Using SMS for Healthcare

June 14, 2010

Over 4.1 billion cell phones are in use globally, and they are quickly becoming a part of the “digital life” for many.Reports indicate that individuals worldwide now use Internet-based and mobile technologies to find health-related information more frequently than ever before. Although cell phones are more common than computers in some areas of sub-Saharan Africa, it is important to note that they are frequently low-cost models with less features as opposed to high-tech smartphones, so mobile web-based information and applications may not be available.

As a means of delivering health-related information in remote areas, many clinics and organizations have begun to utilize short message service (SMS) technology. SMS or “texting” is a mature technology that is supported worldwide on all cellular network operators, through which messages of up to 160 characters can be delivered to a user’s cell phone. In regions where “personal computer technology” may not be available, it is possible to better ensure the delivery of health-related information through the use of basic cell phones and SMS technology. Over the past few years, SMS-based systems have been put in place throughout the developing world to combat diseases like malaria, provide medical and health information, and support rescue and relief efforts following natural disasters.

In regions where malaria is prevalent, SMS systems, such as the “SMS for Life” program currently in use in Africa, have been implemented to deliver information about the availability of treatment and medications. This program allows the inventory of anti-malarial medications at healthcare facilities throughout Africa, particularly in remote areas, to be tracked by clinics and aid organizations to improve distribution rates. Similar programs which allow physicians to monitor their patients at a distance have been put into practice for other diseases, including a program to ensure the provision of quality care to patients with HIV/AIDS in Kenya. This type of patient-monitoring SMS program has also been instituted to allow healthcare workers in Rwanda to monitor pregnant patients remotely, provide basic health and well-being information to patients throughout Africa, and provide clinic location information to patients in India.

SMS systems have also been established following natural disasters, such as the earthquake that struck Haiti on January 12, 2010. A number of relief organizations set up SMS shortcodes, which assisted individuals searching for friends and family members. Shortcodes are set numbers – usually only five digits long – used to quickly and easily gather messages for delivery. Additionally, SMS messaging and shortcodes allowed for a simplified donation process to a number of aid organizations providing assistance in Haiti.

Although mobile applications, smartphones, and other cutting edge technologies have provided enormous advancements in healthcare, high-tech solutions are not always appropriate for worldwide use. In settings where reliable Internet connectivity may not be available and where basic cell phones are the norm, SMS-based systems allow for the distribution of health-related information to a wider audience.

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On Neglected Tropical Diseases

January 11, 2010

Malaria, HIV/AIDS, and tuberculosis are often considered the most pressing disease-related threats to individuals in the developing world and the quest to eradicate them receives a large portion of government and private funding. However, a group of conditions known collectively as neglected tropical diseases (NTDs) have a more widespread and devastating effect on the lives of people in many regions of sub-Saharan Africa, Southeast Asia, and Latin America. These regions account for up to 90 percent of the disease burden for this group of 13 parasitic and bacterial conditions. Reports from the Global Network for Neglected Tropical Diseases indicate that these parasitic and bacterial infections affect over 1.4 billion people, most of whom survive on less than US$1.25 per day. While NTDs may not necessarily kill those infected, they can lead to malnutrition, anemia, a range of disabilities (most often blindness), stunted growth, and greater susceptibility to other illnesses.

Neglected Tropical Diseases

Clockwise from top left: An egg of the roundworm, which causes Ascariasis; a man with Lymphatic Filariasis being examined by a physician; the whipworm, which causes Trichuriasis; and a child receiving antibiotic treatment for Trachoma.

Individuals affected by NTDs live primarily in tropical and subtropical climates, and many experience more than one infection or parasite at a given time. According to the World Health Organization (WHO), the majority of individuals affected by NTDs live in remote and rural areas, urban slums, or areas experiencing conflict situations. Seventy percent of infections occur in low- or lower-middle income areas, and are frequently caused by unsafe water and poor housing and sanitation conditions. Further, NTDs contribute to a cycle of poverty in which children are likely to become infected due to their poor living conditions, and once infected they may experience delays in cognitive development inhibiting their ability to escape their impoverished conditions.

