Introduction of Mobile Health Tools to Support Ebola Surveillance and Contact Tracing in Guinea

"An informatics system consisting of a mobile health application and business intelligence software was used for collecting and analyzing Ebola contact tracing data. This system offered potential to improve data access and quality to support evidence-based decision making for the Ebola response in Guinea. Implementation challenges included software limitations, technical literacy of users, coordination among partners, government capacity for data utilization, and data privacy concerns."

This article describes a real-time m-Health information collection system for contact tracing developed and deployed in 2014 during the Ebola epidemic that began in December of 2013. It was first deployed in Conakry, Guinea, and expanded to 5 prefectures by April 2015. The system is built upon a smartphone-based contact tracing system that is linked to analytics and data visualisation software. It uses the mobile application CommCare and business intelligence software Tableau and allows for: 

"(1) improved quality of work through built-in algorithms for contact tracers to follow; 

(2) realtime identification of contacts who have not been visited, allowing same-day intervention; and

(3) stronger accountability of contact tracers through time stamps and collection of GPS [global positioning system] points with their surveillance data."

Contact tracing is used in epidemic control to identify and monitor all people exposed to someone with a confirmed infection to miminise person-to-person transmission. Barriers to contact tracing were: the large numbers (4,000) of contacts, a high degree of mobility of individuals, and a resistance to tracing due to fear and stigma. Locally recruited and trained "contact tracers" visited each contact daily for 21 days to monitor for symptoms of Ebola. Monitoring of the work of tracers is done by supervisors doing random "spot checks".

The m-Health system was devised to provide a more direct and time-sensitive response than the paper-based reporting system. Open Data Kit (ODK)-based software CommCare was chosen for its longitudinal tracking function, its flexibility of reassignment of user informative, and the implementation team's familiarity with its algorithm-based decision support features. Local language instructions, protocols, and content were created in a multimedia context for Guinean use, and a training video was made. Dashboards were created for navigation. Goals were: to reduce time between data entry and data consumption and to strengthen work quality and data quality. Performance indicators were included to track the work of contact tracers.

The project required phones, solar chargers, solar panels, SIM cards, and data storage, as well as computers and modems to ensure regular access to data. There was a training of trainers and then training of supervisors and contact tracers. Tracers registered their current contacts and began uploading data under discrete usernames. By May of 2015, 210 contact tracers were monitoring 9,000 contacts.

Paper-based tracing was compared to CommCare tracing as validation of accuracy for specific time periods. Training on miscommunication, misunderstanding, misuse of phones, and errors in referencing were addressed with hardware changes, SIM card management protocols, and refresher trainings. Software refinements were accompanied by refresher trainings. Capacity building in data analysis for community health settings was needed for information officers to be deployed to local offices.

The researchers conclude that m-Health applications have demonstrated potential in Ebola contact tracing. Challenges include introducing technology in the midst of a complex emergency and accompanying deployment with close managerial oversight. They observed that "a strong information system... especially if embedded in a strong primary health care system... can not only serve to prevent emerging epidemics but also be adapted and leveraged for activities such as contact tracing in the event of a disease outbreak."