Can Digital Tools Be Used for Improving Immunization Programs?

From both sides of the needle: Understanding effective interventions for facilitating non-national immunization program vaccine decision making in China

Vaccination decisions are influenced by various psychological and practical factors. In China, non-National Immunization Program (non-NIP) vaccines, which are voluntary and self-paid, add uncertainty and autonomy to the decision-making process. Effective communication between providers and recipients is crucial but understudied. This study aims to integrate their perspectives, identify strategies for facilitating vaccination decisions, and analyze their mechanisms. From July to December 2023, semi-structured interviews were conducted with 17 caregivers and 12 vaccination providers across five Chinese provinces. Participants shared their experiences and decision-making processes regarding non-NIP vaccines. The Behaviour Change Wheel framework guided the analysis, utilizing iterative coding and directed content analysis. Thirteen Behavior Change Techniques were identified, with feedback, monitoring, and environmental restructuring being the most common. Key intervention functions included Persuasion, Education, and Training. We further mapped how these interventions influence non-NIP vaccine decisions. Capability was enhanced through education and effective communication, providing necessary knowledge and skills. Opportunity was increased via infrastructural improvements and societal support, making vaccines more accessible and endorsed by the community. Motivation was driven by clear communication of vaccination benefits and risks, reinforced by societal norms through public health messaging. By understanding the mechanisms influencing vaccination behaviors and interacting with stakeholders, tailored strategies can be developed. Healthcare providers can enhance service accessibility and offer evidence-based guidance with reminders, monitoring, and incentives to ensure compliance. For recipients, reliable information, sustained engagement, timely communication, and motivational opportunities are essential. A multi-dimensional approach involving multiple stakeholders is crucial for promoting non-NIP vaccine uptake.

Electronic Immunization Registry in Rwanda: Qualitative Study of Health Worker Experiences

BACKGROUND

Monitoring childhood immunization programs is essential for health systems. Despite the introduction of an electronic immunization registry called e-Tracker in Rwanda, challenges such as lacking population denominators persist, leading to implausible reports of coverage rates of more than 100%.

OBJECTIVE

This study aimed to assess the extent to which the immunization e-Tracker responds to stakeholders' needs and identify key areas for improvement.

METHODS

In-depth interviews were conducted with all levels of e-Tracker users including immunization nurses, data managers, and supervisors from health facilities in 5 districts of Rwanda. We used an interview guide based on the constructs of the Human, Organization, and Technology-Fit (HOT-Fit) framework, and we analyzed and summarized our findings using the framework.

RESULTS

Immunization nurses reported using the e-Tracker as a secondary data entry tool in addition to paper-based forms, which resulted in considerable dissatisfaction among nurses. While users acknowledged the potential of a digital tool compared to paper-based systems, they also reported the need for improvement of functionalities to support their work, such as digital client appointment lists, lists of defaulters, search and register functions, automated monthly reports, and linkages to birth notifications and the national identity system.

CONCLUSIONS

Reducing dual documentation for users can improve e-Tracker use and user satisfaction. Our findings can help identify additional digital health interventions to support and strengthen the health information system for the immunization program.

Emerging Trends of Gold Nanostructures for Point-of-Care Biosensor-Based Detection of COVID-19

In 2019, a worldwide pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged. SARS-CoV-2 is the deadly microorganism responsible for coronavirus disease 2019 (COVID-19), which has caused millions of deaths and irreversible health problems worldwide. To restrict the spread of SARS-CoV-2, accurate detection of COVID-19 is essential for the identification and control of infected cases. Although recent detection technologies such as the real-time polymerase chain reaction delivers an accurate diagnosis of SARS-CoV-2, they require a long processing duration, expensive equipment, and highly skilled personnel. Therefore, a rapid diagnosis with accurate results is indispensable to offer effective disease suppression. Nanotechnology is the backbone of current science and technology developments including nanoparticles (NPs) that can biomimic the corona and develop deep interaction with its proteins because of their identical structures on the nanoscale. Various NPs have been extensively applied in numerous medical applications, including implants, biosensors, drug delivery, and bioimaging. Among them, point-of-care biosensors mediated with gold nanoparticles (GNPSs) have received great attention due to their accurate sensing characteristics, which are widely used in the detection of amino acids, enzymes, DNA, and RNA in samples. GNPS have reconstructed the biomedical application of biosensors because of its outstanding physicochemical characteristics. This review provides an overview of emerging trends in GNP-mediated point-of-care biosensor strategies for diagnosing various mutated forms of human coronaviruses that incorporate different transducers and biomarkers. The review also specifically highlights trends in gold nanobiosensors for coronavirus detection, ranging from the initial COVID-19 outbreak to its subsequent evolution into a pandemic.

Digital Gamification Tools to Enhance Vaccine Uptake: Scoping Review

BACKGROUND

Gamification has been used successfully to promote various desired health behaviors. Previous studies have used gamification to achieve desired health behaviors or facilitate their learning about health.

OBJECTIVE

In this scoping review, we aimed to describe digital gamified tools that have been implemented or evaluated across various populations to encourage vaccination, as well as any reported effects of identified tools.

METHODS

We searched Medline, Embase, CINAHL, the Web of Science Core Collection, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, Academic Search Premier, PsycInfo, Global Health, and ERIC for peer-reviewed papers describing digital gamified tools with or without evaluations. We also conducted web searches with Google to identify digital gamified tools lacking associated publications. We consulted 12 experts in the field of gamification and health behavior to identify any papers or tools we might have missed. We extracted data about the target population of the tools, the interventions themselves (eg, type of digital gamified tool platform, type of disease/vaccine, type and design of study), and any effects of evaluated tools, and we synthesized data narratively.