The seven most common NTDs are: Ascariasis, Hookworm, Lymphatic Filariasis, Onchocerciasis, Scistosomiasis, Trachoma, and Trichuriasis. These diseases, many of which are caused by parasitic intestinal worms known as helminthes, have the most devastating impact on those who contract them. For example, Ascariasis, resulting from roundworm infestation, affects 800 million people; and trichuriasis, resulting from whipworm, affects 600 million. Helminths rob children of nutrients and can lead to stunted growth, iron-deficiency anemia, and protein malnutrition. They are at an increased risk of contracting parasitic worms, as are the elderly and pregnant women. Over 40 million pregnant women are infected with hookworms, parasitic worms that attach to the small intestine and suck blood from their host, increasing vulnerability to malaria and additional blood loss during labor.

Based on Disability-Adjusted Life Years (DALYs), which refer to the years of healthy life lost to disability or premature death, NTDs are a greater health burden than tuberculosis or malaria, and approach the level of burden of HIV/AIDS. In addition, NTDs are the cause of approximately 534,000 deaths worldwide each year. Through programs to distribute medications, the WHO, pharmaceutical companies, government agencies, and international aid organizations hope to ensure fewer lives are lost. Coordinated efforts have allowed for the rapid deployment of inexpensive diagnostic tools, medications, and treatments, many of which can be administered by trained non-medical staff including teachers and community health workers. Medications are often distributed in “rapid-impact packages,” reducing costs and putting less strain on already weakened healthcare systems in the areas where NTDs are most prevalent. These packages also offer the opportunity to bundle life-saving drug treatments with other interventions such as antimalarial bed nets or nutritional supplements.

Through these and other similar efforts, it has been possible to reduce the occurrence of a number of conditions in many parts of the world. The number of cases of guinea worm disease, also known as dracunculiasis, has fallen from 3.5 million in the 1980s to just 4,619 in 2008, and the WHO has declared eradication in Nigeria and Uganda. Many other conditions are now found only in remote villages and are nearing total eradication through education programs, medication distribution, and improved sanitation.

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Tobacco Use Worldwide

December 23, 2009

Currently, approximately one third of the global population over the age of 15 – about 1.1 billion people – smoke cigarettes. Tobacco use continues to be the leading preventable cause of death worldwide, killing at least five million people each year. Trends from illness and death related to tobacco use indicate that by 2030, tobacco use will contribute to the deaths of more than 10 million people worldwide each year, 70 percent of whom live in the developing world. Though various strategies are in place, including bans on smoking in public areas, restrictions on advertisements for tobacco products, and increased taxes on cigarettes, the number of people who use tobacco has not significantly decreased. A recently released report from the World Health Organization (WHO) details cigarette and smokeless tobacco consumption and seeks to find an approach that may lessen the use of these products.

Global Tobacco Use

The WHO report indicates that though 22 of the world’s most populous 100 cities are now “smoke-free,” this only accounts for 5.4 percent of the world’s population. In 2008, the WHO established a set of guidelines aimed at helping nations to reduce smoking, which include:

  1. Monitoring tobacco use and the policies to prevent it,
  2. Protecting people from tobacco smoke,
  3. Offering people help to quit using tobacco,
  4. Warning people about the dangers of tobacco,
  5. Enforcing bans on tobacco advertising, promotion, and sponsorship, and
  6. Raising taxes on tobacco.

However, reports indicate that less than 10 percent of the world’s population is covered by any one of these measures. Additionally, only two percent of individuals live in nations that have comprehensive and widely-accepted smoke-free laws, and 94 percent are not protected by any laws against smoking.

