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.

Added Value of Electronic Immunization Registries in Low- and Middle-Income Countries: Observational Case Study in Tanzania.

BACKGROUND: There is growing interest and investment in electronic immunization registries (EIRs) in low- and middle-income countries. EIRs provide ready access to patient- and aggregate-level service delivery data that can be used to improve patient care, identify spatiotemporal trends in vaccination coverage and dropout, inform resource allocation and program operations, and target quality improvement measures. The Government of Tanzania introduced the Tanzania Immunization Registry (TImR) in 2017, and the system has since been rolled out in 3736 facilities in 15 regions. OBJECTIVE: The aims of this study are to conceptualize the additional ways in which EIRs can add value to immunization programs (beyond measuring vaccine coverage) and assess the potential value-add using EIR data from Tanzania as a case study. METHODS: This study comprised 2 sequential phases. First, a comprehensive list of ways EIRs can potentially add value to immunization programs was developed through stakeholder interviews. Second, the added value was evaluated using descriptive and regression analyses of TImR data for a prioritized subset of program needs. RESULTS: The analysis areas prioritized through stakeholder interviews were population movement, missed opportunities for vaccination (MOVs), continuum of care, and continuous quality improvement. The included TImR data comprised 958,870 visits for 559,542 patients from 2359 health facilities. Our analyses revealed that few patients sought care outside their assigned facility (44,733/810,568, 5.52% of applicable visits); however, this varied by region; facility urbanicity, type, ownership, patient volume, and duration of TImR system use; density of facilities in the immediate area; and patient age. Analyses further showed that MOVs were highest among children aged <12 months (215,576/831,018, 25.94% of visits included an MOV and were applicable visits); however, there were few significant differences based on other individual or facility characteristics. Nearly half (133,337/294,464, 45.28%) of the children aged 12 to 35 months were fully vaccinated or had received all doses except measles-containing vaccine-1 of the 14-dose under-12-month schedule (ie, through measles-containing vaccine-1), and facility and patient characteristics associated with dropout varied by vaccine. The continuous quality improvement analysis showed that most quality issues (eg, MOVs) were concentrated in <10% of facilities, indicating the potential for EIRs to target quality improvement efforts. CONCLUSIONS: EIRs have the potential to add value to immunization stakeholders at all levels of the health system. Individual-level electronic data can enable new analyses to understand service delivery or care-seeking patterns, potential risk factors for underimmunization, and where challenges occur. However, to achieve this potential, country programs need to leverage and strengthen the capacity to collect, analyze, interpret, and act on the data. As EIRs are introduced and scaled in low- and middle-income countries, implementers and researchers should continue to share real-world examples and build an evidence base for how EIRs can add value to immunization programs, particularly for innovative uses.