A New Paradigm for Disease Surveillance in Vietnam

Lindsay B. Katona, MPH,1,2 Joseph M. Rosen, MD,3 Nguyen C. Vu, MD,4 Cuong K. Nguyen, PhD,4 Linh T. Dang, BA,4 Vu D. Thiem, MD, PhD,5 Khanh C. Nguyen, MD, MHS,5 Kyle G. Ratner, PhD,6 Kevin Gan,7 and Peter Katona, MD 7 1

University of New England College of Osteopathic Medicine, Biddeford, Maine. 2 Columbia University Mailman School of Public Health, New York, New York. 3 Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire. 4 Institute of Population, Health, and Development, Hanoi, Vietnam. 5 National Institute of Hygiene and Epidemiology, Hanoi, Vietnam. 6 The Ohio State University, Columbus, Ohio. 7 University of California, Los Angeles, Los Angeles, California.

Abstract Medical surveillance data from all government health clinics in Vietnam are currently collected through a slow, paper-driven process. Short message service (SMS) technology delivered through mobile phones offers a simple solution to improving the speed through which disease surveillance information can be collected. Identifying health concerns earlier with this mobile-based disease surveillance system has the potential to improve the care for patients seen at community health clinics as well as predict more quickly that a medical emergency, such as a pandemic, will occur. Thus, we piloted the feasibility of an SMS-based disease surveillance system designed for healthcare workers in Vietnam to directly report disease information on diarrhea and influenza-like illness to a central data repository using their mobile phones and an intuitive, user-friendly platform. This article reports data from 1,579 patient data entries in 20 Vietnamese health clinics during a 6month period. Key words: disaster medicine, information management, medical records, m-health, telemedicine

Introduction

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n Vietnam, medical and public health disease surveillance is multitiered. Data is first collected at 10,848 government health clinics. This information is then aggregated at 687 district preventive medicine centers. Further data aggregation occurs at 63 provincial preventive medicine centers, then at four more sophisticated regional institutes. Finally, the data arrive at the centralized

DOI: 10.1089/tmj.2013.0250

National Institute of Hygiene and Epidemiology (NIHE) for analysis and dissemination as shown in Figure 1.1 This is a cumbersome process and the community health workers are only involved at the very beginning and unlikely to get any feedback. The use of technology to enhance surveillance capabilities has been demonstrated using application programming interfaces through Twitter and Facebook.2,3 In Vietnam, mobile phones are ubiquitous, whereas Internet access and smartphones are much less available.3 Therefore, the challenge in Vietnam and countries like it is to improve disease surveillance through basic mobile technology. Vietnam is an ideal place to test a simple mobile phone-based disease surveillance.4 The population has one of the highest per capita numbers of mobile phones in the world.5,6 Nearly everyone has a mobile phone and is adept at sending short message service (SMS) messages because it is less expensive than using voice minutes or data on a smartphone. In the current work, we piloted a mobile phone-based disease surveillance system in 20 health clinics, referred to in Vietnam as ‘‘commune clinics’’ in two provinces, Hung Yen and Hoa Binh. We examined the flexibility of using this system by asking community health workers to report cases of diarrhea and influenza-like illness (ILI). These symptoms have been studied in the past in Vietnam.7,8 We hypothesized that given the ubiquity of mobile phones in Vietnam, local healthcare workers would demonstrate proficiency in using our system, and we would thus be able to establish its viability.

