We’ve been receiving variants of this question. Someone has mild symptoms of respiratory disease and when calling their country’s health authorities, they are asked to stay home and advised that no testing will be done. Why? What is happening? Let’s break it down.
First it’s important to understand that testing comes in mainly two “flavours” This is true for any virus, not just the virus that causes COVID19 - called SARS-CoV-2.
These tests can detect part of the genome of a virus. These are called quantitative or real-time PCR tests (q-PCR) and are done in fluids from the body where we are most likely to find the virus.
In the case of #COVID19 the virus is most easily found in the respiratory system of the body: swabs of nasal cavities or throat, sputum (the mucus that comes up when a person coughs), or something called bronchoalveolar lavage - fluid collected from the lungs through a medical procedure.
These tests are called “serology”. They detect a type of defenses that the body’s immune system has made against the virus, called antibodies. Serology tests are normally performed in blood (actually in the more liquid part of the blood called serum, hence the name). These tests do NOT show that the person has the virus right now, but they can prove that the person HAD the virus at some point in the past or that they were recently infected, depending on the type of serology test done.
As of this writing, existing tests for COVID19 fall into the first category only. They detect the genome of the virus. Thus it only makes sense to carry them out when the person has an active infection (i.e. has symptoms). They could also be carried out in people who are at high risk of infection during active surveillance and contact tracing efforts (e.g. people who have been in close contact with someone known to have the COVID19 virus).
In people with mild symptoms or asymptomatic, these tests become harder because the person may not be able to cough up sputum, and material from the nasal or throat swabs may not be enough to produce reliable testing results.
If a person has no symptoms or very mild ones, a serology test may provide better information, as it can show if the person has been infected at any point in time and now has immunity against the virus. However, as of this writing, serology tests for COVID19 are not yet available.
Testing requires having specialized personnel collecting the samples, transporting them to the laboratories, and processing them for testing, as well as sharing back results. Sample collection and handling needs to be carried out with appropriate protective equipment so that the healthcare workers do not risk infection.
All these logistic efforts need to be weighed out against all other competing priorities during an outbreak.
When the first cases start in a country, normally contact tracing and testing of individuals suspected to have the virus will be prioritized. This is because health authorities are trying to contain the virus from spreading more widely in the community and need to monitor how it’s moving around.
However, when the number of cases increases and there is wide community spread, it becomes very laborious and time consuming to follow up all contacts of COVID19 cases. At this point, testing of asymptomatic contacts or of people with mild symptoms is weighed out against all other priorities, such as managing the surge in cases, providing healthcare to those who are sick, ensuring safety of healthcare workers, and ensuring adequate supplies of hospital materials and equipment. Testing at this point may be prioritized for those with severe symptoms and those requiring hospitalization.
In this setting, when testing more broadly in the community may not be as highly prioritized, to ensure that those who might be sick do not transmit the virus to others, blanket recommendations or mandates to stay home may be issued.
It is also important to remember that, because to date there is no treatment for COVID19, a test is not required to determine a treatment course.
While testing needs to be weighted against all other priorities at the height of an outbreak, testing of asymptomatic or mild cases is important for a number of reasons.
1.People who test positive for COVID19 may be more likely to stay home than those who are not sure if they have the infection.
2.People who have symptoms may feel very anxious if they can't get tested.
3.Testing a wider number of people can give a more reliable picture of the extent of the epidemic.
4.Widespread testing also allows to get a more accurate case fatality rate. For example, if you only test hospitalized cases and you have 100 cases and 5 deaths, that results in a case fatality rate of 5% (5/100). But if you test in the community and find an additional 400 mild and asymptomatic cases, your case fatality rate would decrease to 1% (5/500).
Countries have taken different approaches to testing, with some testing more broadly as many contacts and mild symptomatic cases as possible, while others have focused testing at the hospital and specific “sentinel” sites, as well as testing contacts in localities where there is not as yet widespread community transmission. As we have seen, these approaches may also vary depending on the stage of the epidemic in a country.
Other reasons why testing may vary among countries is availability of testing kits, laboratory equipment and materials and skilled human resources.
When looking at testing, it is important to consider not only the absolute number of tests a country is carrying out, but also the number of tests compared to the total population in that country (which you can express as number of tests per hundred thousand (100K) people, for instance).
As an example, as of this writing, US, Spain and South Korea are on top of the chart in the number of tests performed . But when seen as tests per 100K, it is Iceland, Bahrain and Norway (all countries with smaller total populations) that top the charts.
When serology tests become available, more widespread community testing might occur. This will help us to understand how many people have actually been infected with the virus without showing symptoms. In the meantime, with the current tests that only show who is infected when the testing takes place, testing approaches will continue to vary depending on the phase of the outbreak a country is in, the country’s own capacity, and a number of other factors.
Here you can find WHO’s interim guidance for laboratory testing of COVID19 (technical document).
This older video from Feb 26, from the Wall Street Journal does a good job of pointing out all the challenges with testing.
This Wikipedia page is the best site I’ve been able to find that tracks number of tests performed in each country, using different sources of data.
So COVID19 is all over the news. We now know that in most cases (around 81%) it causes only mild symptoms (cough, fever, etc), whereas in more severe ones, it can cause pneumonia.
In fact, it was a cluster of pneumonia cases in Wuhan, China, for which there was no known cause, that triggered the investigation leading into the discovery of the disease we now call COVID-19.
But what is pneumonia and what does it look like/feel like to have pneumonia?
Pneumonia is an inflammation of the lungs. In most cases, it is caused by an infection. The infection can be caused by viruses, bacteria or fungi. COVID-19 is caused by a virus (called SARS-CoV-2), so COVID is classified as a viral pneumonia.
Normally, when you breathe in, the air travels into your lungs and fills the air sacs in them, from where your blood gets oxygenated. When an infection of these air sacs occurs, they become inflamed and fill with fluid, secretions or pus making it difficult to breath as this blocks normal air flow and thus oxygenation. This is pneumonia.
Symptoms. Pneumonia can range in severity from mild to life-threatening. Fever can be a symptom, as well as dry or productive (mucus-producing) cough. Pneumonia can feel like tightness in the chest, especially when breathing in. It can also cause a person to breath faster than normal, in some cases even up to a point where they may only be able to speak a few words before having to take the next breath. It might feel difficult to breath and the person may feel overall fatigue.
