Our large training cohort in Porto Novo

This past Thursday we conducted the first of several training sessions to introduce our vaccine tracking system to the frontline health workers responsible for the system’s successful use. In fact, the success of this project in Benin–and of the organization as a whole–is far more dependent on the people sitting on the other side of those desks than it is on us. In this particular session, those people included the state director of health and his lieutenant in charge of primary health delivery (under which fall vaccination services), the WHO national vaccination coordinator, municipal-level vaccination program officials and two representatives from each clinic that has been selected for participation in our pilot project.

Dr. Biey Jose of WHO

The training lasted nearly six hours, and even with that marathon session, we will still need to do individual follow-up at clinics to answer questions and ensure proper use. We had approximately 40 people in attendance that represented a wide array of capability. Training was conducted in French by our new regional coordinator, Fidele Marc, supported by our far less fluent staff, Shawn and Mark.

Some of the training is intuitive. At the highest level, we are teaching vaccination professionals about a vaccination tracking system, something that is, at a high level, very similar to what they’re already using. The real difficulty comes from the fact that we have to teach people how to use a computer. We take for granted our own computer literacy which makes it challenging to teach someone who has literally never typed a single character nor even once clicked a mouse. We planned for this as best we could from day one. The software is designed to be as basic and intuitive as possible; the process flow mirrors what the health workers already do with paper records. Also, a large part of our training is dedicated to basic computer usage: turning it on and off, moving the cursor with the track pad, selecting options, entering information with the keyboard, etc.

The good news is that while training is difficult and time intensive, it is entirely within our own ability to overcome. So many other aspects of our project rely on external input: e.g. funders deciding to support us, government officials providing approvals. Training is unique in the sense that all we have to do is dedicate enough time and effort to reach our goals. As an added benefit, we are teaching basic computer literacy to a cadre of people that otherwise would never build that skill set. This prepares them well for a world, even here, that is rapidly becoming digitized and greatly enhances their career prospects.

Vaccination workers learning how to use the system

Fortunately, the hard work starts paying off tomorrow. First thing Monday morning, we start training, and we start at the top. We will be teaching the Ministry of Health officials and policymakers in the vaccination program how our system functions. We will get to make high-level health officials treat each other like they’re children about to receive vaccines. The role-playing part of the training is going to be the most entertaining part for us; more importantly, it will likely be the most instructive part for those being trained.

Once we finish with the Ministry on Monday, we will move out into the field for the rest of the week to train frontline health workers. As a key element of that training, we will get to introduce many people to a computer for the first time. Updates over the course of the week may be sporadic due to internet availability, but when present, they should be chock full of photos.

VaxTrac has had many milestones to celebrate over the past few years: winning the Gates grant, successfully testing the prototype, hiring additional staff members. This coming week will rank among those achievements, if not above them. By this time next week, hundreds of health workers will be using the VaxTrac system as an integral part of their everyday work. Hundreds of thousands of people will begin to see improved health outcomes in their communities.

As exciting as this is to us, we have not lost sight that this is arguably the first step–or certainly among the early steps–of a long road to success.

We were able to enjoy a relaxed workload for the first few days upon arrival. Our key contact, the WHO country manager in charge of childhood vaccinations, was stranded in Chad. As such, we were left to our own devices with the majority of our meetings pushed to the end of the week. This suited us just fine as we had a backlog of work that needed to get done. The accelerated nature of this project meant that we were still putting the finishing touches on the software translation and training materials.

Work has ramped up the past few days. We spent Thursday at the Ministry of Health providing a summary of the project to the Director General. She is already aware of the project and had already signed off. This meeting was as much to make introductions as anything else and to fine tune a couple of the project’s details. I provided a general overview of the project in French (my apologies to the Francophone world for what I did to your language). After I wrapped up, she only had two questions for me.

As background, I have sat through these meetings before. In fact, we do this in every country we visit. The results of these meetings are rarely positive. High-level policymakers are forced to sit through meetings where a couple of young Americans tell them how their vaccination systems can be improved. In most cases, these are the same policymakers who helped shepherd their health programs from coverage levels of 40% up to current levels of anywhere from 60%-90%. For the most part, they have done admirable work. So the only questions we usually get are to the tune of “Why are you here?” Which is why we were pleasantly surprised by the questions posed by the Director General in Benin.

Question the first: “When can we scale up?” For context, we are four days into a six-month project. We have not trained a single health worker. We have not scanned a single child’s fingerprints. And yet already, the Director General is thinking about how we can maximize the impact by moving from a small pilot project to a sub-national or national size. Here at VaxTrac, we probably consider ourselves big thinkers (we are out to revolutionize the international vaccine system, you know). And even we were thrown off for just a minute by the Director General’s ability to see the potential benefit and already start to move down the path of progress.

