

This suggests that there may be issues with the cold chain transportation of vaccines in the region. In the developing world, transporting vaccinations is complicated as high temperatures, scarce resources, unreliable electricity, and long distances between health care facilities can all break the chain.

Mobile vaccine refrigerator. Photo Credit: True Energy

This means that as UNICEF, WHO and the Kenyan MOH roll out of their campaigns, they must take extra precautions to make sure vaccine spoilage is minimized as much as possible. So many children’s lives depend on the vaccines being functional and on time.

Most, if not all of the vaccines being distributed in the campaigns will be transported using mobile vaccine refrigerators. There are mobile refrigerators currently in use all over the developing world that utilize innovative vaccine monitoring systems.

SmartConnect box

True Energy, a company highlighted in the past supplies a grid powered or solar powered refrigerator that offers vial vaccine monitoring to monitor the temperature of the vaccines along the cold chain. They also include a SmartConnect SMS monitoring system that sends out an SMS to the recipient alerting them of temperature changes along the cold chain for instantaneous monitoring.

PATH is one organization that has purchased these vaccine refrigerators with the SmartConnect capability. UNICEF has also commissioned these refrigerators from True Energy and is shipping the refrigerators for use in over 30 countries. Furthermore, the True Energy refrigerators meet WHO cold chain requirements.

Therefore, there should be no excuse for inadequate monitoring of vaccines amidst the vaccination campaigns. The technologies exist to ensure cold chain efficiency. Moreover, UNICEF and WHO have both recently dabbled with these existing technologies.

With reports that the drought in the Horn of Africa has not yet reached its peak, the vaccination efforts must be successful or millions of children may suffer the consequences.

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Grad students build novel tool in fight against malaria

Photo Credit: geardiary.com

A new faction has joined in the war against malaria: graduate students. A group of students developed a malaria diagnostic tool that will be rolled out in India and Ethiopia this summer.  Called, the Lifelens project, the tool uses a micro lens on the camera of mobile phones that can ultimately test for and diagnose malaria.

Created by Harvard Business School student Cy Khormaee and UC Davis doctoral student Wilson To, the lifelens product attaches a $50 micro lens to the camera of a Windows 7 enabled smartphone.

With the camera in place, the phone can then capture high-resolution images of the cells in a drop of blood that is placed on the micro lens. Windows 7 software quickly analyzes the images, confirming the presence or absence of malaria. Once the images are analyzed, the results can be sent to public health workers and other health professionals via SMS for further assessment and data collection.

Current standard practices in malaria diagnosis involve administering a rapid diagnostic test (RDT). This method takes a blood sample, usually off of the finger of the patient, and then exposed to a cotton swab containing a solution that reacts with malaria antigens that may be in the blood. However, this method is inefficient and produces many false positives, with only a 40% accuracy rate.

Photo Credit: springwise.com

The lifelens tool acts as a powerful microscope and can easily be sterilized for further immediate usage. It is also more accurate than RDT since it detects malaria cells directly. To and Khormaee say that in the long run, the lifelens tool will be more cost effective than current RDT detection methods.

However, there are some obstacles. The lifelens tool only operates on a Windows 7 enabled smartphone. These phones cost hundreds of dollars and may be affordable in resource poor areas. Also, the lifelens tool is not the only novel technological tool in the malaria detection space. Disposable tests are already in wide use, and others are developing diagnosis technologies, including a DNA-based one that could, like Lifelens, test for malaria and other illnesses.

The lifelens project received an award in the Microsoft sponsored Imagine Cup competition that featured innovative technological tools that use Microsoft software. With this award in hand, To and Khormaee plan to roll out a testing phase for their tool in India and Ethiopia.

Virtually all deaths from malaria occur in the developing world with 90% occurring in Africa. Any advancement in malaria diagnosis is highly valued. The lifelens project is aiming to change the way infectious disease diagnosis is handled. “Malaria is just the beginning,” says To. “We’re building a platform.”

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Army of mothers set to fight malaria in Mali

It was recently announced that an initiative called Mobiles Against Malaria will be launched in Bamako, Mali. The initiative will be executed using mothers who are community health workers in an effort to use mobile phones to prevent, diagnose and treat malaria in a more effective way than it has been.

The project is being funded by Akvo, a foundation created in 2008 that uses open source web and mobile software to attract funders to a spread of projects being done in the developing world.

