Step in Malaria Elimination: Using Handmade Webscope to improve malaria Diagnosis and access among a
The Office of Diseases Prevention and Control 1 Chiangmai

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Malaria, although preventable and treatable, is still the world’s deadliest mosquito-borne disease with 216 million cases and 655,000 deaths in 2010. Despite the progress of WHO Member States’ efforts to reduce the burden, the antimalarial drug resistance emerged in the Greater Mekong Sub-region and has posted a risk of spreading to other regions especially Sub-Saharan Africa, home to 90% of the disease. From 2008 to 2010, there were approximately 73,000 reported cases of malaria in Thailand. Over 90% occurred in the most at-risk population, i.e. pregnant women, children, undocumented migrants, and poor ethnic minorities living in hard-to-reach remote border areas. Mae-Hong-Son was one of the top ten highest malaria incidence provinces. The province is situated in a mountain range bordered to Myanmar with many hard-to-reach areas. The low household income status, frequent border crossings of local people and migrant workers, and limited public health services were the main obstacles to prevention of malaria deaths. Moreover, trade-off between a reduction of malaria incidence and decreased levels of naturally acquired immunity, in particular among young children, pregnant women, and non-immune visitors to malarious areas, was an increased risk for severe or fatal illness. Severe malaria usually developed 3-7 days after fever onset, and some non-immune patients died within 24 hours. In addition, the emergence of multidrug resistance of malaria parasites to current antimalarial treatments made case management more difficult. Most at-risk populations spent significant proportions of their income on direct and indirect costs of treatment. Cost associated with time off from work and transportation to seek treatment further reduced household income. Poor school performance due to malaria illness and absenteeism reduced children’s chances of escaping from poverty. Malaria thus locked people in poverty trap. Malaria microscopy, as recommended by the World Health Organization (WHO), has been a gold standard for malaria diagnosis since 1949 in Thailand. It has provided a great impact on malaria control program by decreasing the morbidity and mortality and thus saved a large number of people’s lives. The technique is also a key tool for tracking drug resistance emergence and will contribute to malaria elimination achievement. However, due to variable performance characteristics, blood smears require periodic quality assurance (QA) monitoring at the Regional Reference Laboratory. Every 10 days, blood slides are submitted to the Regional Laboratory for QA for confirmation of all positive slides and random cross-checking of 10 percent negative slides. Although, transportation in Thailand has become more convenient and faster, the average time for slides to be confirmed at the Regional Reference Laboratory and QA report results provided at the point of care can take up to 21 days (range 16 - 66 days). For some cases that are misdiagnosed, this delay can significantly affect treatment outcomes of malaria patients. Waiting even one or two days for treatment can mean life or death to a patient with malaria. Moreover, insufficient regular monitoring and refreshed training in malaria microscopic diagnosis, the malaria mortality rate remained constant or even steadily increased in some areas.

B. Strategic Approach

 2. What was the solution?
To address the problem of delayed quality assurance for microscopic diagnosis in rural remote areas, this initiative is an installation of low-cost innovative handmade webcam connected microscope (Webscope) to existing microscope to provide real-time expert’s feedback and training for laboratory technicians and clinicians to improve case management of malaria, and increase trust and the integrity in malaria quality control system. This initiative targets the poorest and most vulnerable people living in remote rural areas with limited access to health care, and ensures that they receive timely, quality-assured diagnosis and treatment for malaria. In order to ensure achievement of malaria elimination, the initiative has built enthusiastic participation of the initiative team, malaria experts, malaria field workers, stakeholders and network partners.

