El-Khatib et al. Conflict and Health (2018) 12:42 https://doi.org/10.1186/s13031-018-0177-6 RESEARCH Open Access SMS-based smartphone application for disease surveillance has doubled completeness and timeliness in a limited- resource setting – evaluation of a 15-week pilot program in Central African Republic (CAR) Ziad El-Khatib1,2,3*, Maya Shah1, Samuel N Zallappa4, Pierre Nabeth5, José Guerra5, Casimir T Manengu6, Michel Yao6, Aline Philibert1, Lazare Massina4, Claes-Philip Staiger7, Raphael Mbailao4, Jean-Pierre Kouli1, Hippolyte Mboma1, Geraldine Duc1, Dago Inagbe1, Alpha Boubaca Barry1, Thierry Dumont1, Philippe Cavailler1, Michel Quere1, Brian Willett1, Souheil Reaiche1, Hervé de Ribaucourt1 and Bruce Reeder1,8 Abstract Background: It is a challenge in low-resource settings to ensure the availability of complete, timely disease surveillance information. Smartphone applications (apps) have the potential to enhance surveillance data transmission. Methods: The Central African Republic (CAR) Ministry of HealthandMédecinsSansFrontières(MSF)conducteda 15-week pilot project to test a disease surveillance app, Argus, for 20 conditions in 21 health centers in Mambéré Kadéi district (MK 2016). Results were compared to the usual paper-based surveillance in MK the year prior (MK 2015) and simultaneously in an adjacent health district, Nana-Mambére (NM 2016). Wilcoxon rank sum and Kaplan-Meier analyses compared report completeness and timeliness; the cost of the app, and users’ perceptions of its usability were assessed. Results: Two hundred seventy-one weekly reports sent by app identified 3403 cases and 63 deaths; 15 alerts identified 28 cases and 4 deaths. Median completeness (IQR) for MK 2016, 81% (81–86%), was significantly higher than in MK 2015 (31% (24–36%)), and NM 2016 (52% (48–57)) (p < 0.01). Median timeliness (IQR) for MK 2016, 50% (39–57%) was also higher than in MK 2015, 19% (19–24%), and NM 2016 29% (24–36%) (p < 0.01). Kaplan-Meier Survival Analysis showed a significant progressive reduction in the time taken to transmit reports over the 15-week period (p <0. 01). Users ranked the app’s usability as greater than 4/5 on all dimensions. The total cost of the 15-week pilot project was US$40,575. It is estimated that to maintain the app in the 21 health facilities of MK will cost approximately US$18,800 in communication fees per year. Conclusions: The app-based data transmission system more than doubled the completeness and timeliness of disease surveillance reports. This simple, low-cost intervention may permit the early detection of disease outbreaks in similar low-resource settings elsewhere. Keywords: Surveillance, mHealth, Limited resource settings, Innovation and health * Correspondence: [email protected] 1Médecins Sans Frontières (MSF), Geneva, Switzerland 2Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. El-Khatib et al. Conflict and Health (2018) 12:42 Page 2 of 11 Background Cameroon are covered by two Cameroonian operators. Since 1998, the World Health Organization (WHO) Re- Only a basic Global System for Mobile communication gional Office for Africa and Member States have adopted (GSM) telecommunication service is available. the Integrated Disease Surveillance and Response (IDSR) Health facilities in CAR are expected to submit disease strategy [1]. The Technical Guidelines to support this surveillance reports to the district health office accord- strategy emphasize the identification of priority diseases ing to the national protocol: diseases requiring immedi- using standardized case definitions, reporting mecha- ate notification (Alerts) within 24 h; a summary of all nisms, epidemiological data analysis and field investiga- notifiable diseases by 5:00 pm Wednesday each week. tion, outbreak response, communication and feedback [1]. Both reports are normally transmitted on standard paper Completeness and timeliness of disease reporting are es- forms, although some staff in the health facilities use sential attributes of an effective disease surveillance sys- their own mobile phones and telephone credit to do so. tem [1–3]. Yet, in low-resource settings it is challenging In 2013–14 CAR experienced a period of violent for health facilities to deliver paper-based surveillance re- conflict between religious and ethnic communities ports to national authorities in a timely manner [4, 5]. which compromised the health care system, including Smartphone