Laws banning smoking – including the use of cigarettes, cigars, and hookahs – in public places will come into force in 2010 in many areas of the world. According the Syrian Society for Countering Cancer, 60 percent of adult men and 23 percent of women in Syria smoke, and 98 percent of Syrians are affected by second-hand smoke exposure. Other nations face similarly high rates of tobacco use and smoking-related illness and death. The high incidence of tobacco-related deaths in the Philippines (90,000 per year), Malaysia (10,000 per year), and Vietnam (40,000 per year) has caused concern in these regions, but fully effective smoking bans are not yet in place. Reports indicate that the majority of smokers in some Southeast Asian countries are men, and that as many as 75 percent of men smoke, compared to fewer than 20 percent of women who do. In Cambodia, for example, roughly half of the older women do use tobacco, but favor smokeless chewing tobacco, which many women begin during pregnancy to help lessen prenatal nausea.

Over the past four years, smoking rates have decreased in developed nations including the United States, Japan, and Western Europe as anti-smoking laws gain momentum. However, the World Lung Foundation (WLF) indicates that “More than 80 percent of those with premature deaths [from smoking] would occur in low- and middle-income countries.” Since 1960, according to the WLF, “the global production of tobacco has increased 300 percent in low- and middle-resource countries while dropping more than 50 percent in high-resource countries.” In China and India, over half a billion men consume tobacco, and other nations are facing similar problems of mass consumption of tobacco use. Tobacco is a contributing cause to heart attacks, strokes, diabetes, cancers and asthma worldwide, regardless of how it is consumed (smoked, chewed, etc.). According to Ala Alwan, the WHO non-communicable diseases expert, more than 80 percent of the WHO’s projected cancer deaths are likely to occur in the poorest regions of Africa. To increase awareness and provide education about the dangers of smoking, the WHO is planning to establish a regional hub there in 2010.

It remains to be seen how much impact the efforts of the WHO and other organizations will have with regard to decreasing the number of individuals who use tobacco. Through newly established laws, increased taxation, and outreach and education about the dangers of cigarettes and smokeless tobacco products, it may be possible to urge individuals to quit smoking or not to start at all.

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Mobile Medical Apps

November 9, 2009

New technologies, both mobile and Internet-based, hold potential medical applications that may advance care. Through cellular telephones, netbooks, and laptops, physicians and healthcare providers are now able to utilize these technological improvements at the point of care. Non-profit organizations, research teams at universities, and other groups are working to develop applications for use on cell phones, often with integrated web-based features, to ensure that medical knowledge is fully accessible worldwide.
Image by Deborah Ervin
Web-based iConsult, the flagship program of the iCons in Medicine initiative, allows for collaboration between healthcare providers worldwide through a teleconsultation software and social networking website. The iConsult application, which functions like email, is easy-to-use, reliable, and designed for use in areas with limited or intermittent connectivity. The system facilitates knowledge transfer worldwide by pairing Volunteers, medical specialists who lend their expertise, with Requestors, medical professionals who work for non-profits in remote or medically underserved areas. Through the software and website, Volunteers and Requestors may collaborate on difficult medical cases from a distance, providing specialty advice that otherwise might not be available. Volunteers in the iCon Network who elect to take part in iConsult agree to provide at least three teleconsults per year. The iConsult software allows Requestors to upload a case consultation form, including digital images, and discuss potential diagnoses and treatments on a one-to-one basis with Volunteers in a secure environment. Other organizations, like InSTEDD (Innovative Support to Emergencies Diseases and Disasters), develop free and open source technologies to enable seamless and reliable collaboration between individuals working in the developing world and areas affected by conflict situations or natural disasters. GeoChat is a mobile communications service designed to allow for group communications via cellular telephones and online. The technology can be used in humanitarian crises to ensure that individuals who may be trapped, injured, sick, or in need of assistance can be reached quickly and their needs addressed. Unlike platforms that are only web-based, InSTEDD’s GeoChat allows healthcare providers and others to form a team and use SMS messaging, email, and/or a web browser to share information based on their location, providing an accurate documentation of conditions in a given region.

