Cutaneous leishmaniasis among Syrian refugees in Jordan.

INTRODUCTION: Old World cutaneous leishmaniasis (CL) is one of the most prevalent vector-borne diseases within the World Health Organization's Eastern Mediterranean Region. The conflict in the Syrian Arab Republic generated large population movements and raised concerns about spreading of CL to countries where Syrians have relocated, including Jordan. METHODS: A review of electronic and paper-based registries of CL cases in Jordan was conducted to assess burden of disease and associated socio-demographic factors. RESULTS: Increasing numbers of CL cases have been reported in Jordan between 2010 and 2016 (from 140 to 281), paralleled by significant increases in incidence rate (from 2.09 per 100 000 person-years, 95% CI (1.77-2.47), to 2.87 per 100 000 person-year, 95% CI (2.55-3.22), p = 0.002) and in the proportion of cases who are Syrian (from 8.6%-55.2%, p < 0.001). Syrian refugees have higher odds of presenting with leishmaniasis than Jordanian nationals (adjusted OR 7.1, 95% CI (6.3-8.0), p = 0.000). CONCLUSIONS: Presence of large numbers of Syrian refugees within Jordan has so far not contributed to increased risk of developing CL for Jordanians, however surveillance, diagnosis and case management for CL should be reinforced to meet the increased burden. Electronic surveillance can help identify priority populations and areas for interventions.

Perceptions of use of a case-based, integrated national electronic public health surveillance system in Jordan.

Collection of real-time, standardized data remains a challenge for public health surveillance systems. The use of mobile information technology may facilitate this. A national case-based public health surveillance system was introduced in Jordan in 2015 using mobile tablets and an online framework. After training on the system, users were surveyed about their perceptions of it. Of 596 participants attending the training, 580 (97.3%) completed the survey. The majority of users were nurses (58.5%). Overall perceptions of the system were highly positive across 5 areas of functionality (standardized case definitions, clinical guidance on signs and symptoms, risk factors and laboratory guidance, SMS and Email alerts for notifiable diseases, one-hour reporting of information via an online framework). In all areas, over 80% of participants thought the system would help their work and would save time in identifying notifiable diseases and reporting this information centrally. Further work is encouraged to evaluate the system and consider the application of cloud-based models in other settings.

Design and implementation of a national public health surveillance system in Jordan.

Understanding and improving the health status of communities depend on effective public health surveillance. Adoption of new technologies, standardised case definitions and clinical guidelines for accurate diagnosis, and access to timely and reliable data, remains a challenge for public health surveillance systems however and existing public health surveillance systems are often fragmented, disease specific, inconsistent and of poor quality. We describe the application of an enterprise architecture approach to the design, planning and implementation of a national public health surveillance system in Jordan. This enabled a well planned and collaboratively supported system to be built and implemented using consistent standards for data collection, management, reporting and use. The system is case-based and integrated and employs mobile information technology to aid collection of real-time, standardised data to inform and improve decision-making at different levels of the health system.

Implementation of a Cloud-Based Electronic Medical Record to Reduce Gaps in the HIV Treatment Continuum in Rural Kenya.

BACKGROUND: Electronic medical record (EMR) systems are increasingly being adopted to support the delivery of health care in developing countries and their implementation can help to strengthen pathways of care and close gaps in the HIV treatment cascade by improving access to and use of data to inform clinical and public health decision-making. METHODS: This study implemented a novel cloud-based electronic medical record system in an HIV outpatient setting in Western Kenya and evaluated its impact on reducing gaps in the HIV treatment continuum including missing data and patient eligibility for ART. The impact of the system was assessed using a two-sample test of proportions pre- and post-implementation of EMR-based data verification and clinical decision support. RESULTS: Significant improvements in data quality and provision of clinical care were recorded through implementation of the EMR system, helping to ensure patients who are eligible for HIV treatment receive it early. A total of 2,169 and 764 patient records had missing data pre-implementation and post-implementation of EMR-based data verification and clinical decision support respectively. A total of 1,346 patients were eligible for ART, but not yet started on ART, pre-implementation compared to 270 patients pre-implementation. CONCLUSION: EMR-based data verification and clinical decision support can reduce gaps in HIV care, including missing data and eligibility for ART. A cloud-based model of EMR implementation removes the need for local clinic infrastructure and has the potential to enhance data sharing at different levels of health care to inform clinical and public health decision-making. A number of issues, including data management and patient confidentiality, must be considered but significant improvements in data quality and provision of clinical care are recorded through implementation of this EMR model.

