ib bygbjerg, md, dsci, professor of example of wired mothers · • malaria tanzania the prevalence...
TRANSCRIPT
Maternal health Malaria and mHealth
bull Overview of presentation
bull eHealth amp mHealth
bull Example of Wired Mothers
bull Application to MIPbroader maternal health
bull Additional possibilitiesopportunities
bull Words of caution
bull A MIP app
Ib Bygbjerg MD DSCI professor of International health Copenhagen School of Global Health Denmark
Forms of e-health
bull Electronic health records enabling the communication of patient data between different healthcare professionals (GPs specialists etc)
bull Telemedicine physical and psychological treatments at a distance bull Consumer health informatics use of electronic resources on medical topics by healthy
individuals or patients bull Health knowledge management eg in an overview of latest medical journals best practice
guidelines or epidemiological tracking (examples include physician resources such as Medscape and MDLinx)
bull Virtual healthcare teams consisting of healthcare professionals who collaborate and share information on patients through digital equipment (for transmural care)
bull mHealth or m-Health includes the use of mobile devices in collecting aggregate and patient level health data providing healthcare information to practitioners researchers and patients real-time monitoring of patient vitals and direct provision of care (via mobile telemedicine)
bull Medical research using Grids powerful computing and data management capabilities to
handle large amounts of heterogeneous data bull Healthcare Information Systems also often refer to software solutions for appointment
scheduling patient data management work schedule management and other administrative tasks surrounding health
WHO Bulletin focuses on eHealth The May 2012 issue of the Bulletin is fully dedicated to eHealth
bull The Bulletins theme issue on eHealth has three main objectives
bull to provide an authoritative critical and independent overview of current knowledge about appropriate trans-disciplinary methods and applications in eHealth
bull to include contributors from developing countries bull to strengthen the commitment of high-level decision-
makers to address eHealth interoperability issues and to widen the application of eHealth
(The last bullit somehow summarizes my Mission )
Key words in the May issue WHO Bulletin
bull Evidence base for eHealth bull Credibility of electronic health technologies bull Impact of eHealth bull E-health in LMIC countries bull Telemedicine networks bull Infant diagnosis of HIV infection in Zambia through mobile phone bull Access to specialized health care bull Improving quality and use of data bull Sentinel surveillance of influenza in Madagascar bull mHealth for behaviour change bull Research agenda for the field of mHealth bull International collaboration in eHealth bull Public good of health research and development
Key words if linked with MIP
bull Evidence base for e-health on MIP bull Credibility of electronic health technologies for MIP bull Impact of eHealth on control MIP bull eHealth in LMIC countries applied on MIP bull Telemedicine networks for management of MIP bull Diagnosis of malaria in mother and infant in Africa through mobile phone bull Access to specialized health care for MIP in Africa bull Improving quality and use of data in MIP bull Sentinel surveillance of malaria in Africa bull mHealth for behaviour change in prevention and control of malaria in
Africa bull Research agenda for the field of mHealth in relation to malaria bull International collaboration in eHealth to control malaria bull Public good of health research and development using eHealth in malaria
control
OPPORTUNITIES Phone connections have more than tripled in 10 years
httpwwwenrecahealthdkarchivewiredmothers
PI Stine Lund MD ISIM
Wired Mothers Initiative mHealth
Very few studies of sufficient quality
Limited evidence of actual and wide-scale impactsoutcomes
Even less from developing countries
Wired Mothers mHealth study Background
Sources Noordam et al Improvement of maternal health servcies through the use of mobile phones Trop Med Int Health 2011 Tamrat et al An Analysis of mHealth in Maternal and Newborn Health Programs and Their Outcomes Around the World Matern Child Health J 2011
Wired Mothers Intervention
Community
bull Pregnant Women
Health Center
bull Midwife
Hospital
bull Doctor
bull Nurse
bull Ambulance
Person Person
Person Person
Text Messages
Health Education
Increased health attendances across the continuity of care
Urban women more than 5 times likely to delivery with SBA in intervention group
Did not reach significance in SBA amongst rural women
Increased adherence to procedures
Positive outcomes linked to intervention communication system
Intervention widely accepted amongst health workers and women
Wired Mothers Conclusions
bull Malaria Tanzania The prevalence of malaria among febrile children has gone down dramatically
bull While the treatment recommendations in IMCI have changed despite the evidence that only 10 of children may have malaria all these children are treated for malaria at great expense and risk D-tree together with the Swiss Tropical Institute are testing an innovative approach to the diagnosis and treatment of children with fever in Tanzania using hand held electronic decision support incorporating the use of RDTs for children that have fever We expect to show that it is feasible and necessary to
bull Revise procedures for the management of childhood illness (IMCI) incorporating more sophisticated clinical algorithms based on current evidence about disease patterns and drug resistance
bull Rapidly incorporate these changes into treatment algorithms in an electronic format and
bull Demonstrate improved clinical and cost-effectiveness of electronic algorithms when compared to the used of paper based IMCI algorithms
M for Malaria Management Ongoing discussion Mobile Phone-based Inventory management
in the Malaria Treatment amp Prevention community
bull From GHDonline (Kenneth Rudd) ltmalariaghdonlineorggt bull To davie musongwe simwaba ltdsimwabayahoocomgt bull Sent Friday 11 May 2012 344 PM bull Subject Re [Malaria Treatment amp Prevention] Mobile Phone-based Inventory Management bull Kenneth Rudd replied to the discussion Mobile Phone-based Inventory Management in the Malaria Treatment amp
Prevention community bull bull Reply contents
bull FYI there are now many initiatives to utilize mobile phones as a way to track and even provide sorts of ldquotelemedicinerdquo and we will likely see more as in more and more places the infrastructure for mobile phone technology is in places where there wonrsquot be internet access for a long time to come if ever I even saw a mounting device where smartphones can be mounted onto microscopes such that images can be sent via SMS
bull bull -Kenny bull
Data and Image Transfer Using Mobile Phones
Images sent by mobile internet
Feedback to sender by text message
Strengthen Microscopy-Based Diagnostic such as malaria tb bacterial vaginosis stool parasites and eggs
M for Microscope and Medical Monitoring mHealth
care Several initiatives have shown previously that mobile phones
can be used to take pictures through a microscope [812ndash14] or be
modified to serve asa microscope [1516] The next logical step isto send the captured imagesvia mobile networks for example to a
reference laboratory for confirmation of diagnosis by an expert
For this study we developed a system of mobile phone-basedimaging in combination with a data transfer and responseplatform We piloted the performance of this system in Uganda
and discussed itsacceptability and potential applications with localstakeholders
Methods
Ethics StatementEthicsapproval or written informed consent wasnot required as
this isa methodology proof of concept paper Our focuswas firstly
on capturing a microscopy image of sufficient quality and then onthe Information Technology (IT) part to send the captured image
using the mobile phone Patientsrsquo personal information or anysamples IDrsquos that might allow tracing of patients was not used
Informed consent for discussions with colleagues at the health
centers was obtained verbally prior to site visits
LocationIn Uganda the health system is based on a referral system
consisting of different levels I indicating the lowest and IV thehighest level at higher levels more facilities and expertise are
available [17] The image capture wascarried out by a laboratorytechnologist at the National Tuberculosis (TB) Reference Labo-
ratory (NTRL) in Kampala district two laboratory technicianstwo assistants and a student at Nkozi Hospital laboratory in Nkozi
Mpigi district and five laboratory assistants at several level III andIV health centers from both these districts The data transfer
system was tested by a laboratory technologist and a doctor at theInternational Hospital of Kampala (IHK) and by IT specialistsfrom a local IT company in Kampala
Materials usedLaboratory samplesfrom theday before or set aside for training
purposesor external quality control of the health center were used
in our study These could not be linked to patients in any waySamples were initially collected as part of the routine activities
of the laboratories and either made anonymous or -in the case ofblood slides for blood parasites- an unlabelled duplicate slide was
sometimes used In the case of urine we used a drop of urine thatwas placed on an unlabelled slide and put under the microscope
for examination
Slide preparationAt NTRL and the TB health centres the slides selected for this
study were sputum slides for TB training purposesor QC samples
were stained with Ziehl Neelsen Blood slidesfor malaria that wereused at Nkozi hospital and the health centres in the other sites
were stained with Giemsa staining technique Urine and stoolslides were unstained direct wet preparations Auramine staining
was used for the detection of TB in sputum by fluorescentmicroscopy Staining of samples was performed in a European
laboratory
Image capture systemThe system is composed of a traditional light microscope
connected via a connector used as a positioning device to a Java-enabled mobile phone with camera see Figure 1 The connector
prototype was designed prior to this feasibility study [8] For this
study we used the 406 and the 1006 oil immersion objectives ofthe Olympus CX 21 Olympus CX31 Olympus CX41 and
Humascope (Human) light microscopes and the 406 objectives ofthe Olympus CX21 FluoLED Olympus BX41 and Nikon AFX-
IIA fluorescent microscopes Different camera phones were usedmainly Nokia candy bar models see Table 1 for an overview The
image resolution varied from 03 megapixels (MP) to 5MP Onsome occasions the digital zoom of the mobile phone camera was
used to enlarge a specific area of the microscopy field and magnifythe micro-organism to be identified
Data transfer systemEnd user and server software of the image transfer system were
designed A draft form for use on the mobile phone wasdeveloped
for the end user to record ID sample type health center data andupload images from the mobile phone
An end user version of this software including mobile Internetwaspre-installed asan extra application on a Java enabled mobile
phone A server version of this image transfer system was installedlocally in Kampala Uganda We used Orange as our mobile
internet provider as they cover both Mpigi and Kampala districts[18] The end user recorded fictional information on the draft
form took the required picture(s) and pressed lsquolsquosendrsquorsquo The imagewas then sent automatically via the pre-installed mobile Internetconnection of the mobile phone stored in the database of the
central server and a confirmation text message that the image hadbeen received was sent to the end user Anyone with access to thecentral server could log on via an Internet page to this server and
examine the received image store it elsewhere or give instantfeedback via a text message or voice call to the end userrsquosphone
Additionally the image could be enlarged on the computer screenusing the digital zoom function of the computer in order to
magnify areas of interest
Testing procedures1 a Captur e of image without connector Laboratory staff
members at Nkozi hospital NTRL and the health centres were
Figure 1 The prototype connector which attaches a mobilephone to a microscope The prototype connector was designed byTU Delft and TNO The connector is adjustable to fit all sizes of candybar phones and some slide phones It also consists of adjustable screwsto fit most regular light microscopesdoi101371journalpone0028348g001
Mobile Phones to Support Microscopy Diagnosis
PLoS ONE | wwwplosoneorg 2 December 2011 | Volume 6 | Issue 12 | e28348
Sources Tuijn et al Data and Image Transfer Using Mobile Phones to Strengthen Microscopy-Based Diagnostic Services in Low and Middle Income Country Laboratories PLOS December 2011
Africa at the forefront of the global Mobile Money industry
Transfer credit between phones with a simple text message
Mobile money transfer allows those without a bank account to transfer funds as quickly and easily as sending a text message
M for Money transfer mPESA
mHealth and smartphones ndash for what for whom and to be used by whom
bull Mobile phones or smartphones were NOT primarily developed for medicine or health but for communication
bull Potentials for their application in medicine and health are enormous
bull Why are (some) researchers and health professionals a bit hesitant to apply mHealth
mHealth and Malaria ndash un-used and under-researched
bull PubMedgov Your search for mhealth and malaria retrieved no results (May 2012)
bull mhealth Results 52
bull mobile phones and malaria Results 11
bull mobile phones and pregnancy Results 75 but gt half of these on risk for fetus of microwaves
bull mobile phones and malaria and pregnancy
Your search for mhealth and malaria and pregnancy retrieved no results
Malaria in pregnancy research priorities by 2007 Lancet Infect Dis 2007 Feb7(2)169-74
Malaria in pregnancy priorities for research Greenwood B Alonso P ter Kuile FO Hill J Steketee RW
bull ldquoWe have selected the following as the highest priorities for research bull identification of new safe and effective drugs to treat malaria in
pregnancy bull identification of new drugs to replace sulfadoxine-pyrimethamine for
intermittent preventive treatment in pregnancy bull identification of optimum combinations of control measures in different
epidemiological settings bull and determination of optimum ways of scaling-up the use of insecticide-
treated mosquito nets and intermittent preventive treatmentrdquo bull p173
Integration of malaria control with reproductive health programmes ldquoAn important area of operational research is how malaria control can be integrated more effectively than in the past with reproductive health and other programmes directed at women of childbearing age
M for Malaria In Pregnancy and ANC Reaching the most remote and vulnerable
bull Q Would mHealth empower pregnant women to reach the health system
bull A probably cf lsquoWired Mothersrsquo
bull Q Would mHealth enable peripheral HCW to reach and refer to central health care levels
bull A probably cf lsquoWired Mothersrsquo amp lsquoD-Treersquo
bull Q Should we aim at a vertical intervention or
bull as an integrated part of ANC
Maternal Death and Assessment of Substandard Care in Relation to Obstetric Complications and Infections in a Rural HospitalNorth-Western Tanzania
Thesis D Damm 2012 lt 4 of Maternal Death caused by Malaria
All 4 ways of audit showed that of 84 women 30 died from infection 70 of these Puerperal Sepsis 10-20 other Severe infections of these 3 possibly malaria
MIP and mHealth as an opportunity to improve maternal and child health
bull MIP is a visible target
bull MIP control is prioritized by governments NGOs and donor agencies
bull MIP can be used as an effective rsquofoot in the doorrsquo for promoting maternal health so
bull MIP isshould be an integrated part of ANC and Child Care even if most women in malarious areas actually die from other causes and
bull mHealth for MIP should be an integrated part of ANC and Child Care
Words of warning bull Kaplan 2006
In developing world shared mobile telephone use is important
bull Sharing may be a serious drawback to use of mobile telephones as a healthcare intervention in terms of stigma and privacy
bull Regulatory reforms required if mobile phones be used for healthcare
bull Code of conduct available wwhonchHONcodeConducthtml
bull Maaloslashe Bygbjerg Onesmo et al 2012
bull The decision to perform an Emergency Cesarian Section [in Tanzanian rural hospital] was often made by a doctor being contacted by a nurse-midwife by telephone without the doctor examining the women which made the decision less qualified
Forms of e-health
bull Electronic health records enabling the communication of patient data between different healthcare professionals (GPs specialists etc)
bull Telemedicine physical and psychological treatments at a distance bull Consumer health informatics use of electronic resources on medical topics by healthy
individuals or patients bull Health knowledge management eg in an overview of latest medical journals best practice
guidelines or epidemiological tracking (examples include physician resources such as Medscape and MDLinx)
bull Virtual healthcare teams consisting of healthcare professionals who collaborate and share information on patients through digital equipment (for transmural care)
bull mHealth or m-Health includes the use of mobile devices in collecting aggregate and patient level health data providing healthcare information to practitioners researchers and patients real-time monitoring of patient vitals and direct provision of care (via mobile telemedicine)
bull Medical research using Grids powerful computing and data management capabilities to
handle large amounts of heterogeneous data bull Healthcare Information Systems also often refer to software solutions for appointment
scheduling patient data management work schedule management and other administrative tasks surrounding health
WHO Bulletin focuses on eHealth The May 2012 issue of the Bulletin is fully dedicated to eHealth
bull The Bulletins theme issue on eHealth has three main objectives
bull to provide an authoritative critical and independent overview of current knowledge about appropriate trans-disciplinary methods and applications in eHealth
bull to include contributors from developing countries bull to strengthen the commitment of high-level decision-
makers to address eHealth interoperability issues and to widen the application of eHealth
(The last bullit somehow summarizes my Mission )
Key words in the May issue WHO Bulletin
bull Evidence base for eHealth bull Credibility of electronic health technologies bull Impact of eHealth bull E-health in LMIC countries bull Telemedicine networks bull Infant diagnosis of HIV infection in Zambia through mobile phone bull Access to specialized health care bull Improving quality and use of data bull Sentinel surveillance of influenza in Madagascar bull mHealth for behaviour change bull Research agenda for the field of mHealth bull International collaboration in eHealth bull Public good of health research and development
Key words if linked with MIP
bull Evidence base for e-health on MIP bull Credibility of electronic health technologies for MIP bull Impact of eHealth on control MIP bull eHealth in LMIC countries applied on MIP bull Telemedicine networks for management of MIP bull Diagnosis of malaria in mother and infant in Africa through mobile phone bull Access to specialized health care for MIP in Africa bull Improving quality and use of data in MIP bull Sentinel surveillance of malaria in Africa bull mHealth for behaviour change in prevention and control of malaria in
Africa bull Research agenda for the field of mHealth in relation to malaria bull International collaboration in eHealth to control malaria bull Public good of health research and development using eHealth in malaria
control
OPPORTUNITIES Phone connections have more than tripled in 10 years
httpwwwenrecahealthdkarchivewiredmothers
PI Stine Lund MD ISIM
Wired Mothers Initiative mHealth
Very few studies of sufficient quality
Limited evidence of actual and wide-scale impactsoutcomes
Even less from developing countries
Wired Mothers mHealth study Background
Sources Noordam et al Improvement of maternal health servcies through the use of mobile phones Trop Med Int Health 2011 Tamrat et al An Analysis of mHealth in Maternal and Newborn Health Programs and Their Outcomes Around the World Matern Child Health J 2011
Wired Mothers Intervention
Community
bull Pregnant Women
Health Center
bull Midwife
Hospital
bull Doctor
bull Nurse
bull Ambulance
Person Person
Person Person
Text Messages
Health Education
Increased health attendances across the continuity of care
Urban women more than 5 times likely to delivery with SBA in intervention group
Did not reach significance in SBA amongst rural women
Increased adherence to procedures
Positive outcomes linked to intervention communication system
Intervention widely accepted amongst health workers and women
Wired Mothers Conclusions
bull Malaria Tanzania The prevalence of malaria among febrile children has gone down dramatically
bull While the treatment recommendations in IMCI have changed despite the evidence that only 10 of children may have malaria all these children are treated for malaria at great expense and risk D-tree together with the Swiss Tropical Institute are testing an innovative approach to the diagnosis and treatment of children with fever in Tanzania using hand held electronic decision support incorporating the use of RDTs for children that have fever We expect to show that it is feasible and necessary to
bull Revise procedures for the management of childhood illness (IMCI) incorporating more sophisticated clinical algorithms based on current evidence about disease patterns and drug resistance
bull Rapidly incorporate these changes into treatment algorithms in an electronic format and
bull Demonstrate improved clinical and cost-effectiveness of electronic algorithms when compared to the used of paper based IMCI algorithms
M for Malaria Management Ongoing discussion Mobile Phone-based Inventory management
in the Malaria Treatment amp Prevention community
bull From GHDonline (Kenneth Rudd) ltmalariaghdonlineorggt bull To davie musongwe simwaba ltdsimwabayahoocomgt bull Sent Friday 11 May 2012 344 PM bull Subject Re [Malaria Treatment amp Prevention] Mobile Phone-based Inventory Management bull Kenneth Rudd replied to the discussion Mobile Phone-based Inventory Management in the Malaria Treatment amp
Prevention community bull bull Reply contents
bull FYI there are now many initiatives to utilize mobile phones as a way to track and even provide sorts of ldquotelemedicinerdquo and we will likely see more as in more and more places the infrastructure for mobile phone technology is in places where there wonrsquot be internet access for a long time to come if ever I even saw a mounting device where smartphones can be mounted onto microscopes such that images can be sent via SMS
bull bull -Kenny bull
Data and Image Transfer Using Mobile Phones
Images sent by mobile internet
Feedback to sender by text message
Strengthen Microscopy-Based Diagnostic such as malaria tb bacterial vaginosis stool parasites and eggs
M for Microscope and Medical Monitoring mHealth
care Several initiatives have shown previously that mobile phones
can be used to take pictures through a microscope [812ndash14] or be
modified to serve asa microscope [1516] The next logical step isto send the captured imagesvia mobile networks for example to a
reference laboratory for confirmation of diagnosis by an expert
For this study we developed a system of mobile phone-basedimaging in combination with a data transfer and responseplatform We piloted the performance of this system in Uganda
and discussed itsacceptability and potential applications with localstakeholders
Methods
Ethics StatementEthicsapproval or written informed consent wasnot required as
this isa methodology proof of concept paper Our focuswas firstly
on capturing a microscopy image of sufficient quality and then onthe Information Technology (IT) part to send the captured image
using the mobile phone Patientsrsquo personal information or anysamples IDrsquos that might allow tracing of patients was not used
Informed consent for discussions with colleagues at the health
centers was obtained verbally prior to site visits
LocationIn Uganda the health system is based on a referral system
consisting of different levels I indicating the lowest and IV thehighest level at higher levels more facilities and expertise are
available [17] The image capture wascarried out by a laboratorytechnologist at the National Tuberculosis (TB) Reference Labo-
ratory (NTRL) in Kampala district two laboratory technicianstwo assistants and a student at Nkozi Hospital laboratory in Nkozi
Mpigi district and five laboratory assistants at several level III andIV health centers from both these districts The data transfer
system was tested by a laboratory technologist and a doctor at theInternational Hospital of Kampala (IHK) and by IT specialistsfrom a local IT company in Kampala
Materials usedLaboratory samplesfrom theday before or set aside for training
purposesor external quality control of the health center were used
in our study These could not be linked to patients in any waySamples were initially collected as part of the routine activities