RESULTS

Of 1402 records, we included 28 (2%) peer-reviewed papers and 10 digital gamified tools lacking associated publications. The experts added 1 digital gamified tool that met the inclusion criteria. Our final data set therefore included 28 peer-reviewed papers and 11 digital gamified tools. Of the 28 peer-reviewed papers, 7 (25%) explained the development of the tool, 16 (57%) described evaluation, and 2 (7%) reported both development and evaluation of the tool. The 28 peer-reviewed papers reported on 25 different tools. Of these 25 digital gamified tools, 11 (44%) were web-based tools, 8 (32%) mobile (native mobile or mobile-enabled web) apps, and 6 (24%) virtual reality tools. Overall, tools that were evaluated showed increases in knowledge and intentions to receive vaccines, mixed effects on attitudes, and positive effects on beliefs. We did not observe discernible advantages of one type of digital gamified tool (web based, mobile, virtual reality) over the others. However, a few studies were randomized controlled trials, and publication bias may have led to such positive effects having a higher likelihood of appearing in the peer-reviewed literature.

CONCLUSIONS

Digital gamified tools appear to have potential for improving vaccine uptake by fostering positive beliefs and increasing vaccine-related knowledge and intentions. Encouraging comparative studies of different features or different types of digital gamified tools could advance the field by identifying features or types of tools that yield more positive effects across populations and contexts. Further work in this area should seek to inform the implementation of gamification for vaccine acceptance and promote effective health communication, thus yielding meaningful health and social impacts.

Go.Data as a digital tool for case investigation and contact tracing in the context of COVID-19: a mixed-methods study

BACKGROUND

A manual approach to case investigation and contact tracing can introduce delays in response and challenges for field teams. Go.Data, an outbreak response tool developed by the World Health Organization (WHO) in collaboration with the Global Outbreak Alert and Response Network, streamlines data collection and analysis during outbreaks. This study aimed to characterize Go.Data use during COVID-19, elicit shared benefits and challenges, and highlight key opportunities for enhancement.

METHODS

This study utilized mixed methods through qualitative interviews and a quantitative survey with Go.Data implementors on their experiences during COVID-19. Survey data was analyzed for basic univariate statistics. Interview data were coded using deductive and inductive reasoning and thematic analysis of categories. Overarching themes were triangulated with survey data to clarify key findings.

RESULTS

From April to June 2022, the research team conducted 33 interviews and collected 41 survey responses. Participants were distributed across all six WHO regions and 28 countries. While most implementations represented government actors at national or subnational levels, additional inputs were collected from United Nations agencies and universities. Results highlighted WHO endorsement, accessibility, adaptability, and flexible support modalities as main enabling factors. Formalization and standardization of data systems and people processes to prepare for future outbreaks were a welcomed byproduct of implementation, as 76% used paper-based reporting prior and benefited from increased coordination around a shared platform. Several challenges surfaced, including shortage of the appropriate personnel and skill-mix within teams to ensure smooth implementation. Among opportunities for enhancements were improved product documentation and features to improve usability with large data volumes.

CONCLUSIONS

This study was the first to provide a comprehensive picture of Go.Data implementations during COVID-19 and what joint lessons could be learned. It ultimately demonstrated that Go.Data was a useful complement to responses across diverse contexts, and helped set a reproducible foundation for future outbreaks. Concerted preparedness efforts across the domains of workforce composition, data architecture and political sensitization should be prioritized as key ingredients for future Go.Data implementations. While major developments in Go.Data functionality have addressed some key gaps highlighted during the pandemic, continued dialogue between WHO and implementors, including cross-country experience sharing, is needed ensure the tool is reactive to evolving user needs.

So Many Choices, How Do I Choose? Considerations for Selecting Digital Health Interventions to Support Immunization Confidence and Demand

Childhood vaccines are a safe, effective, and essential component of any comprehensive public health system. Successful and complete child immunization requires sensitivity and responsiveness to community needs and concerns while reducing barriers to access and providing respectful quality services. Community demand for immunization is influenced by multiple complex factors, involving attitudes, trust, and the dynamic relationship between caregivers and health workers. Digital health interventions have the potential to help reduce barriers and enhance opportunities for immunization access, uptake, and demand in low- and middle-income countries. But with limited evidence and many interventions to choose from, how do decision makers identify promising and appropriate tools? Early evidence and experiences with digital health interventions for immunization demand are presented in this viewpoint to help stakeholders make decisions, guide investment, coordinate efforts, as well as design and implement digital health interventions to support vaccine confidence and demand.

Informing the design of a whole of life immunisation register for Australia

INTRODUCTION

In 2016, Australia launched a whole life immunisation register, the Australian Immunisation Register (AIR), building on a universal childhood register established in 1997. Immunisation Information Systems are well established in Europe, the US and elsewhere. However, a national system covering immunisation across the lifespan, with complete capture of the population and satisfactory data quality, is rare.

METHODS

A national workshop was convened in 2016 with key stakeholders from the government, new and existing vaccine users, and vaccine providers to review the ideal features of the AIR to ensure optimal effectiveness. This workshop focused on the functionality needed to identify population groups newly included in the register and support the achievement of high immunisation coverage in these groups eligible for National Immunisation Program vaccines.

RESULTS

Key recommendations included the need for bidirectional data flow between the AIR and providers; systematic approaches to the capture and recording of accurate and complete data to ascertain important denominators for subpopulations, includingAboriginal and Torres Strait Islander status, medical risk factors, occupation, ethnicity, country of birth, and vaccines given during pregnancy; linkage with other government datasets including notifiable diseases; the capture of adverse events following immunisation; ease of access by patients, providers; and by researchers.