Testing. These symptoms may be bad enough to prompt a visit to the doctor or clinic, or even, when symptoms are severe, to an emergency department. Once there, doctors would aim to diagnose if the person has pneumonia. They may request blood tests to check the markers or indicators for inflammation and infection. They may also likely request a chest x-ray to capture a picture of what is happening in the lungs and air sacs.
Depending on these results, they may aim to find the cause of the infection (remember that pneumonia can be caused by a variety of germs), and tests for specific viruses or bacteria may be requested (in the current situation, COVID-19 testing may be included).
Treatment. Antibiotics can be used for bacterial pneumonias, but for viral pneumonias - like COVID19 - antibiotics are not useful and supportive treatment is used. Supportive treatment or “symptom management” means helping the person cope better with the symptoms and be more comfortable. It includes things such as controlling fever and cough, giving fluids and rest. This helps to support the body until it manages to get rid of the infection by itself.
Depending on the results of the various tests and if general measures such as heart rate, oxygen levels and blood pressure are stable, doctors may send the person to manage pneumonia at home.
Hospitalisation. However, elderly people and/or those with preexisting conditions such as being immunocompromised, lung disease (things such as COPD or emphysema) or other long term conditions might be admitted to hospital for further monitoring. If a person’s oxygen levels were compromised due to the infection, they might also get admitted to the hospital, especially if they require oxygen through nasal prongs or a face mask.
For COVID19 pneumonia in particular, data shows the majority of COVID-19 cases at this stage of the illness recover and are able to get discharged from hospital.
However, in some cases of pneumonia whether COVID-19 or due to other causes, a person’s condition might worsen while being in hospital. They may experience increasing shortness of breath, such that they are only able to talk in single words or not at all, extreme difficulty breathing and higher oxygen needs.
Under these conditions, doctors may advise a further supportive measure called mechanical ventilation. Here, a breathing tube is inserted through a person's mouth and down towards the lungs. The tube is hooked to a machine called a ventilator, which helps the person breathe. Once the person gets better and is able to breathe again on their own, the tube is removed.
People hooked to a mechanical ventilator will normally be cared for in an intensive care unit (ICU). So far, the studies available show that only 5% or less of all hospitalised patients with COVID-19 require a mechanical ventilator.
Here you can read more about pneumonia in general (The Mayo Clinic website).
You can read more about mechanical ventilation here (American Thoracic Society)
What is COVID-19?
It is a disease caused by SARS-CoV-2, a new virus from the Coronavirus family, which was first identified in Wuhan, China in December 2019.
Coronaviruses are a large family of viruses found in animals and humans. They cause a range of illnesses from a cold to more severe life threatening conditions such as Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS).
COVID19 has a lower fatality rate then
SARS and MERS but has unfortunately resulted in more deaths (2618) than
SARS and MERS combined (1774), due to a much larger number of cases.
A recent Lancet article places the COVID-19 case fatality rate is 2.5%. However, it has been reported to be higher than 3% on the epicentre of the outbreak, the Wuhan region but as low at 0.7% in other provinces of China.
As the virus has spread, countries have seen very different fatality rates. These are influenced by both the capacity and resilience of the health care structures and by the testing methods chosen by that country. Countries that test more widely in the community will see a larger number of mild cases and thus a lower fatality rate. If testing is only done in people with symptoms or those arriving a the hospital, the fatality rate may be higher.
What are the symptoms of COVID-19?
According to 3 papers published by JAMA and the Lancet, the main symptoms when people arrive at hospital include fever (83%-98%), cough (59-82%), fatigue (44-69%), confusion (9%), headache (8%), diarrhoea and vomiting (1-3%). The severity of the symptoms range from mild to life threatening.
Not all cases need hospitalisation. Many (around 80%) have mild symptoms and can be managed at home.
However, 91-100% of patients admitted to hospital for COVID-19 had #pneumonia and abnormal findings of chest CT. These 3 research papers also showed that 26-32% of patients hospitalised in China required admission into an intensive care unit. Other countries, however, have seen lower intensive care admissions rates.
How is it COVID-19 treated?
There is so far no specific treatment for COVID-19. Like many other viral infections, it is managed through supportive care. This means rest, fluids, hydration and fever control. For severe cases treatment may have to include care to support vital organs, for example, respiratory support from a ventilator.
Are antibiotics effective in preventing and treating COVID-19?
Antibiotics do not work against COVID-19 as it is caused by a virus. Antibiotics only work on bacterial infections. Therefore antibiotics shouldn’t be used as treatment or prevention of COVID-19. If a bacterial infection develops on top of the COVID19 infection, then antibiotics could be used.
How long is the incubation period for COVID-19?
The incubation period is known as the time elapsed between the time of infection and the start of the symptoms. According to Journal of the American Medical Association – the incubation period is reported to be 5.2 days (95% CI, 4.1-7.0). However it has been suggested that it could be as long as 14 days. Most experts are citing 2 to 14 days, and people in quarantine are being asked to remain isolated for 14 days if they don't show symptoms.
How do I protect myself from getting COVID-19?
The WHO recommends:
- Wash hands with soap and water or alcohol based hand rub for at least 20 seconds. Hand washing is one of the most effective measures we can use to prevent spread of respiratory infections.
- Maintain social distancing, stay 1 metre away between you and other people, particularly if they are sick. WHY? Because if you are too close you can breathe in the droplets containing the virus.
- Practice respiratory hygiene – when coughing or sneezing, cover your nose and mouth with a flexed elbow or tissue. Then discard the tissue and wash your hands. WHY? Because this reduces the spread of droplets from mucus secretions which can transmit the virus.
- Avoid touching your eyes, nose or mouth with unwashed hands. Why? Because you can transfer the virus from your hands or a contaminated surface to your body.
What do I do if I come in contact with someone who has now been diagnosed with COVID-19?
1. Let your local health department or local doctor your concerns of COVID-19 infection.
2. Watch for signs and symptoms of infection, fever, dry cough and shortness of breath.
3. Some countries are asking for 14 days of self-quarantine, in your home. Check with your health care professional.
4. If symptoms appear, call your health care provider, or go to the emergency department. Call before presenting to the emergency room if possible to help reduce the spread to others and to health professionals.
How long does it take for a vaccine to be created for COVID-19?