 3. How did the initiative solve the problem and improve people’s lives?
Microscope is the best existing tool for malaria diagnosis in all areas including in remote areas without electricity but solar cell is provided. Diagnosis with microscope has more advantages to the patient in identification of different malaria-causing parasites (P. falciparum, P. vivax, P. malariae and P. ovale), their various parasite stages, including gametocytes, and the quantification of parasite density to monitor response to treatment. To date, parasite resistance to antimalarials has been documented in three of the five malaria species known to affect humans, i.e. P. falciparum, P. vivax and P. malariae. Parasite resistance results in a delayed or incomplete clearance of parasites from the patient’s blood when the person is being treated with an antimalarial. The poorest and most vulnerable malaria patients who are not able to receive treatment in hospital would have severe symptoms and died. Moreover, only microscope can be used in field work for regular monitoring of drug resistance and enables the malaria control programme to change treatment guideline whenever essential. However, the most common error in diagnosis with microscope was human error due to insufficient knowledge, skills, motivation, and expert consultation. Inadequate manpower, budget and regular monitoring and refreshed training in malaria microscopic diagnosis were among the main causes of this problem. Nevertheless, Information Communications Technology (ICT) system has rapidly improved and allocated to cover the whole country and people can get access to low cost or even free services in most areas. Therefore, ICT system with malaria Webscope microscopic diagnosis is clearly the solution for critical diagnosis to prevent malaria death in the poor and most vulnerable people in remote areas. The goal of the project was to save lives of malaria patients in remote rural areas, by increasing the performance of malaria field workers in accuracy of malaria microscopic diagnosis and reducing time for blood slide confirmation. In the equivocal malaria case, a 30 – 40 minutes consultation about the blood film was viewed live online using team viewer free program. Afterward the patients were treated according to the consultation. The images of the blood slide were also used to encourage patients’ drug compliance and their return for follow up treatment. This will give the patients the best chance of full recovery and prevent the emergence of antimalarial drug resistance. The target groups of this initiative were classified into three groups. The first target group was health-workers who use Webscope for malaria diagnosis. The second target group was all malaria patients, Thais and Non-Thais, who received health services from health-workers. And to achieve malaria elimination, the third target group was the most at-risk people including the poorest and school children living in remote rural areas as well as non-immune visitors. The Project had five strategies aiming at harnessing innovation and stakeholder engagement to scale up community-based diagnostic testing and treatment for all malaria patients. The first strategy, provide a new Quality Assurance system using Information Communications Technology (QA-ICT system), through creating ownership and user-centered and participating design system which made the malaria field workers accept and actively participate in the project. The second strategy, transfer technology, by setting up a training course. The third strategy, build a unity team, by promoting camaraderie between checkers and field health-workers aiming to improve working harmony environment. The fourth strategy, implement regular monitoring and supervision via internet, to ensure that the tool and the system function accurately, precisely and perfectly. The fifth strategy, ensure transferability and sustainability, through model development to ensure that Webscope can be replicated for diagnosis of other diseases.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
Handmade Webscope is creative and innovative in that, to the best of our knowledge, it is the first affordable, real-time, internet-based malaria microscopic diagnosis equipment in remote areas. Webscope, a quality assembled camera equipment mounted onto an existing microscope, offers a high quality video and still images of blood slides that is user-friendly, low cost, simple and easy to use. With minimal training, malaria field workers can use it correctly and effectively. Most importantly it eliminates time lag between diagnosis and treatment as all from different places can view the same picture or image at the same time. It clearly reduces the risk of losing malaria patient and further spread of malaria parasites into a community. Besides appropriate treatment, real-time interactive discussion between malaria field workers and expert microscopist is a powerful inspiring and low cost learning tool. Quick diagnosis and treatment also boosts confidence of malaria field workers and patients. Compare to commercial microscopic equipment designed for microscope with the same quality of image, Webscope is 75 times cheaper and can be built with locally available parts. Globally the Webscope can be replicated with minimal cost in other resource-poor areas that can access to internet.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The Office of Disease Prevention and Control (ODPC) 1 Chiang Mai, is responsible for conducting research and creating innovative methods for effective prevention and control of diseases in eight provinces in Northern Thailand. Mae Hong Son is one of the eight provinces with the highest malaria incidence. Ninety percent of the province is mountainous forest lining from the north to the south of the province with a 483-kilometer long border to Myanmar with high movement of people across the border through out the year. People in this area are from different ethnics and origins including Thai natives, Tai people (Tai Yai), Chinese, Burmese, and 63 percent of the residents are hill tribes such as Mhong, Lisu, Lahu, Lua and Pagakayor. In 2012, there were 243,251 of them that were at risk to malaria. The annual malaria incidence rate was 6.12 per 1,000 population, ranked third of the country and was higher than 32 times of the country’s rate. According to the existing infrastructure, Vector Borne Disease Units (VBDU) are located in malarial endemic areas. Each VBDU has 5- 6 malaria workers. One of them provides care at malaria clinic (passive case detection) while the rest travel to remote villages with light microscopes and antimalarial drugs (active case detection). They prepare and examine blood slides in the village and treat infected patients immediately. Under this project, in situation when the diagnosis was equivocal for malaria infection, malaria worker return to the clinic to consult experts online and returned to the village to provide treatment if the slide was determined positive. Access to efficient and qualified diagnosis to be used as a basis to provide prompt antimalarial treatment will be a significant factor to prevent death of malaria patients and to control the spreading of disease in the community.
 6. How was the strategy implemented and what resources were mobilized?
The methodology was based on the “learning-by-doing” theoretical and practical principle. The basic of the process was technology transfer while increasing enthusiasm and the sense of ownership on the initiative and leadership in malaria elimination. The existing malaria control field infrastructure is composed of one VBDC in a provincial city and 10 VBDU in districts and sub-districts with 91 permanent staff. The main local partners are school, border patrol police and local administrative organization. In 2009, internet malaria online was starting in Mae Hong Son. At the same time, deep sorrow of one malaria death has urged ODPC 1 team an idea of using internet to reduce time of confirming blood slide, using ideal real time consultation 24 hours via internet. The initiative tool must be affordable to allow realistic deployment and use in the field units with easy replacement. The available commercial microscope camera is too expensive and too complicated for using in remote areas. Cheap and common use Webcam was selected and many models from different companies were tested for the quality of image with all malaria parasite species. A webcam with specifications offering a high quality image was identified, modified, then trialed and brought back to the reference lab for improvement. By late 2010, both malaria field workers and microscope experts were involved at the starting point of the initiative, selected and designed the tool including the system setting up, of which malaria field worker can easily learn and adopt. The webcam connected microscope (Webscope) was completed and then tested in 5 malaria clinics in comparison with a commercial camera microscope. The user survey was carried out after 8 months of trials, producing very high levels of satisfaction. The local malaria field worker strongly suggested using of the innovative “Webscope” as a tool for further work. However, there were some suggestions for modification of a connecting adaptor and of the extension cord that were accepted. Field trials were then repeated to ensure that reliability of the Webscope was equivalent to direct examination of blood films under the microscope. End users were very satisfied with the Webscope and the method. The malaria field workers and development team discussed and agreed new procedures for using the Webscope and new monitoring and evaluation method. From September 2011 till now the Webscope has been in use in all 10 Vector Borne Units in Mae Hong Son. The malaria workers and development team monitor it through bi-monthly teleconference calls and ad hoc teleconference for difficult cases. A the end of each day 10% of the negative blood slides and 100% of the positive slides are randomly selected, recorded as a video and sent to the reference lab. The next day an expert microscopist examines all of them and sends back the results to the health workers. In case of any disagreement, the relevant blood slide is put on screen online for discussion towards reaching a consensus. A patient with erroneous results is immediately followed up for appropriate treatment. In 2014 - 2016 the initiative was extended to another 84 malaria clinics in other remote parts of Thailand including 3 red zone provinces. The initiative had also been incorporated into the work plan of the Department of Disease Control for replication to use as diagnosis of intestinal parasitic infection for the most at risk population and students in schools in rural remote areas. Along with expansion of the initiative, Webscope was remodeled due to a variety of existing microscope model used in different areas. Monitoring and evaluation of implementation of the initiative in other parts of Thailand is ongoing.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
Webscope was developed by a technical team of the regional ODPC 1 laboratory, then tested for reliability, validation and refinement of all elements by malaria field workers with a technical support of Biomedical and Public Health Informatics (BIOPHICs), Mahidol University. Later, the Department of Diseases Control, Thailand MOPH funded the project for scaling up to cover all districts in Mae Hong Son province. Internet expenses were supported by Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). Malaria field workers mandated malaria case management in hard-to-reach areas. Local administrative organizations were a critical success component of this initiative with continuous support in budget and equipment such as solar cell, microscope. They also provided vehicles and gasoline for transportation and organization of Malaria Champaign, and played a major role in promoting community participation, At the opening of school semester, students including Thai and non-Thai, returned from their home mostly from high risk areas were tested for malaria using Webscope by malaria field workers and Border Patrol Police (BPP). The BPP acted in accordance with the Royal Program initiated by HRP Princess Sirindhorn in elimination of childhood malaria in the region. The BPP teacher educated children via Webscope and assisted health care providers to follow up students who were affected by malaria. Non-government Organizations (NGOs) coordinated and educated migrants and refugees for malaria prevention and collected and sent blood slides for malaria detection in suspected cases. Community leaders were volunteers in preparing community for active case detection identified risk person and filled cultural and communication gaps to ensure that people in the communities receive early diagnosis and actively participate in malaria elimination. Importantly, family cares were needed for treatment success due to completion of treatment and follow up.

