APL Helps Liberia Better Prepare for Health Threats

Nearly two years have passed since the deadly outbreak of Ebola in Liberia began to taper off, but the root causes of the epidemic — dilapidated health facilities, shortages of staff and equipment, and fractured trust in the system — persist.

Two analysts from the Johns Hopkins Applied Physics Laboratory’s National Health Mission Area traveled twice to Liberia’s capital, Monrovia, last year to deploy APL-developed disease surveillance tools that will leave the country better prepared to deal with future outbreaks.

During their first visit, Shraddha Patel, a public health specialist, and Rich Wojcik, a computer programmer, visited the medical clinical at the Edward Binyah Kesselly (Camp EBK) military training facility to meet with stakeholders from the Armed Forces of Liberia (AFL) to take stock of their current public health and disease surveillance capabilities and processes, and to get buy-in.

They were joined by representatives from the Naval Medical Research Unit 3 (NAMRU-3), which sponsored the project. NAMRU-3 is the largest Department of Defense overseas biomedical research facility and has been in the region for decades, conducting research on a range of diseases and performing infectious disease surveillance to support military personnel deployed to Africa, the Middle East and Southwest Asia.

At Camp EBK, Patel and Wojcik found several conditions that might hinder successful disease surveillance efforts: there was no internet service, electricity was provided by a generator, and patient records were kept in paper logbooks that deteriorated over time. Additionally, data collection was not always standardized, so the data was not always consistent.

They installed the Suite for Automated Global Electronic bioSurveillance (SAGES) toolkit. Developed by APL in collaboration with the U.S. Department of Defense, the SAGES software suite collects, analyzes, visualizes and shares information within a national disease surveillance system. Individual tools may be used to complement existing disease surveillance systems, or used all together to create an end-to-end capability.

“We configured SAGES data entry tools to reflect the data needs of AFL,” Patel explained. “For example, we looked at the data that was being collected in the paper logbooks and included most, if not all, of those fields in the web-based data-entry form. When a certain field has a certain set of options that can be selected — for example, a list of symptoms, diagnoses or clinics — those fields were configured as multi-select fields so that the user can easily select an entry from a pull-down. This replaces a clinician manually handwriting something in the logbook, that may or may not be consistent with the proper selections that should be used in a particular field in the logbook.”

They also provided training to AFL personnel from four military medical clinics throughout the country. “These individuals were not doctors; they were clinicians and trained health workers,” Patel said. Prior to the training, she and Wojcik took four brand-new laptops donated by the Henry Jackson Foundation and configured them with SAGES tools. “When we started the training session the next day, we realized that some users had never used a computer or laptop before,” she said. “While most of the attendees had personal smartphones or tablets, some had never used an actual keyboard, mouse or Microsoft Windows.”

In a related effort, the APL duo teamed up with epidemiologists from the JHU Bloomberg School of Public Health to provide similar support to Liberia’s Ministry of Health and Social Welfare. They visited Redemption Hospital, a facility that was crippled and briefly closed during the peak of the Ebola epidemic. They discovered, among other things, that inpatient and outpatient records were kept on paper and often destroyed to make room for new records.

“We are in the process of building out dashboards for the Ministry of Health’s headquarters that will allow aggregated data from various hospitals and clinics, such as Redemption, to be visualized using graphs and maps,” Patel explained. “These dashboards will allow epidemiologists to analyze health data both temporally and spatially. For disease surveillance, knowing when and where cases are occurring is critical.”

The work in Liberia is just one of the many projects in the National Health Mission Area’s Health Surveillance program designed to assist public health end users in their effort to collect, analyze and visualize population-based data, both in the United States and overseas, said Sheri Lewis, the mission area’s program area manager for Research and Applications. 

“Working directly with the epidemiologist and public health officials in countries in various regions of the world helps us understand the needs and challenges faced when trying to improve local capacity to perform disease surveillance,” she said. “These capabilities, while today are predominantly focused on human health, have applicability to plants and animals as well, which rounds out our desired One Health approach.”