May 18, 2011 Fighting the Good Fight: Vaccine Progression with Synflorix
VaxTrac’s mission is to end the unnecessary deaths of children worldwide by making vaccination programs more accessible and effective. The administration and tracking of the vaccines is obviously where we come in, but we always get excited when a new vaccine is developed. Synflorix™, developed by GlaxoSmithKline (GSK), is a pediatric pneumococcal vaccine that protects against life-threatening diseases such as meningitis and bacterial pneumonia, as well as middle ear infections. It is basically ten vaccines in one and each dose takes a year to make. Each individual strain is grown and developed separately, and at the very end of the process they are brought together as one vaccine. While the vaccine alone is very exciting, the greatest part is that it is being provided at a heavy discount through the innovative financing mechanism known as the Advance Market Commitment (AMC).
AMC is designed to bring heavily discounted vaccines to children living in the world’s poorest countries; Kenya was the first African country to receive Synflorix™ through the program (January of this year), Sierra Leone, Yemen, and certain countries in Latin America are also eligible to receive the vaccine. Nicaragua began vaccinating children in late 2010 and Guyana is introducing vaccines this year. GAVI anticipates that more than 40 developing countries will receive pneumococcal vaccines through the AMC by 2015. Over the next decade, GSK has committed to provide up to 30 million doses annually under the AMC. Both GSK and Pfizer signed 10-year contracts through the AMC to provide up to 300 million doses each of their pneumococcal vaccines, at an approximate reduction of 90% of the cost in developed markets. This is great news!
Backed by five donor countries – the United Kingdom, Canada, Russia, Norway and Italy – and the Bill & Melinda Gates Foundation, the AMC is exactly what is needed to make significant reductions in vaccine preventable deaths of children worldwide. One major component not yet addressed is the administration and tracking of the vaccinations in each approved country. We already know that vaccines are wasted through poor administration and tracking methods – the use of VaxTrac’s system coupled with the AMC’s distribution of Synflorix™, could change the future of children in many countries.
We are working tirelessly to continue to improve our system, software and processes. Currently, we are raising funds for our second in-country test pilot. Stay tuned to our blog to see what country we visit next as we continue to fight the good fight!
To donate to our cause, please visit the Get Involved! tab on the site. Every dollar helps.
March 1, 2011 What’s keeping us busy in software development.
Registration Screen Concept- May 2010
Considering where we are now, I find it astonishing that we started writing our software only 9 months ago. When we went to India in November, we had a useful but jagged solution. As the scope of our first pilot was only 6 weeks, we focused on benchmarking our ability to acquire fingerprints from our target populations and work through some of the confounding human factors.
We were forced to make changes on the fly to our biometrics software to stop false rejections of very small fingers. By the end of the pilot, we were passing the patients’ age as a thresholding level which patched the issue, but gave us another thing to keep track of. We were also logging finger images of patients who we had trouble scanning, but since the initial failure was highly correlated with combative patients, these extra scans were also difficult to acquire.
In the 3 months that we’ve been back, we’ve made strides in addressing these problems. We now are able to automatically send for analysis anonymized finger images of patients who present a difficulty to operators. While this won’t be included in release versions, it will help us improve our methods during and after our next pilot. Additionally, it should now be possible to scan patients of all ages without the need for a thresholding factor, allowing DOB to only be input the first time the child is being registered. Lastly, we made small flow improvements in the registration module. It used to be necessary to scan left-right-left-right, adding time and communication to the process. Now we complete two scans on the left before moving on to the right.
Registration Screen - March, 2011
Arguably the most clear lesson learned during the last pilot was once a child realizes they’re going to receive a shot, they typically don’t want to cooperate any more. Once a child becomes combative, it is much more difficult to get a good scan of their fingers. The most simple solution to this problem is to remove our unit from the injection area. We’ll see how simple this is to do in the field, but without cost prohibitive sedation or massive amounts of candy, this is the best way to keep kids calm while we scan them. It seems like a small problem, but looking back, it was far and away our greatest source of rescans and failures.
At the moment, we’re gearing up for a late March-April follow up pilot. Our main goal is to benchmark our re-identification capability. We’ll be working with the entire spectrum of ages, from infancy up to near adulthood. We’re expanding to a larger number of outlets, and pushing hard for inclusion in government clinics. If we achieve an acceptable re-identification rate during our stay, we’ll be leaving technology in place and this will become our first full time installation.
