Standard Operating Procedures - Real-Time
Contents
1. Diabetes E Bopitiya Diabetes_mellitus Deegalla Diarrhoea y Dunakadeniya Y O symptom Run Screening Figure 8 Massive Screening Panel setting of parameters and values Click the blue square next to label Disease which will display the list of diseases Click on the particular set of disease you wish to monitor e g dengue Diabetes Diarrhoea To select multiple disease hold the CTRL button and click on the desired diseases Similar to Disease click on the blue square next to label Location This will select all the locations to generate the alerts Finlay click on Run Screening which will almost immediately generate a list of alerts as shown in Figure 8 Click once more on the Massive Screening Panel to shrink it then you can see the Time Series and Recent Massive Screening Results close to each other Click on the button Log Scale De select or uncheck the legend labels All Data Current Query and MS Baseline which will leave you with the MS Pvalue and Results Query displayed in the Time Series window When you select a alert or Massive Screening Result the plot will change Figure 8 shows the example of the results disease Diarrhoea location Narammala and Pvalue 0 02 We are mostly interested in alerts that have a Pvalue closer to zero where Pvalue 0 02 is considerably high Alert window yellow in Figure 8 shows where T Cube would have generated the alert as early as Nov 10 The list of Massive Screening results a2. location Narammala 3 8893744e 02 NOV 30 2009 28 Figure 9 Massive screening results and time series plot for selected result Pivot Table Time Series Poor Performers Start Over gt gt disease location gt gt disease Diabetes age grp location Attributes age gro gender sympton Rows disease Columns location reciente oo o o o o o o 158 o 10 cree o o o o 13 1 67 oj 4 o 23 o 13 oj 8 o o o o o o o o ol oj oj oj o o ol o oj oj armes simetom sO a o 16 Figure 10 Pivot Table with disease in rows and locations in columns with counts in cells One can use the pivot table to view counts of the disease for all the locations First navigate to the Pivot Table by clicking the labeled tab Drag and drop the dimension Disease in to the Rows and Location in to the Columns After a few seconds a table with total counts corresponding to the respective location and disease will be displayed in each of the cells see Figure 9 Use the Start Date and End Date controls at the bottom of the table to adjust the dates to your liking Start Over gt gt disease location gt gt disease Acute Diarrheal Disease age grp location Attributes gender Son simpion Rows iease age of Columns location A ar da ccna dect scalar 5 24 11 10 at 11 8 7 36 29 158 Figure 11 Pivot Table for selected disease split by age group and locations Acute _Dlarr
3. 8 5 3 8 5 4 8 5 5 8 5 6 8 5 7 8 5 8 8 5 9 8 5 10 8 5 11 officials and health workers for the purpose of responding to those communicated events Health events detected through the manual section 7 3 and automated section 7 4 must be first determined and verified to be authentic by disease outbreak analysts and decision makers Only trained and authorized users should be allowed to issue alerts with use of the Messaging Alerting Module Authenticated events of interest authorized by designated decision makers should be relayed through the MAM specifically the Alert submodule Alerts should be issued to only those health workers and health officials that should be included in the distribution list 1 e recipients Although it is permissible to issue just in time fabricated CAP messages it is highly recommended in order to preserve the integrity and completeness of the message to avoid ambiguity to use predefined templates to issue the CAP messages For the purpose of the RTBP a typical CAP template would have the following fields populated Status Message Type Source Scope Restriction Language Category Event Audience Description Instruction Headline Web Contact Resource Description URL User should change the Status field to Alert or Exercise from Draft and complete the Description field before issuing the message These fields not populated in the template must be
4. completed prior to issuing the message Sender Incident Sender Name Response Type Priority Urgency Severity Certainty Effective Expire and Area Description Overall the user should check all values before sending a message because once the message is sent it cannot be revoked In the event a user does want to correct or amend an issued message then they should re issue the same message but changing the Message Type to Update There are three delivery types long text short text and voice text messages The RTBP will use short text and long text delivery types only with SMS Email and Web as the three different delivery technologies 8 6 Survey and other Messages Purpose Health officials or health workers to use the survey messages sub module of the messaging alerting module for receiving ad hoc information from the field or other 8 6 1 The survey name key and question should precise and concise to avoid any ambiguity that may confuse the survey subjects 8 6 2 Health officials and health workers should use the Message Console or Survey Messages to issue messages or requesting field information that are not health category alerts such as requesting an emergency meeting of the Medical Officers 8 7 Subscribing to RTBP messages Purpose Ensure health workers and health officials will receive issued messages 8 7 1 Ifa Health Official or Health Worker changes their email or mobile phone number they should immedi
5. not directly relay the alert to other health officials or health workers without proper verification of the detected event and obtaining authorization from the designated decision makers The health departments DDHS and MOH offices should provide a list of recipients a template of the content for receiving the detected events The disseminated messages are restricted to health officials responsible for analyzing health data and making decisions on the severity of the disease outbreak threat i e intended for health officials acting in the capacity of event detection and decision making with respect to disease surveillance Health officials designated to receive the detected alerts must assess the communicated event using TCWI to verify and authenticate the event of interest by filtering the dataset with the received parameters on time period and description disease syndrome gender age group and location The health officials assessing the communicated alerts should use the same template mentioned in 7 5 2 to record the true or false characteristics of the automatically detected and alerted event 7 5 Reporting bugs and problems Purpose report any issues related to the TCWI application to RTBP personnel 8 8 1 Any bugs problems unusual observations or enhancement requests with respect to the TCWI application should be reported through the Feedback option fourth tab from the left provided in TCWI application A copy of the