CONCLUSIONS

Some recommendations from the workshop have informed the development and future utility of the AIR. Some recommendations from the workshop have been integrated into the current iteration of the AIR, which is more important than ever given the roll-out of COVID-19 vaccines. The accuracy and validity of data have subsequently improved through data entry controls, data integrity checks and reporting requirements. Access to AIR data for research remains protracted and costly, limitingresearch potential.

Design, Development, and Deployment of an Electronic Immunization Registry: Experiences From Vietnam, Tanzania, and Zambia

INTRODUCTION

There is growing interest among low- and middle-income countries to introduce electronic immunization registries (EIRs) that capture individual-level vaccine data. We compare the design, development, and deployment of EIRs in Vietnam, Tanzania, and Zambia. Through desk review and the authors' firsthand implementation experiences, we describe experiences related to timeline, partnerships, financial costs, and technology and infrastructure.

IMPLEMENTATION EXPERIENCE

The country cases highlight the multi-year timeline required to implement an EIR at scale and the benefit of multiple iterative cycles to pilot and redesign the system before achieving scale. Of the 3 countries, only Vietnam has achieved nationwide scale of the EIR, which took 7 years. In all 3 countries, national government leadership as part of an interdisciplinary team (with experience in leadership, technology, and immunization) was important to ensure country ownership and sustainability. Where international software developers were contracted, partnering with a local software company helped improve responsiveness and sustainability. Across all 3 countries, governments contributed significant in-kind time in addition to investments from donors. Cost savings were observed in Tanzania and Zambia, largely driven by health worker time savings from using the EIR. All 3 case countries underscore the need to understand the local technology and infrastructure context and design the EIR to fit the context. In Vietnam, an initial landscape assessment was conducted to assess technology and infrastructure, whereas in Tanzania and Zambia, user advisory groups provided insights. Existing infrastructure informed EIR design decisions, such as choosing a system with offline functionality in Tanzania and Zambia. All 3 countries have a local partner to provide ongoing technical support.

CONCLUSION

Comparing implementation factors across these cases highlights practical experience and recommendations that complement existing EIR guidance documents. The findings and recommendations from this study can inform other countries considering or in the process of implementing an EIR.

BNT162b2 COVID-19 Vaccine Safety among Healthcare Workers of a Tertiary Hospital in Italy

Millions of people have died because of the COVID-19 pandemic. The vaccination campaign helped tackle the pandemic and saved millions of lives. In a retrospective pharmacovigilance study, we explored the safety of the BNT162b2 (Comirnaty) vaccine among healthcare workers (HCWs) in a large Italian teaching hospital, and 2428 Adverse Events Reports (AERs) filed by HCWs after the administration of the first dose of vaccine were collected and analyzed, reporting the results quantitively and comparing them to the vaccine Summary of Product Characteristics (SPC). Spearman's correlation coefficients were computed to investigate the correlation among reported adverse effects, and recurrent clusters of symptoms were investigated through the Principal Component Analysis (PCA) and k-means Cluster Analysis. The BNT162b2 vaccine's safety profile was favorable, with predominant reports of early onset, mild, non-serious and short-term resolved symptoms. We observed higher than the expected frequency for various non-serious undesirable effects, especially among those listed and classified as less common in the SPC. Furthermore, we identified three clusters of adverse effects that were frequently reported together, defined by the presence/absence of fatigue, malaise, localized pain, chills, pyrexia, insomnia, nausea and injection site pain. Post-marketing pharmacovigilance activities, together with targeted public health interventions, can be valuable tools to promote vaccination and improve the control of the spread of the pandemic, especially in sensitive settings and populations such as hospitals and healthcare professionals.

Effects of vaccine registration on disease prophylaxis: a systematic review

BACKGROUND

The impact of the pandemic caused by the coronavirus (SARS-CoV-2), causing the disease COVID-19, has brought losses to the world in terms of deaths, economic and health problems. The expected return of the public to activities adapted to the new health situation led to discussions about the use of vaccination and its effects. However, the demand for proof of vaccination showed how inconsistent, unregistered, and uncontrolled this health process is with current technologies. Despite the proven effectiveness of vaccines in reducing infection rates, mortality, and morbidity, there are still doubts about their use in preventing certain infections and injuries, as well as the use of digital medical records for identification at public events and disease prevention. Therefore, this review aims to analyze the use of digital immunization cards in disease prevention in general.

METHODS

A systematic review of Science, PubMed/MEDLINE, LILACS /BSV, CINALH, and IEEE and Xplore was performed using PRISMA guidelines. The authors summarized the studies conducted over the last decade on the impacts of prophylaxis by control through immunization cards. Studies were selected using the following terms: Vaccination; Mobile Applications; Health Smarts Cards; Immunization Programs; Vaccination Coverage. For data analysis, we used Mendeley, Excel, RStudio, and Bibliometrix software among others.

RESULTS

A total of 1828 publications were found. After applying eligibility criteria (Articles published in Portuguese, Spanish or English in the last 10 years). Studies that only dealt with paper or physical records were excluded, as well as studies that were not linked to their country's health Department, as a possibility of bias exists with these types of information). After removing duplicates and applying filters 1 and 2, we included 18 studies in this review. This resulted in 18 papers that met our priori inclusion criteria; it was found that the most relevant sources were from the databases of the Institute of Electrical and Electronics Engineers (IEEE).

CONCLUSIONS

Considering the selected studies, we found that scientific evidence and epidemiological surveillance are essential tools to characterize the efficiency and effectiveness of immunization passport protection intervention and to ethically justify them. Technological development of digital vaccine passports can assist in vaccination programs and positively impact disease prophylaxis.