Question the second: “What assistance can we provide?” We do not ever work without government approval of our projects, which generally amounts to government officials not actively objecting to our work as long as we do not place any increased burden on their staff. Essentially, they will let us do what we need to do but that’s the extent of their involvement. To hear a high-ranking official offer us a blank check gave us pause a second time in as many minutes. We rattled off a few “would-be-nice-to-have”s and each duly got a response of “Done.”

I get the impression that the further we delve into the vaccination system of Benin, the more often we will find ourselves pleasantly surprised. Benin is still one of the poorest countries on Earth. Yet, they have one of the most admired vaccine track records among their peer nations. And even they would likely say that their vaccination system has room for improvement. It is this open-mindedness and the general willingness to collaborate and embrace innovative ideas that bodes well for further improvement.

Hardware

The cornerstone of one of our tracking units is a small, inexpensive netbook computer. Netbooks offer several advantages for how we use them. They are lightweight which puts less of a burden on vaccinators already often tasked with carrying cold boxes full of vaccines. They are energy-efficient which allows them to run on battery out in the field for days without requiring access to electricity. In addition to the netbook, the other key hardware element is the fingerprint scanner, which attaches via USB.

Software

Our software is rather unique. We custom built it, including the fingerprint processing since the use case (tiny fingers of small children) is unaddressed by commercially-available software. Because of the weak or nonexistent communication infrastructure in the most rural areas, we rely on physical data transfer. This requirement led us to employ a less-common type of database. Expect more detail on some of the technical features in a  future post. For now, we will walk through a couple of the steps and you will be able to see actual screenshots of our software.

The process starts by gathering basic information about the child. In the picture below, the health worker is being asked the gender of the child. We also record the date of birth and can record other ancillary information that might be of interest, like what relative brought the child in to be vaccinated or the literacy of the parents. This screenshot highlights an important design feature: simplicity. Health workers fall all across the spectrum of training and capability, so we were forced to design for the most minimally trained. As such, the choices available to the health worker are been minimized and the software flow is as linear as possible. The health worker does not have to choose between several available paths. There is one path and the user can only move in one dimension (forward or backward along the same path).

Selecting the child's gender

After we collect basic information about the child, it is time to scan his or her fingerprints and search for those in the database. In the two images below, you can see the interface health workers use to acquire those fingerprints. From the first screenshot, the health worker will scan the child’s left thumbprint and then the right thumbprint. Once an image is acquired, the software immediately evaluates the quality of the image. Essentially it asks: “Is this image of a high enough quality that it is able to be matched?” We do not want to waste time trying to match a really bad image. The green check marks in the second screenshot tell the health worker that good images were acquired and the system can now search the database for the child. If the images are not good enough, the health worker is told to re-scan the fingerprint.

Prompting the health worker to scan the child's fingerprints

Confirmation that the fingerprint images are of an acceptable quality

Once we have identified the patient, the health worker has several options. As our systems are adopted into new regions, it is inevitable that we will be seeing children at various stages through the immunization schedule. The “View or Modify Patient History” option will show the health worker the vaccination record and allow it to be manually updated. This is useful if we see a child for the first time but he or she has already received some vaccinations. We can copy information from that child’s vaccine card into the system. This option is also useful if a parent has lost the child’s vaccine card and is curious about which vaccines the child has received, which vaccines the child still needs, and when the parent should return with the child for those needed vaccines.

Options available to health worker after patient is identified

When the health worker goes to administer vaccines, they see the electronic version of the vaccine card with more information shown to them to make their job easier. Each row represents a specific vaccine (the Measles vaccine, for instance, or the Diptheria-Tetanus-Pertussis combined vaccine) and each box to the right of the vaccine represents a required dose according to the national immunization schedule. The vaccines and doses are color-coded so the health worker can quickly determine which vaccines to administer. If a vaccine is highlighted in green, the entire series for that vaccine has been completed; if it is orange, then the child is eligible to receive a dose of that vaccine that day; if it is not highlighted, then the health worker knows that the child needs one or more doses but is not eligible for them that day based on either the child’s age or time since the last dose. The health worker can then direct the parent to return in a specific amount of time.

Doses are colored similarly to the vaccine. If a specific dose is in green, it has been previously administered. If it is orange, the child is eligible to receive that dose on that day. If it is in gray, the child still needs the dose but is not eligible for it that day.

Electronic version of the vaccine card

Benin is a sliver of a country sandwiched between Ghana and Nigeria (with the slight buffer of Togo on one side) along what used to be known as the Slave Coast of Africa. It is home to nearly 10 million people, with French as the national language. Most notably, Benin is the birthplace of Voodoo and was also the departure point for the many of the slaves exported to the  Americas.