6. project cannot cover the costs then the project faces the risk of the cellular operator discontinuing the service and jeopardizing the data collection Once the SIM has been activated the user should contact the provider customer service to activate GPRS and Internet connectivity The project will pre load or to pup the users phone with a fixed amount that is more than sufficient for the communications requirements of the project 6 3 Installing the m HealthSurvey Purpose establishing the applications required for communicating health data from the field to the data center 6 3 1 A copy of the application download instructions can be obtained from the designated supervisor program coordinator at the PHC Sarvodaya It is also available on the web lt include link gt 6 3 2 If required contact the m HealthSurvey training and general support to get assistance with downloading the application Contact details are in Table 3 below 6 3 3 If the user encounters difficulties with entering the URL then they may request that the m HealthSurvey training and general support person to SMS the URL web link The prospective user may click on the link in the SMS which should direct them to the web site hosting the application 6 3 4 A second option is for the user to bookmark the application download link in the mobile phone itself A third option is to write down the URL on paper 6 3 5 In the pilot stage of the RTBP the installation proc
7. 365 all day every day year around 9 1 2 An uninterrupted power service unit should be installed to ensure no disruptions are caused by power failure 9 1 3 In the event the power is unavailable for an extensive periods beyond the capacity of the UPS the SysAdmin should notify all health workers and health officials via SMS using the Sahana Messaging Module to refrain from submitting data to avoid any data losses and data processing or data reporting activities respectively 9 1 4 During any server maintenance the the SysAdmin should notify all health workers and health officials via SMS using the Sahana Messaging Module to refrain from submitting data to avoid any data losses and data processing or data reporting activities respectively 9 1 5 Upon restoration of the server and re initiating the services the SysAdmin should notify the health workers and health officials via SMS that the may resume data submission data processing and data reporting functions 9 2 System Administrator 9 1 1 A SysAdmin must be on call 24 7 365 all day every day year around to administer the server 9 1 2 Ifa SysAdmin is not physically present at the data center such as on weekends then the SysAdmin should setup a remote administration system to manage the server 9 13 Ifthe SysAdmin cannot remotely administer the server such as the case of having to physically reboot the server and restore services in a situation described in 8 1 3 t
8. A is 14 7 2 ACCESS TOWN bane yup ince badass ad ahaa da eg ede aati da eos 14 73 Manual Amialy sis ii is 14 T4 Automated eyent E rd iod 15 T3 REPO bussand ROW aa liso 16 A O 16 O RE OUT aie a NG Es SN a La T Se ly A adie Sage 17 A E ETA 17 Re NC COS GM MAAM a O E N a A eas E S 17 8 3 Initializing messaging Capable ssc d 17 9 4 Automated alero oe i e aa e use Eee E ETE aeien 18 8 5 Issuing CAP messages for Response s sesesesesessseessressessseesseeessetesstessensseesseeesseeeereessserereeessee 19 8 0 Survey and other MESA oido 19 97 Subscibe to RBP Messages a 20 SE POUNDS DO dot 20 SS CANA A n E E nse eet an een 20 9 DATACENTER ide ici he oS A hearse ea 21 O ven re PR ee Pe oe Dene ne A E E A N eee erent A Sentra 21 DDS YS STA PNG AITAL A eaten a vn tahoe decades ado tate e a as 21 9 3 Database Administration cional rra tousaccespaccandscdcndnacousedeaveaatecavsseduesddeeens pecans 21 10 APPENDIX Two main detection analysis SC MALIOS ccceseceseteceeseceeeeceeeeceeaeeceseeeeeeeeeeenaaaees 22 10 1 Scenario A Investigating a suspected or ongoing disease Outbreak oooonnonnnonnnnncnnocnconncnononos 22 10 2 Scenario B Monitoring high priority notifiable communicable diseases ooocnnnnnnnnninnnc 26 Index of Tables Table 1 List of acronyms and DesCTIDUONS cisnes dera ss deneceeandceeantauseaedsantien st desedanasvandaieds 7 Table 2 Contacts list for Super US ie cos 10 Table 3 Contacts for health wo
9. Standard Operating Procedures Real Time Biosurveillance Program Version 0 3 December 25 2009 DLR N Easia eo AAA ON A eee ae mA www lirneasia net Author Nuwan Waidyanatha LIRNEasia 12 Balcombe Place Colombo 08 Sri Lanka Revision History Date Version Description Person Name 08 10 09 0 1 Prepare first draft of the document Nuwan Waidyanatha 10 12 09 0 2 Update with T Cube and Alerting procedures Nuwan Waidyanatha 12 25 09 0 3 Add uses cases for t cube user operations Nuwan Waidyanatha Artur Dubrawski Table of Contents O A a E a a lah ce hice teh aaa ee E lade cea Se hate 3 NN 3 3 Bak Srouin ti cid 4 4 Definitions and ADBreviatiOMs oasacesseccvecscdebsscecenssaceateseevactuanaccesabedecdtaavecaceebagencvansavuatavdeoseadsagedevesdesess rs 6 5 SUPER USER Sua ii dida 7 SA User aACCOuUNtSon ocn ea r EEEE EEEE A E EKE aia 7 5 2 Updating Location iii ds ir 7 E TEN 7 TR 8 e A e a e a E Gey esau au aatdeucde A aE 8 5 6 Contacto oie n a E Ye cea E a E ia dos 9 6 HEALTH WORKERS nido 10 61 Acqiirino amo ble phone titi a 10 6 2 Getting connected to then Won aia 10 6 3 Installing the mc ASIN A embuawenteraaesnee 11 6 4 Initializing the msHc alii 11 6 3 Submitting PAELLA aia raid 11 6 0 Application Min EA A A AS 12 6 7 Wiobile Phone Talmtenance a aaae a E E E e O EEEE 12 6 8 Reporting BUS AA PA ota 12 ON COMA ae 13 T Analysis and Event Detecta cda dciiiad irritan credibilidad Eai 14 TA TA
10. T Cube Web Interface TCWD loading data manipulating time series maps and pivot tables as described in the manual It is recommended that the user go through the main manual and the exercises described in that manual before engaging in the activities described in this document Detection analysis Scenarios 10 1 Scenario A Investigating a suspected or ongoing disease outbreak Assume you have been notified or have come to learn of increased cases of a particular disease and want to investigate that particular disease then follow the steps described in this section but do not restrict yourself to just these steps You may use all other features available in TCWI as well Time Series Analysis Temporal Scan After loading the data click on the Query Panel to expand Figure 1 Click the blue square next to label Disease which will display the list of diseases Click in the check box i e mark with V of the particular disease you wish to investigate e g Common cold Rename the query name in the text box located next to label Name e g common cold and click Save Scroll down to Time Series Analysis display De select i e uncheck All Data and Current Query Now you should see the saved query e g common cold as shown in Figure 2 Y Query Selection Panel Click to show hide Reset Query Show Query Values Selection 1 252 values 1 6 attributes Name comm coldl disease JA location DJA age_grp OA gender OA sign OA TO
