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<h2 class="hd hd-2 unit-title">The Background</h2>
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<h4>The Background</h4>
<p>This section explores the use of technology for active surveillance of disease outbreaks and public health emergencies. To illustrate this, we will focus on the real life application of mobile phone technology for active surveillance of the Ebola Virus Disease (EVD) during both intense and low level transmissions of EVD in several communities surrounding Monrovia, the capital city of Liberia. </p>
<p>The most deadly, complex, largest and longest outbreak of Ebola Virus Disease originated in early December 2013, from a tiny village in Guinea, West Africa. However, the EVD outbreak in Guinea was not officially reported for the first time until March 2014 in West Africa. As of February 2015, the EVD in West Africa accounted for 22,525 cases (confirmed, suspected and probable) with Liberia accounting for 42% (8,745) of these cases. Liberia also accounts for 42% (3,746 out of 9,004) of all of the deaths resulting from the EVD. However, at the peak of the epidemic in Liberia in September 2014, Liberia accounted for 49% of all of the cases (approximately 6,500 of the total 13,200 suspected, probable, and confirmed). About 50% of Liberia’s reported cases occurred in the most populous county, Montserrado County (Figure 1). With a population of 1.5 million it is the most populous county and contains the capital city, Monrovia. Most of the Ebola deaths that occurred in Montserrado County are in the densely populated urban and peri-urban communities in Monrovia. These sprawling densely populated urban slums like West Point, New Kru Town tend to accelerate the spread of the EVD. This is further complicated by the continuous movements of contacts leading to secondary transmissions and infections in the densely populated county. </p>
<p></p>
<p> Densely populated urban centers pose challenges to an effective Ebola response including loss to follow-up, explosive Ebola deaths from in- and out migration of contacts, and the fluid nature of the movements in the city.</p>
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<h4>Figure1. Rural and Urban Montserrado, showing the 22 Epidemiological Zones</h4>
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Unit Exercise
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<legend id="2c1a6c76dff445be92726778da2e3fc8_2_1-legend" class="response-fieldset-legend field-group-hd">The spread of EVD was fastest in the most rural areas of the country.</legend>
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<h2 class="hd hd-2 unit-title">Community-Based Initiative (CBI) Model</h2>
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<h4>Introduction</h4>
<p>The report examines a critical epidemiology-surveillance response in Montserrado County. The response combines community-based active surveillance and the application of mobile technology to actively track transmission in all communities in Montserrado County. The Community-Based Initiative (CBI) was developed by the author and others to break the transmission chain in Montserrado County and its densely populated capital Monrovia. The initiative involves working with local community leaders and youth groups to conduct house to house search for those with potential signs of EVD in order to rapidly isolate potential cases from the population. It involves simple door-to-door surveys by community leaders, women, youth and other key stakeholders. </p>
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<h4>Overview of the CBI Model</h4>
<p>The CBI model was initially developed and successfully implemented in the urban slum of West Point. It was developed as a result of the quarantine because of reports that there were secret burials of potential Ebola victims and that the sick were being hidden from the authorities due to distrust of the government Ebola response. These two factors were deemed responsible for massive outbreaks of the infection Ebola. Working with the local leadership in West Point, including the Commissioner, we were able to discover 34 deaths that had not been reported. We were then able to identify and trace all of their contacts. There was enhanced discovery of sick people in the community and prompt referral to the Holding Center for immediate transfer to the Ebola Treatment Unit (ETU). As a result, many EVD transmissions in the very highly congested West Point slum were averted. The active case finders and the local leaders developed a mechanism for community-based quarantine of contacts to further prevent the spread of the Ebola infection. As a result of the success in West Point, the model was sucessfully scaled-up in several Ebola hot-spots in and around Monrovia to actively seek out Ebola cases and thus break the transmission of EVD at the community level.</p>
<p>The goal of the CBI model was to get the local authorities to accept the realities of Ebola and mount an active surveillance in their communities in order to stop the transmission cycle. The stages of the model (Figure 1) included the following events:</p>
<p>1. Engage communities in mass meeting to review the Ebola situation and propose bottom-up strategies to eliminate Ebola from the respective communities </p>
<p>2. Plan community mapping of all houses, blocks, communities, zones and district for reporting</p>
<p>3. Conduct training in simple messages and active case finding</p>
<p>4. Provide logistics and set-up reporting structure (Mobile application)</p>
<p>5. Dispatch locally selected active case finding team in community (1:25 houses) and initiate the process</p>
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<h4>Figure 1. The Strategic Pillars of the CBI</h4>
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<h4>CBI Model for Ebola Survillance</h4>
