1. Workshop on Simulation Exercise for AI Focusing
on Information Technology
Stung Treng Province, Cambodia, October 13‐15, 2008
After Action Report
Taha A. Kass‐Hout, MD, MS
Draft of 12/04/2008
Our primary aim was to provide and test a prototype emergency response system based on open source
technologies that would strengthen the response capabilities of Rapid Response Teams (RRT), referral
hospital, first responders and local communities within the provinces, villages and communes in the
setting of an avian influenza pandemic. A series of user‐centered design sessions and training with the
MoH, RRT team and various community members were conducted before and during the exercise. More
specifically, participating RRT and hospitals needed to validate and get training on existing plans, and to
develop Pandemic Response Plans for their province, for effective communication prevention and
control of the spread of disease and leverage the open source tools we developed in‐country to help
them achieve this goal.
2.
Table of Contents
Introduction....................................................................................................................................................... 3
The Simulation Exercise ..................................................................................................................................... 3
The Situation.............................................................................................................................................................3
The Objective and Opportunity ................................................................................................................................4
The Approach............................................................................................................................................................4
The Exercise: Avian Flu Outbreak in 3 Villages on October 15, 2008 .......................................................................5
Pandemic Alert Period (WHO Pandemic Stages 3 and 4).....................................................................................5
Pandemic Alert Period (WHO Pandemic Stage 5) ................................................................................................5
Participants ..........................................................................................................................................................6
Participants Feedback .......................................................................................................................................10
Cell Phone Use ........................................................................................................................................................10
Using Geochat.........................................................................................................................................................11
Challenges and Opportunities............................................................................................................................11
Costs and sustainability......................................................................................................................................12
Conclusion ........................................................................................................................................................13
Appendix I: Agenda...........................................................................................................................................14
Simulation Exercise for AI focusing on Information Technology, Sekong Star Hotel (Stung Treng), 13‐15 October,
2008 ........................................................................................................................................................................14
Appendix II: Strategic Opportunities..................................................................................................................15
Opportunities to Enhance Disease Detection and Response for Cambodia and the MBDS Region.......................15
Surveillance Data Storage and Management.....................................................................................................16
Direct Participation of Labs Laboratory .............................................................................................................17
Unstructured Text and RSS Feeds ......................................................................................................................17
Collaboration......................................................................................................................................................17
Analytics and Visualization.................................................................................................................................17
Appendix III: Mekong Region Geochat Coverage [to date] .................................................................................17
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3. Workshop on Simulation Exercise for AI Focusing on Information
Technology: Stung Treng Province, Cambodia, October 13-15, 2008
Routine health facility based disease surveillance systems, such as those on which most MBDS countries
depend, could provide neither a complete nor a representative picture of health problems in the
communities. This is primarily due to the fact that patients who cannot get access to public health
facilities or who choose not to use them are not reported by these systems. In order to overcome this
limitation, we augment facility‐based health information systems with a community‐based approach
based upon a collaborative network of people involved in the systematic detection and reporting of
health‐related events from their
community. We tested this initial
capability (InSTEDD’s Geochat) in a cross‐
sector and cross‐province Avian Influenza
(AI) community simulation exercise in
Stung Treng province, Cambodia. This
collaborative effort was sponsored by
InSTEDD and conducted jointly with the
Stung Treng Provisional Health
Department (PHD), Cambodia CDC, and
Cambodia Ministry of Health (MoH.)
Introduction The Stung Treng province faces many health
problems and often relies on the public health system or its
community‐based organizations for help in lieu of medical
practitioners or clinics. It also turns to affordable cell phones in lieu
of landlines for mobility, and cost savings. Public health practitioners
and community practitioners who provide local services find ongoing
communication with individuals in communities of need, to be a
challenge. InSTEDD worked with Cambodia Ministry of Health,
Cambodia CDC, Stung Treng Provisional Health Department, local
health centers, and simulated participation of cross‐border officials
to help address this challenge using text‐messaging (SMS) as an
affordable means to improve outreach communication and
disseminate multi‐directional information among various agencies
and those in the field. SE Asia Region (Source: Wikipedia)
The Simulation Exercise
The Situation Public health officials are on alert because of increasing concerns about the prospect of
an influenza pandemic. Moreover, because of recent problems with the availability and strain‐specificity
of flu vaccines, as well as the rising specter of the avian flu, officials from Cambodia Ministry of Health
(MoH), CDC and Stung Treng Provisional Health Department (PHD) are alarmed about the potential
inability to prevent or contain a human pandemic once it erupts in a few villages. Cambodia MoH, in
coordination with Cambodia CDC, adopted and adapted the WHO Global pandemic preparedness plan
to prepare for, respond to, and contain an outbreak of pandemic flu. With a population of >100,000
(>25,000 in the city), and many more visiting the province each day, the Stung Treng province was the
focus of the exercise (Please see Appendix I for agenda). Furthermore, since Lao PDR became an ASEAN
member, many national roads have been renovated and/or constructed, with support from many
international donors. Geographical isolation, which has always been a characteristic of Lao PDR, is
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6. • Create a Health Event for each cluster that is linked to the “overall” H5N1 Health Event.
