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?
Mekong region has been identified as an area of major threat in the global fight to contain malaria. In 2012, there were over 25,000 reported cases of malaria in Thailand of which over 90 % occurred along the Mekong region of Thai-Myanmar border. Mae-Hong-Son is a province situated in a mountainous range abutting Myanmar border. Mae Sarieng district in Mae Hong Son has the highest malaria rate in Mae Hong Son province, an annual incidence rate 10.6 per 1,000). . Population growth, human settlements in forested and forest-fringed areas, and socio-political and economic dynamics are driving forces that exert increased interconnectedness among the border populations. Border crossings of local people and migrations of workers result in increased malaria transmission, limiting public health efforts to control malaria along the border region. Annual income for a typical border resident is 1,085 USD compared to a Thai national average of 4,650 USD. Distance from a pocket border village to a nearest malaria 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. Essential components of malaria control include accurate and timely diagnoses. Malaria clinics in Thailand are often located in remote, malarial endemic areas. A typical malaria unit consists of 5- 6. Field-Health-Workers (FHWs). One FHW provides care at the malaria clinic while the rest travel to remote villages equipped with light microscopes and antimalarial drugs. FHWs prepare blood slides, examined them in the field and treat infected patients immediately. Brought back to the FHW bring back all the blood slides to the malaria clinic every ten days. In situation when a blood slide is equivocal for malaria infection, the FHW will return to the clinic to consult with colleagues and return to the village to provide treatment if the slide was deemed positive. Microscopic evaluation of blood smear is currently the gold standard in malaria diagnosis. Due to variable performance characteristics, the blood smears require periodic quality assurance (QA) monitoring at the Regional Reference Lab. Blood slides submitted to the Regional Labs are evaluated every 10 days for confirmation. The QA activities involves random cross-checking of 10 percent of all slides tested negative and a hundred percent of all slides tested positive in the field by FHWs. In 2011, misdiagnosis of malaria detected by cross-checking was 47 cases, which composed of 28 false-negatives form 10,533 negative cases , 7 false-positives and 12 incorrect parasite species from 1,227 positive cases. Seventy-eight percent of misdiagnosis for malaria occurred in Mae Sarieng. Although the accuracy is up to standard, the average time lag from the day the blood slide was obtained to the day it is reported back to the malaria units is 21 days (range 16-66 days). Inappropriate and delayed treatment may contribute to drug resistance increasing the spread of malaria. Therefore, we developed and initiated webcam connected microscopes to improve accuracy of malaria diagnoses and to reduce treatment delays.

