Using Webcam Connected Microscope to Improve Diagnostic Accuracy and Reduce Malaria Treatment Delay
Office of Diseases Prevention and Control # 10 Chiangmai

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
In 2012, there were 43 malarial deaths and approximately 25,000 reported cases of malaria in Thailand of which over 90 % occurred along the border areas. Mae-Hong-Son is a province situated in a mountainous range abutting Myanmar border. Cross-border movements occur due to economic and political insecurities; people from Myanmar migrate to Thailand seeking a better quality of life. These border crossings of local people and migrations result in increased malaria transmission, limiting public health efforts to control malaria along the border region. The annual incidence of malaria along this region is 32 times higher than the rest of Thailand. Population growth, human settlements in forested and forest-fringed areas, and socio-economic dynamics are driving forces that exert increased interconnectedness among the border populations. Annual income for a typical border resident is 35,000 Baht (1,085 USD) compared to a Thai national average of 150,000 Baht (4,650 USD). Distance from a pocket border village to the nearest malaria service unit can be 50 km requiring up to 7 hours of walking through mountainous forest terrain without access to public road. The situation is worse during the rainy season, the peak malaria season. The average cost for a malaria patient to get diagnoses and treatment at a district hospital is approximately 700 Baht (21 USD) (range 300 -1500 Baht (15 - 47 USD)). In addition, the treatment of P.faciparum, a resistance strain, has significantly increased (from 6 Baht (0.2 USD) to 217 Baht (6.7 USD)) and achieving a parasitological cure is problematic. The essential components of malaria control are accurate and timely diagnoses. Malaria clinics in Thailand are often located in remote, high–endemic malarial areas along the border. The clinics provide microscope diagnosis and treatment free of charge. A typical malaria clinic consists of 5 to 6 Trained-Field-Health-Workers (TFHWs). One TFHW stays at the malaria clinic while the rest travel to remote villages equipped with a natural light microscope, other necessary equipment, and antimalarial drugs. All the blood slides are examined in the field and sent to a malaria clinic every ten days or more depending on the distance. For more difficult cases, the TFHW may return to the clinic to consult with colleagues, before returning to the village to provide treatment. Although microscopy is the gold standard in malaria diagnosis, this technique has variable performance characteristics requiring a comprehensive, active quality assurance (QA) programme. The quality assurance programme includes routine randomized cross-checking of 10% negative and 100% positive blood slides submitted to the regional reference lab, every ten days for confirmation. In fiscal year 2011, misdiagnosis of malaria blood slides detected by cross-checking was 0.40 percent (47 misdiagnose from total 11,780), composed of 28 false-negatives, 7 false-positives and 12 incorrect parasite species. Although the accuracy is up to standard, the average time lag from the day the blood is examined to the day it is reported back to the sites is as long as 21 days. Inappropriate and delayed treatment can lead to drug resistant malaria and the spread of malaria.

