Electronic disease surveillance, another important component of a comprehensive global public health disease prevention and control strategy, contributes significantly to capacity building and support for IHR (2005) compliance in partner countries. Using electronic methods for data collection and analysis has the potential to improve the accuracy and timeliness of outbreak detection, as well as to provide situational awareness during, or in the aftermath of, an outbreak or pandemic. The AFHSC-GEIS network has supported numerous initiatives in electronic disease surveillance during the past several years, in partnership with several DoD overseas laboratories, host-country Ministries of Health and Defense and our technical partner, the Johns Hopkins University Applied Physics Laboratory (JHU/APL).
AFHSC-GEIS has relied on the extensive experience that JHU/APL acquired in the design and implementation of the Electronic Syndromic Surveillance for Early Notification of Community-based Epidemics (ESSENCE) system . This electronic disease surveillance system, used worldwide at all DoD military treatment facilities (MTFs), the U.S. Veterans Health Administration system and at least 12 states in the United States, served as a model for a toolkit approach to deploying electronic surveillance within the AFHSC-GEIS network. Tools have been created to enable data collection from the most sophisticated data sources to remote settings where data have traditionally been difficult, if not impossible, to collect. These tools have far-reaching applicability in any resource-limited setting, whether overseas or after a disaster in the United States. The following describes some of the efforts that have focused on adapting electronic or syndromic surveillance techniques to resource-limited settings.
Two electronic surveillance efforts were developed at AFRIMS in Southeast Asia and optimized in 2009, including a project with the Royal Thai Army (RTA) in remote border areas, as well as a pilot short message service (SMS)-based project in the Philippines, part of a joint effort with JHU/APL and the Cebu City Health Office (CHO). The Thai Unit-Based Surveillance (UBS) project commenced in 2001 and originally covered areas along the Thai-Cambodia border where the Thai MoH did not have disease surveillance capabilities. The project, developed by the RTA with support from AFRIMS and AFHSC-GEIS, reports diseases in both military and local civilian populations by faxing reports or by voice via military radio. In 2009, the Thai-Myanmar border area was added and an additional 497 personnel were trained. Version 2.0 of the UBS simplified data collection from 216 symptoms and categorization into 12 syndromes that are consistent with the Thai MoH’s reporting requirements. This updated system added questions about poultry exposure, leptospirosis, novel A/H1N1 infection and chickungunya virus infection. Although no major outbreaks of disease were detected by this system in 2009, it continued to provide situational awareness for the RTA and Thai MoH.
Dengue fever poses a significant health threat in the Philippines. Current hospital-based surveillance is highly valid, but poorly suited for rapid identification of dengue ”hot spots” because of delays associated with laboratory confirmation. To capture this important data for the purposes of surveillance, a more rapid, but less specific surveillance method was implemented and compared to the standard sentinel surveillance system. This pilot study implements and evaluates a simple dengue surveillance protocol using SMS text messages to send daily, person-based dengue surveillance data from local Barangay Health Centers (BHCs) to the city health office (CHO) in Cebu City. The pilot activity was originally established in five clinics as of March 2009, but was soon instituted in all BHCs in the city. Beginning July 1, 2009, all BHCs have been identifying all patients reporting to clinic with fever. Each day, BHC personnel send this information to the CHO, creating a text message for each patient with fever. The SMS message contains the date and clinic name, as well as the patient’s name, age, gender and symptoms. The message is transferred into a Microsoft Access© database, cleaned, and starting July 2010, reviewed in the ESSENCE Desktop Edition application to identify statistically significant increases in reported fever cases.
Meanwhile, NAMRU-2 continued to support the optimization of the Early Warning Outbreak Recognition System (EWORS) at 11 reference and provincial hospitals in the Lao PDR allowing local MoH officials to monitor the impact and burden of tropical and infectious diseases in the country in real time. The CDC currently funds most of the operating budget for EWORS in Lao PDR. The system, jointly developed by the Indonesian MoH and NAMRU-2 with AFHSC-GEIS funding, is also being used in Indonesia as the national reporting system. EWORS has additionally been used in Cambodia, Peru and Vietnam, although it is no longer in use in these countries because local health authorities favored other surveillance systems.
In South America, NMRCD-Peru supported major efforts in electronic disease surveillance, including continuation and optimization of Alerta, a public-private initiative that has revolutionized surveillance for the Peruvian military during the past seven years. The Alerta system has seen recent expansion to all branches of the Peruvian military, as well as adoption by the MoH of one other country in the region—Panama. This system identified 17 outbreaks during 2009, including influenza, dengue, mumps, malaria, hepatitis A and respiratory disease.
Finally, in collaboration with the JHU/APL group, NMRCD-Peru worked to develop an electronic syndromic surveillance system based on open-source software for use in resource-limited environments. As a result, the system can be sustained without continued major investments or software licensing fees. This effort involved the development of interactive voice response reporting, as well as building a web-based infrastructure and database on an open-source version of the ESSENCE system (OpenESSENCE) in use in the United States. Additionally, NMRCD-Peru supported the systematic evaluation of these electronic surveillance systems and research on ways to improve reporting via electronic systems .
These electronic surveillance initiatives constitute a vibrant portfolio that capitalizes on the expertise of the JHU/APL group and numerous AFHSC-GEIS partners at overseas laboratories and within host-country Ministries of Health and Defense. Many of the lessons learned, challenges, successes and failures have been shared within this network of collaborators, and a harmonized strategy is emerging to develop and deploy an electronic disease surveillance system that is modular and responsive to various needs found in developing settings. This approach should assist many countries in complying with IHR (2005) by the 2012 deadline.