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Interim Report Ref 0402A5_L48

Website for Sleman District DHF Surveillance Report:

Prof. Hari Kusnanto, MD, DrPH (Principal Investigator) Anis Fuad, DEA (Co-principal Investigator) Sunartono, MD, MS (Co-principal Investigator)

Center for Health Informatics and Learning Faculty of Medicine Gadjah Mada University


Dengue hemorrhagic fever (DHF) is an endemic disease with high morbidity and mortality in Indonesia. Although several major outbreaks have occurred in the past, DHF control is fragmented and reactive to political and social concerns. Case management in hospitals and insecticide spraying are the focus of response to the DHF crises almost every year in endemic areas. The objective of the study is to establish a web-based surveillance system and knowledge provision which is user-friendly and easily available from the web-site. The areas of the study are Sleman District and Yogyakarta Municipality. In the first stage of the study, reports from all hospitals serving Sleman population were collected, and the location of where DHF cases live were identified and geocoded using global positioning systems. The temporal and spatial distributios of DHF cases were mapped, so that the pattern of DHF spread could be learned and continuously updated. Workshops, seminars and discussions have been held to socialize the preliminary results of the study, and motivate actions to stop further incidence of DHF cases in the study areas. The study has been greatly supported by the health care personnel working in the district and municipal health offices, hospitals and community health centers, and community members who are active in vector control movements. Innovation of disease reporting using SMS messaging integrated in the report database has been adopted by hospital personnel. The ultimate objective of the project is the significant reduction of DHF incidence to approaching zero level, which will be continuously monitored using time-series analyses. Soft system and qualitative approaches, are the methods of choice for translating the evidence produced by the study into concerted efforts in DHF control, especially through community-based initiatives.

Research Problem

Dengue hemorrhagic fever (DHF) is an endemic disease in most urban areas of Indonesia. The disease poses continuous threats of serious morbidity and mortality, often in the form of outbreaks, with a number of fatal cases. DHF control strategies are fragmented. Hospital physicians diagnose and treat DHF cases. District health office staff regularly collect data about DHF cases admitted to hospitals serving the population in the district. The data are then made available to the community health centers, which are responsible for epidemiological investigation and reporting, community-based vector control and early recognition of symptoms, signs and spread of DHF cases. District health office is responsible for area spraying activities as a response to reported DHF cases in a neighborhood. It is well known that the problems with dengue go beyond the health sector. Concerted efforts involving public organizations, private sectors and communities are needed to design and implement DHF control strategy. Numerous factors, such as insufficient waste collection and management, non-biodegradable containers, improper tire disposal, increased number of water storage containers, and inadequate septic system conditions, are responsible for the increasing intensity of DHF spread. The research problem addressed in this study is whether web-based mapping of DHF cases provide better insights about the incidence and spread of the disease. The study is also interested in the role of integrated information and communication technology to improve disease surveillance, clinical management, and organized community efforts for vector control and early recognition of DHF symptoms and signs.

Research Findings

The main research findings obtained six months after the beginning of the study are the awareness about the goals of the study among partners who participated in the study, namely Sleman District Health Office and Yogyakarta Municipal Health Office and community health centers, hospitals serving the population living in Sleman District and the city of Yogyakarta, community members who are active and organized for vector control initiatives. The support of study partners has facilitated routine data collection from hospitals and district/municipal health offices, mapping the locations with GPS to identify and record the latitude and longitude of where the patients live, and publishing the geocoded map on the web-site. Preliminary findings of the recording and reporting systems implemented by Sleman District Health Office and Yogyakarta Municipality Health Office suggest that routine surveillance reporting has often been too late, so that immediate actions to prevent and control DHF outbreaks are limited. The database structures for reporting DHF cases maintained by Sleman District and Yogyakarta Municipal Health Offices are incompatible with each other (Figure 1 and 2). The occurences of DHF cases were recorded according to the month of the incidence in Sleman, but in Yogyakarta municipality the date of DHF

diagnosis in the hospital was recorded in the database, which was updated weekly. The DHF cases in Yogyakarta city were widespread and evenly distributed over the whole city (Figure 3). Meanwhile, DHF cases in Sleman district were concentrated in the periurban areas (Figure 4).

were concentrated in the periurban areas (Figure 4). Figure 1. Database structure of DHF cases maintained

Figure 1. Database structure of DHF cases maintained by Sleman District Health Office with codes for village, community heatlh promotion area, and month of diagnosis

community heatlh promotion area, and month of diagnosis Figure 2. Database structure of DHF cases maintained

Figure 2. Database structure of DHF cases maintained by Yogyakarta Municipality Health Office include the date of diagnosis, the hospital to which the patients are admitted