 8. What were the most successful outputs and why was the initiative effective?
1) The main successful output of the initiative was the development of Webscope which was reliable, user-friendly, cost effective, and applicable in any endemic malaria and hard-to-reach areas. The malaria field workers were inhabitants in remote areas who had no opportunity to use technology before the initiative began. This initiative had created a novel mechanism with direct benefits to quality malaria management delivered to target population by increasing motivation and developing enthusiasm of malaria field workers, who played an important role in hard-to-reach areas. 2) The next successful output was development and engagement of stakeholders and partners at all levels so the existing resources were utilized effectively to support all activities reflecting accomplishments of the initiative implementation. Advantages of engagement also benefited a unique of insight specific malaria issues, built trust in informal and formal communications in target areas, and increased harmony environment of team work. 3) Community participation was an output from promotion and empowerment of community in order to help the initiative access to hard-to-reach population especially most at risk people such as the under 5 children, pregnant women, migrants, internally displaced people, daily cross-border workers, and the elderly. With this initiative, high quality of malaria diagnosis were delivered to these groups to promote equality in access to care and human rights. 4) This initiative was designed for health system strengthening especially competency of human resources through planned trainings and trainings without agenda. The objectives were accomplished perfectly during the project timeline. Knowledge management of lesson learned was reported to the national level to be used as evidence to policy decision making. Currently there are 94 Webscopes, scaling up from 10 at the beginning in Mae Hong Son since 2012, to other endemic provinces in Thailand. The National Malaria Elimination Plan in Thailand also has set up a work plan to implement Webscope in all health service units, including health care centers and hospitals in remote areas. The plan also incorporates application of its use for microscopic diagnosis of other diseases The Webscope innovation and engagement system targeted most at risk people who were central to the design and delivery of the services. All outputs of our initiative intensively responded to the United Nations Sustainable Development Goals (SDGs) in providing quality malaria management towards malaria elimination goal.