of the laboratories and either made anonymous or -in the case ofblood slides for blood parasites- an unlabelled duplicate slide was
sometimes used In the case of urine we used a drop of urine thatwas placed on an unlabelled slide and put under the microscope
for examination
Slide preparationAt NTRL and the TB health centres the slides selected for this
study were sputum slides for TB training purposesor QC samples
were stained with Ziehl Neelsen Blood slidesfor malaria that wereused at Nkozi hospital and the health centres in the other sites
were stained with Giemsa staining technique Urine and stoolslides were unstained direct wet preparations Auramine staining
was used for the detection of TB in sputum by fluorescentmicroscopy Staining of samples was performed in a European
laboratory
Image capture systemThe system is composed of a traditional light microscope
connected via a connector used as a positioning device to a Java-enabled mobile phone with camera see Figure 1 The connector
prototype was designed prior to this feasibility study [8] For this
study we used the 406 and the 1006 oil immersion objectives ofthe Olympus CX 21 Olympus CX31 Olympus CX41 and
Humascope (Human) light microscopes and the 406 objectives ofthe Olympus CX21 FluoLED Olympus BX41 and Nikon AFX-
IIA fluorescent microscopes Different camera phones were usedmainly Nokia candy bar models see Table 1 for an overview The
image resolution varied from 03 megapixels (MP) to 5MP Onsome occasions the digital zoom of the mobile phone camera was
used to enlarge a specific area of the microscopy field and magnifythe micro-organism to be identified
Data transfer systemEnd user and server software of the image transfer system were
designed A draft form for use on the mobile phone wasdeveloped
for the end user to record ID sample type health center data andupload images from the mobile phone
An end user version of this software including mobile Internetwaspre-installed asan extra application on a Java enabled mobile
phone A server version of this image transfer system was installedlocally in Kampala Uganda We used Orange as our mobile
internet provider as they cover both Mpigi and Kampala districts[18] The end user recorded fictional information on the draft
form took the required picture(s) and pressed lsquolsquosendrsquorsquo The imagewas then sent automatically via the pre-installed mobile Internetconnection of the mobile phone stored in the database of the
central server and a confirmation text message that the image hadbeen received was sent to the end user Anyone with access to thecentral server could log on via an Internet page to this server and
examine the received image store it elsewhere or give instantfeedback via a text message or voice call to the end userrsquosphone
Additionally the image could be enlarged on the computer screenusing the digital zoom function of the computer in order to
magnify areas of interest
Testing procedures1 a Captur e of image without connector Laboratory staff
members at Nkozi hospital NTRL and the health centres were
Figure 1 The prototype connector which attaches a mobilephone to a microscope The prototype connector was designed byTU Delft and TNO The connector is adjustable to fit all sizes of candybar phones and some slide phones It also consists of adjustable screwsto fit most regular light microscopesdoi101371journalpone0028348g001
Mobile Phones to Support Microscopy Diagnosis
PLoS ONE | wwwplosoneorg 2 December 2011 | Volume 6 | Issue 12 | e28348
Sources Tuijn et al Data and Image Transfer Using Mobile Phones to Strengthen Microscopy-Based Diagnostic Services in Low and Middle Income Country Laboratories PLOS December 2011
Africa at the forefront of the global Mobile Money industry
Transfer credit between phones with a simple text message
Mobile money transfer allows those without a bank account to transfer funds as quickly and easily as sending a text message
M for Money transfer mPESA
mHealth and smartphones ndash for what for whom and to be used by whom
bull Mobile phones or smartphones were NOT primarily developed for medicine or health but for communication
bull Potentials for their application in medicine and health are enormous
bull Why are (some) researchers and health professionals a bit hesitant to apply mHealth
mHealth and Malaria ndash un-used and under-researched
bull PubMedgov Your search for mhealth and malaria retrieved no results (May 2012)
bull mhealth Results 52
bull mobile phones and malaria Results 11
bull mobile phones and pregnancy Results 75 but gt half of these on risk for fetus of microwaves
bull mobile phones and malaria and pregnancy
Your search for mhealth and malaria and pregnancy retrieved no results
Malaria in pregnancy research priorities by 2007 Lancet Infect Dis 2007 Feb7(2)169-74
Malaria in pregnancy priorities for research Greenwood B Alonso P ter Kuile FO Hill J Steketee RW
bull ldquoWe have selected the following as the highest priorities for research bull identification of new safe and effective drugs to treat malaria in
pregnancy bull identification of new drugs to replace sulfadoxine-pyrimethamine for
intermittent preventive treatment in pregnancy bull identification of optimum combinations of control measures in different
epidemiological settings bull and determination of optimum ways of scaling-up the use of insecticide-
treated mosquito nets and intermittent preventive treatmentrdquo bull p173
Integration of malaria control with reproductive health programmes ldquoAn important area of operational research is how malaria control can be integrated more effectively than in the past with reproductive health and other programmes directed at women of childbearing age
M for Malaria In Pregnancy and ANC Reaching the most remote and vulnerable
bull Q Would mHealth empower pregnant women to reach the health system
bull A probably cf lsquoWired Mothersrsquo
bull Q Would mHealth enable peripheral HCW to reach and refer to central health care levels
bull A probably cf lsquoWired Mothersrsquo amp lsquoD-Treersquo
bull Q Should we aim at a vertical intervention or
bull as an integrated part of ANC
Maternal Death and Assessment of Substandard Care in Relation to Obstetric Complications and Infections in a Rural HospitalNorth-Western Tanzania
Thesis D Damm 2012 lt 4 of Maternal Death caused by Malaria
All 4 ways of audit showed that of 84 women 30 died from infection 70 of these Puerperal Sepsis 10-20 other Severe infections of these 3 possibly malaria
MIP and mHealth as an opportunity to improve maternal and child health
bull MIP is a visible target
bull MIP control is prioritized by governments NGOs and donor agencies
bull MIP can be used as an effective rsquofoot in the doorrsquo for promoting maternal health so
bull MIP isshould be an integrated part of ANC and Child Care even if most women in malarious areas actually die from other causes and
bull mHealth for MIP should be an integrated part of ANC and Child Care
Words of warning bull Kaplan 2006
In developing world shared mobile telephone use is important
bull Sharing may be a serious drawback to use of mobile telephones as a healthcare intervention in terms of stigma and privacy
bull Regulatory reforms required if mobile phones be used for healthcare
bull Code of conduct available wwhonchHONcodeConducthtml
bull Maaloslashe Bygbjerg Onesmo et al 2012
bull The decision to perform an Emergency Cesarian Section [in Tanzanian rural hospital] was often made by a doctor being contacted by a nurse-midwife by telephone without the doctor examining the women which made the decision less qualified
WHO Bulletin focuses on eHealth The May 2012 issue of the Bulletin is fully dedicated to eHealth
bull The Bulletins theme issue on eHealth has three main objectives
bull to provide an authoritative critical and independent overview of current knowledge about appropriate trans-disciplinary methods and applications in eHealth
bull to include contributors from developing countries bull to strengthen the commitment of high-level decision-
makers to address eHealth interoperability issues and to widen the application of eHealth
(The last bullit somehow summarizes my Mission )
Key words in the May issue WHO Bulletin
bull Evidence base for eHealth bull Credibility of electronic health technologies bull Impact of eHealth bull E-health in LMIC countries bull Telemedicine networks bull Infant diagnosis of HIV infection in Zambia through mobile phone bull Access to specialized health care bull Improving quality and use of data bull Sentinel surveillance of influenza in Madagascar bull mHealth for behaviour change bull Research agenda for the field of mHealth bull International collaboration in eHealth bull Public good of health research and development
Key words if linked with MIP
bull Evidence base for e-health on MIP bull Credibility of electronic health technologies for MIP bull Impact of eHealth on control MIP bull eHealth in LMIC countries applied on MIP bull Telemedicine networks for management of MIP bull Diagnosis of malaria in mother and infant in Africa through mobile phone bull Access to specialized health care for MIP in Africa bull Improving quality and use of data in MIP bull Sentinel surveillance of malaria in Africa bull mHealth for behaviour change in prevention and control of malaria in
Africa bull Research agenda for the field of mHealth in relation to malaria bull International collaboration in eHealth to control malaria bull Public good of health research and development using eHealth in malaria
control
OPPORTUNITIES Phone connections have more than tripled in 10 years
httpwwwenrecahealthdkarchivewiredmothers
PI Stine Lund MD ISIM
Wired Mothers Initiative mHealth
Very few studies of sufficient quality
Limited evidence of actual and wide-scale impactsoutcomes
Even less from developing countries
Wired Mothers mHealth study Background
Sources Noordam et al Improvement of maternal health servcies through the use of mobile phones Trop Med Int Health 2011 Tamrat et al An Analysis of mHealth in Maternal and Newborn Health Programs and Their Outcomes Around the World Matern Child Health J 2011
Wired Mothers Intervention
Community
bull Pregnant Women
Health Center
bull Midwife
Hospital
bull Doctor
bull Nurse
bull Ambulance
Person Person
Person Person
Text Messages
Health Education
Increased health attendances across the continuity of care
Urban women more than 5 times likely to delivery with SBA in intervention group
Did not reach significance in SBA amongst rural women
Increased adherence to procedures
Positive outcomes linked to intervention communication system
Intervention widely accepted amongst health workers and women
Wired Mothers Conclusions
bull Malaria Tanzania The prevalence of malaria among febrile children has gone down dramatically
bull While the treatment recommendations in IMCI have changed despite the evidence that only 10 of children may have malaria all these children are treated for malaria at great expense and risk D-tree together with the Swiss Tropical Institute are testing an innovative approach to the diagnosis and treatment of children with fever in Tanzania using hand held electronic decision support incorporating the use of RDTs for children that have fever We expect to show that it is feasible and necessary to
bull Revise procedures for the management of childhood illness (IMCI) incorporating more sophisticated clinical algorithms based on current evidence about disease patterns and drug resistance
bull Rapidly incorporate these changes into treatment algorithms in an electronic format and
bull Demonstrate improved clinical and cost-effectiveness of electronic algorithms when compared to the used of paper based IMCI algorithms
M for Malaria Management Ongoing discussion Mobile Phone-based Inventory management
in the Malaria Treatment amp Prevention community
bull From GHDonline (Kenneth Rudd) ltmalariaghdonlineorggt bull To davie musongwe simwaba ltdsimwabayahoocomgt bull Sent Friday 11 May 2012 344 PM bull Subject Re [Malaria Treatment amp Prevention] Mobile Phone-based Inventory Management bull Kenneth Rudd replied to the discussion Mobile Phone-based Inventory Management in the Malaria Treatment amp
Prevention community bull bull Reply contents
bull FYI there are now many initiatives to utilize mobile phones as a way to track and even provide sorts of ldquotelemedicinerdquo and we will likely see more as in more and more places the infrastructure for mobile phone technology is in places where there wonrsquot be internet access for a long time to come if ever I even saw a mounting device where smartphones can be mounted onto microscopes such that images can be sent via SMS
bull bull -Kenny bull
Data and Image Transfer Using Mobile Phones
Images sent by mobile internet
Feedback to sender by text message
Strengthen Microscopy-Based Diagnostic such as malaria tb bacterial vaginosis stool parasites and eggs
M for Microscope and Medical Monitoring mHealth
care Several initiatives have shown previously that mobile phones
can be used to take pictures through a microscope [812ndash14] or be
modified to serve asa microscope [1516] The next logical step isto send the captured imagesvia mobile networks for example to a
reference laboratory for confirmation of diagnosis by an expert
For this study we developed a system of mobile phone-basedimaging in combination with a data transfer and responseplatform We piloted the performance of this system in Uganda
and discussed itsacceptability and potential applications with localstakeholders
Methods
Ethics StatementEthicsapproval or written informed consent wasnot required as
this isa methodology proof of concept paper Our focuswas firstly
on capturing a microscopy image of sufficient quality and then onthe Information Technology (IT) part to send the captured image
using the mobile phone Patientsrsquo personal information or anysamples IDrsquos that might allow tracing of patients was not used
Informed consent for discussions with colleagues at the health
centers was obtained verbally prior to site visits
LocationIn Uganda the health system is based on a referral system
consisting of different levels I indicating the lowest and IV thehighest level at higher levels more facilities and expertise are
available [17] The image capture wascarried out by a laboratorytechnologist at the National Tuberculosis (TB) Reference Labo-
ratory (NTRL) in Kampala district two laboratory technicianstwo assistants and a student at Nkozi Hospital laboratory in Nkozi
Mpigi district and five laboratory assistants at several level III andIV health centers from both these districts The data transfer
system was tested by a laboratory technologist and a doctor at theInternational Hospital of Kampala (IHK) and by IT specialistsfrom a local IT company in Kampala
Materials usedLaboratory samplesfrom theday before or set aside for training
purposesor external quality control of the health center were used
in our study These could not be linked to patients in any waySamples were initially collected as part of the routine activities
of the laboratories and either made anonymous or -in the case ofblood slides for blood parasites- an unlabelled duplicate slide was
sometimes used In the case of urine we used a drop of urine thatwas placed on an unlabelled slide and put under the microscope
for examination
Slide preparationAt NTRL and the TB health centres the slides selected for this
study were sputum slides for TB training purposesor QC samples
were stained with Ziehl Neelsen Blood slidesfor malaria that wereused at Nkozi hospital and the health centres in the other sites
were stained with Giemsa staining technique Urine and stoolslides were unstained direct wet preparations Auramine staining
was used for the detection of TB in sputum by fluorescentmicroscopy Staining of samples was performed in a European
laboratory
Image capture systemThe system is composed of a traditional light microscope
connected via a connector used as a positioning device to a Java-enabled mobile phone with camera see Figure 1 The connector
prototype was designed prior to this feasibility study [8] For this
study we used the 406 and the 1006 oil immersion objectives ofthe Olympus CX 21 Olympus CX31 Olympus CX41 and
Humascope (Human) light microscopes and the 406 objectives ofthe Olympus CX21 FluoLED Olympus BX41 and Nikon AFX-
IIA fluorescent microscopes Different camera phones were usedmainly Nokia candy bar models see Table 1 for an overview The
image resolution varied from 03 megapixels (MP) to 5MP Onsome occasions the digital zoom of the mobile phone camera was
used to enlarge a specific area of the microscopy field and magnifythe micro-organism to be identified
Data transfer systemEnd user and server software of the image transfer system were
designed A draft form for use on the mobile phone wasdeveloped
for the end user to record ID sample type health center data andupload images from the mobile phone
An end user version of this software including mobile Internetwaspre-installed asan extra application on a Java enabled mobile
phone A server version of this image transfer system was installedlocally in Kampala Uganda We used Orange as our mobile
internet provider as they cover both Mpigi and Kampala districts[18] The end user recorded fictional information on the draft
form took the required picture(s) and pressed lsquolsquosendrsquorsquo The imagewas then sent automatically via the pre-installed mobile Internetconnection of the mobile phone stored in the database of the
central server and a confirmation text message that the image hadbeen received was sent to the end user Anyone with access to thecentral server could log on via an Internet page to this server and
examine the received image store it elsewhere or give instantfeedback via a text message or voice call to the end userrsquosphone
Additionally the image could be enlarged on the computer screenusing the digital zoom function of the computer in order to
magnify areas of interest
Testing procedures1 a Captur e of image without connector Laboratory staff
members at Nkozi hospital NTRL and the health centres were
Figure 1 The prototype connector which attaches a mobilephone to a microscope The prototype connector was designed byTU Delft and TNO The connector is adjustable to fit all sizes of candybar phones and some slide phones It also consists of adjustable screwsto fit most regular light microscopesdoi101371journalpone0028348g001
Mobile Phones to Support Microscopy Diagnosis
PLoS ONE | wwwplosoneorg 2 December 2011 | Volume 6 | Issue 12 | e28348
Sources Tuijn et al Data and Image Transfer Using Mobile Phones to Strengthen Microscopy-Based Diagnostic Services in Low and Middle Income Country Laboratories PLOS December 2011
Africa at the forefront of the global Mobile Money industry
Transfer credit between phones with a simple text message
Mobile money transfer allows those without a bank account to transfer funds as quickly and easily as sending a text message
M for Money transfer mPESA
mHealth and smartphones ndash for what for whom and to be used by whom
bull Mobile phones or smartphones were NOT primarily developed for medicine or health but for communication
bull Potentials for their application in medicine and health are enormous
bull Why are (some) researchers and health professionals a bit hesitant to apply mHealth
mHealth and Malaria ndash un-used and under-researched
bull PubMedgov Your search for mhealth and malaria retrieved no results (May 2012)
bull mhealth Results 52
bull mobile phones and malaria Results 11
bull mobile phones and pregnancy Results 75 but gt half of these on risk for fetus of microwaves
bull mobile phones and malaria and pregnancy
Your search for mhealth and malaria and pregnancy retrieved no results
Malaria in pregnancy research priorities by 2007 Lancet Infect Dis 2007 Feb7(2)169-74
Malaria in pregnancy priorities for research Greenwood B Alonso P ter Kuile FO Hill J Steketee RW
bull ldquoWe have selected the following as the highest priorities for research bull identification of new safe and effective drugs to treat malaria in
pregnancy bull identification of new drugs to replace sulfadoxine-pyrimethamine for
intermittent preventive treatment in pregnancy bull identification of optimum combinations of control measures in different
epidemiological settings bull and determination of optimum ways of scaling-up the use of insecticide-
treated mosquito nets and intermittent preventive treatmentrdquo bull p173
Integration of malaria control with reproductive health programmes ldquoAn important area of operational research is how malaria control can be integrated more effectively than in the past with reproductive health and other programmes directed at women of childbearing age
M for Malaria In Pregnancy and ANC Reaching the most remote and vulnerable
bull Q Would mHealth empower pregnant women to reach the health system
bull A probably cf lsquoWired Mothersrsquo
bull Q Would mHealth enable peripheral HCW to reach and refer to central health care levels
bull A probably cf lsquoWired Mothersrsquo amp lsquoD-Treersquo
bull Q Should we aim at a vertical intervention or
bull as an integrated part of ANC
Maternal Death and Assessment of Substandard Care in Relation to Obstetric Complications and Infections in a Rural HospitalNorth-Western Tanzania
Thesis D Damm 2012 lt 4 of Maternal Death caused by Malaria
All 4 ways of audit showed that of 84 women 30 died from infection 70 of these Puerperal Sepsis 10-20 other Severe infections of these 3 possibly malaria
MIP and mHealth as an opportunity to improve maternal and child health
bull MIP is a visible target
bull MIP control is prioritized by governments NGOs and donor agencies
bull MIP can be used as an effective rsquofoot in the doorrsquo for promoting maternal health so
bull MIP isshould be an integrated part of ANC and Child Care even if most women in malarious areas actually die from other causes and
bull mHealth for MIP should be an integrated part of ANC and Child Care
Words of warning bull Kaplan 2006
In developing world shared mobile telephone use is important
bull Sharing may be a serious drawback to use of mobile telephones as a healthcare intervention in terms of stigma and privacy
bull Regulatory reforms required if mobile phones be used for healthcare
bull Code of conduct available wwhonchHONcodeConducthtml
bull Maaloslashe Bygbjerg Onesmo et al 2012
bull The decision to perform an Emergency Cesarian Section [in Tanzanian rural hospital] was often made by a doctor being contacted by a nurse-midwife by telephone without the doctor examining the women which made the decision less qualified
Key words in the May issue WHO Bulletin
bull Evidence base for eHealth bull Credibility of electronic health technologies bull Impact of eHealth bull E-health in LMIC countries bull Telemedicine networks bull Infant diagnosis of HIV infection in Zambia through mobile phone bull Access to specialized health care bull Improving quality and use of data bull Sentinel surveillance of influenza in Madagascar bull mHealth for behaviour change bull Research agenda for the field of mHealth bull International collaboration in eHealth bull Public good of health research and development
Key words if linked with MIP
bull Evidence base for e-health on MIP bull Credibility of electronic health technologies for MIP bull Impact of eHealth on control MIP bull eHealth in LMIC countries applied on MIP bull Telemedicine networks for management of MIP bull Diagnosis of malaria in mother and infant in Africa through mobile phone bull Access to specialized health care for MIP in Africa bull Improving quality and use of data in MIP bull Sentinel surveillance of malaria in Africa bull mHealth for behaviour change in prevention and control of malaria in
Africa bull Research agenda for the field of mHealth in relation to malaria bull International collaboration in eHealth to control malaria bull Public good of health research and development using eHealth in malaria
control
OPPORTUNITIES Phone connections have more than tripled in 10 years
httpwwwenrecahealthdkarchivewiredmothers
PI Stine Lund MD ISIM
Wired Mothers Initiative mHealth
Very few studies of sufficient quality
Limited evidence of actual and wide-scale impactsoutcomes
Even less from developing countries
Wired Mothers mHealth study Background
Sources Noordam et al Improvement of maternal health servcies through the use of mobile phones Trop Med Int Health 2011 Tamrat et al An Analysis of mHealth in Maternal and Newborn Health Programs and Their Outcomes Around the World Matern Child Health J 2011
Wired Mothers Intervention
Community
bull Pregnant Women
Health Center
bull Midwife
Hospital
bull Doctor
bull Nurse
bull Ambulance
Person Person
Person Person
Text Messages
Health Education
Increased health attendances across the continuity of care
Urban women more than 5 times likely to delivery with SBA in intervention group
Did not reach significance in SBA amongst rural women
Increased adherence to procedures
Positive outcomes linked to intervention communication system
Intervention widely accepted amongst health workers and women
Wired Mothers Conclusions
bull Malaria Tanzania The prevalence of malaria among febrile children has gone down dramatically
bull While the treatment recommendations in IMCI have changed despite the evidence that only 10 of children may have malaria all these children are treated for malaria at great expense and risk D-tree together with the Swiss Tropical Institute are testing an innovative approach to the diagnosis and treatment of children with fever in Tanzania using hand held electronic decision support incorporating the use of RDTs for children that have fever We expect to show that it is feasible and necessary to
