Acharya: A Preliminary COVID-19 Triage App on WhatsApp

Introduction. The World Health Organization (WHO) has declared the COVID-19 outbreak as a global pandemic - it has claimed ~80,000 lives, with over 1.3 million confirmed cases worldwide [1]. After ravaging the healthcare systems and economies of several developed countries around the world (e.g., USA, Italy, Spain), COVID-19 has come to India's doorstep, and it is critical for us to take proactive measures to mitigate the impact of COVID-19 on the Indian healthcare system, and on its citizens. To this end, we introduce Acharya, a WhatsApp based messaging platform and chatbot service which interacts with people (via simple interactive questions) to assess (i) their potential risk of COVID-19 infection; and (ii) whether they qualify (or need) to get tested for COVID-19, as per current ICMR guidelines. In addition, Acharya sends periodic messages to all registered users on WhatsApp to (i) raise awareness about COVID-19 symptoms and preventative measures among the Indian population at scale; (ii) debunk prevalent pseudo-scientific misinformation about COVID-19.

The Problem. The quality of healthcare infrastructure in India is well below the world average (e.g., in 2016, India scored 41.2 points on the Health Access and Quality (HAQ) index, whereas the world average score was 54.4 [2]), and hence, there is a very real danger of Indian healthcare systems getting overwhelmed if COVID-19 infections start spreading at an exponential rate. Specifically, given shortages in the supply of testing kits, it is impossible to test everybody with COVID-19 symptoms (and this problem is going to worsen as our healthcare systems get stretched to the limit). To this end, ICMR regularly updates its testing strategy, and all tests at Indian government hospitals are administered according to this strategy [3]. The current strategy (as of 7th April 2020) is to administer a test only if any of these conditions are satisfied:

1. All symptomatic individuals who have undertaken international travel in the last 14 days.
2. All symptomatic contacts of laboratory-confirmed cases.
3. All symptomatic health care workers.
4. All hospitalized patients with Severe Acute Respiratory Illness (fever AND cough and/or shortness of breath).
5. Asymptomatic direct and high-risk contacts of a confirmed case should be tested once between day 5 and day 14 of coming in his/her contact.

Unfortunately, there is very little awareness of this testing strategy among the general population. The current situation is that if any person develops COVID-19 symptoms, they need to go to hospitals in-person and get their symptoms checked by a doctor, who then determines whether a COVID-19 test is needed or not (this determination of the requirement of a COVID-19 test is done as per ICMR guidelines listed above [3]). This current mode of operation is undesirable for two reasons: (i) it unnecessarily forces the patient to go to a hospital (where there is an increased risk of exposure to COVID-19 as compared to his home) to find out whether he/she should (and will) get tested for COVID-19. (ii) It burdens hospital staff with conducting triage of potentially benign symptoms when they are already short-staffed in dealing with actual COVID-19 cases.

We now explain how Acharya addresses this challenge by explaining its workflow. Consider the following motivating scenario:

Ram lives in Delhi (a COVID-19 hotspot in India), and he is very concerned about his own health, as he has developed cough-and-cold symptoms over the last two days. He is worried about being potentially infected with COVID-19, but at the same time, he is scared of going to the hospital to get himself checked, due to the high risk of contracting COVID-19 infection at a hospital. He has also been getting a lot of conflicting misinformation around COVID-19 from various WhatsApp groups, and he does not know what information is trustworthy and reliable. To get advice, Ram opens his WhatsApp app on his phone and initiates a conversation with Acharya (which will show up as a regular WhatsApp contact in his app).

Acharya has three different functionalities to help Ram with his problem: (i) via an interactive chatbot service, Acharya can triage Ram's risk of COVID-19 infection and determine whether he needs to go to the hospital to get tested for COVID-19 or not (if a test is needed, Acharya proceeds to connect Ram with local healthcare providers); (ii) if Ram does not qualify for a COVID-19 test (as per ICMR guidelines) but has persistent cough-and-cold symptoms, Acharya proactively follows up with Ram every day (for the next 1 or 2 weeks) to track the progress of his condition. If Ram's condition worsens at any point in time, Acharya can help connect Ram with a local healthcare provider. Finally, (iii) Acharya proactively pushes critical news, information, and myth-busters on COVID-19 (including details on symptoms and how people can protect themselves and others) to all users registered with Acharya.

We illustrate all three functionalities below (the illustrations below are in English but Acharya supports multiple Indian languages to reach a greater audience):

Feature 1: Interactive Chatbot for Preliminary Triage Two sample conversations are shown above: (i) in the conversation on the left, Acharya determines that a COVID-19 test is needed and proceeds to book a test appointment at the local hospital; (ii) in the conversation on the right but in the other one, Acharya suggests that a COVID-19 test is not necessary, and advises the patient to rest at home instead of going to a hospital.