Use of Mobile Information Technology during Planning, Implementation and Evaluation of a Polio Campaign in South Sudan.

BACKGROUND: Use of mobile information technology may aid collection of real-time, standardised data to inform and improve decision-making for polio programming and response. We utilised Android-based smartphones to collect data electronically from more than 8,000 households during a national round of polio immunisation in South Sudan. The results of the household surveys are presented here, together with discussion of the application of mobile information technology for polio campaign planning, implementation and evaluation in a real-time setting. METHODS: Electronic questionnaires were programmed onto Android-based smartphones for mapping, supervision and survey activities during a national round of polio immunisation. National census data were used to determine the sampling frame for each activity and select the payam (district). Individual supervisors, in consultation with the local district health team, selected villages and households within each payam. Data visualisation tools were utilised for analysis and reporting. RESULTS: Implementation of mobile information technology and local management was feasible during a national round of polio immunisation in South Sudan. Red Cross visits during the polio campaign were equitable according to household wealth index and households who received a Red Cross visit had significantly higher odds of being aware of the polio campaign than those who did not. Nearly 95% of children under five were reported to have received polio immunisation (according to maternal recall) during the immunisation round, which varied by state, county and payam. A total of 11 payams surveyed were identified with less than 90% reported immunisation coverage and the least poor households had significantly higher odds of being vaccinated than the most poor. More than 95% of households were aware of the immunisation round and households had significantly higher odds of being vaccinated if they had prior awareness of the campaign taking place. CONCLUSION: Pre-campaign community education and household awareness of polio is important to increase campaign participation and subsequent immunisation coverage in South Sudan. More emphasis should be placed on ensuring immunisation is equitable according to geographic area and household socio-economic index in future rounds. We demonstrate the utility of mobile information technology for household mapping, supervision and survey activities during a national round of polio immunisation and encourage future studies to compare the effectiveness of electronic data collection and its application in polio planning and programming.

Implementation of a cloud-based electronic medical record for maternal and child health in rural Kenya.

BACKGROUND: Complete and timely health information is essential to inform public health decision-making for maternal and child health, but is often lacking in resource-constrained settings. Electronic medical record (EMR) systems are increasingly being adopted to support the delivery of health care, and are particularly amenable to maternal and child health services. An EMR system could enable the mother and child to be tracked and monitored throughout maternity shared care, improve quality and completeness of data collected and enhance sharing of health information between outpatient clinic and the hospital, and between clinical and public health services to inform decision-making. METHODS: This study implemented a novel cloud-based electronic medical record system in a maternal and child health outpatient setting in Western Kenya between April and June 2013 and evaluated its impact on improving completeness of data collected by clinical and public health services. The impact of the system was assessed using a two-sample test of proportions pre- and post-implementation of EMR-based data verification. RESULTS: Significant improvements in completeness of the antenatal record were recorded through implementation of EMR-based data verification. A difference of 42.9% in missing data (including screening for hypertension, tuberculosis, malaria, HIV status or ART status of HIV positive women) was recorded pre- and post-implementation. Despite significant impact of EMR-based data verification on data completeness, overall screening rates in antenatal care were low. CONCLUSION: This study has shown that EMR-based data verification can improve the completeness of data collected in the patient record for maternal and child health. A number of issues, including data management and patient confidentiality, must be considered but significant improvements in data quality are recorded through implementation of this EMR model.