bull Revise procedures for the management of childhood illness (IMCI) incorporating more sophisticated clinical algorithms based on current evidence about disease patterns and drug resistance
bull Rapidly incorporate these changes into treatment algorithms in an electronic format and
bull Demonstrate improved clinical and cost-effectiveness of electronic algorithms when compared to the used of paper based IMCI algorithms
M for Malaria Management Ongoing discussion Mobile Phone-based Inventory management
in the Malaria Treatment amp Prevention community
bull From GHDonline (Kenneth Rudd) ltmalariaghdonlineorggt bull To davie musongwe simwaba ltdsimwabayahoocomgt bull Sent Friday 11 May 2012 344 PM bull Subject Re [Malaria Treatment amp Prevention] Mobile Phone-based Inventory Management bull Kenneth Rudd replied to the discussion Mobile Phone-based Inventory Management in the Malaria Treatment amp
Prevention community bull bull Reply contents
bull FYI there are now many initiatives to utilize mobile phones as a way to track and even provide sorts of ldquotelemedicinerdquo and we will likely see more as in more and more places the infrastructure for mobile phone technology is in places where there wonrsquot be internet access for a long time to come if ever I even saw a mounting device where smartphones can be mounted onto microscopes such that images can be sent via SMS
bull bull -Kenny bull
Data and Image Transfer Using Mobile Phones
Images sent by mobile internet
Feedback to sender by text message
Strengthen Microscopy-Based Diagnostic such as malaria tb bacterial vaginosis stool parasites and eggs
M for Microscope and Medical Monitoring mHealth
care Several initiatives have shown previously that mobile phones
can be used to take pictures through a microscope [812ndash14] or be
modified to serve asa microscope [1516] The next logical step isto send the captured imagesvia mobile networks for example to a
reference laboratory for confirmation of diagnosis by an expert
For this study we developed a system of mobile phone-basedimaging in combination with a data transfer and responseplatform We piloted the performance of this system in Uganda
and discussed itsacceptability and potential applications with localstakeholders
Methods
Ethics StatementEthicsapproval or written informed consent wasnot required as
this isa methodology proof of concept paper Our focuswas firstly
on capturing a microscopy image of sufficient quality and then onthe Information Technology (IT) part to send the captured image
using the mobile phone Patientsrsquo personal information or anysamples IDrsquos that might allow tracing of patients was not used
Informed consent for discussions with colleagues at the health
centers was obtained verbally prior to site visits
LocationIn Uganda the health system is based on a referral system
consisting of different levels I indicating the lowest and IV thehighest level at higher levels more facilities and expertise are
available [17] The image capture wascarried out by a laboratorytechnologist at the National Tuberculosis (TB) Reference Labo-
ratory (NTRL) in Kampala district two laboratory technicianstwo assistants and a student at Nkozi Hospital laboratory in Nkozi
Mpigi district and five laboratory assistants at several level III andIV health centers from both these districts The data transfer
system was tested by a laboratory technologist and a doctor at theInternational Hospital of Kampala (IHK) and by IT specialistsfrom a local IT company in Kampala
Materials usedLaboratory samplesfrom theday before or set aside for training
purposesor external quality control of the health center were used
in our study These could not be linked to patients in any waySamples were initially collected as part of the routine activities
of the laboratories and either made anonymous or -in the case ofblood slides for blood parasites- an unlabelled duplicate slide was
sometimes used In the case of urine we used a drop of urine thatwas placed on an unlabelled slide and put under the microscope
for examination
Slide preparationAt NTRL and the TB health centres the slides selected for this
study were sputum slides for TB training purposesor QC samples
were stained with Ziehl Neelsen Blood slidesfor malaria that wereused at Nkozi hospital and the health centres in the other sites
were stained with Giemsa staining technique Urine and stoolslides were unstained direct wet preparations Auramine staining
was used for the detection of TB in sputum by fluorescentmicroscopy Staining of samples was performed in a European
laboratory
Image capture systemThe system is composed of a traditional light microscope
connected via a connector used as a positioning device to a Java-enabled mobile phone with camera see Figure 1 The connector
prototype was designed prior to this feasibility study [8] For this
study we used the 406 and the 1006 oil immersion objectives ofthe Olympus CX 21 Olympus CX31 Olympus CX41 and
Humascope (Human) light microscopes and the 406 objectives ofthe Olympus CX21 FluoLED Olympus BX41 and Nikon AFX-
IIA fluorescent microscopes Different camera phones were usedmainly Nokia candy bar models see Table 1 for an overview The
image resolution varied from 03 megapixels (MP) to 5MP Onsome occasions the digital zoom of the mobile phone camera was
used to enlarge a specific area of the microscopy field and magnifythe micro-organism to be identified
Data transfer systemEnd user and server software of the image transfer system were
designed A draft form for use on the mobile phone wasdeveloped
for the end user to record ID sample type health center data andupload images from the mobile phone
An end user version of this software including mobile Internetwaspre-installed asan extra application on a Java enabled mobile
phone A server version of this image transfer system was installedlocally in Kampala Uganda We used Orange as our mobile
internet provider as they cover both Mpigi and Kampala districts[18] The end user recorded fictional information on the draft
form took the required picture(s) and pressed lsquolsquosendrsquorsquo The imagewas then sent automatically via the pre-installed mobile Internetconnection of the mobile phone stored in the database of the
central server and a confirmation text message that the image hadbeen received was sent to the end user Anyone with access to thecentral server could log on via an Internet page to this server and
examine the received image store it elsewhere or give instantfeedback via a text message or voice call to the end userrsquosphone
Additionally the image could be enlarged on the computer screenusing the digital zoom function of the computer in order to
magnify areas of interest
Testing procedures1 a Captur e of image without connector Laboratory staff
members at Nkozi hospital NTRL and the health centres were
Figure 1 The prototype connector which attaches a mobilephone to a microscope The prototype connector was designed byTU Delft and TNO The connector is adjustable to fit all sizes of candybar phones and some slide phones It also consists of adjustable screwsto fit most regular light microscopesdoi101371journalpone0028348g001
Mobile Phones to Support Microscopy Diagnosis
PLoS ONE | wwwplosoneorg 2 December 2011 | Volume 6 | Issue 12 | e28348
Sources Tuijn et al Data and Image Transfer Using Mobile Phones to Strengthen Microscopy-Based Diagnostic Services in Low and Middle Income Country Laboratories PLOS December 2011
Africa at the forefront of the global Mobile Money industry
Transfer credit between phones with a simple text message
Mobile money transfer allows those without a bank account to transfer funds as quickly and easily as sending a text message
M for Money transfer mPESA
mHealth and smartphones ndash for what for whom and to be used by whom
bull Mobile phones or smartphones were NOT primarily developed for medicine or health but for communication
bull Potentials for their application in medicine and health are enormous
bull Why are (some) researchers and health professionals a bit hesitant to apply mHealth
mHealth and Malaria ndash un-used and under-researched
bull PubMedgov Your search for mhealth and malaria retrieved no results (May 2012)
bull mhealth Results 52
bull mobile phones and malaria Results 11
bull mobile phones and pregnancy Results 75 but gt half of these on risk for fetus of microwaves
bull mobile phones and malaria and pregnancy
Your search for mhealth and malaria and pregnancy retrieved no results
Malaria in pregnancy research priorities by 2007 Lancet Infect Dis 2007 Feb7(2)169-74
Malaria in pregnancy priorities for research Greenwood B Alonso P ter Kuile FO Hill J Steketee RW
bull ldquoWe have selected the following as the highest priorities for research bull identification of new safe and effective drugs to treat malaria in
pregnancy bull identification of new drugs to replace sulfadoxine-pyrimethamine for
intermittent preventive treatment in pregnancy bull identification of optimum combinations of control measures in different
epidemiological settings bull and determination of optimum ways of scaling-up the use of insecticide-
treated mosquito nets and intermittent preventive treatmentrdquo bull p173
Integration of malaria control with reproductive health programmes ldquoAn important area of operational research is how malaria control can be integrated more effectively than in the past with reproductive health and other programmes directed at women of childbearing age
M for Malaria In Pregnancy and ANC Reaching the most remote and vulnerable
bull Q Would mHealth empower pregnant women to reach the health system
bull A probably cf lsquoWired Mothersrsquo
bull Q Would mHealth enable peripheral HCW to reach and refer to central health care levels
bull A probably cf lsquoWired Mothersrsquo amp lsquoD-Treersquo
bull Q Should we aim at a vertical intervention or
bull as an integrated part of ANC
Maternal Death and Assessment of Substandard Care in Relation to Obstetric Complications and Infections in a Rural HospitalNorth-Western Tanzania
Thesis D Damm 2012 lt 4 of Maternal Death caused by Malaria
All 4 ways of audit showed that of 84 women 30 died from infection 70 of these Puerperal Sepsis 10-20 other Severe infections of these 3 possibly malaria
MIP and mHealth as an opportunity to improve maternal and child health
bull MIP is a visible target
bull MIP control is prioritized by governments NGOs and donor agencies
bull MIP can be used as an effective rsquofoot in the doorrsquo for promoting maternal health so
bull MIP isshould be an integrated part of ANC and Child Care even if most women in malarious areas actually die from other causes and
bull mHealth for MIP should be an integrated part of ANC and Child Care
Words of warning bull Kaplan 2006
In developing world shared mobile telephone use is important
bull Sharing may be a serious drawback to use of mobile telephones as a healthcare intervention in terms of stigma and privacy
bull Regulatory reforms required if mobile phones be used for healthcare
bull Code of conduct available wwhonchHONcodeConducthtml
bull Maaloslashe Bygbjerg Onesmo et al 2012
bull The decision to perform an Emergency Cesarian Section [in Tanzanian rural hospital] was often made by a doctor being contacted by a nurse-midwife by telephone without the doctor examining the women which made the decision less qualified
Key words if linked with MIP
bull Evidence base for e-health on MIP bull Credibility of electronic health technologies for MIP bull Impact of eHealth on control MIP bull eHealth in LMIC countries applied on MIP bull Telemedicine networks for management of MIP bull Diagnosis of malaria in mother and infant in Africa through mobile phone bull Access to specialized health care for MIP in Africa bull Improving quality and use of data in MIP bull Sentinel surveillance of malaria in Africa bull mHealth for behaviour change in prevention and control of malaria in
Africa bull Research agenda for the field of mHealth in relation to malaria bull International collaboration in eHealth to control malaria bull Public good of health research and development using eHealth in malaria
control
OPPORTUNITIES Phone connections have more than tripled in 10 years
httpwwwenrecahealthdkarchivewiredmothers
PI Stine Lund MD ISIM
Wired Mothers Initiative mHealth
Very few studies of sufficient quality
Limited evidence of actual and wide-scale impactsoutcomes
Even less from developing countries
Wired Mothers mHealth study Background
Sources Noordam et al Improvement of maternal health servcies through the use of mobile phones Trop Med Int Health 2011 Tamrat et al An Analysis of mHealth in Maternal and Newborn Health Programs and Their Outcomes Around the World Matern Child Health J 2011
Wired Mothers Intervention
Community
bull Pregnant Women
Health Center
bull Midwife
Hospital
bull Doctor
bull Nurse
bull Ambulance
Person Person
Person Person
Text Messages
Health Education
Increased health attendances across the continuity of care
Urban women more than 5 times likely to delivery with SBA in intervention group
Did not reach significance in SBA amongst rural women
Increased adherence to procedures
Positive outcomes linked to intervention communication system
Intervention widely accepted amongst health workers and women
Wired Mothers Conclusions
bull Malaria Tanzania The prevalence of malaria among febrile children has gone down dramatically
bull While the treatment recommendations in IMCI have changed despite the evidence that only 10 of children may have malaria all these children are treated for malaria at great expense and risk D-tree together with the Swiss Tropical Institute are testing an innovative approach to the diagnosis and treatment of children with fever in Tanzania using hand held electronic decision support incorporating the use of RDTs for children that have fever We expect to show that it is feasible and necessary to
bull Revise procedures for the management of childhood illness (IMCI) incorporating more sophisticated clinical algorithms based on current evidence about disease patterns and drug resistance
bull Rapidly incorporate these changes into treatment algorithms in an electronic format and
bull Demonstrate improved clinical and cost-effectiveness of electronic algorithms when compared to the used of paper based IMCI algorithms
M for Malaria Management Ongoing discussion Mobile Phone-based Inventory management
in the Malaria Treatment amp Prevention community
bull From GHDonline (Kenneth Rudd) ltmalariaghdonlineorggt bull To davie musongwe simwaba ltdsimwabayahoocomgt bull Sent Friday 11 May 2012 344 PM bull Subject Re [Malaria Treatment amp Prevention] Mobile Phone-based Inventory Management bull Kenneth Rudd replied to the discussion Mobile Phone-based Inventory Management in the Malaria Treatment amp
Prevention community bull bull Reply contents
bull FYI there are now many initiatives to utilize mobile phones as a way to track and even provide sorts of ldquotelemedicinerdquo and we will likely see more as in more and more places the infrastructure for mobile phone technology is in places where there wonrsquot be internet access for a long time to come if ever I even saw a mounting device where smartphones can be mounted onto microscopes such that images can be sent via SMS
bull bull -Kenny bull
Data and Image Transfer Using Mobile Phones
Images sent by mobile internet
Feedback to sender by text message
Strengthen Microscopy-Based Diagnostic such as malaria tb bacterial vaginosis stool parasites and eggs
M for Microscope and Medical Monitoring mHealth
care Several initiatives have shown previously that mobile phones
can be used to take pictures through a microscope [812ndash14] or be
modified to serve asa microscope [1516] The next logical step isto send the captured imagesvia mobile networks for example to a
reference laboratory for confirmation of diagnosis by an expert
For this study we developed a system of mobile phone-basedimaging in combination with a data transfer and responseplatform We piloted the performance of this system in Uganda
and discussed itsacceptability and potential applications with localstakeholders
Methods
Ethics StatementEthicsapproval or written informed consent wasnot required as
this isa methodology proof of concept paper Our focuswas firstly
on capturing a microscopy image of sufficient quality and then onthe Information Technology (IT) part to send the captured image
using the mobile phone Patientsrsquo personal information or anysamples IDrsquos that might allow tracing of patients was not used
Informed consent for discussions with colleagues at the health
centers was obtained verbally prior to site visits
LocationIn Uganda the health system is based on a referral system
consisting of different levels I indicating the lowest and IV thehighest level at higher levels more facilities and expertise are
available [17] The image capture wascarried out by a laboratorytechnologist at the National Tuberculosis (TB) Reference Labo-
ratory (NTRL) in Kampala district two laboratory technicianstwo assistants and a student at Nkozi Hospital laboratory in Nkozi
Mpigi district and five laboratory assistants at several level III andIV health centers from both these districts The data transfer
system was tested by a laboratory technologist and a doctor at theInternational Hospital of Kampala (IHK) and by IT specialistsfrom a local IT company in Kampala
Materials usedLaboratory samplesfrom theday before or set aside for training
purposesor external quality control of the health center were used
in our study These could not be linked to patients in any waySamples were initially collected as part of the routine activities
of the laboratories and either made anonymous or -in the case ofblood slides for blood parasites- an unlabelled duplicate slide was
sometimes used In the case of urine we used a drop of urine thatwas placed on an unlabelled slide and put under the microscope
for examination
Slide preparationAt NTRL and the TB health centres the slides selected for this
study were sputum slides for TB training purposesor QC samples
were stained with Ziehl Neelsen Blood slidesfor malaria that wereused at Nkozi hospital and the health centres in the other sites
were stained with Giemsa staining technique Urine and stoolslides were unstained direct wet preparations Auramine staining
was used for the detection of TB in sputum by fluorescentmicroscopy Staining of samples was performed in a European
laboratory
Image capture systemThe system is composed of a traditional light microscope
connected via a connector used as a positioning device to a Java-enabled mobile phone with camera see Figure 1 The connector
prototype was designed prior to this feasibility study [8] For this
study we used the 406 and the 1006 oil immersion objectives ofthe Olympus CX 21 Olympus CX31 Olympus CX41 and
Humascope (Human) light microscopes and the 406 objectives ofthe Olympus CX21 FluoLED Olympus BX41 and Nikon AFX-
IIA fluorescent microscopes Different camera phones were usedmainly Nokia candy bar models see Table 1 for an overview The
image resolution varied from 03 megapixels (MP) to 5MP Onsome occasions the digital zoom of the mobile phone camera was
used to enlarge a specific area of the microscopy field and magnifythe micro-organism to be identified
Data transfer systemEnd user and server software of the image transfer system were
designed A draft form for use on the mobile phone wasdeveloped
for the end user to record ID sample type health center data andupload images from the mobile phone
An end user version of this software including mobile Internetwaspre-installed asan extra application on a Java enabled mobile
phone A server version of this image transfer system was installedlocally in Kampala Uganda We used Orange as our mobile
internet provider as they cover both Mpigi and Kampala districts[18] The end user recorded fictional information on the draft
form took the required picture(s) and pressed lsquolsquosendrsquorsquo The imagewas then sent automatically via the pre-installed mobile Internetconnection of the mobile phone stored in the database of the
central server and a confirmation text message that the image hadbeen received was sent to the end user Anyone with access to thecentral server could log on via an Internet page to this server and
examine the received image store it elsewhere or give instantfeedback via a text message or voice call to the end userrsquosphone
Additionally the image could be enlarged on the computer screenusing the digital zoom function of the computer in order to
magnify areas of interest
Testing procedures1 a Captur e of image without connector Laboratory staff
members at Nkozi hospital NTRL and the health centres were
Figure 1 The prototype connector which attaches a mobilephone to a microscope The prototype connector was designed byTU Delft and TNO The connector is adjustable to fit all sizes of candybar phones and some slide phones It also consists of adjustable screwsto fit most regular light microscopesdoi101371journalpone0028348g001
Mobile Phones to Support Microscopy Diagnosis
PLoS ONE | wwwplosoneorg 2 December 2011 | Volume 6 | Issue 12 | e28348
Sources Tuijn et al Data and Image Transfer Using Mobile Phones to Strengthen Microscopy-Based Diagnostic Services in Low and Middle Income Country Laboratories PLOS December 2011
Africa at the forefront of the global Mobile Money industry
Transfer credit between phones with a simple text message
Mobile money transfer allows those without a bank account to transfer funds as quickly and easily as sending a text message
M for Money transfer mPESA
mHealth and smartphones ndash for what for whom and to be used by whom
bull Mobile phones or smartphones were NOT primarily developed for medicine or health but for communication
bull Potentials for their application in medicine and health are enormous
bull Why are (some) researchers and health professionals a bit hesitant to apply mHealth
mHealth and Malaria ndash un-used and under-researched
bull PubMedgov Your search for mhealth and malaria retrieved no results (May 2012)
bull mhealth Results 52
bull mobile phones and malaria Results 11
bull mobile phones and pregnancy Results 75 but gt half of these on risk for fetus of microwaves
bull mobile phones and malaria and pregnancy
Your search for mhealth and malaria and pregnancy retrieved no results
Malaria in pregnancy research priorities by 2007 Lancet Infect Dis 2007 Feb7(2)169-74
Malaria in pregnancy priorities for research Greenwood B Alonso P ter Kuile FO Hill J Steketee RW
bull ldquoWe have selected the following as the highest priorities for research bull identification of new safe and effective drugs to treat malaria in
pregnancy bull identification of new drugs to replace sulfadoxine-pyrimethamine for
intermittent preventive treatment in pregnancy bull identification of optimum combinations of control measures in different
epidemiological settings bull and determination of optimum ways of scaling-up the use of insecticide-
treated mosquito nets and intermittent preventive treatmentrdquo bull p173
Integration of malaria control with reproductive health programmes ldquoAn important area of operational research is how malaria control can be integrated more effectively than in the past with reproductive health and other programmes directed at women of childbearing age
M for Malaria In Pregnancy and ANC Reaching the most remote and vulnerable
bull Q Would mHealth empower pregnant women to reach the health system
bull A probably cf lsquoWired Mothersrsquo
bull Q Would mHealth enable peripheral HCW to reach and refer to central health care levels
bull A probably cf lsquoWired Mothersrsquo amp lsquoD-Treersquo
bull Q Should we aim at a vertical intervention or
bull as an integrated part of ANC
Maternal Death and Assessment of Substandard Care in Relation to Obstetric Complications and Infections in a Rural HospitalNorth-Western Tanzania
Thesis D Damm 2012 lt 4 of Maternal Death caused by Malaria
All 4 ways of audit showed that of 84 women 30 died from infection 70 of these Puerperal Sepsis 10-20 other Severe infections of these 3 possibly malaria
MIP and mHealth as an opportunity to improve maternal and child health
bull MIP is a visible target
bull MIP control is prioritized by governments NGOs and donor agencies
bull MIP can be used as an effective rsquofoot in the doorrsquo for promoting maternal health so
bull MIP isshould be an integrated part of ANC and Child Care even if most women in malarious areas actually die from other causes and
bull mHealth for MIP should be an integrated part of ANC and Child Care
Words of warning bull Kaplan 2006
In developing world shared mobile telephone use is important
bull Sharing may be a serious drawback to use of mobile telephones as a healthcare intervention in terms of stigma and privacy
bull Regulatory reforms required if mobile phones be used for healthcare
bull Code of conduct available wwhonchHONcodeConducthtml
bull Maaloslashe Bygbjerg Onesmo et al 2012
bull The decision to perform an Emergency Cesarian Section [in Tanzanian rural hospital] was often made by a doctor being contacted by a nurse-midwife by telephone without the doctor examining the women which made the decision less qualified
OPPORTUNITIES Phone connections have more than tripled in 10 years
httpwwwenrecahealthdkarchivewiredmothers
PI Stine Lund MD ISIM
Wired Mothers Initiative mHealth
Very few studies of sufficient quality
Limited evidence of actual and wide-scale impactsoutcomes
Even less from developing countries
Wired Mothers mHealth study Background
