Changes in on-time vaccination following the introduction of an electronic immunization registry, Tanzania 2016-2018: interrupted time-series analysis.

BACKGROUND: Digital health interventions (DHI) have the potential to improve the management and utilization of health information to optimize health care worker performance and provision of care. Despite the proliferation of DHI projects in low-and middle-income countries, few have been evaluated in an effort to understand their impact on health systems and health-related outcomes. Although more evidence is needed on their impact and effectiveness, the use of DHIs among immunization programs has become more widespread and shows promise for improving vaccination uptake and adherence to immunization schedules. METHODS: Our aim was to assess the impact of an electronic immunization registry (EIR) using an interrupted time-series analysis to analyze the effect on proportion of on-time vaccinations following introduction of an EIR in Tanzania. We hypothesized that the introduction of the EIR would lead to statistically significant changes in vaccination timeliness at 3, 6, and > 6 months post-introduction. RESULTS: For our primary analysis, we observed a decrease in the proportion of on-time vaccinations following EIR introduction. In contrast, our sensitivity analysis estimated improvements in timeliness among those children with complete vaccination records. However, we must emphasize caution interpreting these findings as they are likely affected by implementation challenges. CONCLUSIONS: This study highlights the complexities of using digitized individual-level routine health information system data for evaluation and research purposes. EIRs have the potential to improve vaccination timeliness, but analyses using EIR data can be complicated by data quality issues and inconsistent data entry leading to difficulties interpreting findings.

Toward Understanding Death.

Evidence-based approaches to preventing child death require evidence; without data on common causes of child mortality, taking effective action to prevent these deaths is difficult at best. Minimally invasive tissue sampling (MITS) is a potentially powerful, but nascent, technique to obtain gold standard information on causes of death. The Gates Foundation committed to further establishing the methodology and obtain the highest quality information on the major causes of death for children under 5 years. In 2018, the MITS Surveillance Alliance was launched to implement, refine, and enhance the use of MITS across high mortality settings. The Alliance and its members have contributed to some remarkable opportunities to improve mortality surveillance, and we have only just begun to understand the possibilities on larger scales. This supplement showcases studies conducted by MITS Surveillance Alliance members and represents a significant contribution to the cause-of-death literature from high mortality settings.

Use of technology for public health surveillance reporting: opportunities, challenges and lessons learnt from Kenya.

BACKGROUND: Effective public health surveillance systems are crucial for early detection and response to outbreaks. In 2016, Kenya transitioned its surveillance system from a standalone web-based surveillance system to the more sustainable and integrated District Health Information System 2 (DHIS2). As part of Global Health Security Agenda (GHSA) initiatives in Kenya, training on use of the new system was conducted among surveillance officers. We evaluated the surveillance indicators during the transition period in order to assess the impact of this training on surveillance metrics and identify challenges affecting reporting rates. METHODS: From February to May 2017, we analysed surveillance data for 13 intervention and 13 comparison counties. An intervention county was defined as one that had received refresher training on DHIS2 while a comparison county was one that had not received training. We evaluated the impact of the training by analysing completeness and timeliness of reporting 15 weeks before and 12 weeks after the training. A chi-square test of independence was used to compare the reporting rates between the two groups. A structured questionnaire was administered to the training participants to assess the challenges affecting surveillance reporting. RESULTS: The average completeness of reporting for the intervention counties increased from 45 to 62%, i.e. by 17 percentage points (95% CI 16.14-17.86) compared to an increase from 49 to 52% for the comparison group, i.e. by 3 percentage points (95% CI 2.23-3.77). The timeliness of reporting increased from 30 to 51%, i.e. by 21 percentage points (95% CI 20.16-21.84) for the intervention group, compared to an increase from 31 to 38% for the comparison group, i.e.by 7 percentage points (95% CI 6.27-7.73). Major challenges for the low reporting rates included lack of budget support from government, lack of airtime for reporting, health workers strike, health facilities not sending surveillance data, use of wrong denominator to calculate reporting rates and surveillance officers having other competing tasks. CONCLUSIONS: Training plays an important role in improving public health surveillance reporting. However, to improve surveillance reporting rates to the desired national targets, other challenges affecting reporting must be identified and addressed accordingly.

