The development of ICTs industries especially mobile technologies and GIS has given the opportunities to apply it in the area of development and public health including public health emergency. Literature retrieval is conducted to review the use of ICTs especially mobile technologies, Internet and GIS in the area of public health, the concept of emergency public health, and lesson learned from the use of ICT in the recent emergencies. The disadvantages and advantages of using ICTs are discussed to give some consideration in applying the technologies in the area of emergency public health.
The Information and Communication Technology (ICT) field has been growing significantly in the last decade, and has been applied in many sectors including development, education, and health sectors. The United Nations (UN) recognised the need to emphasise the important use of ICT in achieving Millennium Development Goals (MDG), and created a Global Alliance of ICT and Development (GAID) in 2006, with the objective to increase the role of ICT in achieving international development Agenda (UN, 2010). The use of ICT for health also has been widely introduced especially in European countries. The European Commission (EC) launched a program called e-Health, an ICT tools and services for health. The program covers broad ranges of issues in health such as disease prevention, monitoring, management of disease and telemedicine (EC, 2011).
World Health Organisation (WHO) through their Global Alert and Response (GAR) program recently launched a technical collaboration involving various resources, networks, and institutions in providing ICT solutions to predict, prevent and support Public Health Emergencies (PHE). The first meeting of this collaboration was conducted in Geneva in 2009, involving academia, Non Government Organisations (NGOs) and private sectors. This meeting addressed the needs to carry out research and development of ICT tools and solution on PHE field of works. (WHO, 2010)
Despite recent policy development as well as the use of ICT in emergency public health by humanitarian organisation or public health expertise in the field, fewer documents are found regarding this topic. Therefore, a literature reviews on the topic of ICT and public health especially in emergency public health surveillance is conducted to investigate ICT use public health, in recent emergency situation and discuss some advantages and disadvantages using this technology.
ICT Terminology and Definition
There is no single agreed terminology or definition of ICT, and it is a challenge to find the exact definition of it. A document from DFID defines ICTs as “technologies that facilitate communication and the processing and transmission of information by electronic means” (Marker P; et al, 2002) which cover broad range of aspects. Thus, to limit the scope of the topic, the essay will only focus in the use of mobile phones, Internet, and the Geographic Information System (GIS).
A literature retrieval using the University Liverpool library Discover application, Google, Google Scholar and PubMed is used to retrieve journals with combination following terms “mobile phones”, “Internet”, “GIS”, “ICT”, “Technologies”, “health”, “public health”, “health surveillance”, “emergency”, “disaster”.
The mobile phones and Internet use in public health
Since the breakthrough of mobile phone connectivity in early 80’s, mobile phone communication has been rapidly growing in the last 10 years. The mobile phone technologies have widely reached the world, even the most rural areas in developing countries, such as sub-Saharan Africa. Approximately 45 percent of sub-Saharan African villages were covered by mobile phone signal in 2006 (International Communication Union, 2007). Surprisingly in India, a sanitation study conducted by United Nation University (UNU) discover the proportion of population which has access to mobile phone (45%) is higher than access to toilets (35%) (UNU, 2010).
In developed countries, mobile technologies have been widely used in the area of public health programs and have contributed to increase the effectiveness of public health program intervention (Kaplan, W.A.,2006). For example, the use of mobile phones to improve the coverage of public health surveillance in Germany (Hu, S.S, 2011) and to increase community participation in health surveillance in USA (Freifeld, C. C. 2010). Mobile phone technology also contribute to an efficient health protection program due to its ubiquitous coverage (Stern, A., 2009).
In developing countries, where the coverage is not as high compared to developed world, yet, the rapid growing mobile phones connectivity creates opportunities to use these communication technologies in the area of public health programs. For examples, mobile phones are used in data collection and reporting for a large area household health survey in South Africa, where mobile phones increase the efficiency by reducing data loss and enabling timely reporting directly to the server for analysis (Tomlinson, M., 2009). There is also one example in India where mobile phone technologies are used to sustain good adherence of antiretroviral treatment of HIV/AIDS (Shet, A., 2011). However the evidence regarding the overall cost effectiveness using mobile technologies in developing countries for public health program is still limited and required further study (Kaplan, W.A., 2006).