Sources Noordam et al Improvement of maternal health servcies through the use of mobile phones Trop Med Int Health 2011 Tamrat et al An Analysis of mHealth in Maternal and Newborn Health Programs and Their Outcomes Around the World Matern Child Health J 2011
Wired Mothers Intervention
Community
bull Pregnant Women
Health Center
bull Midwife
Hospital
bull Doctor
bull Nurse
bull Ambulance
Person Person
Person Person
Text Messages
Health Education
Increased health attendances across the continuity of care
Urban women more than 5 times likely to delivery with SBA in intervention group
Did not reach significance in SBA amongst rural women
Increased adherence to procedures
Positive outcomes linked to intervention communication system
Intervention widely accepted amongst health workers and women
Wired Mothers Conclusions
bull Malaria Tanzania The prevalence of malaria among febrile children has gone down dramatically
bull While the treatment recommendations in IMCI have changed despite the evidence that only 10 of children may have malaria all these children are treated for malaria at great expense and risk D-tree together with the Swiss Tropical Institute are testing an innovative approach to the diagnosis and treatment of children with fever in Tanzania using hand held electronic decision support incorporating the use of RDTs for children that have fever We expect to show that it is feasible and necessary to
bull Revise procedures for the management of childhood illness (IMCI) incorporating more sophisticated clinical algorithms based on current evidence about disease patterns and drug resistance
bull Rapidly incorporate these changes into treatment algorithms in an electronic format and
bull Demonstrate improved clinical and cost-effectiveness of electronic algorithms when compared to the used of paper based IMCI algorithms
M for Malaria Management Ongoing discussion Mobile Phone-based Inventory management
in the Malaria Treatment amp Prevention community
bull From GHDonline (Kenneth Rudd) ltmalariaghdonlineorggt bull To davie musongwe simwaba ltdsimwabayahoocomgt bull Sent Friday 11 May 2012 344 PM bull Subject Re [Malaria Treatment amp Prevention] Mobile Phone-based Inventory Management bull Kenneth Rudd replied to the discussion Mobile Phone-based Inventory Management in the Malaria Treatment amp
Prevention community bull bull Reply contents
bull FYI there are now many initiatives to utilize mobile phones as a way to track and even provide sorts of ldquotelemedicinerdquo and we will likely see more as in more and more places the infrastructure for mobile phone technology is in places where there wonrsquot be internet access for a long time to come if ever I even saw a mounting device where smartphones can be mounted onto microscopes such that images can be sent via SMS
bull bull -Kenny bull
Data and Image Transfer Using Mobile Phones
Images sent by mobile internet
Feedback to sender by text message
Strengthen Microscopy-Based Diagnostic such as malaria tb bacterial vaginosis stool parasites and eggs
M for Microscope and Medical Monitoring mHealth
care Several initiatives have shown previously that mobile phones
can be used to take pictures through a microscope [812ndash14] or be
modified to serve asa microscope [1516] The next logical step isto send the captured imagesvia mobile networks for example to a
reference laboratory for confirmation of diagnosis by an expert
For this study we developed a system of mobile phone-basedimaging in combination with a data transfer and responseplatform We piloted the performance of this system in Uganda
and discussed itsacceptability and potential applications with localstakeholders
Methods
Ethics StatementEthicsapproval or written informed consent wasnot required as
this isa methodology proof of concept paper Our focuswas firstly
on capturing a microscopy image of sufficient quality and then onthe Information Technology (IT) part to send the captured image
using the mobile phone Patientsrsquo personal information or anysamples IDrsquos that might allow tracing of patients was not used
Informed consent for discussions with colleagues at the health
centers was obtained verbally prior to site visits
LocationIn Uganda the health system is based on a referral system
consisting of different levels I indicating the lowest and IV thehighest level at higher levels more facilities and expertise are
available [17] The image capture wascarried out by a laboratorytechnologist at the National Tuberculosis (TB) Reference Labo-
ratory (NTRL) in Kampala district two laboratory technicianstwo assistants and a student at Nkozi Hospital laboratory in Nkozi
Mpigi district and five laboratory assistants at several level III andIV health centers from both these districts The data transfer
system was tested by a laboratory technologist and a doctor at theInternational Hospital of Kampala (IHK) and by IT specialistsfrom a local IT company in Kampala
Materials usedLaboratory samplesfrom theday before or set aside for training
purposesor external quality control of the health center were used
in our study These could not be linked to patients in any waySamples were initially collected as part of the routine activities
of the laboratories and either made anonymous or -in the case ofblood slides for blood parasites- an unlabelled duplicate slide was
sometimes used In the case of urine we used a drop of urine thatwas placed on an unlabelled slide and put under the microscope
for examination
Slide preparationAt NTRL and the TB health centres the slides selected for this
study were sputum slides for TB training purposesor QC samples
were stained with Ziehl Neelsen Blood slidesfor malaria that wereused at Nkozi hospital and the health centres in the other sites
were stained with Giemsa staining technique Urine and stoolslides were unstained direct wet preparations Auramine staining
was used for the detection of TB in sputum by fluorescentmicroscopy Staining of samples was performed in a European
laboratory
Image capture systemThe system is composed of a traditional light microscope
connected via a connector used as a positioning device to a Java-enabled mobile phone with camera see Figure 1 The connector
prototype was designed prior to this feasibility study [8] For this
study we used the 406 and the 1006 oil immersion objectives ofthe Olympus CX 21 Olympus CX31 Olympus CX41 and
Humascope (Human) light microscopes and the 406 objectives ofthe Olympus CX21 FluoLED Olympus BX41 and Nikon AFX-
IIA fluorescent microscopes Different camera phones were usedmainly Nokia candy bar models see Table 1 for an overview The
image resolution varied from 03 megapixels (MP) to 5MP Onsome occasions the digital zoom of the mobile phone camera was
used to enlarge a specific area of the microscopy field and magnifythe micro-organism to be identified
Data transfer systemEnd user and server software of the image transfer system were
designed A draft form for use on the mobile phone wasdeveloped
for the end user to record ID sample type health center data andupload images from the mobile phone
An end user version of this software including mobile Internetwaspre-installed asan extra application on a Java enabled mobile
phone A server version of this image transfer system was installedlocally in Kampala Uganda We used Orange as our mobile
internet provider as they cover both Mpigi and Kampala districts[18] The end user recorded fictional information on the draft
form took the required picture(s) and pressed lsquolsquosendrsquorsquo The imagewas then sent automatically via the pre-installed mobile Internetconnection of the mobile phone stored in the database of the
central server and a confirmation text message that the image hadbeen received was sent to the end user Anyone with access to thecentral server could log on via an Internet page to this server and
examine the received image store it elsewhere or give instantfeedback via a text message or voice call to the end userrsquosphone
Additionally the image could be enlarged on the computer screenusing the digital zoom function of the computer in order to
magnify areas of interest
Testing procedures1 a Captur e of image without connector Laboratory staff
members at Nkozi hospital NTRL and the health centres were
Figure 1 The prototype connector which attaches a mobilephone to a microscope The prototype connector was designed byTU Delft and TNO The connector is adjustable to fit all sizes of candybar phones and some slide phones It also consists of adjustable screwsto fit most regular light microscopesdoi101371journalpone0028348g001
Mobile Phones to Support Microscopy Diagnosis
PLoS ONE | wwwplosoneorg 2 December 2011 | Volume 6 | Issue 12 | e28348
Sources Tuijn et al Data and Image Transfer Using Mobile Phones to Strengthen Microscopy-Based Diagnostic Services in Low and Middle Income Country Laboratories PLOS December 2011
Africa at the forefront of the global Mobile Money industry
Transfer credit between phones with a simple text message
Mobile money transfer allows those without a bank account to transfer funds as quickly and easily as sending a text message
M for Money transfer mPESA
mHealth and smartphones ndash for what for whom and to be used by whom
bull Mobile phones or smartphones were NOT primarily developed for medicine or health but for communication
bull Potentials for their application in medicine and health are enormous
bull Why are (some) researchers and health professionals a bit hesitant to apply mHealth
mHealth and Malaria ndash un-used and under-researched
bull PubMedgov Your search for mhealth and malaria retrieved no results (May 2012)
bull mhealth Results 52
bull mobile phones and malaria Results 11
bull mobile phones and pregnancy Results 75 but gt half of these on risk for fetus of microwaves
bull mobile phones and malaria and pregnancy
Your search for mhealth and malaria and pregnancy retrieved no results
Malaria in pregnancy research priorities by 2007 Lancet Infect Dis 2007 Feb7(2)169-74
Malaria in pregnancy priorities for research Greenwood B Alonso P ter Kuile FO Hill J Steketee RW
bull ldquoWe have selected the following as the highest priorities for research bull identification of new safe and effective drugs to treat malaria in
pregnancy bull identification of new drugs to replace sulfadoxine-pyrimethamine for
intermittent preventive treatment in pregnancy bull identification of optimum combinations of control measures in different
epidemiological settings bull and determination of optimum ways of scaling-up the use of insecticide-
treated mosquito nets and intermittent preventive treatmentrdquo bull p173
Integration of malaria control with reproductive health programmes ldquoAn important area of operational research is how malaria control can be integrated more effectively than in the past with reproductive health and other programmes directed at women of childbearing age
M for Malaria In Pregnancy and ANC Reaching the most remote and vulnerable
bull Q Would mHealth empower pregnant women to reach the health system
bull A probably cf lsquoWired Mothersrsquo
bull Q Would mHealth enable peripheral HCW to reach and refer to central health care levels
bull A probably cf lsquoWired Mothersrsquo amp lsquoD-Treersquo
bull Q Should we aim at a vertical intervention or
bull as an integrated part of ANC
Maternal Death and Assessment of Substandard Care in Relation to Obstetric Complications and Infections in a Rural HospitalNorth-Western Tanzania
Thesis D Damm 2012 lt 4 of Maternal Death caused by Malaria
All 4 ways of audit showed that of 84 women 30 died from infection 70 of these Puerperal Sepsis 10-20 other Severe infections of these 3 possibly malaria
MIP and mHealth as an opportunity to improve maternal and child health
bull MIP is a visible target
bull MIP control is prioritized by governments NGOs and donor agencies
bull MIP can be used as an effective rsquofoot in the doorrsquo for promoting maternal health so
bull MIP isshould be an integrated part of ANC and Child Care even if most women in malarious areas actually die from other causes and
bull mHealth for MIP should be an integrated part of ANC and Child Care
Words of warning bull Kaplan 2006
In developing world shared mobile telephone use is important
bull Sharing may be a serious drawback to use of mobile telephones as a healthcare intervention in terms of stigma and privacy
bull Regulatory reforms required if mobile phones be used for healthcare
bull Code of conduct available wwhonchHONcodeConducthtml
bull Maaloslashe Bygbjerg Onesmo et al 2012
bull The decision to perform an Emergency Cesarian Section [in Tanzanian rural hospital] was often made by a doctor being contacted by a nurse-midwife by telephone without the doctor examining the women which made the decision less qualified
httpwwwenrecahealthdkarchivewiredmothers
PI Stine Lund MD ISIM
Wired Mothers Initiative mHealth
Very few studies of sufficient quality
Limited evidence of actual and wide-scale impactsoutcomes
Even less from developing countries
Wired Mothers mHealth study Background
Sources Noordam et al Improvement of maternal health servcies through the use of mobile phones Trop Med Int Health 2011 Tamrat et al An Analysis of mHealth in Maternal and Newborn Health Programs and Their Outcomes Around the World Matern Child Health J 2011
Wired Mothers Intervention
Community
bull Pregnant Women
Health Center
bull Midwife
Hospital
bull Doctor
bull Nurse
bull Ambulance
Person Person
Person Person
Text Messages
Health Education
Increased health attendances across the continuity of care
Urban women more than 5 times likely to delivery with SBA in intervention group
Did not reach significance in SBA amongst rural women
Increased adherence to procedures
Positive outcomes linked to intervention communication system
Intervention widely accepted amongst health workers and women
Wired Mothers Conclusions
bull Malaria Tanzania The prevalence of malaria among febrile children has gone down dramatically
bull While the treatment recommendations in IMCI have changed despite the evidence that only 10 of children may have malaria all these children are treated for malaria at great expense and risk D-tree together with the Swiss Tropical Institute are testing an innovative approach to the diagnosis and treatment of children with fever in Tanzania using hand held electronic decision support incorporating the use of RDTs for children that have fever We expect to show that it is feasible and necessary to
bull Revise procedures for the management of childhood illness (IMCI) incorporating more sophisticated clinical algorithms based on current evidence about disease patterns and drug resistance
bull Rapidly incorporate these changes into treatment algorithms in an electronic format and
bull Demonstrate improved clinical and cost-effectiveness of electronic algorithms when compared to the used of paper based IMCI algorithms
M for Malaria Management Ongoing discussion Mobile Phone-based Inventory management
in the Malaria Treatment amp Prevention community
bull From GHDonline (Kenneth Rudd) ltmalariaghdonlineorggt bull To davie musongwe simwaba ltdsimwabayahoocomgt bull Sent Friday 11 May 2012 344 PM bull Subject Re [Malaria Treatment amp Prevention] Mobile Phone-based Inventory Management bull Kenneth Rudd replied to the discussion Mobile Phone-based Inventory Management in the Malaria Treatment amp
Prevention community bull bull Reply contents
bull FYI there are now many initiatives to utilize mobile phones as a way to track and even provide sorts of ldquotelemedicinerdquo and we will likely see more as in more and more places the infrastructure for mobile phone technology is in places where there wonrsquot be internet access for a long time to come if ever I even saw a mounting device where smartphones can be mounted onto microscopes such that images can be sent via SMS
bull bull -Kenny bull
Data and Image Transfer Using Mobile Phones
Images sent by mobile internet
Feedback to sender by text message
Strengthen Microscopy-Based Diagnostic such as malaria tb bacterial vaginosis stool parasites and eggs
M for Microscope and Medical Monitoring mHealth
care Several initiatives have shown previously that mobile phones
can be used to take pictures through a microscope [812ndash14] or be
modified to serve asa microscope [1516] The next logical step isto send the captured imagesvia mobile networks for example to a
reference laboratory for confirmation of diagnosis by an expert
For this study we developed a system of mobile phone-basedimaging in combination with a data transfer and responseplatform We piloted the performance of this system in Uganda
and discussed itsacceptability and potential applications with localstakeholders
Methods
Ethics StatementEthicsapproval or written informed consent wasnot required as
this isa methodology proof of concept paper Our focuswas firstly
on capturing a microscopy image of sufficient quality and then onthe Information Technology (IT) part to send the captured image
using the mobile phone Patientsrsquo personal information or anysamples IDrsquos that might allow tracing of patients was not used
Informed consent for discussions with colleagues at the health
centers was obtained verbally prior to site visits
LocationIn Uganda the health system is based on a referral system
consisting of different levels I indicating the lowest and IV thehighest level at higher levels more facilities and expertise are
available [17] The image capture wascarried out by a laboratorytechnologist at the National Tuberculosis (TB) Reference Labo-
ratory (NTRL) in Kampala district two laboratory technicianstwo assistants and a student at Nkozi Hospital laboratory in Nkozi
Mpigi district and five laboratory assistants at several level III andIV health centers from both these districts The data transfer
system was tested by a laboratory technologist and a doctor at theInternational Hospital of Kampala (IHK) and by IT specialistsfrom a local IT company in Kampala
Materials usedLaboratory samplesfrom theday before or set aside for training
purposesor external quality control of the health center were used
in our study These could not be linked to patients in any waySamples were initially collected as part of the routine activities
of the laboratories and either made anonymous or -in the case ofblood slides for blood parasites- an unlabelled duplicate slide was
sometimes used In the case of urine we used a drop of urine thatwas placed on an unlabelled slide and put under the microscope
for examination
Slide preparationAt NTRL and the TB health centres the slides selected for this
study were sputum slides for TB training purposesor QC samples
were stained with Ziehl Neelsen Blood slidesfor malaria that wereused at Nkozi hospital and the health centres in the other sites
were stained with Giemsa staining technique Urine and stoolslides were unstained direct wet preparations Auramine staining
was used for the detection of TB in sputum by fluorescentmicroscopy Staining of samples was performed in a European
laboratory
Image capture systemThe system is composed of a traditional light microscope
connected via a connector used as a positioning device to a Java-enabled mobile phone with camera see Figure 1 The connector
prototype was designed prior to this feasibility study [8] For this
study we used the 406 and the 1006 oil immersion objectives ofthe Olympus CX 21 Olympus CX31 Olympus CX41 and
Humascope (Human) light microscopes and the 406 objectives ofthe Olympus CX21 FluoLED Olympus BX41 and Nikon AFX-
IIA fluorescent microscopes Different camera phones were usedmainly Nokia candy bar models see Table 1 for an overview The
image resolution varied from 03 megapixels (MP) to 5MP Onsome occasions the digital zoom of the mobile phone camera was
used to enlarge a specific area of the microscopy field and magnifythe micro-organism to be identified
Data transfer systemEnd user and server software of the image transfer system were
designed A draft form for use on the mobile phone wasdeveloped
for the end user to record ID sample type health center data andupload images from the mobile phone
An end user version of this software including mobile Internetwaspre-installed asan extra application on a Java enabled mobile
phone A server version of this image transfer system was installedlocally in Kampala Uganda We used Orange as our mobile
internet provider as they cover both Mpigi and Kampala districts[18] The end user recorded fictional information on the draft
form took the required picture(s) and pressed lsquolsquosendrsquorsquo The imagewas then sent automatically via the pre-installed mobile Internetconnection of the mobile phone stored in the database of the
central server and a confirmation text message that the image hadbeen received was sent to the end user Anyone with access to thecentral server could log on via an Internet page to this server and
examine the received image store it elsewhere or give instantfeedback via a text message or voice call to the end userrsquosphone
Additionally the image could be enlarged on the computer screenusing the digital zoom function of the computer in order to
magnify areas of interest
Testing procedures1 a Captur e of image without connector Laboratory staff
members at Nkozi hospital NTRL and the health centres were
Figure 1 The prototype connector which attaches a mobilephone to a microscope The prototype connector was designed byTU Delft and TNO The connector is adjustable to fit all sizes of candybar phones and some slide phones It also consists of adjustable screwsto fit most regular light microscopesdoi101371journalpone0028348g001
Mobile Phones to Support Microscopy Diagnosis
PLoS ONE | wwwplosoneorg 2 December 2011 | Volume 6 | Issue 12 | e28348
Sources Tuijn et al Data and Image Transfer Using Mobile Phones to Strengthen Microscopy-Based Diagnostic Services in Low and Middle Income Country Laboratories PLOS December 2011
Africa at the forefront of the global Mobile Money industry
Transfer credit between phones with a simple text message
Mobile money transfer allows those without a bank account to transfer funds as quickly and easily as sending a text message
M for Money transfer mPESA
mHealth and smartphones ndash for what for whom and to be used by whom
bull Mobile phones or smartphones were NOT primarily developed for medicine or health but for communication
bull Potentials for their application in medicine and health are enormous
bull Why are (some) researchers and health professionals a bit hesitant to apply mHealth
mHealth and Malaria ndash un-used and under-researched
bull PubMedgov Your search for mhealth and malaria retrieved no results (May 2012)
bull mhealth Results 52
bull mobile phones and malaria Results 11
bull mobile phones and pregnancy Results 75 but gt half of these on risk for fetus of microwaves
bull mobile phones and malaria and pregnancy
Your search for mhealth and malaria and pregnancy retrieved no results
Malaria in pregnancy research priorities by 2007 Lancet Infect Dis 2007 Feb7(2)169-74
Malaria in pregnancy priorities for research Greenwood B Alonso P ter Kuile FO Hill J Steketee RW
bull ldquoWe have selected the following as the highest priorities for research bull identification of new safe and effective drugs to treat malaria in
pregnancy bull identification of new drugs to replace sulfadoxine-pyrimethamine for
intermittent preventive treatment in pregnancy bull identification of optimum combinations of control measures in different
epidemiological settings bull and determination of optimum ways of scaling-up the use of insecticide-
treated mosquito nets and intermittent preventive treatmentrdquo bull p173
Integration of malaria control with reproductive health programmes ldquoAn important area of operational research is how malaria control can be integrated more effectively than in the past with reproductive health and other programmes directed at women of childbearing age
M for Malaria In Pregnancy and ANC Reaching the most remote and vulnerable
bull Q Would mHealth empower pregnant women to reach the health system
bull A probably cf lsquoWired Mothersrsquo
bull Q Would mHealth enable peripheral HCW to reach and refer to central health care levels
bull A probably cf lsquoWired Mothersrsquo amp lsquoD-Treersquo
bull Q Should we aim at a vertical intervention or
bull as an integrated part of ANC
Maternal Death and Assessment of Substandard Care in Relation to Obstetric Complications and Infections in a Rural HospitalNorth-Western Tanzania
Thesis D Damm 2012 lt 4 of Maternal Death caused by Malaria
All 4 ways of audit showed that of 84 women 30 died from infection 70 of these Puerperal Sepsis 10-20 other Severe infections of these 3 possibly malaria
MIP and mHealth as an opportunity to improve maternal and child health
bull MIP is a visible target
bull MIP control is prioritized by governments NGOs and donor agencies
bull MIP can be used as an effective rsquofoot in the doorrsquo for promoting maternal health so
bull MIP isshould be an integrated part of ANC and Child Care even if most women in malarious areas actually die from other causes and
bull mHealth for MIP should be an integrated part of ANC and Child Care
Words of warning bull Kaplan 2006
In developing world shared mobile telephone use is important
bull Sharing may be a serious drawback to use of mobile telephones as a healthcare intervention in terms of stigma and privacy
bull Regulatory reforms required if mobile phones be used for healthcare
bull Code of conduct available wwhonchHONcodeConducthtml
bull Maaloslashe Bygbjerg Onesmo et al 2012