In addition to web-based initiatives, many organizations have begun developing and distributing applications for smartphones, creating a new base of information for both physicians and the general public. An analysis published by Manhattan Research in February 2009 indicates that more than 10 million adults in the United States use mobile devices to access health information. This figure may include individuals who chose to purchase the Merck Manual Home Health Handbook (3rd Edition) in its iPhone application format. Users can reference a range of health topics on-the-go with this and other similar applications. The Merck Manual is available in both a home and professional edition, and features a search engine and the ability to bookmark and email subjects. Other organizations, such as health insurance company Medica, are making efforts to increase the public’s awareness about healthcare and its costs through iPhone applications like Main Street Medica. The application, which is available to all consumers, not only Medica members, offers users the chance to compare the cost of common procedures at hundreds of clinics and facilities.

Though some look for health information on their own, a recent Opinion Research Corporation survey found that 64 percent of consumers turn to their physicians for health advice and feel that they are their most trusted source of health information. In an effort to ensure that healthcare providers have up-to-date information, organizations like Emerging Solutions in Pain (ESP) have also begun releasing mobile applications intended for use by medical professionals. ESP has launched an application for healthcare professionals involved in pain management or addiction medicine called ESP Mobile, which provides multimedia information in a mobile format and also includes up-to-date information and educational programs in pain management, news articles, and clinical support resources for providers. Physicians at Houston-based Memorial Herman Healthcare System use this and a number of other iPhone applications, including Airstrip OB, which displays medical notes and real time vital statistics of women as they approach delivery. The thousands of doctors and nurses within the 11 hospitals that comprise the System also utilize apps in the emergency room to quickly identify medications – particularly useful “if an unconscious patient comes in with a pocketful of pills.”

Other applications may be of use to both physicians and patients including language translation applications and a number of websites and mobile applications developed to provide up to the minute disease outbreak tracking and evaluation. Primarily focused on the medical community, applications like the Arabic Language Buddy, which provides real time, two-way English-Arabic translation; and Jibbigo, which converts English to Spanish and vice versa, offer potential tools for doctors working in regions where they are not fluent in the native language. Websites developed by the United States government and a joint effort from Microsoft Corp. and Emory University are more focused on providing patients with information, and may help individuals determine if their symptoms indicate possible H1N1 virus infection and warrant a doctor visit. Outbreaks Near Me, a mobile application for the iPhone developed by researchers at the Children’s Hospital of Boston, provides real time tracking of the spread of H1N1 infection. IntuApps application Swine Flu Tracker provides similar information as well as maps and “threat level” indicators.

Both mobile applications and web-based tools provide a chance to share information and knowledge across borders and ensure that quality medical care is delivered worldwide. New innovations continue to flood the marketplace, and it remains to be seen what the next improvement in healthcare technology will bring.

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The Flu Vaccine

October 12, 2009

As new cases and concerns about seasonal flu and swine flu (H1N1) continue to spread worldwide, two vaccines have recently been made available. Both the nasal spray vaccine and injectable vaccine for seasonal flu have proven effective for specific portions of the population, however distribution is still slow. For the H1N1 (swine flu) virus, The Baltimore Sun reports, availability is still an issue and many areas have not yet received enough doses to meet the demand. While many in the developed world do not yet have access to the H1N1 vaccine, Dr. Bernadine Healy notes that the problem is even greater in the developing world. To help these nations fight the pandemic, the United States has agreed to donate 10 percent of its vaccination supply to the World Health Organization (WHO) – eight other nations will make similar donations.

Fantastic Image by Deborah Ervin

Inoculating individuals for both viruses is complicated by the time frame in which the vaccinations can occur. If one chooses nasal spray for both seasonal and swine flu, they must wait four weeks between doses, while if one is injected for one virus and uses nasal spray for the other, they can be administered together. Discovery Health reports that doctors recommend annual flu shots to lessen the chances of becoming ill. Individuals as young as six months can be inoculated, according to the Centers for Disease Control and Prevention (CDC) and side effects are reported to be minor. Because the virus used to make the seasonal flu vaccine is dead, it is not possible to contract flu from a flu shot, however one may expect a low-grade fever 8 to 24 hours following injection, a swollen or tender area around the injection site, a slight headache or chills within 24 hours.

