Research

Disease Outbreak, Health Systems, Healthcare Workforce, Infectious Diseases, International Aid, Research, Vaccination

Lessons Learned from Ebola

~Written by Kelly Ann Hanzlik (Contact: kelly_hanzlik@hotmail.com)

According to the World Health Organization, 28,616 people contracted Ebola and 11,310 lives were lost during the Ebola epidemic. After so many lives lost and the hopeful, but understandably tentative countdown of Ebola free days continues once again in West Africa, it is imperative that we take a moment to consider what we learned from the devastating and tragic epidemic.

I spoke with Dr. Ali S. Khan, former senior administrator for the Centers for Disease Control and Prevention, former Assistant Surgeon General, and current Dean of the University Of Nebraska College Of Public Health. He noted initially, that there is always the risk of importation of cases; that is how it started he reminds us. He elaborated further that the epidemic “changed the response from the WHO and caused a change in political focus by the nations involved that will affect future outbreaks and ensure native capabilities, as well as link them to the global response.” He also noted that new medical counter measures, such as vaccines and related therapeutics, were also the result of the Ebola impact. When asked about what we learned, he did not hesitate. “The first thing was a new vaccine that permits a novel prevention strategy using ring vaccination to prevent spread and new cases. The second is the new monoclonals and antivirals for treatment.” He also noted the better understanding of the viral progression and clinical diseases that will influence options for acute treatment and follow up of convalescents.

Ebola has provided us with a virtual plethora of opportunities to learn about the disease, its treatment and control, as well as the control of other infectious illnesses through our attempts to prevent its spread as well as through our failures, and successes. We gained valuable treatment modalities and tactics that will likely be used in future outbreaks of Ebola, as well as many other infectious diseases.

Ebola taught us other things too. It has been some time since global health has taken center stage. Ebola changed that. During the epidemic, one could not watch the news or go through a day without hearing an update on the latest development in the Ebola crisis. Although other infectious diseases like Plague, Polio, AIDS, SARS, H1N1, Cholera, and now Zika have captured the world’s attention, few diseases have made such an intense impact, nor caused the uproar and fervor that Ebola elicited. Ebola reminded us that global health is public health and affects us all, and as such, deserves to be a priority for national and international focus and funding for everything from vaccine development and research, to capacity for response locally, nationally, and internationally. Global health has teetered on the edge of public awareness, and remained a quiet player in the competition of priorities in national budgets. Today, it is abundantly clear how vital this sector is to each nation’s, as well as the world’s health, safety, success and even its survival.

Another effect from the Ebola crisis was the opportunity to educate people about public health and the transmission of infectious disease. Through education, public health officials were able to promote behaviors that ensured the safety and health of the public. It is stunning that in this day and age, we persist in so many behaviors that put us and those we interact with at risk. The discrepancy in what we say we will do, and what we are actually willing to commit to and take action on, looms large. Persisting low vaccination rates and the prevalence of infectious diseases such as sexually transmitted diseases, measles, pertussis and influenza show this. Ebola offers yet another opportunity to demonstrate the connection between our behaviors and our risks and disease.

Ebola also showed us that many nations continue to lack sufficient financing, infrastructure, facilities, support and medical staff to treat their own populations. Endemic conditions like malaria, and neglected tropical diseases like Guinea worm disease, Yaws, Leishmaniasis, Filariasis, and Helminths, as well as other conditions continue to affect millions globally.  Maternal and childhood morbidity and mortality rates remain deplorable as well. And millions of children around the world continue to suffer and die of malnutrition and disease before they reach the age of five. This is unacceptable, especially because proper treatment and cures for these conditions exist. Ebola also highlighted the need for treatments for chronic non-infectious conditions as well.

Moreover, Ebola clearly demonstrated the enormous need that remains for sufficiently trained medical professionals and healthcare staff to provide adequate care for many populations throughout the world. The loss of so many extraordinary and heroic staff that dedicated their lives to helping others in need under the most daunting and challenging of circumstances was devastating to those whom they served, and must not be in vain.


Additionally, Ebola provided us with yet another chance to relearn lessons about the role of safety in giving aid to others in need. We learned that we cannot just rush in with aid, but must recall the basics that every first responder and medical student must learn:  Ensure scene safety before giving care, and first do no harm. Ebola showed us the necessity to strategize and prepare to give care by utilizing personal protective equipment. It also reminded us very quickly that we could indeed do harm, and worsen the epidemic when we acted without first assessing the situation and ensuring proper protection and preparation.

So, it remains to be seen just how much we will learn from Ebola. Will we learn from our mistakes? Will we take the global view in the future, or the narrow one? Will we truly live by the motto of the Three Musketeers and be "one for all and all for one", or persist in "it's all about me"? Only time will tell. 

Community Engagement, Economic Burden, Healthcare Workforce, Innovation, Research

Part II-Prototypes Bring Ideation to Life

~Written by Lauren Spigel, Monitoring and Evaluation Coordinator (Contact: lauren.spigel@vaxtrac.com; Twitter: @vaxtrac)

Also published on VaxTrac blog


Welcome to the second installment of our blog series on human centered design. In our introductory post we broke down what human centered design means for designers and implementers of international development projects. Our most recent post gave a case example of how we’re building empathy with health workers in Nepal. This post will share a case example of how we’re prototyping different iterations of a monitoring and evaluation (M&E) dashboard for our staff in Benin.

Once you have worked with your project partners to determine what you want to design or test, the most effective way to get useful feedback from the people you’re designing for is to prototype what you want to test.

Sam facilitating the feedback session on VaxTrac monitor

Prototyping allows you to get feedback on something concrete rather than abstract. It is the difference between asking someone to describe their perfect cup of coffee versus giving them three different cups of coffee to critique. They will have a better grasp of what you are trying to design, and you will get more specific and useful feedback.

