1. Development and Application of an Integrated Travel Health Surveillance and Information System at Destinations (TravHeSID)
dr. I Md. Ady Wirawan, MPH, Ph.D
I Made Kerta Duana, SKM, MPH
Ni Made Dian Kurniasari , SKM, MPH
dr. Wayan Citra Wulan Sucipta Putri, MPH
Ketut Hari Mulyawan, S.Kom, MPH
Dr. Christian Suharlim, MD, MPH
PSKM FK Universitas Udayana &
Harvard School of Public Health

2. Outline Background Aims Study’s Urgency State of the Art
Research Road Map
Research Methods
Output
International Partner
Budget and Schedule

3. Number of international travelers to Bali has increased significantly
Background
Number of international travelers to Bali has increased significantly
The increasing trend has been accompanied by the rise in travel related morbidity and mortality

4. Number of international travelers

5. Travel-related morbidities

6. Background
Travelers are considered an important population from epidemiology point of view due to their mobility, and risks of importing and exporting diseases
Currently available travel health surveillance system relies on ill-returned travelers data and has been mainly designed for country of origin at developed nations

7. Aims
Mapping health hazards and risks at tourism areas in Bali, and develop items for providing area-specific travel health information
Mapping facilities that provide travel health services in Bali
Assessing feasibility and acceptability of using a surveillance system accessible by travelers and health facilities through mobile handheld device
Developing a system that enables travelers to access specific travel health information at tourism areas, health facilities nearby, and report symptoms or illness through the mobile handheld device.
Conducting implementation research comparing areas which are included in the systems and areas which are not

8. Study’s urgency
Currently available travel health surveillance systems are collecting data from ill returned travellers, specifically designed for country of origin in developed countries,
This project will be the first to develop and apply an integrated system that involves travel health surveillance and area-specific travel health information at destination areas in a developing country.
The first system to gather travel epidemiology data from disease surveillance on travellers, both during travelling and post-travelling
Implementation of this system is expected to benefit both travellers’ health and local community health

9. State of the Art
Current travel health surveillance system: GeoSentinel, EuroTravNet, CanTravNet
Outreach patients
Travel clinic patients
Input
GeoSentiel Sites
Clinical alerts
Regular summaries
Aggregated Database
GeoSentinel Sites
ISTM members
Outreach providers
Other networks
Networks

10. GeoSentinel current network and participating sites

11. Limitations of GeoSentinel system
Ill returned travelers – convenience sampling
Different characteristics of population and destinations
No participating sites in Indonesia
lack of information on symptoms, risk factors, and diseases that could potentially be employed to improve surveillance system and public health in general

12. Local surveillance system
Little has been known about common diseases or symptoms experienced specifically by travelers to Indonesia.
Lack of robust and integrated system that also involve travelers in such destination areas.
Current surveilance system in Bali or Indonesia in general has been focused on the diseases affecting local population

13. Local surveillance system
Current surveillance system has not included travelers as its one of target population.
Current data on diseases among travelers have been relied on the reporting of health facilities and hospitals that provide services to tourists.
There is no regular travel health surveilance currently in place to gather data from all tarvel clinics or hospitals.
One of the efforts related to this has been sporadic investigation to toursim areas or facilities when authority got notification of cases
(Informal Communication with dr. Raka Susanti, the Head of Surveillance Section, Bali Health Province, 2017)

14. Research Road Map Phase I Phase II Phase III
Mapping health hazards and risks at tourism areas
Mapping facilities that provide travel health services
Develop items/factors for providing area-specific travel health information
Phase II
Assessing feasibility and acceptability of using a surveillance system accessible by travelers and health facilities through mobile handheld device (may include mobile application, SMS, push notification, etc)
Developing a system that enables travelers to access specific travel health information at tourism areas, health facilities nearby, and report symptoms or illness through the mobile handheld device (ex: appointment system)
Phase III
Implementation research comparing areas which are included in the systems and areas which are not

15. Research Methods Phase Ia: Mapping health hazards at tourism areas
Mapping facilities that provide travel health services
Hazard identification: descriptive study using observations, interviews, hazard level measurement.
Initial geotagging of sites will be performed using global positioning system, including coverage of the sites.
Improvements in initial geotagging of sites may include additional hazard identification or evaluation of subsequent data received through the mobile surveillance system.
Risk assessment: descriptive study using qualitative and semi- quantitative risk assessment tools
Sites: 8 regencies and 1 city, with approximately 172 tourism areas

16. Research Methods Phase Ib
Developing items for providing area-specific travel health information
An exploratory factor analysis (EFA) study will be carried out to identify complex interrelationships among items to produce a valid and reliable items/factors.
About 100 participants will be recruited as the sample for this study to enable proper data analysis.