B. Strategic Approach

 2. What was the solution?
Mae Hong Son is one of eight provinces in the responsibility of the Office of Diseases Prevention and Control #10 (ODPC). The key missions of ODPC10 are developing quality integrated health systems for basic, specialized, emergency medicines and surveillance; and developing health care system and mechanisms for public health care standards. Mae Sarieng district in Mae Hong Son has highest malaria incidents in Mae Hong Son province. In 2011, there were 503 malaria cases and 47,379 people were at risk of malaria (annual incidence rate 10.6 per 1,000). Of all misdiagnoses in the province, 78.8% of occurred in Mae Sarieng. Based on the mission of the ODPC 10, two main issues related to malaria are improving the quality control system and the performance of TFHWs to increase malaria diagnostic accuracy and reduce treatment delay. A more timely quality control was introduced by using a high-resolution Webcam Connected Microscope (WCM). The image quality of the WCM is high with a resolution of 1600 x1200 pixels. In the video mode, the frame rate is 30 fps. The resolution of a still image is 2 megapixels and can be enhanced up to 8 megapixels. WCM is equipped with a built-in microphone. WCM is an affordable (4,000 Baht or 124 USD) and user-friendly tool that provides high quality and simple software with a symbolic tool-set. The first application of WCM in increasing the accuracy of malaria microscope diagnosis is for live consultation of difficult cases (a dilemma situation). A WCM is installed on one eyepiece of a microscope and connected to a computer. The TFHW can then examine a blood film on the computer screen and the image of the blood film can be recorded as a still photo or video file. If a TFHW is uncertain about the diagnosis, the WCM will be activated and connect to the internet for online consultation with an expert microscopist at the reference laboratory. During the consultation, the blood film is viewed live online using team viewer, a free program. The average consultation time is about 30 – 40 minutes. The patient’s subsequent treatment is determined according to the consultation. The technique results in reducing the time needed to confirm the diagnosis, and dispense appropriate and prompt treatment without losing a patient due to the long delay between visits, known as “follow up loss”. The malaria patient also saves money and travel time, avoiding additional diagnoses and the possibility of receiving the wrong treatment. Furthermore the community and the health care system are saved from further spread of malarial infection. All the blood films that had been discussed online are re-examined again by an expert microscopist to ensure the diagnostic accuracy of WCM. The second application of WCM is in saving the video file of blood films during examination. The files are uploaded on the setting system by the end of each day. The next day an expert microscopist at a reference lab re-examines the video of blood film according to the system setting (10% negative and 100% positive). This can reduce the time used for confirming blood film from an average of 21 days in the traditional system to 24 hours in the new system. The misdiagnosed blood films are discussed in a live conference between TFHW and microscopist to reach a consensus. All the patients were followed up and received appropriate treatment within a day of reporting (the next day after visiting a malaria clinic). The rapid response eliminates the “follow up loss” problem. Currently OPDC 10 plans to provide WCM for all malaria clinics in the remote areas.