November 19, 2010 Food: VaxTrac enjoys its own Green Revolution
Food is a favorite topic of travel junkies. As Mark said in an earlier post, I am more controlled by my stomach than he is, so I’ll take a stab at describing the cuisine of Narnaul.
A smaller roadside veggie market.
As India is a largely Hindu country, there are a number of items that aren’t on most menus. Cows, being sacred, are used only for their milk. In fact, Mark told me it’s illegal to slaughter a cow in some Indian states. That may have been a lie to stop what would have become a quest through Delhi for a hamburger, but I’ll give him the benefit of the doubt. In most towns you can find a couple of places that may serve chicken. In larger areas you may also find mutton. The majority of restaurants in this part of the country though are strictly vegetarian.
I’ll admit this, for the first 7 days I was in India I was hungry all the time. Between the jetlag, and the typical Mark breakfast of coffee and a cliff bar, by the time we ate lunch after returning from the field, it was 3:30 and I was ravenous. To add insult to my hunger, we went strictly vegetarian for the first few days. We spent that weekend rationing eggs between those to be fried and those to be fried and put on top of the Indian equivalent of ramen noodles. Those were dark times. On Monday, I made it known that I had to eat the meat of another animal. We went out to lunch at one of the two hotels in town that regularly serves foreigners and thus carries chicken. I’ve never enjoyed simple karahi chicken so much. Right there I swore an oath that I wouldn’t go hungry again.
The chaos of the central market.
After finishing up at the office, we had Neeraj escort us to the local market. It’s really a site to behold. Rows of narrow shops opening onto the street, in front of each one a street vendor’s cart. People weave through the carts and parked motorbikes, while cars and bikes honk incessantly. Complicating life for the traveler, the list of foods one would be wise to avoid includes unpasteurized dairy (which is all local dairy) and delicious street food. We broke both of those rules with zeal and barely an ill effect.
You're well served to check the cauliflower for insects.
Neeraj brought us to the green-grocer portion of the market where there were hundreds of feet of stalls, each one with a vendor selling pretty much the same vegetables. We bought the essentials of the local diet; onions, ginger, garlic, tomatoes, potatoes, and even some cauliflower. The plan was to make subzee, a catch all term for a pot of vegetable curry. We then proceeded to the dry grocer for grains and oil, and then to a pot shop for, you guessed it, a pot and a stirring spoon. The spice store was my favorite. It’s amazing to see a 50lb sack of tumeric displayed with the top cut open and the burlap rolled down. Our haul cost us roughly $10 with the bulk of that going to our new pot and spoon. As an example, a kilogram of onions will run you roughly $0.60.
Armed with all the stock goods, we went home, did a little work and then made dinner. We’d forgotten the only knife we owned was a serrated paring knife which added an element of danger. Also the onions here can make you cry from across the room. It really is a miracle no one lost a finger in the early going. The meal of subzee and rice was tasty but in my mind not ultimately satisfying. Something was clearly missing but we weren’t sure what. The veggie curries from the local eateries were more rich and filling, even when they didn’t contain any cheese. The next night we made dal, which is a lentil dish that’s ubiquitous in this part of the world. It was delicious but I still felt something was missing from our diet.
Subzee and Rice! Our first home cooked meal.
On Thursday we stocked up for the long weekend. We thought we’d identified the missing ingredient to our meals, bread or more specifically chapatis. The ingredients are simple; wheat flour, water, oil, salt. You roll out that dough into thin discs and then fry the dough in ghee. I’d heard of ghee from my parents but we never used it at home as they claimed it was unhealthy. It’s a major constituent of the diet here in the state of Haryana, and it’s basically just clarified butter. As we found out, it’s delicious and the fat kick our bodies were craving. That night we made a curry of boiled eggs and potatoes, and set about making our first chapatis. They were a bit on the flaky side, but fried dough is delicious in almost any form. That dinner was our finest work to date. We later found out that Chipatis don’t need to be fried in butter. That realization didn’t really change much.
Curried Eggs and Potatoes- Deeelish.
Chipatis!