11. acts list for super user Super user should be provided with a list of important contact information Role Name Email Mobile Phone Fixed Phone M HealthSurvey Sheeba Rayar rsheebhaOtenet res in 919600079139 914422570428 SW Support Vincy Pushpa Mary vincy Otenet res in 919790865253 BSM SW Pradeeper Damendra pradeeper respere com 94772928456 94112500511 Support Mifan Careem mifan Orespere com 94773437283 MAM SW Pradeeper Damendra pradeeper respere com 94772928456 94112500511 Support Mifan Careem mifan Orespere com 94773437283 DBA Vincy Mary vincy Otenet res in 919790865253 914422570428 Manoj Silva manojsilva_silva yahoo com 94773963123 General RTBP Suma Prashant suma tenet res in 919717763888 914422570428 support Pubudini Weerakoon danushkaweerakoonO gmail com 94776244810 94776244810 6 HEALTH WORKERS The standard operating procedures given below are for the users of the m HealthSurvey mobile application namely the health workers participating in the data collection and digitization process of the real time biosurveillance program RTBP These standard procedures are recommended guidelines and are not rules that will be strictly enforced but users are encouraged to abide by the procedures as much as they can 6 1 Acquiring a mobile phone Purpose keep an account of the mobile phones provided through the RTBP 6 1 1 6 1 2 6 1 3 6 1 4 6 1 5 A mobile phone will be g
12. anu Otenet res in 919747010875 919747010875 training and general Pubudini Weerakoon danushkaweerakoon O gmail com 94776244810 support M HealthSurvey Sheeba Rayar rsheebha tenet res in 919600079139 914422570428 Technical Support Vincy Pushpa Mary vincy tenet res in 919790865253 7 Analysis and Event Detection Health officials entrusted with the routine task of analyzing health case data for detecting adverse events should read this section This section covers the procedures involving the T Cube Web Interface TCWD and processes 7 1 Training Purpose build capacity to operate the newly introduced TCWI 8 1 1 Users should receive training through the RTBP to operate the TCWI for the purpose of analyzing health data in detecting disease outbreaks 8 1 2 A copy of the user manual Tutorial that describes the step by step process for analyzing the data can be found in TCWI second hyper link from the left http 202 69 197 116 8080 TCubeWebGUI Tutorial html 8 1 3 Given that the RTBP at present is a pilot users should be given training on expectations and format of reporting the performance of the application such as recording whether the application proposed adverse health events are true or false alerts as well as any enhancements bugs or fault encountered with the TCWI application 7 2 Accessing TCWI Purpose introduce the basic requirements for setting up TCWI for health officials use 8 2 1 The healt
13. ately notify an RTBP member listed in Table 4 8 7 2 User wanting to receive CAP messages via the Internet through the Fire Fox Browser will need to install the CAP Fire Fox plug in 8 8 Reporting bugs and problems 8 8 3 Any bugs problems or observations or enhancement requests with respect to the MAM should be reported to an RTBP member in Table 4 8 8 4 The Research Assistant will meet with the users each month to assess the workability problems and performance of the TCWI 8 9 Contact information 8 9 2 Health officials should be provided with a list of important contact information Table 5 Contacts list for health officials Role Name Email Mobile Phone Fixed Phone General Complaints Janakiraman janu tenet res in 919747010875 919747010875 Pubudini Weerakoon danushkaweerakoon gmail com 94776244810 TCWI MAM General Suma Prashant suma tenet res in 919717763888 914422570428 support Pubudini Weerakoon danushkaweerakoon gmail com 94776244810 TCWI technical Michael Beysak mjbaysek cs cmu edu 14122686233 support Robin Sabhnani sabhnani cs cmu edu 14125510631 MAM technical Pradeeper Damendra pradeeper respere com 94772928456 94112500511 support Mifan Careem mifan respere com 94773437283 9 DATA CENTER 9 1 Server 9 111 SysAdmin should ensure that the server hosting the Sahana BSM database BSM web application TC WI and MAM should be operational 24 7
14. d by faults in the application 6 8 1 If the health worker encounter a bug fault in the m HealthSurvey or is unable to perform a particular function the following procedures should be applied 6 8 2 The fault should be first recorded in the Journal indicating the function that was attempted exact steps work flow before encountering the problem the fault and any error messages the application may have displayed 6 8 3 The fault should be reported to RTBI Sarvodaya via voice SMS or email with particulars of contact details for the RTBP staff is given in Table 3 below 6 8 4 The fault should be discussed with the field coordinator or research assistant during the monthly meeting to ensure the 6 9 Contact information Purpose for users seek immediate assistance with respect to the m HealthSurvey technology or the RTBP processes 6 9 1 Health workers should be provided with a list of important contact information and should they should store this information in their mobile as well as a printed copy Table 3 Contacts for health workers to use Role Name Email Mobile Phone Fixed Phone Super User Suma Prashant suma tenet res in 919717763888 914422570428 Pubudini Weerakoon danushkaweerakoon O gmail com 94776244810 General Complaints Janakiraman janu Otenet res in 919747010875 919747010875 Pubudini Weerakoon danushkaweerakoon O gmail com 94776244810 M HealthSurvey Janakiraman j
15. d tested in the state of Tamil Nadu s Sivaganaga District in India and North Western Province s Kurunegala District in Sri Lanka There are twenty four Village Health Nurses VHNs administering Health Sub Centers HSCs in the four Primary Health Center PHC divisions Thirukostiyur Nerkuppai Keelasevalpatty and Sevenipatti of Sivaganga District along with the PHC staff and Sector Health Nurses SHNs are responsible for submitting data They are also responsible for assisting the Medical Officers and Health Inspectors with responding to disease outbreaks Sarvodaya Sri Lanka s largest community embedded NGO has established Comprehensive Community Healthcare Programs in all districts in Sri Lanka The community health centers providing primary healthcare are called Suwadana Centers These centers are managed by local village volunteers who have been trained in primary healthcare Sixteen of the Suwadana Center Volunteers abbreviated as Suwacevo from four Medical Officer of Health MOH divisions Wariyapola Kuliyapitiya Pannala and Udubeddewa in Kurunegala Dstrict have been selected to assist in the RTBP These volunteers will be collecting patient data from the nearby health facilities hospitals clinics general practitioners etc as well as records of patients visiting the Suwadana Centers The RTBP has developed a mobile application m HealthSurvey a web application with database Sahana Biosurveillance Module BSM a web accessible anal
