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Lessons for Ebola, from 3 years of water source mapping & monitoring in the African continent

Ebola 2014 — The current Ebola epidemic in West Africa which was first noted in the spring of this year began quietly but has now escalated to include five countries (Guinea, Liberia, Nigeria, Senegal, Sierra Leone) and an estimated 3707 suspected/confirmed cases with 1848 deaths (US Centers for Disease Control and Prevention Ebola Page, August 31st, 2014). The WHO declared this Ebola Virus Disease (EVD) epidemic a Public Health Emergency of International Concern on August 8, 2014 (WHO on Ebola Virus Disease). Despite this declaration, the new Ebola cases continue. Recently the Rt value for this epidemic was reported to be greater than 1 and less than 2 (R>1 and R<2) (Nishiura H. and Chowell G. Eurosurveillance 2014). These numbers soberly reminds us that the number of Ebola cases are not slowing down but are in fact growing which, appeals for immediate and urgent action to reduce and cease Ebola transmission. This plea has been echoed by prominent virologist and infectious disease experts, Richard E. Besse, Michael T Osterholm and “Science Magazine.”

To aid in this global problem, Annie Feighery, an expert in using technology to improve public health, describes lessons she has learned from her work in West Africa with mWater, a mobile water sanitation tracking system, and how these lessons can be applied to the current Ebola situation.

Alyson

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Lessons for Ebola, from 3 years of water source mapping & monitoring in the African continent

by Annie Feighery

The West Africa Ebola outbreak has been said to be the World’s Katrina. This means we are witnessing one of our lifetimes’ worst tragedies which is largely due to the significant gaps in the local health infrastructure. Many of the stressors in what is now the worst Ebola outbreak on record are not directly Ebola-related, but rather legacy problems from generations of broken health systems. For years, the water and sanitation field has worked under very similar conditions in West Africa and learned valuable lessons about frontline health monitoring which we believe can be applied to the Ebola Response. Here we recount lessons learned on Report Systems, Checklists and Public Engagement from our work through mWater in West Africa that may be fundamental to Ebola reporting and management.

In 2011, I co-founded the organization mWater to develop technology to help communities and individuals have access to safe water by harnessing the power of smartphone technology. Our first partners were UN Habitat, the City of Mwanza, Tanzania, and the local water utility in Mwanza. It wasn’t as simple as mapping, though. By creating a unique ID number for water sources, we were able to attach information to a source that could be updated over time. In the case of water, we mapped whether the source was functioning and we used a cheap but highly effective field test to update whether it was contaminated with E. coli, an indicator bacteria for more dangerous contaminants.

Since then, we’ve expanded our application to map sanitation facilities, schools, health clinics, communities, and households. Each is a different type of site that can have a broad range of data associated with it, and that data can be updated over time with mWater surveys. The result is an infrastructure that allows data-driven policies and improved municipal management. Most important, thanks to continued investment in mWater from USAID, Water.org, WaterAid, and The Water Trust, we can now offer this service to any community or organization for free, via the mWater app and online portal. What started in Mwanza has grown to more than 2000 free and independent users in 54 countries and 7 countries where large organizations contract our services for specific projects. Our user base includes communities, governments, utilities, scientists, and organizations who build infrastructure by mapping and monitoring sites, conducting M&E surveys, and deploying health worker checklists on mobile phones and tablets.

We have learned critical lessons about how the approach of monitoring water sources over time can also be helpful in addressing major public health issues. Currently, the biggest health emergency on our planet is the West African Ebola outbreak. Our technology can help. Our team is working around the clock to leverage our software for emergency response, mapping, and monitoring of this Ebola outbreak. But our biggest contribution may be our lessons learned about digital epidemiology.

Listed below are three lessons on Report Systems, Checklists, and Public Engagement which we think encompass the critical knowledge gained over our past three years that could increase the situational awareness and health capacity for the Ebola health crisis.14986886991_799e7067e1_m

Report symptoms Frontline community health workers are the best way to gather information in developing countries. For Ebola-stricken countries, the military is also being deployed as frontline health workers, conducting temperature checks and enforcing quarantines. We found that data from health workers is more accurate when health workers are asked to report symptoms rather than conduct the diagnosis themselves. A diagnosis needs local context. For example, we asked 35 health care providers throughout Mwanza to define the symptoms of diarrhea. We received a range of 18 answers including red eyes, weakness, and fever. The WHO definition of three or more loose stools in a day was only the fourth most frequent response. This is likely because many individuals in this region go their whole lifetimes without a solid stool. A loose stool in this context is not a relevant symptom. However, a case that the health worker finds significant enough to report with a list of symptoms the health worker can tick off in checked boxes makes the data actionable, regardless of the accuracy of the diagnosis.

