- Anna Geofrey
Sokoine University of Agriculture, Tanzania
- Maulilio J. Kipanyula
Sokoine University of Agriculture, Tanzania
- Kadeghe Fue
Sokoine University of Agriculture, Tanzania
- Camilius Sanga
Sokoine University of Agriculture, Tanzania
Rabies continues to be one of the most perilous viral diseases that affect the nervous system and remains a significant threat to public health across the globe. Available data that show that rabies claims about 59,000 human lives annually. Most industrialized countries have eliminated rabies from domestic dog populations. Conversely, in most of the developing countries, rabies remains endemic in domestic dog populations and poorly controlled. One of the challenges in eradicating rabies in developing countries is attributed to ineffective surveillance systems. Different stakeholders have developed solutions to address this problem without tangible outcomes. Estimation of the economic burden particularly in developing countries is difficult because of the inadequacy of update and reliable surveillance data. Certainly, it is very challenging even to obtain basic information on how many human lives are lost due to rabies and the economics behind preventing the disease amongst those exposed. Up-to-date, official reporting of incidence data on rabies and rabies exposures status remains desperately poor in most canine rabies-endemic countries. Consequently, there is increasingly underestimation of the true burden of the diseases. Worse still data from active surveillance studies highlight the disparities between officially reported and recorded and likely occurring rabies deaths. In some cases, it has been shown that there are higher mortality rates than officially reported data, especially in resource deprived areas. This calls for a need to establish an integrated surveillance system, which allows data to be shared openly among different stakeholders dealing with rabies. The paper presents the state of art of rabies in Tanzania and evaluates the application of ICT in surveillance. It also advocates for a need of a comprehensive approach to addressing the problem. Development and adoption of integrated surveillance systems for rabies and other zoonotic diseases remain a nightmare in many developing countries including Tanzania. This paper calls for the development of an integrated standard mechanism for countries to assess their rabies status and measure progress in eliminating the disease. Such a system will fill the missing link between surveillance and control measures.
Rabies is one of the deadly infectious diseases of the nervous system, with a case-fatality rate approaching 100% in both animals and humans. The disease is established on all continents apart from Antarctica; most cases are reported in Africa and Asia, with thousands of deaths recorded annually (Fooks et al., 2014). The World Health Organization (WHO) estimates that up to 99% of human rabies cases are transmitted by a bite of an infected dog. It is estimated that rabies causes about 59,000 human deaths every year, especially in economically disadvantaged areas of Africa and Asia where awareness and access to post exposure prophylaxis can be limited or non-existent (Anyiam et al., 2016). However, the estimated annual figures of human rabies fatalities are probably underestimated due to poor reporting system (Hergert and Nel, 2013).
The most cost-effective approach to eliminate the global burden of human rabies is to control canine rabies rather than expansion of the availability of human prophylaxis. Mass vaccination campaigns with parenteral vaccines, and advances in oral vaccines for wildlife have made it possible for several countries worldwide to eliminate rabies in terrestrial carnivores (Fooks et al., 2014). It has been postulated that in order to eliminate rabies from domestic dog population in an endemic area at least 70% of the dog population needs to be vaccinated during an annual rabies mass vaccination campaign and breaks the cycle of transmission (Coleman et al., 1996). Certainly, decreasing canine rabies automatically decreases the number of human deaths (Cleaveland et al., 2002). However, in many African countries, the proportion of dogs vaccinated against rabies is far below 70%. Treatment for human rabies is often inaccessible and expensive than the cost of programmes for control and prevention of dog rabies (Ope et al., 2013; Bardosh et al., 2014; Hatch et al., 2016).