• Spawn tasks for each new Health Event for development of case definitions, and for monitoring
selected indicators.
• Create new groups (as necessary) for RRT and local (village lead and local authorities) response
teams for each of these clusters.
Participants A participant survey was conducted after the training (we received 55 responses
(~73.33% response rate).) Based on this survey, the majority of participants (12 Female (23.5%) and 39
Male (76.5%), 4 missing responses) had health or public health backgrounds as follows:
• There were a total of 20 nurses (37%, 1 missing response), 12 nurses primarily used Nokia
phones (60%), and they joined multiple groups with the majority being in the Yellow2 group (11
(55%)), Yellow1 group (4 (20%)), and Blue1 group (2 (10%).)
• There were a total of 12 MDs (22%, 1 missing response), 9 MDs primarily used Nokia phones
(75%), and they uniformly joined multiple groups (majority are in group Yellow2 (25%).)
• There was 1 participant with a
formal degree in public health
(MPH) who used a Nokia phone and
joined the Green3 group.
• Other participants 11 (20%) had
various background or training (data
entry, laboratory, midwife,
pharmacy, physiotherapy, infectious
diseases, malaria and diarrhea, or
Geochat Training conducted by the InSTEDD Team
IT); the majority have used Nokia
phones (73%), and uniformly
Geochat Group n %
joined multiple groups.
Blue1 (simulated cross-border—Champasak) 4 7.5
• 19% of participants did not Green1 (Kampot) 4 7.5
specify their background or Green2(Takeo) 2 3.8
training. Green3 (Kompong Speu) 2 3.8
• Almost half the participants (23 Green4 (Ratanakiri) 0 0
(42.59%), 1 missing response) Green5 (Mondulkiri) 2 3.8
were between the ages of 36‐45 Green6 (Kampong Cham) 3 5.7
Yellow1 (Rapid Response Team) 6 11.3
year. 3 under 25 years old
Yellow2 (Provincial Health and Reference Hospital) 18 34
(5.56%, 1 missing response), 14 Yellow3 (Authorities) 7 13.2
between the ages of 26‐35 years Yellow4 (Others) 5 9.4
(25.93%, 1 missing response),
and 14 over 45 years old (25.93%, 1 missing response.)
• Most participants had electricity at work (47 (85.45%)) and at home (48 (90.57%), 2 missing
responses), had phone coverage at home (50 (94.34%), 2 missing responses) and work (51
(92.73%), and had Computer at home (32 (60.38%), 2 missing responses) and at work (26
(47.27%).) The majority of participants did not have Internet at home (18 (33.96%), 2 missing
responses) nor at work (13 (23.64%).)
The participants; per instructions from CDC, broke out into 3 major groups of ~20 people in each group
(2 provinces in each group) and CDC facilitated various preparedness and response plan discussions in a
Q/A format specifically targeted at the local level. For the purpose of the exercise, we further broke the
3 groups into Geochat groups to match their roles. Various SMS messages were exchange during the
simulation exercise following the Ministry of Health communication policy. Participants were then asked
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8. CDC ALL Parties Suspect AI outbreak in Sangsay AI pteus nov Stung
Stung Treng Treng
4. Step Four: CDC immediately follows‐up with clear case definition for suspect AI.
Communicating Geochat Message Khmer Translation (using
Parties English characters)
CDC ALL 7 Suspect AI case definition, Niyominey karaney sagsay AI:
Provisional Health fever > 38c with kamdov leus 38c, pagnaha
Departments and respiratory problem phlov danghoem ( khaork, hot,
simulated cross‐ (cough, dyspnea, sore chheu kor, hear sambor) reu
border throat, runny nose) or roksangna phseng phseng
other symptom (diarrhea, (reak, chheusach dom
myalgia, etc.) AND close cheadoeum) NOUNG ban pah
contact with poultry (sick pal cheamuoy sat del chheu reu
or dead chicken) over last gnab khnong kamlong 7 thgney
7 days mun
5. Step Five: While CDC awaits further testing, given the matched case definition above in the
villages, CDC orders authorities to close access to villages immediately.