Prototyping also gives you the flexibility to test a variety of unique ideas without spending the resources on a project that might not work the first time.

The Problem
Our team in Benin needed a new, more efficient way to monitor our project. As we trained new health workers to use VaxTrac and added an entirely new health zone to our scope of work, our field team had to process more data than ever before.

Each field supervisor had devised his own method of monitoring how health workers use the tablets, what bugs occur in the software, and how to compare tablet-based reporting to paper-based reporting. Meanwhile, back in DC, our Learn team stayed busy exporting data from CommCare reports and spending a lot of time converting data into a more useful format.

It quickly became clear that we needed a more efficient way of tracking data so that our field-based team could spend less time entering data into spreadsheets and more time responding to health worker needs, prioritizing resources and tracking progress over time.

Prototyping Solutions to Test the Best Ideas
To solve this problem, we have been working with our team to design a monitoring tool that will allow our field supervisors to monitor the project more easily. After a series of feedback sessions interspersed with a variety of paper monitoring tool prototypes, we decided the best solution would be to design a web-based data dashboard that can automatically populate with data from CommCare, such as when a form is submitted, the time it takes to complete a form, when a child is fully immunized, among other pieces of data. We are also working to incorporate additional pieces of data such as, data use, battery level of the tablet and the last time the tablet had an internet connection.

In order to get feedback from our team in Benin, we designed a live prototype of a monitoring and evaluation (M&E) dashboard:
 

M&E Dashboard Prototype


Our DC staff brought the prototype to our Benin staff during a trip to Benin a couple weeks ago. We held a focus group and asked our team questions about the types of data they want to monitor on the dashboard, how data should be grouped, how data should be displayed and how they would use the dashboard.

By providing a concrete example of an M&E dashboard, we were able to elicit specific and useful feedback from our team in Benin. The designing of the dashboard is an ongoing project. We will continue to get feedback and iterate on our designs until we come up with a solution that meets everyone’s needs.

Check out the final post in our series about human centered design, where we’ll give examples of how we keep iterating on our projects even after we implement.

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To learn more about incorporating design thinking into your projects, contact Lauren at lauren.spigel@vaxtrac.com or check out IDEO’s resources.

Community Engagement, Economic Development, Healthcare Workforce, Innovation, Organizations, Research

Part I- To Get Inspired, Build Empathy into Your Project Plan

~Written by Lauren Spigel, Monitoring and Evaluation Coordinator (Contact: lauren.spigel@vaxtrac.com; Twitter: @vaxtrac)

Also published on VaxTrac blog

Build Empathy First
In our first blog post about human centered design, we talked about building empathy for design thinking. But what does “empathy” really mean, and how does it translate into research methodology?

To have empathy is to understand another’s perspective. If your goal is to build empathy with the community you’re designing for, it’s important to budget time, space and resources to talk to a variety of project stakeholders about the challenge you’d like to solve before the project starts. While it’s difficult to convince donors to spend money on an extended R&D phase, giving communities a voice at the onset of your project can save your organization time and money by allowing stakeholders to voice their opinions and be active participants in the design process.

The methods we use to build empathy are reminiscent of the research methods found in academic settings. Human centered design is especially akin to the philosophy of community based participatory research (CBPR), which also recognizes that when given a voice, communities are best equipped to identify sustainable solutions to challenges they face. Like CBPR and more traditional qualitative research methods, human centered design relies on interviews, focus groups, observations, surveys, card sorts, among other interactive methods, such as role plays, immersion and community mapping to elicit feedback from stakeholders.

Let’s dive into the case example of how we are building empathy with health workers in Nepal to improve our user interface and workflow.

The Problem
The clinics we work with in Nepal are fundamentally different than the clinics we work with in Benin. In Benin, the clinics are urban and busy. There are vaccination sessions almost every day. Caregivers bring their children to the clinics for vaccinations.

By contrast, the clinics we work with in Nepal are rural. The population is dispersed. As a result, vaccinations only happen a few days a month. There may be one or two sessions that take place at the main clinic, but there are usually also a number of outreach sessions, in which the health workers walk several hours to sub-health posts within their catchment areas. Since the population is small, only a few children come to each session.

Building Empathy through Brainstorming and Workflow Cards
There are a number of methods we could use to get into the mindset of the health worker. The key is to remember that health workers are the experts. They understand their job better than anyone else. Our job is to listen, build empathy for what they experience in their jobs and translate that into our software design.

We are starting with the goal of understanding health workers’ workflows in different situations. In other words, what do health workers do to prepare for a vaccination session? What happens during a session? What happens after?

Our DC-based team started by brainstorming objects, people and actions involved in a vaccination session. We scoured the internet for images to represent everything that we came up with. We put together sample workflow cards and brought it to our project partners in Nepal.

Draft Workflow Cards (Source: vaxtrac.com)


Seeing the sample workflow cards inspired our in-country partners Amakomaya to continue the brainstorm. They looked at our cards and told us what images worked and which images did not convey the right meaning. They grabbed a marker and started brainstorming their own list. We sketched images together.

We designed an interactive activity with health workers to use the workflow cards to get a better understanding of the different workflows they use during vaccination sessions. We are currently working to add Amakomaya’s feedback into an updated version of the workflow cards, which we will test out with a group of health workers early this year.
Using cards with simple images on them is a great way to get health workers talking about how they do their work. Cards are tangible objects that health workers can put in their hands and arrange in different ways. It gives the group a visual to refer to when someone has a question. It allows our team and health workers to identify gaps in the work flow as well as pain points.

We hope that by understanding current workflows and processes, we can understand the challenges that health workers face in their daily jobs and iterate our software so that it improves their workflow.

