Next-Generation Vaccine Cards: New Technology for Improved Equity in East Africa

Above. A mother walks down the street of an urban informal settlement in Nairobi, Kenya.

Global vaccine coverage has plateaued and, with pandemic-related disruptions, even declined in the last decade—presenting a major challenge for health equity in many communities.

While universal vaccine coverage is broadly desired, reaching under- and non-vaccinated children will require innovation in health data systems:

• High-quality data that allows providers, health facilities, and governments to quickly identify and respond to gaps in coverage. 
• Reliable tools that allow parents and caregivers to better access vaccines for their children in a timely manner.

An interdisciplinary team of researchers from the African Population and Health Research Center (APHRC) and the University of Michigan has co-designed an ambitious project to promote vaccine equity in Kenya and Uganda—The Next Generation Vaccine Card: Innovative Technology to Improve Vaccine Equity in Rural and Urban Settings in East Africa.

The team is developing a “digital card,” using electronic records accessed and updated by medical providers and families. The card facilitates a more secure method for caregivers in underserved populations to maintain vaccination records. It is also an advancement in the collection of individual data at health facilities and within communities to allow improved monitoring of vaccine schedules.

“Studies in Kenya suggest that when caregivers have better access to data and reminders, they are more likely to have on-time vaccination rates for their children,” said Gershim Asiki, research scientist with the APHRC and co-PI on the project.

In Kenya, the team will focus on urban populations in two of the capital city’s informal settlements. Around 60% of the population in Nairobi lives in more than 200 urban informal settlements, where socioeconomic status is relatively low. In Uganda, the team will work with the community in and around Kasese, a rural location.

In both settings, said Asiki, “public registration systems are done manually and are inadequate, making it difficult to track children for vaccinations. At the household level, caregivers have inadequate access to vital health information because of poor storage of paper vaccination cards, which leads to loss of the cards or the cards getting worn out.”

Asiki and Mutua in front of the African Population and Health Research Center in Nairobi.

As a result, card retention is very low. “Among mothers who report that their babies were vaccinated, only half can produce a card. When vaccination cards are not available, information on vaccination due dates is lost, and children end up missing vaccinations or being vaccinated late,” said Asiki.

East African countries are among the least vaccinated in the world. In Kenya only 80% of children aged 12-23 months complete vaccination, only 55% in Uganda. These figures are well below the 90% target set by the World Health Organization. In Nairobi’s informal settlements, only 66% of children complete their vaccinations—lower than in Nairobi overall (77%) and rural Kenya (80%). In Uganda, 1.6% of infants in rural communities do not receive any vaccination compared to 0.5% in urban areas.

Kenya and Uganda’s low vaccination rates and disparities in coverage are due in large part to persistent challenges in monitoring vaccination coverage and identifying vulnerable populations.

Our highly consultative process will promote uptake and sustainability of the program we develop.
–Gershim Asiki

“The current paper-based vaccine cards and records used by healthcare facilities and caregivers are vulnerable to being lost, are often incomplete, and can be difficult to compare across clinics. Retrieval of information is usually cumbersome and often nearly impossible.” Asiki notes. Even among children who do receive vaccines, “a lack of precise, reliable information of to whom, when, and where vaccines were administered at individual, facility, and population levels hinders effective control of vaccine-preventable diseases.”

The digital vaccine card solution relies heavily on a single technology: the cell phone. Mobile phone penetration rates are very high in East Africa, including in vulnerable populations. And phones are used broadly for cash transfers, even in hard-to-reach populations.

“Prior efforts to implement electronic vaccine cards have failed in many low- and middle-income countries, including Kenya and Uganda, in part because they were insufficiently engaged with the diverse needs of key stakeholders,” said Emily Treleaven, research assistant professor with the U-M Institute for Social Research and co-PI on the project.

The digital vaccine card and registry can succeed where others have failed, said Treleaven, because all data collection, monitoring, and coordination by healthcare providers and parents will be tied to a mobile phone platform: “text messaging capabilities, including reminders and alerts to parents, lets vaccine data travel with a child while allowing health systems to tailor outreach efforts at the individual and community levels.”