Drawing a lesson from Kilosa district Tanzania where rabies is endemic, lack of appreciation and awareness that rabies can be prevented and controlled by massive dog vaccination schedules has remained a deadlock (Kipanyula et al., 2015). Figure 1 and Figure 2 show the number of dogs in different villages in Kilosa district Tanzania and the number of dogs vaccinated, the data were collected from users through the interview and were analyzed to determine the dog owners’ response toward mass dog vaccination. Eliminating rabies require coordinated and sustainable long-term strategy supported by robust human and animal health systems. An integrated, holistic approach for information sharing is crucial for example using one health approach. This may require step wise approach allowing inter-sectoral surveillance data sharing based on participatory approach and coordinated intervention by all stakeholders. Evidence has shown that elimination of rabies in most of the developed countries was driven by: the strategic stepwise approach that focused primarily on reservoirs in conjunction with massive dog rabies vaccination campaigns, the establishment of a database for rabies surveillance and long term political commitment and resources availability. It is until when developing countries replicate this approach, otherwise rabies will continue to pose a significant human health problem. Use of ICT such as mobile phones, radios, televisions, websites and crowdsourcing to improve the communication of rabies surveillance information at different levels is likely to make a difference. This will facilitate awareness, timely reporting and response to rabies incidences (Kipanyula et al, 2015; Hatch et al., 2016).
The goal of this paper was to review state of the art literature, which contribute to the development of an effective, efficiency and low-cost surveillance system for detecting, identifying, controlling and monitoring rabies in Tanzania. Our hypothesis was that through public crowd sourcing of incidences of rabies outbreak via mobile telephones and web based system, combined with open and public reporting of such incidences in real-time through the Internet, radio and TV, will decrease the number of incidences.
|Figure 1. The number of dogs in villages in Kilosa (adapted from Kipanyula, 2015)|
|Figure 2. Number of dogs vaccinated in villages in Kilosa (adapted from Kipanyula, 2015)|
Traditionally, paper based reporting system has been in use for decades. Overtime the system has proven to be inefficient due to several factors within and beyond human control. Some of well documented challenges include: incompleteness of surveillance forms at the time of submission, difficulties to submit hard copies of the disease surveillance forms because of poor infrastructure, lost forms, large piles of reports, difficulties in records indexing, weather conditions or challenging terrain, especially in the developing countries like Tanzania (Mtema, 2013). Following submission of forms, the system demands re-entry of the data at central data processing and analysis points. Passing data through different levels make it possible for the introduction of unexpected human errors. Considering the whole process of handling of data and given challenges highlighted above, there is significant delayed acquisition, processing and response to disease events occurring particularly in remote and resource limited areas.
In recent years, we have witnessed intense research on the application of Information and Communication Technology (ICT) in integrated disease surveillance system (IDS) to help overcome the challenges in encountered in paper based reporting of rabies incidences and further expansion in hard-to-reach populations in Tanzania. This has increased the involvement of the private sector, and the use of other modes of communication like e-mail, mobile phones and voicemails. Though the use of ICT tools, it is possible to reach many people to create awareness on rabies. The ICT based rabies surveillance systems support easy awareness creation (i.e. sensitization) and a more rapid and timely reporting, and response to rabies incidences (Ncube et al., 2010; Mtema, 2013). Furthermore, ICT facilitates one health approach and improve communication between veterinary and human health services by making both Departments aware of surveillance data through the database. Furthermore, it facilitates the speed of communication which is most critical to contain or stamp out an outbreak, save lives, and prevent or minimize the detrimental effect to the communities. Although ICT appears to be simply a communication tool for sharing of surveillance data, it is challenging, however, to set up an effective communication system, and even more so in poorly established infrastructure in the developing countries like Tanzania. Future advances in ICT and wide application of human sensor web technologies minimize the above challenges (Qekwana et al., 2010; ITU, 2014). Some of the key components of the IDS include: Integration and decentralization of surveillance activities through establishment of surveillance units at national, state and district levels; Human Resource Development through training of State Surveillance Officers, District Surveillance Officers, multi-disciplinary Rapid Response Teams, and other veterinary and medical professions on all aspects of disease surveillance; Use of ICT for collection, collation, compilation, analysis and dissemination of data through a web portal and strengthening of public health laboratories (Kant., 2010). Some of the ICT application have shown tangible outputs in various settings, and are summarized below (McCall et al., 2011).
