In mass vaccination campaigns, large volumes of data must be managed efficiently and accurately. In a reactive oral cholera vaccination (OCV) campaign in rural Haiti during an ongoing epidemic, we used a mobile health (mHealth) system to manage data on 50,000 participants in two isolated communities. Data were collected using 7-inch tablets. Teams pre-registered and distributed vaccine cards with unique barcodes to vaccine-eligible residents during a census in February 2012. First stored on devices, data were uploaded nightly via Wi-fi to a web-hosted database. During the vaccination campaign between April and June 2012, residents presented their cards at vaccination posts and their barcodes were scanned. Vaccinee data from the census were pre-loaded on tablets to autopopulate the electronic form. Nightly analysis of the day' s community coverage informed the following day' s vaccination strategy. We generated case-finding reports allowing us to identify those who had not yet been vaccinated. During 40 days of vaccination, we collected approximately 1. 9 million pieces of data. A total of 45,417 people received at least one OCV dose; of those, 90. 8% were documented to have received 2 doses. Though mHealth required up-front financial investment and training, it reduced the need for paper registries and manual data entry, which would have been costly, time-consuming, and is known to increase error. Using Global Positioning System coordinates, we mapped vaccine posts, population size, and vaccine coverage to understand the reach of the campaign. The hardware and software were usable by high school-educated staff. The use of mHealth technology in an OCV campaign in rural Haiti allowed timely creation of an electronic registry with population-level census data, and a targeted vaccination strategy in a dispersed rural population receiving a two-dose vaccine regimen. The use of mHealth should be strongly considered in mass vaccination campaigns in future initiatives.
In mass vaccination campaigns and other large-scale health interventions, healthcare providers are challenged to find a data collection system that allows timely, accurate, and efficient management of large volumes of data. Traditional paper-based data collection systems have been used effectively in health programs for generations, and can result in high quality data. However, public health programs that use paper-based data systems and wish to analyze data must compensate for staff, paper records, time, and funding to digitize data, potentially adding vulnerability to human-introduced error [1]–[3]. With continuously expanding mobile networks [4], [5], mobile health (mHealth) solutions are an increasingly attractive and acceptable way to collect, manage, and analyze information [6], [7]. Direct electronic data collection can result in higher quality data [3], [8]–[13] and can produce a cleaner database more rapidly [3], [8], [10], [14], [15]. Direct data entry has also been shown to be faster and less expensive when compared to paper-based data collection [3]. Though employed in various health and research settings, the use of mHealth has not been extensively documented in mass vaccination campaigns in resource-limited settings. The worst cholera outbreak in recent history has been ongoing in Haiti since October 2010, which began only ten months after a devastating earthquake struck near Port-au-Prince, the country' s capital. As of October 2013, the Haitian Ministry of Health has reported over 8,360 cholera-related deaths and over 684,000 cases of cholera [16]. In December 2011, Haiti' s Ministry of Health, and implementing partners Groupe Haïtien d' Étude du Sarcome de Kaposi et des Infectieuses Opportunistes (GHESKIO) and Partners In Health, initiated a plan to vaccinate 100,000 residents with oral cholera vaccine in two areas—50,000 in Port-au-Prince, and 50,000 in two rural communities in the Artibonite Valley. The context, strategies used, acceptability, feasibility, and vaccine coverage rates of these oral cholera vaccination (OCV) campaigns are described in detail elsewhere [17]. Fueled by an ongoing epidemic that continued to claim lives, there was urgency to complete vaccination prior to the forthcoming rainy season. We sought to demonstrate that a mass OCV campaign was possible in an epidemic, rural, resource-limited setting [18]. As a result, we documented individual-level information with greater detail than is typical in mass vaccination campaigns to understand granular-level coverage, uptake of the vaccine, trace vaccination adverse reactions, and evaluate vaccine effectiveness after the campaign [19]. We also wanted to ensure as complete vaccination coverage as possible to leverage the herd-immunity effect of the vaccine [20]–[22]. In order to collect the depth of information needed within a short period of time, we used an electronic mHealth solution with the primary aims of (1) providing a timely, efficient data management system, and (2) mapping and documenting detailed information on campaign community coverage and vaccine uptake for 50,000 vaccinees in two isolated communities in rural Haiti.