We are using this lesson for Ebola with our own launched platform for symptom reporting. Within five seconds, frontline health workers can press their finger on a map to indicate location, automatically filing a report to the cloud-based management dashboard. The app works on and offline, which is important in low-resource regions that can have sparse connectivity. If they have time, users can provide more detailed information on symptoms with tick-checked boxes. Previous digital epidemiology attempts have attempted to focus on reports from doctors and other official sources, limiting information to a slow but steady stream from experts. The lesson with crowd-sourced data is that the validity of the data increases with the “n”, the number of reports, as opposed to traditional studies that increase validity with source quality. We are doing everything we can to increase reports, including eliminating barriers such as literacy and time expectations. We are focusing on the point of data being at the biggest interface with the community, the frontline.

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Follow checklists Frontline health workers have a lot of information to remember, from diverse fields such as public health, sanitation, and community development. One very simple innovation that has been shown to dramatically reduce complications in hospitals is the use of checklists. We work to apply this same concept to community health workers, who provide the frontline health information interface for communities in developing countries. Mobile technology can help ensure that best practices make it all the way through the last mile and into the frontlines.

We can already use our Surveyor platform to deliver a checklist to smartphones, allowing us to add questions or steps that are automatically pushed to health workers and monitor whether they are using the tools provided. Real time data gathered in a cloud-based database can use checklist results from one survey to trigger another enumerator’s questions. Symptoms queried can be adapted in real time, based on growing situational awareness. All data in checklists can be quickly monitored as indicators in the Portal, a management website that deploys surveys, collects their responses in real time, and allows users to download their data as CSV forms.

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Listen to the public. In a large survey of the population in Mwanza, we found that water scarcity was a bigger concern for them than water contamination. As a public health scientist, I know this is due to a survivor’s bias, where only people who survived the age of five and have the gut flora needed to survive high levels of fecal contamination are around to tell their neighbors, their family, or me about what they are worried about. I know epidemiologically that waterborne disease is the second biggest cause of infant mortality on the globe and an indicator for the other big threats to child well-being, namely lung infection and malnutrition. But I have learned that also meeting the self-assessed needs of a community is a critical must to any policy.

In water, focusing on self-assessed needs allowed the city to make a policy decision based on digital epidemiology with local buy-in. We mated the need of water scarcity with the health policy need of protecting water supply by providing more and safer water sources. Our data motivated the city to stop supporting any further construction of shallow wells, which were found to be frequently contaminated, instead approving boreholes and piped kiosks and taps for their own expansion and NGO donations.

Translating this lesson to Ebola, the communities affected are rarely hit with Ebola itself, but instead are regularly hit with diarrhea and lung infection and they have a chronic shortage of medical staff to treat those illnesses. The targeted response to Ebola while these more common life-threatening conditions go under-treated has caused distrust between communities and the emergency agencies. Taking the self-assessed need as a critical priority would mean we should also provide resources for lung infection, diarrhea, and other local health priorities alongside our effort to provide resources and expertise for Ebola.

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Annie Feighery is a digital epidemiologist based in New York City and the CEO of mWater, a non-profit tech start-up that develops innovations for water, sanitation and health. The organization provides free and open access platforms for mapping and monitoring infrastructure, for deploying mobile surveys and for real time visualizations of health data. For more information, visit www.mWater.Co and follow @mWaterCo on Twitter. To use mWater’s free Ebola monitoring platform, visit Ebola.BroadSt.org.
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Marie Anne and the WHO investigate Cholera in Sierra Leone

I believe accurate reporting of infectious diseases, including diarrhoeal diseases, to be a significant issue of consideration in both developed and developing nations.  Accurate reporting by the individual, as well as by medical and government institutions, is imperative for analysis of infectious disease epidemiology. With accurate reporting, especially of cholera cases and cholera typing, appropriate therapeutic and preventative measures can be put in place. 

Here, Marie Anne Chattaway, a microbiologist from the UK, describes her experiences working with the WHO in Sierra Leone establishing an Enteric Bacteria Laboratory in Sierra Leone.  Their goal was to aid cholera diagnosis and reporting in this region.  I can’t thank Marie Anne (marie.chattaway@hpa.org.uk) enough for sharing her project.  I wish her and the taskforce every success in the future.

Thank you to Marie Anne, WHO and Sierra Leone.      