16. en_POX o Cholera o Cholesterol O Cold My Common_Cold O Conjunctivitis O constipation symptom GA Figure 2 Expanded Query Panel with attributes The time series plot for the selected disease e g common cold compared with the time series plot of All Data may not show any disparities for you to identify any significant increases or decreases in disease counts Therefore it is recommended that you run Temporal Scan to find periods in time where there are statistically significant differences of the selected disease e g common cold 1751 20 0 C All Data 150 17 5 125 15 0 gt n E E Current Query 5 100 a Z 3 100 5 75 E o 75 Y comm cold 50 50 25 25 0 0 0 tscan comm cold 7 Sep 14 Sep 21 Sep 28 Sep 5 Oct 12 Oct 19 Oct 26 Oct 2 Nov 9 Nov 16 Nov 23 Nov DATE Save Counts to File 22 Auto v O Log Scale O Linear Scale Y Analysis Panel Click to show hide Choose Method Temporal Scan v Series name fiscan comm cold Target Cl Auto update on target change Baseline All Data v C Auto update on baseline change Temporal scan window size 7 Pvalue threshold p 95 Scan option Upper Tail v Da Sassen Estimation type Prospective Estimation window size 7 Rename CI Constrain Baseline Mapply FOR Figure 3 Time Series display showing saved query and temporal scan results with Analysis Panel Select Target tscan comm cold First set the parameters in the Ana
17. ess of the m HealthSurvey does not offer a user authentication process to ensure the person downloading the application is an authorized user Therefore the download instructions including the access information to the web link for downloading the application should not be publicized to avoid any tampering 6 4 Initializing the m HealthSurvey Purpose personalize and configure the application to suit the working environment 6 4 1 After installation follow the instructions in the User Manual to configure the application such as downloading the list of disease symptoms and signs and registering the profile and locations 6 4 2 If the user had setup the profile before and the user is prompted with a message indicating the user profile already exists then the user must contact RTBP member in Table 3 for the database administrator to remove the previous instance of the profile in order Thereafter proceed with registering the Profile 6 4 3 If the user has downloaded the list of locations but wants to renew the list then simply rerun the same steps of acquiring the list of locations 6 5 Submitting Patient records Purpose describe the various scenarios and precautionary measures that need be taken by health workers when submitting data through the m HealthSurvey 6 5 1 Once the m HealthSurvey has been installed section 5 3 and the application is initialized section 5 4 the user 1s ready to begin sending patient case data 6 5 2 Hea
18. gai District will develop a set of CAP message templates in the MAM to issue both manual and automated alerts 8 3 2 In addition to CAP messages the project will also develop templates and configure the 8 3 3 8 3 4 MAM for issuing none standardizes messaging See sections 8 6 8 8 below for issuing messages The message templates should be clearly distinguished between public private or restricted alerts The RTBP will only issue restricted alerts in this phase of the project where the audience will comprise health workers and health officials The health department should register the recipients and create recipient groups to efficiently selecting message recipients at the time of sending the messages 8 4 Automated alerting Purpose issuing automated CAP messages through the TCWI application to health 8 4 1 8 4 2 8 4 3 8 4 4 8 4 5 8 4 6 8 4 7 8 4 8 8 4 9 8 4 10 department personnel to alert them of auto detected events CAP Messages issued by TCWI on auto detected events are intended for health officials acting in the capacity of event detection analysts and decision makers with respect to disease surveillance Automatic event detection alerts should be issued only by the TCWI s automated event detection process These alerts will use CAP as a standard and should issue a short text SMS and long text Email message For the purpose of the RTBP this CAP template would be repopulate with the fol
19. h officials intending to use the TCWI should have a strong stable Internet connection to the personal computer they are accessing T Cube 8 2 2 To access the TCWI the user must first log in to the RTBP web interface and navigate to the Biosurveillance Module Health officials authorized to use the TCWI should be granted permission i e user name and password through the RTBP web interface 8 2 3 Access TCWI by clicking on the menu item Real Time Analysis followed by clicking the hyperlink Click to access T Cube Web Interface for real time analysis 7 3 Manual Analysis Purpose detect adverse events in the health dataset generated through the m HealthSurvey see Appendix A 7 3 1 Itis recommended that the health departments DDHS or RE office perform analysis on a daily basis However the organization may opt on their own schedule or frequency of using the TCWI 7 3 2 7 3 3 7 3 4 7 3 5 Instructions for frequent monitoring of communicable or notifiable disease is given in Appendix A Section 10 2 and for suspected or ongoing diseases is given in Appendix A section 10 1 The TCWI application will receive data from the RTBP database that contains data received through the m HealthSurvey see section 6 mobile application Users will need to refresh the data i e load the data in to TCWT before an analysis cycle as frequent as once a day If a user has reason to believe that the data is not current then they
20. he date slider has been moved to Oct 18 2009 which shows a high score of 0 9964 between Oct 12 and Oct 18 Also shows another period Sep 09 to Oct 07 with a high score ranging from 0 700 to 0 8500 Sep 3 2009 gt Fix window lt Oq 18 2009 carr Nam 175 f1 0 150 Los y Common_Cold 125 COUNTS aJ0 5 v Scores 7 Sep 14 Sep 21 Sep 28 Sep 5 Oct 12 Oct Scan window size 100 Slide window by 1 Stare Animation Figure 6 Spatial scan score and time series plot for disease under investigation Figure 6 shows the corresponding map with the global score of 0 9964 One area around the Hospital in Katupotha with a count about 270 blue circle and score of 0 833 orange Place mouse pointer inside the circle and click to view the name of location and corresponding counts List will also show the counts of neighboring villages From the color scheme we may conclude that the neighboring areas Lanka opal score 0 9964 270 540 810 1080 Sep 3 2009 Fix window 04 18 2009 Figure 7 Spatial Scan map with counts and scores of disease under investigation are also showing relatively high counts of the disease under investigation common cold By changing the date slider or date arrows the user can see the colors in the respective areas to change proportional to the score 10 2 Scenario B Monitoring high priority notifiable comm