CHW's at work. Photo Credit: Akvo

Mobile phones will be used by the mothers who were recruited as community health workers(CHW) to record data from neighborhoods on malaria. The CHW’s will visit each household in a particular neighborhood ready to ask pre-formulated questions.

The answers to the questions will be gathered on the mobile phones. For example, some of the questions asked may be ‘how many people live in the house’ and ‘how many people are ill’ and ‘what is the number of newborns’.

After gathering all of the necessary answers, the data will be sent via SMS to a central database located at a local hospital. It is hoped that NGO’s and local organizations will take advantage of the databases to analyze the trends and assist households in need of help. Officials hope the SMS data collection system will shed light on estimating how many insecticide-treated nets are needed in the poor areas in Bamako.

These community health workers will travel to malaria impacted areas around the capital city of Bamako to administer a revamped program. An older version was implemented using CHW’s who tested 2,796 children for malaria with a finger prick test after visiting nearly 100,000 households. That framework will be enriched by the introduction of the SMS-based frontline data collection.

The use of mothers as the CHW’s is a hallmark feature of this program. That along with using the SMS based frontline data collection sets this malaria detection program apart from other ones going on in Africa. Using mothers presents several advantages:

  • mothers are trusted in the community
  • they easily gain trust from other women from whom data is being collected
  • they can persuade women to visit hospitals using that established trust
  • they often have insider knowledge to the neighborhoods they work in
  • they ensure use of treated mosquito nets
  • they support treatment adherence

Along with attaining malaria specific data such as households using insecticide treated bednets, officials hope the program will create easier access to information on the burden. They also hope the cell phone-based application will improve patient management via a cell phone risk assessment and triaging tree, strengthen patient history documentation in the field, enable clinical communication (text, image, audio) between community health workers and clinics, and provide access to previously unrecorded health information.

The program aims to use mothers and cell phones to decrease costs of malaria detection and treatment while improving the access to treatment and treatment adherence. The program will train and utilize 50 CHW’s and 2 hospitals over the span of a year. It hopes that using mobile phones will build off of prior success.



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Tweets track down dengue fever in Brazil

Photo Credit: chinaview.cn

A research group led by scientists in Brazil has developed software that tracks outbreaks of dengue fever using the social media outlet twitter. This software was created thanks to coordination between two Brazilian National Institutes of Science and Technology, led by Wagner Meira, a computer scientist at the Federal University of Minas Gerais.

The software is designed to detect the word “dengue” in tweets and information about the sender’s location. The software analyzes the sentence structure and wording to determine if tweets are appropriate for dengue surveillance. Tweets that are deemed spurious or unrelated to dengue fever are filtered out.

During the testing phase, the researchers examined 2,447 tweets about dengue fever sent through the social networking portal between January and May 2009. They found a strong correlation between personal experience tweets about dengue and official data on outbreaks from the Brazilian Ministry of Health.

The research team now plans to analyze 181,845 tweets sent between December 2010 and April 2011, but are waiting for the ministry’s 2011 data before they do so. They also plan to incorporate other key words, mostly symptoms of dengue fever, into their detection scheme to gather more tweets.

Photo Credit: Twitter

This is the first time social media has been used for dengue fever surveillance, but it is not the first time social media has been used for real-time epidemic surveillance. Twitter was used to follow the 2009 swine flu pandemic. Furthermore, it is the first attempt to gather information on people tweeting about their personal experience of a disease.

Google also introduced Google Dengue Trends last month, which records spikes in web searches for dengue fever. Therefore, using social media for surveillance is not a new practice, and nor is tracking dengue using technology. However, Meira’s method is an innovative and efficient way to track dengue fever.

Dengue fever, which can cause hemorrhagic deaths, plagues Brazil ever year. Moreover, every year it emerges in different locations than before. Most Brazilians know how to control and even eradicate the disease, but the majority of citizens don’t take any precautions against it.

On top of that, outbreak notifications take several weeks to process and analyze which impedes officials from assisting citizens. Using Twitter messages could mean a much faster response, says Meira. “It isn’t predicting the future but the present,” he says. “This means we aren’t weeks behind like we used to be.”

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New mHealth service gives Iraq options for monitoring health

Iraq’s largest private telecommunications company, Asiacell, announced this week the launch of its mobile health content download and SMS service which is now available to its prepaid and postpaid subscribers. Asiacell is the only mobile telecom company providing coverage for all of Iraq.

