Feasibility of implementing Integrated Management of Childhood Illnesses through Mobile Technology

Background

The Integrated Management of Childhood Illnesses (IMCI) strategy was launched by WHO and partners in 1995 to reduce child mortality by enhancing frontline health workers' (FHWs) ability to diagnose and manage childhood illnesses, and strengthen overall health systems. However, although IMCI is associated with decreased child mortality, numerous studies have shown its impact has been limited due to persistent barriers to implementation.

Methods

We developed a digitized version of IMCI (eIMCI) using Android technology to overcome implementation problems, including poor protocol compliance, lengthy trainings, paper-based data collection, and gaps in the referral system. The feasibility and efficacy of eIMCI was assessed through a mixed-methods pilot study encompassing baseline and end-line surveys, interviews, and Focus Group Discussions, in a low-resource rural district of Punjab, Pakistan. During the 8 weeks of deployment, a total of 1,978 children were enrolled in the eIMCI application by 10 participating FHWs, and 47 electronic referrals were generated.

Results

Preliminary outcomes showed reduced disease occurrence (for example, diarrhea decreased from 48% at baseline to 29% at endline), increased adherence to IMCI protocol, and strengthened health system linkages (facility referrals increased from 5% at baseline to 45% at endline). FHWs reported enhanced performance, as well as an improved community response to their services.

Discussion

Indicating the feasibility and efficacy of eIMCI deployment in a low-resource setting, evidence from the pilot demonstrates the benefit of digitizing the IMCI protocol. eIMCI is a digital health solution with the potential to significantly reduce child mortality and improve service delivery and performance of FHWs.

Key messages

eIMCI is a feasible solution for the implementation of IMCI strategy in developing countries and demonstrates increased compliance and enhanced performance by the frontline health workers. Implementation of eIMCI can result in a significant reduction in child morbidity and mortality via timely referrals of patients and reduced disease occurrence.

Real-time immunization trends in under-2 children in Pakistan: insights from big data analysis

Background

Despite the provision of free-of-cost vaccines in Pakistan, fully immunized child (FIC) coverage in Sindh province remains low at 49%. In 2012, we developed and piloted the Zindagi Mehfooz (Safe Life; ZM) Digital Immunization Registry, an Android-based platform that enables vaccinators to enroll and track child level immunization data of children in the catchment population. In 2017, ZM was scaled-up across Sindh province and is currently being used by 2,284 vaccinators across 1,526 facilities serving >48 million (m) population.

Methods

All children under-2 years of age visiting EPI centers are enrolled. At enrollment, caregiver and child bio-data and child immunization history are recorded, and the child is provided with a unique Quick Response (QR) code for identification. For follow-up immunization visits, 3 SMS reminders are sent to caregivers, and upon immunization, child history is retrieved by scanning the QR code and vaccination record updated. ZM allows real-time access to data and generation of monitoring reports. Data from ZM was used to calculate coverage rates, timeliness, and trends for immunization coverage in Sindh.

Results

From Oct'17 to Dec'19, more than 2.4m children and 0.8m women were enrolled in the Registry, while >17m immunizations were administered. The FIC coverage in 12-23 months old children has increased from 49% (at baseline) to 57% for children enrolled in ZM. Additionally, pentavalent-3 coverage increased from 59% to 68%.

Discussion

ZM demonstrates the potential of DIRs to improve immunization outcomes within low-resource settings by enabling better child tracking and a higher retention rate. Additionally, the big dataset provides the opportunity to identify real-time trends and provides actionable data for evidence-based decision making.

Key messages

ZM Immunization Registry has strengthened the current EPI program through increased FIC coverage and timeliness through better tracking of children and increased retention. Big Data from ZM can be used to analyze immunization trends of global relevance, and guide strategic policy decisions for improving immunization coverage and equity, based on actionable data insights.

