Health in Action Participatory Epidemiology: Use of Mobile Phones for Community-Based Health Reporting Clark C. Freifeld1,2*, Rumi Chunara1,2, Sumiko R. Mekaru1,3, Emily H. Chan1,2, Taha Kass-Hout4, Anahi Ayala Iacucci5, John S. Brownstein1,2,6 1 Children���s Hospital Informatics Program at Harvard-Massachusetts Institute of Technology, Division of Health Sciences and Technology, Boston, Massachusetts, United States of America, 2 Division of Emergency Medicine, Children���s Hospital Boston, Boston, Massachusetts, United States of America, 3 Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America, 4 Public Health Surveillance Program Office, Office of Surveillance, Epidemiology, & Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America, 5 Internews, Nairobi, Kenya, 6 Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States of America In traditional clinical and public health structures, information flows through a hierarchy of providers and local or na- tional authorities, who then communicate with the public via periodic announce- ments [1]. Meanwhile, broad adoption of the Internet around the world has enabled a new class of participatory systems that allow people to contribute and share information and work together in real time [2]. Wikipedia is perhaps the best- known such project. In the field of public health, online patient communities pro- vide a forum for patients to share their experiences, collect information, and in- form biomedical researchers [3���5]. Partic- ipatory systems in which data and intelli- gence are gathered from the population, traditionally through discussion or surveys, have also been used to gain an under- standing of disease transmission, especially for zoonotic diseases [6]. However, new internet community-based systems repre- sent a departure from the careful control, verification, and data-informed actions of traditional structures, but can provide advantages in scalability, coverage, timeli- ness, and transparency. Furthermore, en- gaging the public transforms users from passive recipients of information to active participants in a collaborative community, helping to improve their own health as well as the health of those around them. The rise in adoption of mobile phones and the Internet, in both industrialized and developing countries, has provided additional opportunities in ������crowdsour- cing,������ which is engaging large groups of people to perform a task [7,8]. Mobile phones hold particular promise for this type of opportunity because they can be used as point-of-care devices, function in remote locations, and are readily carried and used at any time [9,10]. In this paper we outline examples of mobile systems for public health, illustrating some of the key concepts, opportunities, and successes made possible through the combination of emerging mobile technologies and user engagement (Table 1). We also detail our own contribution, the Outbreaks Near Me application for iPhone and Android smart- phones (For images and further informa- tion please see: http://www.healthmap. org/outbreaksnearme/), built on the HealthMap [11,12] outbreak monitoring platform. Participatory Mobile Systems for Public Health The use of mobile systems for health is a growing field with several participatory systems for public health. Selected systems are introduced here the applications and geographies covered are outlined in Table 1. One of the earliest efforts, Frontli- neSMS (http://www.frontlinesms.com), is a platform for collecting and communi- cating information via short message service (SMS) [13]. The system is distrib- uted freely (open source), and allows information to be sent and received through a data hub consisting of a laptop and an inexpensive cell phone. Users send ������broadcast������ messages through this hub to groups of people, including basic forms requesting information, or emergency warning messages, and can also collect the responses via SMS. FrontlineSMS also allows citizens in remote areas to commu- nicate their specific problems and needs directly to health workers who would not otherwise have the capacity to interact with populations in these areas using traditional methods. The system has been used in many countries, and its health- focused spin-off project, FrontlineSMS: Medic (http://medic.frontlinesms.com), is working with partners in Malawi, Burundi, Bangladesh, and Honduras, among others. Begun in response to postelection vio- lence in Kenya in 2007, Ushahidi (http:// ushahidi.com) gained broad recognition and acclaim as an important resource for citizens and responders in the aftermath of the earthquake in Port-au-Prince, Haiti on 12 January 2010 [14]. The system pro- vides an open-source platform for collect- ing individual reports from users through SMS, Web, and email and provides tools for translating, classifying, and georeferen- cing these reports the newest version of The Health in Action section is a forum for individuals or organizations to highlight their innovative approaches to a particular health prob- lem. Published December 7, 2010 This is an open-access article distributed under the terms of the Creative Commons Public Domain declaration which stipulates that, once placed in the public domain, this work may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. Funding: The work is funded thanks to a grant from Google.org. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. Citation: Freifeld CC, Chunara R, Mekaru SR, Chan EH, Kass-Hout T, et al. (2010) Participatory Epidemiology: Use of Mobile Phones for Community-Based Health Reporting. PLoS Med 7(12): e1000376. doi:10.1371/ journal.pmed.1000376 * E-mail: clark.freifeld@childrens.harvard.edu Abbreviations: CDC, US Centers for Disease Control and Prevention ILI, influenza-like illness SMS short message service PLoS Medicine | www.plosmedicine.org 1 December 2010 | Volume 7 | Issue 12 | e1000376