The cost of diagnostic uncertainty: a prospective economic analysis of febrile children attending an NHS emergency department.

BACKGROUND: Paediatric fever is a common cause of emergency department (ED) attendance. A lack of prompt and definitive diagnostics makes it difficult to distinguish viral from potentially life-threatening bacterial causes, necessitating a cautious approach. This may result in extended periods of observation, additional radiography, and the precautionary use of antibiotics (ABs) prior to evidence of bacterial foci. This study examines resource use, service costs, and health outcomes. METHODS: We studied an all-year prospective, comprehensive, and representative cohort of 6518 febrile children (aged < 16 years), attending Alder Hey Children's Hospital, an NHS-affiliated paediatric care provider in the North West of England, over a 1-year period. Performing a time-driven and activity-based micro-costing, we estimated the economic impact of managing paediatric febrile illness, with focus on nurse/clinician time, investigations, radiography, and inpatient stay. Using bootstrapped generalised linear modelling (GLM, gamma, log), we identified the patient and healthcare provider characteristics associated with increased resource use, applying retrospective case-note identification to determine rates of potentially avoidable AB prescribing. RESULTS: Infants aged less than 3 months incurred significantly higher resource use than any other age group, at £1000.28 [95% CI £82.39-£2993.37] per child, (p < 0.001), while lesser experienced doctors exhibited 3.2-fold [95% CI 2.0-5.1-fold] higher resource use than consultants (p < 0.001). Approximately 32.4% of febrile children received antibiotics, and 7.1% were diagnosed with bacterial infections. Children with viral illnesses for whom antibiotic prescription was potentially avoidable incurred 9.9-fold [95% CI 6.5-13.2-fold] cost increases compared to those not receiving antibiotics, equal to an additional £1352.10 per child, predominantly resulting from a 53.9-h increase in observation and inpatient stay (57.1 vs. 3.2 h). Bootstrapped GLM suggested that infants aged below 3 months and those prompting a respiratory rate 'red flag', treatment by lesser experienced doctors, and Manchester Triage System (MTS) yellow or higher were statistically significant predictors of higher resource use in 100% of bootstrap simulations. CONCLUSION: The economic impact of diagnostic uncertainty when managing paediatric febrile illness is significant, and the precautionary use of antibiotics is strongly associated with increased costs. The use of ED resources is highest among infants (aged less than 3 months) and those infants managed by lesser experienced doctors, independent of clinical severity. Diagnostic advances which could increase confidence to withhold antibiotics may yield considerable efficiency gains in these groups, where the perceived risks of failing to identify potentially life-threatening bacterial infections are greatest.

Monitoring and Validation of the Global Replacement of tOPV with bOPV, April-May 2016.

The phased withdrawal of oral polio vaccine (OPV) associated with the Polio Eradication and Endgame Strategic Plan 2013-2018 began with the synchronized global replacement of trivalent OPV (tOPV) with bivalent OPV (bOPV) during April - May 2016, a transition referred to as the "switch." The World Health Organization's (WHO) Strategic Advisory Group of Experts (SAGE) on Immunization recommended conducting this synchronized switch in all 155 OPV-using countries and territories (which collectively administered several hundred million doses of tOPV each year via several hundred thousand facilities) to reduce risks of re-emergence of vaccine-derived polioviruses. Safe execution of this switch required implementation of an associated independent monitoring strategy, the primary objective of which was verification that tOPV was no longer available for administration post-switch. This strategy had to be both practical and rigorous such that tOPV withdrawal could be reasonably employed and confirmed in all countries and territories within a discreet timeframe. Following these principles, WHO recommended that designated monitors in each of the 155 countries and territories visit all vaccine stores as well as a 10% sample of highest-risk health facilities within two weeks of the national switch date, removing any tOPV vials found. National governments were required to provide the WHO with formal validation of execution and monitoring of the switch. In practice, all countries reported cessation of tOPV by 12 May 2016 and 95% of countries and territories submitted detailed monitoring data to WHO. According to these data, 272 out of 276 (99%) national stores, 3,741 out of 3.968 (94%) regional stores, 16,144 out of 22,372 (72%) district level stores, and 143,050 out of 595,401 (24%) of health facilities were monitored. These data, along with field reports suggest that monitoring and validation of the switch was efficient and effective, and that the strategies used during the process could be adapted to future stages of OPV withdrawal.