Stage of HIV presentation at initial clinic visit following a community-based HIV testing campaign in rural Kenya.

BACKGROUND: The Kenyan Ministry of Health and partners implemented a community-based integrated prevention campaign (IPC) in Western Kenya in 2008. The aim of this study was to determine whether the IPC, compared to Voluntary Counselling and Testing (VCT) services, was able to identify HIV positive individuals earlier in the clinical course of HIV infection following testing. METHODS: A total of 1,752 adults aged over 15 years who tested HIV positive through VCT services or the IPC, and subsequently registered at initial clinic visit between September 2008 and September 2010, were considered in the analysis. Multivariable logistic regression models were developed to assess the association of CD4 count and WHO clinical stage of HIV infection at first clinic appointment with age group, gender, marital status and HIV testing source. RESULTS: Male gender and marital status were independently associated with late HIV presentation (WHO clinical stage 3 or 4 or CD4 count ≤ 350 cells/µl) at initial clinic visit. Patients testing HIV positive during the IPC had significantly higher mean CD4 count at initial clinic visit compared to individuals who tested HIV positive via VCT services. Patients testing HIV positive during the IPC had more than two times higher odds of presenting early with CD4 count greater than 350 cells/µl (adjusted OR 2.15, 95% CI 1.28 - 3.61, p = 0.004) and presenting early with WHO clinical stage 1 or 2 of HIV infection (adjusted OR 2.39, 95% CI 1.24 - 4.60, p = 0.01) at initial clinic visit compared to individuals who tested HIV positive via VCT services. CONCLUSION: The community-based integrated prevention campaign identified HIV positive individuals earlier in the course of HIV infection, compared to Voluntary Counselling and Testing services. Community-based campaigns, such as the IPC, may be able to assist countries to achieve earlier testing and initiation of ART in the course of HIV infection. Improving referral mechanisms and strengthening linkages between HIV testing and treatment services remain a challenge and electronic medical record (EMR) systems may support monitoring of patients throughout the HIV care and treatment continuum.

Rapid implementation of an integrated large-scale HIV counseling and testing, malaria, and diarrhea prevention campaign in rural Kenya.

BACKGROUND: Integrated disease prevention in low resource settings can increase coverage, equity and efficiency in controlling high burden infectious diseases. A public-private partnership with the Ministry of Health, CDC, Vestergaard Frandsen and CHF International implemented a one-week integrated multi-disease prevention campaign. METHOD: Residents of Lurambi, Western Kenya were eligible for participation. The aim was to offer services to at least 80% of those aged 15-49. 31 temporary sites in strategically dispersed locations offered: HIV counseling and testing, 60 male condoms, an insecticide-treated bednet, a household water filter for women or an individual filter for men, and for those testing positive, a 3-month supply of cotrimoxazole and referral for follow-up care and treatment. FINDINGS: Over 7 days, 47,311 people attended the campaign with a 96% uptake of the multi-disease preventive package. Of these, 99.7% were tested for HIV (87% in the target 15-49 age group); 80% had previously never tested. 4% of those tested were positive, 61% were women (5% of women and 3% of men), 6% had median CD4 counts of 541 cell/µL (IQR; 356, 754). 386 certified counselors attended to an average 17 participants per day, consistent with recommended national figures for mass campaigns. Among women, HIV infection varied by age, and was more likely with an ended marriage (e.g. widowed vs. never married, OR.3.91; 95% CI. 2.87-5.34), and lack of occupation. In men, quantitatively stronger relationships were found (e.g. widowed vs. never married, OR.7.0; 95% CI. 3.5-13.9). Always using condoms with a non-steady partner was more common among HIV-infected women participants who knew their status compared to those who did not (OR.5.4 95% CI. 2.3-12.8). CONCLUSION: Through integrated campaigns it is feasible to efficiently cover large proportions of eligible adults in rural underserved communities with multiple disease preventive services simultaneously achieving various national and international health development goals.