An Iraqi man holds a cell phone. Photo Credit: Mario Tama, Getty Images

The new service offers information on various health practices which can be discriminately selected by the user. Asiacell offers a weekly and a daily health update service. The daily health updates include information on women’s health, men’s health, children’s health, dieting, mental health, and diabetes. Albeit a little more limited, the weekly updates is a downloadable service which only cover topics such as sports and fitness, mental health, and emergency medicine.

Customers can subscribe to the daily SMS service, by sending a blank SMS message to the toll-free short code “2330”, and then send their preferred health topic, which they can choose from a list that will be automatically sent via SMS, to short code “2331”.  This service costs IQD 2,500 ($2.14) per month.

Subscribers can also download content on a weekly basis by sending the number “1” to short code “2332” for sports and fitness information, or to “2333” for mental health information, or to “2334” for emergency medicine information. This service costs IQD 2,000 ($1.71) per month.

A similar service operates in India called mDhil which uses SMS to send health messages on various topics. The service overcame social stigmas regarding certain topics of health such as reproductive health, and became one of the most successful mHealth programs in India. Asiacell’s new service faces identical hurdles in Iraq and hopes to prevail like mDhil did.

Photo Credit: Asiacell

Asiacell is the only telecom provider to cover all of Iraq. They provide services to nearly 8 million of the estimated 31 million living in Iraq. This is remarkable given that just 5 years ago under the reign of Saddam Hussein, less than one million Iraqis had access to land lines and the average civilian did not have access to a mobile phone. Despite that and the war which ruined telecommunication infrastructure, Iraqis now have steady access to telecom services, especially mobile phones.

It is probably due to the increased access to information that has led Iraqis to become more health conscious claims Asiacell. Dr. Mustafa Adil, an Iraqi physician, said that maintaining a healthy lifestyle has become a major concern for communities, as people are more aware of the importance of following the latest health advancements and practices. He explained that Asiacell’s Mobile Health service supports the healthcare sector’s goal to promote sound health habits.

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Mobile health quizzes get a 2.7 million Euro boost

Text to Change (TTC), an mHealth non-profit organization based in the Netherlands, announced earlier this month that they will receive a €2.7 million grant to expand its services. TTC provides an SMS-based educational service to improve the health of citizens in eight countries in Africa and one in South America.

Already a big contributor in mHealth development, TTC hopes to become a leader in the field with the reception of its multi-million Euro grant from the Dutch Ministry of Foreign Affairs via Connect4Change (C4C), a consortium funded by the Dutch Ministry of Foreign Affairs that develops mobile based solutions on issues of poverty in Africa and Latin America. TTC will partner with C4C to expand its services to 11 more countries in Africa and South America by the end of this year.

Implementing ICT in the 11 countries is a top priority for both TTC and C4C. They are hoping the mutual partnership will make establishing ICT services an easier task as the expansion continues. According to TTC, the game plan calls for TTC to provide “low” technologies like SMS and mobile voice services while C4C provides “high” technologies such as mobile internet and video transfer. Therefore, TTC and C4C will play different roles.

C4C will also invest its time reaching out to local entities on the ground to strengthen ICT networks. TTC will focus on improving health outcomes through their established mobile phone initiatives.

TTC sets up their mobile platform through the recipient country’s mobile service infrastructure already in place. They then subscribe mobile phone users to their programs which use SMS communication to inform people of HIV testing, treatment clinics, and other health related services at no cost to the recipients.

TTC SMS system Photo Credit: TTC

TTC programs offer the information through a free educational quizzing service where participants are quizzed about a specific health topic. As participants answer the questions correctly, they are sent more rounds of questions, again at no cost. If the participant can answer enough questions correctly, he/she receives incentives such as phone credit, t-shirts and health products.

Thus far, TTC has reached thousands of individuals with their programs on HIV/AIDS, malaria, and reproductive health. Furthermore, to assess the impact of ICT in the countries they are currently working in, TTC will even conduct large scale ICT evaluations over the next few years in those countries.

TTC is poised to make an impact in ICT through their mobile services. Their work is just another example of how mobile phones are being used as a medium to educate, inform and save lives. The tag-team partnership with C4C will be expanded to all 11 target countries by the end of this year. However, we will have to wait some time before confirming the outcome of this joint strategic approach.

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