Communicating Parties Geochat Message Khmer Translation (using English
characters)
CDC/PHD Authorities (e.g., Close access to Bit kar chang choul phum
Police) village
6. Step Six: At this point, villages are in self‐sustainment mode where each village lead coordinate
and collaborate with families and local authorities to issue Quarantine, distribute medication
and PPE masks, request help from local authorities in maintaining order in the village and
making sure Quarantine is in effect for identified cases, alert local hospitals or treatment centers
of the situation so they prepare infection control units, and help the sick reach local treatment
center per protocol. For training purposes we relaxed the assumption of hierarchical reporting
at the very end of the exercise by letting information flow freely within workgroups, in particular
for those representing field workers. This allowed users to get more familiar with the software
and be more creative in coordinating an outbreak/pandemic response.
Communicating Geochat Message Khmer Translation (using English
Parties characters)
General Messages 1. Does anyone have a 1. Teu nak na mean lan te?
among field car? 2. Yeun trov ka thnam
workers, first 2. We need medicine 3. Yeun trov ka PPE
responders, 3. We need PPEs 4. Nor na chea prathean phom?
authorities, and 4. Who is the head of 5. Cruosa trov ka aha
government village? 6. Knhon trov ka mazut
officials at CDC and 5. Family needs food 7. Men anugnat ouy mean ka
provisional levels. 6. I need mazut choub chum nov wat
(gasoline) 8. Te phsa boeuk reu nov?
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9. 7. No gathering allowed 9. Te sala boeuk reu nov?
at Pagoda 10.Knom trov ka lanpet
8. Is market open? 11.Teu mean avey ouy yeung
9. Is school open? chhouy te?
10.I need an ambulance 12.Ter yerng ach chuoy avey
11.Can we help? ban?
12.What can we do to 13.Ter neak mean thnam
help? bonthem te?
13.Do you have extra 14.Bat yerng mean thnam
medicine? 15.Ter neak mean thnam krob
14.Yes, we have extra kran te?
medicine 16.Te yerng khmean thnam te
15.Do you have enough 17.Ter neak mean PPE bonthem
medicine? te?
16.No, we don’t have 18.Bat yerng mean PPE
any medicine 19.Ter neak mean PPE krob kran
17.Do you have extra te?
PPEs? 20.Te yerng khmean PPE te
18.Yes, we have extra 21.Ter yerng ach tor tuol
PPEs chumnuoy pi Quarantine te?
19.Do you have enough
PPEs?
20.No, we don’t have
any PPEs
21.Can we get help with
Quarantine
The findings of this simulation exercise suggest potential use of SMS text‐messaging as a communication
medium for bi‐directional exchange between field practitioners, field practitioners and central, and
cross sectors. A contribution of this simulation exercise is the data collection in a community setting in
bridging the digital divide where affordability is a limitation. The following figure shows the overall
number of messages exchanged during the exercise (including test and training messages)
Total Messages (exercise and training) Exchanged during the AI Simulation Exercise.
October 13, 2008 thru October 15, 2008, Stung Treng, Cambodia
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10. Exercise Phase Delivery Date Number of Messages Number of Parts Message Status
Actual Exercise 10/15/2008 1 1 Error delivering message
Actual Exercise 10/15/2008 2204 2213 Received by recipient
Actual Exercise 10/15/2008 26 26 Delivered to gateway
Training 10/14/2008 16 16 Error delivering message
Training 10/14/2008 776 776 Received by recipient
Training 10/14/2008 62 62 Delivered to gateway
Training 10/13/2008 5 5 Error delivering message
Training 10/13/2008 496 496 Received by recipient
Training 10/13/2008 48 48 Delivered to gateway
Breakdown and Status of Messages (exercise and training) Exchanged during the AI Simulation Exercise,
October 13, 2008 thru October 15, 2008, Stung Treng, Cambodia
Total Messages (exercise only) Exchanged during the morning of the AI Simulation Exercise,
October 15, 2008, Stung Treng, Cambodia
Participants Feedback According to the survey results (using Likert scale and open‐ended
questions) we provide the following summary:
Cell Phone
Use
Participants
used a total of
14 different
phone with
the majority of
participants
(73%) used
Nokia (2 users
did not have
phone during
the exercise, 3 missing responses.) The majority of the phones did not support local Khmer language (47
(94%), 5 missing responses).) MobiTel code (012) provided mobile service for 2/3rd of the phones (33
(67.35%)), and Sinawatra (code 011) were the service provider for 1/3rd of the phones (16 (32.65%).)