Using mobile immunization vans to cover under-served populations in hard-to-reach areas

Background

In Pakistan, only 66% of children receive their basic vaccinations. However, the figure masks significant inequalities in vaccine coverage between urban and rural residences, slums and areas distantly located from EPI centers. Frequent outbreaks of vaccine-preventable diseases such as polio and measles, in urban cities like Karachi, signal the need for expanding vaccine services to underserved areas. In Apr'19, we introduced the Mobile Immunization Van initiative in Karachi in collaboration with EPI Sindh. Currently, two vans are deployed in hard-to-reach areas and slums to immunize under-2 children for routine vaccines.

Methods

Before the van visit, mobilization efforts are conducted in targeted areas to encourage caretakers to bring their child for vaccination. On the day of visit, the van is parked at a central location, and announcements are played on a loudspeaker to attract caregivers. All vaccinations are administered in the van, and entries are recorded in Government's Digital Immunization Registry along with GIS coordinates of immunized children. The data is then automatically transferred on to a web-dashboard for analysis and tracking.

Results

From Apr'19 to Jan'20, the vans have vaccinated 2,867 children, out of which 50% had never been immunized prior to the van visit. Of those who received their follow-up vaccines from the van, 80% were at least 4 weeks beyond from their vaccine due date. GIS analysis of van data confirmed that immunizations were conducted in slums, and areas distantly located from EPI centers. Moreover, compared to government outreach activity, proportion of BCG, Penta3 and Measles1 administrations in slums was higher through the vans by 5%, 6%, and 4% respectively.

Conclusions

The vans provide an opportunity for immunizing never-vaccinated children and children defaulting on their vaccine schedule, from the most vulnerable geographies, while simultaneously enrolling them in the Government's EPI Program for effective tracking.

Key messages

The mobile vans help achieve universal immunization coverage through provision of vaccine services in slum and rural hard-to-reach areas with limited access to government-provided services. The mobile vans help vaccinate and capture never-immunized children into the Government’s EPI records, reducing the number of children missed through routine services.

Assessment of immunization service delivery in Pakistan: A cross-sectional survey of health facilities

Background

Routine childhood immunization coverage in Pakistan remains sub-par, in part, due to the poor quality of service delivery. This study aims to summarize the quality of immunization centers throughout the Sindh province, Pakistan, by assessing all Government vaccination facilities and their associated health workers.

Methods

A health facility and worker assessment survey adapted from tools developed by BASICS and EPI-Sindh was used to record facility infrastructure, processes, and human resources. Using expert panel ranking, we developed critical criteria to indicate items immunization centers need to be operational (vaccinator, a cold box or refrigerator, and vaccine supplies) as well as high, low, and moderate function requirements and their respective scores.

Results

Out of 1396 centers assessed, 1236 (88.5%) were operational, while 1209 (86.6%) offered immunization services. Only 793 (66.0%) of the functional immunization facilities met the critical criteria. The average scores for high, moderate, and low function requirements were significantly lower for centers that did not meet the critical criteria. Of 2,153 healthcare workers interviewed, 1874 (87.1%) were vaccinators. 1805 (96.3%), 1655 (88.3%), and 1387 (74.0%) were trained in vaccination, cold chain, and inventory, respectively.

Discussion

One out of three immunization centers in Sindh lack the critical components essential for quality vaccination services. Health workers have adequate training and experience, suggesting that sub-optimal vaccination center quality is due to inadequate infrastructure and inefficient processes. Our study presents innovative and critical research findings with high-impact policy implications for identifying and addressing gaps to improve vaccination uptake within an LMIC setting.

Key messages

Every 2 out of 5 facilities in Sindh Province lacked essential equipment for immunizations such as vaccines, vaccinator and cold box for vaccination. In all health facilities, the health workers appear sufficiently trained, indicating that poor quality may be due to missing infrastructure and inefficient processes in resource-constrained settings.

Validation of mobile Decision Support System for scheduling age-appropriate immunizations

Background

The prevalence of missed opportunities for immunization among children is estimated to be 32.2%. The introduction of new vaccines in EPI schedule and lack of training of frontline health workers (FHWs) on the guidelines for number and spacing of doses and manual construction of vaccine schedules based on a child's age deteriorates efficiencies of FHWs, especially in forecasting catch-up schedules. We have designed and tested the validity of an innovative Decision Support System Application Programming Interface (DSS-API) which will automatically generate an age-appropriate immunization schedule for a child.