Disposing of Excess Vaccines After the Withdrawal of Oral Polio Vaccine.

Until recently, waste management for national immunization programs was limited to sharps waste, empty vaccine vials, or vaccines that had expired or were no longer usable. However, because wild-type 2 poliovirus has been eradicated, the World Health Organization's (WHO's) Strategic Advisory Group of Experts on Immunization deemed that all countries must simultaneously cease use of the type 2 oral polio vaccine and recommended that all countries and territories using oral polio vaccine (OPV) "switch" from trivalent OPV (tOPV; types 1, 2, and 3 polioviruses) to bivalent OPV (bOPV; types 1 and 3 polioviruses) during a 2-week period in April 2016. Use of tOPV after the switch would risk outbreaks of paralysis related to type 2-circulating vaccine-derived poliovirus (cVDPV2). To minimize risk of vaccine-derived polio countries using OPV were asked to dispose of all usable, unexpired tOPV after the switch to bOPV. In this paper, we review the rationale for tOPV disposal and describe the global guidelines provided to countries for the safe and appropriate disposal of tOPV. These guidelines gave countries flexibility in implementing this important task within the confines of their national regulations, capacities, and resources. Steps for appropriate disposal of tOPV included removal of all tOPV vials from the cold chain, placement in appropriate bags or containers, and disposal using a recommended approach (ie, autoclaving, boiling, chemical inactivation, incineration, or encapsulation) followed by burial or transportation to a designated waste facility. This experience with disposal of tOPV highlights the adaptability of national immunization programs to new procedures, and identifies gaps in waste management policies and strategies with regard to disposal of unused vaccines. The experience also provides a framework for future policies and for developing programmatic guidance for the ultimate disposal of all OPV after the eradication of polio.

Administering Multiple Injectable Vaccines During a Single Visit-Summary of Findings From the Accelerated Introduction of Inactivated Polio Vaccine Globally.

Background: In 2013, the World Health Organization's (WHO's) Strategic Advisory Group of Experts (SAGE) recommended that all 126 countries using only oral polio vaccine (OPV) introduce at least 1 dose of inactivated polio vaccine (IPV) into their routine immunization schedules by the end of 2015. In many countries, the addition of IPV would necessitate delivery of multiple injectable vaccines (hereafter, "multiple injections") during a single visit, with infants receiving IPV alongside pentavalent vaccine (which covers diphtheria, tetanus, and whole-cell pertussis; hepatitis B; and Haemophilus influenzae type b) and pneumococcal vaccine. Unanticipated concerns emerged from countries over acceptability of multiple injections, sites of administration, and safety. We contextualized the issues surrounding multiple injections by documenting concerns associated with administration of ≥3 injections, existing evidence in the published literature, and findings of a systematic review on administration practices and techniques. Methods: Concerns associated with multiple-injection visits were documented from meetings and personal communications with immunization program managers. Published literature on the acceptability of multiple injections by providers and caregivers was summarized, and a systematic review of the literature on administration practices was completed on the following topics: spacing between injection sites (ie, vaccine spacing), site of injection, route of injection, and procedural preparedness. WHO and United Nations Children's Fund data from 2013-2015 were used to assess multiple-injection visits included in national immunization schedules. Results: Healthcare provider and caregiver attitudes and practices indicated concerns about infant pain, potential adverse effects, and uncertainty about vaccine effectiveness with multiple-injection visits. Published literature reinforced the record of safety and acceptance of the recommended schedule of IPV by the SAGE, but the evidence was largely from developed countries. Parental acceptance of multiple injections was associated with a positive provider recommendation to the caregiver. Findings of the systematic review identified that the intramuscular route is preferred over the subcutaneous route for vaccine administration and that the vastus lateralis muscle is preferred over the deltoid muscle for intramuscular injections. Recommendations on vaccine spacing and procedural preparedness were based on practical necessities, but comparative evidence was not identified. During 2013-2015, 85 countries added IPV to their immunization schedules, 46 (55%) of which adopted a schedule resulting in 3 injectable vaccines being administered in a single visit. Conclusion: The multiple-injection experience identified gaps in guidance for future vaccine introductions. Global partner organizations quickly mobilized to assess, document, and communicate the existing global experience on multiple-injection visits. This evidence-based approach provided reassurance to opinion leaders, health workers, and professional societies, thus encouraging uptake of IPV as a second or third injection in an accelerated manner globally.

