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February 14, 2012

The Wisdom of SAGES

soldier receives medical treatment
Health officials in Cebu City, Philippines, worked with the APL team to implement SAGES and reduce data collection and analysis times.

Building on work that began in the 1990s, APL has partnered with the Armed Forces Health Surveillance Center to develop software that helps countries with limited resources track disease.

The Suite for Automated Global Electronic bioSurveillance, or SAGES, is a collection of modular, freely available software developed for electronic surveillance in countries with little funding for public health initiatives. SAGES has been used by governments in Cambodia, the Philippines, Nicaragua, and Peru, and it will be introduced in Cameroon, Djibouti, and additional countries in 2012.

Using SAGES alone or with existing applications, governments can develop inexpensive, customized systems to collect and track information about the spread of disease. "The ability to more quickly assess disease activity gives countries the chance to more effectively use limited resources," says Sheri Lewis, operational disease surveillance program manager in the Homeland Protection Business Area. "And they can also more easily comply with the World Health Organization's recently modified International Health Regulations, which were developed to help prevent and respond to global health threats."

SAGES is already proving its value: In one instance, APL public health and IT specialists worked with health officials in Cebu City, Philippines, to reduce the time needed to observe patient health trends. Reports once tallied on paper and reported weekly or monthly are now electronically recorded and analyzed daily. Cebu City is expanding the program and developing additional site-specific software.

"As the sponsor of this program, we have been extremely satisfied with the piloting of SAGES and look forward to expanding the scope to more developing settings in all regions of the world," says Navy Commander David Blazes, chief of the Armed Forces Health Surveillance Center's Global Emerging Infections Surveillance and Response System Division. "SAGES has the potential to substantially improve global health security."

The SAGES suite focuses on four categories: data collection; analysis and visualization; modeling; and communications. "Data collection can be the most challenging aspect of disease surveillance," says Lewis. "Every country has different capabilities and preferences for the technology it uses. We have to select one that is readily available, cost effective, and easy to incorporate into its existing health services."

SAGES is flexible enough to accommodate those differences. System users in Peru, for example, tap a technology called interactive voice response (IVR) to enter large amounts of data through a telephone keypad. But in the Philippines, where IVR phone calls are too expensive, local health departments receive information through basic text messages.

SAGES analysis and visualization tools are built upon the Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE), which was developed more than decade ago by APL and the Department of Defense. ESSENCE collects, processes, and analyzes nontraditional data sources such as over-the-counter drug sales or school absenteeism to identify disease activity in a community, allowing users to query, analyze, and visualize the data.

The analysis and visualization tools within SAGES are based on the features and functionality of the ESSENCE system. SAGES web-based and desktop applications are both freely available and offer additional capabilities such as language internationalization. They are deployable using only open-source software and allow for less expensive hardware options. Another plus is that the suite of software modules allows multiple countries to share patient data with two-way communication between public health officials and common formats for graphics describing disease activity.

One of the most helpful SAGES tools is our modeling, simulation, and evaluation capability," adds Lewis. "We have developed electronic disease surveillance exercises to train users. These exercises also test system features to ensure the tools are meeting the users' needs. In the future, we plan to leverage our experience in agent-based infectious disease modeling and predictive disease modeling to further inform the disease surveillance process."

SAGES-like tools have also proven effective at home. U.S. epidemiologists have used them to detect disease activity earlier than with traditional laboratory-based surveillance and can monitor community health in the face of a known threat. "Public health surveillance is undergoing a revolution driven by advances in the field of technology," says Homeland Protection Business Area Executive José Latimer. "If we can provide tailored technology to resource-limited countries and work to identify and train champions on the ground, we can help improve health security globally by enabling rapid response to many of the threats to public health."