applications (known as apps) have been the disease surveillance system as shown by changes developed to support data transmission between health in the level of completeness of disease reporting from facilities and district offices in a number of low-income 2011 to 2015 (Fig. 1). In some districts of the country, countries, including several in sub-Saharan Africa [2, 6, 7]. that conflict continues to the present day, while in Apps have the potential to improve surveillance [8, 9]and other districts, such as Mambéré-Kadéi (MK), tensions to hasten control of potential epidemics. To our know- persist, but only scattered episodes of violence have ledge, apps have been used to collect and transmit data on occurred. During the period of the PAP study (2015– a limited number of diseases [3, 5, 7]orinanemergency 2016), differences in the level of security within the context [10, 11] but not on a large portfolio of health con- district of MK due to religious violence and non-tar- ditions in a context of post-conflict insecurity. This report geted armed conflict were modest: higher in the more describes the implementation and evaluation of an app distant sub-districts of Gadzi and Amada Gaza (Euro- surveillance system for the notification of Alerts and pean Interagency Security Forum (EISF) risk level transmission of Weekly Reports on 20 conditions ‘medium’) and lower in those districts near to the dis- from 21 health facilities in the southwestern part of trict capital of Bérbérati (EISF risk level ‘low’)[12]. Central African Republic (CAR), in a pilot study enti- Shortly after the onset of the unrest, Médecins Sans tled “Projet d’Alerte Précoce” (PAP; Early Warning Frontières (MSF) deployed its mission in CAR and in Project, in French). 2015 the MOH and MSF explored how to support the disrupted national disease surveillance system. Due to Study context and objectives movement of displaced populations, there was considerable The district of Mambéré Kadéi (MK) is the second lar- risk of outbreaks of epidemic and vaccine-preventable dis- gest health district in CAR with an area of 30,203 km2 eases [13]. To accelerate data transmission and a public and estimated population of 460,000. For the purpose of health response, MOH and MSF proposed a pilot project this pilot study, the Ministry of Health (MOH) identified using an app reporting system in the district of MK. The 21 ‘sentinel’ health facilities (3 hospitals, 18 health main objectives were: 1) to improve the completeness and centers) as these were the principal facilities still func- timeliness of disease surveillance information reaching the tioning within the district and represented all seven district health office, and 2) to evaluate the use of the app sub-districts. Eleven of the health facilities were located to enhance data transmission between the health facilities in the sub-district of Berberati, two in each of the and the district health office. sub-districts of Gadzi, Gamboula and Amada Gaza, and one in each the sub-districts of Carnot, Dédé Makouba and Sosso Nakombo. The district health office, which in- Methods cludes the office of the Director of Surveillance, is lo- The software cated in the city of Berbérati. Travel time by car or The disease surveillance app, Argus, has been devel- motorcycle from the health facilities to the district oped and made available by the Support to National health office ranges from 25 min for the closest facility Surveillance team in the World Health Organization to 9 h for the most distant. Communities in the district (WHO) Office in Lyon, France [14]. Argus is an inte- are connected by earth roads but lack public systems of grated solution that comprises a smartphone app and water, sewer and electricity. Cellular network service in complementary laptop ‘server’ program that permits the district is provided by three telecommunications the reception, validation, analysis and presentation of operators, while villages located on the border with data in a dashboard format. El-Khatib et al. Conflict and Health (2018) 12:42 Page 3 of 11 Fig. 1 Overview of the Completeness (%)* of Weekly Reports at the District of Mambere-kadei during years 2011 through 2015 [28]. *According to WH0, the accepted cutoff point of completeness (%) is 80% [16]; w = week The Argus app performs three operations: i) Alert,to paper-based disease surveillance report forms in French provide an immediate notification