In short, previous tools have met the needs of some—but not all—end users. “Parents and caregivers, clinic staff, and policymakers all interact with electronic systems in different ways,” said Treleaven. An effective system must consider each group. “By centering the needs of parents and caregivers, then moving outward to address the needs of healthcare providers and database officials, our approach supports the development of a tool that can be adopted broadly and sustainably.”

The Next-Generation Vaccine Card project was awarded $1.1 million from the U-M Center for Global Health Equity as part of the Center’s Global Vaccine Equity Initiative because the project’s secure, open-source application complements, rather than competes with, existing provider-facing electronic medical record and vaccination record systems.

“The proposal to develop a digital vaccine card in collaboration with Kenyan and Ugandan partners directly tackles one of the most enduring challenges of childhood vaccination—the lost vaccine card,” said Matthew Boulton, Center associate director and senior associate dean for Global Public Health at the U-M School of Public Health. “Providing an easily accessible digital shot record for ready use by moms, clinicians, and health departments is truly innovative because it overcomes the unrealistic expectation that a physical vaccine card will always be available on demand.”

This project should help us reach more children in a variety of communities. And we know that achieving high vaccination coverage is the most successful public health intervention in reducing deaths from infectious diseases.”
–Martin Mutua

The team in Nairobi is optimistic and wants to make the app accessible as soon and as widely as possible.

“This project comes at the right time,” said Martin Kavao Mutua, a researcher and statistician with the APHRC. “Both the urban communities in Nairobi and the rural communities in Uganda have significant barriers to accessing basic medical services and basic water and sanitation services. This project should help us reach more children in a variety of communities. And we know that achieving high vaccination coverage is the most successful public health intervention in reducing deaths from infectious diseases.”

Throughout the project, the APHRC and U-M teams have also been meeting regularly with stakeholders from the Kenyan and Ugandan Ministries of Health. Ministry representatives actively participated in initial workshops, directly informed the final study design, and now have important ongoing roles in the project, including implementation of the intervention.

“Ministry of Health representatives can serve as advocates for further integration of our proposed system with their own efforts to improve electronic medical record systems more broadly,” said Mutua. “And engaging them fully from the beginning will ensure this partnership and our results meets their needs as policymakers and cultural influencers in Kenya and Uganda.”

Through better access to accurate vaccination status information and better maintenance of child vaccination records, Gershim Asiki believes “a successful digital vaccine card really will revolutionize vaccination coverage in East Africa by bridging equity gaps in rural and urban settings.”

For Asiki, it is essential to the project’s success that the team draws in experts from a variety of academic disciplines: “Our project embraces principles of co-design in proposal development and implementation. Our highly consultative process will promote uptake and sustainability of the program we develop,” he said.

The participatory nature of the project figures big in the full rollout of the Next-Generation Vaccine Card. “Implementation in real-world settings and evaluation rigor require an interdisciplinary team of academicians, including social scientists, demographers, anthropologists, epidemiologists, statisticians, health economists, health system experts, clinicians and health policy makers,” Asiki said. “And with our partners at the University of Michigan, that’s exactly the team we’ve put together.”

—Josh Messner

Other members of the project team include Godfrey Adero (Research Officer, APHRC), David Hutton (Health Management and Policy, U-M School of Public Health), Patrick Ilboudo (Health Economist, APHRC), Caroline Karugu (Statistician, APHRC), Gwenyth Lee (Epidemiology and Biostatistics, Rutgers University), Stephen Luchacha (Software developer, APHRC), Emily Martin (Epidemiology, U-M School of Public Health), Daniel Maina (Data Scientist, APHRC), Nelson Mbaya (Software developer, APHRC), Richard Sanya (Postdoctoral Research Scientist, APHRC), Geoffrey Siwo (U-M Center for Global Health Equity).

Our collaborating partners include Alfred Driwale (Assistant Commissioner of Health Services/Program Manager, Uganda National Expanded Program on Immunization), Asinja Kapuru (Consultant, Obstetrician and Gynaecologist- Kagando Hospital, Uganda), Mary Munyangwa (Consultant Paediatrician, Kagando Hospital, Uganda), Rose Jalang’o (Strategic Information Management and Communications, National Vaccines and Immunization Program, Kenya), Everlyne Etemesi (Program Officer, National Vaccines and Immunization Program, Kenya), and Catherine Mwaniki (Nairobi County EPI Coordinator).