There are many steps when creating a vaccine and while there is ongoing developments and new technology this process can take months and sometimes years. For example it took 20 months to develop a vaccine ready for human trials for the 2003 SARS outbreak (this does not mean it is approved for human use). It took 5 years for an Ebola vaccine to be approved for use.
Dr. Anthony Fauci, the director of the American National Institute of Allergy and Infectious Diseases, said that a preliminary clinical trial may get off the ground in as little as three months. But researchers would still need to conduct extensive testing to prove a vaccine is safe and effective.
Should I wear a mask? Do masks help?
According to the Journal of American Medical Association there is little benefit to wearing the common surgical face mask in preventing you from getting COVID-19. Surgical masks are used to as one way protection for the wearer of the mask, so that their droplets as slowed in spreading. The common surgical masks are not close fitting enough to filter all the small particles of COVID-19.
The WHO only recommends using this mask when you have respiratory symptoms or if you are healthy, when you are caring for someone with COVID19 (or other respiratory infection).
The WHO states that using a mask alone is not guaranteed to stop infections and should be combined with other preventative measures such as frequent hand washing, avoiding touching your face and practicing respiratory hygiene.
Respiratory hygiene means that when coughing or sneezing, you cover your nose and mouth with a flexed elbow or tissue. Then discard the tissue and wash your hands as this reduces the spread of germs and viruses on contaminated objects or people that you touch).
N95 respirator mask is a specific type of surgical mask that is close fitting and filters a high percentage of droplets.These are used by health professionals.
Please note that all masks are single use, need to be changed regularly, and when they become wet need to be replaced as they can harbour germs. The WHO has published graphics on how to wear and remove masks to prevent the spread of germs. (https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/when-and-how-to-use-masks)
The first thing to note is that when HIV is inside the body it infects the cells that are part of the immune system, particularly the “Helper T-cells” (Helper T-cells are complex cells but simply explained, they coordinate the immune response).
Second, HIV is a particular type of virus called a retrovirus, a retrovirus integrates its own genome into the DNA of the host cell. The way HIV does this, is to write its own genetic code into the DNA of infected Helper T-Cells so when the T-Cell naturally replicates to make more Helper T-cells, it’s daughter cells will also carry the HIV DNA inside.
Finally and unfortunately, by hiding in the DNA of the Helper T-cells, HIV can lie dormant (i.e. not making more copies of itself) and undetected for years. If the virus does not replicate inside these cells, neither the immune system nor the current HIV treatment can are able to detect the Helper T cells with HIV DNA inside them.
Thus, even if the treatment controls all replicating virus (i.e. virus that is making more copies of itself inside infected cells), the virus DNA lying dormant will not be eliminated. At any point, an infected Helper T Cell could reactive and start spreading the HIV virus again. Thus, people need to be on treatment continuously, so that if a dormant HIV reactivates, it can be immediately controlled by the treatment.
All this makes it extremely difficult to “cure” HIV as a SINGLE Helper T-cell with HIV DNA can reactive the virus.
1. HIV and AIDS are the same thing
HIV and AIDS are often used interchangeably in the media and society often finds it difficult to tell them apart. But HIV and AIDS aren’t the same thing!
HIV, Human Immunodeficiency Virus, is the virus that infects a person and attacks the immune system. People can live with HIV without having any symptoms for many years. If they start treatment, they may never have visible symptoms of the infection.
AIDS, Acquired Immunodeficiency Syndrome, is the disease that develops later in people with HIV that remain untreated. It’s the stage of HIV infection where the symptoms usually appear. A person is said to have AIDS when their T CD4 count (a key type of immune system cells) falls below 200 or their immune system is so weakened that it makes them vulnerable to opportunistic infections, illnesses and cancers (which cause the symptoms).
But thanks to advances in HIV treatment, most people with HIV will never have AIDS as their immune systems are kept protected by the treatment and viral load is kept so low.
2. HIV and AIDS are a death sentence
Forty years ago the death rate from AIDS was very high and there were very few treatment options available. HOWEVER, nowadays there are advanced treatment options and AIDS is no longer considered a death sentence, but a manageable chronic illness.
A study published in the Lancet HIV in 2017 states that on average, a 20-year old with HIV who began treatment immediately will have a life expectancy of 78 years, very close to a normal life expectancy. That’s why it is important to start treatment as soon as possible after diagnosis and maintain it throughout, for optimum long term health.
People living with HIV, similarly to people without HIV; can implement good habits to improve health, such as stopping smoking, exercising more and eating healthy.
3. HIV and AIDS can be caught from food sources, casual human contact and insect bites
HIV can only be transmitted through a direct exchange of body fluids such as semen, vaginal fluids, breast milk or blood.
Other body fluids such as saliva, sweat and tears cannot transmit HIV. It is extremely unlikely to contract HIV from kissing as HIV is not spread through saliva, but if the person has a sore or bleeding gums then there is an elevated risk, however overall transmission through kissing is extremely rare.
HIV cannot be spread through physical contact so shaking hands, hugging, sharing food, using the same toilet seat and normal casual human contact does not transmit HIV. Knowing this can reduce the stigma attached to a diagnosis of HIV.
4. People living with HIV look and feel sick
Some people get a short “flu-like” illness when they first contract HIV but most people don’t feel or look sick at all. It can take many years for some people with HIV to feel sick and start developing symptoms (see Myth Number 1 on HIV and AIDS).
However, while not visible, their immune system is becoming weaker, so early detection and treatment is key to ensure people living with HIV can live a healthy life.
That’s why regular testing for HIV in all sexually active people is so important.
5. HIV medications do more harm than good
WRONG. This is a dangerous and harmful myth.
HIV medication has side effects, but there is overwhelming evidence that treatment save lives. The HIV medications available today have cut death rates from AIDS by around 80%. HIV medications keep people alive and healthy and reduce the risk of transmitting HIV to others. HIV treatments prevent the disease from moving from one stage to the next and developing into AIDS.
There are of course challenges with HIV medications: HIV treatment can be expensive in some countries, and similar to treatments for other chronic diseases, it can be challenging for the person to take the treatment every day. However, HIV treatment works and keeps the person healthy.
6. HIV only affects homosexual men
HIV is transmitted through an exchange of body fluids, this means ANYONE who comes into contact with fluids such as semen, vaginal fluids, breast milk or blood, can potentially contract the virus. Today, the majority of HIV positive people in the world contracted HIV through heterosexual sex.