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<legend id="56be42a53f7b4074acdf3693f52cfebc_2_1-legend" class="response-fieldset-legend field-group-hd">Which of the following was found to be most critical for the success of EVD control attempts?</legend>
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<h2 class="hd hd-2 unit-title">Mobile Application in the CBI Ebola Surveillance</h2>
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<h4>Introduction</h4>
<p>When the CBI model was first launched in West Point, data was collected daily and sent via SMS messages. The key data that was collected everyday by the active case finders and their supervisors was the total number of houses visited, the total number of sick people, the total number of dead bodies, the total number of patients sent to the Ebola Treatment Unit (ETU) and the total number of visitors to the household. After collating the SMS messages, the information was sent as an email to the Chief Medical Officer (CMO) at the Ministry of Health and Social Welfare (MoH&SW). This method of data collection, transmission and utilization was impossible to scale-up to about 66,000 houses from the original 5,300 houses in West Point. A paper-based data collection form that was developed by the team was introduced. These forms would come a few days late, although a summary of the data continue to come near real-time via the SMS messaging.</p>
<p><img src="/assets/courseware/v1/9b1c1f1de59d198208e085d3fa0e5fc9/asset-v1:MITx+HST.936x+1T2019+type@asset+block/fig_37.4.png" alt="" type="saveimage" target="[object Object]" preventdefault="function (){r.isDefaultPrevented=n}" stoppropagation="function (){r.isPropagationStopped=n}" stopimmediatepropagation="function (){r.isImmediatePropagationStopped=n}" isdefaultprevented="function t(){return!1}" ispropagationstopped="function t(){return!1}" isimmediatepropagationstopped="function t(){return!1}" width="846" height="525" /></p>
<p>Paper-Based Survey</p>
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<h4>Data Integration</h4>
<p>Because the use of paper-based form to collect and report data in combination with the SMS messaging was leading to delays or loss of crucial epidemiological data from the ACF in the community, a system to integrate community-based tracking using cell phone technology linked to a central database at the head office of this project was needed. Thus, daily updates would be captured in real time to collect data including coordinates of infected homes using GPS technology.</p>
<p>The data required included: suspected cases, visitor movements (a major source of major outbreaks), surveillance of religious centers, make-shift clinics and herbalist centers in the communities. These centers have repeatedly served as reservoir for continuous EVD transmission in the communities. Data that captures dangerous practices such as washing of the dead bodies and secret burials was needed. </p>
<p>In order to rapidly implement a response that would effectively break the transmission of EVD within the dense and mobile populations of Monrovia and Montserrado County, a mobile application was developed through a partnership with academia that would track community level data on drivers of transmissions. The mobile application was crucial for the work of success of the CBI model. The paper-based form was converted into a cellphone application. The application was hosted and co-managed at Yale University; the issue of security, privacy and access was jointly addressed by the teams from Liberia and the United States.</p>
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<p>Ebola Surveillance Dashboard</p>
<p>The mobile application project was piloted in the Caldwell Township, which was one of the Ebola hotspots. The team from Yale University acquired 25 mobile phones, loaded the application and used them for the initial pilot phase of the project. Because of the limited number of phones, a combination of cell phones and paper-based reporting was employed. This required driving over bad and impassable roads in Montserrado to collect the paper reports. At times, they had to have the summaries of these report SMS text or have the supervisors of the ACF to call in and give their report. As a result of these challenges, only monthly summary reports were available. There was delay in the reporting to the Ministry of Health and Social Welfare and the National Ebola Incident Management System (IMS). Further, separate reports were created and sent to World Health Organization and to the United Nations Development Program because they were responsible for different geographical regions. Monthly instead of daily reporting, the delays, and the need for separate reports were major barriers to mount an immediate Ebola response or influence key decisions by the National Ebola IMS. After more cell phones were deployed, daily reporting became possible.</p>
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<h4>Project Implementation Structure</h4>
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<h2 class="hd hd-2 unit-title">Challenges and Future Directions</h2>
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<h4>Challenges and Future Directions</h4>