For rapid detection and response to any outbreak, natural or deliberate, a sensitive surveillance system is essential. It is considered that a good communication system is the ‘brain’ of the surveillance system. It is the speed of communication which matters most to contain or stamp out an outbreak, save lives, and prevent misery. As pointed out above it is challenging, however, to set up an effective communication system, to increase public awareness on rabies. Televisions and radios are frequently used by veterinary and public health officials or central authorities within the district to educate people on various issues. These media of communication also disseminate information on public health related matters including rabies incidences in the area (WHO, 2002). Radios are cheaper compared to televisions. They can still be used also in rural areas where there is lack of electricity thus serving as an ideal means of communication. The high costs associated with casting a program on televisions and radios has remained to be a great challenge. Thus due to un-timely communication and coordination of rabies despite the use of radio and television still the disease has continued to be a public health concern (Mazigo, 2011; Mboera and Rumisha, 2004; Sambo, 2012; Hatch et al., 2016). A novel framework for the use of radio in communicating rabies information can be adopted from Sanga et al. (2013). Radios and Televisions cannot be used for reporting isolated and emerging cases of rabies but can only be used to inform the public on outbreaks and serious public health threats.
The Internet has revolutionized efficient health-related communication and epidemic intelligence worldwide (Chunara et al., 2012; Choi et al., 2016). Recent studies have shown that the increased frequency of Internet use for acquiring health information has contributed to the rise of web-based early detection systems for infectious diseases through various methodologies (Choi et al., 2016). The principal concept of this tool is that disease-related information is retrieved from a wide range of available real-time electronic data sources, which play critical roles in the identification of early events and situational preparedness by offering current, highly local information about outbreaks, even from remote areas that have been unapproachable by traditional global public health efforts (Keller et al., 2009; Choi et al., 2016).
The use of web based information system has brought opportunities and increased possibilities of community involvement in rabies cases identification, detection, alerting, monitoring, controlling, mapping and reporting (Adigwe, 2012; Mwabukusi et al., 2014). Mapping of all areas that are usually affected by the disease outbreak can be made possible by using the web-based geographical system to increase the citizen’s awareness of the disease and the precautions that can be taken to prevent it. Also, the database queries can help the public health and veterinary professionals to know which areas within the district need more attention for operations such as; dog mass vaccination campaigns and stocking of health centers with sufficient PEP. The justification for advocating the use of the web-based system; the system database can provide an easy, cost effective and reliable means for reporting, monitoring and controlling of rabies (Luba, 2012). The main obstacle for a wide application of web-based diseases surveillance system is the internet connectivity.
Although traditional pen-and-paper methods of disease reporting are not efficient or practical in complex emergencies, there are still used in developing countries. Instead, reporting formats can be provided on mobile phones, making it easy for both human and animal health professionals to enter data and send reports. Such a system will help reduce errors, decrease the time used in reporting and facilitate compliance with reporting schedules. Mobile phones facilitate real time communication, therefore, may be ideal in rabies surveillance: The ultimate result will be increased people participation in control programs such as dog mass vaccinations, communication between people and veterinary centers in case of disease outbreak and hence structural barriers, poor infrastructure, cost for transportation to access health and veterinary services will no longer be a problem (Mtema et al., 2016). Despite recent improvements, not all areas have mobile network coverage with internet capacities like 3G or 4G technology, resulting in an incomplete picture of the public health information. However, combining mobile phone service with a paper-based reporting system in areas where there is no network access is likely to give good coverage. The use of satellite phones in areas of the network would help to strengthen the system further. Even in areas where the network is working, there may be shortage of electricity supply to recharge the phone batteries; future interventions should consider the use of mobile phones with a silicon solar panel embedded into the shell of the phone. It has been advocated that wherever possible Global Positioning System (GPS) enabled mobile phones with geographic information system (GIS) capability should be used. The reporting system can be programmed to automatically generate geo-referenced data for each text message, which could help to track the disease reported with more specified locations (Snyder & Dazzo, 2011).