Check out our next post in our series about human centered design next week, where we’ll give examples of how we’ve been prototyping a monitoring and evaluation dashboard with our team in Benin.
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To learn more about incorporating design thinking into your projects, contact Lauren at lauren.spigel@vaxtrac.com or check out IDEO’s resources

Infectious Diseases, Research, Vaccination, Health Systems, Government Policy

Defeating Tuberculosis: A Possibility?

~Written by Sarah Khalid Khan (Contact: sk_scarab@yahoo.com)

Disease has always played a part in reforming community and geographical distribution of people through the ages. The bubonic plague, the Spanish flu, cholera and tuberculosis (TB), are some of the illnesses that have altered human history. Interestingly, TB has been glorified in literature more than others. The characters, Mimi in La boheme, Fantine in Les Miserables and Satine in Moulin Rouge all met with a similar fate at the hands of this disease.

According to the Global Tuberculosis Report 2015, the year 2015 is considered a turning point for TB as the global community progressed from Millennium Development Goals (MDGs) to Sustainable Development Goals (SDGs). TB mortality has decreased by 47% since 1990. Between 1990 and 2014, as a result of correct and timely diagnosis, 43 million lives were saved. We have made progress by moving from the “Stop TB Strategy” to the “End TB Strategy”. According to the latter, the targets for 2030 are to reduce the number of TB deaths by 90% and incidence by 80% (1).

Source: TBAlert.org

These statistics give us hope for a world without TB. But, having worked in a tertiary hospital in a low middle-income country, I have my doubts. Although the statistics reported by the World Health Organization (WHO) are the best available at the moment, these are estimates with very wide confidence intervals and may not provide a precise idea of the current situation in low and low middle income countries (LIC and LMICs).

In the surgical ward where I worked, one-third of the abdominal procedures were for perforation due to abdominal TB. To my knowledge, patient records were maintained through an electronic health system on the hospital server. Hard copies of the records were kept in nurses’ offices or junior doctors; duty rooms. These were put in storage, usually available for 4 to 5 years. The conditions of the storage area were extremely shabby and damp, where paper records could hardly survive. Electronic records, however, were said to be available in perpetuity. No one knew if these records were ever shared with the WHO to help with estimates. Popular opinion was that if the world knew the actual incidence and prevalence of diseases like TB in countries like ours it would be an embarrassment. Regardless, it is essential to have as accurate as possible estimates to converge efforts towards a TB free world.

Despite the best intentions and apparently achievable goals, the situation remains grim. According to the WHO, TB still imposes a great burden on the world. In 2014, 9.6 million new cases of TB were diagnosed while 1.5 million people died as a result of TB (2). Despite the history of this disease, research for newer TB drugs has been limited (3). In 2012, a new drug for multidrug resistant TB was introduced after a drought of 50 years (4). In addition, though BCG vaccines are part of immunization programs in countries where the disease is endemic, the current vaccine was developed in 1921 and is not entirely effective (5). A systemic review and meta-analysis that included articles from 1950 to 2013 reported 19% efficacy against TB in vaccinated children compared to non-vaccinated children (6). Although current research is encouraging there are questions of affordability of newer drugs for low resource countries where TB is more prevalent. Furthermore, five percent of the global burden of TB is due to multidrug resistant strains (7). The research required for averting these cases poses additional problems of affordability, availability and accessibility in LICs and LMICs.

Children present another area of grave concern. It is estimated that 550,000 children are infected with TB each year. The condition is frequently overlooked in children, often due to delayed and inefficient diagnosis (8). Adoption of the latest recommended diagnostic tools by the WHO is a challenge in itself because accessibility, affordability and availability again come into play in LICs and LMICs. Since TB flourishes in poor living conditions, the current global refugee and migrant situation has increased concerns about TB exposure, infection and transmission (9).

It is time that LICs and LMICs focus on establishing the true burden of major diseases like TB, and work towards adopting recommended diagnostic tools and treatment for all forms of TB. Unless the state actors and international community work together, the policies and aid provided will continue to fall short and the target to end TB will remain out of reach.

 

References:

1. World Health Organization. Global Tuberculosis Report 2015. 2015.

2. World Health Organization. Research for Tuberculosis Elimination. 2014.

3. Frick M. 2014. Report on Tuberculosis Research Funding Trends, 2005-2013. [Internet]. Treatment Action Group. 2015. Available from: http://www.treatmentactiongroup.org/sites/tagone.drupalgardens.com/files/tbrd2012 final.pdf

4. Médecins Sans Frontières, International Union Against Tuberculosis and Lung Disease. DR-TB Drugs Under the Microscope. Sources and prices for drug-resistant tuberculosis medicines. 2nd edition. 2013.

5. World Health Organization. Tuberculosis vaccine development [Internet]. World Health Organization; 2015 [cited 2016 Mar 19]. Available from: http://www.who.int/immunization/research/development/tuberculosis/en/

6. A Roy et al. Effect of BCG vaccination against Mycobacterium tuberculosis infection in children: systemic review and meta-analysis.  BMJ 2014; 349:g4643

7. World Health Organization. Multidrug Resistant Tuberculosis (MDR-TB). 2015.

8. World Health Organization. Combating Tuberculosis in Children. 2015.

9. World Health Organization. Tuberculosis prevention and care for migrants. 2014.

Community Engagement, Research, mHealth, Innovation

How to Incorporate Design Thinking into your ICT4D Projects: A Blog Series

~Written by Lauren Spigel, Monitoring and Evaluation Coordinator (Contact: lauren.spigel@vaxtrac.com; Twitter: @vaxtrac)

Also published on the VaxTrac blog

2015 was a year abuzz with talk about human centered design in the international development community. Words like “human centered” and “design thinking” may sound like international development buzzwords on par with “sustainability” and “capacity building” (thanks Devex), but behind the words are tangible methods you can use to elicit feedback from the people your project serves and use their insights to build better, smarter solutions.