A scoping review of active, participant-centred, digital adverse events following immunization (AEFI) surveillance: A Canadian immunization research network study

BACKGROUND

Post-licensure adverse events following immunization (AEFI) surveillance is conducted to monitor vaccine safety, such as identifying batch/brand issues and rare reactions, which consequently improves community confidence. The integration of technology has been proposed to improve AEFI surveillance, however, there is an absence of description regarding which digital solutions are successfully being used and their unique characteristics.

OBJECTIVES

The objectives of this scoping review were to 1) map the research landscape on digital systems used for active, participant-centred, AEFI surveillance and 2) describe their core components.

METHODS

We conducted a scoping review informed by the PRISMA Extension for Scoping Reviews (PRSIMA-ScR) guideline. OVID-Medline, Embase Classic + Embase, and Medrxiv were searched by a medical librarian from January 1, 2000 to January 28th, 2021. Two independent reviewers determined which studies met inclusion based on pre-specified eligibility criteria. Data extraction was conducted using pre-made tables with specific variables by one investigator and verified by a second.

RESULTS

Twenty-seven publications met inclusion, the majority of which came from Australia (n = 15) and Canada (n = 6). The most studied active, participant-centred, digital AEFI surveillance systems were SmartVax (n = 8) (Australia), Vaxtracker (n = 7) (Australia), and Canadian National Vaccine Safety (CANVAS) Network (Canada) (n = 6). The two most common methods of communicating with vaccinees reported were short-message-service (SMS) (n = 15) and e-mail (n = 14), with online questionnaires being the primary method of data collection (n = 20).

CONCLUSION

Active, participant-centred, digital AEFI surveillance is an area actively being researched as depicted by the literature landscape mapped by this scoping reviewWe hypothesize that the AEFI surveillance approach herein described could become a primary method of collecting self-reported subjective symptoms and reactogenicity from vaccinees, complementing existing systems. Future evaluation of identified digital solutions is necessary to bring about improvements to current vaccine surveillance systems to meet contemporary and future public health needs.

The Use of Digital Technologies to Support Vaccination Programmes in Europe: State of the Art and Best Practices from Experts' Interviews

Digitalisation offers great potential to improve vaccine uptake, supporting the need for effective life-course immunisation services. We conducted semi-structured in-depth interviews with public health experts from 10 Western European countries (Germany, Greece, Italy, Luxembourg, Malta, the Netherlands, Norway, Poland, Portugal, and the United Kingdom) to assess the current level of digitalisation in immunisation programmes and retrieve data on interventions and best practices. Interviews were performed using an ad hoc questionnaire, piloted on a sample of national experts. We report a mixed level of digital technologies deployment within vaccination services across Europe: Some countries are currently developing eHealth strategies, while others have already put in place robust programmes. Institutional websites, educational videos, and electronic immunisation records are the most frequently adopted digital tools. Webinars and dashboards represent valuable resources to train and support healthcare professionals in immunisation services organisation. Text messages, email-based communication, and smartphone apps use is scattered across Europe. The main reported barrier to the implementation of digital-based programmes is the lack of resources and shared standards. Our study offers a comprehensive picture of the European context and shows the need for robust collaboration between states and international institutions to share best practices and inform the planning of digital intervention models with the aim of countering vaccine hesitancy and increasing vaccine uptake.

Telemedicine and Virtual Reality at Time of COVID-19 Pandemic: An Overview for Future Perspectives in Neurorehabilitation

In catastrophic situations such as pandemics, patients' healthcare including admissions to hospitals and emergency services are challenged by the risk of infection and by limitations of healthcare resources. In such a setting, the use of telemedicine interventions has become extremely important. New technologies have proved helpful in pandemics as a solution to improve the quality of life in vulnerable patients such as persons with neurological diseases. Moreover, telemedicine interventions provide at-home solutions allowing clinicians to telemonitor and assess patients remotely, thus minimizing risk of infection. After a review of different studies using telemedicine in neurological patients, we propose a telemedicine process flow for healthcare of subjects with chronic neurological disease to respond to the new challenges for delivering quality healthcare during the transformation of public and private healthcare organizations around the world forced by COVID-19 pandemic contingency. This telemedicine process flow represents a replacement for in-person treatment and thereby the provision equitable access to the care of vulnerable people. It is conceptualized as comprehensive service including (1) teleassistance with patient counseling and medical treatment, (2) telemonitoring of patients' health conditions and any changes over time, as well as (3) telerehabilitation, i.e., interventions to assess and promote body functions, activities, and consecutively participation. The hereby proposed telemedicine process flow could be adopted on a large scale to improve the public health response during healthcare crises like the COVID-19 pandemic but could equally promote equitable health care independent of people's mobility or location with respect to the specialized health care center.

Acceptability, Barriers and Facilitators of Mobile Text Message Reminder System Implementation in Improving Child Vaccination: A Qualitative Study in Northwest Ethiopia

Background

Mobile phone text message-based mHealth interventions have shown promise in improving health service delivery. Despite the promising findings at a small scale and few contexts, implementing new technologies as part of changes to health care services is inherently challenging. Though there is a potential to introduce mHealth initiatives to health systems of developing countries, existing evidence on the barriers and facilitators of implementation in different contexts is not adequate. Therefore, this study aimed to explore the acceptability, barriers and facilitators of implementing mobile text message reminder system for child vaccination in Ethiopia.

Methods

This study applied a phenomenological study design. The study was conducted in north-west, Ethiopia between July 28 and August 19, 2020. A total of 23 participants were purposively selected for the in-depth and key informant interviews. We used an interview guide to collect data and audio-records of interviews were transcribed verbatim. Coding was done to identify patterns and thematic analysis was conducted using ATLAS ti7 software.

Results

The findings indicated that mothers were receptive to mobile text message reminders for their child’s vaccination. Low mobile phone ownership, access to mobile network, access to electricity and illiteracy among the target population were identified as barriers that would affect implementation. Confidentiality and security-related issues are not barriers to implementation of text message reminders for child vaccination service. Facilitators for implementation include stakeholder collaboration, providing orientation/training to users, and willingness to pay by clients.