 3. How did the initiative solve the problem and improve people’s lives?
WCM is creative and innovative because it is the world’s first affordable real-time internet-based malaria diagnostic tool. WCM offers a high quality video and still image that requires no expensive and complicated equipment. With minimal training and experience users can use WCM correctly and effectively. Most importantly it eliminates the time lag between diagnosis and treatment that can lead to “follow up loss”, drug resistant malaria, and further spread of malaria among the population. Besides appropriate treatment, the real-time interactive discussion between the TFHW and the expert microscopist is a powerful, inspiring and low cost learning tool. The quick diagnosis and treatment also boosts confidence of the TFHW and the patients. Compared to commercial microscopic equipment designed for webcam, WCM is 25 times cheaper and can be built with locally available parts. The image quality of WCM is high comparable to the more expensive ones. WCM enables local malaria clinics in remote areas to provide appropriate treatment with minimal cost and without delay. Globally the WCM can be replicated with minimal cost in other resource-poor areas that have access to computer and internet. Finally, WCM can be modified and upgraded easily as technology improves.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The key strategies of WCM project involved the active participation of TFHWs, utilization of accessible and affordable communications equipment and technology, and existing infrastructure: malaria clinics and the internet. The chronology in developing WCM was started in 2009, when a team of key persons, that included TFHWs of Mae Sarieng Malaria clinic, and the expert microscopist from the reference laboratory in Chiang Mai, conducted a needs assestment for a better diagnostic tool. Past experince indicated that viewing different spots on the same blood film could lead TFHW in the field and the expert microscopist at the reference laboratory to interpret and diagnose a blood film differently. The team therefore explored a way for people in different locations to precisely review and discuss a blood film together in the same way. This led the team to review and compare costs and performances of existing digital microscopic cameras as well as a method to transmit a blood film to a different location for simultanous viewing and discussion with minimum cost and effort. Then, the expert microscospist surveyed, reviewed, acquired and tested various commercial webcams available domestically and internationally. Findings from the survey and testing served as a quality benchmark for the webcam-based diagnostic tool that the team set out to develop. In 2009 to 2010, based on the aforementioned survey of existing webcams, the expert microscopist and other colleagues at the reference laboratory designed and assembled an experimental WCM from locally available parts. Afterward the team from the reference laboratory conducted 2 field tests of the experimental WCM involving 5 malaria clinincs in Mae Hong Son province. During 2010 - 2011, the participating TFHWs pilot tested and evaluated the experimental WCM. The results of the pilot test were used by the development team at the reference laboratory to modify the first WCM. Field tests were then repeated to ensure that the reliability of the WCM was equal to direct examination of blood films under the microscope, and potential users were satisfied with the tool and method. The field TFHWs and the deveopment team discussed and agreed upon a new procedure for using WCM as well as a new monitoring and evaluation method. Between 2011 to 2012, the modified WCM was used in a malaria clinic in Mae Sarieng district. The TFHWs and the development team in Chiang Mai monitored and evaluated WCM by bimonthly teleconference calls and adhoc teleconference for difficult cases. At the end of each day, 10% of negative blood slides were randomly selected together with 100% of the positive blood slides, recorded as a video and sent to the reference lab. The next day, an expert microscopist rechecked all the recorded files and sent the results back to the TFHW in the malaria clinic in Mae Sarieng. If there was any disagreement, the blood films were put online for discussion to reach a consensus decision. The patients with erroneous results were followed up for an appropriated treatment. From September 2013, the team developed a scaled up plan to increase WCM use to 10 new sites in the province. The development team also developed a monitoring and evaluation plan for a blood slide bank using an online data base that can be monitored daily by the expert microscopist.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The stakeholders involved in the implementation are the TFHW who participated in the WCM design and in learning how to use the WCM and computer. The medical scientist at the reference laboratory created the WCM and set up the new system of quality control. Staff of the Center of Excellence for Biomedical and Public Heath Informatice – BIOPHICS), a non-governmental organization affiliated with Mahidol University, were responsible for developing computer software for WCM, instructions for WCM programme and online diagnosis. The Strategic Planning Committee and Executive Board Funding Committee of ODPC 10 allocated a part of the budget for implementation of initial WCM project. Last but not least, the Executive Board Committee of Department of Diseases Control (DDC), Ministry of Public health allocated the grand budget for implementation of WCM in all remote malaria clinics, 10 sites.
 6. How was the strategy implemented and what resources were mobilized?
The resources for this initiative were composed of startup costs for one site approximately 90,000 Baht (2,790 USD). These were composed of microscopes 60,000 Baht (1,860 USD), Computers 20,000 Baht (620 USD), WCM 4,000 Baht (124 USD) and miscellaneous 6,000 Baht (186 USD) e.g. blood film preparation set, stationery and waste disposal setup. In addition, the operating expenses are approximately composed of expenses for implementation, monitoring and evaluation of the initiative, THB. 60,000 (1,855 USD), partial salaries of 2 TFHWs involved in the initiative, 4,320 Baht per month (134 USD), partial salary of the expert microscopist = 3,000 Baht per month (93 USD), malaria clinic and office maintenance = 1,800 Baht per month (56 USD) and blood slide preparation = 5 Baht per patient (0.15 USD). The initial WCM project had one site at the malaria clinic in Mae Sarieng. The TFHW was trained in the use of the WCM and programme on-site during a visit of the team from the reference laboratory, for a cost of around 20,000 Baht (620 USD). The implementation of 10 sites is needed to save time and traveling budget. The expense for training was approximately 5,000 Baht per persons (155 USD), which was supported by DDC. Moreover, there are in-kind contributions from BIOPHICS (salaries for IT persons, internet access, computer programme development, and field monitoring and evaluation)

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The most successful of this project is the WCM which provides an affordable and reliable diagnosis tool and a modern system of quality control using internet technology. The image quality of the WCM is high with a resolution of 1600 x1200 pixels. In the video mode, the frame rate is 30 fps. The resolution of a still image is 2 megapixels and can be enhanced up to 8 megapixels. WCM is equipped with a built-in microphone. WCM is an affordable (4,000 Baht or 124 USD) and user-friendly tool that provides high quality and simple software with a symbolic tool-set. Therefore, TFHWs were satisfied and actively participate in the programme. The accuracy of malaria microscope diagnosis has increased from 98.6% in 2011 to 99.1% in 2012, to 99.5% in 2013. The time to confirm microscope malaria diagnosis was reduce from an average of 21 days to 24 hours, and for dilemma situations within 30 minutes. The other TFHWs in remote malaria clinics also wanted to join the project to support their work. At present, WCM has been implemented in all remote malaria clinics (10 sites with 70 TFHWs) in Mae Hong Son province. The TFHWs who use this tool have more confidence in reporting the result of malaria diagnosis by microscope. They also use WCM to exchange their experience and knowledge of malaria diagnosis via the social network (Facebook) with colleges. During 2011 to 2012 there were 24 dilemma situation consultations which resulted in all patients receiving the appropriate treatment following the consultation. The chances of the malaria parasite spreading to the community were reduced. Moreover, it is more economical for the patient due to improved accuracy in diagnosis and treatment, and the elimination of the expense of a lengthy follow up.

