SMS-based smartphone application for disease surveillance has doubled completeness and timeliness in a limited-resource setting – evaluation of a 15-week pilot program in Central African Republic (CAR)

El-Khatib, Ziad; Shah, Maya; Zallappa, Samuel N; Nabeth, Pierre; Guerra, José; Manengu, Casimir T; Yao, Michel; Philibert, Aline; Massina, Lazare; Staiger, Claes-Philip; Mbailao, Raphael; Kouli, Jean-Pierre; Mboma, Hippolyte; Duc, Geraldine; Inagbe, Dago; Barry, Alpha Boubaca; Dumont, Thierry; Cavailler, Philippe; Quere, Michel; Willett, Brian; Reaiche, Souheil; de Ribaucourt, Hervé; Reeder, Bruce

Mobile phone-based surveillance systems have been pilot tested in several contexts in the past decade. General syndromic surveillance projects in Papua New Guinea [22] , Cambodia [2] , and Madagascar [23] have produced moderate improvements in the completeness and timeliness of reporting, e.g. an increase in completeness from 40% prior to 70% during the pilot in Papua New Guinea. Targeted surveillance programs for malaria [24] , rabies [3] , and influenza in Uganda, Tanzania, and Kenya [7] , respectively, produced considerable improvements in report timeliness, eg. a reduction in the median reporting delay for influenza in Kenya from 21 to 7 days. Mobile The proportion of transmission initiated = Total reports partially or fully received × 100 / total N reports expected from sub-districts) b The proportion of transmission complete = Total reports fully received × 100 / total N reports expected from sub-districts) c As the surveillance focal points were absent from their health facilities for the booster-training workshop in Berberati during epidemiological week 14, they did not submit their Weekly Reports until returning the following week. Therefore completeness, but not timeliness of reports, was calculated for week 14 technology appears also to have enhanced surveillance in emergency settings, such as following the earthquakes in Sichuan, China [10] and Haiti [11] . However, larger, comprehensive mobile phone-based surveillance systems have not been assessed in post-conflict settings with ongoing insecurity. This project assesses the impact, feasibility, and cost of using mobile technology for the surveillance of a broad range of notifiable conditions using a simple SMS-based application in a post-conflict setting. Our study shows that, within weeks, the completeness and timeliness of weekly surveillance reports can be considerably improved, and the improvement maintained, despite the remoteness of the healthcare centers and primitive road conditions. Although sub-districts were highly compliant in submitting weekly reports on their mobile devices, the proportion whose transmissions were successfully completed differed significantly ( Table 2) . Of the two distant sub-districts with the medium-level security risk (Gadzi and Amada-Gaza), one managed a high level of completeness (Gadzi 73.3%) relative to the other (Amada-Gaza 43%). Conversely, two sub-districts in areas of low security risk near the capital (Sosso-Nakombo, Dede-Makouba) managed only 66.7% and 56.7% levels of completeness, respectively. The consistently high level of submission of weekly reports from all sub-districts suggests that remoteness and level of insecurity did not constrain the use of the technology in the health centers. Rather, we suspect that the differences seen between sub-districts in report completeness and timeliness may relate more to the quality of the communications network, the aptitude of the participating staff and, in several settings, the need for motorcycle taxi transport to a nearby community to access a telecommunications network. The electronic reporting system in the present project was rated as highly usable by participating staff. This may reflect a readiness of the staff to adopt new technology for digital surveillance, however we do not have baseline information with which to measure changes in perceptions or technical skills. The cost of the pilot was higher than mobile disease surveillance interventions reported in other contexts [6]