21. heal Disease wore olol eolo o H O o o o o o o o o olo N P O O N O O UW NO a 0 o ojej m oj oj mjo Ww w o wol ele NO o H o H If the user wants to investigate a single disease slitting it by dimension click on the disease you wish to investigate e g Acute_Diarrheal_Disease which will show a drop down panel with the list of attributes as shown in Figure 9 In our example we have selected age_group as the dimension which results in the table shown in Figure 10 To return to the previous table as in Figure 9 with all diseases and all location click on the link disease location placed on the top of the page next to link Start Over
22. hen the SysAdmin should be able to arrive at the data center within a short period i e within one hour the latest 9 3 Database Administration 9 3 1 A backup of the database should be taken on the first day of each month 9 3 2 The database should contain at least past three years of data Any data older than three years can be archived 10 APPENDIX Two main detection analysis scenarios Purpose Give the epidemiology units PDHS REU Sri Lanka and DDHS IDSP Tamil Nadu a set of guidelines for carrying out the operations of the two main detection analysis scenarios 1 Investigating a suspected or ongoing disease outbreak and 2 routine monitoring of notifiable communicable high priority disease Scope These instructions or standard operating procedures for investigating known disease outbreaks and monitoring high priority i e communicable diseases or notifiable disease are for the RTBP Real Time Biosurveillance Program users namely health officials belonging to the Deputy Director of Health Services Integrated Disease Surveillance Program DDHS IDSP and the Provincial Director of Health Services Regional Epidemiology Units PDHS REU staff members The DDHS IDSP and PDHS REU should apply the Scenario B for monitoring the 21 disease in Sri Lanka and 11 diseases in Tamil Nadu Scenario A is for investigating any event of ongoing or potential disease outbreak Background Reader should be familiar with the basics of accessing
23. ill need to use this disease as it is suspected for several of those cases to emerge in the risk area This process will avoid any misspelling of the new disease and will avoid any data integrity problems that may affect the T Cube analysis tool and detection algorithms 5 4 1 These procedures should be applied in the event a new disease not previously listed has been identified for the first time such as Swine Flu H1N1 virus 5 4 2 Super user should include this disease to the Sahana Biosurveillance Module 5 4 3 Super user should send an SMS message for large volume of users or Voice call for fewer manageable volume of user through the Sahana Messaging Module instructing all health workers to immediately execute the download list function 5 4 4 Users should immediately execute the download list function in the m HealthSurvey 5 4 5 The Users should attempt to generate a dummy health survey patient case to see if the new disease has been included in the list of diseases User should not submit this record and should cancel 5 5 Screening diagnosis list Purpose keep the disease symptom and sign lists clean without duplicate entries and misspelled entries to avoid the statistical analysis from false inference 5 5 1 Super user should check the disease symptom and sign list in the database for any duplicate or misspelled entries 5 5 2 Should use the search function of the BSM Diagnosis to carry out this process refer the Saha
24. iven to those health workers participating in the RTBP pilot The PHC Sarvodaya should provide the name and contact information of the health workers participating in the project The health worker receiving a mobile phone will be asked to sign a document indicating they have received the mobile phone and that the main purpose of the mobile phone is for the purpose of the RTBP and should not be misused or abused If the mobile phone is lost or stolen the project is not required to replace the mobile phone If the mobile phone is damaged then the health worker should notify RTBI Sarvodaya and return the damaged mobile phone to receive a replacement 6 2 Getting connected to the network Purpose establish the communications link between the field and the datacenter 6 2 1 6 2 2 6 2 3 6 2 4 6 2 5 User must obtain the mobile network access SIM card on their own under their own name Thereby the project cannot be held accountable for misuse of the phone or excess expenses incurred on personal communications If the user already has a SIM card they may continue to use the same and the project will pay a fixed fee for the utilization with respect to the project work The project may opt to purchase the SIM in the project s name for the user and pay the utilization fees as in the case in Tamil Nadu This option would require setting additional procedures for controlling the usage and payments If the user abuses the usages and the
25. lowing fields Status Message Type Source Scope Restriction Language Category Event Audience Description Instruction Headline Web Contact Resource Description URL TCWI process should change the Status field to Alert or Exercise from Draft and complete the Description field before issuing the message The fields not populated in the template must be completed by TCWI prior to issuing the message Sender Incident Sender Name Response Type Priority Urgency Severity Certainty Effective Expire and Area Description The Description field with the time period disease syndrome gender age group and location information The received alert should be verified by the recipients with the aid of the TCWI and filtering the dataset with the received parameters on time period disease syndrome gender age group and location Recipients of these alerts should not directly relay the alert to other health officials or health workers without proper verification of the received event situational reports from TCWI and obtaining authorization from the designated decision makers Once the automatically detected event has been verified and authenticated with approval to relay it is only then that the health department should follow the procedures outlined in section 8 5 8 5 Issuing CAP messages for Response Purpose communicate situational awareness reports on diseases to respective health 8 5 1 8 5 2
