Dengue hemorrhagic fever (DHF) has been the leading cause of hospitalization and death among children in Southeast Asia since the first DHF cases were reported from hospitals in Manila, in the 1950s (Gubler, 2002). At the end of 2003 and the beginning of 2004, the number of DHF cases increased dramatically in at least 12 of 32 provinces in Indonesia (Ahmad, 2004; Arya and Varma, 2004). Yogyakarta Special Region has been among the first provinces highly endemic for DHF until now. Most DHF cases are diagnosed in hospitals, equipped with diagnostic facilities. However, the epidemiologic investigation in the community is carried out by public health staff at the community health center (puskesmas), once notified by the hospital that a DHF case lives in the administrative catchment area of the health center. An outbreak of DHF is assessed by district health office, and control measures are decided by district health officials (Kusnanto, 2003). The fragmented DHF control in the community is unfortunate, because the health administrators, the local government and the community usually respond to an outbreak when too many persons have already came down with the disease, and preventable DHF fatalities have occured. A web-based surveillance system which records and publishes accumulated number of DHF cases in every subdistrict or village every day, will facilitate an integrated approach in the detection and control of DHF cases in the community.

 

Sleman District in Yogyakarta Special Region reported the highest incidence of DHF in the province. All community health centers in the district are equipped with personal computers for reporting and recording activities. Some health centers send monthly reports to the district health office on line (dial-up), or in floppy discs. Only 70% of health centers are connected with a telephone line, however, all health centers have access to the internet via mobile phones. There are 6 hospitals (2 public and 4 private) serving the community of Sleman District. All hospitals have some electronic data processing in their medical record unit, one private hospital owns a well-developed web-site. A web-based recording and reporting system which identifies the number of DHF cases in every village in Sleman District automatically published in a geographic map, and continuously updated once a diagnosis of DHF is made, will be established by providing facilities for web design, web hosting, and data entry to the surveillance database system. The web-based surveillance system would be particularly useful if it also provides rules for decision support regarding the prevention and control of DHF in the community.

 

 

The purpose of the project is to integrate DHF surveillance and control activities among health care personnel and public health administrators through a web-based geographic information and decision support system, so that hospitals, community health centers and health offices are able:

The ultimate objective of the project is to establish “zero tolerance” norm toward the incidence of DHF in the community. The DHF surveillance system will serve as a prototype of web-based data entry, data processing, and decision-support system which may become learning tools for other DHF endemic areas, not only in Indonesia, but also Southeast Asia, West Pacific and the Carribeans.

 

 

The community who live in urban and suburban areas, especially in densely populated villages, where the incidence of DHF is highest in Sleman district, will be the direct beneficiaries of the project. The health sector as the leading agent of DHF control in the community will learn from the project how to plan, advocate, mobilize resources, and implement DHF control based on the evidence suggested by the data. The information regarding the spatio-temporal distribution of DHF incidence in the area may encourage community participation in the eradication of breeding places of Aedes aegypti.

 

 

The project consists of initiatives to improve DHF surveillance system through better networking and decision support. It is expected that these initiatives will motivate public health and health care personnel to expand the web-based surveillance system not only for DHF, but also for other important diseases, such as tuberculosis and vaccine-preventable diseases. Information and communication technology will be more readily available in the near future. Better computers, with literally unlimited speed and storage capacity, the availability of powerful open sources for software and netware development, and improved computer literacy among public health and health care workforce could be capitalized to ensure the sustainability of the project.

 

 

The development of web-based DHFsurveillance system needs collaborative inquiry to understand the problematic situations, where people are viewed not as passive objects, but as active subjects. Soft systems methodology (Checkland, 1972; Checkland and Holwell, 1998) has been used to address systems development with multiple and unclear objectives, often perceived differently by these subjects. There are 7 stages of soft system methodology (Table 1).

 

Database design to facilitate DHF surveillance will use mysql, one of the most popular open-source database management software. The web-based interfaces will be constructed using PHP version 4.2.2, another popular open-source software. To monitor the time-space clustering of DHF incidence in Sleman district, a simple web-based geographic information system (GIS) is used. The geoposition of the houses where the DHF cases live will be plotted in the map using global positioning system (GPS). The construction of the web-based map (under PHP version 4.2.2) was supported by WHO grant (SE/04/225281) to the Center for Health Informatics and Learning, Gadjah Mada University, Indonesia.

 

 

 

 

 

 

 

 

The web-based DHF geographic information and decision support system will not achieve its objectives without the commitment of the local government, public health and health care personnel, and the community at large, to engage in the early warning system of DHF outbreak and continuous DHF vector control in the community. The networked surveillance system is only a tool to facilitate concerted efforts in the utilization of data, systematically collected, processed and presented in an electronic virtual map, to inform necessary activities to control the spread of DHF in the community. The main output of the project is a report on the effectiveness of the web-based DHF surveillance system in driving appropriate actions to highlight possible DHF outbreaks, to ensure appropriate resources to provide care to DHF cases, and to prevent the spread of DHF in the community. The report will be published on the website, and rewritten to be published in a peer-reviewed journal.

 

           

Process monitoring will be carried out in the form of documented minutes of meetings, rich pictures produced to describe the problem situation, conceptual models, and changes in DHF surveillance system required by the participants of the study. The number of hits representing the use of the web-based geographic information system will be recorded. The intensities of DHF control activities and the decreasing incidence of DHF in Sleman district indicatethe ultimate achievement of the project. Time-series analysis of the reported cases of DHF will be done to describe the trend of DHF incidence, controlling for seasonal fluctuations.