Questions/Answers

In 2013, the MoPH disease surveillance system continued to fail to prevent the spread of diseases, causing a nationwide epidemic spread of Dengue hemorrhagic fevers resulting in 154,444 infected and 136 deaths. After discovering that only 55.17% of the 88 hospitals in the 8th region utilized computerized data to track the spread of communicable diseases within the region and that only 56.32% were able to provide punctual reports on the onset of diseases, it was decided that changes were desperately needed. The objectives of the research, therefore, were to: 1. Observe region 8’s existing methodology and system for the surveillance and investigation of communicable diseases; 2. Design and implement a system for the surveillance and investigation of communicable diseases that would utilize modern technologies, methodologies and mindsets, to be implemented on a district level, to improve region 8’s ability to detect, investigate and control the onset of diseases within the region with greater efficiency; 3. Evaluate the performance of the new system by analyzing its ability to control the spread of Dengue Fevers and Diarrhea; and if proven successful 4. Expand the implementation of the new system to manage and control other health issues within the region.

The ability to control the spread of diseases and other health issues within a region via modern technologies would contribute significantly to the wellbeing of the people within the region. The use of mobile technologies would allow for real-time detection of onsets of diseases, allowing health services to stage interventions and significantly reduce the numbers of the afflicted. Furthermore, the accumulated data can be used to: identify additional risk factors; formulate evaluative factors to further improve upon existing system; and encourage communal participation in the control and prevention of diseases which would result in a healthier, more equitable society.

As Dengue hemorrhagic fever, Diarrhea and pneumonia are the preeminent cause of death for newborns and children under the age of 5 in Thailand, the ability to monitor and control the spread of diseases would enable health services to significantly decrease the mortality rates of newborns and children, further strengthening the management of health risks per indicator 3.2 and 3d. Furthermore, the expansion of the system to address other health issues have allowed the region to manage and limit the number of deaths caused by traffic accidents and non-communicable diseases, aligning with indicators 3.4 and 4.6.

Thailand is constantly plagued by Dengue hemorrhagic fever epidemics. 2013 saw 154,369 people afflicted, resulting in 133 deaths. Worse still, 2015 saw 142,925 afflicted and 141 deaths. Food poisoning and diarrhea is also a major cause of death for the children and elderlies of Thailand. Complications caused by stroke and Ischemic Heart disease resulting in hospitalization and death are also common occurrences within the populace. And as if death by preventable diseases are not enough, Thailand is one of the world leaders in the numbers of population death caused by traffic accidents. In 2013 the populace of region 8 was amongst the highest in the country in the affliction of food poisoning and diarrhea, it saw 10,642 afflicted with Dengue hemorrhagic fever, resulting in 14 deaths. Yet it had consistently been and continued to be allocated the lowest amount of human resources and funding out of all the regions. Therefore, primary prevention of diseases and injuries is vital to the wellbeing of the people, as the region does not have the necessary amount of resources to care for the infirmed to the same standard as other regions for the same number of patients. The new system was direly needed.

The new system implemented by region 8, pursuant to this research, shifted from a report-based system to a real-time system, instantaneously relaying information on potential sources of health risks or onset of epidemics to all relevant parties. This enables expeditious deployments of Surveillance Rapid Response Team (SRRT), composed of local health volunteers, to investigate and eradicate all risks within a span of hours. The move to modern technology meant that all reporting can be done via smartphones and photographic evidence and GPS can be used to pinpoint locations and to confirm the deployment of the SRRT.

The new system is based on the 506 electronic investigation surveillance system proposed by the Ministry of Health, which is severely limited. It can only be implemented in District level hospitals and, in practice, required at least 15 days to report onset of diseases discounting the additional time to analyze the report to decide on further actions. Furthermore, on top of being a report-based system, that is hospital-focused instead of contributing to a centralized database, it is also a passive surveillance system, requiring people to be infirmed before it could take action, which would have been too late.