26. lth workers submitting patient data through the m HealthSurvey mobile application or Sahana BSM Case Management web application should integrate the data recording and submission as part of the patient care process i e immediately after examining the patient that patient s case record must be entered in to the application and sent 6 5 3 If the health worker encounters problems with the mobile phone or the m HealthSurvey application it is only in this situation that the health worker should note patient records on paper to submit the data once the technology is operational 6 6 Application maintenance Purpose make sure the application is current always operational and ready to use 6 6 1 Health workers should refrain from unnecessarily deleting the application As this would result in re installation and initialization i e following procedures in sections 5 3 ad 5 4 6 6 2 The user is recommended to run the download list at least once every two weeks to renew the list of disease symptom and signs 6 7 Mobile Phone maintenance Purpose make sure that the hardware is always operational and ready to use 6 7 1 Monthly connection tariffs and utilization fees must be paid on time to ensure uninterrupted providers service 6 7 2 The battery must be charged frequently to ensure uninterrupted operation of the mobile phone 6 8 Reporting Bugs and problems Purpose avoid any data loss or usability complications that may be cause
27. lysis Panel see Figure 2 In Select Target box click on the saved query in this case common cold Immediately the parameters in the analysis panel will be displayed Leave all default values as they are but change the following parameters Choose Method Temporal Scan Baseline All Data Scan Option Upper Tail Estimation Type Prospective Estimation Window Size 7 Apply False Detection Rate FDR V check Change the Series Name to one that you can be identified e g tscan comm cold After all parameters are set and the series name is changed click Submit to execute temporal scan Once the process is complete and graphs are displayed click on Log Scale located at the bottom right corner of the plots The Temporal Scan scores are shown by the plot in red with legend label tscan comm cold Figure 2 shows two periods Oct 12 19 and Nov 9 16 with high scores of disease under investigation in this case common cold The plot of the disease under investigation common cold is in purple Map analysis Spatial Scan Please do not click on the Back Forward Refresh buttons during using this interface Map Display has been initialized Time Series Maps Pivot Tables Poor Performers Please select the spatial attribute in your dataset Dataset 1 location y C Clear Map Figure 4 Loading the map for spatial scan Navigate in to the Map section set the Dataset 1 Location and click Load Map Figure 3 After several seconds
28. na BSM User Manual 5 5 3 This procedure should be executed once a week during the first six months from the time of the initial implementation After the first six months from the time of the implementation this procedure can be executed once a month 5 5 4 Search disease list using the BSM Diagnosis menu first the disease list second symptoms list and finally the signs list 5 5 5 Apply the search process in alphabetical order Thus this step must be applied at least twenty six times for each disease symptom and sign list 5 5 6 If any misspelled or duplicates are found note the that disease symptom or sign name and the corrected version 5 5 7 Give the list of misspelled or duplicates with the corrections to the DBA to make the corrections 5 5 8 DBA should first make the appropriate corrections in the bsm_disease bsm_symptoms bsm_signs bsm_dis_symp and bsm_dis_sign tables 5 5 9 Next the DBA should make the corrections in the bsm_cases bsm_case_symp and bsm_case_sign tables 5 5 10 Finally the health workers i e m HealthSurvey users should be notified via SMS or efficient communication method instructing them to immediately execute the download list function in the m HealthSurvey to update the diagnosis list 1 e disease symptom and sign lists 5 6 Contact information Purpose for the super user to contact the respective personnel with any required assistance to complete the procedures 5 6 1 Table 2 Cont
29. ndard Reports and MAM applications will be accessed 5 1 5 The users should be assigned permission only those functions i e menu items as defined by the list in 6 1 3 5 2 Updating Locations Purpose keep the list of locations clean without unwanted data duplicate entries and misspelled entries to avoid the statistical analysis from false inference 5 2 1 Ifa location is added to or removed from the database then the super user should send an SMS to those applicable users Example a village may be added or removed from a PHC MOH division Then the PHC MOH and HSC Suwadana Center should be notified of the change in order to update their list of locations see m HealthSurvey User Manual 5 3 Updating Diagnosis Definition Diagnosis implies establishing the relationship between the diseases and associated lists of symptoms and signs Purpose enhance the list of disease symptoms and signs for the health workers to use 5 3 1 Super user should use the BSM to add or delete diagnosis Instructions on managing the diagnosis can be found in the Sahana BSM Case Management User Manual 5 3 2 Ifthe disease symptom and signs list is updated by the super user then the super user upon completion should send an SMS to the users instructing them to execute the download list function in order to renew the list 5 4 Emergence of a new disease Purpose to include the newly introduced disease in the health workers mobile phone memory The w
30. ng surveys and other messaging 8 1 1 Users must receive training through the RTBP to operate the MAM for the purpose of issuing health category situational reports using the CAP standard 8 1 2 A copy of the user manual Sahana Alerting using the Common Alerting Protocol User Guide version 1 0 describing the step by step process of initializing and issuing CAP messages can be obtained through the RTBP or the web link INSERT LINK HERE 8 1 3 Given that RTBP is at present is a pilot users should be given training on reporting acceptability of CAP usability of the software performance of the application and any bugs fault encountered with the MAM applications 8 2 Accessing MAM Purpose basic requirements for accessing MAM for health department personnels use 8 2 1 The health departments intending to use the MAM should have a strong stable Internet connection to the personal computer they are accessing MAM through 8 2 2 To access the MAM the user must first log in to the RTBP web interface and navigate to the Messaging Module Health officials authorized to use the MAM should be granted access i e user name and password through the RTBP web interface 8 3 Initializing messaging capabilities Purpose setup of message templates and recipient lists that need to be configured in the MAM prior to issuing health category alerts 8 3 1 RTBP team and Health departments in the respective project sites Kurunegala and Sivagana