The risk of contracting HIV is not about who you are, it’s about what you do. People who have unprotected sex with someone whose status they don’t know are potentially putting themselves at risk of HIV and other sexually transmitted diseases.
7. It’s OK to have unprotected sex if both partners have HIV.
There are different strains of HIV and a partner may have a different strain. Acquiring a new strain can make the treatment a lot more difficult and limit treatment option, particularly if a strain is resistant to certain HIV medication. It is recommended to continue to practice safe sex even among partners where both live with HIV.
8. It is not possible to have sex with a person living with HIV without contracting the virus.
Research in the Lancet and NEJM has shown multiple times that in people with HIV who are consistently taking their medication and have undetectable HIV viral load, HIV is not transmittable. This study looked at both heterosexual and homosexual relations.
9. Women who are living with HIV will transmit HIV to their babies
Without treatment, the risk of transmission from mother to baby varies around an average of 25%. If the mother starts treatment early in pregnancy and has an undetectable viraul load by the time of birth, the risk of the baby getting HIV is reduced to less than 1%.
Currently, 82% of HIV positive pregnant women are receiving lifesaving treatment, which will prevent mother-to-child transmission of HIV.
All pregnant women should be tested for HIV.
The virus can also be transmitted through breast milk, however mother and baby can take medication to prevent the infection from passing to the baby through breastfeeding.
10. There is a cure for HIV
While recent media news have published stories of the second patient to have been ‘cured’ of HIV, health experts are cautioning that the treatment used in this patient and the famous “Berlin” patient, is considered very risky and cannot be practically applied to all people living with HIV.
Although there is no present cure, current treatment with antiretrovirals allows people living with HIV to have healthy lives with the same life expectancy as those who don’t have HIV.
Some time ago, I was invited to give a training in Monitoring and Evaluation (M&E) in Burundi. During the exercise I was reminded of why people tend to hate M&E so much, and usually leave it as the last thing to think about when you’re planning and implementing a project or programme.
M&E helps to gather information on what your intervention or project is doing, how well it is performing and whether it is achieving its goals. M&E can also provide guidance on how to improve or change future intervention activities. Proper M&E is fast becoming an important accountability requisite from funding agencies and donors.
If your intervention aims to keep adolescent girls in school, for instance, Monitoring would be used to check progress throughout the intervention, and Evaluation to show how much impact your project had at the end.
But most often than not, M&E is seen as a burden, an administrative requisite or an afterthought. Even when people and organizations know M&E is valuable in theory, they have trouble giving it the time, effort and funding it deserves.
It’s past the time that we got better at M&E, so here’s my take on the 5 most common mistakes we make as project coordinators when it comes to M&E, and what to do instead. Let me know in the comments what other common ones I should add to this list! And for those of you not used to M&E terminology, I’ve added a glossary at the end
The logframe lays out the logic of your project, how your activities transform into results and into impact.
Getting clear on the logic of your intervention and how will you be changing the current state of affairs (the “before”, e.g. girls dropping out of school) to a better one (the “after”, e.g. girls staying in school and thriving), requires more than one brain. If you can, gather together your team, stakeholders and others and discuss the logical steps to get from the before to the after, through your intervention. Then distill this logic into the logframe.
If you don’t have a team, try to explain your logframe at least to one other person, to test the coherence and clarity of your approach. If you can’t explain it properly, it’s not clear!
If your intervention or programme is very complicated (for example, you are using educational, health and livelihoods interventions to improve the outcomes for teenage girls), then you’ll have a hard time fitting it into a logframe. You’ll probably feel like you’re trying to fit a square peg into a round hole.
Drop the logframe for a while and try using a theory of change approach instead (or other, similar methodologies). This will allow you to get the “big picture” of how all the parts of your programme fit together and drive change. From there, you can “zoom in” and create several logframes for specific components (e.g educational, health) of your programme.
The logframe is a tool to help you think through the logic of your intervention. This logic will change and improve as you start your intervention, talk to more people, find mistakes in your approach, etc. Thus, its valid to start with a first logframe and keep improving it from there as you move forward and learn.
Unfortunately, many donor organizations will require you to submit a logframe when applying for funding and then stick to that logframe if the funding is approved.
This is a classic. I get called in to carry out evaluations of projects at the end of a 3 to 5 year period. The organization wants to measure change, that is, how much they managed to improve things from the start of the project. Yet, sometimes there is no “baseline”. There was never a measurement, before starting the intervention, of how things stood (the “before”). Thus, even if we measure how things are now (the “after”), the evaluation cannot measure how things improved in a quantitative manner.
For example, if your intervention aims to help keep girls in school, but there was no baseline measurement of how many girls (number and percentage) were dropping out before the intervention was started, there will be no solid comparison point to what we measure now at the end of the project.
There are some ways around it, like carrying out qualitative assessments (e.g. interviews and surveys) to ask people if and how the intervention helped. You could also find secondary data for the area in the past, and extrapolate to get a baseline number, but these techniques will have a lot of biases.
Collecting data can be a dreary and tedious task. Yet someone always has to do it.
I’ve been impressed more than once when speaking to the frontline data collectors in different programs about all the ideas they have on how to improve the data collection process. I’ve gotten brilliant suggestions on using prompts in software apps to ensure the right data always gets collected and how to organize the work to ensure a larger area of a village is covered in a survey.
However, most of the time, data collectors don’t get asked about the data collection process, they’re not even explained why the task is so important, and never showed the results and analyses of the data they are spending so much time and effort collecting.
Data collectors are your allies. The quality of your data depends on them doing a great job, consistently, throughout the intervention. This is tough. Make sure you bring them into the discussion from the start, make them feel ownership of the data collection process, and that they understand why their job is so critical. Share results back with them, you’ll be surprised at the level of insight they can provide you.
Baseline - it is the current status of services and outcome-related measures before an intervention, against which progress can be assessed and compared.
Evaluation - is episodic and reflective, conducted either at intervalled stages or at the end of a project, programme or organisation. It uses both external and internally collected data.
Intervention - a specific activity or set of activities intended to bring about change in a targeted population.
Logframe - short for Logical Framework, is a management tool used to improve the design of interventions. It identifies strategic elements such as inputs, outputs, activities, outcomes and impact. Also looks at the causal relationships, indicators and the assumption of risks that may influence success and failure. It therefore, facilitates planning, execution and monitoring and evaluation of an intervention.