Information such as rabies outbreak, dog vaccination campaigns can just be sent to people through SMS or voice call within the village. Also by using a Mobile application such as SMS, mobile based systems and mobile apps, it is easy to collect data since it is automatically uploaded into a database and is available on a real-time basis. This data can be used to precisely combat the disease in specific areas, allowing the institution of appropriate interventions to target societies. With the mobile technology, data on the server can be viewed simultaneously by both the veterinary and public health centers. This helps quickly provision of services to the areas that are affected by the disease (Asangansi and Braa, 2010).
Popular GIS applications like QGIS and Arc Map have been used to develop maps that can explicitly show health disparities along different areas. Jerrett et al., (2001) explained intersection of medical geography, environmental epidemiology, and spatial analysis and they reviewed how to apply spatial analysis in environmental health research. Emch et al., (2012) presented a case study of how social network and spatial analytical methods can be used simultaneously for disease transmission modeling. Bennett and Tang (2006) reported about agent based models of adaptive, spatially aware, and mobile entities. Rabies is carried by dogs who are spatially moving agents that can be modeled to predict future of the disease and effectiveness of the current approaches. This means that use of GIS in spatial and social network analysis can help us better understand disease transmission cycles.
Recently, some prominent geo-informatics experts have described disease map as having some prioritized properties that can help public health experts and practitioners to understand well the maps. Beyer et al., (2012) argued that as the disease map user group grows, disease maps must prioritize several essential properties that support public health uses of disease maps. They identified and described five important properties of disease maps that will produce maps appropriate for public health purposes: (1) Control the population basis of spatial support for estimating rates, (2) display rates continuously through space, (3) provide maximum geographic detail across the map, (4) consider directly and indirectly age–sex-adjusted rates, and (5) visualize rates within a relevant place context.
Integration of the shape files developed in these applications can be made available through internet. The maps can be used to develop layers that can explicitly show the relationship between economic social attributes and health centers availability and distance from most of the villages. These approaches can greatly work to combat rabies in developing countries.
Human sensor web is a very effective method of rabies surveillance; it helps the veterinary and public health professionals to get real-time data on diagnosis (Trigoni and Krishnamachari, 2012). In Tanzania, this notion of human sensor web was tested and deployed to design solution on a mobile reporting system for functionality of water points in rural Tanzania under the SEMA project (Wesselink et al., 2015). If it could be applied in the context of rabies, then it would be easy to detect and timely report outbreaks in both public health and veterinary facilities. Human sensing is a method of crowd-sourcing whereby ICT devices are employed for data collection in a particular field of specialization. Human Sensor Web (HSW) is a network of people who interact with their devices in order to forward their observations to a designated receiving server in the form of messages (such as SMS and emails). The operating principle is based on the accessibility of ICT tools (such as mobile phones) by non-experts to use them as sensory nodes in order to generate useful data regarding various location-oriented phenomena. The method would allow sharing of rabies information to wider audiences (Leventhal, 2013). Studies have shown that use of rapid diagnostic kit for the diagnosis of rabies using saliva, or cerebrospinal fluid from living animals or brain homogenate to detect rabies virus antigens requires only training of veterinary and public health staff on how to use it and sharing of results could adopt human sensor notion. In brief, the rabies antigen test device is an immunochromatographic assay for the qualitative detection of rabies virus antigen in canine, bovine, Raccoon dog’s secretions of saliva, and brain homogenates. The kit has a letter of “T” and “C” as test line and control line on the surface of the card. Both the test line and control line in result window is not visible before applying any samples. The control line is used for procedural control. Certainly, the control line should always appear if the test procedure is performed properly and the test reagents of control line are working. A purple test line will be visible in the result window if there are enough rabies antigen in the specimen. The specially selected rabies antibodies are used in test band as both capture and detector materials. These enable the device to identify rabies antigen in animal blood with a high degree of accuracy. Wider application of this kit may improve diagnosis and help to avoid unnecessary killing of dogs in endemic countries. This will allow early detection of dogs with rabies virus and thus allow prompt management of the disease (Nishizono, 2008). Thus, the kit is suitable for screening and surveillance of a large number of rabies-suspected animals in laboratories with proper facilities for biohazard in endemic areas because of its simple, rapid, reliable, and cost-saving properties (Nishizono, 2008). The laboratories in Kilosa health and veterinary centers could adapt the use of these human sensors that do not require expertise to use it. By doing so, the rabies diagnosis could be done promptly and at low-cost. This could change the way suspected animals with rabies are dealt and foster objective planning of rabies control strategies and dog mass vaccination schedules (Leventhal, 2013). Systems which support human web sensor web are limited in Tanzania (Pascoe et al., 2012); thus there is need of adapting existing architecture for implementing such systems (Figure 3).