the platform further allows for submission via voice message���essential for illiterate users. Aggregated information is presented on a map-based interface accessible via Web and mobile phone. Regarding the Ushahidi deployment in Haiti, Craig Clark of the United States Marine Corps said, ������I cannot overemphasize to you what the work of the Ushahidi/Haiti has provided. It is saving lives every day���.I say with confidence that there are 100s of these kinds of [success] stories������ [15]. Ushahidi has also been deployed in several other countries, including Afghanistan, Uganda, Malawi, and Zambia. Along the same lines of using SMS communication for situational awareness, GeoChat, one of a suite of open-source software tools designed by InSTEDD (http://instedd.org) [16], aims to achieve faster and more coordinated responses to disease outbreaks and natural disasters. GeoChat enables team members to com- municate their position and important information using text messages, email, or a Web browser, with data instantly synchronized on every user���s mobile Summary Points N Traditional health systems serve a key role in protecting populations, but are typically hierarchical, and information often travels slowly. N Novel Internet-based collaborative systems can have an important role in gathering information quickly and improving coverage and accessibility. N Mobile Internet usage is growing rapidly worldwide, making real-time information tools more readily available to both clinicians and the general public. N We present a brief summary of some promising mobile applications for health monitoring and information sharing, together with preliminary results from a study of our deployment of a smartphone application which enabled the general public to report infectious disease events. N These early efforts at tapping the power of mobile software tools illustrate potentially important steps in improving health systems as well as engaging the public as participants in the public health process. Table 1. Overview of selected mobile applications for health. Organization Creation Date Example Deployments and Locations Summary of Technology (System Description: Technology and Users, Costs, Openness) Web Site FrontlineSMS, FrontlineSMS: Medic 2005 Many applications, including health & emergency alerts, as well as pest/disease control. Malawi, Honduras, other developing countries. N Two-way communication platform via short messaging service (SMS) ��� only requires mobile phone connection, no Internet, between people whose contact information is known. N Software is open source (no cost to users), each implementation requires one laptop and cellular phone. N Anyone can contribute information by SMS if they know the hub access information (phone number). http://www.frontlinesms. com http://medic.frontlinesms. com Ushahidi 2007 Wildlife tracking (Kenya). Tracking medical supply stockouts: Kenya, Uganda, Malawi and Zambia. Disaster response: 4636 project following Port- au-Prince earthquake in January 2010. N Platform used to collect and visualize crisis data from mobile phones. Data is presented in an online-accessible format. N Software is open source, requires Internet-connected computer (server) for each implementation. N Implementations have used a variety of levels of publicity for contribution information, reaching different populations (e.g. Haiti implementation incorporated widely publicized SMS shortcode number, Twitter hashtags, Web contribution, etc). http://ushahidi.com GeoChat 2008 Natural disasters in Thailand, Cambodia and other locations. N Platform is hosted on the Internet and harnesses Web, email, SMS and Twitter. N Open source software can be downloaded for free or available as a hosted service. N System designed as a group communications technol- ogy for use between members of a crisis response team users have the possibility to contribute through a variety of methods including an SMS gateway (SMS without a mobile connection). http://instedd.org/ geochat Asthmapolis 2010 Asthma attack and inhaler usage tracking. Currently pilot testing in USA. N GPS-enabled inhaler coupled with an application for the iPhone, to track and aggregate inhaler usage and location. N Inhaler and mobile diary are not available as of the time of this writing. N Results of patient inhaler use information will be made available to the patient and appropriate physicians and scientists for individual and population surveillance. http://www.asthmapolis. org Outbreaks Near Me (HealthMap community) 2009 Infectious diseases ��� available free to consumers worldwide, generally most popular in developed countries. N Real-time disease outbreak reporting (from personal experience or official sources). N Applications available for free. N Anyone can download the application and contribute from multiple types of smartphones, data can be viewed by anyone via smartphone or the Web. http://healthmap.org/ outbreaksnearme doi:10.1371/journal.pmed.1000376.t001 PLoS Medicine | www.plosmedicine.org 2 December 2010 | Volume 7 | Issue 12 | e1000376