Ethics approval was obtained from Partners Institutional Review Board (Boston, MA) for secondary analysis of the data collected during the census and campaign. All data were collected as part of a public health campaign (approved by the Haitian National Bioethics Committee); informed consent was not required during the campaign. The vaccination campaign was conducted in Bocozel and Grand Saline, two sections in the Artibonite Valley of Haiti [17]. Bocozel was initially the targeted section for the campaign, but after census showed fewer than expected residents, the vaccination campaign area was extended to Grand Saline. Both of these agricultural communities are isolated and have poor road infrastructure, making access and travel to and within the areas difficult. A census was conducted in Bocozel in February 2012 to pre-register eligible residents and to deliver an education campaign on hygiene and sanitation messages [17], [23]. All non-pregnant residents over 1 year old living in the section were invited to be vaccinated. A unique number was assigned to each house within each locality, and was marked on the door or wall of the house and recorded in the census database. Other variables recorded at the time of census were full name, gender, age, and locality (neighborhood) of residence. A census was not conducted in Grand Saline. The vaccination campaign followed from April to June 2012 in two phases to avoid a schedule conflict with an oral polio vaccination campaign. Phase 1 targeted adults and children aged 10 years and older from Bocozel, and Phase 2 targeted children 1–9 years old from Bocozel, as well as all Grand Saline residents [17]. A three-tiered campaign strategy was used: community centers, schools, churches, and communal areas throughout the area were designated as fixed vaccination posts—44 in Bocozel and 11 in Grand Saline. When data demonstrated that attendance at the fixed vaccination posts began to wane, the supervisor and project managers moved to mobile posts, and subsequently to a door-to-door strategy. Data were collected using handheld Samsung (Seoul, South Korea) Galaxy Tabs with a 7-inch display running Android operating system; 50 tablets were used during the census, and 40 during the vaccination campaign. The software platform was built by a contracted partner (Majella Global Technologies, Portland, ME, USA) on Open Data Kit. External battery packs with dual USB charging ports provided a portable, backup power supply. Data records were first stored locally on devices in the field, and uploaded nightly via office Wi-Fi to a secure, web-hosted database. Online registries were subsequently downloaded nightly for analysis. All tablets and computers were password-protected and encrypted [24], [25]. Those interested in being vaccinated received a vaccine card either during the census, or at the vaccination post if they had not been included in the census for some reason. The vaccine card included a unique numeric barcode, full name, gender, age, locality (neighborhood) of residence, and spaces to record the date of each vaccination. We retrieved and input resident information by using the tablets' barcode-scanning function. Manual entry of the barcode number was possible if scanning failed. Receipt of each of two OCV doses was confirmed on the card with custom-made rubber stamps. Locally recruited Haitians staffed 50 teams during the census and 40 teams during the vaccination campaign. Census teams of two had one enumerator and one community guide, and were managed by a total of 10 supervisors; vaccination teams consisted of one enumerator, two vaccinators, and one community guide, and were managed by a total of 20 supervisors. All enumerators were high school-educated. Two-day trainings were conducted prior to the census and the vaccination campaign, covering use of hardware and software, in-depth review of the data collection forms, communication style, and role-play. We also conducted refresher trainings before each new dose throughout the campaign to review software functions, updates to data collection forms, feedback from the previous dose for improved data quality, and practice scenarios. Each night, data records collected in the field were uploaded from each tablet and merged into a web-hosted database. At the end of census, population data were downloaded from the web-hosted electronic database and formatted in Microsoft Excel to become a dataset, or a “lookup table”. The lookup table was loaded back on to all tablets and embedded within the electronic forms, and served as a locally stored database from which previously collected population data could be retrieved. From April to June 2012, residents presented their cards at vaccination posts to receive OCV. Residents could go to any post, since census data was available on all tablets. Residents' barcodes were scanned and their personal census information automatically populated form fields (name, age, gender, locality of residence). We then added information at each encounter including enumerator and supervisor names, vaccination date, dose, and manufacturing batch number. The datasets were cleaned and newly updated lookup tables were loaded onto tablets between each vaccine phase. Each tablet had multiple data collection forms to provide appropriate ways to record information. The main two forms were autopopulated with vaccinee information by barcode, or by looking up the family name if a resident lost her/his vaccine card or if the barcode did not function. For those whose records could not be located on a tablet by barcode or family name, an office-based team could search any combination of identifiers in the database by desktop computer; we were then able to retrieve the original barcode number linked with the individual. If her/his record could not be located in the computer database, a new vaccine card was issued and a new registration form was completed to collect her/his information (see Figure 1). After initial days of vaccination at fixed and mobile posts, we used our electronic databases and a custom-built analysis tool to generate case-finding reports of all residents who were expected to be vaccinated, but had still not received dose 1 (or who had received dose 1, but had not come for his/her second follow-up dose) [17]. For example, during phase 1, after vaccination records from the tablets were uploaded to the electronic registry database, we could compare the current vaccination registry with the original census database to identify individuals who had registered for OCV during the census, but still needed their first OCV dose. Our teams went door-to-door, locating individuals by the unique numbers assigned to each household during the census. There was no case-finding in Grand Saline because no census was performed there. The software included automatic check features, such as logic branching and requiring a