|Figure 3. Architectural of the proposed rabies surveillance system based on human sensor web (adapted from Brownstein et al., 2008)|
The web is becoming the interface for reporting information about diseases, prevention, surveillance and control. The study by Brownstein et al. (2009) presents a seminal paper discussing how the web is being used to harness public health system globally. According to Brownstein et al. (2009), the weakness of Internet based system for diseases surveillance is information overload, false or bias reports, high cost, contributor bias, imprecise resolution, lack of specificity of signals, and sensitivity to external forces such as media interest or bias or misinformation. According to Chunara et al. (2013), mobile phone and the Internet provide tools for collecting disease surveillance data directly from individual citizens (i.e. crowdsourcing). However, crowdsourcing is still at infancy stage in many African countries (Chuene & Mtsweni, 2015).
According to Chunara et al. (2013) crowdsourcing is defined as:
…the process of obtaining services, ideas, or other information via a large group from the public, rather than a specific set of people (such as government institutions or hospitals).
Boulos et al. (2009) suggested that crowdsourcing is the proposed solution to address some of the weakness mentioned by Brownstein et al. (2009). According to Boulos et al. (2009) crowdsourcing for surveillance system involves the use human (i.e. citizen or crowd) to sense and report surveillance information to a web or mobile based surveillance information system. Also, it involves the use of specialized sensor devices to send information to web or mobile based surveillance information system which aggregates or fuses information from different sources (i.e. micro blogging, mobile phones enabled by GPS, SMS). Boulos et al. (2009) Architecture can be used in implementing crowdsourcing platform for rabies surveillance (Figure 4).
|Figure 4. Architectural of the proposed rabies surveillance system based on crowdsourcing application (adapted from Boulos et al., 2009)|
Crowdsourcing platform can help control of rabies by establishing collaboration of individuals and group of individuals (i.e. crowd) to contribute their ideas in order to solve the problems. This can be done using few veterinary and health centers available in a region. Encouraging and providing responsibilities to citizens to find ways and methods to eliminate rabies in their region is the best and effective method to collect rabies data (Callaghan, 2015). Collaboration or participatory communities created especially for rabies reporting and the investigation of rabies-related incidence gives individual participants to view themselves as a problem solver in a society. This is what is termed participatory citizen sensing (Boulos et al., 2009). According to Boulos et al. (2009) sensing is a process of detecting physical presence and converting that data into signal which can read by an instrument or observer (citizen). Citizen science can be done through commissioned payment or volunteer (Bonney et al., 2009). There is a developing notion of biocitizenry that being a citizen scientist, and sharing personal health information, or collaborative data collection (Swan, 2012). Thus, this act of participatory problem solving in disease surveillance using intelligence from citizens (i.e. crowd) is called crowdsourcing.
In Tanzania, crowdsourcing applications have been piloted in agriculture and health sector (Madon et al., 2014; Sanga et al., 2016, Mwangungulu et al., 2016). Madon et al. (2014) reported on the use of mobile phones for collecting health data from the field to control neglected tropical diseases. They argue that even through user generated data (i.e. crowdsourcing) can be obtained there is a need to decision support system so that there will be decentralization on the use of such data.