Alyson

Marie Anne and Cholera in Sierra Leone

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Picture 1: Map of Sierra Leone

I first became interested in developing countries when I started to volunteer for JIDC (The Journal of Infection in Developing Countries) a couple of years ago as a scientific editor and reviewer where the focus was mentoring scientists to publish their research in a scientific journal. I have been working with enteric pathogens for over five years at the Health Protection Agency of the UK and now realise just how much of an impact bacterial enteric infection has in developing countries. Until now, I had only managed to help from the UK, but the outbreak in Sierra Leone provided me with an opportunity to really use my microbiological skills where it was needed the most.

Cholera outbreak in Sierra Leone

Sierra Leone (Picture 1) has recently battled its worst cholera outbreak in 15 years. In

Picture 2: Crowded housing at risk of cholera

Picture 2: Crowded housing at risk of cholera

July and August 2012, the epidemic rapidly spread to all but one of Sierra Leone’s 13 districts. With a combination of crowded housing (Picture 2), unsafe water supplies, poor sanitation and the rainy season ahead, intervention was paramount. On 16 August 2012, the Sierra Leone government declared the outbreak to be a public health emergency, and established the Presidential Taskforce on Cholera. As of 2 October 2012, there had been 20,736 cases, including 280 deaths (case fatality rate or CFR=1.35%). The western area of the country where the capital city of Freetown is located was the most affected area with more than 50% of total cases. Initial training and some supplies were provided to the Central Public Health Reference Laboratory (CPHRL), Lakka and Connaught Hospital, in Freetown by the World Health Organization (WHO) and International Centre for Diarrhoeal Diseases Research, Bangladesh (ICDDR,B).  The Global Outbreak Alert Response Network (GOARN) later requested a microbiologist to further evaluate laboratory facilities and provide technical advice and assistance to strengthen laboratory services for detection of cholera cases, capacity for confirmation by laboratory identification and for conducting differential diagnosis for main enteric pathogens (e.g., Vibrio cholera, Shigella, Salmonella, E. coli). The Health Protection Agency (HPA), UK, sent a microbiologist from the Gastrointestinal Bacteria Reference Unit (GBRU) to undertake this task from 10 October to 8 November 2012.

Travel to Freetown

The HPA was already involved with the cholera outbreak with a focus on epidemiology and case management; Sarika Desai and William Welfare from the HPA had already been deployed as WHO consultants. The specific request for a microbiologist to go to Sierra Leone for the month came later and though I had volunteered to go, in the end I had only 24 hours’ notice that I was on the flight the next day and that urgent supplies were needed. Needless to say, my two large suitcases were filled with consumables as well as clothes, a ridiculous amount of a range of pharmaceutical products (which I did end up using – unfortunately), and insect repellent (the insects still got me, though). I’m not sure what part of the journey was the worst: the bad turbulence on the plane with the woman behind me screaming; the small speedboat trip across the sea in the pitch black;  the jolting of the spine across the dirt tracks in the jeep;, or the sickness on arriving when adapting to the humidity and heat (as you know, we English are used to the cold). Either way, I did make it in one piece and was so happy that I didn’t crash in the plane and impressed by the stunning views (Picture 3) that actually I didn’t mind the bumpy roads.

Picture 3: One of the many stunning views in Freetown

Picture 3: One of the many stunning views in Freetown

Assessment of the laboratory

I was fortunate that there was a dedicated laboratory which had been selected to develop testing based at the Central Public Health Reference Laboratory (CPHRL) in Lakka. It was an hour away from the WHO office. Prior to intervention the department was faced with challenges of the lack of supplies, shortage of available trained staff, poor processing systems, and inadequate Health and Safety protocols in the enteric bacteria section of the CPHRL. The icddr-b had done a fantastic emergency response but further work was now required to establish and maintain an enteric bacteria laboratory in Sierra Leone.

Establishing an Enteric Bacteria Laboratory in Sierra Leone

Before training could even begin, a supplies stock system with the support of the WHO, HPA, CDC and Ministry of Health and Sanitation (MoHS) was set up to receive the required equipment and supplies. Molly Freemen from the Enteric Diseases Laboratory Branch of the CDC joined me for 11 days and the collaboration of all these organisations enabled the success of this mission. Intense training of multiple staff was necessary to maintain function after I left and the staff worked incredibly hard, even coming in at weekends and public holidays. A quality accredited process was set up, including the design of request forms for necessary information, the development of protocols for taking samples, receiving and logging the samples into CPHRL, and testing and recording results on the enteric result database for reporting (Picture 4). A surveillance link was also set up

Picture 4: Left to Right: Musu Abu entering laboratory results with Marie Anne Chattaway

Picture 4: Left to Right: Musu Abu entering laboratory results with Marie Anne Chattaway

so that regular weekly reporting of confirmed enteric pathogens is fed back. The two weeks of practical (Picture 5) and theoretical training was followed by intense three-day theory and practical competency testing. Staff were then certificated in “Isolation and identification of Vibrio cholerae, Salmonella typhi, non-typhoida, lSalmonella, Shigella sp. and E. coli O157” and “Health and Safety and Quality Systems in the enteric bacteria laboratory” (Picture 6).