Methods

Using a multi-country setting approach, DSS was deployed in six immunization facilities of Pakistan and Bangladesh between July 2019 to April 2020. Details of all visiting children were recorded in database. Information on date of birth and past immunization history was used by the DSS-API to determine an individualized age-appropriate immunization schedule. These schedules were compared to the gold standard's outputs calculated by an immunization expert.

Results

A total of 6,241 vaccination events were recorded from all the sites. Using area under the curve, the calculated sensitivity of DSS to determine age-appropriate immunization schedule was found between 99-100% for the individual EPI vaccines, while the specificity of the DSS algorithm was found between 98-100%.

Conclusions

DSS is a feasible feature that can be incorporated in Digital Immunization Registries to accurately schedule routine and catch-up immunizations and can effectively reduce Missed Opportunities for Immunizations by assisting FHWs through automatic construction of immunization schedules.

Key messages

DSS-API is a unique application that can improve process efficiencies of frontline health workers by automatic generation of accurate age-appropriate catch-up vaccine schedules. DSS has the potential to reduce missed opportunities for immunization (MOI) and improve immunization coverage and timeliness among children aged under 2 years.

Evaluating mobile conditional cash transfers for improving immunization coverage in Pakistan

Background

Despite progress in increasing immunization coverage, poor uptake of vaccines remains a challenge, particularly in LMICs. In part, this is due to the poor socio-economic status of caregivers, lack of motivation, and parental procrastination. While there is evidence that large (≥100 USD) incentives can overcome these problems, research on small incentives that are more appropriate for an LMIC setting is sparse. Our study addresses this gap by evaluating the impact of small (≤12 USD) CCTs in increasing immunization coverage for children under the age of two.

Methods

A 2-year program utilizing two small incentive schemes of different amounts (high: USD9; low: USD5) was implemented in Shikarpur District, Pakistan. Caregivers (with children 0-24 months) visiting any of the 33 study immunization centers were given the opportunity to enroll. All consenting parent-child pairs were randomized in one of the two incentive schemes and incentives were disbursed following each immunization visit, using mobile money. A baseline and end-line survey was conducted to evaluate changes in pre-post coverage.

Results

A total of 63,336 participants were enrolled between March 2016 - April 2018, of which 41,483 were randomized in the high or low incentive schemes (remaining caregivers were enrolled in the no-incentive group). Results show a 13% and 28% increase in age-appropriate coverage for Measles-1 (M1) and fully immunized children (FIC) compared to the baseline (FIC:16%, M1: 38%). There was no difference in M1 coverage between the high and low incentive schemes.

Discussion

Small CCTs have induced positive behavioral change and are a powerful tool for improving immunization coverage and compliance within LMICs.

Key messages

Small mobile conditional cash transfers (USD<12) can serve as nudges to parents and lead to behavioral shifts resulting in improved immunization outcomes for children. There was no significant difference in outcomes between high and low incentives, indicating that small mobile conditional cash transfers were equally effective in improving immunization coverage.

Evaluating small conditional cash transfers to improve vaccine coverage and timeliness in Pakistan

Background

Low immunization coverage rates have prompted the need to design effective demand-side interventions to improve uptake. Simple SMS reminders and large (≥USD 100) incentives have been demonstrated to effectively increase immunization coverage. However, research on small incentives (≤USD 15) for immunization is sparse and there is uncertainty regarding the optimal structure of incentives in terms of size, schedule, and design.

Methods

A 12-arm randomized controlled trial is being conducted in Karachi, Pakistan with 10 incentive arms of varying size (amount), schedules (progressivity) and design (certainty of payment), an exclusive SMS arm and control arm. The incentives are provided through two mechanisms: mobile air time and mobile-money through a mobile-money provider. Children were enrolled when they presented to the study sites for either BCG, Penta-1, or Penta-2 vaccine.