17. Research Methods Phase IIa
Assessing feasibility and acceptability of using using a surveillance system accessible by travelers and health facilities through mobile handheld device.
Design 1: descriptive quantitative study using self- administered questionnaire
Samples: international travelers to Bali recruited through arrival hall at the airport (convenience sampling of about 150 visitors)
Design 2: qualitative studies using in-depth interview and focus group discussion
Samples: travel clinics or hospitals owners, medical doctors, surveillance officer at provincial and district health offices (purposive sampling involving about 30 samples)

18. Research Methods Phase IIb
Development of a a surveillance system accessible by travelers and health facilities through mobile handheld device for travelers at destination
An algorithm will be developed based on the results of the Phase I of the studies.
This will be use to develop a system accessible through mobile handheld device that can provide area-specific health hazards, risks, and facilities.
The main component will be aggregation of data to a database if visitors use the system to visit health facilities, or alternatively visitors can report symptoms or accidents through the system.

19. Research Methods Phase III
Implementation research comparing areas which are included in the systems and areas which are not
This phase of the study is to assess whether using of the system increase reporting of diseases and accidents at tourism areas.
Other outcome variables of the study are utilization rate of the systems and frequency of travel health information received by travelers.
An interrupted time-series with multiple before-after design will be used for this study. Assessment will be done every 3 months for about 1 year, to reduce the secular trend effects.

20. Included in the TravHeSID
Phase III study design P S
Group 1
Group 2
Included in the TravHeSID
Using current system
Before
After
Interme- diate

21. Output
This first phase of the project will result in a comprehensive database of health hazards, risks, and medical facilities at tourism areas in Bali.
Secondly, a system accessible from mobile handheld devices will be developed, and fostering a travel health network involving private and public travel medicine centres as well as district and provincial health offices.
The results from this study will be published in Journal of Travel Medicine (ISI Journal Citation Reports Impact Factor: 1,579, Indexed by Scopus, Web of Science, PubMed, Medline, etc)

22. International Partner
The international partner roles are mainly on providing consultancy on study design, providing inputs during protocol development, and assisting reports and manuscript writing. Workshops and site visits will be performed to assist local researchers on data management and data quality control.
Dr. Christian Suharlim, MD, MPH, a research associate at the Center of Health Decision Science, Harvard School of Public Health will be involved as a co-investigator for this study.
He is also the President of the Postdoctoral Association at the Harvard T.H. Chan School of Public Health actively involved in many health-related activities at Harvard
His current work involve collecting and managing data for a 2.3 million US$ immunization costing and financing under Gates Foundation.

23. International Partner
In 2013, he advised a $500,000 USAID MDR-TB surveillance program in Universitas Andalas and provided on-site technical assistance in data management.
From the development of this proposal he has actively involved on how to design the system, including the possibility of developing
crowdsourced-input machine learning to provide feedback or info for hazard geotagging, and
consideration on low uptake and utilization rate of mobile apps, and
subsequently suggested using SMS-based system, identical to worldwide weather warning

24. Budget Summary
We request a total of Rp. 448,182,000 for the duration of 3 years. The estimated costs for the first, second, and third year are Rp. 149,062,000, Rp. 149,160,000, and Rp. 149,960,000, respectively.
Based on cost components, the salary will be about Rp. 110,880,000, equipment costs about Rp. 43,000,000, consumable materials cost Rp. 124,752,000, travel expenses are approximately Rp. 80,800,000, and other miscellaneous items cost about Rp. 88,750,000.

25. Schedule