Early Infant Diagnosis Data Transmission System Using Mobile Phones in Zimbabwe 5-7 May, 2015 9th INTEREST Workshop Harare, Zimbabwe Henry Chidawanyika, MSc hchidawanyika@zimhisp.rti.org Rita Sembajwe, MSPH Ponesai Nyika RTI International is a trade name of Research Triangle Institute. www.rti.org
Presentation summary 2 Background Opportunities identified for implementing appropriate ICT solution in Early Infant Diagnosis (EID) system Technology considerations and selection SMS based early infant HIV diagnosis DNA PCR results transmission system (eeid) Positive outcomes of eeid Challenges Scale up and sustainability Conclusion
Project Overview Building Health Data Dissemination and Information Use Systems in the Republic of Zimbabwe also known as ZimHISP (Zimbabwe Health Information Support Program) 3
Project Overview Strengthening the Zimbabwe Ministry of Health and Child Care (MoHCC) with Health Information Systems through: Increasing capacity of MoHCC to independently coordinate and conduct effective HIS strengthening activities. Increasing health data dissemination and use for decision making at the national-, provincial-, district-, and facility-level. Strengthening information and communication technology (ICT) capacity to develop and maintain the national health information systems (DHIS2), patient-level systems, and other health information systems. 4
Background Early Infant Diagnosis (EID) system System for testing HIV exposed infants for HIV using DNA PCR as early as possible. Sample collected from infants at 6 weeks of age Dried Blood Spots (DBS) collected at health facility and sent to collection centers DBS collected by courier to national testing laboratories (NMRL, Mutare, Mpilo) 5
Background Early Infant Diagnosis (EID) system Captured in lab EID system Results verified and released in lab EID system Results printed in lab EID system and dispatched to collection centers Results collected by Health Institutions Results given to infants (care givers) 6
PMTCT DNA PCR EID Background 437347 Expected pregnancies per year 70133 Expected exposed infants per year (2013 estimates) 62014 HIV positive expecting mothers were identified 7 46192 EID DNA PCR samples of infants aged less than 2yrs were tested in 2014 (of which 33249 were for infants aged between 6-8wks)
Background DNA PCR EID Challenges Sample transportation challenges. Long results turnaround time (TAT) from collection of sample to giving results to infant (and take action) 8
Opportunities for SMS based results transmission system Programmatic Along the EID system chain there are stages that could benefit from use of appropriate ICT tools as follows: Pre-notification of laboratories of samples collected: Could potentially assist lab in planning workload; assist laboratory and health facility in tracking samples transmission Laboratory Information management system: Tracking of samples in the laboratory during processing (from reception to results printing) 9 Transmission of results from the laboratory to health facility: Could result in faster transmission of results to health facilities thereby reducing results TAT
Opportunities for SMS based results transmission system Programmatic: Notification of care givers when results are at health facility: Could result in faster and efficient communication with infant care givers (mothers) assisting in timely collection of results from health facilities thereby reducing results TAT 10
Opportunities for SMS based results transmission system ICT: Country already had laboratory information management system specifically designed for managing EID samples at the laboratory Country already had established electronic RDNS/WDSS using SMS based technology that was appropriate for use in remote facilities. Some factors and results from RDNS/WDSS that influenced the adoption of the eeid system. WHO: 2005 through 2011 timeliness and completeness of disease reporting oscillated below 40% and increased to more than 90% by 2014. 11
12 Opportunities for SMS based results transmission system ICT: Expanding mobile network coverage - around 2010 only 8.8% of rural health facilities had functional fixed-line telephones and only 11.3% had functional VHF radios. In 2011 more than 1200 health facilities had network coverage (excluding district / provincial / peri-urban and urban health facilities) Expanded the number of facilities reporting from about 600 in 2010 to 1600 in 2014 Establishment of DHIS2 as an online system and central data repository. Equipment in the form of RDNS/WDSS mobile phone already available and in use at health facilities
Opportunities for SMS based results transmission system Improvements in completeness of RDNS/WDSS 120 RDNS/WDSS Completeness 2010-2015 100 80 % 60 40 2015 2014 2013 2012 2011 2010 20 13 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 Weeks
14 Mobile Technology Selection for eeid/rdns/wdss Hardware considerations: Mobile phone (feature phone) Affordable (purchase and replacement) Mobile network compatibility User friendly Provision of electrical power Software considerations: Offline compatibility Technology USSD/GPRS/SMS (free, user formatted, etc) User friendly Open source Customizable Form completion vs unstructured/formatted SMS
15 Mobile Technology Selection for eeid/rnds/wdss Pilot for the technology GPRS based system Software Java Rosa, ODK Open Source Form based data entry Cheaper running cost(vs SMS) GPRS service not reliably available in more places Offline capability was limited SMS based system Software FrontlineSMS Open Source Form based data entry Higher running cost(vs GPRS) SMS service was reliably available in more places Offline capability good
