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Early Infant Diagnosis Data Transmission System Using Mobile Phones in Zimbabwe

Henry Chidawanyika, MSc hchidawanyika@zimhisp.rti.org

Rita Sembajwe, MSPH Ponesai Nyika

5-7 May, 2015 9th INTEREST Workshop

Harare, Zimbabwe

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Presentation summary

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

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Project Overview

Building Health Data Dissemination and Information Use Systems in the Republic of Zimbabwe

also known as ZimHISP (Zimbabwe Health Information Support

Program)

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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.

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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)

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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)

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Background PMTCT DNA PCR EID 437347 Expected pregnancies per year

70133 Expected exposed infants per year

(2013 estimates)

62014 HIV positive expecting mothers were identified

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)

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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)

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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)

Transmission of results from the laboratory to health facility:

Could result in faster transmission of results to health facilities thereby reducing results TAT

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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

Opportunities for SMS based results transmission system

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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.

Opportunities for SMS based results transmission system

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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

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0

20

40

60

80

100

120

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

RDNS/WDSS Completeness 2010-2015

2015

2014

2013

2012

2011

2010

Improvements in completeness of RDNS/WDSS Opportunities for SMS based results transmission system

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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

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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

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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

Mobile Technology Selection for eEID/RNDS/WDSS

FrontlineSMS version 1.7 Technology

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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)

Mobile Technology Selection for eEID/RNDS/WDSS

FrontlineSMS version 1.7 Technology

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FrontlineSMS Mobile Client Used by nurses to submit pre-notification and client contacts to laboratory

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FrontlineSMS Server Application • Validates incoming

messages (Built in house wrap around solution)

• Triages messages to DHIS2

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Original HIV DNA PCR EID system

SMS based early infant diagnosis of HIV PCR results transmission system (eEID) SMS based early infant diagnosis of HIV PCR results transmission system (eEID)

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• SMS is used for: • Notification of new samples facility lab • Notification of lab results lab facility • Notification of results availability lab consenting mother

• Part of PMTCT Programme

• Uses SMS to report pediatric

HIV DNA PCR results

• At >1200 health facilities • All 3 labs participating as of

2015

Photo: Tanzania HMIS

SMS based HIV PCR results transmission system (eEID) NEW HIV DNA PCR EID system

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SMS based HIV PCR results transmission system (eEID) NEW HIV DNA PCR EID system

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EID HIV DNA PCR results and messages transmitted

Positive outcomes to date

*Counted messages sent out regardless of date of collection **Quarter 1

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

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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.

31260 (68%) of HIV DNA PCR results for EID were sent by SMS (out of a total of 46192 tests done).

HIV DNA PCR EID outcomes

Positive outcomes to date

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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

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Challenges faced Client side: User training and quality thereof

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)

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Challenges faced Client side: Credit availability - sometimes credit was not

correctly recorded on health facility phones resulting in non- transmission of pre-notifications to laboratory

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

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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

Indoor residual spraying (IRS) - 2014, VMMC (latest addition - 2015)

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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)

Work with service provider charge SMS costs to central number (in the long term)

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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 scalable

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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

Improved use of results for faster initiation of infants.

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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].

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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.