If we break down the jargon, human centered design means to listen to the people that you are building a program for – before, during and after implementation. You listen to them because they are the experts. If you are designing an app for health workers to register patient data, you listen to health workers because they are experts on their workflow and needs. If you are designing an educational SMS system for youth, youth are experts in understanding what they want to know and how they want to discover that information. Simply put, human centered design is a series of methods implementers can use to engage with users throughout a project’s lifespan.

The human centered design process walks us through methods we can use during three key phases

  1. Inspiration: defining the problem, the audience, understanding facilitators and barriers
  2. Ideation: brainstorming ideas, testing out prototypes, finding the best solution
  3. Implementation: choosing the best idea and implementing it, while still getting feedback and iterating

While human centered design is typically thought about in terms of technology projects, in recent years, the concept has been applied more broadly to solve complex global health challenges. In an interview with WIRED magazine, Melinda Gates, Co-Chair and Trustee of the Bill and Melinda Gates Foundation, described human centered design as “meeting people where they are and really taking their needs and feedback into account.” It sounds intuitive that we would want to understand the needs of the people we serve, but we often lack the tools and resources to do this well.

We are writing a three-part blog series to share our own experiences designing a mobile vaccine registry system for health workers. Our blog series will give case examples of the methods we used at various stages of the human design process. The first post will focus on how we are building empathy with health workers in Nepal to improve our user interface and workflow. The second post will look at how we’ve been prototyping a monitoring and evaluation dashboard with our team in Benin. Lastly, our final post will emphasize the importance of iterating after implementation by sharing our experience customizing our software, based on user feedback in Benin and Nepal.
We hope you will be able to use our experience to incorporate human centered design into your own projects.

To learn more about incorporating design thinking into your projects, contact Lauren at lauren.spigel@vaxtrac.com or check out IDEO’s resources

Economic Burden, Infectious Diseases, Innovation, Non-Communicable Diseases, Research, Vaccination, Children

Recent Therapeutic Advancements in Combating Dengue and Glioma

~Written by Kate Lee, MPH (Contact: kate@recombine.com)

Sanofi-Pasteur's Dengvaxia has been approved for the prevention of the four subtypes of dengue in children over 9 years old and adults under 45 years old. Photo Credit: European Pharmaceutical Review

Infectious and chronic diseases are some of the top priorities in global health. Abundant funding, both from the government and private sector, is poured into therapeutics research to help decrease morbidity and mortality from both types of diseases. For example, recent news has highlighted two promising therapies with the potential to alleviate the global burden of two diseases: dengue fever, an infectious disease, and glioblastoma, a chronic disease.

After 20 years of research, Sanofi, a French pharmaceutical company, developed Dengvaxia, a vaccine to prevent dengue. Mexico is the first country to approve the vaccine for use in children over the age of nine and adults under the age of 45. A clinical trial last year found the vaccine to have an effectiveness of 60.8% against four strains of the virus[1]. Sanofi bypassed European and US regulations and sought regulatory approval for Dengvaxia in dengue-endemic countries. According to their press release, the vaccine, “will be priced at a fair, affordable, equitable, and sustainable price... and may be distributed for free in certain countries”[2].

Dengue is a febrile viral illness that is spread via the bite of an infected mosquito, and is endemic to tropical and sub-tropical climates. According to the World Health Organization (WHO), about 400 million people globally are infected with the dengue virus each year. Prevention has been limited to effective mosquito control and appropriate medical care[3]. These measures are often either ineffectively implemented, or there are limited, or no available medical resources in the community. Dengvaxia has the potential to reduce the burden of dengue, especially in developing countries that are particularly hard-hit with the disease. Future research could be directed towards making the vaccine more effective in children, as severe forms of dengue are the leading cause of illness and death in children in Asian and Latin American countries[3].

As one tropical virus is being prevented, another virus is being used to combat brain cancer. Researchers at Harvard and Yale have teamed up to use vesicular stomatitis virus (VSV) and Lassa virus, to search for and destroy cancer cells in mice[4]. Lassa is a febrile illness, usually transmitted by rodents, and is endemic to tropical and subtropical regions of the world[5]. VSV has been studied for many years and is generally effective in killing cancer cells; it becomes deadly to the patient when it reaches the brain[4,6]. Interestingly, including Lassa virus appears to make VSV safe for cancer therapy in the brain.

Researchers created a Lassa-VSV chimera, an organism that includes the genetic codes of two different organisms, to target glioma, one of the deadliest forms of brain cancer, which accounts for more than 80% of primary malignant brain tumors[7]. Glioblastoma is the most common form of glioma and is associated with poor survival, making this chimeric treatment a potential life saver for many patients. The next step in the treatment development process is primate research to evaluate safety. This is still a long way from the initiation of human trials, and eventual market, but promising nevertheless, for the millions of people globally who are affected by brain cancer.

Dengvaxia and the Lassa-VSV chimera represent recent advancements in therapeutics with potentially significant global impact for brain cancer and dengue respectively - diseases that affect populations in many nations.

References:

1.     Sanofi's Dengvaxia, World's First Dengue Vaccine, Approved For Use In Mexico. International Business Times. http://www.ibtimes.com/sanofis-dengvaxia-worlds-first-dengue-vaccine-approved-use-mexico-2219515. Published December 10, 2015. Accessed December 20, 2015.

2.     World’s First Dengue Vaccine Approved After 20 Years of Research. Bloomberg Business. http://www.bloomberg.com/news/articles/2015-12-09/world-s-first-dengue-vaccine-approved-after-20-years-of-research. Published December 9, 2015. Accessed December 20, 2015.

3.     Dengue and severe dengue. World Health Organization. http://www.who.int/mediacentre/factsheets/fs117/en/. Updated May 2015. Accessed December 20, 2015.