Monitoring - is the ongoing collection of data in order to track the progress of a project, program or organisation.
Primary Data - data that is observed or collected directly from a first hand experience
Programme - multiple projects which are managed and delivered in a single package
Project - has a defined start and end, it has a specific set of operations and is designed to accomplish a specific goal.
Qualitative Data - data that is measured in the form of words rather than numbers, can be analysed through common and diverse themes, patterns and ideas
Quantitative Data - data that is measured on a numerical scale, can be analysed using statistical methods and can be displayed using tables, charts and graphs.
Secondary Data - is research data that has been previously gathered and can be accessed by researchers
Theory of Change - explains how a group of early and intermediate accomplishments set the stage for producing long-range results. It articulates the assumptions about the process through which change will occur and specifies the ways in which all of the required early and intermediate outcomes related to achieving the desired long term change will be brought about and documented as they occur.
Films about epidemics tend to have a common feature: the astute doctor who at some point manages to put the pieces together, realizes what is happening and pinpoints where the epidemic started. Normally, by this point in the movie, many people have fallen sick and the death count is mounting.
These “aha moment” scenes highlight an important feature of epidemics: they start quietly, many times in hard to reach communities, far from astute doctors and hospitals.
Maybe it starts with a child getting sick with some strange symptoms. A child getting sick is, sadly, not news. Children get sick often around the world, and in poor communities even more so because they may be undernourished, may not have access to vaccinations, or even toilets and clean water.
Then another child gets sick, with similar symptoms, and then some adults. But the health center is far, and getting there is costly. There might be some fees to see a doctor or nurse. One mother takes her child to a traditional healer. Another goes to a local drugstore. Others just ride it out at home. Some will die in the community, and the health authorities will not hear about it.
Maybe one child will get very, very sick. Sick enough that the family will do everything in its power to take the kid to a health center. It might take a few hours to get there.
At the primary healthcare center, the attending nurse may not know what this is, but recognize that it’s serious, and send the family to the nearest hospital, which might still be very far away. If they are lucky there will be an ambulance. If not, the family will need to figure out how to take their loved one to the hospital. The hospital might be in a city where they’ve never been to before, and where they speak a different language. They will have to use their hard-earned savings, or even borrow money for the trip and the health care costs.
At the hospital, the child with the strange symptoms is finally seen by an astute doctor. But here’s the catch: No matter how astute the doctor, she is just seeing a single patient. She has no idea that back in that faraway community, several people have fallen sick, and some have died. How is she supposed to guess, from a single case, that this is the start of an epidemic?
Even if the doctor at the hospital is worried enough that she asks for specific laboratory tests, and informs the health and surveillance authorities, things take time. In many countries, only the national laboratories in the capital will have the capacity to run tests for certain diseases. Results may take a week or two.
By the time enough sick people are seen at the hospital so that the astute physician can put the pieces together, there might be five or ten times as many cases in the community. A month or more from the initial case may have gone by. The disease might have spread to neighboring communities.
And yet the astute physician was not the only person who figured out something was wrong. The people living in that community were the first to know. The community knows what the ebb and flow of common diseases looks like for them. They know when something is “off”.
They just didn’t have a way of telling someone who could act on this information.
What if we could change this?
What if we could provide the means, and the confidence, to key community members, so they could inform health authorities when something is wrong in their community? Would this allow us to stop epidemics sooner? To prevent unnecessary disease and deaths?
This is the premise of Community Based Surveillance, a relatively new concept that is all the rage among the people fighting epidemics. Community Based Surveillance, or CBS for short, is “the systematic detection and reporting of events of public health significance within a community by community members”. A definition that was officially agreed by the Technical Contributors to the June 2018 WHO Meeting in France.
But how can community members, who are not doctors, or nurses, or epidemiologists, figure out what is going on? How can they know what this disease is? That there is an outbreak?
That’s not what CBS asks from them. CBS is based on the assumption that communities do not have trained clinicians among them and that they live far away from health care centers. It is also based on the assumption that community members, with appropriate training, can distinguish particular groups of symptoms and raise the alarm if these symptoms meet a “community case definition”. A community case definition is something simple like “any person with three or more loose stools in 24 hours”, which can be used for acute watery diarrhea/cholera.
Now, if you know anything about diarrhea, you might be thinking that this definition is too wide. People get diarrhea for many reasons that have nothing to do with cholera. Many, many cases will be reported if we use this. Same with a “fever and bleeding” definition for potential haemorrhagic fevers such as Ebola.
Yes, that is one downside of CBS, it has what we call a high sensitivity (it will detect a lot of cases) but a low specificity (a lot of those cases will be false positives, i.e. they will be diarrhea, but not cholera, or fever, but not haemorrhagic fever).
That’s why CBS cases need to be counted separately from cases detected by a clinician using a clinical case definition, or cases that have been confirmed by a laboratory test, which are much more stringent. Otherwise we’d be adding pears and apples.
The interesting thing is that, when you train community members on this community case definition for acute watery diarrhea, they will be the first ones to challenge you on it, saying that everyone gets diarrhea but that this is not serious in many cases.
Community members know when things look different or “off”. In different areas, you can tweak and agree on the definition together with them. If they’ve seen cholera, they’ll be able to tell you what it looks like and what are the common terms used to describe it.
But yes, in the end, we will get a lot of “false positives”, that is, reports on people who have indeed some diarrhea, but which is not cholera. That’s ok. What the system needs is a way to weed these out and respond to the true cases.
A key part of CBS is that the community members need a way of communicating the cases they are observing to someone who can raise the alarm, or directly to a health center or a health authority. This can be done in various ways.
We could leverage technology and use an app. But while smartphone use has expanded widely, it is still not common in some remote communities, and they pose other challenges like requiring daily recharging of the battery in places where there might be no electricity.
We can also use the good old clunky mobile phone, either through calls or SMS. These sturdy phones have batteries that last for many days, and SMS are cheap.
The designated community member, upon seeing a case in the community that fits one of the case definitions he or she has been trained on, calls or sends and SMS to a designated person, who might be someone at a health clinic. The designated contact person will ask follow up questions. If the case seems to fit the definition, or there are signs of alarm, the contact person raises the alarm and a clinician from the nearest health center is informed and can come down to the community to investigate.