The Internet use and connectivity also have grown very rapidly in the last decade. In 2010, 28.7 percent of people in the world have access to Internet, which increase by 444.8 percent from 2000. Astonishingly, 10.9 percent of people in Africa have access to Internet and more than 825 million people (21.5%) in Asia do too (Miniwatts Marketing Groups, 2011).
The Internet for many years has been contributing to the public health area especially in education and research sectors as well as applied public health program. Internet based surveillance has been commonly used in developed countries. The latest development internet Web 2.0 platforms such as Facebook, twitter or YouTube have drastically revolutionized the public health information sharing between public health institutions and the community (Holt, C., 2011; Khan, A.S., 2010).
Geographic Information System (GIS) use in Public Health
GIS is a system which integrates the cartography, statistical analysis and database technology through capturing, analyzing, managing and presenting the data with reference to geographic location using hardware, software and the data itself. It allows us to view, understand, question, interpret and visualize data in various ways and shows the relationship to with their geographical location in the form of maps, globe, report and charts (Xu, G., 2007).
GIS has close connection with the epidemiology science for many years. The first epic example is the use of geographic information by John Snow to investigate a cholera outbreak in London back in 1854. However literature retrieval for study using keyword of GIS is mostly published after 1995 (Kaiser, R., 2003). Since the use of GIS with the development of computerised version of GIS has increased the use of GIS in public health as it is revolutionise the collection, analysis and presentation of public health data.
Data management using GIS requires a Geo-coded data containing coordinates of the location around the world. Tremendous growing industry of cheap Global Positioning System (GPS) devices has led to the fact that many places in the world have been geo-coded even places in Africa (ITU, 2007). GPS is constellation of earth orbiting US-Government satellites that transmit information to hand-held or built-in receivers that can calculate a location with a potential precision of one square meters (Xu, G., 2007).
GIS currently has widely used in most of the area of public health, mostly used in disease surveillance, risk analysis, health access and community health profiling (Nykiforuk, C.I.J.,2011). The disease surveillance, particularly the communicable disease surveillance, is the most popular GIS use in the area of public health, as it allows spatial aspects of infection chains, environment condition and changes over time (Maheswaran, R., 2004).
Emergency Public Health Surveillance
Public health surveillance is the “continuous, systematic collection, analysis and interpretation of health-related data needed for the planning, implementation, and evaluation of public health practice” (WHO, 2011). The purpose of disease surveillance is to monitor trends, provide early warning of outbreaks and as a tool to monitor the effectiveness of public health intervention (WHO, 2005). It is a fundamental aspect in fighting any communicable disease which involves routine case counts of disease and demographic data of patients (Bloland, Peter B. 2003).
During a disaster emergency situation caused by either complex emergencies or natural disaster, diseases, especially communicable disease such as measles, diarrhoea, cholera, malaria can become easily spread among the affected population, because of disruption of public health system and increase vulnerability of people (Sphere, 2011). Surveillance system, therefore, should be simple, flexible, acceptable and situation specific and should be established at the initial stage in an emergency response, so it can be used to monitor disease outbreak threats and plan an intervention as early as possible to prevent further spread of the disease (Connolly M.A, 2005).
During the acute phase of an emergency situation, some major diseases/syndrome have to become priorities and be systematically monitored from beginning, which are bloody diarrhoea, acute watery diarrhoea, suspected cholera, lower respiratory tract infection, measles and meningitis. Depending on endemicity of the disaster affected areas, malaria and viral hemorrhagic fevers usually should be included (Connolly M.A, 2005).