Conclusion

In this study, using mobile phone text message reminders for child vaccination services are acceptable by clients. Barriers identified were related to inadequate ICT infrastructure and other technical issues. Addressing the potential barriers and leveraging the existing opportunities could optimize the implementation in resource-limited settings. Before actual implementation, program implementers should also consider providing orientation to users on the proposed mHealth program.

Cognitive Telerehabilitation for Older Adults With Neurodegenerative Diseases in the COVID-19 Era: A Perspective Study

The COVID-19 pandemic is a global health problem that is radically transforming public and private healthcare organizations around the world, negatively affecting the rehabilitative treatments of non-COVID pathologies as well. In this situation, it becomes crucial to be able to guarantee the continuity of care also to all those patients with neurodegenerative diseases unable to reach healthcare services. Remote communication technologies are gaining momentum as potentially effective options to support health care interventions-including cognitive rehabilitation-while patients can stay safely at home. In this context, we are implementing HomeCoRe (i.e., Home Cognitive Rehabilitation software) in order to offer an innovative approach and a valid support for home-based cognitive rehabilitation in neurodegenerative diseases, such as mild cognitive impairment and early dementia. HomeCoRe has been developed within a research project between engineers and clinicians in order to obtain a usable and safe cognitive rehabilitation tool. This software has multiple advantages for patients and therapists over traditional approaches, as shown in its use in hospital settings. HomeCoRe could then represent an opportunity for accessing cognitive rehabilitation in all those situations where patients and therapists are not in the same location due to particular restrictions, such as COVID-19 pandemic.

Consumer acceptability and validity of m-Health for the detection of adverse events following immunization - The Stimulated Telephone Assisted Rapid Safety Surveillance (STARSS) randomised control trial

INTRODUCTION

Monitoring for adverse events following immunisation (AEFI) is critical for vaccine pharmacovigilance. Given the global and expanding availability of mobile phones their utility for consumer-based vaccine safety surveillance is of interest but little is known about consumer acceptability. This study nested within the Stimulated Telephone Assisted Rapid Safety Surveillance (STARSS) randomised control trial sought to evaluate the acceptability of SMS for AEFI surveillance.

METHODS

The primary STARSS study was a multi-centre RCT evaluating the efficacy of repeated SMS prompts for AEFI surveillance with participants being adult vaccinees or parents of children receiving any vaccine. This nested study enrolled primary RCT participants who completed a detailed computer assisted telephone interview to determine their attitudes towards SMS-based surveillance and ascertain their knowledge and attitudes toward vaccine safety, efficacy, data privacy and use of electronic health records. Attitudes to surveillance and related behaviour were used as measures of acceptability.

RESULTS

20% (1200/6555) of the participants were enrolled and 1139 completed the full-length questionnaire. 96% indicated that SMS-based surveillance after immunisation to check the safety of the vaccine "should be done" but 62% of all respondents said it should be done but consent should be sought first. Neither vaccine safety attitudes nor attitudes toward privacy were associated with opposition to SMS-based surveillance. In terms of SMS related behaviour demographic rather than attitudinal factors were associated with non-compliance.

CONCLUSION

Overall, the attitude towards SMS-based surveillance was very favourable. Experiencing the SMS surveillance has the effect of reducing opposition to an SMS surveillance system, and at the same time increasing the likelihood of a preference for prior consent. Detection of a vaccine safety signal could be impeded in particular demographic groups who are non-compliant and we should undertake further research to understand why these groups are non-compliant and how this can be improved.

Efficacy of m-Health for the detection of adverse events following immunization - The stimulated telephone assisted rapid safety surveillance (STARSS) randomised control trial

INTRODUCTION

Passive surveillance is recommended globally for the detection of adverse events following immunisation (AEFI) but this has significant challenges. Use of Mobile health for vaccine safety surveillance enables a consumer-centred approach to reporting. The Stimulated Telephone Assisted Rapid Safety Surveillance (STARSS) a randomised control trial (RCT) sought to evaluate the efficacy and acceptability of SMS for AEFI surveillance.

METHODS

Multi-centre RCT, participants were adult vaccinees or parents of children receiving any vaccine at a trial site. At enrolment randomisation occurred to one of two SMS groups or a control group. Prompts on days 2, 7 and 14 post-immunisation, were sent to the SMS group, to ascertain if a medical event following immunisation (MEFI) had occurred. No SMS's were sent to the control participants. Those in the SMS who notified an MEFI were pre-randomised to complete a computer assisted telephone interview or a web based report to determine if an AEFI had occurred whilst an AEFI in the controls was determined by a search for passive reports. The primary outcome was the AEFI detection rate in the SMS group compared to controls.

RESULTS

We enrolled 6,338 participants, who were equally distributed across groups and who received 11,675 vaccines. The SMS group (4,225) received 12,675 surveillance prompts with 9.8% being non-compliant and not responding. In those that responded 90% indicated that no MEFI had been experienced and 184 had a verified AEFI. 6 control subjects had a reported AEFI. The AEFI detection rate was 13 fold greater in the SMS group when compared with controls (4.3 vs 0.3%).

CONCLUSION

We have demonstrated that the STARSS methodology improves AEFI detection. Our findings should inform the wider use of SMS-based surveillance which is particularly relevant since establishing robust and novel pharmacovigilance systems is critical to monitoring novel vaccines which includes potential COVID vaccines.