Once the investigation by the clinician gets triggered, we’ve linked our CBS system into the regular epidemiological surveillance and outbreak investigation system used in the country. Now the normal chain of events and alerts is engaged, where information is shared from the ground and up towards the higher levels of the Ministry of Health through pre-established channels. Cool, eh?
It’s all well and fine to talk about community members detecting signs and symptoms and raising the alarm, but who exactly in the community are we talking about here?
Well, it depends. What we want is people who are well connected in the community and well regarded and trusted by others, so people will come to them to let them know when something is wrong. You want someone with a bit of initiative and self-motivation. It would be good if they can read and write, although this is not always a requisite.
The most important thing is that the community and community leaders agree on having this person designated as the relay for CBS. I’ve seen different models for who becomes a CBS relay.
The Red Cross and Red Crescent Movement is one of the players closest to the communities who are pioneering CBS. In many cases, they already have a great network of volunteers in communities around the world, and many of them are trained in first aid and community health, making them prime candidates for CBS relays.
Many countries have Community Health Workers (CHW), who receive shorter or longer basic health training and are attached to a health center or a health post, and who can be easily trained in CBS.
In other places, pilots are being tested, training teachers and school principals, who in turn teach students about the community case definitions. It’s still too early to say what model works best, and most probably, the “best model” will vary from one context to another.
The key point is that these CBS relays, whoever they are, not only detect people with signs and symptoms and raise the alarm, but are also capable of giving good health prevention advice to the families who report cases to them. For example, in cases of diarrhea, CBS relays counsel on hand-washing, rehydration, correct latrine use and making water safe to drink.
In cases of potential measles (rash and fever), CBS relays advise parents to keep their children out of school. They also refer people to the nearest health center or health post. The idea is that these actions can help stop the transmission of the disease until the clinician can come down to verify what’s going on.
Many issues can preclude CBS from working correctly. How do we keep these CBS relays motivated and engaged, if they are doing this work voluntarily? Should we pay them? Can clinicians at health centers cope with the additional workload required by these visits? Do health centers have the means (motorcycles, fuel, etc) to send their clinicians to investigate? What do we do when there is no mobile phone network?
As any “new” intervention, CBS still needs to prove it’s worth. This is challenging, after all, we are trying to prove that something - i.e. an epidemic outbreak - didn’t happen. But serious efforts are ongoing to measure results and I’m hopeful than in the coming years we’ll start seeing great outcomes.
Acknowledgements: This article came to be thanks to the many opportunities I’ve had of working with the Norwegian and Danish Red Cross, as well as the International Federation of the Red Cross and Red Crescent Societies, in their CBS projects and trainings. It reflects the learnings gained from discussions with many fantastic colleagues.
Exciting Internship in Public Health with Global Health Advisors
Who are we?
Global Health Advisors is a small, dynamic organization with a vision to improve global health around the world by strengthening what we believe are core pillars of successful interventions: strong evidence, ongoing training and motivated teams.
We support Norwegian and international organizations and NGOs with technical advice in global health; research, monitoring and evaluation; and training development.
We work in several thematic areas, including Epidemiology and Surveillance, Infectious Diseases (HIV, TB, malaria, cholera, vaccine-preventable diseases), Maternal and Child health, Sexual and Reproductive health, health equity and barriers in access to care, Psychosocial support and Mental Health.
Want to join the team?
This internship position is most suitable for someone finishing a master’s in public health or similar diploma. However, if you have most of the items below, it doesn’t matter to us what your degree is, as long as you are willing to learn!
What we offer
What we are looking for in an intern:
Skills that you need to bring along – We’ll help you develop them further!
Writing and communication skills:
How to apply
Send an email to firstname.lastname@example.org with:
Send us an email: email@example.com
I’m just back from Burundi, a small, beautiful country in Africa, sandwiched between Rwanda, Democratic Republic of Congo and Tanzania. It’s capital, Bujumbura, sits on the shore of the deep, gorgeous Lake Tanganyika, where on a clear day you can see the mountains of DRC on the other side.
I went to Burundi with the Norwegian Red Cross to support trainings on a really cool strategy to fight cholera.
Cholera, as you probably know, is a diarrheal disease that still kills people in the 21st century (between 21,000 and 140,000 per year, according to WHO). It causes vomiting and what we call Acute Watery Diarrhea or AWD.
Acute, because it starts very suddenly and lasts only a few days. Watery, because the diarrhea very quickly becomes mostly water. It’s even called “rice water diarrhea”, as it looks like the whitish water left behind after you’ve washed rice. (I hope you are not having lunch while reading this!). The reason for all this water is because the bacteria that causes cholera, Vibrio cholera, has a toxin that pumps water out of the cells in the intestines.
Cholera can quickly (in a matter of hours) lead to dehydration that can result in death, even in healthy adults. Basically, it’s the dehydration that kills the person, so the treatment for cholera focuses on keeping the person well hydrated while the body fights off the infection.
In severe cases, if the person has lost consciousness or can't drink enough, this has to be done by giving the person fluids intravenously at a hospital or clinic. But in the majority of cases, giving fluids orally is enough.
When I talk about fluids I’m not talking about water, though. Water is fine for rehydration purposes in regular life, but in cases of AWD, oral rehydration solutions (ORS) with the right concentration of salts and sugar allow a much faster rehydration and a better balance of electrolytes, and thus have a much better track record of saving lives.
In any given cholera epidemic, most people won’t develop symptoms, although they will still shed the bacteria in their faeces and thus transmit the infection. Among those who do develop symptoms, only around 20% will be severe cases requiring intravenous fluids and hospitalization.
But what usually happens is that most people with symptoms end up at hospitals or cholera treatment centers anyway. In a bad epidemic, this can overwhelm the healthcare system. Plus it usually means that people are coming to the hospital late in the disease, and more dehydrated.
So, how can we provide access to rehydration closer to home to all those cases that don’t require hospitalization? Well, if you come from a middle or high income country, you might be thinking, “Duh… just go to the pharmacy and buy one of those electrolyte drinks”.
Unfortunately, that doesn’t work in poor communities in developing countries, or in camps for displaced people, which is where cholera epidemics usually happen. Here there’s usually no pharmacies, no electrolyte drinks, and most importantly, no clean and safe drinking water.
Enter the ORPs, short for Oral Rehydration Points. A place in the community where community health workers can provide water purification tablets and sachets to prepare ORS.