Mwangungulu et al. (2016) piloted crowdsourcing application in identifying areas where mosquitoes are abundant or less abundant without surveying. Community members (i.e. crowd) were trained how to report areas with abundant mosquitoes through participatory mapping using GIS. The use of crowdsourcing approach was cost effective in controlling malaria.
Sanga et al. (2016) piloted the use of a web and mobile based platform (UshauriKilimo) to all crowd to report on suspicious rabid animals, rabies disease outbreak, treatment of affected dogs. Also through UshauriKilimo veterinary and health centers and crowd can share information on rabies education, what first aid kit can be given to the rabid patient and rabies data and information generated from the crowd. Data collected from the crowd is populated in real time on map and instantly all involved users/ parties / stakeholders are notified to take appropriate measures. Examples of stakeholders are police, local communities, public health officer, community worker and law enforcement agents (e.g. local leaders – village executive officers, ward executive officers). These stakeholders can be linked by crowdsourcing application (USAID, 2013) in diseases surveillance. Thus, crowdsourcing facilitates quick response from veterinary and health centers to the areas of the disease outbreak. Also, it can increase the number of dog owners’ participation in dog mass vaccination schedules.
Many people are now using social networks to express their opinions regarding the vast number of topics. Most people use it to complain whenever a problem rises in the society. The geotagged tweets, Facebook status, picture updates in Instagram allow researchers to know the location of the person who writes the twit. Understanding human mobility is crucial for a broad range of applications from disease prediction to communication networks (Jurdak et al., 2015). Jurdak et al., (2015) proposed Twitter as a proxy for human mobility, as it relies on publicly available data and provides high resolution positioning when users opt to geotag their tweets with their current location.
Diseases like rabies can be combated by using big data analysis approach of reading social media status of the users and report to the disease surveillance systems. This method has been shown to be very successful in some topics already. For example, the study by Jiang et al., (2015) indicated that the filtered social media messages are strongly correlated to the Air Quality Index and can be used to monitor the air quality dynamics to some extent. So with this method, rabies surveillance can be monitored using filtered social media messages. Bosley et al., (2013) concluded that twitter can be filtered to identify public knowledge and information seeking and sharing about cardiac arrest. To better engage via social media, healthcare providers can distil tweets by user, content, temporal trends, and message dissemination. Furthermore, Nagar et al., (2014) reported the first study to stress test Twitter for daily city-level data for New York City. Extraction of personal testimonies of infection-related tweets was done and demonstrated Twitter’s strength both qualitatively and quantitatively for ILI-ED prediction compared to alternative daily datasets mixed with awareness-based data such as GSQ.
This is a cost-effective method however Yang and Mu (2015) reported that these social media platforms may limit most of the information. For example, the Twitter APIs only allows free access to a one percent convenience sampling of tweets. Data acquired are restricted to users with public profiles. These may bring some bias to study results.
The paper presents the state of art of rabies surveillance and evaluates the application of ICT in as a part of the integrated approach. There is a mixture of approaches from traditional to modern approaches supported by ICTs. The shortcoming of these approaches is that they operate in in discipline related silos. This calls for Government to integrate different ICT solutions (i.e. unified approach) for surveillance of diseases developed by various organizations. The Government and other stakeholders involved in addressing zoonotic diseases like rabies should develop a framework which can guide stakeholders’ participatory implementation of such blended approaches with citizens forming the center of the approach (i.e. human centred). UshauriKilimo in Tanzania is an example of a mobile based system which has been developed through involvement of user from initial phase (analysis) to final phase (implementation) (Sanga et al., 2016). This tool can be customized as (1) early warning information system for rabies (2) crowdsourcing platform for rabies surveillance (3) web based rabies advisory system (4) mobile based rabies advisory system (5) cloud based rabies advisory system. (6) e-learning and mobile learning for rabies.
This research was previously published in the International Journal of User-Driven Healthcare (IJUDH), 7(1); edited by Ashok Kumar Biswas, pages 13-26, copyright year 2017 by IGI Publishing (an imprint of IGI Global).
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