bull The decision to perform an Emergency Cesarian Section [in Tanzanian rural hospital] was often made by a doctor being contacted by a nurse-midwife by telephone without the doctor examining the women which made the decision less qualified
Wired Mothers Initiative mHealth
Very few studies of sufficient quality
Limited evidence of actual and wide-scale impactsoutcomes
Even less from developing countries
Wired Mothers mHealth study Background
Sources Noordam et al Improvement of maternal health servcies through the use of mobile phones Trop Med Int Health 2011 Tamrat et al An Analysis of mHealth in Maternal and Newborn Health Programs and Their Outcomes Around the World Matern Child Health J 2011
Wired Mothers Intervention
Community
bull Pregnant Women
Health Center
bull Midwife
Hospital
bull Doctor
bull Nurse
bull Ambulance
Person Person
Person Person
Text Messages
Health Education
Increased health attendances across the continuity of care
Urban women more than 5 times likely to delivery with SBA in intervention group
Did not reach significance in SBA amongst rural women
Increased adherence to procedures
Positive outcomes linked to intervention communication system
Intervention widely accepted amongst health workers and women
Wired Mothers Conclusions
bull Malaria Tanzania The prevalence of malaria among febrile children has gone down dramatically
bull While the treatment recommendations in IMCI have changed despite the evidence that only 10 of children may have malaria all these children are treated for malaria at great expense and risk D-tree together with the Swiss Tropical Institute are testing an innovative approach to the diagnosis and treatment of children with fever in Tanzania using hand held electronic decision support incorporating the use of RDTs for children that have fever We expect to show that it is feasible and necessary to
bull Revise procedures for the management of childhood illness (IMCI) incorporating more sophisticated clinical algorithms based on current evidence about disease patterns and drug resistance
bull Rapidly incorporate these changes into treatment algorithms in an electronic format and
bull Demonstrate improved clinical and cost-effectiveness of electronic algorithms when compared to the used of paper based IMCI algorithms
M for Malaria Management Ongoing discussion Mobile Phone-based Inventory management
in the Malaria Treatment amp Prevention community
bull From GHDonline (Kenneth Rudd) ltmalariaghdonlineorggt bull To davie musongwe simwaba ltdsimwabayahoocomgt bull Sent Friday 11 May 2012 344 PM bull Subject Re [Malaria Treatment amp Prevention] Mobile Phone-based Inventory Management bull Kenneth Rudd replied to the discussion Mobile Phone-based Inventory Management in the Malaria Treatment amp
Prevention community bull bull Reply contents
bull FYI there are now many initiatives to utilize mobile phones as a way to track and even provide sorts of ldquotelemedicinerdquo and we will likely see more as in more and more places the infrastructure for mobile phone technology is in places where there wonrsquot be internet access for a long time to come if ever I even saw a mounting device where smartphones can be mounted onto microscopes such that images can be sent via SMS
bull bull -Kenny bull
Data and Image Transfer Using Mobile Phones
Images sent by mobile internet
Feedback to sender by text message
Strengthen Microscopy-Based Diagnostic such as malaria tb bacterial vaginosis stool parasites and eggs
M for Microscope and Medical Monitoring mHealth
care Several initiatives have shown previously that mobile phones
can be used to take pictures through a microscope [812ndash14] or be
modified to serve asa microscope [1516] The next logical step isto send the captured imagesvia mobile networks for example to a
reference laboratory for confirmation of diagnosis by an expert
For this study we developed a system of mobile phone-basedimaging in combination with a data transfer and responseplatform We piloted the performance of this system in Uganda
and discussed itsacceptability and potential applications with localstakeholders
Methods
Ethics StatementEthicsapproval or written informed consent wasnot required as
this isa methodology proof of concept paper Our focuswas firstly
on capturing a microscopy image of sufficient quality and then onthe Information Technology (IT) part to send the captured image
using the mobile phone Patientsrsquo personal information or anysamples IDrsquos that might allow tracing of patients was not used
Informed consent for discussions with colleagues at the health
centers was obtained verbally prior to site visits
LocationIn Uganda the health system is based on a referral system
consisting of different levels I indicating the lowest and IV thehighest level at higher levels more facilities and expertise are
available [17] The image capture wascarried out by a laboratorytechnologist at the National Tuberculosis (TB) Reference Labo-
ratory (NTRL) in Kampala district two laboratory technicianstwo assistants and a student at Nkozi Hospital laboratory in Nkozi
Mpigi district and five laboratory assistants at several level III andIV health centers from both these districts The data transfer
system was tested by a laboratory technologist and a doctor at theInternational Hospital of Kampala (IHK) and by IT specialistsfrom a local IT company in Kampala
Materials usedLaboratory samplesfrom theday before or set aside for training
purposesor external quality control of the health center were used
in our study These could not be linked to patients in any waySamples were initially collected as part of the routine activities
of the laboratories and either made anonymous or -in the case ofblood slides for blood parasites- an unlabelled duplicate slide was
sometimes used In the case of urine we used a drop of urine thatwas placed on an unlabelled slide and put under the microscope
for examination
Slide preparationAt NTRL and the TB health centres the slides selected for this
study were sputum slides for TB training purposesor QC samples
were stained with Ziehl Neelsen Blood slidesfor malaria that wereused at Nkozi hospital and the health centres in the other sites
were stained with Giemsa staining technique Urine and stoolslides were unstained direct wet preparations Auramine staining
was used for the detection of TB in sputum by fluorescentmicroscopy Staining of samples was performed in a European
laboratory
Image capture systemThe system is composed of a traditional light microscope
connected via a connector used as a positioning device to a Java-enabled mobile phone with camera see Figure 1 The connector
prototype was designed prior to this feasibility study [8] For this
study we used the 406 and the 1006 oil immersion objectives ofthe Olympus CX 21 Olympus CX31 Olympus CX41 and
Humascope (Human) light microscopes and the 406 objectives ofthe Olympus CX21 FluoLED Olympus BX41 and Nikon AFX-
IIA fluorescent microscopes Different camera phones were usedmainly Nokia candy bar models see Table 1 for an overview The
image resolution varied from 03 megapixels (MP) to 5MP Onsome occasions the digital zoom of the mobile phone camera was
used to enlarge a specific area of the microscopy field and magnifythe micro-organism to be identified
Data transfer systemEnd user and server software of the image transfer system were
designed A draft form for use on the mobile phone wasdeveloped
for the end user to record ID sample type health center data andupload images from the mobile phone
An end user version of this software including mobile Internetwaspre-installed asan extra application on a Java enabled mobile
phone A server version of this image transfer system was installedlocally in Kampala Uganda We used Orange as our mobile
internet provider as they cover both Mpigi and Kampala districts[18] The end user recorded fictional information on the draft
form took the required picture(s) and pressed lsquolsquosendrsquorsquo The imagewas then sent automatically via the pre-installed mobile Internetconnection of the mobile phone stored in the database of the
central server and a confirmation text message that the image hadbeen received was sent to the end user Anyone with access to thecentral server could log on via an Internet page to this server and
examine the received image store it elsewhere or give instantfeedback via a text message or voice call to the end userrsquosphone
Additionally the image could be enlarged on the computer screenusing the digital zoom function of the computer in order to
magnify areas of interest
Testing procedures1 a Captur e of image without connector Laboratory staff
members at Nkozi hospital NTRL and the health centres were
Figure 1 The prototype connector which attaches a mobilephone to a microscope The prototype connector was designed byTU Delft and TNO The connector is adjustable to fit all sizes of candybar phones and some slide phones It also consists of adjustable screwsto fit most regular light microscopesdoi101371journalpone0028348g001
Mobile Phones to Support Microscopy Diagnosis
PLoS ONE | wwwplosoneorg 2 December 2011 | Volume 6 | Issue 12 | e28348
Sources Tuijn et al Data and Image Transfer Using Mobile Phones to Strengthen Microscopy-Based Diagnostic Services in Low and Middle Income Country Laboratories PLOS December 2011
Africa at the forefront of the global Mobile Money industry
Transfer credit between phones with a simple text message
Mobile money transfer allows those without a bank account to transfer funds as quickly and easily as sending a text message
M for Money transfer mPESA
mHealth and smartphones ndash for what for whom and to be used by whom
bull Mobile phones or smartphones were NOT primarily developed for medicine or health but for communication
bull Potentials for their application in medicine and health are enormous
bull Why are (some) researchers and health professionals a bit hesitant to apply mHealth
mHealth and Malaria ndash un-used and under-researched
bull PubMedgov Your search for mhealth and malaria retrieved no results (May 2012)
bull mhealth Results 52
bull mobile phones and malaria Results 11
bull mobile phones and pregnancy Results 75 but gt half of these on risk for fetus of microwaves
bull mobile phones and malaria and pregnancy
Your search for mhealth and malaria and pregnancy retrieved no results
Malaria in pregnancy research priorities by 2007 Lancet Infect Dis 2007 Feb7(2)169-74
Malaria in pregnancy priorities for research Greenwood B Alonso P ter Kuile FO Hill J Steketee RW
bull ldquoWe have selected the following as the highest priorities for research bull identification of new safe and effective drugs to treat malaria in
pregnancy bull identification of new drugs to replace sulfadoxine-pyrimethamine for
intermittent preventive treatment in pregnancy bull identification of optimum combinations of control measures in different
epidemiological settings bull and determination of optimum ways of scaling-up the use of insecticide-
treated mosquito nets and intermittent preventive treatmentrdquo bull p173
Integration of malaria control with reproductive health programmes ldquoAn important area of operational research is how malaria control can be integrated more effectively than in the past with reproductive health and other programmes directed at women of childbearing age
M for Malaria In Pregnancy and ANC Reaching the most remote and vulnerable
bull Q Would mHealth empower pregnant women to reach the health system
bull A probably cf lsquoWired Mothersrsquo
bull Q Would mHealth enable peripheral HCW to reach and refer to central health care levels
bull A probably cf lsquoWired Mothersrsquo amp lsquoD-Treersquo
bull Q Should we aim at a vertical intervention or
bull as an integrated part of ANC
Maternal Death and Assessment of Substandard Care in Relation to Obstetric Complications and Infections in a Rural HospitalNorth-Western Tanzania
Thesis D Damm 2012 lt 4 of Maternal Death caused by Malaria
All 4 ways of audit showed that of 84 women 30 died from infection 70 of these Puerperal Sepsis 10-20 other Severe infections of these 3 possibly malaria
MIP and mHealth as an opportunity to improve maternal and child health
bull MIP is a visible target
bull MIP control is prioritized by governments NGOs and donor agencies
bull MIP can be used as an effective rsquofoot in the doorrsquo for promoting maternal health so
bull MIP isshould be an integrated part of ANC and Child Care even if most women in malarious areas actually die from other causes and
bull mHealth for MIP should be an integrated part of ANC and Child Care
Words of warning bull Kaplan 2006
In developing world shared mobile telephone use is important
bull Sharing may be a serious drawback to use of mobile telephones as a healthcare intervention in terms of stigma and privacy
bull Regulatory reforms required if mobile phones be used for healthcare
bull Code of conduct available wwhonchHONcodeConducthtml
bull Maaloslashe Bygbjerg Onesmo et al 2012
bull The decision to perform an Emergency Cesarian Section [in Tanzanian rural hospital] was often made by a doctor being contacted by a nurse-midwife by telephone without the doctor examining the women which made the decision less qualified
Very few studies of sufficient quality
Limited evidence of actual and wide-scale impactsoutcomes
Even less from developing countries
Wired Mothers mHealth study Background
Sources Noordam et al Improvement of maternal health servcies through the use of mobile phones Trop Med Int Health 2011 Tamrat et al An Analysis of mHealth in Maternal and Newborn Health Programs and Their Outcomes Around the World Matern Child Health J 2011
Wired Mothers Intervention
Community
bull Pregnant Women
Health Center
bull Midwife
Hospital
bull Doctor
bull Nurse
bull Ambulance
Person Person
Person Person
Text Messages
Health Education
Increased health attendances across the continuity of care
Urban women more than 5 times likely to delivery with SBA in intervention group
Did not reach significance in SBA amongst rural women
Increased adherence to procedures
Positive outcomes linked to intervention communication system
Intervention widely accepted amongst health workers and women
Wired Mothers Conclusions
bull Malaria Tanzania The prevalence of malaria among febrile children has gone down dramatically
bull While the treatment recommendations in IMCI have changed despite the evidence that only 10 of children may have malaria all these children are treated for malaria at great expense and risk D-tree together with the Swiss Tropical Institute are testing an innovative approach to the diagnosis and treatment of children with fever in Tanzania using hand held electronic decision support incorporating the use of RDTs for children that have fever We expect to show that it is feasible and necessary to
bull Revise procedures for the management of childhood illness (IMCI) incorporating more sophisticated clinical algorithms based on current evidence about disease patterns and drug resistance
bull Rapidly incorporate these changes into treatment algorithms in an electronic format and
bull Demonstrate improved clinical and cost-effectiveness of electronic algorithms when compared to the used of paper based IMCI algorithms
M for Malaria Management Ongoing discussion Mobile Phone-based Inventory management
in the Malaria Treatment amp Prevention community
bull From GHDonline (Kenneth Rudd) ltmalariaghdonlineorggt bull To davie musongwe simwaba ltdsimwabayahoocomgt bull Sent Friday 11 May 2012 344 PM bull Subject Re [Malaria Treatment amp Prevention] Mobile Phone-based Inventory Management bull Kenneth Rudd replied to the discussion Mobile Phone-based Inventory Management in the Malaria Treatment amp
Prevention community bull bull Reply contents
bull FYI there are now many initiatives to utilize mobile phones as a way to track and even provide sorts of ldquotelemedicinerdquo and we will likely see more as in more and more places the infrastructure for mobile phone technology is in places where there wonrsquot be internet access for a long time to come if ever I even saw a mounting device where smartphones can be mounted onto microscopes such that images can be sent via SMS
bull bull -Kenny bull
Data and Image Transfer Using Mobile Phones
Images sent by mobile internet
Feedback to sender by text message
Strengthen Microscopy-Based Diagnostic such as malaria tb bacterial vaginosis stool parasites and eggs
M for Microscope and Medical Monitoring mHealth
care Several initiatives have shown previously that mobile phones
can be used to take pictures through a microscope [812ndash14] or be
modified to serve asa microscope [1516] The next logical step isto send the captured imagesvia mobile networks for example to a
reference laboratory for confirmation of diagnosis by an expert
For this study we developed a system of mobile phone-basedimaging in combination with a data transfer and responseplatform We piloted the performance of this system in Uganda
and discussed itsacceptability and potential applications with localstakeholders
Methods
Ethics StatementEthicsapproval or written informed consent wasnot required as
this isa methodology proof of concept paper Our focuswas firstly
on capturing a microscopy image of sufficient quality and then onthe Information Technology (IT) part to send the captured image
using the mobile phone Patientsrsquo personal information or anysamples IDrsquos that might allow tracing of patients was not used
Informed consent for discussions with colleagues at the health
centers was obtained verbally prior to site visits
LocationIn Uganda the health system is based on a referral system
consisting of different levels I indicating the lowest and IV thehighest level at higher levels more facilities and expertise are
available [17] The image capture wascarried out by a laboratorytechnologist at the National Tuberculosis (TB) Reference Labo-
ratory (NTRL) in Kampala district two laboratory technicianstwo assistants and a student at Nkozi Hospital laboratory in Nkozi
Mpigi district and five laboratory assistants at several level III andIV health centers from both these districts The data transfer
system was tested by a laboratory technologist and a doctor at theInternational Hospital of Kampala (IHK) and by IT specialistsfrom a local IT company in Kampala
Materials usedLaboratory samplesfrom theday before or set aside for training
purposesor external quality control of the health center were used
in our study These could not be linked to patients in any waySamples were initially collected as part of the routine activities
of the laboratories and either made anonymous or -in the case ofblood slides for blood parasites- an unlabelled duplicate slide was
sometimes used In the case of urine we used a drop of urine thatwas placed on an unlabelled slide and put under the microscope
for examination
Slide preparationAt NTRL and the TB health centres the slides selected for this
study were sputum slides for TB training purposesor QC samples
were stained with Ziehl Neelsen Blood slidesfor malaria that wereused at Nkozi hospital and the health centres in the other sites
were stained with Giemsa staining technique Urine and stoolslides were unstained direct wet preparations Auramine staining
was used for the detection of TB in sputum by fluorescentmicroscopy Staining of samples was performed in a European
laboratory
Image capture systemThe system is composed of a traditional light microscope
connected via a connector used as a positioning device to a Java-enabled mobile phone with camera see Figure 1 The connector
prototype was designed prior to this feasibility study [8] For this
study we used the 406 and the 1006 oil immersion objectives ofthe Olympus CX 21 Olympus CX31 Olympus CX41 and
Humascope (Human) light microscopes and the 406 objectives ofthe Olympus CX21 FluoLED Olympus BX41 and Nikon AFX-
IIA fluorescent microscopes Different camera phones were usedmainly Nokia candy bar models see Table 1 for an overview The
image resolution varied from 03 megapixels (MP) to 5MP Onsome occasions the digital zoom of the mobile phone camera was
used to enlarge a specific area of the microscopy field and magnifythe micro-organism to be identified
Data transfer systemEnd user and server software of the image transfer system were
designed A draft form for use on the mobile phone wasdeveloped
for the end user to record ID sample type health center data andupload images from the mobile phone
An end user version of this software including mobile Internetwaspre-installed asan extra application on a Java enabled mobile
phone A server version of this image transfer system was installedlocally in Kampala Uganda We used Orange as our mobile
internet provider as they cover both Mpigi and Kampala districts[18] The end user recorded fictional information on the draft
form took the required picture(s) and pressed lsquolsquosendrsquorsquo The imagewas then sent automatically via the pre-installed mobile Internetconnection of the mobile phone stored in the database of the
central server and a confirmation text message that the image hadbeen received was sent to the end user Anyone with access to thecentral server could log on via an Internet page to this server and
examine the received image store it elsewhere or give instantfeedback via a text message or voice call to the end userrsquosphone
Additionally the image could be enlarged on the computer screenusing the digital zoom function of the computer in order to
magnify areas of interest
Testing procedures1 a Captur e of image without connector Laboratory staff
members at Nkozi hospital NTRL and the health centres were
Figure 1 The prototype connector which attaches a mobilephone to a microscope The prototype connector was designed byTU Delft and TNO The connector is adjustable to fit all sizes of candybar phones and some slide phones It also consists of adjustable screwsto fit most regular light microscopesdoi101371journalpone0028348g001
Mobile Phones to Support Microscopy Diagnosis
PLoS ONE | wwwplosoneorg 2 December 2011 | Volume 6 | Issue 12 | e28348
Sources Tuijn et al Data and Image Transfer Using Mobile Phones to Strengthen Microscopy-Based Diagnostic Services in Low and Middle Income Country Laboratories PLOS December 2011
Africa at the forefront of the global Mobile Money industry
Transfer credit between phones with a simple text message
Mobile money transfer allows those without a bank account to transfer funds as quickly and easily as sending a text message
M for Money transfer mPESA
mHealth and smartphones ndash for what for whom and to be used by whom
bull Mobile phones or smartphones were NOT primarily developed for medicine or health but for communication
bull Potentials for their application in medicine and health are enormous
bull Why are (some) researchers and health professionals a bit hesitant to apply mHealth
mHealth and Malaria ndash un-used and under-researched
bull PubMedgov Your search for mhealth and malaria retrieved no results (May 2012)
bull mhealth Results 52
bull mobile phones and malaria Results 11
bull mobile phones and pregnancy Results 75 but gt half of these on risk for fetus of microwaves
bull mobile phones and malaria and pregnancy
Your search for mhealth and malaria and pregnancy retrieved no results
Malaria in pregnancy research priorities by 2007 Lancet Infect Dis 2007 Feb7(2)169-74
Malaria in pregnancy priorities for research Greenwood B Alonso P ter Kuile FO Hill J Steketee RW
bull ldquoWe have selected the following as the highest priorities for research bull identification of new safe and effective drugs to treat malaria in
pregnancy bull identification of new drugs to replace sulfadoxine-pyrimethamine for
intermittent preventive treatment in pregnancy bull identification of optimum combinations of control measures in different
epidemiological settings bull and determination of optimum ways of scaling-up the use of insecticide-
treated mosquito nets and intermittent preventive treatmentrdquo bull p173
Integration of malaria control with reproductive health programmes ldquoAn important area of operational research is how malaria control can be integrated more effectively than in the past with reproductive health and other programmes directed at women of childbearing age
M for Malaria In Pregnancy and ANC Reaching the most remote and vulnerable
bull Q Would mHealth empower pregnant women to reach the health system
bull A probably cf lsquoWired Mothersrsquo
bull Q Would mHealth enable peripheral HCW to reach and refer to central health care levels
bull A probably cf lsquoWired Mothersrsquo amp lsquoD-Treersquo
bull Q Should we aim at a vertical intervention or
bull as an integrated part of ANC
Maternal Death and Assessment of Substandard Care in Relation to Obstetric Complications and Infections in a Rural HospitalNorth-Western Tanzania
Thesis D Damm 2012 lt 4 of Maternal Death caused by Malaria
All 4 ways of audit showed that of 84 women 30 died from infection 70 of these Puerperal Sepsis 10-20 other Severe infections of these 3 possibly malaria
MIP and mHealth as an opportunity to improve maternal and child health
bull MIP is a visible target
bull MIP control is prioritized by governments NGOs and donor agencies
bull MIP can be used as an effective rsquofoot in the doorrsquo for promoting maternal health so
bull MIP isshould be an integrated part of ANC and Child Care even if most women in malarious areas actually die from other causes and
bull mHealth for MIP should be an integrated part of ANC and Child Care
Words of warning bull Kaplan 2006
In developing world shared mobile telephone use is important
bull Sharing may be a serious drawback to use of mobile telephones as a healthcare intervention in terms of stigma and privacy