4.     Using a deadly virus to kill cancer: Scientists experiment with new treatment. The Washington Post. https://www.washingtonpost.com/national/health-science/using-a-deadly-virus-to-kill-cancer-scientists-experiment-with-new-treatment/2015/12/07/7d30bc5a-9785-11e5-8917-653b65c809eb_story.html. Published December 7, 2015. Accessed December 20, 2015.

5.     Lassa fever. World Health Organization. http://www.who.int/mediacentre/factsheets/fs179/en/. Updated March 13, 2015. Accessed December 20, 2015.

6.     Viral Therapy in Treating Patient with Liver Cancer. ClinicalTrials.gov. https://clinicaltrials.gov/ct2/show/NCT01628640. Updated July 2015. Accessed December 20, 2015.

7.     Schwartzbaum J A, Fisher J L, Aldape K D, Wrensch M. Epidemiology and molecular pathology of glioma. Nature Clinical Practice Neurology (2006) 2, 494-503. doi:10.1038/ncpneuro0289

Vaccination, Innovation, Research, Infectious Diseases, Health Insurance

Will We Witness the End of HIV in Our Lifetime?

~Written by Theresa Majeski (Contact: theresa.majeski@gmail.com; Twitter: @theresamajeski)

December 1st of every year is designated as World AIDS Day, a day devoted to increasing knowledge and awareness about the impact of HIV/AIDS around the world. This year is no different, and over the last few months and years some exciting things have been happening regarding HIV/AIDS.

The year 2013 has become known as the “turning point” or “tipping point” in the HIV/AIDS epidemic. This describes the fact that 2.3 million people began anti-retroviral medication in 2013 while only 2.1 million new infections were diagnosed. In other words, more people are receiving treatment and fewer people are becoming infected than ever before. If we keep this accelerating HIV scale-up through 2020, UNAIDS predicts we could see the end of HIV/AIDS by 2030

Figure 1. WHO infograph detailing the impact of expanding ART (antiretroviral therapy)

In the United States there has been a lot of media coverage, over the last year or two, surrounding pre-exposure prophylaxis (PrEP) for use by HIV-negative people to prevent HIV infection. PrEP is daily medication regimen utilizing an HIV drug called Truvada. Studies have shown that people who take PrEP as directed were 92% less likely to contract HIV. However, although it is increasing, PrEp usage remains lower than anticipated. Some barriers include a lack of PrEP awareness in people who are most at risk for HIV, some medical provider resistance to prescribing PrEP and some inconsistent insurance coverage. Additionally, PrEP continues to suffer from an image problem. When PrEP first became available, many critics were skeptical of its effectiveness in real-world settings and thought that it would undo years of work to educate folks about the dangers of HIV/AIDS. Critics also thought that being able to take a daily drug to prevent HIV would promote promiscuity and unsafe sex. A recent study in JAMA Internal Medicine proves the critics wrong on some of their fears.

An HIV/AIDS vaccine has been on the horizon ever since the epidemic was discovered. However, as we learned more about HIV, it became apparent that developing a vaccine was going to be a challenging effort. While there continue to be many HIV vaccines at various stages of development, scientists are excited about one being developed by one of the scientists who identified HIV as the cause of AIDS, Dr. Robert Gallo. His team at the University of Maryland School of Medicine’s Institute of Human Virology is beginning human trials on a potentially groundbreaking HIV vaccine. Instead of targeting different HIV viral markers to help the immune system recognize and eliminate HIV-infected cells, Dr. Gallo and his team’s vaccine targets HIV when it enters the body to prevent it from infecting cells.

All of these promising developments relating to HIV/AIDS should not overshadow the challenges that still lie ahead. Many people do not know they have HIV because they’ve never been tested. The Berkshire town of Reading in the UK is expanding its HIV testing program by offering free tests because it has more than double the UK average of HIV-positive people. The number of HIV-positive people in Russia continues to increase and has reached almost 1 million people. Some countries are passing anti-gay legislation and there is a direct link between criminalizing laws and increased rates of HIV. These are the challenges some parts of the world face in the efforts to end the HIV/AIDS epidemic.

World AIDS Day provides a way for everyone to get involved in the fight against HIV/AIDS. It’s an annual day to think about the people who’ve lost their lives to AIDS-related illnesses and to champion efforts to prevent more people from losing their lives due to HIV/AIDS related causes. This December 1st do a little research, learn about the burden of HIV/AIDS in your community, and decide how to get involved. Together we can end HIV/AIDS in our lifetime.

Disease Outbreak, Health Systems, Infectious Diseases, Innovation, mHealth, Research

Technology is Changing the Way Infectious Diseases are Tracked

~Written by Theresa Majeski (Contact: theresa.majeski@gmail.com; Twitter: @theresamajeski)

Technology is progressively becoming a bigger part of our lives. This holds true in high-income countries and in low- and middle-income countries. By 2012, three quarters of the world’s population had gained access to mobile phones, pushing mobile communications to a new level. Of the over 6 billion mobile subscriptions in use worldwide in 2012, 5 billion of them were in developing countries. The Pew Research Center’s Spring 2014 Global Attitudes survey indicated that 84% of people owned a mobile phone in the 32 emerging and developing nations polled. Internet access is also increasing in low- and middle-income countries. The 2014 Pew Research Center survey indicated that the Internet was at least occasionally used by a median of 44% of people living in the polled countries.

The increase in Internet and mobile phone access has significant implications for how infectious diseases can be better tracked around the world. Although robust and validated traditional methods of data collection rely on established sources like governments, hospitals, environmental, or census data and thus suffer from limitations such as latency, high cost and financial barriers to care. An example of a traditional infectious disease data collection method is the US Centers for Disease Control and Prevention’s (CDC) influenza-like illness (ILI) surveillance system. This system has been the primary method of measuring national influenza activity for decades but suffers from limitations such as differences in laboratory practices, and patient populations seen by different providers, making straightforward comparisons between regions challenging. On an international scale, the WHO receives infectious disease reports from its technical institutions and organizations. However, these data are limited to areas within the WHO’s reach and may not capture outbreaks until they reach a large enough scale.