Public Health surveillance has six core activities from detection, registration, confirmation, reporting, analysis and feedback, which have aspect of communication and information sharing (figure.1) (Connolly M.A, 2005). In a coordinative emergency response, such as in disaster or responding to a disease outbreak, the effectiveness and the success of an emergency public surveillance system also relies on data collection, reporting and also sharing between different institutions to plan coordinative public health intervention (WHO, 2005). During an acute emergency situation phase, routine data reporting should be conducted at least weekly (Sphere, 2011) and in any epidemic threats situation usually need immediate notification (Connolly, 2005). Thus, communication and data information sharing should use the fastest, and reliable tools, which bring the ICT into attention for emergency public health expertise.
Figure 1 shows the conceptual framework of public health surveillance and action. In order to make it effectively work, support activities such as communication, trainings, supervision and resource person are needed.
ICT Use in Public Health Emergency Situation
The use of mobile phones in Surveillance Reporting
During Sichuan 8.0 Earthquake response in 12 May 2008, which killed more than 80,000 people and 5 million more become homeless, one of the urgent issues after the disaster is detection of occurrence of epidemic-prone diseases. The existed electronic surveillance system using dial-up and broadband internet connection was paralyzed by the earthquake and in order to immediately reactivate the disease surveillance, the Chinese Center for Disease Control and Prevention set up a mobile phone emergency reporting system. 495 light-powered mobile phones, which were installed with data input application and capacity to transmit data to national database, were delivered to local health providers in 14 counties, which hardly hit by the earthquake. Within one week the surveillance report from local health providers returned to normal level. The mobile phone reporting system effectively restored the reporting capacity of health care and contributed to effective public health response during the disaster. In disaster prone areas, this innovation can be taken as part of disaster preparedness plan. Recommendation from this approach is to use the mobile phone with GPS capacity for accurate location tracking and restriction of phone usage. (Yang, C.; et all 2009).
Internet Based Emergency Health Surveillance
In the 2010 Haiti disaster response, Haitian Ministry of Public Health, Pan American Health Organisation (PAHO) and Center for Communicable Disease and Prevention (CDC) launched an emergency surveillance system called IDPSS (Internally Displaced Population Surveillance System) in response to no existence of data sharing and illness tracking among NGOs, even though, the NGOs conducted routine disease surveillance internally. Due to high turnover of NGOs personnel, as well as geographic distribution of NGO, Google Group was established to improve the communication. This Internet based mailing list group has effectively increased timely and reciprocal communication between the IDPSS coordinator and NGOs as well as among the NGOs themselves. NGOs can send the electronic file of their surveillance report and the compiled results were distributed among members through the Google Groups in various presentation including GIS based Map (figure 1). Within 6 months of the operation, the IDPSS already had 177 members, representing 60 different NGOs and coordinating agencies. The IDPSS provided weekly surveillance reports and continuously improved the quality of the data as more information was collected along with the improvements in logistics and infrastructure. Recommendation from the implementation of this program clearly stated the need in developing communication strategies using locally available Internet and cellular networks for future humanitarian response (CDC, 2010)
Unlike other natural disaster where surveillance system was used to prevent communicable disease, during Hurricane Katrina, internet-based morbidity surveillance system was used to monitor non-communicable disease in Georgia. The system has contributed to the disaster response in monitoring the disease trends among affect the affected population living in the sponsored shelter and proved that Internet is essential in collecting health data during emergency situation. (Cookson, Susan T. 2008).
The use of GIS in emergency situation
The Centers for Disease Control and Prevention (CDC) has been using the GIS-based analysis in public health especially in communicable disease surveillance since 1990 (Maheswaran, R 2004). The use of GIS based application has continue to become routine in public health humanitarian emergencies (Kaiser,Reinhard 2003). The use of GIS also has contribute to quality improvement of the disaster preparedness plan in health sector through mapping pre existing chronic disease and health assets in the disaster prone areas (Holt,J.B. 2008).
GIS also has been used in many outbreak situations, such as dengue outbreak preparedness in Srilanka (Pathirana,S. 2009) and diarrhea outbreak investigation in South Africa (Bessong,P.O. 2009). GIS has improved the ability in infectious disease outbreaks investigation and response through clustering the cases based on its geographical features (Kaiser,Reinhard 2003).