bull Regulatory reforms required if mobile phones be used for healthcare
bull Code of conduct available wwhonchHONcodeConducthtml
bull Maaloslashe Bygbjerg Onesmo et al 2012
bull The decision to perform an Emergency Cesarian Section [in Tanzanian rural hospital] was often made by a doctor being contacted by a nurse-midwife by telephone without the doctor examining the women which made the decision less qualified
Wired Mothers Intervention
Community
bull Pregnant Women
Health Center
bull Midwife
Hospital
bull Doctor
bull Nurse
bull Ambulance
Person Person
Person Person
Text Messages
Health Education
Increased health attendances across the continuity of care
Urban women more than 5 times likely to delivery with SBA in intervention group
Did not reach significance in SBA amongst rural women
Increased adherence to procedures
Positive outcomes linked to intervention communication system
Intervention widely accepted amongst health workers and women
Wired Mothers Conclusions
bull Malaria Tanzania The prevalence of malaria among febrile children has gone down dramatically
bull While the treatment recommendations in IMCI have changed despite the evidence that only 10 of children may have malaria all these children are treated for malaria at great expense and risk D-tree together with the Swiss Tropical Institute are testing an innovative approach to the diagnosis and treatment of children with fever in Tanzania using hand held electronic decision support incorporating the use of RDTs for children that have fever We expect to show that it is feasible and necessary to
bull Revise procedures for the management of childhood illness (IMCI) incorporating more sophisticated clinical algorithms based on current evidence about disease patterns and drug resistance
bull Rapidly incorporate these changes into treatment algorithms in an electronic format and
bull Demonstrate improved clinical and cost-effectiveness of electronic algorithms when compared to the used of paper based IMCI algorithms
M for Malaria Management Ongoing discussion Mobile Phone-based Inventory management
in the Malaria Treatment amp Prevention community
bull From GHDonline (Kenneth Rudd) ltmalariaghdonlineorggt bull To davie musongwe simwaba ltdsimwabayahoocomgt bull Sent Friday 11 May 2012 344 PM bull Subject Re [Malaria Treatment amp Prevention] Mobile Phone-based Inventory Management bull Kenneth Rudd replied to the discussion Mobile Phone-based Inventory Management in the Malaria Treatment amp
Prevention community bull bull Reply contents
bull FYI there are now many initiatives to utilize mobile phones as a way to track and even provide sorts of ldquotelemedicinerdquo and we will likely see more as in more and more places the infrastructure for mobile phone technology is in places where there wonrsquot be internet access for a long time to come if ever I even saw a mounting device where smartphones can be mounted onto microscopes such that images can be sent via SMS
bull bull -Kenny bull
Data and Image Transfer Using Mobile Phones
Images sent by mobile internet
Feedback to sender by text message
Strengthen Microscopy-Based Diagnostic such as malaria tb bacterial vaginosis stool parasites and eggs
M for Microscope and Medical Monitoring mHealth
care Several initiatives have shown previously that mobile phones
can be used to take pictures through a microscope [812ndash14] or be
modified to serve asa microscope [1516] The next logical step isto send the captured imagesvia mobile networks for example to a
reference laboratory for confirmation of diagnosis by an expert
For this study we developed a system of mobile phone-basedimaging in combination with a data transfer and responseplatform We piloted the performance of this system in Uganda
and discussed itsacceptability and potential applications with localstakeholders
Methods
Ethics StatementEthicsapproval or written informed consent wasnot required as
this isa methodology proof of concept paper Our focuswas firstly
on capturing a microscopy image of sufficient quality and then onthe Information Technology (IT) part to send the captured image
using the mobile phone Patientsrsquo personal information or anysamples IDrsquos that might allow tracing of patients was not used
Informed consent for discussions with colleagues at the health
centers was obtained verbally prior to site visits
LocationIn Uganda the health system is based on a referral system
consisting of different levels I indicating the lowest and IV thehighest level at higher levels more facilities and expertise are
available [17] The image capture wascarried out by a laboratorytechnologist at the National Tuberculosis (TB) Reference Labo-
ratory (NTRL) in Kampala district two laboratory technicianstwo assistants and a student at Nkozi Hospital laboratory in Nkozi
Mpigi district and five laboratory assistants at several level III andIV health centers from both these districts The data transfer
system was tested by a laboratory technologist and a doctor at theInternational Hospital of Kampala (IHK) and by IT specialistsfrom a local IT company in Kampala
Materials usedLaboratory samplesfrom theday before or set aside for training
purposesor external quality control of the health center were used
in our study These could not be linked to patients in any waySamples were initially collected as part of the routine activities
of the laboratories and either made anonymous or -in the case ofblood slides for blood parasites- an unlabelled duplicate slide was
sometimes used In the case of urine we used a drop of urine thatwas placed on an unlabelled slide and put under the microscope
for examination
Slide preparationAt NTRL and the TB health centres the slides selected for this
study were sputum slides for TB training purposesor QC samples
were stained with Ziehl Neelsen Blood slidesfor malaria that wereused at Nkozi hospital and the health centres in the other sites
were stained with Giemsa staining technique Urine and stoolslides were unstained direct wet preparations Auramine staining
was used for the detection of TB in sputum by fluorescentmicroscopy Staining of samples was performed in a European
laboratory
Image capture systemThe system is composed of a traditional light microscope
connected via a connector used as a positioning device to a Java-enabled mobile phone with camera see Figure 1 The connector
prototype was designed prior to this feasibility study [8] For this
study we used the 406 and the 1006 oil immersion objectives ofthe Olympus CX 21 Olympus CX31 Olympus CX41 and
Humascope (Human) light microscopes and the 406 objectives ofthe Olympus CX21 FluoLED Olympus BX41 and Nikon AFX-
IIA fluorescent microscopes Different camera phones were usedmainly Nokia candy bar models see Table 1 for an overview The
image resolution varied from 03 megapixels (MP) to 5MP Onsome occasions the digital zoom of the mobile phone camera was
used to enlarge a specific area of the microscopy field and magnifythe micro-organism to be identified
Data transfer systemEnd user and server software of the image transfer system were
designed A draft form for use on the mobile phone wasdeveloped
for the end user to record ID sample type health center data andupload images from the mobile phone
An end user version of this software including mobile Internetwaspre-installed asan extra application on a Java enabled mobile
phone A server version of this image transfer system was installedlocally in Kampala Uganda We used Orange as our mobile
internet provider as they cover both Mpigi and Kampala districts[18] The end user recorded fictional information on the draft
form took the required picture(s) and pressed lsquolsquosendrsquorsquo The imagewas then sent automatically via the pre-installed mobile Internetconnection of the mobile phone stored in the database of the
central server and a confirmation text message that the image hadbeen received was sent to the end user Anyone with access to thecentral server could log on via an Internet page to this server and
examine the received image store it elsewhere or give instantfeedback via a text message or voice call to the end userrsquosphone
Additionally the image could be enlarged on the computer screenusing the digital zoom function of the computer in order to
magnify areas of interest
Testing procedures1 a Captur e of image without connector Laboratory staff
members at Nkozi hospital NTRL and the health centres were
Figure 1 The prototype connector which attaches a mobilephone to a microscope The prototype connector was designed byTU Delft and TNO The connector is adjustable to fit all sizes of candybar phones and some slide phones It also consists of adjustable screwsto fit most regular light microscopesdoi101371journalpone0028348g001
Mobile Phones to Support Microscopy Diagnosis
PLoS ONE | wwwplosoneorg 2 December 2011 | Volume 6 | Issue 12 | e28348
Sources Tuijn et al Data and Image Transfer Using Mobile Phones to Strengthen Microscopy-Based Diagnostic Services in Low and Middle Income Country Laboratories PLOS December 2011
Africa at the forefront of the global Mobile Money industry
Transfer credit between phones with a simple text message
Mobile money transfer allows those without a bank account to transfer funds as quickly and easily as sending a text message
M for Money transfer mPESA
mHealth and smartphones ndash for what for whom and to be used by whom
bull Mobile phones or smartphones were NOT primarily developed for medicine or health but for communication
bull Potentials for their application in medicine and health are enormous
bull Why are (some) researchers and health professionals a bit hesitant to apply mHealth
mHealth and Malaria ndash un-used and under-researched
bull PubMedgov Your search for mhealth and malaria retrieved no results (May 2012)
bull mhealth Results 52
bull mobile phones and malaria Results 11
bull mobile phones and pregnancy Results 75 but gt half of these on risk for fetus of microwaves
bull mobile phones and malaria and pregnancy
Your search for mhealth and malaria and pregnancy retrieved no results
Malaria in pregnancy research priorities by 2007 Lancet Infect Dis 2007 Feb7(2)169-74
Malaria in pregnancy priorities for research Greenwood B Alonso P ter Kuile FO Hill J Steketee RW
bull ldquoWe have selected the following as the highest priorities for research bull identification of new safe and effective drugs to treat malaria in
pregnancy bull identification of new drugs to replace sulfadoxine-pyrimethamine for
intermittent preventive treatment in pregnancy bull identification of optimum combinations of control measures in different
epidemiological settings bull and determination of optimum ways of scaling-up the use of insecticide-
treated mosquito nets and intermittent preventive treatmentrdquo bull p173
Integration of malaria control with reproductive health programmes ldquoAn important area of operational research is how malaria control can be integrated more effectively than in the past with reproductive health and other programmes directed at women of childbearing age
M for Malaria In Pregnancy and ANC Reaching the most remote and vulnerable
bull Q Would mHealth empower pregnant women to reach the health system
bull A probably cf lsquoWired Mothersrsquo
bull Q Would mHealth enable peripheral HCW to reach and refer to central health care levels
bull A probably cf lsquoWired Mothersrsquo amp lsquoD-Treersquo
bull Q Should we aim at a vertical intervention or
bull as an integrated part of ANC
Maternal Death and Assessment of Substandard Care in Relation to Obstetric Complications and Infections in a Rural HospitalNorth-Western Tanzania
Thesis D Damm 2012 lt 4 of Maternal Death caused by Malaria
All 4 ways of audit showed that of 84 women 30 died from infection 70 of these Puerperal Sepsis 10-20 other Severe infections of these 3 possibly malaria
MIP and mHealth as an opportunity to improve maternal and child health
bull MIP is a visible target
bull MIP control is prioritized by governments NGOs and donor agencies
bull MIP can be used as an effective rsquofoot in the doorrsquo for promoting maternal health so
bull MIP isshould be an integrated part of ANC and Child Care even if most women in malarious areas actually die from other causes and
bull mHealth for MIP should be an integrated part of ANC and Child Care
Words of warning bull Kaplan 2006
In developing world shared mobile telephone use is important
bull Sharing may be a serious drawback to use of mobile telephones as a healthcare intervention in terms of stigma and privacy
bull Regulatory reforms required if mobile phones be used for healthcare
bull Code of conduct available wwhonchHONcodeConducthtml
bull Maaloslashe Bygbjerg Onesmo et al 2012
bull The decision to perform an Emergency Cesarian Section [in Tanzanian rural hospital] was often made by a doctor being contacted by a nurse-midwife by telephone without the doctor examining the women which made the decision less qualified
Increased health attendances across the continuity of care
Urban women more than 5 times likely to delivery with SBA in intervention group
Did not reach significance in SBA amongst rural women
Increased adherence to procedures
Positive outcomes linked to intervention communication system
Intervention widely accepted amongst health workers and women
Wired Mothers Conclusions
bull Malaria Tanzania The prevalence of malaria among febrile children has gone down dramatically
bull While the treatment recommendations in IMCI have changed despite the evidence that only 10 of children may have malaria all these children are treated for malaria at great expense and risk D-tree together with the Swiss Tropical Institute are testing an innovative approach to the diagnosis and treatment of children with fever in Tanzania using hand held electronic decision support incorporating the use of RDTs for children that have fever We expect to show that it is feasible and necessary to
bull Revise procedures for the management of childhood illness (IMCI) incorporating more sophisticated clinical algorithms based on current evidence about disease patterns and drug resistance
bull Rapidly incorporate these changes into treatment algorithms in an electronic format and
bull Demonstrate improved clinical and cost-effectiveness of electronic algorithms when compared to the used of paper based IMCI algorithms
M for Malaria Management Ongoing discussion Mobile Phone-based Inventory management
in the Malaria Treatment amp Prevention community
bull From GHDonline (Kenneth Rudd) ltmalariaghdonlineorggt bull To davie musongwe simwaba ltdsimwabayahoocomgt bull Sent Friday 11 May 2012 344 PM bull Subject Re [Malaria Treatment amp Prevention] Mobile Phone-based Inventory Management bull Kenneth Rudd replied to the discussion Mobile Phone-based Inventory Management in the Malaria Treatment amp
Prevention community bull bull Reply contents
bull FYI there are now many initiatives to utilize mobile phones as a way to track and even provide sorts of ldquotelemedicinerdquo and we will likely see more as in more and more places the infrastructure for mobile phone technology is in places where there wonrsquot be internet access for a long time to come if ever I even saw a mounting device where smartphones can be mounted onto microscopes such that images can be sent via SMS
bull bull -Kenny bull
Data and Image Transfer Using Mobile Phones
Images sent by mobile internet
Feedback to sender by text message
Strengthen Microscopy-Based Diagnostic such as malaria tb bacterial vaginosis stool parasites and eggs
M for Microscope and Medical Monitoring mHealth
care Several initiatives have shown previously that mobile phones
can be used to take pictures through a microscope [812ndash14] or be
modified to serve asa microscope [1516] The next logical step isto send the captured imagesvia mobile networks for example to a
reference laboratory for confirmation of diagnosis by an expert
For this study we developed a system of mobile phone-basedimaging in combination with a data transfer and responseplatform We piloted the performance of this system in Uganda
and discussed itsacceptability and potential applications with localstakeholders
Methods
Ethics StatementEthicsapproval or written informed consent wasnot required as
this isa methodology proof of concept paper Our focuswas firstly
on capturing a microscopy image of sufficient quality and then onthe Information Technology (IT) part to send the captured image
using the mobile phone Patientsrsquo personal information or anysamples IDrsquos that might allow tracing of patients was not used
Informed consent for discussions with colleagues at the health
centers was obtained verbally prior to site visits
LocationIn Uganda the health system is based on a referral system
consisting of different levels I indicating the lowest and IV thehighest level at higher levels more facilities and expertise are
available [17] The image capture wascarried out by a laboratorytechnologist at the National Tuberculosis (TB) Reference Labo-
ratory (NTRL) in Kampala district two laboratory technicianstwo assistants and a student at Nkozi Hospital laboratory in Nkozi
Mpigi district and five laboratory assistants at several level III andIV health centers from both these districts The data transfer
system was tested by a laboratory technologist and a doctor at theInternational Hospital of Kampala (IHK) and by IT specialistsfrom a local IT company in Kampala
Materials usedLaboratory samplesfrom theday before or set aside for training
purposesor external quality control of the health center were used
in our study These could not be linked to patients in any waySamples were initially collected as part of the routine activities
of the laboratories and either made anonymous or -in the case ofblood slides for blood parasites- an unlabelled duplicate slide was
sometimes used In the case of urine we used a drop of urine thatwas placed on an unlabelled slide and put under the microscope
for examination
Slide preparationAt NTRL and the TB health centres the slides selected for this
study were sputum slides for TB training purposesor QC samples
were stained with Ziehl Neelsen Blood slidesfor malaria that wereused at Nkozi hospital and the health centres in the other sites
were stained with Giemsa staining technique Urine and stoolslides were unstained direct wet preparations Auramine staining
was used for the detection of TB in sputum by fluorescentmicroscopy Staining of samples was performed in a European
laboratory
Image capture systemThe system is composed of a traditional light microscope
connected via a connector used as a positioning device to a Java-enabled mobile phone with camera see Figure 1 The connector
prototype was designed prior to this feasibility study [8] For this
study we used the 406 and the 1006 oil immersion objectives ofthe Olympus CX 21 Olympus CX31 Olympus CX41 and
Humascope (Human) light microscopes and the 406 objectives ofthe Olympus CX21 FluoLED Olympus BX41 and Nikon AFX-
IIA fluorescent microscopes Different camera phones were usedmainly Nokia candy bar models see Table 1 for an overview The
image resolution varied from 03 megapixels (MP) to 5MP Onsome occasions the digital zoom of the mobile phone camera was
used to enlarge a specific area of the microscopy field and magnifythe micro-organism to be identified
Data transfer systemEnd user and server software of the image transfer system were
designed A draft form for use on the mobile phone wasdeveloped
for the end user to record ID sample type health center data andupload images from the mobile phone
An end user version of this software including mobile Internetwaspre-installed asan extra application on a Java enabled mobile
phone A server version of this image transfer system was installedlocally in Kampala Uganda We used Orange as our mobile
internet provider as they cover both Mpigi and Kampala districts[18] The end user recorded fictional information on the draft
form took the required picture(s) and pressed lsquolsquosendrsquorsquo The imagewas then sent automatically via the pre-installed mobile Internetconnection of the mobile phone stored in the database of the
central server and a confirmation text message that the image hadbeen received was sent to the end user Anyone with access to thecentral server could log on via an Internet page to this server and
examine the received image store it elsewhere or give instantfeedback via a text message or voice call to the end userrsquosphone
Additionally the image could be enlarged on the computer screenusing the digital zoom function of the computer in order to
magnify areas of interest
Testing procedures1 a Captur e of image without connector Laboratory staff
members at Nkozi hospital NTRL and the health centres were
Figure 1 The prototype connector which attaches a mobilephone to a microscope The prototype connector was designed byTU Delft and TNO The connector is adjustable to fit all sizes of candybar phones and some slide phones It also consists of adjustable screwsto fit most regular light microscopesdoi101371journalpone0028348g001
Mobile Phones to Support Microscopy Diagnosis
PLoS ONE | wwwplosoneorg 2 December 2011 | Volume 6 | Issue 12 | e28348
Sources Tuijn et al Data and Image Transfer Using Mobile Phones to Strengthen Microscopy-Based Diagnostic Services in Low and Middle Income Country Laboratories PLOS December 2011
Africa at the forefront of the global Mobile Money industry
Transfer credit between phones with a simple text message
Mobile money transfer allows those without a bank account to transfer funds as quickly and easily as sending a text message
M for Money transfer mPESA
mHealth and smartphones ndash for what for whom and to be used by whom
bull Mobile phones or smartphones were NOT primarily developed for medicine or health but for communication
bull Potentials for their application in medicine and health are enormous
bull Why are (some) researchers and health professionals a bit hesitant to apply mHealth
mHealth and Malaria ndash un-used and under-researched
bull PubMedgov Your search for mhealth and malaria retrieved no results (May 2012)
bull mhealth Results 52
bull mobile phones and malaria Results 11
bull mobile phones and pregnancy Results 75 but gt half of these on risk for fetus of microwaves
bull mobile phones and malaria and pregnancy
Your search for mhealth and malaria and pregnancy retrieved no results
Malaria in pregnancy research priorities by 2007 Lancet Infect Dis 2007 Feb7(2)169-74
Malaria in pregnancy priorities for research Greenwood B Alonso P ter Kuile FO Hill J Steketee RW
bull ldquoWe have selected the following as the highest priorities for research bull identification of new safe and effective drugs to treat malaria in
pregnancy bull identification of new drugs to replace sulfadoxine-pyrimethamine for
intermittent preventive treatment in pregnancy bull identification of optimum combinations of control measures in different
epidemiological settings bull and determination of optimum ways of scaling-up the use of insecticide-
treated mosquito nets and intermittent preventive treatmentrdquo bull p173
Integration of malaria control with reproductive health programmes ldquoAn important area of operational research is how malaria control can be integrated more effectively than in the past with reproductive health and other programmes directed at women of childbearing age
M for Malaria In Pregnancy and ANC Reaching the most remote and vulnerable
bull Q Would mHealth empower pregnant women to reach the health system
bull A probably cf lsquoWired Mothersrsquo
bull Q Would mHealth enable peripheral HCW to reach and refer to central health care levels
bull A probably cf lsquoWired Mothersrsquo amp lsquoD-Treersquo
bull Q Should we aim at a vertical intervention or
bull as an integrated part of ANC
Maternal Death and Assessment of Substandard Care in Relation to Obstetric Complications and Infections in a Rural HospitalNorth-Western Tanzania
Thesis D Damm 2012 lt 4 of Maternal Death caused by Malaria
All 4 ways of audit showed that of 84 women 30 died from infection 70 of these Puerperal Sepsis 10-20 other Severe infections of these 3 possibly malaria
MIP and mHealth as an opportunity to improve maternal and child health
bull MIP is a visible target
bull MIP control is prioritized by governments NGOs and donor agencies
bull MIP can be used as an effective rsquofoot in the doorrsquo for promoting maternal health so
bull MIP isshould be an integrated part of ANC and Child Care even if most women in malarious areas actually die from other causes and
bull mHealth for MIP should be an integrated part of ANC and Child Care
Words of warning bull Kaplan 2006
In developing world shared mobile telephone use is important
bull Sharing may be a serious drawback to use of mobile telephones as a healthcare intervention in terms of stigma and privacy
bull Regulatory reforms required if mobile phones be used for healthcare
bull Code of conduct available wwhonchHONcodeConducthtml
bull Maaloslashe Bygbjerg Onesmo et al 2012
bull The decision to perform an Emergency Cesarian Section [in Tanzanian rural hospital] was often made by a doctor being contacted by a nurse-midwife by telephone without the doctor examining the women which made the decision less qualified
bull Malaria Tanzania The prevalence of malaria among febrile children has gone down dramatically
bull While the treatment recommendations in IMCI have changed despite the evidence that only 10 of children may have malaria all these children are treated for malaria at great expense and risk D-tree together with the Swiss Tropical Institute are testing an innovative approach to the diagnosis and treatment of children with fever in Tanzania using hand held electronic decision support incorporating the use of RDTs for children that have fever We expect to show that it is feasible and necessary to