Figure 1. CDC Flu View Interactive dashboard: http://gis.cdc.gov/grasp/fluview/fluportaldashboard.html

Compared to traditional global infectious diseases data collection methods, crowdsourcing data allows researchers to gather data in near real-time, as individuals are diagnosed or even before diagnosis in some instances. Furthermore, getting individuals involved in infectious disease reporting helps people become more aware of and involved in their own health. Crowdsourcing infectious disease data provides previously hard to gather information about disease dynamics such as contact patterns and the impact of the social environment. Crowd-sourced data does have some limitations, including data validation and low specificity.

Internet-based applications have resulted in new crowd-sourced infectious disease tracking websites. One example is HealthMap. HealthMap is a freely available website (and mobile app) developed by Boston Children’s Hospital which brings together informal online sources of infectious disease monitoring and surveillance. HealthMap crowd-sources data from libraries, governments, international travelers, online news aggregators, eyewitness reports, expert-curated discussions, and validated official reports to generate a comprehensive worldwide view of global infectious diseases. With HealthMap you can get a worldwide view of what is happening and also sort by twelve disease categories to see what is happening within your local area. 

Figure 2. HealthMap. http://www.healthmap.org/en/

Another crowd-sourced infectious disease tracking platform was Google’s Flu Trends, and also their Dengue Trends. Google was using search pattern data to estimate incidence of influenza and dengue in various parts of the world. Google’s Flu Trends was designed to be a syndromic influenza surveillance system acting complementary to established methods, such as CDC’s surveillance. Google shut down Flu Trends after 2014 due to various concerns about the validity of the data. As an initial venture into using big data to predict infectious diseases, Flu (and Dengue) Trends have provided information that researchers can use to improve future big data efforts. 

With the increase of mobile phone access around the world, organizations have started using short message service (SMS), also known as text messaging, as a method of infectious disease reporting and surveillance. Text messaging can be used for infectious disease reporting and surveillance in emergency situations where regular communication channels may have been disrupted. After a 2009 earthquake in Sichuan province, China, regular public health communication channels were damaged. The Chinese Center for Disease Control and Prevention distributed solar powered mobile phones to local health-care agencies in affected areas. The phones were pre-loaded with necessary software and one week after delivery, the number of reports being filed returned to pre-earthquake levels. Mobile phone reporting accounted for as much as 52.9% of total cases reported in the affected areas during about a two-month time period after the earthquake. 

Text message infectious disease reporting and surveillance is also useful in non-emergency settings. In many malaria-endemic areas of Africa, health system infrastructure is poor which results in a communication gap between health services managers, health care workers, and patients. With the rapid expansion and affordability of mobile phone services, using text-messaging systems can improve malaria control. Text messages containing surveillance information, supply tracking information and information on patients’ proper use of antimalarial medications can be sent from malaria control managers out in the field to health system managers. Text messaging can also be sent by health workers to patients to remind them of medication adherence and for post-treatment review. Many text message based interventions exist, but there is a current lack of peer-reviewed studies to determine the true efficacy of text message based intervention programs.

Increasing global access to the Internet and mobile phones is changing the way infectious diseases are reported and how surveillance is conducted. Moving towards crowd-sourced infectious disease reporting allows for a wider geographical reach to underserved populations that may encounter outbreaks, which go undetected for a delayed period. While crowdsourcing such data does have limitations, more companies than ever are working on using big data and crowd-sourced data in a reliable way to inform the world about the presence of infectious diseases.

Climate Change, Infectious Diseases, Poverty, Research, Disease Outbreak

Climate Change and Health, Part 3: Infectious Disease

~Written by Joann Varickanickal (Contact: joann.varickanickal@gmail.com)

This is my final post of a three part series on climate change and health. The first post looked at how climate change will influence the onset and severity of droughts in some areas. The second post examined how some regions are predicted to see an increase in droughts, which would decrease food supply; thus, increasing nutrient deficiencies in those areas. This post will briefly discuss the influence of climate change on waterborne diseases.

Change in climate, including the increases in temperature and changes in rainfall patterns may lead to an increase in waterborne diseases, where insect vectors contaminate the water (Shuman, 2010). Often, higher temperatures are needed for some insects to complete their life cycle. This is the case for mosquitoes, as they live in warm, aquatic habitats (Shuman, 2010). With an increase in temperature and more flooding, there will be an increase in mosquitoes (Shuman, 2010). Thus, there may be an increase in the transfer of dengue and malaria (Ramasamy & Surendran, 2011). These warm, aquatic habitats will also be ideal for snails, which transfer schistomiasis (Ramasamy & Surendran, 2011). Furthermore, with a rise in sea levels, there is likely to be an increase in saline levels (Ramasamy & Surendran, 2011). Certain types of mosquitoes and snails have a high tolerance for salt water and are thus able to breed in water with high salt concentrations (Ramasamy & Surendran, 2011).

Taken from: Watts N, Adger W N, Agnolucci P, Blackstock J, Byass, P, Cai W, Costello A (2015). Health and climate change: policy responses to protect public health. The Lancet, 6736(15)

The relationship between climate change and health is complex because there are many different contributing factors and there is limited scientific evidence for many regions, several of which are under-resourced (New York Times, 2015). Furthermore, areas of high-resource have not been impacted in the same way, due to advantages as simple as air conditioning (New York Times, 2015). Thus, more scientific evidence is needed, to determine more ways in which climate change could possibly influence the health of a population. More recognition also needs to be given to this issue so that contingency plans can be made for possible outbreaks of diseases that were discussed in this blog post.

