Catching Health Emergencies Upstream

Our project aims to develop and test field ready tools to capture cause of death information in humanitarian settings employing modern technology easily used by frontline workers and will cover adult and maternal and child deaths. The verbal autopsy/social autopsy (VASA) tool integrates Johns Hopkins' SA instrument used to examine the circumstances of death with the WHO's VA questionnaire for identifying biomedical cause of death. Our solution would be a computer assisted tool to rapidly capture the information needed to identify cause of death. This will be accomplished through computer assisted algorithms developed jointly by experts from public health, medicine, and database and software development fields. Employing modern technology for input verification, data transfer, and analysis from a central hub, the data gathered will be rapidly fed back to global health monitoring bodies, health NGOs, and national health authorities. 

Rapid changes in patterns of death are commonly an early indicator of infectious disease crises.  Delayed recognition of novel disease pathogens can hinder effective responses. Yet there are very large populations and even entire countries where there is little or no tracking of mortality, let alone its causes.     

In 2021, 85 million people were displaced due to conflict and disasters. Monitoring cause of death in humanitarian settings is challenging due to insecurity, limited access, and fragile capacity. These populations represent not only large “data black holes" but also powder kegs for infectious disease epidemics due to poor sanitation, environmental disruption, undernutrition, overcrowding, and lack of surveillance. While advanced analytics allow estimates of mortality with limited datasets, the humanitarian community has been unable to identify causes of death and near misses. 

A major barrier is the lack of field-friendly tools which produce data for rapid analyses. Innovative sentinel systems can rapidly capture cause of death in small representative samples and make the difference between an averted health crisis or an incipient move towards an explosion. Furthermore, as mobility in these crises settings is high, modern technologies should be utilized for data integration at regional and global levels. 

Our project aims to develop and test field ready tools to capture cause of death information in humanitarian settings using modern technology easily used by front line workers and will cover adult, maternal and child deaths. Our solution would be a computer-assisted tool to rapidly capture the information needed to identify cause of death, which will be accomplished through computer assisted algorithms developed jointly by experts from public health and medicine and database and software. It will build on an existing tool described below. 

The Verbal Autopsy/Social Autopsy (VASA) tool integrates the SA instrument developed by JHSPH to examine the circumstances of death with the WHO VA questionnaire to identify the biomedical cause and has been utilized in various normal low resource settings with functional health systems and public services. We will build on this experience but moving it towards the very specific requirements of humanitarian settings such as Yemen, Afghanistan and possibly in Myanmar and many African nations. Employing modern technology for input verification, data transfer and analysis from a central hub, the data thus gathered will be rapidly fed back to global health monitoring bodies, health NGOs and national health authorities. 

First and foremost, our solution targets populations living in humanitarian contexts. We envision our solution’s ultimate impact to be reducing their suffering through an improved evidence-base to detect and correctly respond to public health threats. We expect to identify their main disease risks and contribute to early recognition of a deteriorating health situation through the sentinel VASA and allowing early intervention before outbreaks can spread and further increase mortality.

The solution itself is to be later used by people working in civil registration and vital statistics, UN and agencies with an international mandate, health service providers, humanitarian agencies. It will allow them to conduct situation assessments to better tailor and evaluate interventions. Conducting public health programmes without a clear understanding of the burden of disease in a specific population carries the risk of designing ineffective interventions or worse, of planning projects that do more harm than good. The speed at which the data is compiled and made widely available is key in humanitarian settings. Our solution ensures a rapid turnaround of results and data for end-users such as humanitarian organizations and decision-makers, who will be able to adjust their actions in a timely manner according to the evidence produced with our solution.

While advanced analytics allow estimates of mortality with limited datasets, the humanitarian community has been unable to identify causes of death and near misses – a critical blind spot. A major barrier is the inability to deploy field-friendly tools which can produce data that can be rapidly analysed. Other issues are the fragmented information on humanitarian action, and the inefficient use of the existing data, even if limited. Integrating data at regional and global levels on mortality in crisis-affected populations can visualize trends, patterns and ultimately bring assistance to thousands high-risk for infectious diseases and infection-related mortality.

The WHO recognizes COD and near misses as a crucial bit of health information that has been neglected. This is at the cost of identifying trends of concern for infectious disease and other outbreaks downstream because clusters of deaths or life-threatening conditions have not been monitored or even broadly tracked to sound alarms. We are drawing on experiences of WHO and other partners who have developed a tool for cause of death but which is lengthy and does not use technological options for rapidity of analyses and feedback.

