Smartphones used to fight spread of malaria

When a malaria research project in Uganda was expanded into a full-fledged malaria case-tracking effort across the country in 2006, health officials saw the move as a great opportunity to save lives. After all, malaria is the number one cause of death in Uganda, and occurs throughout 95 per cent of the country, according to one of the research project’s coordinators.

But after starting with such promise, the project quickly became mired in a series of technology shortcomings. The original database application used to keep and sort information — an ancient version of Epi Info — was an old, slow, flat-file database that was difficult to use and to search.

Even worse, the only way to get that case data out of the malaria project sites dotting the country was through paper printouts carried by human couriers. The couriers traveled in vehicles over bad roads on trips that took several days and cost around $550 per excursion.

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Adding to the troubles: There were no Internet connections available in the nine remote, rural locations where the data collection centres were located, and there was little or no electricity anyway.

Fixing the problems would require an entirely new approach.

It finally all came together this spring after the introduction of a few key high-tech tools — a modern relational database, nine smartphones and a remote-access software application that was originally meant for a completely different use. These pieces were all brought in to fill the gaps and drastically speed the collection of the data to help fight the spread of malaria inside the country.

Using a smartphone from a remote location in Uganda to send data on patients, the incidence rate of the disease and the effects of interventions.

Now the malaria case data can be collected at research sites across Uganda, sent wirelessly using smartphones, then quickly entered into research databases at a central location in Kampala, the capital of the country.

But it wasn’t easy getting there.

The Uganda Malaria Surveillance Project (UMSP) began to conduct clinical trials for malaria drugs in 2001. The project was expanded to track individual cases starting in 2006. Because of the courier-based collection system, it regularly took eight months for the incoming data to be added into the database, making it out-of-date for tracking malaria and its treatment in real time.

All of that changed, however, after two tech-savvy experts, and one expert in the community-health arena, heard about the problems. They visited Uganda in October 2008 to witness the difficulties with their own eyes so they could investigate ways to fix them.

What they found was a situation reminiscent of a Rube Goldberg diagram, with one change affecting a host of other needed changes, all linked together in a confusing and ultimately messy chain of disconnected technologies.

“They needed consistent data reporting done easily and quickly,” says Josh Mailman, director of technical operations for the Global Health Research Foundation (GHRF) in Los Altos, Calif., a non-profit organization that helps bring health technology to underserved populations around the world. “Their original database required brute force to get reporting out of it.”

The first fix began this past March when Mailman returned to the research project’s headquarters in Kampala with a new Dell quad-core server and a modern relational database that’s under a royalty-free licensing arrangement from Health Metric Systems in Palo Alto, Calif.

Each of the nine remote malaria project facilities across Uganda had already been equipped with a computer and other equipment, including solar panels and inverters that power the computers in the absence of modern electrical power grids. That gear was brought in about two years ago by UMSP partner institutions.

But the new improved database and central server dramatically exposed the weaknesses in the courier-based data-transfer system.

“I was sitting in a meeting while they talked about how they were happy with how they could now get their data into reports easier, but they were still having delays of several months just getting the collected data from the field offices,” Mailman says. “They had a data collection problem which was as big as or bigger than their original database problem.”

“If we were in the U.S., we’d be getting connected to the Internet and sending the data in real-time,” Mailman says. “But here there’s often no electricity, and the computer they were using may be the only one in the entire clinic.”

Running a landline for an Internet connection was prohibitively expensive and would have taken up to 12 months to install, if it was even possible, he said. There are Internet cafes in larger towns around Uganda where data-entry staffers could have transmitted the data, but that would have introduced the potential for computer viruses and confidentiality issues. “That could have caused massive problems for their simple IT systems,” he said.

Workers in the main malaria project data centre in Kampala, Uganda, process case information that is coming in via smartphones.

A second option was out, too. Because the project operates on a shoestring budget, there was no money to pay for expensive satellite phones to transmit the data.

Mailman also considered using generic cell phones to connect to the remote computers so they could transmit the data, but dropped that idea quickly. The concern was that with so few PCs available, having unrestricted cell phone access might be a lure for unauthorized users to use the cell phones to transmit their own e-mail or other files. This could potentially expose the core IT systems to viruses and other technical problems in remote locations where repair help was not easily available.

With land lines, satellite phones and generic cell phones exhausted as possibilities, Mailman began to wonder if more specialized smartphones with integrated MicroSD cards for data transfer might solve the problem. And that’s when he thought about a product he already uses for remote access to his home and work computers — LogMeIn Rescue — which works with Windows Mobile, Symbian and BlackBerry smartphones.

The software is sold as a secure application that corporate IT staffs or managed service providers can use to support remote users anywhere in the world. But UMSP is putting the application to a different use — with LogMeIn Rescue, staff members in the Kampala headquarters can instantly and securely retrieve the collected data from the smartphones in the field.

By installing the LogMeIn application on smartphones and deploying a single phone to each of the nine remote data collection sites, data entry workers in each facility are able to copy their collected malaria database file information onto a MicroSD card and insert it into the phone. Once the phones are turned on, the devices can transmit the data wirelessly to the central Dell server in Kampala.

And since the files are small, the transfers amount to only about 320KB for each clinic per month, which costs less than $5 monthly for service at each location. That means data-transfer costs of about $45 a month for the entire program, which is far less than the almost $2,200 monthly required by the slow and inefficient courier system.

They were spending $25,000 a year to collect the data and now it’s costing about $540 a year, “and they are getting the data while it is still vital,” Mailman says.

After returning to the U.S. from Uganda, Mailman contacted Woburn, Mass.-based LogMeIn for help and the company agreed to provide free LogMeIn Rescue software and services for the malaria project workers. Palm Inc. donated five Treo 750W smartphones and Mailman was able to buy four more in online auctions.

In April, the nine LogMeIn-equipped Treo phones were taken to Uganda for distribution by Dr. Grant Dorsey, an associate professor in the division of infectious diseases at the University of California in San Francisco. After some training, the remote workers began successfully using the Treos to transmit their malaria data in May.

In an e-mail reply, Ruth Kigozi, the monitoring and evaluation coordinator for the malaria tracking program in Kampala, said the use of smartphones has transformed the way malaria case data is collected and analyzed. “Data is received within the first week of the current month, providing for timely analysis and dissemination,” she wrote.

Malaria contributes up to 40 per cent of hospital outpatient visits, 20 per cent of hospital admissions and 14 per cent of hospital deaths in Uganda, Kigozi says.

Dr. Erica Weirich, founder and director of the GHRF, says the improvements brought about by the technology additions are critical to the malaria tracking project.

“Originally, when the UMSP program started, there was little reliable data on patients, on the disease or on the effects of interventions,” Weirich says. “Doctors and researchers can now see what is happening quickly, and spend more time preventing and healing the disease. Having the data back so rapidly allows you to try new things and see if they are working, which is very powerful.”