Picture 6: Left to Right: Musu Abu, Fay Rhodes and Marie Anne Chattaway in Enteric Bacteriology, Quality and Health & Safety training

Picture 5: Left to Right: Musu Abu, Fay Rhodes and Marie Anne Chattaway in Enteric Bacteriology, Quality and Health & Safety training

Challenges and future Work

To sustain the new laboratory service, there is still much work to be done.  The supply system must be managed to ensure stock is available when needed.  Regular testing at the laboratory and reporting of results are essential for monitoring the cholera situation in the country. The biggest challenge will be the organisation and implementation of regular sample collection and transport to CPHRL.  Without regular samples from the districts, the testing competency and surveillance cannot be maintained. The impact of this part of the international response has been considerable; there is now a system for detecting and confirming cholera and other enteric pathogens within Sierra Leone.  If this laboratory component of surveillance is sustained it will lead to a better understanding of the incidence of cholera in the country and provide earlier recognition should the infection become epidemic again, thus enabling a rapid response.

Picture 6: Left to Right: Molly Freeman, Ahmed Foray Samba, Musu Abu, Slyvester Kamanda, Dr Abdual Kamara, Fay Rhodes and Marie Anne Chattaway. Other staff who participated and not in this photo include Eric Sefoi and Doris Harding.

Picture 6: Left to Right: Molly Freeman, Ahmed Foray Samba, Musu Abu, Slyvester Kamanda, Dr Abdual Kamara, Fay Rhodes and Marie Anne Chattaway. Other staff who participated and not in this photo include Eric Sefoi and Doris Harding.

Would I recommend this experience

Absolutely! It was an amazing experience, from networking and collaborating on an international scale with the most amazing and interesting people to experiencing the culture. I felt a real sense of achievement seeing how I can personally make a difference. It is hard work, working long hours with little breaks in sometimes difficult conditions, but the end result was worth any hardship. My favourite challenge was when I first opened the incubator to find lots of small ants favouring the Trypticase Soy agarplates. At first I didn’t think much of it, but when I looked at the plates carefully I saw tiny ant footsteps left by the insects that had walked on a cholera plate just after it had been inoculated. The ants had walked across the plate, dragging the bacteria with it (Picture 7). It is possible that perhaps there is a vector influence with the spread of some diseases that we wouldn’t normally consider!

By Marie Anne Chattaway

**Pictures taken by Marie Anne Chattaway, HPA.

Picture 8: Ant trail spreading cholera on a Trypticase Soy Agar plate (see line from top of plate to the bottom across the middle).

Picture 7: Ant trail spreading cholera on a Trypticase Soy Agar plate (see line from top of plate to the bottom across the middle).

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Dr. Asghar Nazeer – A recent JIDC author!

One of the things I love about JIDC is that it brings together so many people from so many different countries and cultures. When I first started the JIDC blog, I invited everyone in the JIDC community to contribute posts in which they share their science experiences working in a culture different from their own. We’ve had some great posts about adventures in Brazil, China, Vietnam and other places. This week, I am pleased to share Dr. Asgar Nazeer’s story. He is an accomplished scientist and medical doctorand a recent JIDC author.  Dr. Nazeer’sPostcard reflects his life as a researcher as well as his personal values thathe carries through to his work.  It is this kind of spirit and caring that drive the dedication behind JIDC. His story is inspiring!

Alyson

Dr. Asghar Nazeer, MBBS, MPH, MHS, DrPH (Johns Hopkins)

Dr. Asghar Nazeer, together with Dr. Jaffar Al-Tawfiq, is the author of a review article “Methicillin-resistant Staphylococcus aureus metrics for patients in Saudi Arabia” published in the March issue of JIDC.  JIDC came to know that Dr. Nazeer has been selected as a Member under Spotlight for March 2012 by the Delta Omega Honorary Society in Public Health. He was originally inducted into the Delta Omega Honorary Society in Public Health, Alpha Chapter (the society’s founding chapter) in 1994 at Johns Hopkins University and elected as a Lifetime Member in 1995. He is a committed member of the Delta Omega Mentor Network. Dr. Nazeer has more than 27 years’ experience in public health, epidemiology, and clinical medicine. Over the course of his career, Dr. Nazeer has been at the forefront of public health practice. He has won several medals, honors and awards in his homeland and in the United States. JIDC blog therefore took the opportunity to invite him to share his story regarding how he started his career and how his education and research in Johns Hopkins University transformed his calling as a doctor.