Results

A total of 11,197 children were enrolled between Nov 2017 and Oct 2018 with approximately 800 children in each incentive arm and 1600 and 1599 in SMS and Control arm, respectively. As of Jan 09, 2020, Penta-3 and Measles-1 coverage are lowest in the control arm (71% and 60% respectively) and highest in the high-flat-lottery arm (78% and 69% respectively) with uniformly progressing incentive amounts along the immunization schedule.

Discussion

Interim results suggest that small mobile-based incentives coupled with SMS reminders can significantly improve immunization coverage in children. The final analysis will provide robust evidence of this impact and provide policy implications for the most optimal incentive structure that can build caregiver demand for effectively increasing child immunization in an LMIC setting.

Key messages

Small incentives (USD<15) coupled with simple SMS reminders can improve immunization coverage and timeliness in low resource settings in an inexpensive, logistically simple way. The study will provide experimental evidence on optimal incentive design, structure, and size of small incentives for a cost-effective approach to increase immunization coverage and timeliness.

Empowering adolescent girls and creating lifelong champions to improve immunization coverage

Background

Despite the global imperative to 'leave no child behind', one in every 5 children remain deprived of life-saving vaccines. Low immunization coverage is in part due to the weak linkages between community and health system, inaccessibility of outsiders to closely-knit societies and low parental awareness regarding immunizations. The Kiran Sitara (Shining Stars; KS) Adolescent Health and Leadership Program (AHLP), was implemented using adolescent girls (Kiran Sitaras-KSs) as the agents of change, who by virtue of belonging to the community were able to cause a ripple effect in boosting uptake for WHO-recommended immunizations for children under 2 years of age. Our research evaluated the feasibility of the KS community mobilization and validated KS's ability to accurately identify under-immunized and zero-dose (never-vaccinated) children.

Methods

AHLP was implemented in grades 8-10 of two public secondary schools in Shikarpur and Lakhi Town, Pakistan. From April-May, 2017, a door-to-door survey was conducted by KSs followed by visits of trained staff to verify the immunization statuses identified by KSs.

Results

KSs (N = 45) screened 207 children and identified under-immunized and zero-dose children with an accuracy of 74% and 94% respectively.

Conclusions

Our strategy of mobilizing girls from within the communities provides a promising avenue to provide immunization services in high-risk areas that cannot be penetrated through conventional mechanisms. We are actively scaling-up our sustainable solution by implementing AHLP in 250+ schools and creating a force of 100,000+ KSs who can promote health equity today and champion the cause in their capacity as tomorrow's mothers.

Key messages

The Kiran Sitara initiative via its community-centered approach leverages the force of adolescent school girls to boost demand and provide referrals for immunization in unreached geographical pockets. The Kiran Sitara initiative utilizes the power of youth engagement to identify zero-dose and under-immunized children, link them to immunization services and improve knowledge among caregivers.

Modeling and optimization of pectinase-assisted low-temperature extraction of cashew apple juice using artificial neural network coupled with genetic algorithm

In this study, pectinase-assisted extraction of cashew apple juice was modeled and optimized using a multi-layer artificial neural network (ANN) coupled with genetic algorithm (GA). The effect of incubation time, incubation temperature, and enzyme concentration on different responses such as yield, turbidity, ascorbic acid content, polyphenol content, total soluble solids, and pH was also determined. The developed ANN has minimum mean squared error values of 0.83, 40.92, 29.01, and 8.95 and maximum R values of 0.9999, 0.9972, 0.9995, and 0.9996 for training, testing, validation, and all data sets, respectively, which shows good agreement between the actual and predicted values. The optimum extraction parameters obtained using the developed ANN-GA were as follows: an incubation time of 64 min, incubation temperature of 32 °C, and enzyme concentration of 0.078%. The measured value of responses at the optimized process conditions were in accordance with the predicted values obtained using the developed ANN model.