Mobile Technology Selection for eeid/rnds/wdss FrontlineSMS version 1.7 Technology Desktop application with mobile client Automatic compression of SMS to save costs Automatic conversion of SMS to standard database Two-way mobile messaging Ability for client to download new forms 16
Mobile Technology Selection for eeid/rnds/wdss FrontlineSMS version 1.7 Technology Only registered phones allowed to connect Ability to store data when offline to send once online User friendly interface Compatible with feature phones (non-smartphones) Can be linked to email, key word for customized requests/responses Can send normal SMS (essential clients notification) 17
FrontlineSMS Mobile Client Used by nurses to submit pre-notification and client contacts to laboratory 18
FrontlineSMS Server Application Validates incoming messages (Built in house wrap around solution) Triages messages to DHIS2 19
SMS based early infant diagnosis of HIV PCR results transmission system (eeid) Original HIV DNA PCR EID system 20
SMS based HIV PCR results transmission system (eeid) NEW HIV DNA PCR EID system Part of PMTCT Programme Uses SMS to report pediatric HIV DNA PCR results Photo: Tanzania HMIS At >1200 health facilities SMS is used for: All 3 labs participating as of 2015 Notification of new samples facility lab Notification of lab results lab facility Notification of results availability lab consenting mother 21
SMS based HIV PCR results transmission system (eeid) NEW HIV DNA PCR EID system 22
EID HIV DNA PCR results and messages transmitted EID Messages 2013 2014 **2015 *NMRL 2244 38081 7402 *Mpilo 3212 *Mutare 1456 Total 12070 Pre-notification 2753 5319 1749 To Mothers 181 549 853 Positive outcomes to date *Counted messages sent out regardless of date of collection **Quarter 1 23
HIV DNA PCR EID outcomes Positive outcomes to date TAT measured from data of sample collection to date results are released/sent to health by SMS TAT has been reduced from 94 days (11 sites at pilot) to 57 days (as of August 2014) TAT reduced further to 35 days in Q1 2015. This could partially be due to decentralization of testing to two(2) additional labs. 24 31260 (68%) of HIV DNA PCR results for EID were sent by SMS (out of a total of 46192 tests done).
Challenges faced Managing high volumes of SMS based reporting 2013 FrontlineSMS Server could not handle receiving high volumes of messages. Solution: Code developed to handle high volume of messages. No/minimum in-built validation. Solution: wrap around code developed Service provider issues such as offline, slow transmission 25
Client side: User training and quality thereof Challenges faced Some functions are rarely used eg. installing client program, setting server number, downloading forms etc. Hence users rapidly loose skills in using these functions. Users have minimal computer literacy skills (even a phone can be complex) 26
Client side: Challenges faced Credit availability - sometimes credit was not correctly recorded on health facility phones resulting in non- transmission of prenotifications to laboratory 27 Broken phones Limited reporting of non-functional phones Inefficient system for replacement of lost/non- functional phones Feedback and response from national level is slow
Scale up and Sustainability Additional programmes (starting off with RDNS/WDSS) Early infant diagnosis (EID) for PMTCT Programme, MOHCC (2013) - reporting pediatric HIV results through this mobile phone system at >1200 facilities Viral load (VL) results reporting - 2014 Both EID and VL notify care givers/patient when results are at the health facility 28 Indoor residual spraying (IRS) - 2014, VMMC (latest addition - 2015)
Scale up and Sustainability Provider/funding issues Mobile service package is being covered by project for national server and GFATM for HF handset. Negotiations with provider to reduce mobile services costs. Automate adding credit to national server (in short term) 29 Work with service provider charge SMS costs to central number (in the long term)
Conclusion It is feasible to implement SMS based systems for HIV, DNA PCR results for EID in low resource setting SMS based platform seem to positively impact routine TAT for HIV DNA PCR results in low resource setting. Faster access to HIV results can improve access to healthcare for HIV exposed infants Key considerations when selecting SMS based platforms open source easily customizable; user friendly to those in the health service profession; cost efficient 30 scalable
Conclusion There is need to further study the overall reduction in HIV results TAT and carry out cost benefit analysis. This could look at: Sample transportation Efficient laboratories systems (TAT, quality, Improved laboratory information systems) Benefits of patient notification component 31 Improved use of results for faster initiation of infants.
References Ministry of Health and Child Welfare (MoHCW).* (2009). National Health Information Strategy. Harare, Zimbabwe. Ministry of Health and Child Welfare (MoHCW),* RTI International. (2010). Zimbabwe Health Information Capacity Assessment. Harare, Zimbabwe. Nsanzimana S., Ruton H., Lowrance, D. W., et al. (2012). Cell phone-based and Internet-based monitoring and evaluation of the National Antiretroviral Treatment Program during rapid scale-up in Rwanda. Journal for Acquired Immune Deficiency Syndrome, No. 59, e17 e23. FrontlineSMS. (2013). [Online] retrieved from www.frontlinesms.com [Accessed on November 2013]. 32
Acknowledgements This project has been supported by the U.S. President s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Centers for Disease Control and Prevention (CDC) under the terms of Cooperative Agreement Grant No. 1U2GPS003118-01. Additional funding was received from GFATM. 33