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11. Using Geochat Of the 55 complete responses 45 (82.2%) users were able to join a group, 46 (84.4%)
sent at least one message to a group, 47 (85.5%) users receive at least one message from a group, and 3
(5.5%) were unable to use Geochat.
The feedback we received was very positive:
Phone Type n %
• Users favored the training and they: Golden 1 1.9
a. would like similar training in the future (mean 1.3 (95% no phone 2 3.8
CI: 1.1‐1.5 (0.10 SD)), with 1 "Definitely, I would like to Nokia 38 73.1
Nokia 6085 1 1.9
do this type of training again" and 5 "Definitely NOT, I Nokia 6270 1 1.9
would not like to do this type of exercise again", 1 Nokia 63 00 1 1.9
missing response), Nokia 6300 1 1.9
b. felt the training was adequate (mean 1.8 (95% CI: 1.6‐ Nokia 7610 1 1.9
Nokia N 95 1 1.9
2.1 (0.12 SD)), with 1 "Yes, I learned a lot" and 5 "not Nokia N70 1 1.9
really", 2 missing responses) and Nokia N81 1 1.9
c. felt their questions were answered (mean 1.4 (95% CI: Nokia(6120) 1 1.9
Nokia(N95) 1 1.9
1.2‐1.6 (0.10 SD)), with 1 "Yes, all my questions were
Sony Ericson 1 1.9
answered" and 5 "none of my questions were
answered", 5 missing responses.) Geochat Group Preference n
• Users felt confident they can use the system on their own Village health volunteer 41
(mean 1.8 (95% CI: 1.6‐2.1 (0.13 SD)), with 1 being Village health center 45
Completely Confident and 5 Not at all Confident.) District heath department 38
• Users asked for using Geochat immediately (“ASAP”) for real Provincial health department 44
Cambodia CDC 43
life scenarios and in other provinces (1 missing response.)
Provincial RRT 43
Participants were then asked their preference; if they were using National RRT 39
Geochat today, of which group they will join. The following table Authority 36
summarizes the responses for each role (assuming the groups were NGO 27
formed based on the role of participants.) Cross border 33
Other 9
Challenges and Opportunities ICTs have enabled public health
officials in Cambodia (and other countries in the region) to coordinate public health response. More
traditional ICTs like radio and television have been beneficial in disease prevention and epidemic
response. In Cambodia, this has been evident in response to recent Avian Influenza cases, HIV/AIDS,
Malaria and Cholera amongst other diseases. More recent ICTs like mobile phones, email and Internet
could also be used for training, outbreak investigation and coordinated response, and even sending
health alerts to the general public. Although Geochat has the potential to be greatly beneficial for the
public health sector in Cambodia
(and other countries in the Southeast Asia region and similar developing countries), its success is
sometimes marred by challenges and contradictions. This includes the workable condition and costs of
ICT equipment, mobile coverage, level of awareness, and skills of the potential users, technology
compatibility and policy provisions amongst others. The ICT infrastructure status in Cambodia currently
is unable to adequately support the full benefits of Geochat in the public health and health sectors.
Internet access is very limited or non‐existent below the provisional level. Most health centers and
provisional health departments still use manual systems of recording and exchanging weekly and
monthly information. Cost of text‐messaging or accessing the internet (further discussed in next
section), maintaining the equipment and buying new ones are also a challenge. In addition to the costs
and status of infrastructure, there is currently very little emphasis on "horizontal" collaboration (e.g.,
province‐to‐province, or local‐to‐local.) Related to this are the following elements as requested in the
feedback we received from participants:
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12. • Local Khmer language support to make it easier to communicate, especially for those in the
field.