As of late, Benin has much to be proud of. It boasts one of the longest-lasting and most stable democracies in Africa. And from a purely personal standpoint, Cotonou, the most populous city in the country and the capital in all but name, is one of the most developed of the “developing” places we have been. While the country is still quite poor compared to other nations–it ranks 170 of roughly 198 countries in terms of GNI per capita–Benin projects an image of enhanced development in relation to other countries of similar economic status.

We chose Benin as the target country for our pilot project for several reasons. First and foremost, we found a strong operational partner in the country office of the World Health Organization. The WHO has been actively working on our behalf to coordinate with the Ministry of Health and UNICEF prior to the arrival of the VaxTrac team. The other reason we chose Benin was for the country’s track record when it comes to immunization. We can evaluate the government’s emphasis by looking at a few statistics, notably the percentage of vaccines for routine immunization funded by the Government and the improvement in coverage level over the past few years. The former shows the government’s willingness to spend its own money on the problem and the latter shows how effective it has been at using the money.

We have chosen to work in the two communities of Abomey-Calavi and Allada. Abomey-Calavi is practically a suburb of Cotonou, less than 10 km to the north and with a population of over 400,000 people. This town is entirely urban and is served by 12 health facilities. Allada is quite different. While it is only 30 km to the north, it is entirely rural. In fact, it also has 12 health facilities but only serves a population of a little over 100,000 people. Over the next few weeks, we will be training 140 vaccination health workers across the 24 health facilities. Over the course of the six-month project, the VaxTrac systems in those clinics will see approximately 30,000 children to be vaccinated.

The actual project will run for the next six months, though we will only be on the ground for the first three weeks. The project is funded primarily by the Blue Sky Foundation. The overall goal of the project is to install a system in each of 24 health clinics, to train health workers on the use of the system and to capture six months of data on which we can run analyses. Once we get the systems installed and the workers trained, we expect that the systems can operate independently (i.e. without hands-on intervention from us) through the end of the project. Below is a list of our key objectives for the project.

Objectives

1. Determine biometric reliability rate. One of the key novel features of our system is a biometric algorithm specifically designed for infant and young child (<5 yrs) populations. We can run computer simulations with old collected data sets, but there is no substitute for analysis run on hard data captured in the field. In fact, our reliability rate–as calculated through simulations–is over 99%. In other words, how do issues seen in the physical world (dirty or damaged fingerprints, missing fingers, health workers being responsible for acquiring the fingerprints) affect the reliability?
2. Evaluate the system from a human factors perspective. The success of our system is ultimately defined by the extent to which front-line health workers welcome and champion its use in their everyday work. To ensure complete buy-in from those health workers, we need to make the system easy to use. We also need to make sure it does not put any increased burden on already overworked individuals. As it is designed, it should actually make the health workers’ jobs easier, by reducing the amount of time required to gather and record information on each patient.
3. Evaluate our training materials and processes. We face the difficult but necessary task of training nearly 150 health workers on how to use the system. These health workers represent a wide array of skills and capabilities. Some will be professionally trained doctors with proficient English and computer literacy. Others will be teenagers with no formal medical training, no familiarity with computers and a complete lack of English. Everyone on this spectrum of ability and training needs to be able to use the system capably.
4. Identify the obstacles we might face and the resources we will require to scale up. It is not overly difficult to deploy 20 or so systems (although you may want to ask us again near the end of this project). A small team can install all of the units and train the health workers. However, serious issues arise when we start thinking about how to scale up to 200 clinics or even 2,000 clinics. Do we need full-time, local staff to manage the network of systems? Is the large financial commitment of putting a computer in every clinic more than offset by the financial benefit from reduced vaccine wastage?

Coming soon will be an overview of the project and an introduction to Benin. Before we get too far into the project though, I want to take the time to thank the many that have supported us. To our gracious financial backers, the Bill & Melinda Gates Foundation, the Blue Sky Foundation and the many individual donors, let me just say that your decision to support our organization from the thousands of other options that exist out there is incredibly reaffirming of our work. You are directly responsible for improving the lives of hundreds of thousands of people in Benin.

To our Board members, thank you for your continued and unwavering leadership and guidance. And to our family and friends, sincere thanks for the moral support you have provided over the past few years. We could not be doing what we are doing without the help of each and every one of you.

You can get involved today and at a price far lower than the cost of a plane ticket to Benin. Help us spread the news of our work! For all you know, that single share on Facebook or that single retweet will help us get our work in front of a new donor or supporter. We have a powerful network or supporters today, and we would like your help growing that network.

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.

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.

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.