Feature 2: Regular Follow-up with Symptomatic Patients Two sample conversations are shown above. In both the conversations, Acharya proactively follows up with patients who have exhibited their symptomaticity to Acharya. (i) In the conversation on the left, Acharya realizes that the patient's symptoms are getting worse day-by-day and books an appointment for the patient at the local hospital. (ii) In the conversation on the right, Acharya realizes that the patient's existing symptoms have improved, and no new symptoms have been observed. In this case, Acharya promises to continue following up with the patient for the next week.

Feature 3: Periodic Myth-Busters to Mitigate Misinformation Two sample conversations are shown above. In both the conversations, Acharya proactively pushes critical news, information, and myth-busters on COVID-19.

Similar Efforts. To mitigate the spread of COVID-19, several private non-profit organizations have deployed self-assessment surveys and interactive chatbots, which enable people to assess their risk of getting infected with COVID-19. For example, WHO (in collaboration with Rakuten) launched a chatbot on the messaging service Viber to get accurate information about COVID-19 to people in multiple languages [4]. Apollo Hospitals launched Coronavirus Risk Scan, a self-assessment test that can be taken by people in multiple languages to assess their risk of getting infected with COVID-19 [5]. These self-assessment tools have been used widely by people in India (and around the world), e.g., Apollo's Coronavirus Risk Scan has been used by more than 5 million Indian people already [6]. The success of these pilot chatbots highlight the potential impact of these services in raising awareness about COVID-19, and in helping people manage their infection risk.

Why is Acharya different? Acharya improves upon existing services (described above) in three fundamental ways. (i) Acharya leverages the widespread prevalence and virality of WhatsApp in India (there are more than 400 million active WhatsApp users in India [7], Viber, on the other hand, has just 40 million users) to triage Indian citizens at a large scale. (ii) In addition to risk assessment, Acharya also informs users of their eligibility to get a COVID-19 test (as per their current medical symptoms and ICMR guidelines). If they are not eligible, Acharya ensures that users do not expose themselves by going to the hospital unnecessarily. If they are eligible, Acharya books an appointment for them at the local healthcare provider. (iii) Unlike previous tools, Acharya relies on a unique set of insights from Artificial Intelligence (AI) and Natural Language Processing (NLP) to interact with its users in a context-dependent, privacy-preserving and humane manner.

Conclusion. COVID-19 threatens to exert a lot of pressure on the thinly-stretched Indian healthcare system, and it is critical to take proactive measures to develop socio-technical interventions that can reduce the pressure on India's healthcare system. At the same time,  it is also crucial to counter the potentially dangerous misinformation about the virus (e.g., gargling bleach solution kills COVID-19, etc.) that is prevalent on WhatsApp groups in India, as it is important that people only follow medical advice coming from respectable institutions such as Indian Council of Medical Research (ICMR) and WHO. To address these challenges, we introduce Acharya, a WhatsApp based messaging platform and chatbot service to triage preliminary symptoms of COVID-19 in an automated manner (without the involvement of a human healthcare professional), thereby enabling healthcare providers to focus their in-house resources (e.g., doctors, testing kits, hospital beds, ventilators, etc.) on patients requiring critical care.

References

1. Coronavirus disease pandemic, World Health Organization. Apr 8th, 2020. https://www.who.int/emergencies/diseases/novel-coronavirus-2019
2. World Health Day 2019: Access, quality of care ranks India among lowest globally, FirstPost.com, Apr 7th, 2019. https://www.firstpost.com/india/world-health-day-2019-access-quality-of-care-ranks-india-among-lowest-globally-4480939.html
3. Revised Strategy of COVID19 Testing in India (Version 3, dated Mar 3rd, 2020), Indian Council of Medical Research. https://icmr.nic.in/sites/default/files/upload_documents/2020-03-20_covid19_test_v3.pdf
4. WHO and Rakuten Viber fight COVID-19 misinformation with interactive chatbot. World Health Organization. Mar 31st, 2020. https://www.who.int/news-room/feature-stories/detail/who-and-rakuten-viber-fight-covid-19-misinformation-with-interactive-chatbot
5. Apollo Coronavirus Risk Scan, https://covid.apollo247.com/
6. Apollo Hospitals launches Project Kawach to fight COVID-19. Business Today, March 26th 2020. https://www.businesstoday.in/sectors/pharma/apollo-hospitals-launches-project-kavach-to-fight-covid-19/story/399346.html
7. WhatsApp reaches 400 million users in India, its biggest market. Techcrunch, Jul 26th, 2019. https://techcrunch.com/2019/07/26/whatsapp-india-users-400-million/