31. re ordered according to significance with the top most results with Pvalue closer to zero User should go through the list to find any results that are of interest Then click on that to view the time series Thereafter use the Map to view the spatial clustering of the disease which is similar to executing the Map Analysis Spatial Scan procedure described in the previous section In this case the disease under investigation will be the disease name listed in the Massive Screening result which in our example is Diarrhoea All Data 199 TS _ Current Query v L a Z kaj 3 5 04 5 LJ MS Baseline 9 3 25 y MS Pvalues 0 0 7 Result Query 15 Sep 30 Sep 15 Oct 30 Oct 14 Nov 29 Nov DATE Save Counts to UN Auto z Log Scale Linear Scale File gt Analysis Panel Click to show hide gt Massive Screening Panel Click to show hide Y Saved Queries List Panel Click to show hide Show Recent Massive Screening Result 2 disease Diarrhoea location Nadalagamuwa 5 4343464e 03 NOV 30 2009 7 00000 disease Diarrhoea location Nadalagamuwa 1 6945207e 02 NOV 30 2009 14 location Deegalla 2 4906861e 02 NOV 30 2009 21 location Thalgahapotta 2 5169793e 02 NOV 30 2009 28 disease Diarrhoea location A 02 ys Be disease Diabetes location Deegalla 2 9708036e 02 NOV 30 2009 14 disease Diarrhoea
32. report will be sent to you and members of the RTBP project 8 8 2 The Research Assistant will meet with the users each month to assess the usability problems and performance of the TCWI 7 6 Contact information 8 9 1 Health officials should be provided with a list of important contact information Table 4 Contacts list for health officials Role Name Email Mobile Phone Fixed Phone General Complaints Janakiraman janu Otenet res in 919747010875 919747010875 Pubudini Weerakoon danushkaweerakoon gmail com 94776244810 TCWI MAM General Suma Prashant suma tenet res in 919717763888 914422570428 support Pubudini Weerakoon danushkaweerakoon gmail com 94776244810 TCWI technical Michael Beysak mjbaysek cs cmu edu 14122686233 support Robin Sabhnani sabhnani cs cmu edu 14125510631 MAM technical Pradeeper Damendra pradeeper respere com 94772928456 94112500511 support Mifan Careem mifan respere com 94773437283 8 Situational Reporting Health department personnel entrusted with the task of notifying and alerting health officials and health workers on health threats that require response actions should read this section This section covers the procedures involving the Messaging Alerting Module MAM and dissemination of situational reports 8 1 Training Purpose orient and mobilize health departments with issuing health category alerts situational reports conducti
33. rkers if necessary activate relevant response plans 4 Definitions and Abbreviations Table 1 List of acronyms and descriptions BSM Sahana Biosurveillance Module CAP Common Alerting Module DBA Database Administrator HSC Health Sub Center IDSP Integrated Disease Surveillance Program MAM Sahana Alerting Messaging Module MOH Medical Officer of Health PDHS Provincial Director of Health Services PHC Public Health Clinic RE Regional Epidemiologist RTBP Real Time Biosurveillance Program SHN Sector Health Nurse SOP Standard Operating Procedures Suwacevo Sarvodaya Suwadana Center Volunteers SysAdmin System Administrator TCWI T cube Web Interface VHN Village Health Nurse 5 SUPER USERS The super users are mainly the system implementers database administrators system administrators Certain super user operations may be carried out by health officials or supervising health workers 5 1 User accounts Purpose give the health workers access to the TC WI and MAM software 5 1 1 Request for a list of health officials who will need to access the TCWI to analyze the data 5 1 2 Request for a list of health officials who will be responsible for issuing alerts 5 1 3 Create two user groups 1 TCWI and 2 MAM there may be a few overlaps of same user being authorized to analyze and issue alerts 5 1 4 The user accounts should be registered in Sahana where both TCWI Sta
34. rkers to USO uscar ads 14 Table 4 Contacts list for health olficials uti 17 21 Table 5 Contacts list for health Officials oooccccnonononncnnnnnnonononanenicnnnnonononenanaconoconononenanirocccncnnonenaninins 1 Purpose The document describes the Standard Operating Procedures SOPs for data collection data processing data reporting and database system administration Data collection involves e Setting up of the Biosurveillance Module BSM initial information i e implement database through the web application and direct Database Administration DBA functions e Installing configuring and maintaining the m HealthSurvey mobile application e Health worker expected practices in submitting data e Documenting and reporting problems associated with the BSM and m HealthSurvey Data processing involves e Installing configuring and maintaining the T Cube Web Interface TCWI analytical tool e Installing configuring and maintaining the detection algorithms e Health Officials epidemiologist expected practices in analyzing the health data e Defining priority levels for particular diseases e Documenting events of interest e Documenting and reporting problems associated with TCWI and detection algorithms Data reporting involves e Installing configuring and maintaining the Sahana Alerting and Messaging Module MAM e Initializing the MAM contact lists jurisdictions geographical areas message templates e Verifica
35. rt layer In the event the signal is absent the record is stored in the offline storage in the mobile RMS Record Management System until connectivity is established and data is transferred Step 4 Periodically on the average once a day Epidemiologist analyze the information using the T Cube time series and spatial scan web interface software The data is also subject to automated event detection handled by software algorithms that are scheduled to run once a day These algorithms will issue alerts to the Epidemiologist of detected events that may be potential disease outbreaks Step 5 If the Epidemiologist detects an adverse event then a decision is made whether or not to intervene Step 6 Events of interest or adverse events that require intervention and prevention or are worthy of notifying are communicated to those health workers in the effective geographic areas and in certain cases notify a geographical spread wider audience of health workers Structured Common Alerting Protocol CAP messages are generated and issued through the Sahana Alerting Module by the authorized health officials Step 7 A tone down version of the CAP messages that can fit in a SMS are transmitted via GSM cellular networks to the health worker mobile phones The complete CAP message is published on the web for health workers to access through WAP Step 8 Based on the situational reports i e CAP health alerts received the health wo
