Combining Healthcare-Based and Participatory Approaches to Surveillance: Trends in Diarrheal and Respiratory Conditions Collected by a Mobile Phone System by Community Health Workers in Rural Nepal.
Surveillance systems are increasingly relying upon community-based or crowd-sourced data to complement traditional facilities-based data sources. Data collected by community health workers during the routine course of care could combine the early warning power of community-based data collection with the predictability and diagnostic regularity of facility data. These data could inform public health responses to epidemics and spatially-clustered endemic diseases. Here, we analyze data collected on a daily basis by community health workers during the routine course of clinical care in rural Nepal. We evaluate if such community-based surveillance systems can capture temporal trends in diarrheal diseases and acute respiratory infections.



During the course of their clinical activities from January to December 2013, community health workers recorded healthcare encounters using mobile phones. In parallel, we accessed condition-specific admissions from 2011-2013 in the hospital from which the community health program was based. We compared diarrhea and acute respiratory infection rates from both the hospital and the community, and assigned three categories of local disease activity (low, medium, and high) to each week in each village cluster with categories determined by tertiles. We compared condition-specific mean hospital rates across categories using ANOVA to assess concordance between hospital and community-collected data.



There were 2,710 cases of diarrhea and 373 cases of acute respiratory infection reported by community health workers during the one-year study period. At the hospital, the average weekly incidence of diarrhea and acute respiratory infections over the three-year period was 1.8 and 3.9 cases respectively per 1,000 people in each village cluster. In the community, the average weekly rate of diarrhea and acute respiratory infections was 2.7 and 0.5 cases respectively per 1,000 people. Both diarrhea and acute respiratory infections exhibited significant differences between the three categories of disease rate burden (diarrhea p = 0.009, acute respiratory infection p = 0.001) when comparing community health worker-collected rates to hospital rates.



Community-level data on diarrhea and acute respiratory infections modestly correlated with hospital data for the same condition in each village each week. Our experience suggests that community health worker-collected data on mobile phones may be a feasible adjunct to other community- and healthcare-related data sources for surveillance of such conditions. Such systems are vitally needed in resource-limited settings like rural Nepal.
Possible, Bayalpata Hospital, Sanfebagar-10, Achham, Nepal.|Harvard T. H. Chan School of Public Health, Department of Health Policy and Management, Boston, Massachusetts, United States of America.
David J
DJ
Meyers
Boston Children's Hospital, Center for Patient Safety and Quality Research, Boston, Massachusetts, United States of America.|Harvard Medical School, Boston, Massachusetts, United States of America.
Al
A
Ozonoff
Possible, Bayalpata Hospital, Sanfebagar-10, Achham, Nepal.
Ashma
A
Baruwal
United Nations Population Fund, Kathmandu, Nepal.
Sami
S
Pande
Possible, Bayalpata Hospital, Sanfebagar-10, Achham, Nepal.|Harvard Medical School, Boston, Massachusetts, United States of America.
Alex
A
Harsha
Medic Mobile, San Francisco, California, Unuted States of America.
Ranju
R
Sharma
Possible, Bayalpata Hospital, Sanfebagar-10, Achham, Nepal.|Brigham and Women's Hospital, Department of Medicine, Division of Global Health Equity, Boston, Massachusetts, United States of America.|Boston Children's Hospital, Department of Medicine, Division of General Pediatrics, Boston, Massachusetts, United States of America.
Dan
D
Schwarz
Possible, Bayalpata Hospital, Sanfebagar-10, Achham, Nepal.|Brigham and Women's Hospital, Department of Medicine, Division of Global Health Equity, Boston, Massachusetts, United States of America.|Boston Children's Hospital, Department of Medicine, Division of General Pediatrics, Boston, Massachusetts, United States of America.
Ryan K
RK
Schwarz
Possible, Bayalpata Hospital, Sanfebagar-10, Achham, Nepal.
Deepak
D
Bista
Possible, Bayalpata Hospital, Sanfebagar-10, Achham, Nepal.|Brigham and Women's Hospital, Department of Medicine, Division of Global Health Equity, Boston, Massachusetts, United States of America.|University of Washington, Henry M. Jackson School of International Studies, Seattle, Washington, United States of America.
Scott
S
Halliday
Possible, Bayalpata Hospital, Sanfebagar-10, Achham, Nepal.|Brigham and Women's Hospital, Department of Medicine, Division of Global Health Equity, Boston, Massachusetts, United States of America.|Boston Children's Hospital, Department of Medicine, Division of General Pediatrics, Boston, Massachusetts, United States of America.|Harvard Medical School, Department of Medicine, Boston, Massachusetts, United States of America.
Duncan S R
DS
Maru
D040421:Cell Phone; D003150:Community Health Workers; D003967:Diarrhea / Q000453:epidemiology* / Q000517:prevention & control; D006801:Humans; D009390:Nepal / Q000453:epidemiology; D012141:Respiratory Tract Infections / Q000453:epidemiology* / Q000517:prevention & control; D012424:Rural Population