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Ground Zero: Tracking diarrhea at the household level

Updated: Aug 13, 2020

A major concern for Kenya’s Ministry of Health and Sanitation is the management of diarrhea, the 3rd most common cause of mortality in-country; with a case fatality of up to 21%.[1]

The “Ground Zero” program’s sole purpose is an implementation of a mobile phone platform that gathers daily stool information at the household level and relays it to an assigned community health worker (CHW) for intervention. The platform uses “Cohesion©”, our home-grown mobile phone application, that consists of a simple smartphone and portable biometric scanners (Simprints), which collects and collates real-time household level daily loose stool information.

A year of data

Looking at a snapshot of data collected between March 2018 and July 2019, we begin to gain some visibility into the well-being of these communities during this period.

  • Boma: An enclosure of several homes, typically 2 – 4 (Homestead)

  • Phone Handler: COHESU POC within a Boma

“Engagement” can be defined as a log recorded on the mobile application. For this to happen, the phone-handler has to open the application on their device, navigate to the log creation screen, and input the details of their record.

Figure 1: Recorded Logs April 2018 - July 2019

At the peak of engagement - November 2018, Ground Zero (GZ) operations had 62 active Bomas recording ~13 logs/day.

Stool logs at a first glance

The GZ operations deployed at three selected locations around the Lake Victoria basin, Kisumu, Kenya: Rota, Usoma, and Kisian.

The application deployed with a predefined log for stool consistency. The phone-handler had the responsibility of recording any reported cases of loose stool within their Boma using the COHESION App. What this data aimed to derive was repeated cases of loose stool, which would point to a case of diarrhea within that Boma. Our system algorithm that calculates / flags a diarrhea event within a 24Hr period is based on W.H.O definition that states, “Diarrhoea is defined as the passage of three or more loose or liquid stools per day…”[3]

Figure 2 | Interactive: GZ operations March 2018 - July 2019

Figure 2 maps Boma locations.

- Each Boma is represented by a bubble

- The size of the bubble represents the ratio of loose stool logs to total logs recorded

- The colour represents the total number of logs recorded by the Boma

Figure 3: Stool Logs September 2018 - July 2019

In a study assessing seasonal diarrhea cases in Chiga - a flood-prone ward around the Lake Victoria basin, cases of diarrhea reported at the local health center between 2012 to 2016 appear to rise seasonally during the second and fourth quarters of the year. These spikes in diarrhea cases are also shown to correlate with increased rainfall during these periods[2].

Active bomas

Engagement varied between Bomas. 45 of the 73 Bomas on average filed at least 2 logs/day throughout the program. One of the challenges we anticipated was the extent to which total reporting by phone-handlers would be verified and the possibility of unreported cases. To this, the role the community unit plays is critical to the integrity and reliability of our data

Figure 4: Loose Stool Logs by Boma (> 1000 Logs) April 2018 - July 2019

As part of the larger program, phone-handlers and CHW’s went through training on how to how to mix an oral rehydration solution (ORS) in the event of a flagged case of diarrhea, when to refer severe cases of diarrhea to the nearest health facility and their duty to pass this information to other members of their compounds. High-quality Hollow Membrane Water filters were provided to each of the participating Bomas to ensure the provision of clean/safe drinking water for ORS dispensing.


From our log data, we were able to detect cases of diarrhea within our operation households - based on repeated cases of loose stool.

Figure 6: Detected cases of diarrhea August 2018 - July 2019

In the Chiga study, 774 confirmed cases of diarrhea were reported at the health center between 2012 - 2016 [2]. In this 12 month snapshot of data, 351 cases of diarrhea were detected by our platform, immediately highlighting a gap in the tracking of infectious diseases within our communities.

Figure 7: Diarrhea cases per individual by KEPH age groups & gender

Figure 7 shows higher incidences of diarrhea observed in individuals below the age of 25, more in males than females; though this not entirely the case for late childhood (6 - 15) and adults (25 - 60).

However, in the Chiga study, the highest incidence of diarrhea was observed among adults (≥ 18 years), followed by older children [2]. This discrepancy points towards the need for longer-term programs such as this, and the dissemination of this data to stakeholders such as the government, partners, and various interest groups/communities that can power wide-scale integration and adaptation.


1. Management of diarrheal diseases among children under five years: International journal of Community Medicine and Public Health Njeru PM et al. Int J Community Med Public Health. 2017 Aug;4(8):2762- 2766

2.Yeda RA, Omemo P, Makunda N, Okello E, Ayodo G (2019) Epidemiological Assessment of Seasonal Diarrhoea Cases in Flood Prone Chiga Ward, Lake Victoria Basin, Kenya. J Epidemiol Public Health Rev 4(2):

3. WHO: Diarrhoeal disease -

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