bull Revise procedures for the management of childhood illness (IMCI) incorporating more sophisticated clinical algorithms based on current evidence about disease patterns and drug resistance
bull Rapidly incorporate these changes into treatment algorithms in an electronic format and
bull Demonstrate improved clinical and cost-effectiveness of electronic algorithms when compared to the used of paper based IMCI algorithms
M for Malaria Management Ongoing discussion Mobile Phone-based Inventory management
in the Malaria Treatment amp Prevention community
bull From GHDonline (Kenneth Rudd) ltmalariaghdonlineorggt bull To davie musongwe simwaba ltdsimwabayahoocomgt bull Sent Friday 11 May 2012 344 PM bull Subject Re [Malaria Treatment amp Prevention] Mobile Phone-based Inventory Management bull Kenneth Rudd replied to the discussion Mobile Phone-based Inventory Management in the Malaria Treatment amp
Prevention community bull bull Reply contents
bull FYI there are now many initiatives to utilize mobile phones as a way to track and even provide sorts of ldquotelemedicinerdquo and we will likely see more as in more and more places the infrastructure for mobile phone technology is in places where there wonrsquot be internet access for a long time to come if ever I even saw a mounting device where smartphones can be mounted onto microscopes such that images can be sent via SMS
bull bull -Kenny bull
Data and Image Transfer Using Mobile Phones
Images sent by mobile internet
Feedback to sender by text message
Strengthen Microscopy-Based Diagnostic such as malaria tb bacterial vaginosis stool parasites and eggs
M for Microscope and Medical Monitoring mHealth
care Several initiatives have shown previously that mobile phones
can be used to take pictures through a microscope [812ndash14] or be
modified to serve asa microscope [1516] The next logical step isto send the captured imagesvia mobile networks for example to a
reference laboratory for confirmation of diagnosis by an expert
For this study we developed a system of mobile phone-basedimaging in combination with a data transfer and responseplatform We piloted the performance of this system in Uganda
and discussed itsacceptability and potential applications with localstakeholders
Methods
Ethics StatementEthicsapproval or written informed consent wasnot required as
this isa methodology proof of concept paper Our focuswas firstly
on capturing a microscopy image of sufficient quality and then onthe Information Technology (IT) part to send the captured image
using the mobile phone Patientsrsquo personal information or anysamples IDrsquos that might allow tracing of patients was not used
Informed consent for discussions with colleagues at the health
centers was obtained verbally prior to site visits
LocationIn Uganda the health system is based on a referral system
consisting of different levels I indicating the lowest and IV thehighest level at higher levels more facilities and expertise are
available [17] The image capture wascarried out by a laboratorytechnologist at the National Tuberculosis (TB) Reference Labo-
ratory (NTRL) in Kampala district two laboratory technicianstwo assistants and a student at Nkozi Hospital laboratory in Nkozi
Mpigi district and five laboratory assistants at several level III andIV health centers from both these districts The data transfer
system was tested by a laboratory technologist and a doctor at theInternational Hospital of Kampala (IHK) and by IT specialistsfrom a local IT company in Kampala
Materials usedLaboratory samplesfrom theday before or set aside for training
purposesor external quality control of the health center were used
in our study These could not be linked to patients in any waySamples were initially collected as part of the routine activities
of the laboratories and either made anonymous or -in the case ofblood slides for blood parasites- an unlabelled duplicate slide was
sometimes used In the case of urine we used a drop of urine thatwas placed on an unlabelled slide and put under the microscope
for examination
Slide preparationAt NTRL and the TB health centres the slides selected for this
study were sputum slides for TB training purposesor QC samples
were stained with Ziehl Neelsen Blood slidesfor malaria that wereused at Nkozi hospital and the health centres in the other sites
were stained with Giemsa staining technique Urine and stoolslides were unstained direct wet preparations Auramine staining
was used for the detection of TB in sputum by fluorescentmicroscopy Staining of samples was performed in a European
laboratory
Image capture systemThe system is composed of a traditional light microscope
connected via a connector used as a positioning device to a Java-enabled mobile phone with camera see Figure 1 The connector
prototype was designed prior to this feasibility study [8] For this
study we used the 406 and the 1006 oil immersion objectives ofthe Olympus CX 21 Olympus CX31 Olympus CX41 and
Humascope (Human) light microscopes and the 406 objectives ofthe Olympus CX21 FluoLED Olympus BX41 and Nikon AFX-
IIA fluorescent microscopes Different camera phones were usedmainly Nokia candy bar models see Table 1 for an overview The
image resolution varied from 03 megapixels (MP) to 5MP Onsome occasions the digital zoom of the mobile phone camera was
used to enlarge a specific area of the microscopy field and magnifythe micro-organism to be identified
Data transfer systemEnd user and server software of the image transfer system were
designed A draft form for use on the mobile phone wasdeveloped
for the end user to record ID sample type health center data andupload images from the mobile phone
An end user version of this software including mobile Internetwaspre-installed asan extra application on a Java enabled mobile
phone A server version of this image transfer system was installedlocally in Kampala Uganda We used Orange as our mobile
internet provider as they cover both Mpigi and Kampala districts[18] The end user recorded fictional information on the draft
form took the required picture(s) and pressed lsquolsquosendrsquorsquo The imagewas then sent automatically via the pre-installed mobile Internetconnection of the mobile phone stored in the database of the
central server and a confirmation text message that the image hadbeen received was sent to the end user Anyone with access to thecentral server could log on via an Internet page to this server and
examine the received image store it elsewhere or give instantfeedback via a text message or voice call to the end userrsquosphone
Additionally the image could be enlarged on the computer screenusing the digital zoom function of the computer in order to
magnify areas of interest
Testing procedures1 a Captur e of image without connector Laboratory staff
members at Nkozi hospital NTRL and the health centres were
Figure 1 The prototype connector which attaches a mobilephone to a microscope The prototype connector was designed byTU Delft and TNO The connector is adjustable to fit all sizes of candybar phones and some slide phones It also consists of adjustable screwsto fit most regular light microscopesdoi101371journalpone0028348g001
Mobile Phones to Support Microscopy Diagnosis
PLoS ONE | wwwplosoneorg 2 December 2011 | Volume 6 | Issue 12 | e28348
Sources Tuijn et al Data and Image Transfer Using Mobile Phones to Strengthen Microscopy-Based Diagnostic Services in Low and Middle Income Country Laboratories PLOS December 2011
Africa at the forefront of the global Mobile Money industry
Transfer credit between phones with a simple text message
Mobile money transfer allows those without a bank account to transfer funds as quickly and easily as sending a text message
M for Money transfer mPESA
mHealth and smartphones ndash for what for whom and to be used by whom
bull Mobile phones or smartphones were NOT primarily developed for medicine or health but for communication
bull Potentials for their application in medicine and health are enormous
bull Why are (some) researchers and health professionals a bit hesitant to apply mHealth
mHealth and Malaria ndash un-used and under-researched
bull PubMedgov Your search for mhealth and malaria retrieved no results (May 2012)
bull mhealth Results 52
bull mobile phones and malaria Results 11
bull mobile phones and pregnancy Results 75 but gt half of these on risk for fetus of microwaves
bull mobile phones and malaria and pregnancy
Your search for mhealth and malaria and pregnancy retrieved no results
Malaria in pregnancy research priorities by 2007 Lancet Infect Dis 2007 Feb7(2)169-74
Malaria in pregnancy priorities for research Greenwood B Alonso P ter Kuile FO Hill J Steketee RW
bull ldquoWe have selected the following as the highest priorities for research bull identification of new safe and effective drugs to treat malaria in
pregnancy bull identification of new drugs to replace sulfadoxine-pyrimethamine for
intermittent preventive treatment in pregnancy bull identification of optimum combinations of control measures in different
epidemiological settings bull and determination of optimum ways of scaling-up the use of insecticide-
treated mosquito nets and intermittent preventive treatmentrdquo bull p173
Integration of malaria control with reproductive health programmes ldquoAn important area of operational research is how malaria control can be integrated more effectively than in the past with reproductive health and other programmes directed at women of childbearing age
M for Malaria In Pregnancy and ANC Reaching the most remote and vulnerable
bull Q Would mHealth empower pregnant women to reach the health system
bull A probably cf lsquoWired Mothersrsquo
bull Q Would mHealth enable peripheral HCW to reach and refer to central health care levels
bull A probably cf lsquoWired Mothersrsquo amp lsquoD-Treersquo
bull Q Should we aim at a vertical intervention or
bull as an integrated part of ANC
Maternal Death and Assessment of Substandard Care in Relation to Obstetric Complications and Infections in a Rural HospitalNorth-Western Tanzania
Thesis D Damm 2012 lt 4 of Maternal Death caused by Malaria
All 4 ways of audit showed that of 84 women 30 died from infection 70 of these Puerperal Sepsis 10-20 other Severe infections of these 3 possibly malaria
MIP and mHealth as an opportunity to improve maternal and child health
bull MIP is a visible target
bull MIP control is prioritized by governments NGOs and donor agencies
bull MIP can be used as an effective rsquofoot in the doorrsquo for promoting maternal health so
bull MIP isshould be an integrated part of ANC and Child Care even if most women in malarious areas actually die from other causes and
bull mHealth for MIP should be an integrated part of ANC and Child Care
Words of warning bull Kaplan 2006
In developing world shared mobile telephone use is important
bull Sharing may be a serious drawback to use of mobile telephones as a healthcare intervention in terms of stigma and privacy
bull Regulatory reforms required if mobile phones be used for healthcare
bull Code of conduct available wwhonchHONcodeConducthtml
bull Maaloslashe Bygbjerg Onesmo et al 2012
bull The decision to perform an Emergency Cesarian Section [in Tanzanian rural hospital] was often made by a doctor being contacted by a nurse-midwife by telephone without the doctor examining the women which made the decision less qualified
M for Malaria Management Ongoing discussion Mobile Phone-based Inventory management
in the Malaria Treatment amp Prevention community
bull From GHDonline (Kenneth Rudd) ltmalariaghdonlineorggt bull To davie musongwe simwaba ltdsimwabayahoocomgt bull Sent Friday 11 May 2012 344 PM bull Subject Re [Malaria Treatment amp Prevention] Mobile Phone-based Inventory Management bull Kenneth Rudd replied to the discussion Mobile Phone-based Inventory Management in the Malaria Treatment amp
Prevention community bull bull Reply contents
bull FYI there are now many initiatives to utilize mobile phones as a way to track and even provide sorts of ldquotelemedicinerdquo and we will likely see more as in more and more places the infrastructure for mobile phone technology is in places where there wonrsquot be internet access for a long time to come if ever I even saw a mounting device where smartphones can be mounted onto microscopes such that images can be sent via SMS
bull bull -Kenny bull
Data and Image Transfer Using Mobile Phones
Images sent by mobile internet
Feedback to sender by text message
Strengthen Microscopy-Based Diagnostic such as malaria tb bacterial vaginosis stool parasites and eggs
M for Microscope and Medical Monitoring mHealth
care Several initiatives have shown previously that mobile phones
can be used to take pictures through a microscope [812ndash14] or be
modified to serve asa microscope [1516] The next logical step isto send the captured imagesvia mobile networks for example to a
reference laboratory for confirmation of diagnosis by an expert
For this study we developed a system of mobile phone-basedimaging in combination with a data transfer and responseplatform We piloted the performance of this system in Uganda
and discussed itsacceptability and potential applications with localstakeholders
Methods
Ethics StatementEthicsapproval or written informed consent wasnot required as
this isa methodology proof of concept paper Our focuswas firstly
on capturing a microscopy image of sufficient quality and then onthe Information Technology (IT) part to send the captured image
using the mobile phone Patientsrsquo personal information or anysamples IDrsquos that might allow tracing of patients was not used
Informed consent for discussions with colleagues at the health
centers was obtained verbally prior to site visits
LocationIn Uganda the health system is based on a referral system
consisting of different levels I indicating the lowest and IV thehighest level at higher levels more facilities and expertise are
available [17] The image capture wascarried out by a laboratorytechnologist at the National Tuberculosis (TB) Reference Labo-
ratory (NTRL) in Kampala district two laboratory technicianstwo assistants and a student at Nkozi Hospital laboratory in Nkozi
Mpigi district and five laboratory assistants at several level III andIV health centers from both these districts The data transfer
system was tested by a laboratory technologist and a doctor at theInternational Hospital of Kampala (IHK) and by IT specialistsfrom a local IT company in Kampala
Materials usedLaboratory samplesfrom theday before or set aside for training
purposesor external quality control of the health center were used
in our study These could not be linked to patients in any waySamples were initially collected as part of the routine activities
of the laboratories and either made anonymous or -in the case ofblood slides for blood parasites- an unlabelled duplicate slide was
sometimes used In the case of urine we used a drop of urine thatwas placed on an unlabelled slide and put under the microscope
for examination
Slide preparationAt NTRL and the TB health centres the slides selected for this
study were sputum slides for TB training purposesor QC samples
were stained with Ziehl Neelsen Blood slidesfor malaria that wereused at Nkozi hospital and the health centres in the other sites
were stained with Giemsa staining technique Urine and stoolslides were unstained direct wet preparations Auramine staining
was used for the detection of TB in sputum by fluorescentmicroscopy Staining of samples was performed in a European
laboratory
Image capture systemThe system is composed of a traditional light microscope
connected via a connector used as a positioning device to a Java-enabled mobile phone with camera see Figure 1 The connector
prototype was designed prior to this feasibility study [8] For this
study we used the 406 and the 1006 oil immersion objectives ofthe Olympus CX 21 Olympus CX31 Olympus CX41 and
Humascope (Human) light microscopes and the 406 objectives ofthe Olympus CX21 FluoLED Olympus BX41 and Nikon AFX-
IIA fluorescent microscopes Different camera phones were usedmainly Nokia candy bar models see Table 1 for an overview The
image resolution varied from 03 megapixels (MP) to 5MP Onsome occasions the digital zoom of the mobile phone camera was
used to enlarge a specific area of the microscopy field and magnifythe micro-organism to be identified
Data transfer systemEnd user and server software of the image transfer system were
designed A draft form for use on the mobile phone wasdeveloped
for the end user to record ID sample type health center data andupload images from the mobile phone
An end user version of this software including mobile Internetwaspre-installed asan extra application on a Java enabled mobile
phone A server version of this image transfer system was installedlocally in Kampala Uganda We used Orange as our mobile
internet provider as they cover both Mpigi and Kampala districts[18] The end user recorded fictional information on the draft
form took the required picture(s) and pressed lsquolsquosendrsquorsquo The imagewas then sent automatically via the pre-installed mobile Internetconnection of the mobile phone stored in the database of the
central server and a confirmation text message that the image hadbeen received was sent to the end user Anyone with access to thecentral server could log on via an Internet page to this server and
examine the received image store it elsewhere or give instantfeedback via a text message or voice call to the end userrsquosphone
Additionally the image could be enlarged on the computer screenusing the digital zoom function of the computer in order to
magnify areas of interest
Testing procedures1 a Captur e of image without connector Laboratory staff
members at Nkozi hospital NTRL and the health centres were
Figure 1 The prototype connector which attaches a mobilephone to a microscope The prototype connector was designed byTU Delft and TNO The connector is adjustable to fit all sizes of candybar phones and some slide phones It also consists of adjustable screwsto fit most regular light microscopesdoi101371journalpone0028348g001
Mobile Phones to Support Microscopy Diagnosis
PLoS ONE | wwwplosoneorg 2 December 2011 | Volume 6 | Issue 12 | e28348
Sources Tuijn et al Data and Image Transfer Using Mobile Phones to Strengthen Microscopy-Based Diagnostic Services in Low and Middle Income Country Laboratories PLOS December 2011
Africa at the forefront of the global Mobile Money industry
Transfer credit between phones with a simple text message
Mobile money transfer allows those without a bank account to transfer funds as quickly and easily as sending a text message
M for Money transfer mPESA
mHealth and smartphones ndash for what for whom and to be used by whom
bull Mobile phones or smartphones were NOT primarily developed for medicine or health but for communication
bull Potentials for their application in medicine and health are enormous
bull Why are (some) researchers and health professionals a bit hesitant to apply mHealth
mHealth and Malaria ndash un-used and under-researched
bull PubMedgov Your search for mhealth and malaria retrieved no results (May 2012)
bull mhealth Results 52
bull mobile phones and malaria Results 11
bull mobile phones and pregnancy Results 75 but gt half of these on risk for fetus of microwaves
bull mobile phones and malaria and pregnancy
Your search for mhealth and malaria and pregnancy retrieved no results
Malaria in pregnancy research priorities by 2007 Lancet Infect Dis 2007 Feb7(2)169-74
Malaria in pregnancy priorities for research Greenwood B Alonso P ter Kuile FO Hill J Steketee RW
bull ldquoWe have selected the following as the highest priorities for research bull identification of new safe and effective drugs to treat malaria in
pregnancy bull identification of new drugs to replace sulfadoxine-pyrimethamine for
intermittent preventive treatment in pregnancy bull identification of optimum combinations of control measures in different
epidemiological settings bull and determination of optimum ways of scaling-up the use of insecticide-
treated mosquito nets and intermittent preventive treatmentrdquo bull p173
Integration of malaria control with reproductive health programmes ldquoAn important area of operational research is how malaria control can be integrated more effectively than in the past with reproductive health and other programmes directed at women of childbearing age
M for Malaria In Pregnancy and ANC Reaching the most remote and vulnerable
bull Q Would mHealth empower pregnant women to reach the health system
bull A probably cf lsquoWired Mothersrsquo
bull Q Would mHealth enable peripheral HCW to reach and refer to central health care levels
bull A probably cf lsquoWired Mothersrsquo amp lsquoD-Treersquo
bull Q Should we aim at a vertical intervention or
bull as an integrated part of ANC
Maternal Death and Assessment of Substandard Care in Relation to Obstetric Complications and Infections in a Rural HospitalNorth-Western Tanzania
Thesis D Damm 2012 lt 4 of Maternal Death caused by Malaria
All 4 ways of audit showed that of 84 women 30 died from infection 70 of these Puerperal Sepsis 10-20 other Severe infections of these 3 possibly malaria
MIP and mHealth as an opportunity to improve maternal and child health
bull MIP is a visible target
bull MIP control is prioritized by governments NGOs and donor agencies
bull MIP can be used as an effective rsquofoot in the doorrsquo for promoting maternal health so
bull MIP isshould be an integrated part of ANC and Child Care even if most women in malarious areas actually die from other causes and
bull mHealth for MIP should be an integrated part of ANC and Child Care
Words of warning bull Kaplan 2006
In developing world shared mobile telephone use is important
bull Sharing may be a serious drawback to use of mobile telephones as a healthcare intervention in terms of stigma and privacy
bull Regulatory reforms required if mobile phones be used for healthcare
bull Code of conduct available wwhonchHONcodeConducthtml
bull Maaloslashe Bygbjerg Onesmo et al 2012
bull The decision to perform an Emergency Cesarian Section [in Tanzanian rural hospital] was often made by a doctor being contacted by a nurse-midwife by telephone without the doctor examining the women which made the decision less qualified
Data and Image Transfer Using Mobile Phones
Images sent by mobile internet
Feedback to sender by text message
Strengthen Microscopy-Based Diagnostic such as malaria tb bacterial vaginosis stool parasites and eggs
M for Microscope and Medical Monitoring mHealth
care Several initiatives have shown previously that mobile phones
can be used to take pictures through a microscope [812ndash14] or be
modified to serve asa microscope [1516] The next logical step isto send the captured imagesvia mobile networks for example to a
reference laboratory for confirmation of diagnosis by an expert
For this study we developed a system of mobile phone-basedimaging in combination with a data transfer and responseplatform We piloted the performance of this system in Uganda
and discussed itsacceptability and potential applications with localstakeholders
Methods
Ethics StatementEthicsapproval or written informed consent wasnot required as
this isa methodology proof of concept paper Our focuswas firstly
on capturing a microscopy image of sufficient quality and then onthe Information Technology (IT) part to send the captured image
using the mobile phone Patientsrsquo personal information or anysamples IDrsquos that might allow tracing of patients was not used
Informed consent for discussions with colleagues at the health
centers was obtained verbally prior to site visits
LocationIn Uganda the health system is based on a referral system
consisting of different levels I indicating the lowest and IV thehighest level at higher levels more facilities and expertise are
available [17] The image capture wascarried out by a laboratorytechnologist at the National Tuberculosis (TB) Reference Labo-
ratory (NTRL) in Kampala district two laboratory technicianstwo assistants and a student at Nkozi Hospital laboratory in Nkozi
Mpigi district and five laboratory assistants at several level III andIV health centers from both these districts The data transfer
system was tested by a laboratory technologist and a doctor at theInternational Hospital of Kampala (IHK) and by IT specialistsfrom a local IT company in Kampala
Materials usedLaboratory samplesfrom theday before or set aside for training
purposesor external quality control of the health center were used
in our study These could not be linked to patients in any waySamples were initially collected as part of the routine activities
of the laboratories and either made anonymous or -in the case ofblood slides for blood parasites- an unlabelled duplicate slide was
sometimes used In the case of urine we used a drop of urine thatwas placed on an unlabelled slide and put under the microscope
for examination
Slide preparationAt NTRL and the TB health centres the slides selected for this
study were sputum slides for TB training purposesor QC samples
were stained with Ziehl Neelsen Blood slidesfor malaria that wereused at Nkozi hospital and the health centres in the other sites
were stained with Giemsa staining technique Urine and stoolslides were unstained direct wet preparations Auramine staining
was used for the detection of TB in sputum by fluorescentmicroscopy Staining of samples was performed in a European