This solution is innovative in that it combines the strengths of tools with proven success in stable low-and-middle-income countries to create a verbal autopsy tool that is well-adapted for use humanitarian settings. Further, our solution is interdisciplinary, capitalizing on the strengths of social, anthropological, and epidemiologic theory and the benefits of using technology to operationalize 

Our solution will improve infectious disease control currently and in one year for the 865,000 Rohingya refugees in Bangladesh and 700,000 refugees in Mozambique. In five years, we believe that a tested and validated tool, as well as centralized data hubs for cause of death and near misses, can benefit the global population living in violence and conflict affected regions of the world, which is projected to be between 1 - 2 billion individuals. 

The key indicator will be the development of a prototype tool for implementation and data collection. Another indicator will be the number of household level deaths and near misses captured by the tool. The third indicator will be the establishment of a beta version of the regional data hub. In line with the indicators for data in the SDGs, we will consider data reporting and collection as indicators of uptake. Other indicators include: the number of cause of death reports sent out, number of feedback reports from cause of death reports, and number of field staff trained to use the tool. 

Full-time project staff (management/ technical)

2 at JHU, 2 in Mozambique, 2 in Bangladesh

Part-time (field survey teams) 

approx. 30 individuals (15 in each research site), 12-15 person weeks per yea

Contract and consultant staff according to specific skills needed 

5 individuals, 30 person-months 

TOTAL 41 individuals 

The senior researchers on this project are globally known disaster epidemiologists with extensive field experiences in mortality estimation. All investigators have extensive experience with managing large sum grants with multi-site projects. Dr. Guha-Sapir has served as an expert witness for the International Court of Justice for excess mortality in the 2nd Congo War and for the International Criminal Court for mortality estimation in Darfur. She is member of the Lancet Commission on Syria. She manages two of the most well-known databases on disasters (emdat.be) and civil conflicts, and she has extensive experience managing data hubs and global systems. Her work ranges from nutrition to war-related mortality in women and children. Dr. Burnham has done groundbreaking work on estimating mortality in Iraq which has had a significant influence on US policy in the country. He served as a respected member of the Wellcome Trust and UKAid selection boards for research in humanitarian settings. More recently, he has worked on monitoring maternal and child health in Mosul. Both Drs. Burnham and Guha-Sapir have been well-published in top tier scientific journals such as the Lancet, NEJM, and BMJ. Both leads on this project are well-experienced in working in high-insecurity settings and have proven records of high-impact work with influence on regional and global policy. Our steering group will include other well-respected researchers:  Javier Teran (Humanitarian Data Exchange); Philip Settel (Vital Strategies); Daniel Chandramohan (WHO Verbal Autopsy Reference Group Chair), Tefera Darge (Professor University Addis Ababa); and Susan Cutter (University South Carolina).

The team is diverse in both ethnic, gender, and cultural representation. We intend to maintain a strong group solidarity as we have done in our past research projects which have all been successfully completed with both field level impact and scientific outputs. This project team has a long history of successful collaboration, and our project structures allow for frank discussion, sharing of knowledge, and mutual support. This culture of transparency and open-mindedness - both personal and professional - is achieved by regular meetings and discussions over social platforms and by face-to-face meetings as required. 

We see this an exciting new direction, taking forward proven processes. SOLVE is attractive to us as it is clearly willing to step out of the traditional or risk averse approaches to find solutions in a neglected setting. Furthermore, the option to link up with advanced technical skills from the founding members is also an exciting opportunity, something that we don’t find with other support organizations. Overall, having a project in the scope of the SOLVE is great opportunity to build relationships and long-term partnerships with governments, national universities, local and international humanitarian organizations. These partnerships can be with the construction of the diagnostic and data analytic process and can be transitioned to the use of the data once the system is providing data in real time which can be used to manage disease outbreaks for the vulnerable groups. Such partnerships will help refine data collection methods, ensure indicators are aligned with the humanitarian response needs, and organize its analysis and dissemination in a way that will be relevant to the humanitarian response. In this way there will be the maximum potential for impact.

We would greatly appreciate having professional support to set up the creation of global and regional platforms to ensure the interoperability of data. We would benefit from expertise on spatial data processing (e.g., Google) and potential use of satellite sensing (e.g., Sentinel-2). 

Google and Copernicus are two organizations that would greatly help with spatial data processing and data access.