The seasonal flu shot is an inactivated vaccine, and contains three influenza viruses – one A(H3N2) virus, one regular seasonal A(H1N1) virus (which differs from the 2009 H1N1 virus), and one B virus. The viruses used change annually based on international surveillance which track infection trends and scientists estimations about which strains will circulate during the year. In contrast to the flu shot, the nasal-spray flu vaccine contains a weakened but still living flu virus, sometimes called LAIV (live attenuated influenza vaccine). These nasal mists are approved for use in healthy individuals ages two to 49 who are not pregnant. In addition to nasal sprays, Discovery Health reports that researchers at Stanford University and the University of Alabama at Birmingham have been working with naked DNA in an effort to develop a vaccine that could be delivered via shampoo or dermal patch.

Three recent large-scale studies, including a study led by Dr. Arnold S. Monto of the University of Michigan, indicate that while the seasonal flu shot is more effective for adults and safe for women who are pregnant, the intranasal vaccine (nasal spray) is more effective at preventing flu in children. These studies showed 35 to 53 percent fewer cases of flu in children who were given the nasal spray vaccine than those who received injected vaccines. The Los Angeles Times reports that injectable vaccines prevent roughly 50 percent more seasonal flu in healthy adults than the nasal spray vaccines.

Due to the relative newness of the H1N1 vaccine, health authorities have implemented a number of tracking measures to ensure its safety. The Associated Press reports that Harvard Medical School scientists are working to link insurance databases covering 50 million people with vaccination registries to allow them to determine if people visit a doctor after being vaccination as well as the reason for the visit. Johns Hopkins University and the CDC are also working to ensure that any side effects are noted and addressed quickly. These efforts include emailing individuals who have been vaccinated recently to see how they are feeling (Johns Hopkins), and preparing take-home cards asking vaccine recipients to report any side effects to the nation’s Vaccine Adverse Event Reporting system (CDC). These measures are being undertaken as in the Internet-age, the Associated Press notes, one person updating their Facebook status to say that they got a flu shot and feel sick could cause a wave of similar reports.

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Associated Press on the Nasal Spray Flu VaccineThe New York Times on CDC Side Effect Tracking Measures

A Killer in the Developing World

August 17, 2009

HIV/AIDS and malaria are major health concerns worldwide, however the World Health Organization (WHO) reports across much of Asia and Africa secretory diarrhea – which accounts for 1.6 million deaths annually – is an even greater threat. Each day in India, diarrhea-related diseases kill 1,250 people, only slightly fewer than the H1N1 virus has killed globally to date (1,500), according to the WHO. Caused by E.coli, cholera, and other bacteria, viruses, or parasites, diarrhea affects individuals more often in areas that lack safe water and appropriate sanitation. In individuals with secretory diarrhea, infectious agents cause too much water to enter the bowel and be evacuated from the body, leading to excessive dehydration and eventually death if appropriate treatment is not received.

Diarrhea in the Developing World
In nations of the developing world, including Bangladesh, India, Mali, and Pakistan, aid organizations and government agencies have begun distributing zinc supplements to villagers as a treatment for diarrhea. Data from recent studies documented in the August 2009 issue of the Journal of Leukocyte Biology suggest that zinc may help to activate the T-cells needed to destroy viruses and bacteria, including those that cause diarrhea. Time Magazine reports that in tablet or liquid form, zinc can be used in combination with oral-rehydration therapy (ORT). While it is not entirely clear how zinc helps halt diarrhea, Oliver Fontaine, a diarrhea specialist for the WHO, explains that a single course of zinc treatment can stave off diarrhea for three months.

Unlike zinc, which often produces an immediate improvement in an individual’s health, the glucose present in ORT (a solution of sugars and salts) slows the evacuation of fluids allowing for the absorption of electrolytes in the intestines, and halting the progression of dehydration to a chronic state. Because of the delay in the improvement of symptoms with ORT, “Mothers don’t see ORT as real treatment,” according to Eric Swedberg, senior director of health and nutrition at Save the Children U.S. Though ORT is an effective treatment for diarrhea, only about 35 percent of families in diarrhea-stricken countries utilize the method.