B. Strategic Approach

 2. What was the solution?
Mae Hong Son is one of eight provinces under the jurisdiction 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. Based on the mission of the ODPC 10, two main issues related to malaria are: 1) to increase malaria diagnostic accuracy; and 2) to reduce malaria treatment delay by improving the Malaria QA system and training of FHWs. 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 is to enable real-time microscopic consultation of difficult or equivocal diagnostic cases. A WCM is installed on one eyepiece of a microscope and connected to a computer. The TFHW can examine a blood film on the computer screen and the image of the blood film can be recorded as a still photo or a video file. When a TFHW is uncertain about a diagnosis, the WCM will be activated and connected to the internet for online consultation with an expert microscopist at the reference laboratory. During the consultation, the blood film is viewed live online by connecting images from the microscope to a computer using the team viewer program. Due to instantaneous nature of the consultation, treatment plan can be initiated at point of care minimizing loss of follow up. The malaria patient also saves money and travel time, avoiding additional misdiagnosis 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 diagnostic accuracy. The second application of WCM is to save video files of blood films. The files are uploaded onto a centralized computer system at the end of each day. A microscopist at a reference laboratory re-examines the videos of blood films in accordance with established malaria QA protocol (e.g. 10% negative and 100% positive). Initiation of WCM project reduced the time used for confirming blood film from an average of 21 days before implementation to less than 24 hours after implementation. Patients were followed up and received appropriate treatment within a day of reporting. 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 in that, to the best of our knowledge, it is the first affordable, real-time, internet-based malaria diagnostic tool. WCM offers a high quality video and still images of blood slides that is inexpensive, simple, easy to use and assembled camera equipment mounted onto an existing microscope. With minimal training, TFHW can use WCM correctly and effectively. Most importantly, it reduces 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 optimizing malaria diagnosis and treatment, real-time interactive discussions between the FHWs and the microscopists at the reference lab promote communication increasing positive learning experience as well as, boosting confidence among FHWs. 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 comparable to the more expensive microscopes. 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 similar resource-poor areas. 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: 1) WCM development appropriate for use in the field; 2) active participation and training of FHWs, and 3) 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 FHWs of Mae Sarieng Malaria clinic, and the expert microscopist from the reference laboratory in Chiang Mai, conducted a needs assessment for a better diagnostic tool. Past experince indicated that viewing different spots on the same blood film could lead FHW in the field and the expert microscopist at the reference laboratory to interpret and diagnose a blood film differently. The team explored a way for people in different locations to precisely view and discuss a blood film together simultaneously. 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 microscospist surveyed, reviewed, acquired and pilot tested several commercial webcams. 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 experimentalWCM from locally available parts. Afterward the team from the reference laboratory conducted 2 field tests of the experimental WCM at 5 malaria clinincs in Mae Hong Son province for 8 months During 2010 - 2011, the participating FHWs pilot tested and evaluated the experimental WCM. Results of the pilot indicated that FHWs were satified with the image of blood film WCM just some slightly modify of an adapter to fix with eyepice of microscope and the extension cord. 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 FHWs and the deveopment teamdiscussed and agreed upon a new procedure for using WCM as well as a new monitoring and evaluation method. From September 2011 until present, the modified WCMwas used in a malaria clinic in Mae Sarieng district. The FHWs 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 avideo and sent to thereference lab. The next day, an expert microscopistrechecked all the recorded files and sent the results back to the FHW 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 developnent team also developeda 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 FHWs 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 (70 FHWs).
 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 FHWs 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 programmeon-site during a visit of the team from the reference laboratory, for a cost of around 20,000 Baht (620 USD). This cost compose of per diem and accommodation for 3 staffs, gasoline and materials include WCM and document printing. The implementation of 10 sites is needed to save time and traveling budget. The expense for training was approximately 9,000 Baht per persons (278 USD), which was supported by DDC. This cost included per diem, accommodation local transportation, gasoline and materials include WCM and document printing. 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 aspect of this project is FHWs were satisfied with WCM and actively participated in the program. The WCM 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 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. In addition, 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 has reduced from an average of 21 days to 24 hours, and for dilemma situations within 30 minutes. During 2011 and 2012 there were 24 dilemma situation consultations, which resulted in all patients receiving the appropriate treatment following the consultation. These results in reduction the chances of the malaria parasite spreading to the community. Furthermore, the FHWs who use this tool have more confidence in reporting the results 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. The other FHWs 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 (ten sites with 70 FHWs join the program) in Mae Hong Son province. Lastly, WCM is now distributed for using in many microscope diagnosis laboratories; these included Chiangmai University, the Training Center at Prabudabaht Saraburi, the office of diseases prevention and control region 7, the vector borne diseases center and private laboratory sector. The feedback satisfaction form the users were 95% which is above the standard (85%).

 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 program were made according to the analysis of the field tests and questionnaires. Work manual and data collecting forms for new system of quality control via WCM also developed by the team which compose of microscopists and FHWs to ensure it is understood able for the users (microscopist and FHWs). The data forms include the general information of patient, the result of diagnosis, the problems of using WCM and the satisfaction of patient relevant to WCM and the service. Additionally, to monitoring the implementation of the strategy weekly scheduled teleconference calls between FHWs and microscopist were set up and recorded. 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. The annual field monitoring and supervision were included in the project at least once a year. The work manual for monitoring and supervision were developed and use as a tool for data collecting. All data is monthly collected and analyzed and used for planning and improving the system to expand the project for the other malaria clinics in remote areas which have a high malaria incidence.

 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 causethe 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 FHWs 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. The compartments of WCM are general materials, cheap and easy to find.