The Red Cross has now taken the ORP concept one step further by developing ORP kits. These compact kits can be quickly set up in the communities during an epidemic. They contain two key ingredients for treating cholera: a water filter that produces clean and safe drinking water, and sachets of ORS (plus other goodies like soap, water treatment tablets, glasses, jugs, etc).
One of the key resources of the Red Cross is its volunteers, who exist in communities in almost all countries in the world. During an epidemic, community health workers and other health staff can get very busy and be in short supply. Trained volunteers from the Red Cross can provide support by staffing these ORPs.
Volunteers can provide the communities with quick access to rehydration by giving sick people ORS straight away (with cholera, time is key) at the ORP. They also teach families how to prepare the ORS sachets at home (just mix them in a liter of safe drinking water) and how to make water potable by boiling it or treating it. They distribute chlorine tablets for water purification and soap for hand-washing.
Volunteers are trained to detect severe dehydration and quickly refer these cases to the hospital or cholera treatment center. They also provide communities with information on how to prevent cholera, such as washing hands with soap, protecting food from flies, using latrines and avoiding open-air defecation.
My trip to Burundi was about supporting the Burundi Red Cross in training its volunteers to install and use the ORP kits. Burundi has experienced intermittent cholera outbreaks, especially among the areas close to the Tanganyika lake. They now plan to preposition the ORP kits in case they are needed, to be able to respond quickly and give people in affected communities early access to rehydration.
I love simple, practical solutions like this one. I’m looking forward to seeing results from studies analyzing the impact of ORPs during cholera epidemics.
Did you like this post? I’m planning on writing more posts like these on interesting solutions to health topics around the world. Are there any particular subjects you would like to know more about? Please let me know in the comments!
One of my 2017 goals was to read at least 30 books. I'm happy to say that I surpassed that goal. Most of what I read was non-fiction, although I also managed to fit in some fiction books during the holidays :)
Here's a short list of my non-fiction favorites - those that were most useful for my personal and professional growth in 2017 - hoping that you find some inspiration for your 2018 reading list!
And if you have some good recommendations of non-fiction books, please tell me in the comments, I always appreciate a good book recommendation!
MY FOUR FAVORITE BOOKS IN 2017
I know how she does it. How successful women make the most of their time. By Laura Vanderkam.
I have been following Vanderkam's blog for some years and I finally decided to read one of her books. I'm very happy I did! This book busts the myth that women can't "have it all", using evidence from detailed time logs representing 1,001 days in the lives of women who make at least $100,000. Vanderkam presents a great analysis, with many stories and examples, of how busy women successfully and happily juggle life and career, by focusing on 168-hour (one-week periods) instead of on a single day. I thought I was a good time-manager already, but I gained many useful strategies from this book.
Rejection Proof. How I beat fear and became invincible through 100 days of rejection. By Jia Jang.
This quirky book made my days in 2017. Jang decided to overcome his fear of rejection by willingly putting himself on rejection's path for 100 straight days, while recording the whole thing and extracting lessons learned. Each day he planned a new scheme to get rejected, everything from knocking on a stranger's door and asking to plant a flower in their garden, to requesting the building's doorman to lend him 100 dollars. The results are funny, moving and eye-opening. Whether you struggle with fear of rejection or not, this is a great book to help us become more comfortable in asking for what we need (and laughing a bit on the way too!)
Decisive. How to make better choices in life and work. By Dan and Chip Heath.
I'm a big fan of the Heath brothers. Their books are always perfectly polished to ensure a seamless, ordered, and useful reading experience. Decisive is no exception. It combines stories and research to present a 4-step strategy to facilitate decision making, help us to stop agonizing over decisions and avoid biases. Decisive is compelling and funny and I love that they always include neat little summaries and tools to make it easier to remember what you learned from the book.
Option B. Facing adversity, building resilience and finding joy. By Sheryl Sandberg and Adam Grant.
Sandberg (the COO of Facebook and author of Lean In), and Grant (author of Originals and Give and Take), are both favorite authors of mine. But this book is very different from their previous ones. Option B talks about grief. The type of grief we experience from the death of a loved one. Option B has been a beacon for me, as in 2017 we lost a beloved family member. The book has helped us understand and cope better with the pain, confusion and anger that grief brings. It has taught me how to better help others who are dealing with grief, as well. If you or someone you know is dealing with grief, Option B is a great guide and comfort.
They crawl up on our speeches, push themselves comfortably into our well practised presentations, sneak up on us - despite our best efforts - when we are answering questions at a conference or an office meeting.
... you know?
They are called “filler words”, “interjections” or “pause fillers”. Whatever your preferred term, what amazes me is that these little critters exist in so many languages. In French we have “n’est ce pas?” (isn’t it), “donc” (so) and “tu vois?” (you see?). In Spanish we battle “este…” (this) and “entonces…” (then). In Norwegian, from what I’ve seen so far, we have “ikke sant” (right), a guttural non-committal sound that goes something like “mmm-mmm”, and “også” (and).
In Spanish we call them “muletillas”, which translates as “little crutches”, a very appropriate term if you ask me.
What are filler words exactly? They are words that we insert into our spoken language, but almost never written one. They’re often irrelevant words that won’t change the meaning of your sentence, and are used as a transition, to indicate that you haven’t finished speaking while you’re gathering your thoughts, or to soften the end of your sentence.
Filler words can make you look unprepared or hesitant when speaking. Yet, I also think they have a role to play in social integration. If you’ve ever learned a new language among native speakers, you’ve probably noticed that, until you’ve mastered the local filler words, you don’t feel you speak the language fluently. They seem to play a role in facilitating or marking social belonging.
So, do we need to get rid of them or not?
For normal conversation, filler words may not be that problematic. Unless you have more filler words than regular words in your sentence (and some people do!). For speeches and presentations, however, I would recommend to get rid of them. One or two will go unnoticed, but frequent use of them can weaken your presentation.
Easier said than done though.. How do we weed them out when we are not even conscious of using them?
Here are some of the exercises we use in my public speaking courses to diminish or eliminate filler words.
If you are preparing a speech or presentation, the most effective, albeit hardest way to get rid of filler words, is to film yourself and then watch the recording. This is painful, I know. Participants in my courses cringe when I make them watch their videos . But at the end of the course they systematically say this is the part that helped them the most. You’re your harshest critic. The discomfort you feel when watching yourself on video is your most powerful tool to improve your speech.