Implementing the Synchronized Global Switch from Trivalent to Bivalent Oral Polio Vaccines-Lessons Learned From the Global Perspective.

In 2015, the Global Commission for the Certification of Polio Eradication certified the eradication of type 2 wild poliovirus, 1 of 3 wild poliovirus serotypes causing paralytic polio since the beginning of recorded history. This milestone was one of the key criteria prompting the Global Polio Eradication Initiative to begin withdrawal of oral polio vaccines (OPV), beginning with the type 2 component (OPV2), through a globally synchronized initiative in April and May 2016 that called for all OPV using countries and territories to simultaneously switch from use of trivalent OPV (tOPV; containing types 1, 2, and 3 poliovirus) to bivalent OPV (bOPV; containing types 1 and 3 poliovirus), thus withdrawing OPV2. Before the switch, immunization programs globally had been using approximately 2 billion tOPV doses per year to immunize hundreds of millions of children. Thus, the globally synchronized withdrawal of tOPV was an unprecedented achievement in immunization and was part of a crucial strategy for containment of polioviruses. Successful implementation of the switch called for intense global coordination during 2015-2016 on an unprecedented scale among global public health technical agencies and donors, vaccine manufacturers, regulatory agencies, World Health Organization (WHO) and United Nations Children's Fund (UNICEF) regional offices, and national governments. Priority activities included cessation of tOPV production and shipment, national inventories of tOPV, detailed forecasting of tOPV needs, bOPV licensing, scaling up of bOPV production and procurement, developing national operational switch plans, securing funding, establishing oversight and implementation committees and teams, training logisticians and health workers, fostering advocacy and communications, establishing monitoring and validation structures, and implementing waste management strategies. The WHO received confirmation that, by mid May 2016, all 155 countries and territories that had used OPV in 2015 had successfully withdrawn OPV2 by ceasing use of tOPV in their national immunization programs. This article provides an overview of the global efforts and challenges in successfully implementing this unprecedented global initiative, including (1) coordination and tracking of key global planning milestones, (2) guidance facilitating development of country specific plans, (3) challenges for planning and implementing the switch at the global level, and (4) best practices and lessons learned in meeting aggressive switch timelines. Lessons from this monumental public health achievement by countries and partners will likely be drawn upon when bOPV is withdrawn after polio eradication but also could be relevant for other global health initiatives with similarly complex mandates and accelerated timelines.

Country Immunization Information System Assessments - Kenya, 2015 and Ghana, 2016.

The collection, analysis, and use of data to measure and improve immunization program performance are priorities for the World Health Organization (WHO), global partners, and national immunization programs (NIPs). High quality data are essential for evidence-based decision-making to support successful NIPs. Consistent recording and reporting practices, optimal access to and use of health information systems, and rigorous interpretation and use of data for decision-making are characteristics of high-quality immunization information systems. In 2015 and 2016, immunization information system assessments (IISAs) were conducted in Kenya and Ghana using a new WHO and CDC assessment methodology designed to identify root causes of immunization data quality problems and facilitate development of plans for improvement. Data quality challenges common to both countries included low confidence in facility-level target population data (Kenya = 50%, Ghana = 53%) and poor data concordance between child registers and facility tally sheets (Kenya = 0%, Ghana = 3%). In Kenya, systemic challenges included limited supportive supervision and lack of resources to access electronic reporting systems; in Ghana, challenges included a poorly defined subdistrict administrative level. Data quality improvement plans (DQIPs) based on assessment findings are being implemented in both countries. IISAs can help countries identify and address root causes of poor immunization data to provide a stronger evidence base for future investments in immunization programs.