References:

Shuman, E. K. (2010). Global Climate Change and Infectious Diseases. The New England Journal of Medicine , 362 (12), 1061-1063.

Ramasamy, R., & Surendran, S. (2011). Possible impact of rising sea levels on vector-borne infectious diseases. BMC Infectious Diseases , 11 (18).

Tavernise, S. (2015, July 13). Unraveling the Relationship Between Climate Change and Health. Retrieved September 10, 2015, from http://www.nytimes.com/2015/07/14/health/unraveling-the-relationship-between-climate-change-and-health.html?_r=0

Health Systems, Research

Data, Evidence and Strengthening Humanitarian Response

~Written by Victoria Stanford (Contact: vstanford@hotmail.co.uk)

World Humanitarian Day on August 19th marks an opportunity to reflect on the current status of the global humanitarian system. Its workforce, resources and budgets have been pushed further than ever before in the face of increasingly complex and protracted crises. Health partners are currently responding to sustained crises in 32 countries, with the total number of people targeted to receive assistance reaching 74.9 million as of March 2015 (WHO, 2015 (i)). The scope of humanitarian response is therefore obligated to expand and adapt in response to its high-volume demand. Increasingly this means agencies need to include not only emergency relief, but also long-term capacity building and development support into their mandates (SOHS,2015). The nature of humanitarian response is in transition; it is no longer a “stop-gap” between crisis and recovery, but now also forms a significant part of crisis prevention and resistance in disaster-prone settings (OCHA,2015). The system now also involves a multitude of actors, including NGOs-international, local and regional, supranational agencies and even private sector partners. Unsurprisingly, this means the humanitarian system today requires more meaningful collaboration between its various partners which will depend on defining leadership, identifying accountability and ensuring quality.

An evidence-based culture

One of the ways in which these necessary improvements to the system could be achieved is to address its information-base. Information, evidence and data both used by and reported from the humanitarian system should be assessed for its gaps and inadequacies, enabling the system actors to understand the breadth and nature of the crisis they are responding to (Thieren, 2005). Evidence seems an ambiguous and uninspiring concept, one which does not comfortably fit with the misleadingly gung-ho image of the humanitarian sector and its workforce. Despite this, there seems to be an encouraging shift in mind-set within the system; there is a growing appetite for more academically-driven crisis responses which rely on a culture of evidence (Bantavala, 2000). Instead of ad-hoc policies based on individual NGO mandates and values, there is the desire to see a more co-ordinated approach to, particularly, health assistance which relies on useful information collected in a scientific manner, as for any field of study (Robertson, 2002). The effect of not providing good-quality, robust and accurate data is that aid policies, interventions and practices are left unevaluated. The danger here is that this leads to poor representation (often with underestimation) of the extent and nature of population need, and therefore uncertainty about how to provide assistance (Toole, 2001). Even more worrying is that “poor information on a problem is often interpreted to mean that a problem is unimportant” (Murray, 1996). Lacking credible evidence therefore creates a vulnerability for the humanitarian system when it needs to advocate on behalf of in-need populations for support from often unwilling or budget-bound governments and supranational agencies.

Introducing evidence into the humanitarian system

The concept of building an information-base of evidence procured by programme and intervention evaluation is not novel to the humanitarian system. The Joint Evaluation of Emergency Assistance to Rwanda (JEEAR) established in the aftermath of the 1994 genocide was the first system-wide, multinational, multi-donor evaluation, setting a precedent for recognising accountability in humanitarian assistance, largely by incorporating better information management and dissemination (Eriksson, 1996). In much the same way, the SPHERE Guidelines were also developed in answer to the failure of the humanitarian system to adequately respond to this same crisis (Buchanan-Smith, 2003). These guidelines were used to set out key concepts of quality control and ‘core humanitarian standards’ to reign in non-uniformity which leads to discrepancies in intervention performance and effectiveness. However this uniform “best practice” approach has been fiercely criticised by leading agencies such as Doctors without Borders (MSF) who lambasted the SPHERE protocols for discouraging contextualisation, creativity and flexibility (Orbinski,1998). Other initiatives such as ReliefWeb have also attempted to contribute to a growing information-base by creating a publically-available database system which allows individual agencies to report their programmes and outcomes. This and similar efforts however have been limited by a lack of responsible participation and resistance of academics to report findings before submitting for journal publication (Mills,2005). Nevertheless, certain systems exist which have been widely used that aim to provide data and evidence in emergency and crisis settings which should be acknowledged here, furthering the argument that an information-base is critical to the strengthening of the humanitarian response.

The information-base: EWARN and Health Information Systems

EWARN

The EWARN is a surveillance system which collects information on epidemic-prone diseases, using data analysis and statistics to initiate prompt public health responses. The subsequent statistical picture is disseminated to appropriate agencies to set about prioritising and planning interventions (WHO 2015 (ii)).  The EWARN has shown promise in South Sudan where the multi-partner style of data collection and management (using the WHO as a lead agency) means reporting to a central system creates a more timely and efficient response. In 2002 this was used during a suspected viral haemorrhagic fever outbreak and successfully side-stepped disaster (WHO, 2002). Also in countries such as Iraq, the EWARN functions well where the leading agency work closely with the domestic Ministry of Health to optimise the existing surveillance systems and incorporate them into the larger, more co-ordinated picture. This however means that i) an agency has to have the will and necessary legitimacy to take on leadership responsibilities and ii) the crisis in itself needs to be recognised internationally in order to attract actors with sufficient skills and resources to respond to the collected evidence. Further obstacles occur in particularly complex crises such as in Syria, where domestic surveillance systems are disrupted and the reach and physical capabilities of humanitarian agencies in the field is limited (Mala, 2014). Yet along with its various implementations issues, the EWARN in itself lacks the breadth that may be required of an evidence-collecting system within complex emergencies or long-term crisis support, where epidemic control is not the main, or even primary objective.