: January : February : March : April
: January
: February
: March
: April

Figure 3. Distribution of DHF cases in Sleman District (January to April, 2005) indicates concentrated areas with high incidence of cases

indicates concentrated areas with high incidence of cases Figure 4. Distribution of DHF cases in Yogyakarta

Figure 4. Distribution of DHF cases in Yogyakarta Municipality (January to April, 2005) seemed to be evenly distributed all over the city

A closer look to a small area (Figure 5) where DHF cases were reported every month of January to April indicated delayed response by the health authority and the community to prevent the transmission of dengue virus.

the community to prevent the transmission of dengue virus. Figure 5. The clustering of DHF cases

Figure 5. The clustering of DHF cases in a small area of Yogyakarta municipality from January to April 2005.

The incidence of DHF cases fluctuated from time to time (Figure 6), and current efforts to continuously reduce dengue transmission through community participation are expected to minimize the incidence of DHF in Sleman and Yogyakarta Municipality. The map showing DHF distribution in the study area can be accessed at . The map has been regularly updated to motivate the public servants in the health and other sectors, private companies, non-government organization and communities who are living in the study areas to plan and implement initiatives in vector control, early DHF diagnosis and prompt treatment to prevent DHF morbidity and mortality.

The use of SMS messaging is expected to facilitate reporting of DHF cases to district health office, and now is under experimental stage (Figure 7). The messages will be integrated in the database system.

Number of DHF cases

be integrated in the database system. Number of DHF cases Sleman District Yogyakarta Municipality Januar y

Sleman District









Figure 6. The number of reported DHF cases from Sleman District and Yogyakarta Municipality from January to June, 2005

SMS from a hospital

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hospital DBD AF SBY 30 L DEPOK CATU RTUNGGAL 010805 Diagnosis= DBD , nam e of

Diagnosis=DBD, nam e of

patient =

household =

years, gender =

address = DEPOK, CATURTUNGGAL, date of diagnosis = 1 August 2005

Anis Fuad,

SBY, a


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Figure 7. SMS message to report a DHF case

Fulfilment of Objectives

The ultimate objective of this project is the reduction of DHF cases, hopefully, approaching zero level. All participants of the study will be aware, whether this objective is partially met, or at least the downward trend, controlled for seasonality of DHF incidence, is observed by the end of the study. The interim objective of the study is the construction of web-site, where knowledge about the DHF incidence and distribution in the study area could be learned, and comprehensive account on the epidemiology, diagnosis, case management and vector control are available. To achieve the ultimate and interim objectives of the study, technical capacity for data collection, analyses, mapping and publishing of information on the web-site have been fully developed. The objective of the project has also been shared to the health personnel and representatives of the communities who are engaged in community-based vector control initiatives.

Project Design and Implementation

Ongoing activities carried out to date include:

1. Workshops to communicate the rationale, objectives and planned activities to accomplish the objectives of the study have been conducted (Figure 8);

2. Presentations and discussions to clarify and communicate systems thinking in DHF control and elimination were carried out;

3. Collection of records pertaining to new diagnoses of DHF cases living in the study area (weekly updated);

4. Identification of longitude and latitude of the addresses of DHF cases reported from the study area (continuous);

5. Construction of map layers to visualize the temporal and spatial distribution of DHF cases.

Further activities expected to be accomplished in the next 3 months are:

1. Construction and continuous development of a web-site as an easily accessible media to learn about the dynamics of DHF distribution and important knowledge about DHF prevention and control;

2. Data analyses to reveal consistent patterns of DHF temporal and spatial distributions in the study area and to motivate innovations in DHF control activities;

3. Develop an effective, ethical and evidence-based strategy for

communicating study results to health and other sectors, private institutions, non-governmental organizations and communities. The research methods and analytical techniques will combine qualitative and quantitative approaches. Soft systems methods developed by Checkland 1 have

been used to understand the complexity of dengue transmission and determinants of DHF incidence. The time-series analyses are quantitative

1 Checkland P. 1999. Systems thinking, systems practice: includes a 30-year of practice, London:John Wiley

methods which will be used to identify the trend of DHF incidence over previous years, and whether the incidence is significantly further declined after the completion of the study.


Figure 8. Workshops to discuss technical aspects of the study and to build commitment of the partners who are participating in the study

Partnerships with other researches are limited to information sharing, for example during occasional seminars held by the Directorate General of Disease Control in Jakarta, and workshops organized by Tropical Medicine Program and Geographic Information System Working Group at the Gadjah Mada University. The beneficiaries of the project, especially the Sleman District and Yogyakarta Municipal Health Offices have been involved since the inception of the project, and they will continue to participate during the course of the project. The disciplinary orientation of the project is the integration of information and communication system, biostatistics and epidemiology.