 9. What were the main obstacles encountered and how were they overcome?
Malaria field workers were initially not familiar with the new tool and accompanying system but the traditional method in which they were trained. Thus, they had to be incorporated into the development of the Webscope and its introduction to create a sense of ownership. Involvement, familiarization, knowledge, as well as a clear improvement in working system, had brought up their confidence. Closer and quicker collaboration with more supportive colleagues had greatly added value to the project. From the beginning, the potential of this proposed new approach was easy to be explained to colleagues. It offered a vital improvement that lives could be saved. This helped greatly to overcome reticence and win commitment. In some ethnic groups, culture ghost causing sickness is the most solid part of health education communication. Using Webscope as a tool to view their own blood has increase patient trust, confidence and acceptance in malaria field workers. The first model of Webscope, used in Mae Hong Son province, showed a high satisfaction of user. However, when it widely distributed to other regions of Thailand. a problem of fixing focus and diameter of eyepiece was found. Therefore, Webscope model 2 was developed based on the problem of variety in microscope model. The 2nd model of Webscope with focus adjustment using water pipe and rubble foam as a screw and diameter change to fix with the eyepiece of microscope. The new design of Webscope also helped protect the eyepiece of microscope from scratching. It also can be used with stereo-microscope for mosquito dissection and chemical droplet counting in the Dengue Control program in Thailand.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
The key benefit resulting from this initiative were lives being saved in rural remote areas. During 2013 – 2014, among the 24,314 people involved, 1,133 were malaria positive and received appropriate treatment within an hour. 100% of these patients completed drug compliance, and returned for drug monitoring. The length of time involved in the quality control system was drastically reduced from an average of 21 days (range 16 to 66 days) to 10 minutes, and no loss of patients for appropriate treatment. The number of malaria deaths had decreased to zero since 2014. The reduction of hospitalized patients was also noticeable and no severe malaria in Mae Hong Son since then. The poorest malaria patients thus saved money and returned to work, the children with malaria returned to school quicker than before. Therefore, the initiative strongly helped people escape from the malaria poverty trap. Testing malaria and health education during opening of school semester also resulted in early diagnosis, prompt treatment and prevent spreading malaria in schools. The numbers of students with malaria infection in Mae Hong Son province were reducing from 769 in 2012 to 243 cases in 2016. The knowledge sharing occurs daily among malaria field workers. They gained more experience and confidence in diagnosis and were better at retaining the patients in treatment. Better diagnosis and treatment and online discussion motivated malaria field workers to improve their performance and boosted their morale and teamwork. There were no treatment failures, in turn, created a sense of fulfillment for those who were involved and inspired them to strive for better outcomes. Overtime, the relationships among health-workers and between health-workers and malaria-checkers were strengthened and collaborative teamwork and trust improved. Furthermore, ghost causing sickness is a common cultural belief among some ethnic groups of hill tribes. Malaria is one of the diseases with chill symptom that people often think of spirit possessed persons. The initiative invited patients and relatives to involve in diagnosis by viewing their blood on computer monitor and listening to explanation of the difference between malaria infected red blood cell and non-infected red blood cell. It helped the malaria field workers to cope with misbelief that sickness came from ghost, and thus increased drug compliance and return for follow up. The user feedback forms revealed 99% satisfaction which was above the standard score (85%). This initiative can be easily replicated in any other parts of Thailand and other countries as well. In addition, it had been used for microscopic diagnosis of other diseases, e.g. intestinal parasites and tuberculosis. The tool definitely is promising to benefit the poorest and most vulnerable in remote areas. The impact indicators were annual malaria incidence per 1,000 mid-year population among Thais and non-Thais and refugees in camps, the mortality rate and cost effectiveness. All data was collected monthly, analyzed and used for planning and improving the system and expanding the project for other malaria clinics in rural remote areas with high incidence of malaria.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Most people, when got sick but the result turned out negative felt disappointed and did not trust malaria field workers. To build accountability on malaria testing, patients and relatives were made able to see their blood on slides through computer monitor screen in addition to the visual aids of malaria parasites posted at Malaria Clinics. If patient and relatives need a confirmation, online consultation with expert at the regional level can be performed immediately. Health education was delivered with visual aids in order to confirm the malaria testing declared by the field malaria workers. Therefore the initiative clearly offered improved integrity, accountability and satisfaction in health services at malaria clinics in remote areas, and reduced unnecessary anti-malarial drug use. Patients with negative result were advised and transferred to the nearest hospitals for investigation and treatment of other diseases. Prior to implementation of the initiative, there were argument between malaria field workers and expert microscopist due to low parasitemia and examination of different areas of blood film that had given different results. The initiative improved integrity and accountability on the quality control and cross-checking system as blood slides were viewed with the same pictures and at the same time. In addition, the experts had chance to give comments based on the image of blood slide viewing together with malaria field workers. This also helped improve blood slide preparation which was one of the first important step of malaria diagnosis. Last but not least, the initiative was developed for poor people in remote areas by using low cost handmade Webscope combined with the existing microscope. There was no steady need for budget to sustain the activities. The handmade Webscope was simple to build and the technology can be transferred to anyone including students in high school and women. There was no benefits to any business. Using of Webscope along with its quality control system can ensure compliance to the update version of national standard guideline on malaria diagnosis and treatment which was revised according to the international standards (WHO, regional technical committees). QA-ICT system enabled the productive interactive cross checking between the field malaria workers and checker (malaria microscope expert certified by WHO level 1 or 2). Currently, with the worldwide new communication channel through social media such as Line and Facebook, transparency of cross-checking report using image and/or video had increased.

