Deploying DHIS2 for COVID-19 Vaccine Delivery simultaneously in Mozambique, São Tomé and Príncipe, Cape Verde and Guinea-Bissau

Saudigitus supported four Lusophone nations with the rollout of their COVID-19 immunization systems, adapting DHIS2 to meet local needs and overcoming country-specific challenges

In Mozambique, the team from Saudigitus (HISP Mozambique) had one week to transform the EPI program’s paper tools into a DHIS2 system ready to support the launch of the country’s COVID-19 vaccination campaign. In São Tomé and Príncipe, they were embedded with the national team, and adjusted the system based on insights from local health workers at vaccination sites. They shared this experience with vaccination supervisors in Cape Verde so that they could take advantage of these local innovations from the start. In Guinea-Bissau, they moved quickly to help the country deliver a batch of vaccines that were two weeks away from their expiration date. With team members on the ground in each country, Saudigitus was able to customize the DHIS2 COVID-19 Vaccine Delivery Toolkit to meet local needs and provide training and support for data entry, while also keeping in touch and sharing experiences across countries to improve the regional response.

A health worker enters COVID-19 vaccine data into DHIS2 using an Android tablet in Guinea-Bissau

Mozambique: EIR with pre-registration and mobile data entry, daily aggregate monitoring, and AEFI tracking

Saudigitus is based in Mozambique, a country which has years of experience using DHIS2 for a variety of health programs. However, several of these programs have historically worked independently of each other to varying degrees. This was an early challenge in the rollout of DHIS2 for COVID-19 vaccination, and required Saudigitus to work with Mozambique’s EPI program, the HMIS and Pharmacovigilance teams, and the WHO country office to reconcile different versions of paper data collection tools for COVID-19 vaccination into one form, which could then be transitioned to electronic format in DHIS2. By the time the format of this paper tool was finalized, there was only one week before the first 200,000 vaccine doses were scheduled to arrive.

To get the system set up quickly, Saudigitus downloaded and installed the standard DHIS2 Electronic Immunization Registry (EIR) Tracker and Adverse Events Following Immunization (AEFI) metadata packages and modified them to meet local needs. Some of the required adaptations were adjusting the time period between vaccination appointments first and second doses, adding additional questions for patients (such as information on prior infection and pregnancy status), adding specific target vaccination groups, creating a pre-registration program and importing data into it, incorporating the Sinovac vaccine as an option in the package, and adjusting the daily report and dashboard to meet the government’s needs for aggregate reporting. In addition to local input, they also discussed best practices for customization with HISP groups in Sri Lanka and Rwanda — two of the first countries to deploy DHIS2 for COVID-19 vaccination.

Phase 1 of Mozambique’s vaccination campaign targeted front-line healthcare workers. Saudigitus was able to pre-register this group in the EIR system by incorporating HR data into DHIS2, and this information was used to schedule vaccination appointments and to speed up data entry process. At the vaccination centers, data was first recorded on a paper register and then entered into DHIS2 on tablets using the Android Capture App. To support both case-based vaccination management and daily national-level monitoring, Tracker and aggregate data were collected together. Daily aggregate reports were submitted at 2pm each day to populate analytics dashboards for teams at district and national levels. Meanwhile, Tracker data was entered continuously throughout the day. Saudigitus continues to work with MOH authorities on pre-registration approaches targeting the general public vaccination phase.

The vaccination support team faced several challenges in the rapid rollout of this system. Among them were the large size of Mozambique, inadequate internet coverage and mobile device procurement, and the lack of prior experience working with Tracker — the existing DHIS2 immunization system in Mozambique was based on aggregate data. To address these, Saudigitus provided internet connectivity for the devices used in phase 1 of the vaccination campaign, and in coordination with MOH, team members were deployed to various provinces around Mozambique to get input from end users and provide training and support, in addition to convening daily online meetings between district teams to facilitate sharing of challenges and solutions. Thanks to the fairly smooth launch of the system, the national EPI team and other partners are engaged in using Tracker for routine immunization programs, and have requested additional capacity building support. Saudigitus is also working with WHO AFRO on training for national pharmacovigilance supervisors to monitor AEFI data from the COVID-19 campaign, and is collaborating with HISP UiO on interoperability between DHIS2 and VigiFlow as well as DHIS2 and OpenLMIS.

São Tomé and Príncipe: Successfully launching Tracker thanks to thorough planning, on-site support and real-time monitoring and supervision

Health workers verify DHIS2 COVID-19 vaccine data in São Tomé and Príncipe

In São Tomé and Príncipe, Saudigitus was there from the start of the planning process for COVID-19 vaccine distribution. This allowed team members to travel to the different regions where the vaccination took place — visiting 95% of the vaccination sites — to look at strategies for vaccination, and develop solutions for local issues. For example, when vaccinators at some sites discovered they could get more vaccine doses per vial than initially planned, Saudigitus updated the DHIS2 dataset to change it from an automatic calculation to manual entry, to allow for accurate tracking of doses given. They also supported local strategies for locating clients to vaccinate with extra vaccine doses, empowering mobile teams who could reduce dosage loss rate.

Vaccine data entry in São Tomé and Príncipe featured a robust supervision process: Two people work on data entry in each vaccination team, and supervisors collect the paper forms for individuals at the end of each day and compare it against the aggregate data. Thanks to their preparation, training and support, vaccination teams in São Tomé and Príncipe achieved 100% completeness in their reporting, with all vaccination data entered in Tracker. A comparison of their aggregate and Tracker data revealed a match between the data. The high degree of agreement allows São Tomé and Príncipe to transition to Tracker as their primary source for monitoring and reporting in the second dose, allowing them to take advantage of the granularity of Tracker data. These real-time monitoring Tracker dashboards help the EPI, HMIS and surveillance teams understand what is going on at each vaccination site.

This COVID-19 vaccine delivery system is the first national-scale Tracker implementation in São Tomé and Príncipe, which had previously used DHIS2 only for aggregate data. The first training on the use of Tracker was given just two days before vaccination started, which was not enough time to also deliver training on the Android Capture App, so laptops were primarily used for data capture in the first vaccination phase before the first dose. Training on Android has subsequently been given, allowing android devices to be incorporated for mobile data capture in subsequent use of Tracker.

Effective support and information sharing thanks to a regional approach

At the same time as they were working in Mozambique and São Tomé and Príncipe, Saudigitus also supported the deployment of DHIS2 for COVID-19 vaccine delivery in Cape Verde and Guinea-Bissau, and they continue to provide support for COVID-19 surveillance systems in each of them. Working with Ministries of Health, WHO offices, and other agencies across the five Lusophone African countries has allowed Saudigitus to help build a regional community of DHIS2 experts united by language, and facilitates the sharing of ideas and expertise across the region, building capacity for using and adapting DHIS2 to new programs and challenges.

Saudigitus delivers DHIS2 training to health professionals in Cape Verde