Health Information Systems (HIS)

Many large humanitarian agencies have created internal methods of building an evidence-base to guide planning which collect health data in a more integrated manner than the emergency-specific EWARN. The Health Information System (HIS) as a concept is not specific to the humanitarian system. An HIS aims to provide good quality data and its subsequent analysis and dissemination about the health sector, allowing evidence to directly underpin decision-making (WHO, 2008). The UNHCR is a particularly prudent example of an aid agency which has adopted and adapted the HIS for the crisis setting-with relative success. The UNHCR HIS operates on a large scale, collecting data from over 90 camps in over 20 countries (personal research of the UNHCR HIS Twine Application) and providing monthly reports on the status of various essential health indicators. Figure 1 shows the June 2013 report from Gasorwe refugee camp in Burundi. As is shown, the health indicators are compared between camp and national populations which is an essential comparison to make as it allows population-specific intervention. This disaggregation in populations is even more necessary given that protracted crises often see emergency-phase camps become long-term settlements where the health needs of the refugee and host populations overlap (Feldman, 2007)

 

 

The UNHCR HIS however has a number of failures, most notably that it only exists within post-emergency camps which by definition are stable and therefore health status is generally better than newer camps. Also, only those who are registered with the UNHCR are included in statistics and therefore the most vulnerable groups of refugees, particularly internally displaced persons (IDPs) are not included in statistics, leading to misrepresentation of the scale of the problem and increases the likelihood of ignoring a significant amount of human need. In essence, the HIS can provide an excellent framework for the health indicator-based, disaggregated information-base that humanitarian agencies should attempt to create on a system-wide basis. Yet, creative collaboration is required to ensure that high quality data and evidence can be collected from all contexts, in a standardised way that allows inter-agency data exchange and collective responses.

To put it simply, the EWARN and HIS are used here to illustrate that the humanitarian system has already acknowledged the need to use evidence to monitor population need and thus plan response, although efforts are currently inadequate. What is now required is a system-wide, scientific evaluation of the use of evidence as a guide for action in crisis and disaster settings, in order to legitimise humanitarian work on a global scale and safeguard it from opposing forces.

Concluding thoughts: deciding on outcomes

Optimising and prioritising evidence with the aim to strengthen the humanitarian system may force us to reflect on what should be considered as end-points. The outlook that governs public health initiatives can arguably be too consequentialist; they are based on success rates, outcomes and units of ‘effect’ (Robertson, 2002). It could be argued that humanitarianism by its very definition should adhere to a more human-rights based approach that focuses on duty and responsibility. With the increasing burden of human need, the humanitarian system must decide how it will approach new contexts, persisting barriers and emerging challenges such as climate change and the urbanisation of displacement with appropriate credibility and inter-agency consistency that can deliver powerful, effective humanitarian action.

 

References:

Banatavala,N and Zwi,A (2000) Conflict and health Public health and humanitarian interventions: developing the evidence base, BMJ, 321:101–5.

Buchanan-Smith, M. (2003). How the Sphere Project Came into Being: A case study of policy-making in the humanitarian aid sector and the relative influence of research. Overseas Development Institute.

Eriksson J (1996) The International Response to Conflict and Genocide; Lessons from Rwanda, Synthesis Report; Joint Evaluation of Emergency Assistance to Rwanda.

Feldman S (2007) Development assisted integration: a viable alternative to long-term residence in refugee camps? The Fletcher Journal of Human Security, Vol 22:49-68.

Mala P and Ghada M et al (2014) Establishment of the EWARN system for the Syrian crisis: experience and challenges, 16th International Congress on Infectious Diseases: Infectious Disease Surveillance Abstract No.53042; Cape Town, South Africa.

Mills J (2005) Sharing evidence on humanitarian relief, BMJ, 331:1485.

Murray,C and Lopez,A et al (1996) Evidence-based health policy-lessons from the Global Burden of Disease study, Science, 274(5288), p.740.

OCHA (UN Office for the Co-ordination of Humanitarian Affairs) (2015) OCHA in 2014 &2015 Plan and Budget [Online] Available at: https://docs.unocha.org/sites/dms/Documents/OCHA%20in%202014-15%20vF%2072%20dpi%20single%20WEB.pdf[Accessed 6 August 2015]

Orbinski J (1998) On the meaning of Sphere standards to states and other humanitarian actors, Lecture delivered December 3 1998; London.

Robertson D, Bedell R et al (2002) What kind of evidence do we need to justify humanitarian aid? The Lancet, 360:330-33.

SOHS (State of the Humanitarian System), State of the Humanitarian System, ALNAP, Progress Report 2015, April 2014 [Online] Available at: http://www.alnap.org/resource/20489.aspx [Accessed 6 August 2015]

Toole MJ, Waldman RJ & Zwi AB (2001) Complex humanitarian emergencies. In:International PublicHealth, Aspen Publishers, Gaithersburg, pp. 439±500.

Thieren, M. (2005). Health information systems in humanitarian emergencies.Bulletin of the World Health Organization, 83(8), 584-589.

WHO (2002) Weekly Epidemiological Record; Early warning response and surveillance network (EWARN):Southern Sudan, 25 January 2002.

WHO (2008) Health Informaiton Systems; WHO Toolkit.

WHO (2015) (I) WHO Humanitarian Response: Summary of health priorities and WHO projects in interagency strategic response plans for humanitarian assistance to protracted emergencies, April 2015 [Online] Available at: http://reliefweb.int/report/world/2015-who-humanitarian-response-summary-health-priorities-and-who-projects-interagency [Accessed 4 August 2015]

WHO (2015) (II) Early warning systems; emergencies preparedness and response [Online] Available at: http://www.who.int/csr/labepidemiology/projects/ewarn/en/ [Accessed 10 August 2015]