 8. What were the most successful outputs and why was the initiative effective?
Steps and systems for monitoring output and progress of the initiative began with field tests and structured questionnaires to evaluate performance of the WCM and the users’ satisfaction. The results of the questionnaires were compiled and analyzed by the development team at the reference laboratory. Then, modifications of the WCM and the operating computer programme were made according to the analysis of the field tests and questionnaires. Weekly scheduled teleconference calls between TFHWs and microscopist were set up for monitoring and supervision purposes. All blood films which had been in a consultation or teleconference on the weekly schedule were directly re-examined under microscopes to test the reliability of WCM. Annual field monitoring and supervision were included in the project at least once a year. Patient’s evaluation forms were recorded daily and analysed for treatment outcomes and service satisfaction. All patients’ data were kept confidential.

 9. What were the main obstacles encountered and how were they overcome?
The first obstacle of this project is internet system which sometimes fails due to bad weather. The solution is recording blood films in digital format and video files for later review and uploads when the internet signal returns. Secondly, the warm and humid climate can cause the lens of the WCM to become moldy. The instruction for microscope and WCM maintenance comes with ways to prevent this problem. In brief, when microscope and webcam is not in use, it should be kept in a box with desiccants or in a microscope cabinet that contains desiccants and electric lamps, and a daily record of temperature and humidity in the cabinet should be kept. Thirdly, in the areas with no electricity, installment of solar panel for power to run computer, internet modem, and WCM are necessary. ODPC 10 is exploring alternatives to mitigate this problem. Fourth, the attitude of TFHWs who had no direct experience with WCM was doubtful and unsure about diagnostic accuracy of the new method compared with the traditional method that they were trained and familiar with. More exposure to and experience with the new method (WCM) can solve this problem. Lastly, WCM is designed with future modification in mind. When computer technology and the quality of webcams improve, WCM can be modified accordingly. The instruction for WCM comes with the anticipation for future modification.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
In Mae Sareing, in 2012 – 2013, there were 48,069 people were at risk of malaria. The annual incidence rate per 1,000 was dramatically decreased from 7.2 in 2011 to 6.4 in 2012 and 4.8 in 2013. Occurrence of misdiagnoses is significantly reduced compare to the period prior to the implementation of the initiative. From 2011 to 2013, the accuracy of malaria diagnosis was dramatically increased from 98.6 in 2011, 99.1 in 2012 and 99.5 in 2013. The numbers of patients misdiagnosed were reduced from 37 in 2011 to 27 in 2012 and 17 in 2013. The length of time involved in the quality control system is drastically reduced from the average of 21 days (range 16 to 66 days) to 24 hours, and no loss of patient for appropriate treatment. TFHWs gain more experience and confidence in diagnosis and are better at retaining the patients in treatment. Better diagnosis and treatment and online discussion motivate TFHWs to improve their performance and boost their morale and teamwork. Fewer treatment failures, in turn, create a sense of fulfillment for those who are involved and inspire them to strive for better outcomes. Financial burden for malaria patients has been reduced due to quick diagnosis and appropriate treatment. The physical and psychological well-being and health of the patients and their families are also improved. Economic loss due to misdiagnosis that may be incurred by the patients and their families is substantially reduced. In the case of a misdiagnosis in a patient with severe symptoms, he/she must be admitted to a hospital. The cost of medical care at a hospital is approximately 6,500 Baht (202 USD). During 2012 -2013, there were 29 cases of false negative, which had been reported back within 24 hours. Therefore, these patients received the appropriate treatment from the malaria clinic without the cost of medical care at a hospital. The likelihood of malaria drug resistance cannot be verified at this time. But WCM will improve the effectiveness in monitoring and evaluation of the treatment of malaria patients in remote areas, which is important in detecting any drug resistance that might occur.