The growing industry of ICT worldwide and the strong policy endorsement in the use of ICT in development as well as lesson learned from recent humanitarian emergencies, have increased the of use ICT during emergency situation such as disaster (Smith,Patrick C. 2009), more specifically in of Public Health area (WHO, 2006). In term of public health emergency surveillance system, which also strongly depends on routine data collection and up to date disease information (Connolly, M.A, 2005), mobile and Internet technology is a possible way to increase the timely data transfer. The data then can be analyzed, transformed and disseminated to all related stakeholders for policy development or planning the action as soon as possible (Mathew,Dolly 2005). However, in applying ICT in emergency public health surveillance there are some considerations, which need to be taken in account, which are discussed below.
Network resiliency of mobile and wireless technologies
The wide coverage wireless network mobile phones and Internet connectivity bring some advantage in the need to provide fast and reliable data information and communication in emergency public health surveillance (WHO, 2005). Though, this connectivity is not perfectly invulnerable to disaster especially natural disaster, but it is much more resilience than other communication system. For example, during the Japan Tsunami in March 2011, there are huge infrastructure damage, however the Internet networks were recovered in several hours (Daily News Global, 2011). In outbreak situation, where there are no infrastructure damage, mobile or Internet technologies possibly much more feasible to be implemented during investigation or response. However, any planned operation during emergencies should be based on the assessment in order to plan effective responses (Sphere 2011), or it should better to integrate this approach as part of disaster or outbreak preparedness plan (Yang, C.; et all 2009)
Information carrying capacity and data security
There are some limitations on information carrying capacities in mobile phone technology. SMS messaging is only limited to 160 characters and the mobile Internet technologies also have some bandwidth limitation. Therefore, in applying mobile technologies, both mobile phone and mobile internet services need to consider the size and type of data that will be transferred to the server. However during acute phase emergency situation, usually the number of disease to be monitored is only limited to several outbreak potential infectious diseases (Connolly M.A, 2005), so mobile technologies are still feasible to apply.
There are some data security issues, which need to be addressed before applying mobile and Internet technologies in emergency public health surveillance. Data lost is possible to happen due to various reasons such as viruses, or simply due to equipment loss or damage. Data back up plan, as well network security system should be in place before operating the system.
Cost of training and investment in GIS application
The GIS based application is also continuously being used in many humanitarian emergencies with their ability to analyze and present data with connection with its geographical location. However the GIS application needs huge amount of investment from the equipment and training. Initial investment for purchasing GPS, computers, recent GIS software, conducting training as well as recruiting the personnel can cost up to US$100,000 (Kaiser, R., 2003).
GIS softwares commonly available are proprietary software which are mostly expensive. ESRI, a GIS based software developer who develop Arcview GIS, the most advanced and commonly use GIS based application, sold the application at price of US$ 1,500 for single use license (ESRI, 2010). Nonetheless, recently there are free web based GIS applications. However, beside the need of good Internet connection to operate it, a web-based GIS application also has some limitation especially limitation in data entry, analysis and presentation compared to non-web based application. In order to solve the problem, there are also some free or open source GIS applications which are not reliant to Internet access, such combination of Cybertracker for GPS-enabled Personals Digital Assistants (PDA), Open Jump , a Java-based, open source GIS to visualize health data simple analysis; and AccessMod© a free extension from WHO for service availability mapping, although the training for the personnel who operate it should be intensive (Fisher, R.P., 2011).
We have learned that the ubiquitous coverage of mobile and Internet technologies have enabled public health program to reach more people. the Internet also have revolutionized data communication while the GIS with its ability to visualize health data in the relation to its geographical location has enabled comprehensive analyse the data. From study literature although stil limited, the ICT has been effectively use in recent emergency situation such as Sichuan Earthquake, Haiti Earthquake and many others emergency situation caused by disease outbreak. The use of ICT in emergency public health surveillance enabled comprehensive, reliable and timely data reporting and analysis. However, some consideration has to be taken in account before applying this technologies in establishing the emergency public health surveillance, despite its resiliency to be damaged by natural disaster, such as the capacity of data sharing and its security and also the cost to establish this system, especially the GIS system.
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