From that point on, it was smooth sailing. We’d make bread a couple of times a day and enjoy our various curries. It was labor intensive but we enjoyed the craft. Sadly last Tuesday, Mark returned to the states and I drove back from Delhi with a nasty stomach bug. I’d been suffering for 24 hours and I didn’t want to add fuel to the fire by eating anything spicy. When Raju asked if I’d like to stop for a snack on the way home to Narnaul I agreed, thinking I’d order the most bland possible item.
Forty minutes outside of Delhi, Raju pulled off the highway and I saw a symbol recognizable the
Ronald, just as creepy as ever.
world over, Golden Arches. Without prompting and without me mentioning my condition, Raju had brought me to McDonalds. As sophistocated world travels, we’re supposed to scoff at the idea of eating American fast food in foreign countries. I however, was elated. Inside and out, the McDonalds was just as you’d see anywhere in the US. It was eerie. The only noticeable difference beside the Indian employees was the menu. Offering tofu burgers, veggie wraps and the McMaharajah, it almost seemed like the universe was mocking my beef-lust. Mercifully they had chicken nuggets and french fries. I don’t know what it was about the pressed chicken-parts, hydrogenated oils and what passed for BBQ sauce, but it warmed my belly, and quieted my colon. I never thought I’d find comfort in the kitchen of a clown, but on the highway somewhere between Delhi and Jaipur, I’d found the best cure for Delhi belly that I’ve heard of so far.
As the last of the VaxTrac team in India, things have quieted down significantly for me. Without the extra hands in the kitchen I don’t cook every night. I pick my battles carefully with the onions and tiny garlic. I’m already wondering what I’ll miss when I go home next week. I know I’ll think often of our new friends, the daily rhythm of rural life, the roads, and the feral cows. But I fear what will drive me back onto a plane to India in late February won’t be the amazing opportunity we have to change immunization, it’ll be the sweet sweet ghee. It’s melted butter in a tub and it goes with everything! If you’ll excuse me, I have some dough to fry.
November 18, 2010 And then there was one.
Mark left India last Tuesday, charging me with the completion of the pilot program. As I’ve said at this point we’re basically gathering more data to improve our biometrics algorithm. For me it means a couple more field visits and dual boxing a research laptop to log data and an enrollment station while speaking busted Hindi… I feel like a really lame DJ, operating two computers while trying to get a 14 month old to show me his thumb.
When I’m not with the MIF team or out seeing the country, I’m confined to the farmhouse. The solitude’s given a chance to tell you about some we’ve been kicking around for mobile implementation for the past 6 months. I don’t want to get to deep into specifics, but we believe in certain locales it’s possible that we may be able to use $30 “dumb” phones as platforms for biometric enrollment in the next year. That prospect keeps me up at night. It’ll take a confluence of factors along with appropriate local infrastructure to get to that price point, but I think for urban areas where there are hundreds or even thousands of potential vaccination outlets, a truly low cost solution can help drive the kind of penetration we want. The easier we make it for people to use our registry, the more powerful it becomes. Our deep rural solution is still going to require a a more costly handset, but I’m confident hardware prices are going to allow us to do some really cool stuff with that tool also.
Besides developing the next round of platforms, we’re still devoting a good deal of focus to building our organization. Since we like to be able to make rent, a good deal of that thought is given to fund raising. The Gates grant is an amazing opportunity for not only funds but connections, and a kind of street cred and exposure that you can’t get elsewhere. Still, this grant program is project oriented and we’re looking for someone to invest in VaxTrac as an organization. We think we’re making some headway in that direction also. Our goal has always been financial solvency within 5 years, with revenue paying directly for programs and overhead. To do that, we have to make our solution so effective and so cheap that everyone can afford to use it and would be foolish not to.
Will you spend you time learning yoga?
...or perfecting your crane kick?
November 17, 2010 Tech Update!
In case there happens to be anyone out there who reads this blog with a ear toward the technical aspects of our pilot project, I’ll offer what I hope will be a concise update. A quick warning; there will be very few pretty pictures and no cultural anecdotes.