The digital immunization system of the future: imagining a patient-centric, interoperable immunization information system

To ensure the effectiveness of increasingly complex immunization programs in upper-middle and high-income settings, comprehensive information systems are needed to track immunization uptake at individual and population levels. The maturity of cloud systems and mobile technologies has created new possibilities for immunization information systems. In this paper, we describe a vision for the next generation of digital immunization information systems for upper-middle and high-income settings based on our experience in Canada. These systems center on the premise that the public is engaged and informed about the immunization process beyond their interaction with primary care, and that they will be a contributor and auditor of immunization data. The digital immunization system of the future will facilitate reporting of adverse events following immunization, issue digital immunization receipts, permit identification of areas of need and allow for delivery of interventions targeting these areas. Through features like immunization reminders and targeted immunization promotion campaigns, the system will reduce many of the known barriers that influence immunization rates. In light of the global COVID-19 pandemic, adaptive digital public health information systems will be required to guide the rollout and post-market surveillance of the SARS-CoV-2 vaccine.

Determinants of Facility-Level Use of Electronic Immunization Registries in Tanzania and Zambia: An Observational Analysis

We provide a framework to quantify the use of electronic immunization registry systems at the facility level and results show the importance of behavioral and organizational factors in explaining their sustained use in Tanzania and Zambia.

Background:

As more countries transition from paper-based to electronic immunization registries (EIRs) to collect and track individual immunization data, guidance is needed for successful adoption and use of these systems. Little research is available on the determinants of EIR use soon after introduction. This observational study assesses the determinants of facility health care workers’ use of new EIRs in Tanzania and Zambia, implemented during 2016 to 2018.

Methods:

We used EIR data entered between 2016 and 2018 from 3 regions in Tanzania and 1 province in Zambia to measure weekly EIR system use for a total of 50,639 facility-weeks. We joined secondary data on facility characteristics and applied the Performance of Routine Information System Management framework to categorize characteristics as organizational, technical, or behavioral. We used a generalized estimating equations logistic regression model to assess facility characteristics as potential determinants of system use.

Results:

In both countries, the estimated odds of weekly EIR use declined weekly after EIR introduction. In Tanzania, health centers and hospitals had increased odds of system use compared to dispensaries. For each additional health care worker trained in a facility during the EIR introduction, the estimated odds of weekly EIR use increased. Tanzanian facilities that had transitioned entirely to paperless reporting had higher odds of sustained use compared to those maintaining parallel electronic and paper-based reporting systems. In Zambia, distance from the district health office was significantly associated with decreasing odds of system use. There were significant differences in EIR use by district in both countries.

Discussion:

The results highlight the importance of organizational and behavioral factors in explaining sustained EIR use. As EIRs are introduced in new settings, we recommend indicators of engagement and use be built directly into the system so they can be routinely monitored, and course corrections can be implemented as needed.

Determinants of Scale-up From a Small Pilot to a National Electronic Immunization Registry in Vietnam: Qualitative Evaluation

Background

Digital health innovations can improve health system performance, yet previous experience has shown that many innovations do not advance beyond the pilot stage to achieve scale. Vietnam’s National Immunization Information System (NIIS) began as a series of digital health pilots, first initiated in 2010, and was officially launched nationwide in 2017. The NIIS is one of the few examples of an electronic immunization registry (EIR) at national scale in low- and middle-income countries.

Objective

The aim of this study was to understand the determinants of scale-up of the national EIR in Vietnam.

Methods

This qualitative study explored the facilitators and barriers to national scale-up of the EIR in Vietnam. Qualitative data were collected from October to December 2019 through in-depth key informant interviews and desk review. The mHealth Assessment and Planning for Scale (MAPS) Toolkit guided the development of the study design, interview guides, and analytic framework. MAPS defines the key determinants of success, or the “axes of scale,” to be groundwork, partnerships, financial health, technology and architecture, operations, and monitoring and evaluation.

Results

The partnership and operations axes were critical to the successful scale-up of the EIR in Vietnam, while the groundwork and monitoring and the evaluation axes were considered to be strong contributors in the success of all the other axes. The partnership model leveraged complementary strengths of the technical working group partners: the Ministry of Health General Department of Preventive Medicine, the National Expanded Program on Immunization, Viettel (the mobile network operator), and PATH. The operational approach to introducing the NIIS with lean, iterative, and integrated training and supervision was also a key facilitator to successful scale-up. The financial health, technology and architecture, and operations axes were identified as barriers to successful deployment and scale-up. Key barriers to scale-up included insufficient estimates of operational costs, unanticipated volume of data storage and transmission, lack of a national ID to support interoperability, and operational challenges among end users. Overall, the multiple phases of EIR deployment and scale-up from 2010 to 2017 allowed for continuous learning and improvement that strengthened all the axes and contributed to successful scale-up.

Conclusions

The results highlight the importance of the measured, iterative approach that was taken to gradually expand a series of small pilots to nationwide scale. The findings from this study can be used to inform other countries considering, introducing, or in the process of scaling an EIR or other digital health innovations.

Does the use of personal electronic health records increase vaccine uptake? A systematic review

BACKGROUND

Although Personal Electronic Health Records (PEHR) have been identified as innovative tools enabling the provision of patient-centered care and prevention, evidence on the impact of their use is scant. With PEHRs being more and more marketed as easily implementable and cost-effective instruments to provide people with direct control on their health, the question on whether their use might be associated with the priority to improve vaccine coverage arises.

METHODS

We conducted a systematic review following the PRISMA guidelines to retrieve, quantitatively pool and critically appraise the effectiveness of PEHR access on vaccine uptake. Analysis on PEHR effectiveness were carried out for the following comparison strata: i) PEHR access vs no intervention (standard care, no access to PEHR), ii) PEHR access only vs access to PEHR with additional features (e.g. health education materials, active reminders).