By offering zinc in combination with ORT, government-run programs in Ethiopia and Tanzania hope to increase the number of people surviving diarrheal outbreaks. Additionally, efforts are being made in Mali to add zinc to the country’s list of essential drugs, a step towards improving the distribution of the tablets. To halt the recent outbreaks of diarrhea in Nepal that have led to 235 deaths to date, the Office of the Prime Minister has begun coordinating efforts to construct a toilet in each household, provide sources of potable water, and improve waste disposal systems. In addition, the Nepali government has mobilized 298 personnel to aid in providing treatment in the area through 89 health camps.

To support these and other similar efforts, funding for the provision of the potentially life-saving drugs, and awareness of their effectiveness must be increased. In 2007, only four percent of all U.S. funding for research of epidemics in the developing world was devoted to finding solutions to decreasing the number of diarrhea-related deaths. Support from organizations like the Bill and Melinda Gates Foundation have provided some support, but additional funding is still needed not only to ensure that zinc tablets are more widely distributed, but also to assist in efforts to improve the quality of available water and waste treatment measures.

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WHO on Water Treatment and Safe StorageOn Diarrhea and Tuberculosis in IndiaTime Magazine on Zinc to Treat DiarrheaDiarrheal Deaths in NepalOn Zinc Fighting Infection

Innovative, Low-Cost Medical and Diagnostic Tests

August 3, 2009

In the developing world, the availability of many medical technologies is limited by cost, durability, and ease-of-use. This is especially true of expensive diagnostic devices, which  are critical for detecting diseases that are endemic in developing countries. However, researchers are working to develop low-cost, user-friendly alternatives that could improve the ability of healthcare providers to diagnose a range of conditions.

Innovative New Diagnostic Tests Can Save Lives at a Lower Cost

Harvard researchers have developed an alternative microfluidic device that replaces standard silicon, glass, or plastic substrates with treated paper. Fluids flow through the microchannels in the paper device in the same way that they would in a standard chip. Researchers have used the device to test for glucose and protein in urine, but hope to adapt it for the possibility of testing blood samples for HIV/AIDS, dengue fever, or hepatitis. While a traditional microfluidic device costs between $10 and $1,000USD, the materials to create the paper devices, known as microPADS, cost only three cents. The design of the microPAD device allows for several tests to be conducted simultaneously, furthering the cost and resource savings.

To help better diagnose infectious diseases such as malaria and tuberculosis, researchers have developed a microscope that attaches to any cellular telephone with a camera feature. The device, known as a CellScope, is able to illuminate pathogens in a sample treated with fluorescent molecular “tags.” It is estimated that the production of first CellScopes will cost roughly $1,000 each, but with further developments the price could drop to just a few hundred dollars, including the cell phone. Not only can an individual use the microscope to view the pathogens, but they can also send an image to a healthcare facility for assistance making an appropriate diagnostic determination.

Efforts have also been made by scientists at the Burnet Institute to improve HIV-testing procedures. A prototype monitoring test has been designed for use in remote settings. The new test, which uses a finger-prick blood sample, allows individuals to determine their CD4+ T-cell count within 30 minutes. The CD4+ T-cells are critical for healthy immune system function and their levels are a deciding factor with regard to starting anti-retroviral therapy. Standard CD4 tests are often not available in the developing world due to their cost, the need for specialized equipment and trained personnel, and the long wait period to obtain test results.

Though these diagnostic technologies offer improvements in the developing world, as The Wall Street Journal reports, acceptance may be slower in the United States. Some researchers have found success when applying African healthcare models to rural areas of the U.S., and results using low-cost technologies originally conceived for use in the developing world may follow this trend. The use of innovative low-cost testing methods may also assist with telemedicine initiatives, as they allow healthcare providers to conduct necessary tests and provide better diagnostic information to consultants. Through discussion among global health experts – as allowed by telemedicine initiatives like iCons in Medicine – innovative diagnostic tools and other cost-saving measures may become more popular, and help to provide improved care worldwide.

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IEEE spectrum – Inside Technology – Discover Magazine on the microPAD and the CellScopeBurnet Institute CD4+ T-cell Test