 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)
Malaria is an infectious disease of the poor and vulnerable groups in hard-to-reach areas by geography, legal or social status. Among this group, pregnant women and children were the most at risk people which were prioritized to be 100% for all malaria active case detection activities. For example, at least 2 times a year at the beginning of school semester, all students, teachers and all school staff were provided with malaria health education and testing for malaria by Webscope. If malaria positive case was detected, Foci investigation was carried out immediately in target communities. Pregnant women and young children were the main targets for season active case detections using mass blood survey, 2 times a year. The services were also delivered to women who worked at night for picking forest products or stayed in poor condition in forestry areas. Community mobilization measure was also used to expand access to quality malaria management service in community with difference contexts and vulnerable groups. For example, undocumented group including women and children who stayed with fear of be arrested, were reached out to receive malaria services by community mobilization. This effort had resulted in equity of health care.

Contact Information

Institution Name:   The Office of Diseases Prevention and Control 1 Chiangmai
Institution Type:   Government Department  
Contact Person:   Wittaya Liewsaree
Title:   Director  
Telephone/ Fax:   +6653140773
Institution's / Project's Website:  
E-mail:   aung.saejeng@gmail.com  
Address:   447 Lamphun road,
Postal Code:   50000
City:   Muang
State/Province:   Chiangmai
Country:  

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