• More frequent training in Stung Treng and other provinces
• Faster delivery of message once it’s been sent—(during the exercise users experienced delayed
message delivery (in some instances for up to 60‐90 minutes), an issue we believe might be
related to local mobile service provider (MobiTel and/or Sinawatra) since the Geochat system
received all messages in time. Our engineers continue to work with MobiTel and health officials
to find a solution once the problem is further identified.)
When we asked why a user might not want to use Geochat, "Need Geochat as soon as possible to get
only 10 users (or 18% or the total responses) indicated their ready to fight epidemic disease especially AI"
inability to use for the following reasons:
• 3 users (5.5%) find it difficult to use an English‐based "…slow SMS response, hard to communicate
phone across different group” Kampot
• 2 users (3.6%) cannot afford a cell phone
• 3 users (5.5%) find it difficult to use an English‐based "...suggest InSTEDD to support RRT team for
smooth operation because I will learn more
phone AND cannot afford a cell phone from InSTEDD."
• 1 user finds it difficult to use text‐messaging (SMS)
• 1 user (1.8%) worried about delayed response to CDC “I suggest having Geochat training in other
provinces…”
or MoH
We envision Geochat to also enable distance learning for health personnel and others on several health
issues.
Costs and sustainability Though we haven’t conducted an economic study on the annual per capita
cost to the Cambodian government, the Geochat model offers a toll free number to the user through a
SMS gateway at a country or regional level. We anticipate the cost will be only a small fraction of what
would be for each user to use their personal number. Additional costs include occasional visits from
Phnom Penh for training, supervision, and evaluation. This cost would be even lower if the system was
operated by the District once appropriately trained by our team. We anticipate Geochat to be lower
than that of many similar systems running in developing countries to date, because of its use of existing
health infrastructure and staff, which costs much less than projects run by non‐governmental
organizations where additional staff and facilities have to be funded (O’Neill 1993; Cairncross et al.
1997.) The anticipated amount of staff time
required to manage the system will be relatively
small; 1 day per month during the ICT meeting for
central level, plus a half‐day of training, and time
spent on outbreak response, if any. Additional
focus is on training Provisional and District health
departments, health centers and Village Health
Volunteers (VHVs) (3–4 half days per month.)
The InSTEDD Geochat (and other InSTEDD tools) –
coupled with the InSTEDD local innovation lab –
has many attributes that could make it more The Komphun rural Health Center serves over 7000
viable – that is sustainable – than other initiatives. population in the Stung Treng and neighboring
provinces. The center’s director already uses SMS to
First, VHVs and health staff could potentially run
communicate potential outbreak information or
and manage the system by themselves, with little
suspect AI cases to PHD and CDC
technical or supervisory support. Second, the
system augments the existing health system and
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14. Appendix I: Agenda
Simulation Exercise for AI focusing on Information Technology, Sekong Star Hotel
(Stung Treng), 1315 October, 2008
Date/Time Program/Topic presentation Presenter
Day 1
8:00‐8:30 Registration
8:30‐9:30 Opening Session
Welcome Address Director of CDC
Department
Representation of
InSTEDD
Director of Stung Treng
PHD
09:30‐10:00 Tea/Coffee Break
10:00‐12:00 Updated Situation general of AI in the Dr. Ly Sovann
world
Lunch
13:30‐15:00 National Surveillance Response in Dr. Chan Vuthy
Cambodia
15:00‐15:30 Tea/Coffee Break
15:30‐17:00 National Plan for AI Response Dr. Ly Sovann
Day 2
8:00‐8:30 Registration
08:30‐10:00 Discussion on Rapid Containment plan CDC/MOH and RRT/ST
10:00‐10:30 Tea/Coffee Break
10:00‐12:00 Continuous Discussion CDC/MOH and RRT/ST
12:00‐13:30 Lunch
13:30‐15:00 Focusing on information technology InSTEDD Representation
15:00‐15:30 Tea/Coffee Break
15:30‐17:00 Focusing on information technology InSTEDD Representation
(Continuous)
Day 3
8:00‐8:30 Registration
08:30‐10:00 Field testing on information technology
10:00‐10:30 Tea/Coffee Break
10:00‐11:00 Field testing on information technology
(Continuous)
11:00‐11:30 Closing session
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