response, to ensure accuracy and completeness before being saved. During data collection, team supervisors accompanied enumerators and did spot checks to ensure that enumerators were filling in forms correctly. If any errors were found, they were corrected on the tablet if possible, or else recorded in an error log and reported to the Data Manager for resolution in the electronic database daily or at the end of each phase. During vaccination, data collected on vaccine recipients for the vaccine registries were linked directly with census data in the tablet records, allowing for accurate data linking at the point of vaccination. The registries were reviewed nightly or every two nights, and cleaned at the end of each vaccination phase. Enumerators were trained how to take Global Positioning System (GPS) coordinates during staff training. Each morning of vaccination, they recorded the location of the fixed vaccination posts with the tablets' built-in GPS functionality. We mapped locality coordinates in Google Earth, verifying them with local collaborators and against existing databases [26]. We used ArcGIS 10 (ESRI, Redlands, California, USA) to compile this information and generate summary maps of localities, vaccination posts, regional health centers and cold chain storage locations, and population coverage rates. Because localities were recorded as point locations (rather than areas), we visualized community vaccination coverage (Figure 2) and follow-up rates (Figure 3) using population-proportionate bubbles centered over locality point locations. We shifted some locality points that were clustered together to reduce overlapping of the population bubbles and to improve visualization of the data. Additional roads, canals, and water bodies were geocoded from Google Earth to produce a background reference layer. Locality-level vaccination coverage data was not available in Grand Saline because we did not conduct a census there, so aggregated data were visualized. The costs of hardware, software, and training were included in the calculations for determining the cost of implementing mHealth in the census and vaccination campaign in Bocozel and Grand Saline. Hardware costs included tablet computer purchase and rentals, and surge protectors. The cost of external battery packs and tablet accessories were excluded. Software costs included a data-hosting contract and mobile licenses for each tablet computer for the duration of the census and vaccination campaign, and the custom-built analysis tool for generating case-finding reports. Training costs included technology-related on-site training, support, and travel for two 1-week periods, which were estimated to be 40% of total training costs incurred by our contracted software platform partner.
During a 13-day census in Bocozel, we collected over one million pieces of data. Our teams enumerated an average of 14. 6 households, or 53 individuals, per enumerator per day. We enumerated 34,767 individuals in 9,517 households. Of these, 33,441 eligible individuals pre-registered for OCV. During 40 vaccination campaign days in Bocozel and Grand Saline, we collected approximately 1. 9 million pieces of data while distributing 86,659 vaccines to 45,417 individuals. On the first vaccination day, when our vaccination posts were busiest, we documented administering OCV to 6,200 individuals, or 155 vaccinations per enumerator per day. Of those who received at least one dose during the campaign, 90. 8% were also documented to receive two doses [17]. Case-finding reports were generated after initial days vaccinating at fixed and mobile posts during all phases of vaccine administration in Bocozel. When attendance at vaccination posts slowed and vaccination coverage based on census information plateaued, we created a case-generating report with address information of over 11,000 residents (approximately 20% of the target population for the campaign) of Bocozel who had registered for OCV, but had not yet received OCV. Following the vaccination campaign, we mapped 55 vaccination posts and 4 health centers used as cold chain staging areas. We also mapped 53 localities in Bocozel, plus an additional point for Grand Saline. These data were used to generate maps of vaccination post locations [17], community coverage (Figure 2), and second-dose follow up (Figure 3). The total cost of deploying mHealth during the campaign (including census in Bocozel, and vaccination in Bocozel and Grand Saline) was $29,129. Technology-related training cost $6,624; software and development totaled $7,900. Hardware purchase/rentals and surge protectors totaled $14,605, but the cost for hardware is flexible depending on negotiations, demand, and the regularly changing cost of technology.
The use of mobile health technology in a reactive OCV campaign in Haiti allowed timely creation of an electronic vaccination registry with population-level census data, and a targeted vaccination strategy in a dispersed rural population receiving a two-dose vaccine regimen. Direct-entry electronic registries allowed us to evaluate community coverage in near real-time, and to generate case-finding reports that resulted in greater than had occurred with fixed vaccination posts. The collection of GPS coordinates for geospatial mapping allowed us to calculate, plot and visualize community coverage and vaccination follow-up rates, which were important programmatic results in the setting of an epidemic and humanitarian crisis. The use of mHealth should be strongly considered in future mass vaccination campaigns, including during epidemics and situations in which timely access to vaccination coverage data is required.
The World Health Organization (WHO) recently endorsed the creation of a global oral cholera vaccine (OCV) stockpile as part of an integrated, strategic framework to address the re-emerging threat that cholera causes worldwide. In conjunction, the WHO also called for continued monitoring and evaluation around the use of OCV in different settings. In response to the cholera epidemic in Haiti that began in October 2010, Partners In Health, an implementing partner of Haiti' s Ministry of Health, vaccinated 50,000 Haitians in two rural communities in the Artibonite Valley in 2012. In this paper, the authors describe the use of mobile health (mHealth) technology for data collection and geospatial mapping to document this rural OCV campaign, focusing on the utility, benefits, and challenges of mHealth in a reactive campaign in the midst of the ongoing epidemic.
public and occupational health
bacterial diseases
infectious diseases
medicine and health sciences
behavioral and social aspects of health
global health
biology and life sciences
immunology
infectious disease control
vaccination and immunization
Using Mobile Health (mHealth) and Geospatial Mapping Technology in a Mass Campaign for Reactive Oral Cholera Vaccination in Rural Haiti