Measles Outbreak Associated with Vaccine Failure in Adults--Federated States of Micronesia, February-August 2014.

On May 15, 2014, CDC was notified of two laboratory-confirmed measles cases in the Federated States of Micronesia (FSM), after 20 years with no reported measles. FSM was assisted by the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), and CDC in investigating suspected cases, identify contacts, conduct analyses to guide outbreak vaccination response, and review vaccine cold chain practices. During February­August, three of FSM's four states reported measles cases: Kosrae (139 cases), Pohnpei (251), and Chuuk (3). Two thirds of cases occurred among adults aged ≥20 years; of these, 49% had received ≥2 doses of measles-containing vaccine (MCV). Apart from infants aged <12 months who were too young for routine vaccination, measles incidence was lower among children than adults. A review of current cold chain practices in Kosrae revealed minor weaknesses; however, an absence of historical cold chain maintenance records precluded an evaluation of earlier problems. Each state implemented vaccination campaigns targeting children as young as age 6 months through adults up to age 57 years. The preponderance of cases in this outbreak associated with vaccine failure in adults highlights the need for both thorough case investigation and epidemiologic analysis to guide outbreak response vaccination. Routine childhood vaccination coverage achieved in recent years limited the transmission of measles among children. Even in areas where transmission has not occurred for years, maintaining high 2-dose MCV coverage through routine and supplemental immunization is needed to prevent outbreaks resulting from increased measles susceptibility in the population.

A Retrospective Study of Sildenafil Administration in 55 Cats with Cardiopulmonary Disease (2009-2021).

Sildenafil is a drug used to successfully manage a variety of cardiopulmonary disorders in people and dogs, but there is limited information on its use in cats. The objective was to review the medical records of cats that received sildenafil as part of their clinical management. Medical records and pharmacy databases were searched for cats that received sildenafil for ≥24 h between 2009 and 2021, and data were collected from medical records. Fifty-five cats received sildenafil for ≥24 h and were included in the study: 43 with primary cardiac disease (acquired, n = 28; congenital, n = 15) and 12 with primary respiratory disease. Side effects possibly attributed to sildenafil were identified in two cats (systemic hypotension, n = 1; polydipsia, n = 1), and sildenafil was discontinued in the cat with hypotension. Sildenafil was discontinued in an additional three cats due to a lack of improvement in clinical signs. No cat was documented to develop worsening pulmonary edema within 72 h of starting sildenafil. Median duration of sildenafil administration was 87 days (range, 2-2362 days). Sildenafil administration in cats appeared to be generally well-tolerated. Studies are needed to determine whether sildenafil administration to cats with cardiopulmonary disease improves the quality of life or survival times.

Usability and Acceptability of Electronic Immunization Registry Data Entry Workflows From the Health Care Worker Perspective in Siaya, Kenya (Part 3): Pre-Post Study.