Project Output and Dissemination

The output of the project consists of methods, tools and social changes to achieve the ultimate objective of the elimination of DHF incidence in the study area. The main methods developed in this study are:

1. Mapping of geocoded objects using open-source software (Epimap);

2. Integrating raster (aerial photo) and vector maps;

3. Publishing maps in the internet using internet map-server (open source)

Data analyses will be carried out (still ongoing) using Epiinfo and Epimap (an open source statistical software). The basic information about DHF epidemiology, diagnosis, case management, and vector control will be compiled and published in the web-site ( ). The web-site will also present the maps of temporal and spatial distribution of DHF cases in the study area.The most formidable challenge in the study has been how to translate accumulated knowledge and evidence into regulations and community-based actions. Following the success of several communes in Vietnam 2 , it was proposed that dengue control programs should mobilize strong commitment of district health office personnel (health is a leading sector in this effort) in vertical program activities, the vector control should focus on key breeding places of Aedes aegypti, low technology (such as biological control with predacious copepods) should be used, and horizontal program activities led by village leaders, school teachers or other community change agents should be encouraged.The information about dengue prevention and control published in the web-site will

2 Kay B. and Sinh Nam V. 2005. New strategy against Aedes aegypti in Vietnam, Lancet 365:613-617.

include a printable version so that it can be downloaded, printed and distributed to the communities, whenever needed.

The outputs of the study will contribute to knowledge creation, which can be used


course materials and case studies as learning tools for the graduate program


public health, especially in certain subjects, such as public health surveillance

and health information system. A postgraduate student in the Faculty of Engineering, Gadjah Mada University, is currently writing a masters thesis using the data collected in this study.

Capacity Building

The project supports necessary infrastructure (instruments and competence of research personnel) for developing Geographic Information System, not only for surveillance and disease control, but also for other public health purposes. The research organization, Center for Health Informatics and Learning, Gadjah Mada University, has gained important knowledge and skills in social processes of community-based studies, and learned about the application of information and communication technology for social changes. The collaborating partners of the study have developed better insights about the pattern of DHF spatial distribution from time to time, and monitor the effectiveness of disease control activities in certain areas of the district or municipality. In the near future, the output of the study should provide learning opportunities for the community to continuously improve the effectiveness and efficiency of DHF control in their neighborhood. Doctors treating DHF patients in hospitals, private clinics, or community health center may benefit from the data on the distribution of DHF patients which improve probabilistic estimate of DHF diagnoses among their patients. The use of data for community-based activities potentially will enhance health literacy among community members, especially those with limited skills and knowledge about disease control. Community participation become an important element in this study, and will be expected to increase trust and reciprocity as two essential components of social capital.

Project Management

A project is ideally defined by clear scope, time and resources needed to

accomplish the goals of the project. However, in this research project, an opportunity to expand the area of study (not only Sleman District but also Yogyakarta Municipality) was taken to seize the momentum of possible collaboration with the municipality health office, and driven by accumulated data that suggested high DHF morbidity and mortality in both areas. The expansion has some consequences in resource utilization, so that the project management has to exercise efficiency measures for cost-containment without any effect on the quality of the project.

Scientific management of the project needs better planning, especially with regards to publication of the study results in peer reviewed journals. One paper and masters thesis about the technical aspects of the project are being prepared. Technical management of the project is not too complicated, since the commitment of the partners involved in the project remains strong six months after the start of the project. The project also enjoys the skills and competence of computer technicians involved during the project cycle.


The project is expected to bring down significantly the incidence of DHF in the study areas, and the low DHF incidence could be sustained. The more immediate impact of the project will be the change in the behavior of health personnel and the communities towards “zero tolerance” to Aedes aegypti mosquitoes. The role of the project is to provide media for integrated information and learning which is expected to motivate concerted actions towards the prevention, treatment and control of DHF cases. People who live in crowded urban and periurban areas, most of them are socially and economically disadvantaged, will benefit from low morbidity of DHF.

Overall Assessment

The project is very important, because it is expected to bring direct benefit to the population in the study areas, especially marginalized people who live in densely populated urban and periurban neighborhood. Most of the investment is spent in building the infrastructure and capacity of health personnel and other people who are involved in vector control initiatives, early diagnosis and treatment of DHF. To strengthen the credibility and reliability of the project, two key steps should be taken into account:

1. Technical design and implementation of web-based DHF mapping and knowledge support system should be continuously improved to meet the need of the health personnel and community

2. Social and communication strategy to optimize the use of the information published on the web-site so that DHF control will be more effective.


The compact disc containing previous reports of IDRC projects should be distributed to the grant recipients, so that the project report could be designed and planned since the beginning of the project.