Digital health technology used in emergency large-scale vaccination campaigns in low- and middle-income countries: a narrative review for improved pandemic preparedness.

INTRODUCTION: Large-scale vaccination campaigns can benefit from using digital health tools, particularly in low- and middle-income countries (LMICs). Selecting the best tool to fit into a pre-existing digital landscape can be challenging. AREAS COVERED: We conducted a narrative review in PubMed and the grey literature for data available within 5 years to provide an overview of digital health tools used in large-scale vaccination campaigns for outbreak response in LMICs. We discuss tools used along the typical steps of a vaccination process. Digital tool functionalities and technical specifications, open-source options, data privacy and security concerns, and lessons learned from the use of these tools are discussed. EXPERT OPINION: The landscape of digital health tools for large-scale vaccination processes in LMICs is growing. For efficient implementation, countries should prioritize the appropriate tool(s) depending on their needs and available resources, develop a robust framework around data privacy and security, and select sustainable features. Improving internet connectivity and digital literacy in LMICs will facilitate adoption. This review may aid LMICs still needing to prepare large-scale vaccination campaigns in the selection of supporting digital health tools. Further research on impact and cost-effectiveness is needed.

Use of Iris Scanning for Biometric Recognition of Healthy Adults Participating in an Ebola Vaccine Trial in the Democratic Republic of the Congo: Mixed Methods Study.

BACKGROUND: A partnership between the University of Antwerp and the University of Kinshasa implemented the EBOVAC3 clinical trial with an Ebola vaccine regimen administered to health care provider participants in Tshuapa Province, Democratic Republic of the Congo. This randomized controlled trial was part of an Ebola outbreak preparedness initiative financed through Innovative Medicines Initiative-European Union. The EBOVAC3 clinical trial used iris scan technology to identify all health care provider participants enrolled in the vaccine trial, to ensure that the right participant received the right vaccine at the right visit. OBJECTIVE: We aimed to assess the acceptability, accuracy, and feasibility of iris scan technology as an identification method within a population of health care provider participants in a vaccine trial in a remote setting. METHODS: We used a mixed methods study. The acceptability was assessed prior to the trial through 12 focus group discussions (FGDs) and was assessed at enrollment. Feasibility and accuracy research was conducted using a longitudinal trial study design, where iris scanning was compared with the unique study ID card to identify health care provider participants at enrollment and at their follow-up visits. RESULTS: During the FGDs, health care provider participants were mainly concerned about the iris scan technology causing physical problems to their eyes or exposing them to spiritual problems through sorcery. However, 99% (85/86; 95% CI 97.1-100.0) of health care provider participants in the FGDs agreed to be identified by the iris scan. Also, at enrollment, 99.0% (692/699; 95% CI 98.2-99.7) of health care provider participants accepted to be identified by iris scan. Iris scan technology correctly identified 93.1% (636/683; 95% CI 91.2-95.0) of the participants returning for scheduled follow-up visits. The iris scanning operation lasted 2 minutes or less for 96.0% (656/683; 95% CI 94.6-97.5), and 1 attempt was enough to identify the majority of study participants (475/683, 69.5%; 95% CI 66.1-73.0). CONCLUSIONS: Iris scans are highly acceptable as an identification tool in a clinical trial for health care provider participants in a remote setting. Its operationalization during the trial demonstrated a high level of accuracy that can reliably identify individuals. Iris scanning is found to be feasible in clinical trials but requires a trained operator to reduce the duration and the number of attempts to identify a participant. TRIAL REGISTRATION: ClinicalTrials.gov NCT04186000; https://clinicaltrials.gov/ct2/show/NCT04186000.

Leapfrogging with technology: introduction of a monitoring platform to support a large-scale Ebola vaccination program in Rwanda.

Continued outbreaks of Ebola virus disease, including recent outbreaks in the Democratic Republic of the Congo (DRC), highlight the need for effective vaccine programs to combat future outbreaks. Given the population flow between DRC and Rwanda, the Rwanda Ministry of Health initiated a preventive vaccination campaign supported by a vaccination monitoring platform (VMP). The campaign aimed to vaccinate approximately 200,000 people from Rwanda's Rubavu and Rusizi districts with the two-dose vaccine regimen Ad26.ZEBOV, MVA-BN-Filo. The VMP encompassed: biometric identification (iris scanning), mobile messaging, and an interactive reporting dashboard. The VMP collected data used to register and identify participants at subsequent visits. Mobile message reminders supported compliance. To 13 November 2020, the campaign was half complete with Ad26.ZEBOV administered to 116,974 participants and MVA-BN-Filo to 76,464. MVA-BN-Filo should be given to participants approximately 8 weeks after the Ad26.ZEBOV with a compliance window of -14 and +28 days. Of the 83,850 participants who were eligible per this dosing window for the subsequent MVA-BN-Filo vaccine, 91.2% (76,453/83,850) received it and 82.9% (69,505/83,850) received it within the compliance window defined for this campaign. Utilization of the VMP was instrumental to the success of the campaign, using biometric technology, dashboard reporting of near real-time data analysis and mobile phone communication technology to support vaccine administration and monitoring. A comprehensive VMP is feasible in large-scale health-care campaigns, beneficial for public health surveillance, and can allow effective response to an infectious disease outbreak.