Grab a pencil and paper and count your filler words as you watch the recording. Make sure you count each filler word separately, for example, ten “um-ah”, twenty-five “like”, three “er…” and so on. Not all filler words are created equal. Determine which are your most problematic ones, and when do you use them.
Now decide how you are going to tackle them. This is where counting them separately comes in handy.
Substitute by a pause. “Um-ah” and “er” are mostly used when you are trying to gather your thoughts. Instead of eliminating them, try substituting them by a PAUSE. Repeat the phrase and in the place of “er…” say to yourself: “Pause. Breath.” . Take one long breath and then continue. For many of my course participants, imagining the pause as a word that they say only in their minds is much more effective than trying to eliminate the filler word.
We tend to dislike pauses because it seems to us like we are staying silent for too long and the audience will think we’ve forgotten what we wanted to say. The truth is, when you are on the podium, what seems like a one-minute pause to you is usually never more than a couple of seconds to your audience.
Pauses, when used purposefully, can be very powerful tools to create expectation in your audience, to signal a change of subject, or to let what you just said sink in. Don’t be afraid to use them to your advantage.
Substitute by a transition phrase. “So”, “like” and similar filler words are used in transitions. In these cases we can substitute them for “first, second, lastly” , or what I like to call “link sentences”. For example:
After you’ve decided how to tackle your filler words, rehearse your presentation again. This time ask a friend or coworker to listen to you and hold out a red card every time they hear you use a filler word. When this happens, correct yourself immediately and repeat the last phrase or two, this time without the filler word.
You’ve worked so hard on your presentation or speech, don’t let some nasty filler words dilute its power. But remember not be overly perfectionist, if a couple of filler words remain, they will mostly go unnoticed.
Let me know in the comments, what are your most problematic filler words and how have you got rid of them?
If you want to know more about my public speaking courses, go to www.happypublicspeaking.com
I have worked with several NGOs, as well as in hospital, clinics and academia. In many of these places people are collecting AMAZING data from their programmes and projects. Data that I would love to get my hands on to analyse. Unfortunately, in most of these places, they are also collecting these amazing data either on paper or on a spreadsheet (e.g. Excel).
This is frustrating for me for a number of reasons. First, in many cases there is a lot of wasted time and effort, as much of this data is never analyzed. Second, people often don’t realize how precious this data is, and the risks entailed by collecting them on a spreadsheet or on paper. Third, I am one of those people on the other side of the equation, receiving that data for analysis and usually having to deal with the data collection shortfalls.
Let’s be clear here. I’m not waging a war against Excel or any other spreadsheet for that matter. They are highly useful. I use them for a number of things, but they are just not meant to be used for data entry.
So let’s talk about why collecting your data on paper or on a spreadsheet is a bad idea and what better tools you could be using instead.
Data captured and not analysed is a waste of time and effort. Data captured on paper, if it is to be analyzed at all, and thus become useful, will need to be computed manually or be typed into a computer. Both options are inefficient, time-consuming and repetitive, so you want to minimize the time your team spends doing this. I’ve talked with many people in charge of data capturing and they are rarely if ever captivated by they work (shocking!), they just see it as tedious and meaningless.
If you are using paper questionnaires or a spreadsheet with open text cells (that is, cells that allow any type of answer), people collecting the data can fill out their responses any way they want. And trust me, they will do it differently every day, and differently than their colleague. Some will write the date of birth as mm/dd/yyyy while others will use the format dd/mm/yyyy. Distinguishing between the two afterwards can become tricky.
In other cells or paper forms, if you don’t restrict the possible answers (which you CAN do in Excel), some will write “New York”, others “NY”, others “new york” and yet others “ny”. In a clinic, you may have three different names for the same diagnosis. Some will leave key questions blank.
Whenever variability is allowed, it will flourish. The problem with this is that some data may become unusable (if you can’t distinguish the correct date for instance), or will take a longer time to clean up. Result: precious time and effort wasted (and maybe some grumbling from your data analyst).
When data is captured by hand, someone has to pass it to a computer. This is a very common source of errors. When I analyse databases it can sometimes be easy to spot these types of errors: Entries duplicated or mixed up, impossible dates of birth (e.g first of january 2035), etc. A good aim in data collection is always to try to minimize your sources of error.
To understand the difference, let’s first talk about how a data-entry system works.
In programmes designed for data-entry, you capture the data in a “questionnaire” screen, where you only see the questions for the particular person or household for which you are entering data. The questions have a restricted set of answers to choose from (e.g. “New York” but not “NY” for instance). The data you capture in this way is saved in a “table”, that will look similar to Excel, but which not everyone can access.
In contrast, in Excel or similar spreadsheet solutions, you get to see the whole table of data, and you input the data directly into the cell you want. In many cases, you can write the answer in any way you like inside the cell. Thus, using a database instead of Excel results in “cleaner” data (e.g. just one name and not three for the same diagnosis), and it protects your data from mistakes, as access to the table data is restricted.
One of the worst things that I regularly see happening with spreadsheets, unfortunately cannot be fixed. Excel allows you to move/reorder columns or rows independently, which means that you could accidentally reorder the “date of birth” column, while forgetting to do so for the “name” column, resulting in names and dates of birth that don’t match.The problem is that many of these errors cannot be undone, as there is no way to trace them, so the integrity of the data can come into question when errors are evident at the time of analysis.
In most databases created by a data-entry system, the information in a single row, which normally pertains to the same individual (e.g. name, age, sex, etc), is linked together, so that this type of error is not possible.
By now, I hope you are wondering what you can use instead.
There are various user-friendly options out there for data-entry software these days. And many are free. Data collected in them can later be analyzed with your favorite statistical package (or even with Excel if that's your thing!)
If your organization has Office packages, you might want to try Microsoft Access.Two other options that I particularly like, and are widely used in health projects are EpiInfo and EpiData, which are freely available online and not very hard to set up.
For non-routine, small-scale data collection exercises you may want to try out Google forms or Surveymonkey. I’d be hard-pressed to find a more user-friendly option than these two. They are also free for small-scale questionnaires and you can send them out by email. A disadvantage though is that they are online-based, so you need an internet connection.
So what solution are YOU using? And are you happy with it? Let me know in the comments.
Contact me: firstname.lastname@example.org