BACKGROUND: Digital health tools such as electronic immunization registries (EIRs) have the potential to improve patient care and alleviate the challenges that arise from the use of paper-based clinic records for reporting. To address some of these challenges, the Kenya Ministry of Health and the International Training and Education Center for Health Kenya implemented an EIR system in 161 immunizing clinics in Siaya County between 2018 and 2019. The successful implementation of digital health tools depends on many factors, one of which is alignment between the technology and the context in which it is used. One important aspect of that implementation context is the perceptions of the health care workers (HCWs) using the EIR. OBJECTIVE: This study aimed to evaluate HCWs' perceptions of the usability and acceptability of multiple clinic workflows using the new EIR. METHODS: We performed a mixed methods pre-post study using semistructured interviews with HCWs at 6 facilities in Siaya County, Kenya. We interviewed HCWs at each facility 4 times: at baseline and once after the implementation of 3 different workflow modifications (n=24 interviews). The baseline state was dual data entry with paper records and the EIR. We then implemented 3 workflow modifications for 1 full day each: fully paperless data entry, preparation of an appointment diary before patient visits for the day, and a combination of the 2 workflows. We compared ratings and themes across interviews after each of the 4 workflows to understand the changes in the usability and acceptability of the EIR. RESULTS: HCWs considered the EIR clinic workflows to be usable and acceptable. Of the modified workflows, HCWs perceived the fully paperless workflow most favorably. In all workflows, HCWs' perceived benefits included ease of clinical decision-making using the EIR, reduced mental burden of data entry when using the EIR, and ease of identification of errors. Perceived barriers to the workflow included contextual challenges such as staffing shortages and lack of network connectivity, EIR platform challenges such as errors in saving records and missing fields, and workflow challenges such as the dual data entry burden of using paper and digital tools simultaneously. CONCLUSIONS: Fully paperless EIR implementation shows great promise from a workflow acceptability standpoint, contingent upon the presence of supporting contextual clinic factors and the resolution of system performance and design challenges. Rather than trying to identify a singular best workflow, future efforts should provide adequate flexibility for HCWs to implement the new system in their unique clinic context. Future EIR implementation stands to benefit from continued monitoring of EIR adoption acceptability during implementation, both for Siaya's program and for other efforts around the globe, as digital health interventions become more widely used.

Integration of a Digital Health Intervention Into Immunization Clinic Workflows in Kenya: Qualitative, Realist Evaluation of Technology Usability.

BACKGROUND: In an effort to increase vaccination coverage in low-resource settings, digital tools have been introduced to better track immunization records, improve data management practices, and provide improved access to vaccination coverage data for decision-making. Despite the potential of these electronic systems to improve the provision of health services, few digital health interventions have been institutionalized at scale in low- and middle-income countries. OBJECTIVE: In this paper, we aimed to describe how health care workers in Kenya had integrated an electronic immunization registry into their immunization clinic workflows and to use these findings to inform the development of a refined program theory on the registry's usability. METHODS: Informed by realist methodology, we developed a program theory to explain usability of the electronic immunization registry. We designed a qualitative study based on our theory to describe the barriers and facilitators influencing data entry and use. Qualitative data were collected through semistructured interviews with users and workflow observations of immunization clinic sessions. Our findings were summarized by context-mechanism-outcome relationships formed after analyzing our key themes across interviews and workflow observations. Using these relationships, we were able to identify common rules for future implementers. RESULTS: Across the 12 facilities included in our study, 19 health care workers were interviewed, and 58 workflow sessions were observed. The common rules developed from our qualitative findings are as follows: rule 1-ensure that the users complete training to build familiarity with the system, understand the value of the system and data, and know where to find support; rule 2-confirm that the system captures all data needed for users to provide routine health care services and is easy to navigate; rule 3-identify work-arounds for poor network, system performance, and too few staff or resources; and rule 4-make users aware of expected changes to their workflow, and how these changes might differ over time and by facility size or number of patients. Upon study completion, we revised the program theory to reflect the importance of the goals and workflows of electronic immunization registries aligning with reality. CONCLUSIONS: We created a deeper understanding of the underlying mechanisms for usability of the registry. We found that the electronic immunization registry had high acceptability among users; however, there were numerous barriers to using the system, even under ideal conditions, causing a misalignment between the system and the reality of the users' workflows and their environment. Human-centered design and human-factors methods can assist during pilot stages to better align systems with users' needs and again after scale-up to ensure that interventions are suitable for all user settings.

Time Utilization Among Immunization Clinics Using an Electronic Immunization Registry (Part 2): Time and Motion Study of Modified User Workflows.