Mobile training and support (MOTS) service-using technology to increase Ebola preparedness of remotely-located community health workers (CHWs) in Sierra Leone.

BACKGROUND: The Ministry of Health in Sierra Leone has developed and operationalized the national Digital Health Strategy to guide integrated roll out of e-health/mobile health solutions. The goal is that "by 2023 an effective and efficient ICT enabled system supports delivery of quality, accessible, affordable, equitable, and timely healthcare services and moves Sierra Leone closer to achieving universal health coverage". Investing in digital platforms for the education of community health workers (CHWs) in Sierra Leone is a critical strategic approach to strengthening the country's readiness for future Ebola outbreaks. A new national curriculum for this target group is being implemented that is based upon classroom training approaches. In a country where many CHWs are remotely located, the use of technology can be an enabler to reach such individuals with key training content to repeat the most important messages. Here we describe the piloting of a mobile training and support (MOTS) service for CHWs using interactive voice response (IVR) technology in Bo district of Sierra Leone. This training platform delivers voice recorded training content in local languages on the topics of Vaccines and (Ebola) Disease Surveillance & Outbreak Response. METHODS: MOTS was developed in collaboration with the Sierra Leone Ministry of Health & Sanitation. Training content was customized in line with the national training curriculum and case reporting requirements. Local ethical approval was achieved and a test protocol involving recruitment of 125 consenting CHWs was implemented in Bo district of Sierra Leone. Two training modules-one covering vaccination and one covering outbreak response and disease surveillance were delivered to the mobile phones of participants as audio messages in the preferred local language. Knowledge change was assessed largely through pre- and post-quiz assessments also implemented through IVR. RESULTS: Knowledge acquisition was observed in the 123 CHWs completing this pilot assessment. The extent of knowledge acquired was higher with the Vaccine training module when compared to the (Ebola) Disease Surveillance & Outbreak Response module. The technology was readily accepted by this population and their engagement was such that they also provided important elements to be improved prior to further implementation. The order in which training modules are delivered as well as general fatigue of the IVR methodology for participating in the quiz assessments may be of importance and requires further investigation. CONCLUSIONS: Technology should be considered when planning delivery of training to CHWs and can be positioned as a vehicle by which repetitive aspects of important training content can be reinforced without the need for additional classroom presence of the CHW community. Sustainability of such solutions requires cost containment and subsequent software accessibility for authorities in resource limited settings. Transparent partnership and alignment with the Ministry of Health & Sanitation in Sierra Leone from the outset of this project is considered an important element to ensure successful implementation.

Development and performance of conventional HIV-1 phenotyping (Antivirogram®) and genotype-based calculated phenotyping assay (virco®TYPE HIV-1) on protease and reverse transcriptase genes to evaluate drug resistance.

OBJECTIVES: A wide array of monitoring tests is commercially available to gauge HIV-1 disease progression and the overall health status of an HIV-1-infected patient. Viral load tests provide a picture of viral activity, while CD4 cell counts shed light on the immune status and can help physicians to prevent the development of opportunistic infections in patients. On the other hand, genotypic and phenotypic resistance testing and therapeutic drug monitoring help to optimize HIV-1 antiretroviral therapy. Resistance testing is currently recommended within the standard of care guidelines to aid the choice of new drug regimens following treatment failure(s). METHODS: Genotypic testing described here is based on the amplification and sequencing of an HIV-1 protease (PR) and reverse transcriptase (RT) region from a patient sample to identify resistance mutations associated with PR and RT inhibitor resistance. A genotypic test takes a week to perform and the results are reported as a list of detected mutations. The virco®TYPE HIV-1 report uses genotypic data to predict phenotypic susceptibility by linear regression modeling that uses a large correlative database of genotype-phenotype pairs. Phenotypic testing measures the ability of the virus to replicate in the presence of a drug and provides a direct measurement of drug susceptibility in vitro. Since phenotypic analysis is laborious and time consuming (28 days), genotypic resistance testing is currently the standard reference method used for HIV-1 resistance testing. However, a phenotypic test is important when a patient harbors virus with complex genetic patterns, or when the mutational resistance profile for a particular drug is not well-characterized. RESULTS AND CONCLUSIONS: Some of the currently used resistance tests are partially automated enabling laboratories to increase overall efficiency. However, maximum automation and standardization of the process, instruments and software that we have described here can overcome many of the problems encountered with current tests and aims at having a compliant, high-throughput, diagnostic laboratory, which can guarantee sample integrity from sample reception to result reporting. We also describe in detail the development and performance of virco®TYPE HIV-1 (genotype) and Antivirogram® (phenotype) assay on PR and RT genes to evaluate antiretroviral resistance.