RESULTS

Of 3114 identified citations, 8 studies were included, the majority published in the US and before 2015; 62% were randomized trials, the rest having an observational study design. Evidence suggests a moderate positive impact of PEHR access in increasing vaccine uptake, with data available for influenza and pneumococcal vaccines, diabetic patients and childhood immunization. Pooled data report the addition of digital communication features, i.e. the delivery of educational messages, reminders and availability of scheduling features might increase vaccine uptake, as compared to PEHR access alone. However, evidence is not conclusive.

CONCLUSION

While immunization programs are struggling to achieve optimal coverage targets, it seems the potential of PEHRSs supporting informed adherence to vaccines recommendations is neither fully exploited nor explored. Which factors mediate the association between PEHRs access and vaccine uptake? Which PEHRs' design and functional components can maximize their impact? On which target populations? Which PEHR models works better for high-risk populations? Our findings can only partially answer those questions and further experimental research is needed.

Digital Gamification to Enhance Vaccine Knowledge and Uptake: Scoping Review

Background

Vaccine hesitancy is a growing threat to population health, and effective interventions are needed to reduce its frequency. Digital gamification is a promising new approach to tackle this public health issue.

Objective

The purpose of this scoping review was to assess the amount and quality of outcomes in studies evaluating gamified digital tools created to increase vaccine knowledge and uptake.

Methods

We searched for peer-reviewed articles published between July 2009 and August 2019 in PubMed, Google Scholar, Journal of Medical Internet Research, PsycINFO, PsycARTICLES, Psychology and Behavioral Sciences Collection, and SocINDEX. Studies were coded by author, year of publication, country, journal, research design, sample size and characteristics, type of vaccine, theory used, game content, game modality, gamification element(s), data analysis, type of outcomes, and mean quality score. Outcomes were synthesized through the textual narrative synthesis method.

Results

A total of 7 articles met the inclusion criteria and were critically reviewed. Game modalities and gamification elements were diverse, but role play and a reward system were present in all studies. These articles included a mixture of randomized controlled trials, quasi-experimental studies, and studies comprising quantitative and qualitative measures. The majority of the studies were theory-driven. All the identified gamified digital tools were highly appreciated for their usability and were effective in increasing awareness of vaccine benefits and motivation for vaccine uptake.

Conclusions

Despite the relative paucity of studies on this topic, this scoping review suggests that digital gamification has strong potential for increasing vaccination knowledge and, eventually, vaccination coverage.

Estimating the effectiveness of vaccine programs in dog populations

Dogs harbor numerous zoonotic pathogens, many of which are controlled through vaccination programs. The delivery of these programs can be difficult where resources are limited. We developed a dynamic model to estimate vaccination coverage and cost-per-dog vaccinated. The model considers the main factors that affect vaccination programs: dog demographics, effectiveness of strategies, efficacy of interventions and cost. The model was evaluated on data from 18 vaccination programs representing eight countries. Sensitivity analysis was performed for dog confinement and vaccination strategies. The average difference between modelled vaccination coverage and field data was 3.8% (2.3%–5.3%). Central point vaccination was the most cost-effective vaccination strategy when >88% of the dog population was confined. More active methods of vaccination, such as door-to-door or capture-vaccinate-release, achieved higher vaccination coverage in free-roaming dog populations but were more costly. This open-access tool can aid in planning more efficient vaccination campaigns in countries with limited resources.

Retrospective Review of Documentation Practices of Hepatitis B Immunoglobulin, Birth Dose, and Vaccination at the Hospital of Birth, in Thai Nationals and Migrants in Northern Thailand

Background

Vaccination remains the mainstay of prevention of hepatitis B virus (HBV) including birth dose and hepatitis B immunoglobulins (HBIGs). National estimates of vaccination coverage exclude migrants. The objective of this study is to investigate documentation practices of HBV-related infant vaccinations in Northern Thailand including migrants.

Methods

This is a retrospective review of hospital records of women who birthed infants in 2015 at Maharaj Nakorn Hospital, Chiang Mai (CM) or on the Thailand-Myanmar border, Tak.

Results

Of 2522 women, 987 were from CM (861 Thai nationals, 126 migrants) and 1535 were from Tak (651 Thai residence and 884 Myanmar residence). In CM, documentation for the birth dose vaccine (999 of 999, 100%) and HBIG was complete. In Tak, documentation was 1441 of 1549 (93%) for birth dose and 26 of 34 (76.5%) for HBIG, with missed opportunities including home delivery, delay in obtaining hepatitis B e-antigen status, and limitations of the records. Expanded Program of Immunization (EPI) documentation of 3 follow-up vaccinations dwindled with subsequent doses and distance, and complete documentation of 3 HBV EPI vaccines at the hospital of birth was low, 41.5% (1056 of 2547), but equitable for Thai or migrant status.

Conclusions

This review provides strong support for excellent documentation of HBIG and birth dose vaccination in urban and rural settings, and in migrants, consistent with Thailand's vaccination policy and practice. Documentation of the 3 HBV EPI at the hospital of birth decreases with sequential doses, especially in families further away. Innovative data linkage is required to prove coverage and identify gaps.

Countering vaccine hesitancy through immunization information systems, a narrative review

Immunization is one of the most important public health interventions to contrast infectious disease; however, many people nowadays refuse vaccination. Vaccine hesitancy (VH) is due to several factors that influence the complex decision-making process. Information technology tools might play an important role in vaccination programs. In particular, immunization information systems (IISs) have the potential to improve performance of vaccination programs and to increase vaccine uptake. This review aimed to present IIS functionalities in order to counter VH. In detail, we analyzed the automatic reminder/recall system, the interoperability of the system, the decision support system, the web page interface and the possibility to record adverse events following immunization. IIS could concretely represent a valid instrument to increase vaccine confidence, especially trust in both health-care workers and decision makers. There are not enough trials aimed to evaluate the efficacy of IIS to counter VH. Further researches might focalize on this aspect.

