Zindagi Mehfooz (Safe Life) Digital Immunization Registry: Leveraging Low-Cost Technology to Improve Immunization Coverage and Timeliness in Pakistan

Abstract

Background: Despite free access to vaccines through the Expanded Program on Immunization (EPI) in Pakistan, only 54% of children receive all basic vaccinations. The global success of mobile health (mHealth) technologies, particularly, Digital immunization registries (DIRs), offers immense potential for comprehensive improvement in immunization programs. In 2012, we developed and piloted Zindagi Mehfooz (Safe Life; ZM) Digital Immunization Registry, an Android phone-based platform that enables vaccinators to digitally enroll and track the immunization status of their catchment population while allowing real-time access to data and easy generation of monitoring reports. Leveraging cutting edge mHealth technology, ZM includes features such as identification through quick response barcodes, interactive SMS reminders, decision support systems for routine/catch-up immunizations, real-time workforce tracking, predictive analytics for identifying high-risk children and customized report generation for monitoring. In 2017, ZM was scaled up, in collaboration with EPI, across the entire Sindh province and is currently being used by 1589 government vaccinators in 1296 basic health facilities. Objective: We evaluated the ZM Registry in terms of improvement in immunization coverage and timeliness. The primary outcome of interest was fully immunized child (FIC) coverage in children under 2 years of age, ie, a child who has received one dose of Bacillus-Calmette-Guérin (BCG), three doses each of OPV and Pentavalent immunizations, and one dose of Measles vaccine. The secondary outcomes of interest included the Pentavalent-3 coverage rate and dropout rate between BCG and Measles-1 vaccine. Methods: The provincial scale-up commenced in October 2017, and as of July 2018, over 700,000 children between 0-2 years have been enrolled in the Registry. At enrollment, the caretaker's information, child's bio-data, and immunization history are recorded and a unique Quick Response (QR)-code sticker is provided for identification. For the follow-up immunization visits, 3 SMS reminders are sent to parents for each vaccination. At the follow-up immunization, the child's history is retrieved on the phone by scanning the QR-code, and the vaccination record is updated accordingly. Data exported from the ZM DIR records was used to calculate the coverage rate for children enrolled in the Registry and the outcomes were compared with the coverage estimates from the most recent demographic survey (MICS 2014) to determine the impact of the Registry. Results: Full immunization coverage of children (12-23 months) increased significantly from 35% as reported in MICS 2014 to 45% for children enrolled in ZM. Pentavalent-3 coverage of children enrolled in the Registry showed a 7% increase (from 53% reported in MICS 2014 data to 60% for children enrolled in the Registry). The dropout rate from BCG to Measles 1 vaccine was 24% as per the MICS 2014 figures and only 4% for children enrolled in the Registry.

Impact of COVID-19 pandemic response on uptake of routine immunizations in Sindh, Pakistan: An analysis of provincial electronic immunization registry data

“…We used immunization records from the Government of Sindh’s Zindagi Mehfooz (Safe Life) Electronic Immunization Registry (ZM EIR). The ZM EIR [29] is an Android-based application for immunization management that enables vaccinators to enroll and follow children using smartphones. The ZM EIR is rolled-out across 29 districts of Sindh and is used by all 2755 vaccinators (comprising of 12.8% (352/2755) females) working at 1518 public and 151 private immunization clinics across those districts.…”

Impact of COVID-19 lockdown on routine immunisation in Karachi, Pakistan

“…The ZM EIR is an Android-based application that allows vaccinators to enrol and track the vaccination status, geographical location, and biodata (eg, name, sex, and date of birth) of children using smartphones, which has enabled the collection of real-time data for the monitoring and evaluation of service delivery. 7 The Government of Sindh scaled up ZM EIR in 2017 to bolster efforts to achieve universal, timely, and equitable immunisation coverage in the province. From October, 2017, to May, 2020, more than 2•9 million children (aged 0-23 months) and more than 1 million women (aged 15-49 years) were enrolled, and more than 22 million immunisation events have been recorded.…”

Prevalence, geographical distribution and factors associated with pentavalent vaccine zero dose status among children in Sindh, Pakistan: analysis of data from the 2017 and 2018 birth cohorts enrolled in the provincial electronic immunisation registry

“…16 Approximately 60% of all immunisations in the province occur at fixed centres, whereas the rest are delivered through routine and enhanced outreach sessions. 17 Routine outreach is defined as immunisation sessions held in a location other than the immunisation centre, from which vaccinators can go out and return the same day, whereas enhanced outreach is defined as a series of immunisation outreach sessions covering geographic area outside the radius of routine activities. The number of vaccination centres and vaccinators per 1000 population of children under 2 years is 0.98 (range: 0.48-1.84) 13 and 2.07 (range: 1.13-3.02), respectively.…”