Materials and Methods As an initial test of this system, health workers in 20 health clinics were asked to report cases of diarrhea and ILI from July 1 to December 31, 2012. All commune health clinics are staffed by government-employed physicians or nurses with 2 or more years of training (referred to as ‘‘community health workers’’). Although village health workers with minimal training may see a patient prior to presenting at a clinic, each clinic has anywhere from two to six health workers usually serving as the entry point for patient care throughout Vietnam. Asking these health workers to use their own mobile phones for reporting cases of disease is much more costefficient than distributing new equipment, and the workers can be educated in groups to use the system in a matter of only a few hours at one training session. Health workers were also compensated for the 2.5–5 cents per SMS and given a small stipend for participating in the project ($5 U.S./ month). The training taught them how to use SMS to input six fields of patient information (commune code, diagnosis [diarrhea or ILI], age, gender, date presented, and if death had occurred), all of which were also routinely collected for paper reporting. A random review of

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(n = 1,151) and diarrhea (n = 428). Although NIHE officials expected a similar incidence of each disease, the results deviated from this expectation. When analyzing disease by gender, more cases were reported in women (n = 925) than in men (n = 654). Seventy-nine percent of total cases reported for women were due to ILI, and 65% of total cases reported for men were due to ILI. When analyzing data by commune, four communes reported 100 or more cases, whereas five communes reported fewer than 50 cases. The rest of the communes reported 50–100 cases. Descriptive statistics for age indicated that for the youngest age group (0–5 years), the relative percentage of diarrhea cases was higher than for ILI in both provinces; in contrast, for the other age groups, the relative percentage of ILI cases was higher Fig. 1. Patient and healthcare data flow in Vietnam from clinics to hospitals to the than diarrhea cases. The incidence rates for difMinistry of Health (MOH). NIHE, National Institute of Hygiene and Epidemiology. ferent age ranges showed that the rate was higher for the 0–5-year age group as well as the over-40year group for diarrhea, while the rate slowly increased with age for paper records was done to assess that paper data matched the records ILI. drawn from the SMS database. Despite clinics being open seven days a week, of 1,349 cases of ILI The software for this project was independently developed in only 154 (11.4%) were on weekends, and of 512 cases of diarrhea the United States and, along with purchased hardware, was only 72 (14.0%) were on weekends. Both ILI and diarrhea cases brought to Vietnam in July 2012. The hardware included a GSM peaked in September as shown in Figure 2. modem connected to a laptop for collecting data. A Vietnamese Subscriber Identity Module (SIM) card with a local phone number Discussion was connected to the GSM modem to receive messages. In addition The current report describes a pilot test of an SMS disease surto the six fields mentioned above, the software automatically veillance system in Vietnam. In this pilot we tested the feasibility of captured the sender’s phone number and a date/time stamp. This the system by asking community healthcare workers to report cases system was purposely designed to require very little hardware that of diarrhea and ILI as well as six demographic characteristics of could be purchased and assembled at extremely low cost. The data people presenting with these symptoms. This project has the potential were stored at the Institute of Population, Health, and Developto improve the speed and accuracy of disease surveillance reporting ment offices in Hanoi. in Vietnam.

Results Despite training and monitoring, we expected to receive data entry errors. Eighty-two percent of data entries were found to be correct or easily correctable. For example, letters rather than numbers in a numerical field like age were not correctable; a space instead of a comma or an extra letter between fields was easily correctable. The logbooks that health workers used to track all patient information were compared with SMS logs at the end of the pilot, and there was excellent correspondence. In Hoa Binh Province, 558 of 586 patient entries matched for ILI, and 167 of 171 entries matched for diarrhea. Although the primary purpose of this pilot study was not data analysis but testing the system’s functionality, we present a very preliminary description of the 1,579 patient entries from July 1, 2012 through December 31, 2012 from the 20 commune clinics enrolled. When examining total cases of ILI and diarrhea, an almost threefold difference was found between reported cases of ILI

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Fig. 2. Cases of influenza-like illness (ILI) and diarrhea by month.