Understanding the use of digital technology to promote human papillomavirus vaccination - A RE-AIM framework approach

The human papillomavirus virus (HPV) vaccine is effective at preventing various cancers, but coverage falls short of targets that are needed for community protection. Here, we use the RE-AIM implementation framework (Reach, Effectiveness, Adoption, Implementation, Maintenance) to understand how text, email, and electronic health record (EHR) reminders and social media campaigns can be used as part of policy and practice interventions to increase HPV vaccination. These technology-based interventions could be used together and mainstreamed into clinical and system-based practice to have the greatest impact. Of the interventions explored, text-based, email-based, and EHR reminders have the most evidence behind them to support their effectiveness. While there are several studies of promotion of the HPV vaccine on social media, more studies are needed to demonstrate their effects and better methods are needed to be able to attribute results to these interventions.

The use of technology to promote vaccination: A social ecological model based framework

Vaccinations are an important and effective cornerstone of preventive medical care. Growing technologic capabilities and use by both patients and providers present critical opportunities to leverage these tools to improve vaccination rates and public health. We propose the Social Ecological Model as a useful theoretical framework to identify areas in which technology has been or may be leveraged to target undervaccination across the individual, interpersonal, organizational, community, and society levels and the ways in which these levels interact.

Barriers to the success of an electronic pharmacovigilance reporting system in Kenya: an evaluation three years post implementation

Objective

Electronic pharmacovigilance reporting systems are being implemented in many developing countries in an effort to improve reporting rates. This study sought to establish the factors that acted as barriers to the success of an electronic pharmacovigilance reporting system in Kenya 3 years after its implementation.

Materials and Methods

Factors that could act as barriers to using electronic reporting systems were identified in a review of literature and then used to develop a survey questionnaire that was administered to pharmacists working in government hospitals in 6 counties in Kenya.

Results

The survey was completed by 103 out of the 115 targeted pharmacists (89.5%) and included free-text comments. The key factors identified as barriers were: unavailable, unreliable, or expensive Internet access; challenges associated with a hybrid system of paper and electronic reporting tools; and system usability issues. Coordination challenges at the national pharmacovigilance center and changes in the structure of health management in the country also had an impact on the success of the electronic reporting system.

Discussion

Different personal, organizational, infrastructural, and reporting system factors affect the success of electronic reporting systems in different ways, depending on the context. Context-specific formative evaluations are useful in establishing the performance of electronic reporting systems to identify problems and ensure that they achieve the desired objectives.

Conclusion

While several factors hindered the optimal use of the electronic pharmacovigilance reporting system in Kenya, all were considered modifiable. Effort should be directed toward tackling the identified issues in order to facilitate use and improve pharmacovigilance reporting rates.

Electronic Alerts Improve Immunization Rates in Two-month-old Premature Infants Hospitalized in the Neonatal Intensive Care Unit

OBJECTIVE

To determine if an electronic alert improves 2 month immunization rates in infants remaining hospitalized in the neonatal intensive care unit.

METHODS

Institutional Review Board-approved retrospective chart review of 261 infants with birth weights <2 kg and still hospitalized at ≥ 58 days. Charts were reviewed between 2009 and 2013, before and after the 2011 electronic alert was instituted in the electronic medical record from days 56 to 67 to remind providers that immunizations were due. Order and administration dates of two-month vaccine components (Diphtheria, Haemophilus influenza B, Hepatitis B, Pertussis, Pneumococcal, Polio, Tetanus) were determined, and infants were considered fully immunized, partially immunized, or unimmunized by day 90 or discharge, whichever came first.

RESULTS

After the alert, the timing of vaccine orders decreased from day 67 to day 61 (p<0.0001) and vaccine administration decreased from day 71 to day 64 (p<0.0001). Missing vaccine orders decreased from 14% [17/121] to 3% [4/140] (p=0.001) with missing administrations decreasing from 21% [26/121] to 4% [6/140] (p<0.0001). Fully immunized rates increased from 71% [86/121] to 94% [132/140] (p<0.0001).

CONCLUSIONS

A significant improvement in immunization rates in two-month-old infants in the neonatal intensive care unit occurred by 90 days after implementing an alert in the electronic medical record.

Use of m-Health in polio eradication and other immunization activities in developing countries

INTRODUCTION

Reaching the children that are chronically missed by routine immunization services has been a key pillar of success in achieving progress toward polio eradication. The rapid advancement and accessibility of mobile technology ("mHealth") in low and lower middle income countries provides an important opportunity to apply novel, innovative approaches to provide vaccine services. We sought to document the use and effectiveness of mHealth in immunization programs in low and lower middle income countries. We particularly focused on mHealth approaches used in polio eradication efforts by the Global Polio Eradication Initiative (GPEI) to leverage the knowledge and lessons learned that may be relevant for enhancing ongoing immunization services.

METHODS

In June 2016, the electronic database PubMed was searched for peer reviewed studies that focused on efforts to improve immunization programs (both ongoing immunization services and supplemental immunization activities or campaigns) through mobile technology in low and lower middle income countries.

RESULTS

The search yielded 317 papers of which 25 met the inclusion criteria. One additional article was included from the hand searching process. mHealth was used for reminder and recall, monitoring and surveillance, vaccine acceptance, and campaign strategic planning. Mobile phones were the most common mobile device used. Of the 26 studies, 21 of 26 studies (80.8%) reported that mHealth improved immunization efforts.

CONCLUSION

mHealth interventions can effectively enhance immunization services in low and lower middle income countries. With the growing capacity and access to mobile technology, mHealth can be a powerful and sustainable tool for enhancing the reach and impact of vaccine programs.