BACKGROUND: Digital health interventions have the potential to improve the provision of health care services through digitized data collection and management. Low- and middle-income countries are beginning to introduce electronic immunization registries (EIRs) into their routine immunization services to better capture and store childhood vaccination information. Especially in Africa, where 25% of children remain unimmunized or underimmunized, technologies that can help identify children due for a vaccination are particularly important for improving vaccination coverage. However, an improved understanding of the effectiveness of these systems is needed to develop and deploy sustainable EIRs in low- and middle-income countries. OBJECTIVE: We conducted an interventional pretest-posttest design study that sought to improve time efficiency through workflow modifications in Kenyan immunization clinics. Our aim was to describe how activity times differed after introducing workflow modifications that could potentially reduce the time needed to perform routine data entry activities. Our intent was to demonstrate changes in efficiency when moving from the existing dual-data entry workflow to a future paperless workflow by health facility size and experience length of health care workers (HCWs). METHODS: We tested how 3 workflow modifications would affect time utilization among HCWs using the EIR at the point of care compared with baseline immunization clinic workflows. Our outcome of interest was the time taken to complete individual activities and a patient's total time in the clinic where we compared the time spent during the baseline workflow with that during the modified workflow. We used a standardized tool to observe and document the immunization clinic workflow. To estimate differences in time utilization, we used bivariate analyses and fit multivariate linear mixed-effects models. RESULTS: Our study found that for HCWs using an EIR, the introduction of modified workflows decreased the amount of time needed to provide services to children seen in the immunization clinic. With a baseline mean time of 10 minutes spent per child, this decreased by about 3 minutes when the preparation modification was introduced and almost 5 minutes for the paperless and combined modifications. Results pertaining to the EIR's performance and ability to connect to the internet were particularly insightful about potential causes of delays. CONCLUSIONS: We were able to conduct a concise clinical simulation exercise by introducing modified workflows and estimating their impact on time utilization in immunization clinics using an EIR. We found that the paperless workflow provided the largest time savings when delivering services, although this was threatened by poor EIR performance and internet connectivity. This study demonstrated that not only should digital health interventions be built and adapted for particular use cases but existing user workflows also need to adapt to new technology.

Recalibration of thinking about adrenocortical function assessment: how the 'random' cortisol relates to the short synacthen test results.

BACKGROUND: The short synacthen test (SST) is the most commonly performed investigation to assess adrenal function. Appropriate criteria for when an SST is performed are subject to debate. We investigated how random serum cortisol levels relate to SST response. METHODS: We examined random cortisol measurements taken between 04.40-23.55 p.m. results of SST baseline and 30-/60-min cortisol performed over 12 months (225 SSTs) at Salford Royal Hospital. Serum cortisol was measured on the Siemens Centaur Analyser.A 30-60-min cortisol concentration of ≥450 nmol/L defined a pass; 350-449 nmol/L defined borderline. RESULTS: Patients only proceeded to SST if random cortisol was <400 nmol/L. For those not on corticosteroids for at least 2 weeks, 42/43 (97.7%) cases with random cortisol concentration of ≥200 nmol/L had an SST 'pass'. The relation was less clear with corticosteroid treatment (19/35 cases; 54%).For those not taking glucocorticoid treatment (including inhaled/topical corticosteroids) in the previous 2 weeks, 91.8% of SSTs were pass/2.7% borderline/5.5% fail. For those on steroids, 51.9% of SSTs were a pass/11.4% were borderline.In relation to the postsynacthen cortisol pass cut-off of ≥450 nmol/L, in 15/207 (7.2%) of cases, the 60-min cortisol was ≥450 nmol/L (adequate adrenocortical function), but 30-min cortisol was below this. In all cases where the 30-min cortisol did indicate a pass (i.e. was ≥450 nmol/L) the 60-min cortisol was also ≥450 nmol/L. CONCLUSION: Our findings suggest that if the random cortisol level is ≥200 nmol/L, regardless of the time of day and the person was not taking corticosteroid treatment in the previous 2 weeks, SST may not be needed. Our data also suggests that 60-min cortisol retains utility.

Perceptions of factors influencing the introduction and adoption of electronic immunization registries in Tanzania and Zambia: a mixed methods study.