36. should notify the RTBP staff member General Complaints listed in Table 4 to resolve the problem Users should be given a template for recording false positive and true positive events highlighted by TCWI This is to assess and correct the performance of the tool The format should contain the date name of user detected event disease symptoms signs gender age group location and period false true alarm and remarks 7 4 Automated event detection Purpose establish the automated event detection as a redundant process to the manual 7 4 1 7 4 2 7 4 3 7 4 4 7 4 5 7 4 6 7 4 7 7 4 8 process in section 7 3 The T Cube algorithms besides the manual analysis will be automated to run on an established schedule The health officials and RTBP team should determine the schedule Any events detected by the algorithms must be automatically communicated to the health officials responsible for analysis and detection instantaneously via Email and SMS TCWI will issue the alert through the MAM see section 8 for the manual alerting process A CAP template will be developed through the MAM see procedures described in section 8 for TCWI automated alerting process to use T Cube software will populate the template with the required information such as completing the time and description information and send it as CAP message to the predefined recipients section 7 4 4 Recipients of these automated alerts should
37. the map will be displayed with blue circles around the locations where data is available Scroll down to the Attribute Selection Panel and click on the link to expand the panel see Figure 4 Check V the box associated with the Disease list which will show all diseases highlighted in blue indicating all of them to be selected Scroll through list and click on the disease under investigation e g common cold which will be the only disease highlighted in blue shown in Figure 4 Click on the Submit button at the top of the Attribute Selection Panel Almost immediately the map and the time series plot will change reflecting the counts of the submitted query with the disease under investigation i e common cold chosen in our example Y Attribute Selection Panel 1 Click to show hide Submit Ll Reset Split By Select attribute v O Auto Filter M disease L location lage grp L gender LJ sign Cholesterol Cold Common Cold Conjunctivitis Constipation O symptom Temporal window size 7 Max group size 6 k Run Spatial Scan _ Min threshold 7 0 Figure 5 Spatial Scan attribute selection panel Change the Temporal Window Size 7 and Max Group Size 6 Figure 4 After the parameters are set click on Run Spatial Scan The results will comprise the map with global score and time series window with global scores Figure 5 shows the time series for the chosen example common cold in blue and the score in red T
38. tion and Authorization procedures for issuing health alerts 2 Scope This applies to all actors who are part of the Real Time Biosurveillance Program RTBP mainly e health workers submitting data from the field and facilities hospitals clinics health centers e district divisional health officials analyzing the data for disease outbreaks e district divisional health officials issuing alerts to health workers e health workers and health officials responding to health alerts e personnel implementing the technology system e personnel providing technology and process support services e personnel responsible for the upkeep of the Technology The health workers and health officials are the main users of the RTBP while implementers and support personnel are regarded as super users who assist the health workers and health officials with system implementation and troubleshooting Database administrators and system administrations are responsible for the upkeep and smooth functioning of the technology 3 Background RTBP at this stage is a pilot aiming to prove the concept of using mobile phone applications for data collection data mining statistical analysis software for health event detection and Common Alerting Protocol based messaging for disseminating health situational reports The SOP defined in this document are for the purpose of the pilot project and should be revised to suit a full scale implementation The RTBP is being fiel
39. unicable diseases Tamil Nadu and Sri Lanka monitor a set of diseases termed as notifiable disease that are currently communicated through the S P form and H 544 form respectively This section illustrates the steps for carrying out the disease surveillance procedure This procedure should be conducted frequently daily or weekly Time Series Analysis Massive Screen After loading the data click on the Massive Screening Panel to expand Figure 7 Let all default values be as it is but change the following Scan Window Size 7 4 21 28 Estimation Type Prospective Scan Option Upper Tail Check V Last Day Only and Baseline All Data gt Analysis Panel Click to show hide Y Massive Screening Panel Click to show hide Temporal Scan Change Analysis Scan window sizes 7 14 2 Pvalue threshold 0 05 Estimation type Prospective gt Estimation window size 7 Start Date mm dd yyyy 09 03 2009 End Date mm dd yyyy 11 30 2009 Scan Option Upper Tail z Mi last Day Only O Constrain Baseline C Rank Pvalues O Rank Alternate Pvalues C Most significant window only C use Hierarchical Attribute C Use Drill Down Query Baseline All Data z Select attributes upto3 and specific values optional to run massive screening You will be able to select specific values only if the attribute is selected M disease M location Lage grp l gender UL sign Dengue Fever SJ Ammanamulla Dental Carries Bogahapitiya E
40. ytical tool T cube Web Interface TCWI set of auto detection algorithms and a situational awareness reporting web interface Sahana Alerting Messaging Module MAM These application will be field tested for the purpose of proving the concept of automating disease surveillance and notification The RTBP evaluation will scrutinize the social content application and technology layers of the data collection data processing and data reporting processes Health Official generate TA Assue transmit alert sahana Alerting alert receive tomobile device Module Interface health alerts transmit records to database GSM network a Se m HealthSurvey Epidemiologists Figure 1 RTBP actors ICTs processes and information flow indicators Step 1 Health workers record patient information in various registries such as outpatient registry inward registry morbidity report etc Once policies are in place for a wider scale deployment the paper registries can be obsolete and same data can be supplied via electronic means i e skip directly step 2 Step 2 Patient complained symptoms healthcare provider identified signs and diagnosed disease along with patient s gender age and point of care location i e hospital clinic or village name are entered in to the m HealthSurvey mobile application Step 3 Information is sent to the central database through the GSM cellular network over the GPRS transpo
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