We arrived here in early October with the products of the summer’s software development phase. Armed with countless thumb-drives, six netbooks, and a large plastic tupperware crate full of other hardware, we were fairly certain we had everything necessary to start testing our capabilities. We had different goals for three technical categories; hardware, overall software performance, and biometric performance. I’ll try and explain our goals as we progress through each category. Please note these goals were specifically tied to the non-human elements of our project and don’t include consideration such as the acceptance of parents of the idea of biometrics, the willingness of children to be fingerprinted, and a myriad other potential issues we have to be cognizant of.
Hardware:
We made our hardware selection for this project with the intention of using the cheapest
VaxTrac, in vivo
technology that would get the job done. We’re in the process of moving towards smaller, cheaper machines, but as the most important objective of this project was to prove the concepts underlying a biometric vaccination registry, the simplest platform to deploy quickly was a netbook. In the end we went with low-end machines running Atom processors.
We wanted to see if this type of platform could hold up to field conditions. So far it’s performed admirably. Despite the low power processor, it runs the biometric applications all day at an acceptable speed, and the stock RAM configuration has worked well enough for the background applications our database requires. The only downside is the display needs to be cranked up for direct sun. It would be nice if e-ink/LCD dual-mode panels were cheap enough to be workable. Still, the battery life has been sufficient for full days in the field at high brightness. Enrolling around 60 kids in a day, we’ve never dipped below 50% battery. It’s pretty impressive the amount of computer that can be bought for $250 this days, as long as you don’t mind typing on a 94% size keyboard. While netbooks are a workable solution, they’re not ideal for a number of reasons. With the need for constant ventilation and an unsealed keyboard, dust would become a major issue in the mid-term. We’ll be transitioning toward much smaller and (eventually) cheaper platforms before the next field testing phase.
General Software Design:
Our original design basically turned the netbooks into stand-along web servers and called for a hgih number of applications to run simultaneously. Running a server is great for rural settings as it makes synch data via physical transfer a breeze and allows us to easily change things in the field without having to download a completely new build. The predictable problem though is that it eats up memory in a big way. Our goal was to see if the software loaded and operated quickly enough to keep up with the hectic environment around field childhood immunization. Long story short, it’s currently acceptable but we can work on a couple of performance issues to make it easier on the operator. We want our solution to make the job of health workers easier, not give them yet another thing to think about.
Biometric Performance:
Our goal was to improve our capability to enroll small children aged 1-6 in our biometric database in a real world setting. By the end of the pilot, we hoped to gather enough data to improve our enrollment rate to what we deem sufficient for an effective registry deployment in the age group.
The first week was the most difficult. To effectively test the enrollment process and underlying algorithm we had to, as operators, become transparent within the system. Although we had limited experience previously, we figured out the quirks of the hardware fairly quickly and within roughly 120 enrollments, we became close to ‘ideal’ operators. Once we were competent, we began measuring the ability of the system to enroll patients as a function of age and sex. Although we were largely successful, while performing this phase we saw an issue we’d expected. Our hit rate was correlated with the age of the child. We were able to successfully enroll kids all the way down the youngest age, but we were less reliable in doing so at ages under about 2.
We took those results to our biometrics team who were undaunted. With the data provided they made a couple of improvements to be used in the remaining weeks of the pilot. The first is passing the age of the child to the program before a scan is performed and using that to adjust certain acceptance parameters. It’s seems intuitive now, but it made a world of difference. The other is to employ a specialized software tool to gather detailed data about the biometrics of kids that we aren’t for whatever reason able to enroll.
We’ve now finished half of the second trial group with excellent results. The correlation between age and acceptance is much less pronounced. The biggest problem we have is with combative children which will require some lower-tech finesse on our parts. Once they figure out our system isn’t the actual shot, they usually calm down, but some are so nervous they can’t
Deceptively strong, deceptively fast.
help themselves. Anecdotally, ages 2-3 are the biggest wimps. Kids under 2 are blissfully clueless and don’t have very much finger strength with which to disrupt scanning. We’ll be returning to the US with a wealth of data to continue to improve the system for younger children. The goal of course is to reliably identify children as they age from infancy.
Overall:
We’re pleased with the results of the pilot from a technology standpoint. We definitely have work to do before we’re satisfied that we have the right solution for a large scale deployment. Overall though, we’re quite happy that our premise is solid and that we need tweeks rather than large overhauls.
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