BACKGROUND: As technology has become cheaper and more accessible, health programs are adopting digital health interventions (DHI) to improve the provision of and demand for health services. These interventions are complex and require strong coordination and support across different health system levels and government departments, and they need significant capacities in technology and information to be properly implemented. Electronic immunization registries (EIRs) are types of DHI used to capture, store, access, and share individual-level, longitudinal health information in digitized records. The BID Initiative worked in partnership with the governments of Tanzania and Zambia to introduce an EIR at the sub-national level in both countries within 5 years as part of a multi-component complex intervention package focusing on data use capacity-building. METHODS: We aimed to gather and describe learnings from the BID experience by conducting a framework-based mixed methods study to describe perceptions of factors that influenced scale-up of the EIR. Data were collected through key informant interviews, a desk review, EIRs, and health management information systems. We described how implementation of the EIRs fulfilled domains described in our conceptual framework and used cases to illustrate the relationships and relative influence of domains for scale-up and adoption of the EIR. RESULTS: We found that there was no single factor that seemed to influence the introduction or sustained adoption of the EIR as many of the factors were interrelated. For EIR introduction, strong strategic engagement among partners was important, while EIR adoption was influenced by adequate staffing at facilities, training, use of data for supervision, internet and electricity connectivity, and community sensitization. CONCLUSIONS: Organizations deploying DHIs in the future should consider how best to adapt their intervention to the existing ecosystem, including human resources and organizational capacity, as well as the changing technological landscape during planning and implementation.

Low-Cost Animal Rabies Vaccination Clinics in Maryland Facilitate Access to Rabies Vaccination for Pets.

Rabies is a zoonotic disease that poses a serious public health risk. To facilitate pet owner compliance with statewide mandatory animal rabies immunization requirements, Maryland statute requires Maryland's local health departments to conduct low-cost animal rabies vaccination clinics at least twice per year. We describe the outputs of these public low-cost clinics by documenting the number of animals vaccinated, number of clinics held annually, and cost per vaccine to pet owners for the years 2015-2016. These data are compared with clinic data from 2006 to 2008, providing insight into changes that have occurred in the decade interval between the surveys and consequently informing future clinic policies and procedures. The Maryland low-cost rabies clinic model allows for the vaccination of roughly 20,000 pet animals per year, representing ∼1% of the Maryland pet population, and can be adopted by other states to allow for more comprehensive rabies vaccination coverage in other regions of the country.

Redefining vaccination coverage and timeliness measures using electronic immunization registry data in low- and middle-income countries.

Vaccine coverage is routinely used as a performance indicator for immunization programs both at local and global levels. For many national immunization programs, there are challenges with accurately estimating vaccination coverage based on available data sources, however an increasing number of low- and middle-income countries (LMICs) have begun implementing electronic immunization registries to replace health facilities' paper-based tools and aggregate reporting systems. These systems allow for more efficient capture and use of routinely reported individual-level data that can be used to calculate dose-specific and cohort vaccination coverage, replacing the commonly used aggregate routine health information system data. With these individual-level data immunization programs have the opportunity to redefine performance measures to enhance programmatic decision-making at all levels of the health system. In this commentary, we discuss how measures for assessing vaccination status and program performance can be redefined and recalculated using these data when generated at the health facility level and the implications of the use and availability of electronic individual-level data.

Comparison of inflation of third dose diphtheria tetanus pertussis (DTP3) administrative coverage to other vaccine antigens.

Third dose diphtheria tetanus pertussis (DTP3) administrative coverage is a commonly used indicator for immunization program performance, although studies have demonstrated data quality issues with administrative DTP3 coverage. It is possible that administrative coverage for DTP3 may be inflated more than for other antigens. To examine this, theory, we compiled immunization coverage estimates from recent country surveys (n=71) and paired these with corresponding administrative coverage estimates, by country and cohort year, for DTP3 and 4 other antigens. Median administrative coverage was higher than survey estimates of coverage for all antigens (median differences from 26 to 30%), however this difference was similar for DTP3 as for all other antigens. These findings were consistent when countries were stratified by income level and eligibility for Gavi funding. Our findings demonstrate that while country administrative coverage estimates tend to be higher than survey estimates, DTP3 administrative coverage is not inflated more than other antigens.