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 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 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. The numbers of malaria cases in Mae Sareng were reduce from 503 in 2011 to 386 in 2013. Although this outcome cannot be achieved through only one intervention, WCM, the number of patient visited malaria clinic were increase from 1,581 cases in 2011 to 2,632 cases. Additionally the proportion of malaria positive case detection at malaria clinic also increased from 0.43 in 2011 to 0.53 in 2013 compare to hospital. The patients’ satisfaction of the services at malaria clinic from data survey was 98% which are above standard. FHWs gain more experience and confidence in diagnosis and are better at retaining the patients in treatment. Better diagnosis and treatment and online discussion motivate FHWs 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. In addition, the patients who come to the malaria clinic with WCM were not only receive diagnosis and treatment from FHW but also can receive directly from microscopist and also medical doctor at ODPC 10 in Chiangmai. It is no doubt that the WCM project has increase the equity of access to health service by a professional health care of people in remote area. Sharing information and consultation among FHWs and microscopist contributed to FHWs’ productivity boosting their confidence. Overtime, the relationships among FHWs and between FHWs and microscopists were strengthened improving collaborative teamwork and trust. The deliberate process that involves the FHWs in the decision making process empowers them increasing their confidence in in provision of health care. The WCM also increases patients’ involvement in their malaria diagnoses and treatment plans. WCM enabled individual patient to see images of parasites on blood slides, providing opportunity for patient education and treatment instructions. 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. 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 diagnostic tool for malaria to a multipurpose diagnostic and teaching tool. Due to WCM’s high resolution imagery, affordability, portability, and user friendliness, it is currently being used in several training courses domestically and internationally. For example, WCM was used in an international malaria training workshop conducted by the Department of Biochemistry, Faculty of Medicine, Chiang Mai University. In addition, a study of antimalarial drug resistance at ODPC10 in Chiang Mai employed WCM to record images of parasite growth at different incubation period. At ODPC7, Ubonratchathani province, WCM was used to examine size of insecticide droplets. 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. WCM was used in the training of post-graduate students from University of Utah and University of New England. It was also used in an international course on malaria prevention and control officers and medical doctors from South East Asia and Africa supported by the Japan International Cooperation Agency (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 under similar circumstances and difficulties as in Mae Hong Son. Scaled up of this initiative to national level is attainable with minimum cost in equipment and training. Transferability of WCM to neighboring countries is high due to its affordability, minimal training requirements, and ease of maintenance.

 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 include the importance of first obtaining initial buy-ins from FHWs prior to implementation of the project. Cooperation from the FHWs was necessary since they are required to give additional training time to learn a new device and to follow appropriate operating and maintenance procedures. Through encouragement and positive feedback with positive outcomes of patients due to timely and accurate malaria diagnoses, FHWs learn to consult on-line, exchanged ideas and problem solve with colleagues at reference lab and. Timely and on-going communications between field FHWs and FHWs at their respective Malaria Units as well as colleagues at the reference laboratory in Chiang Mai are crucial to the success of the project. 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 FHWs in remote locations. Trainee-friendly training can eventually make the malaria world smaller. In contract to above, it is time-consuming and labor to produce the WCM in a massive number for distribute or implement world-wide, as it is still hand made. Therefore, collaboration with an institute or manufactory where can produce WCM according to the model or better should be included in the program. At present, we are at the initiating of collaborating with Chiangmai Technical College. The student use leisure time for making WCM and get benefit not only payment but also skill for future work related to their education. Additionally, at the beginning of this project patients were not involved in the project only FHW. The time that use for conference in a dilemma of positive or negative result, patients have to wait for longer and they may not be satisfied. Therefore, our team realize and solve this problem by inform the patient and ask them to participate. However, monitoring and evaluation of drug adherence in malaria patient due to WCM project has not yet been done. It is in our plan for the next step in 2014 that we obtain budget from Department of Diseases Prevention and Control for all malaria patient and Global Fund for P.vivax patient, which have to take medicine for 14 days. 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 FHWs 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:   Director of ODPC  
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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