SMS DISEASE SURVEILLANCE IN VIETNAM

Some findings raised interesting questions: Was low reporting in some clinics related to poor compliance or close proximity to District Hospitals, which would lead patients to possibly bypass the clinics? Was the larger number of cases noted in September related to the seasonal variation of disease or the migration of workers corresponding to the planting season? Was the lower number of cases seen on weekends due to the perception that clinics were closed, when in fact they were open? As more data are acquired in the next phase of the project, we will attempt to further address these questions. One of the major concerns with implementing this type of project is that the interest of community health workers up front might not be sustained over time. This is particularly a concern because of the additional burden that reporting presents for already overtaxed healthcare workers, who currently use a logbook to report patient encounters. To address this, there were two times during the pilot period that workers were reminded to use the system. Nonetheless, we could not fully judge the completeness of SMS reporting until SMS entries were compared with paper logbooks at the end of the pilot period, showing excellent association. Another concern was potential government censorship of data, but this concern has so far proven unfounded. Government stakeholders at NIHE were included in the design and implementation of the project and demonstrated substantial enthusiasm for the potential public health benefits. In the next phase of the project, we are expanding to 46 clinics using 3, 6, and 11 data fields to assess differences in accuracy. Data will be sent to a Web site that will automatically aggregate, errorcheck, and analyze messages in real-time. There will be a message sent back to the sender specifying if the original SMS was sent correctly. The data will be available on the Internet so that anyone approved to view all or part of it will have easy access. The location of each clinic will be geotagged to enable the generation of heat maps that allow for the rapid assessment of prevalence and incidence of disease by location. Deviations from the norm will be flagged, many errors will be autocorrected, and analysis will be automated.

An improved surveillance system that more efficiently and accurately delivers vital health information to key decision-makers would ensure better patient tracking, better government accountability, better use of resources, and improved patient care. This SMS-based surveillance system could initially supplement and eventually replace the traditional paper-based system. This pilot project demonstrates one of many ways to improve public health in Vietnam and other countries using readily available, simple-to-use technology at a very low cost.

Disclosure Statement No competing financial interests exist.

REFERENCES 1. Ministry of Health, Vietnam. Circular no. 48/2010/TT-BYT. Available at http:// bit.ly/VqsOCD (last accessed January 27, 2013). 2. Signorini A, Segre, AM, Polgreen, PM. The use of Twitter to track levels of disease activity and public concern in the US during the influenza A H1N1 pandemic. PLoS One 2011;6:e19467. 3. How can I create an SMS-to-Twitter gateway and vice-versa? Available at https://dev.twitter.com/discussions/5650 (last accessed July 3, 2013). 4. Phuc H. New means of communication and socio-cultural changes in Vietnam. Soc Sci Inform Rev 2009;3:19–25. 5. International Telecommunications Union. Available at www.rediff.com/ business/slide-show/slide-show-1-tech-mobile-phone-per-capita-top-10nations/20130515.htm (last accessed June 15, 2013). 6. Index Mundi. Available at www.indexmundi.com/map/?v = 4010 (last accessed June 15, 2013). 7. Fischer TK, Anh DD, Antil L, Cat ND, Kilgore PE, Thiem VD, Rheingans R, Tho le H, Glass RI, Bresee JS. Health care costs of diarrheal disease and estimates of the cost-effectiveness of rotavirus vaccination in Vietnam. J Infect Dis 2005;192:1720–1726. 8. Nguyen HLK. Epidemiology of influenza in Hanoi, Vietnam, from 2001 to 2003. J Infect 2007;55:58–63.

Conclusions In addition to serving as a pilot for Vietnam, this project also serves as a proof of concept to determine whether SMS-based disease surveillance could be used in other countries and for other purposes when mobile phone use is widespread but Internet access and smartphone use are limited. This project achieved the objective of being very simple on the front end and allowing for gradual increases in complexity on the back end.

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Address correspondence to: Peter Katona, MD The David Geffen School of Medicine University of California, Los Angeles 100 UCLA Medical Plaza, Suite 220 Los Angeles, CA 90024 E-mail: [email protected] Received: July 23, 2013 Revised: August 25, 2013 Accepted: August 26, 2013

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A new paradigm for disease surveillance in Vietnam.

Medical surveillance data from all government health clinics in Vietnam are currently collected through a slow, paper-driven process. Short message se...
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