laboratory
Image capture systemThe system is composed of a traditional light microscope
connected via a connector used as a positioning device to a Java-enabled mobile phone with camera see Figure 1 The connector
prototype was designed prior to this feasibility study [8] For this
study we used the 406 and the 1006 oil immersion objectives ofthe Olympus CX 21 Olympus CX31 Olympus CX41 and
Humascope (Human) light microscopes and the 406 objectives ofthe Olympus CX21 FluoLED Olympus BX41 and Nikon AFX-
IIA fluorescent microscopes Different camera phones were usedmainly Nokia candy bar models see Table 1 for an overview The
image resolution varied from 03 megapixels (MP) to 5MP Onsome occasions the digital zoom of the mobile phone camera was
used to enlarge a specific area of the microscopy field and magnifythe micro-organism to be identified
Data transfer systemEnd user and server software of the image transfer system were
designed A draft form for use on the mobile phone wasdeveloped
for the end user to record ID sample type health center data andupload images from the mobile phone
An end user version of this software including mobile Internetwaspre-installed asan extra application on a Java enabled mobile
phone A server version of this image transfer system was installedlocally in Kampala Uganda We used Orange as our mobile
internet provider as they cover both Mpigi and Kampala districts[18] The end user recorded fictional information on the draft
form took the required picture(s) and pressed lsquolsquosendrsquorsquo The imagewas then sent automatically via the pre-installed mobile Internetconnection of the mobile phone stored in the database of the
central server and a confirmation text message that the image hadbeen received was sent to the end user Anyone with access to thecentral server could log on via an Internet page to this server and
examine the received image store it elsewhere or give instantfeedback via a text message or voice call to the end userrsquosphone
Additionally the image could be enlarged on the computer screenusing the digital zoom function of the computer in order to
magnify areas of interest
Testing procedures1 a Captur e of image without connector Laboratory staff
members at Nkozi hospital NTRL and the health centres were
Figure 1 The prototype connector which attaches a mobilephone to a microscope The prototype connector was designed byTU Delft and TNO The connector is adjustable to fit all sizes of candybar phones and some slide phones It also consists of adjustable screwsto fit most regular light microscopesdoi101371journalpone0028348g001
Mobile Phones to Support Microscopy Diagnosis
PLoS ONE | wwwplosoneorg 2 December 2011 | Volume 6 | Issue 12 | e28348
Sources Tuijn et al Data and Image Transfer Using Mobile Phones to Strengthen Microscopy-Based Diagnostic Services in Low and Middle Income Country Laboratories PLOS December 2011
Africa at the forefront of the global Mobile Money industry
Transfer credit between phones with a simple text message
Mobile money transfer allows those without a bank account to transfer funds as quickly and easily as sending a text message
M for Money transfer mPESA
mHealth and smartphones ndash for what for whom and to be used by whom
bull Mobile phones or smartphones were NOT primarily developed for medicine or health but for communication
bull Potentials for their application in medicine and health are enormous
bull Why are (some) researchers and health professionals a bit hesitant to apply mHealth
mHealth and Malaria ndash un-used and under-researched
bull PubMedgov Your search for mhealth and malaria retrieved no results (May 2012)
bull mhealth Results 52
bull mobile phones and malaria Results 11
bull mobile phones and pregnancy Results 75 but gt half of these on risk for fetus of microwaves
bull mobile phones and malaria and pregnancy
Your search for mhealth and malaria and pregnancy retrieved no results
Malaria in pregnancy research priorities by 2007 Lancet Infect Dis 2007 Feb7(2)169-74
Malaria in pregnancy priorities for research Greenwood B Alonso P ter Kuile FO Hill J Steketee RW
bull ldquoWe have selected the following as the highest priorities for research bull identification of new safe and effective drugs to treat malaria in
pregnancy bull identification of new drugs to replace sulfadoxine-pyrimethamine for
intermittent preventive treatment in pregnancy bull identification of optimum combinations of control measures in different
epidemiological settings bull and determination of optimum ways of scaling-up the use of insecticide-
treated mosquito nets and intermittent preventive treatmentrdquo bull p173
Integration of malaria control with reproductive health programmes ldquoAn important area of operational research is how malaria control can be integrated more effectively than in the past with reproductive health and other programmes directed at women of childbearing age
M for Malaria In Pregnancy and ANC Reaching the most remote and vulnerable
bull Q Would mHealth empower pregnant women to reach the health system
bull A probably cf lsquoWired Mothersrsquo
bull Q Would mHealth enable peripheral HCW to reach and refer to central health care levels
bull A probably cf lsquoWired Mothersrsquo amp lsquoD-Treersquo
bull Q Should we aim at a vertical intervention or
bull as an integrated part of ANC
Maternal Death and Assessment of Substandard Care in Relation to Obstetric Complications and Infections in a Rural HospitalNorth-Western Tanzania
Thesis D Damm 2012 lt 4 of Maternal Death caused by Malaria
All 4 ways of audit showed that of 84 women 30 died from infection 70 of these Puerperal Sepsis 10-20 other Severe infections of these 3 possibly malaria
MIP and mHealth as an opportunity to improve maternal and child health
bull MIP is a visible target
bull MIP control is prioritized by governments NGOs and donor agencies
bull MIP can be used as an effective rsquofoot in the doorrsquo for promoting maternal health so
bull MIP isshould be an integrated part of ANC and Child Care even if most women in malarious areas actually die from other causes and
bull mHealth for MIP should be an integrated part of ANC and Child Care
Words of warning bull Kaplan 2006
In developing world shared mobile telephone use is important
bull Sharing may be a serious drawback to use of mobile telephones as a healthcare intervention in terms of stigma and privacy
bull Regulatory reforms required if mobile phones be used for healthcare
bull Code of conduct available wwhonchHONcodeConducthtml
bull Maaloslashe Bygbjerg Onesmo et al 2012
bull The decision to perform an Emergency Cesarian Section [in Tanzanian rural hospital] was often made by a doctor being contacted by a nurse-midwife by telephone without the doctor examining the women which made the decision less qualified
Africa at the forefront of the global Mobile Money industry
Transfer credit between phones with a simple text message
Mobile money transfer allows those without a bank account to transfer funds as quickly and easily as sending a text message
M for Money transfer mPESA
mHealth and smartphones ndash for what for whom and to be used by whom
bull Mobile phones or smartphones were NOT primarily developed for medicine or health but for communication
bull Potentials for their application in medicine and health are enormous
bull Why are (some) researchers and health professionals a bit hesitant to apply mHealth
mHealth and Malaria ndash un-used and under-researched
bull PubMedgov Your search for mhealth and malaria retrieved no results (May 2012)
bull mhealth Results 52
bull mobile phones and malaria Results 11
bull mobile phones and pregnancy Results 75 but gt half of these on risk for fetus of microwaves
bull mobile phones and malaria and pregnancy
Your search for mhealth and malaria and pregnancy retrieved no results
Malaria in pregnancy research priorities by 2007 Lancet Infect Dis 2007 Feb7(2)169-74
Malaria in pregnancy priorities for research Greenwood B Alonso P ter Kuile FO Hill J Steketee RW
bull ldquoWe have selected the following as the highest priorities for research bull identification of new safe and effective drugs to treat malaria in
pregnancy bull identification of new drugs to replace sulfadoxine-pyrimethamine for
intermittent preventive treatment in pregnancy bull identification of optimum combinations of control measures in different
epidemiological settings bull and determination of optimum ways of scaling-up the use of insecticide-
treated mosquito nets and intermittent preventive treatmentrdquo bull p173
Integration of malaria control with reproductive health programmes ldquoAn important area of operational research is how malaria control can be integrated more effectively than in the past with reproductive health and other programmes directed at women of childbearing age
M for Malaria In Pregnancy and ANC Reaching the most remote and vulnerable
bull Q Would mHealth empower pregnant women to reach the health system
bull A probably cf lsquoWired Mothersrsquo
bull Q Would mHealth enable peripheral HCW to reach and refer to central health care levels
bull A probably cf lsquoWired Mothersrsquo amp lsquoD-Treersquo
bull Q Should we aim at a vertical intervention or
bull as an integrated part of ANC
Maternal Death and Assessment of Substandard Care in Relation to Obstetric Complications and Infections in a Rural HospitalNorth-Western Tanzania
Thesis D Damm 2012 lt 4 of Maternal Death caused by Malaria
All 4 ways of audit showed that of 84 women 30 died from infection 70 of these Puerperal Sepsis 10-20 other Severe infections of these 3 possibly malaria
MIP and mHealth as an opportunity to improve maternal and child health
bull MIP is a visible target
bull MIP control is prioritized by governments NGOs and donor agencies
bull MIP can be used as an effective rsquofoot in the doorrsquo for promoting maternal health so
bull MIP isshould be an integrated part of ANC and Child Care even if most women in malarious areas actually die from other causes and
bull mHealth for MIP should be an integrated part of ANC and Child Care
Words of warning bull Kaplan 2006
In developing world shared mobile telephone use is important
bull Sharing may be a serious drawback to use of mobile telephones as a healthcare intervention in terms of stigma and privacy
bull Regulatory reforms required if mobile phones be used for healthcare
bull Code of conduct available wwhonchHONcodeConducthtml
bull Maaloslashe Bygbjerg Onesmo et al 2012
bull The decision to perform an Emergency Cesarian Section [in Tanzanian rural hospital] was often made by a doctor being contacted by a nurse-midwife by telephone without the doctor examining the women which made the decision less qualified
mHealth and smartphones ndash for what for whom and to be used by whom
bull Mobile phones or smartphones were NOT primarily developed for medicine or health but for communication
bull Potentials for their application in medicine and health are enormous
bull Why are (some) researchers and health professionals a bit hesitant to apply mHealth
mHealth and Malaria ndash un-used and under-researched
bull PubMedgov Your search for mhealth and malaria retrieved no results (May 2012)
bull mhealth Results 52
bull mobile phones and malaria Results 11
bull mobile phones and pregnancy Results 75 but gt half of these on risk for fetus of microwaves
bull mobile phones and malaria and pregnancy
Your search for mhealth and malaria and pregnancy retrieved no results
Malaria in pregnancy research priorities by 2007 Lancet Infect Dis 2007 Feb7(2)169-74
Malaria in pregnancy priorities for research Greenwood B Alonso P ter Kuile FO Hill J Steketee RW
bull ldquoWe have selected the following as the highest priorities for research bull identification of new safe and effective drugs to treat malaria in
pregnancy bull identification of new drugs to replace sulfadoxine-pyrimethamine for
intermittent preventive treatment in pregnancy bull identification of optimum combinations of control measures in different
epidemiological settings bull and determination of optimum ways of scaling-up the use of insecticide-
treated mosquito nets and intermittent preventive treatmentrdquo bull p173
Integration of malaria control with reproductive health programmes ldquoAn important area of operational research is how malaria control can be integrated more effectively than in the past with reproductive health and other programmes directed at women of childbearing age
M for Malaria In Pregnancy and ANC Reaching the most remote and vulnerable
bull Q Would mHealth empower pregnant women to reach the health system
bull A probably cf lsquoWired Mothersrsquo
bull Q Would mHealth enable peripheral HCW to reach and refer to central health care levels
bull A probably cf lsquoWired Mothersrsquo amp lsquoD-Treersquo
bull Q Should we aim at a vertical intervention or
bull as an integrated part of ANC
Maternal Death and Assessment of Substandard Care in Relation to Obstetric Complications and Infections in a Rural HospitalNorth-Western Tanzania
Thesis D Damm 2012 lt 4 of Maternal Death caused by Malaria
All 4 ways of audit showed that of 84 women 30 died from infection 70 of these Puerperal Sepsis 10-20 other Severe infections of these 3 possibly malaria
MIP and mHealth as an opportunity to improve maternal and child health
bull MIP is a visible target
bull MIP control is prioritized by governments NGOs and donor agencies
bull MIP can be used as an effective rsquofoot in the doorrsquo for promoting maternal health so
bull MIP isshould be an integrated part of ANC and Child Care even if most women in malarious areas actually die from other causes and
bull mHealth for MIP should be an integrated part of ANC and Child Care
Words of warning bull Kaplan 2006
In developing world shared mobile telephone use is important
bull Sharing may be a serious drawback to use of mobile telephones as a healthcare intervention in terms of stigma and privacy
bull Regulatory reforms required if mobile phones be used for healthcare
bull Code of conduct available wwhonchHONcodeConducthtml
bull Maaloslashe Bygbjerg Onesmo et al 2012
bull The decision to perform an Emergency Cesarian Section [in Tanzanian rural hospital] was often made by a doctor being contacted by a nurse-midwife by telephone without the doctor examining the women which made the decision less qualified
mHealth and Malaria ndash un-used and under-researched
bull PubMedgov Your search for mhealth and malaria retrieved no results (May 2012)
bull mhealth Results 52
bull mobile phones and malaria Results 11
bull mobile phones and pregnancy Results 75 but gt half of these on risk for fetus of microwaves
bull mobile phones and malaria and pregnancy
Your search for mhealth and malaria and pregnancy retrieved no results
Malaria in pregnancy research priorities by 2007 Lancet Infect Dis 2007 Feb7(2)169-74
Malaria in pregnancy priorities for research Greenwood B Alonso P ter Kuile FO Hill J Steketee RW
bull ldquoWe have selected the following as the highest priorities for research bull identification of new safe and effective drugs to treat malaria in
pregnancy bull identification of new drugs to replace sulfadoxine-pyrimethamine for
intermittent preventive treatment in pregnancy bull identification of optimum combinations of control measures in different
epidemiological settings bull and determination of optimum ways of scaling-up the use of insecticide-
treated mosquito nets and intermittent preventive treatmentrdquo bull p173
Integration of malaria control with reproductive health programmes ldquoAn important area of operational research is how malaria control can be integrated more effectively than in the past with reproductive health and other programmes directed at women of childbearing age
M for Malaria In Pregnancy and ANC Reaching the most remote and vulnerable
bull Q Would mHealth empower pregnant women to reach the health system
bull A probably cf lsquoWired Mothersrsquo
bull Q Would mHealth enable peripheral HCW to reach and refer to central health care levels
bull A probably cf lsquoWired Mothersrsquo amp lsquoD-Treersquo
bull Q Should we aim at a vertical intervention or
bull as an integrated part of ANC
Maternal Death and Assessment of Substandard Care in Relation to Obstetric Complications and Infections in a Rural HospitalNorth-Western Tanzania
Thesis D Damm 2012 lt 4 of Maternal Death caused by Malaria
All 4 ways of audit showed that of 84 women 30 died from infection 70 of these Puerperal Sepsis 10-20 other Severe infections of these 3 possibly malaria
MIP and mHealth as an opportunity to improve maternal and child health
bull MIP is a visible target
bull MIP control is prioritized by governments NGOs and donor agencies
bull MIP can be used as an effective rsquofoot in the doorrsquo for promoting maternal health so
bull MIP isshould be an integrated part of ANC and Child Care even if most women in malarious areas actually die from other causes and
bull mHealth for MIP should be an integrated part of ANC and Child Care
Words of warning bull Kaplan 2006
In developing world shared mobile telephone use is important
bull Sharing may be a serious drawback to use of mobile telephones as a healthcare intervention in terms of stigma and privacy
bull Regulatory reforms required if mobile phones be used for healthcare
bull Code of conduct available wwhonchHONcodeConducthtml
bull Maaloslashe Bygbjerg Onesmo et al 2012
bull The decision to perform an Emergency Cesarian Section [in Tanzanian rural hospital] was often made by a doctor being contacted by a nurse-midwife by telephone without the doctor examining the women which made the decision less qualified
Malaria in pregnancy research priorities by 2007 Lancet Infect Dis 2007 Feb7(2)169-74
Malaria in pregnancy priorities for research Greenwood B Alonso P ter Kuile FO Hill J Steketee RW
bull ldquoWe have selected the following as the highest priorities for research bull identification of new safe and effective drugs to treat malaria in
pregnancy bull identification of new drugs to replace sulfadoxine-pyrimethamine for
intermittent preventive treatment in pregnancy bull identification of optimum combinations of control measures in different
epidemiological settings bull and determination of optimum ways of scaling-up the use of insecticide-
treated mosquito nets and intermittent preventive treatmentrdquo bull p173
Integration of malaria control with reproductive health programmes ldquoAn important area of operational research is how malaria control can be integrated more effectively than in the past with reproductive health and other programmes directed at women of childbearing age
M for Malaria In Pregnancy and ANC Reaching the most remote and vulnerable
bull Q Would mHealth empower pregnant women to reach the health system
bull A probably cf lsquoWired Mothersrsquo
bull Q Would mHealth enable peripheral HCW to reach and refer to central health care levels
bull A probably cf lsquoWired Mothersrsquo amp lsquoD-Treersquo
bull Q Should we aim at a vertical intervention or
bull as an integrated part of ANC
Maternal Death and Assessment of Substandard Care in Relation to Obstetric Complications and Infections in a Rural HospitalNorth-Western Tanzania
Thesis D Damm 2012 lt 4 of Maternal Death caused by Malaria
All 4 ways of audit showed that of 84 women 30 died from infection 70 of these Puerperal Sepsis 10-20 other Severe infections of these 3 possibly malaria
MIP and mHealth as an opportunity to improve maternal and child health
bull MIP is a visible target
bull MIP control is prioritized by governments NGOs and donor agencies
bull MIP can be used as an effective rsquofoot in the doorrsquo for promoting maternal health so
bull MIP isshould be an integrated part of ANC and Child Care even if most women in malarious areas actually die from other causes and
bull mHealth for MIP should be an integrated part of ANC and Child Care
Words of warning bull Kaplan 2006
In developing world shared mobile telephone use is important
bull Sharing may be a serious drawback to use of mobile telephones as a healthcare intervention in terms of stigma and privacy
bull Regulatory reforms required if mobile phones be used for healthcare
bull Code of conduct available wwhonchHONcodeConducthtml
bull Maaloslashe Bygbjerg Onesmo et al 2012
bull The decision to perform an Emergency Cesarian Section [in Tanzanian rural hospital] was often made by a doctor being contacted by a nurse-midwife by telephone without the doctor examining the women which made the decision less qualified
M for Malaria In Pregnancy and ANC Reaching the most remote and vulnerable
bull Q Would mHealth empower pregnant women to reach the health system
bull A probably cf lsquoWired Mothersrsquo
bull Q Would mHealth enable peripheral HCW to reach and refer to central health care levels
bull A probably cf lsquoWired Mothersrsquo amp lsquoD-Treersquo
bull Q Should we aim at a vertical intervention or
bull as an integrated part of ANC
Maternal Death and Assessment of Substandard Care in Relation to Obstetric Complications and Infections in a Rural HospitalNorth-Western Tanzania
Thesis D Damm 2012 lt 4 of Maternal Death caused by Malaria
All 4 ways of audit showed that of 84 women 30 died from infection 70 of these Puerperal Sepsis 10-20 other Severe infections of these 3 possibly malaria
MIP and mHealth as an opportunity to improve maternal and child health
bull MIP is a visible target
bull MIP control is prioritized by governments NGOs and donor agencies
bull MIP can be used as an effective rsquofoot in the doorrsquo for promoting maternal health so
bull MIP isshould be an integrated part of ANC and Child Care even if most women in malarious areas actually die from other causes and
bull mHealth for MIP should be an integrated part of ANC and Child Care
Words of warning bull Kaplan 2006
In developing world shared mobile telephone use is important
bull Sharing may be a serious drawback to use of mobile telephones as a healthcare intervention in terms of stigma and privacy
bull Regulatory reforms required if mobile phones be used for healthcare
bull Code of conduct available wwhonchHONcodeConducthtml
bull Maaloslashe Bygbjerg Onesmo et al 2012
bull The decision to perform an Emergency Cesarian Section [in Tanzanian rural hospital] was often made by a doctor being contacted by a nurse-midwife by telephone without the doctor examining the women which made the decision less qualified
Maternal Death and Assessment of Substandard Care in Relation to Obstetric Complications and Infections in a Rural HospitalNorth-Western Tanzania
Thesis D Damm 2012 lt 4 of Maternal Death caused by Malaria
All 4 ways of audit showed that of 84 women 30 died from infection 70 of these Puerperal Sepsis 10-20 other Severe infections of these 3 possibly malaria
MIP and mHealth as an opportunity to improve maternal and child health
bull MIP is a visible target
bull MIP control is prioritized by governments NGOs and donor agencies
bull MIP can be used as an effective rsquofoot in the doorrsquo for promoting maternal health so
bull MIP isshould be an integrated part of ANC and Child Care even if most women in malarious areas actually die from other causes and
bull mHealth for MIP should be an integrated part of ANC and Child Care
Words of warning bull Kaplan 2006
In developing world shared mobile telephone use is important
bull Sharing may be a serious drawback to use of mobile telephones as a healthcare intervention in terms of stigma and privacy
bull Regulatory reforms required if mobile phones be used for healthcare
bull Code of conduct available wwhonchHONcodeConducthtml
bull Maaloslashe Bygbjerg Onesmo et al 2012
bull The decision to perform an Emergency Cesarian Section [in Tanzanian rural hospital] was often made by a doctor being contacted by a nurse-midwife by telephone without the doctor examining the women which made the decision less qualified
MIP and mHealth as an opportunity to improve maternal and child health
bull MIP is a visible target
bull MIP control is prioritized by governments NGOs and donor agencies
bull MIP can be used as an effective rsquofoot in the doorrsquo for promoting maternal health so
bull MIP isshould be an integrated part of ANC and Child Care even if most women in malarious areas actually die from other causes and
bull mHealth for MIP should be an integrated part of ANC and Child Care
Words of warning bull Kaplan 2006
In developing world shared mobile telephone use is important
bull Sharing may be a serious drawback to use of mobile telephones as a healthcare intervention in terms of stigma and privacy
bull Regulatory reforms required if mobile phones be used for healthcare
bull Code of conduct available wwhonchHONcodeConducthtml
bull Maaloslashe Bygbjerg Onesmo et al 2012
bull The decision to perform an Emergency Cesarian Section [in Tanzanian rural hospital] was often made by a doctor being contacted by a nurse-midwife by telephone without the doctor examining the women which made the decision less qualified
Words of warning bull Kaplan 2006
In developing world shared mobile telephone use is important
bull Sharing may be a serious drawback to use of mobile telephones as a healthcare intervention in terms of stigma and privacy
bull Regulatory reforms required if mobile phones be used for healthcare
bull Code of conduct available wwhonchHONcodeConducthtml
bull Maaloslashe Bygbjerg Onesmo et al 2012
bull The decision to perform an Emergency Cesarian Section [in Tanzanian rural hospital] was often made by a doctor being contacted by a nurse-midwife by telephone without the doctor examining the women which made the decision less qualified