Evaluation of storage temperature, packaging system and storage duration on postharvest quality of straw mushroom (Volvariella volvacea)

Volvariella volvacea is an edible mushroom, highly perishable and has a very short shelf life (1-2 days) at room temperature (RT). This research was conducted to determine the postharvest qualities at different storage temperatures (10, 15ºC, and RT) and storage durations (0, 2, 4, 6 and 8 days) in perforated polyethylene (PE) films. V. volvacea stored at 15°C showed lower weight loss, no veil opening and retained higher firmness. Thus, the mushrooms were expanded to examine the optimum packaging systems (perforation, PVC film wrap, vacuum and control) applied to V. volvacea for 0-8 d at 15ºC. PVC film was shown to maintain higher firmness, lower weight loss, browning degree, and PPO enzyme activity compared to other packaging. Minor damages and ultrastructure tissue shrivelling were seen in PVC film packaging. Overall, V. volvacea was best stored at 15°C in PVC film to retain their quality and extend its shelf life.

Demographics of Patients Undergoing Carpal Tunnel Release in an Urban Tertiary Hospital in Malaysia

Introduction: Carpal tunnel syndrome (CTS) is the most commonly encountered neuropathy. The entrapment of the median nerve at the wrist can be corrected with a carpal tunnel release (CTR) procedure. The objective of this retrospective study was to determine the demographic, medical, and surgical characteristics of the patients with CTS who presented for CTR surgery in a tertiary hospital in Malaysia. Materials and Methods: Malaysians patients with CTS who had undergone a CTR during the period from 1st June 2017 to 31st December 2017 were enrolled into the study. Each patient had a minimum follow-up of three months. The demographic data of age, gender, race and occupation, and the comorbid illnesses and associated risk factors were recorded. The prevalence and occurrence of CTS in the dominant or non-dominant hand and the effectiveness of surgical intervention were also noted. Data was collected, analysed and stored in Microsoft Excel and SPSS 25. Results: There was a total of 76 cases of CTR surgeries done in 62 patients in the study. Eighty percent of the patients were female, and most of the patients belonged to the age group of 41-60 years. Malays constituted 74.2% of the patients, and 34% were housewives. Hypertension, dyslipidaemia and diabetes mellitus were the three major comorbidities. Cervical spondylosis was seen in one-fourth of the patients. Bilateral hand involvement was present in 54.8% of patients. 59.7% of CTR surgery was done on the dominant hand alone, 17.7 % CTR on the non-dominant hand alone and 22.6% CTR on both hands. Numbness and pain (50%) were the predominant presenting symptoms. The most positive signs were the Durkan test (77.6%), followed by the Tinel sign at the carpal tunnel and the Phalen's test. At follow-up, three months or more, after the surgery, 75% of the patients showed a satisfactory improvement. Conclusion: Patients, who had undergone CTR, had a higher prevalence of pre-morbid conditions, and a quarter of them presented with associated cervical spondylosis. The most common presentation was a combination of numbness and pain. Many obtained satisfactory improvement post-surgery and thus open surgery could be considered a reliable treatment for CTS.

Navigating the complexities of coordinated conservation along the river Nile

The river Nile flows across 11 African countries, supporting millions of human livelihoods, and holding globally important biodiversity and endemism yet remains underprotected. No basin-wide spatial conservation planning has been attempted to date, and the importance of coordinated conservation planning for the Nile's biodiversity remains unknown. We address these gaps by creating a basin-wide conservation plan for the Nile's freshwater fish. We identify priority areas for conservation action and compare cross-boundary collaboration scenarios for achieving biodiversity conservation targets, accounting for river connectivity. We found that collaborative conservation efforts are crucial for reducing conservation costs, saving 34% of costs compared to an uncoordinated, business-as-usual scenario. While most Nile basin countries benefit from coordinating conservation planning, costs and benefits are unequally distributed. We identify "hot spots" consistently selected as conservation priority areas across all collaboration scenarios, and provide a framework for improving return on conservation investment for large and complex river systems globally.