Dr. Nazeer originates from Pakistan. He a was an outstanding student throughout his high school and college years and won National Talent Scholarships and three gold medals including a Prime Minister of Pakistan Gold Medal for his academic achievements. He graduated in 1983 from King Edward Medical University, the most prestigious school of medicine in Pakistan. He worked as a physician for five years in leading centers-of-excellence offering post-graduate training programs in medical specialties. He was commended as a physician by his patients, superiors, and colleagues and was concentrating in clinical cardiology for advanced certification. However, he was touched by the suffering of his patients and realized that “prevention is better than cure” is not just a cliché but a sound fact. Instead of dealing with the illness of one patient at a time, he thought he should serve populations at large by promoting health and preventing disease. He then decided to leave the lucrative career of a physician and voluntarily adopted public health as his calling to serve the humanity for the greatest good of the greatest number.

As his first public health assignment, he joined the Federal Ministry of Planning and Development, Pakistan, as Assistant Chief of Health Section in 1989 where he contributed to health policy formulation and health-care planning at the national level. He participated in planning, implementing, and evaluating nationwide projects focusing on prevention. In that capacity, he represented his Ministry in projects involving collaboration between the Government of Pakistan and international agencies such as the WHO, UNICEF, World Bank, UNICEF and USAID.

His academic excellence and extensive experience in health policy and planning contributed to his winning the internationally competitive World Bank Graduate Scholarship Program’s Fellowship for studies at Johns Hopkins Bloomberg School of Public Health where he earned MPH, MHS, and DrPH degrees. He won the Advising, Mentoring and Teaching Recognition Award, William H. Draper Fellowship, and Friends of International Health Student Scholarship Award and was inducted into Delta Omega Honorary Society in Public Health, Alpha Chapter.

After completing his coursework for the Dr PH degree at Johns Hopkins, Dr. Nazeer had to leave the USA to attend to his ailing mother, who relied on him for her care and companionship. Dr. Nazeer answered her call without hesitation and gave up chasing his American dream at a juncture when he was winning honors and awards on many fronts. With her consent, he moved to United Arab Emirates where his several siblings worked so that his family could reunite there.

Dr. Nazeer worked for the Federal Ministry of Health, United Arab Emirates, from June 1995 to December 2003 as Senior Public Health Specialist with the Policy and Projects Department. He was involved in several projects and policy initiatives and had the opportunity to collaborate with the World Bank, WHO and other agencies as one of the Ministry of Health’s team members.

He wrote an outstanding dissertation, by utilizing his weekends and vacations while working full-time, which was lauded by his academic and thesis advisors and the dissertation committee. His dissertation focused on developing algebraic methods for evaluating validity and reliability of diagnostic and screening tests from their agreement data in the absence of a gold standard. He applied those methods to cervical cancer screening data for comparing them with the conventional methods. Dr. Nazeer holds women and children’s rights and their health-care priorities in his highest regards. He accordingly named his dissertation as R and Z Conceptual and Analytical Framework as a tribute to his wife’s dedication and sacrifices and his autistic son’s angelic innocence by putting the initials of their names in his dissertation’s title. He truly believes that behind every successful man there is a woman and considers his wife, who is also a physician, as his best friend ever. He also commends the great sacrifices of his mother for supporting him in getting the best education and laying a strong foundation of his career.

Dr. Nazeer resigned from his position in Ministry of Health UAE in 2003 to take on a new assignment as Senior Epidemiology Specialist in the Preventive Medicine Services Division of Saudi Aramco Medical Services Organization. He is still working in the same organization.

In short, Dr. Nazeer graduated as a physician and practiced clinical medicine for five years. He then decided to become a public health professional and obtained his higher education from Johns Hopkins University. His first two years of education in Johns Hopkins Bloomberg School of Public Health were funded by the World Bank Fellowship. He believes that the prayers and untiring support of his mother and his wife, the World Bank’s Fellowship, and studying at Johns Hopkins University transformed his life from a physician to an earnest public health professional who strives to serve the humanity at large on a population level rather than in a clinical setting. To contact him or learn more about his work, click to access his Linkedin profile.

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