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Since its introduction in Mae Sarieng, WCM has been transformed from a simple diagnosis tool to a multipurpose diagnosis and teaching tool. Due to the high resolution imagery, affordability, portability, and user friendliness of WCM, it has been used in many training courses. For example it was used in an international malaria training workshop conducted by the Department of Biochemistry, Faculty of Medicine, Chiang Mai University; in a study of antimalarial drug resistance by recording the image of parasite growth at different points of time in its incubation, for parasite diagnosis training at ODPC 10 in Chiang Mai; and for examination of chemical droplets at ODPC 7, Ubonratchathani province. WCM was also used for diagnosis training and research on drug resistant malaria at the Malaria Training Center, Bureau of Vector Borne Diseases, DDC, MoPH, and in the Department of Biochemistry, Faculty of Medicine, Chiang Mai University. These institutions use this device to record malaria images for research in drug resistant malaria. WCM was used in the training of visiting post-graduate students from University of Utah and University of New England. It was also used in a training course for malaria control officers and medical doctors from Africa supported by the JICA training program. In addition to malaria, WCM can also be used to diagnose other micro-organisms which may be diagnosed by microscope such as bacteria, parasites and worms in remote areas with similar circumstances and difficulties as in Mae Hong Son. Scaled up to the national level, this initiative is attainable with minimum cost in equipment and training. The possibility of a scale-up in neighboring countries is high due to affordable costs, minimal training, and low and easy maintenance. The first step for scale-up can be done by utilizing the twin cities cooperation scheme between Thailand and neighboring countries. The twin city cooperation between Thailand - Laos e.g., Chiang Rai and Bo Kaew, Thailand - Cambodia e.g. Sa Kaew and Ban Tia Min Joei, Thailand - Myanmar e.g Tak and Myaew Dee - can be included in this project.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
Lessons learned for this project include getting cooperation from the field TFHWs who must dedicate their time and effort to learn a new device and procedure, and to cooperate with the development team at the reference laboratory in Chiang Mai. It is also an opportunity for the TFHWs to increase their awareness of accuracy in diagnosis, which is also related to cost, timeliness and cure for the malaria patients. Sharing information with involved TFHWs was productive and increased confidence of TFHWs in the field. Wherever they are, they can communicate as if they were in the same location. This can strengthen relationships between experts who review and verify the diagnoses and the field officers in the area. It also strengthens teamwork and trust between team members. Good communication between the team and relevant persons reduces misunderstandings, prevents potential mistakes, and reduces waste and frustration. It establishes an alliance for mutual benefit between the TFHWs and the microscopist in ODPC 10. The deliberate process that involves the TFHWs and the patients empowers them in malaria treatment and in general health care. The WCM increases patients’ involvement in diagnoses and treatment plans. A patient can see the image of parasite in his/her blood slide and has a chance to ask questions from the case health officers. This is educational and more convincing than the traditional method. As a result, patients’ adherence to treatment improves which in turn leads to a better health care outcome and prevents drug resistant malaria and the further spread of malarial infection. WCM is a valuable teaching tool for on-the-job training through the online system. Online training is cost-effective and reduces trouble associated with travelling, which can be a great motivator for officers working in remote area. The online learning is also an effective mentoring tool between a specialist and the field TFHWs in remote locations. Trainee-friendly training can eventually make the malaria world smaller. Viewing the image of a blood film on a big screen is easier to the eyes and reduces fatigue, enabling the viewer to work better and longer. This is very beneficial for persons with advanced age, or people with poor eyesight, or TFHWs with a high workload. Last but not least, malaria patients were diagnosed quickly and accurately and this can lead to correct malaria treatment. Although it is too early to measure the effect on malaria reduction in such a short time, at least WCM has substantially increased the accuracy of malaria microscope diagnosis and establish an alliance of mutual benefit between the TFHWs and the microscopist. If just one malaria patient survives the disease, it is already worth the investment cost of this initiative.

Contact Information

Institution Name:   Office of Diseases Prevention and Control # 10 Chiangmai
Institution Type:   Government Agency  
Contact Person:   Wittaya Liewsaree
Title:   Directer  
Telephone/ Fax:   +(66) 53 221529
Institution's / Project's Website:  
Address:   47, Chiangmai-Lamphun Road., A.Muang
Postal Code:   50000
City:   Chiangmai

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