At first, the objective of the new system and the studies surrounding it was to manage and control the spread of communicable diseases in region 8. But the system has been successfully expanded to monitor and address other forms of health risks, such as traffic accidents. Currently, in Nakhon Phnom the system is being used to effectively monitor and control individuals with high risk of suicide, a result to be replicate in other provinces. At the behest of region 10, region 8 have provided support, expertise and training of personnel to implement the new system in the region.

In 2014, the research studies and the creation of the new system was financed by leftover funds from region 8’s Inspector-general travel expenses. Through the combined effort and dedication of the research team from Mahidol University, the IT team from every hospital in the region and the public authorities of every provinces that the system which utilizes single page application that can be utilized on desktops, tablets, IOS, Android or any devices capable of using the web browser was created. Meaning that the system can be run using preexisting hardware and personal devices, requiring little to no investments.

The new disease surveillance system can be run using preexisting hardware and personal devices, including but not limited to, personal mobile phones and hospital computers, while the database is run from the regional server, requiring little to no additional investments to implement the system. The system continued to evolve through the works of programmers from the University’s research team and from the IT departments of the region’s hospital. These programmers can continuously adapt the system to respond to changing needs in the constantly changing health climate. The system is designed to directly access information from each hospital’s information system to display the status of the region on a shared dashboard, accessible by all relevant actors and capable of separately displaying results based on geographical areas, at a provincial or district level, motivating decisionmakers, responsible for different areas, to strive to improve as they faces regular comparison against the efforts of their peers. The success of the system at managing a certain health risk means additional opportunities for new additions to be made so that it can then address other social issues. Long term effort to streamline the utility of the system by moving it onto the Cloud have been made.

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The bureau of epidemiology, in the Department of Disease Control provide weekly comparative regional situation reports on the affliction and death caused by Dengue hemorrhagic fever, and annual reports for non-communicable diseases and traffic accidents. Using these reports, region 8 can monitor the impact and effectiveness of the implementation of the new system by comparing the growth or decline in the numbers of those who were afflicted or died to other regions as well as internally, between the 7 different provinces of region 8.

Indicators for regional comparisons (calculate at the rate per 100,000 capita) measures the rate of affliction and death caused by • Dengue hemorrhagic fever; • Traffic related accidents; • Stroke; and • Ischemic heart diseases. Indicators for comparison between provinces within the region measures the average time taken • To report onset of the disease into the system from the moment the afflicted entered health service; • To deploy the SRRT from the moment the onset of the disease was reported; and • To report the completion of disease investigation and control into the system from the moment that SRRT was deployed.

After the new disease monitoring system was implemented, region 8 enjoyed a gradual and consistent rise in the health of its populace. In 2013 it was the region with the highest rate of affliction and death by food poisoning and diarrhea, then by 2017 it was lowest. From 2014 onward, the region has consistently ranked the lowest in the rate of affliction and death caused by Dengue hemorrhagic fever, traffic related accidents, stroke and ischemic heart diseases and was the only region with no death in 2015 from the Dengue hemorrhagic fever epidemic that killed 141 people across the country.

Members of the SRRT are drawn from the community on a voluntary basis to contribute to the investigation and elimination of diseases and issues from their own neighbourhood and actively participate in improving the health climate of the region. On a district level, networks were created to organize and educate members of the SRRT, providing them with basic operational knowledge of the system through local officials and dividing the members into different groups each with their own jurisdictions and responsibilities. In areas impaired with health issue(s) that are markedly different from the norms, regional or district health assemblies will be formed, comprising of administrative officers, educators, police officers, village headmen, local administrations, private organizations and volunteers. This health assembly would formulate a network of shared information and mutual investigations aimed at controlling or eradicating the health issue(s) using the records of the new system as the conduit for information sharing, incidence management and to stage interventions.

• The scope of an innovation should be limited by availability of resources and undertaken with the intent to analyse issues and fill the gaps. Using available resources effectively is key. • Development of information systems require a dedicate team. On their own, facilities have limited human resources, as a region there is more than enough, ‘One region, one hospital’. • Innovation must not increase, but eases workload. • Modern systems must be created on universal platforms that work on all devices. • Stakeholders involvement is the most important factor in diseases control. The system can merely monitor and analyse.