<p>In spite of the success of the CBI model to effectively use a mobile application to track EVD cases in communities, there were numerous challenges during the course of the epidemic in Liberia. Illustrating challenges faced will help future teams in their development of a mobile application. The IT team in Liberia lacked access to the backstage of the data. As a result of this lack of access to the backstage of the application, it became difficult and almost impossible to correct field level mistakes and errors. This forced the IT staff to send an email to Yale to be corrected before it could be reflected in our reports. This defeated the purpose of a real time reporting and tracking mechanism. The developer of the mobile application did not provide a means for the local IT team to make correction in the date of data entry. Hence, there was no capability to correct for data that were not sent on a current date. There were other constraints posed by the mobile application for the end user: the tendency of the mobile application to freeze leading to difficulty in uploading data leading to a delay in obtaining real time data, the mobile application did not have a tool for graphical analysis, and the data had to be exported into excel or copy and paste before analysis was done.</p>
<p>The absence of some basic infrastructure locally to support effective utilization of the mobile application was another bottleneck. For instance, the lack of a constant power source in remote areas to charge the phones caused a delay in receiving constant information. Finding a constant power source from the cell phone companies may be critical moving forward. The absence of a strong signal to operate the phone in some of the most remote parts of the county was another constant source of frustration for the end user in data transmissions.</p>
<p>There were challenges between the end user and our IT team in ensuring that the capacity was developed to consistently collect and transmit the data via the mobile phone application. Firstly, the IT teams did not provide the needed large scale training in the use of the applications considering the low level computer literacy in the nation. Secondly, there were some instances where some supervisors were delinquent in submitting data. This led to a parallel reporting of data by some local community leaders as they bypassed their supervisors who would then send their data late. Finally, there were instances of inadequate and only random supervision by monitors and IT associates to ensure data quality.</p>
<p>The CBI model clearly demonstrated that a robust mobile application can greatly enhance an epidemiology-surveillance system for EVD epidemic in very challenging communities. The success of such a model hinges on the development of an enduring relationship of trust with the communities and their key stakeholders. A combination of community trust and an easily accessible mobile application is critical to the epidemiology-surveillance activities of EVD. Hence, this model can be amplified for use in future outbreaks in complex urban populations. This can be achieved partnerships can be developed with institutions that will invest in developing more robust mobile applications that can help us transition to post-Ebola early warning systems in the community while maintaining functionality for any future Ebola outbreaks. This mobile application must be capable of functioning in normal health services to track other diseases of Public Health Concerns (malaria, diarrhea, Acute Respiratory Infections, Maternal and child mortality) as well as help with the continuous active surveillance that will quickly identify and response to future Ebola outbreaks. However, there are crucial components that must be taken into consideration to make mobile applications user friendly for local managers and IT teams. Such a user-friendly application must have the following characteristics: </p>
<p>(a) An ability to allow local IT access to the backstage by local IT associates</p>
<p>(b) A cheap power source for charging the phones and identifying alternative signals for remote places</p>
<p>(c) A training component that will build the capacity of the local user and mangers to implement a robust monitoring and supervision system as well as higher data quality. </p>
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<legend id="15f75e47014d46bba8884a3111beda85_2_1-legend" class="response-fieldset-legend field-group-hd">It is important to provide local users with backend access to an application because:</legend>
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<h2 class="hd hd-2 unit-title">Impact of the CBI Model</h2>
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<h4>Results</h4>
<p>The combination of the mobile application and the CBI model produced dramatic results. For the period of November 1 to December 5, 2014, data were collected from 152,610 houses. From those houses visited the following results were obtained: (a) 563 sick persons were identified, (b) 59 of these sick persons were taken to the Ebola Treatment Unit (ETU) as suspected and/or probable cases, (c) 169 dead bodies were found in the community, (d) 86 of these dead bodies were safely buried by the authorized burial teams, (e) 1926 visitors were tracked in the various communities and (f) 305 homes were quarantined to reduce interaction with other members of the communities. Other crucial pieces of data that was collected included Ebola-related orphans, homes needing counseling and those who have been integrated into the communities after completing their quarantine.</p>
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<h4>Take Home Messages</h4>
<p>The foregoing results clearly demonstrated that a combination of mobile application and a unique Community Based Intervention contributed to the dramatic reduction in Ebola cases in Montserrado County. As shown in the figure below, developing a system to collect and transmit real time data for analysis and decision-making is critical in the fight against the EVD and other infectious diseases in developing countries. Such a system can be used in the future for reducing the transmission of EVD in densely populated urban populations.</p>
<p></p>
<p>The timely reporting, analysis and feedback of crucial data during Ebola response and any Public Health emergencies is crucial in mounting a robust response </p>
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