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Increased collaboration among partners in Zambia to improve immunization

By Dr. Kristie Clarke, Medical Epidemiologist, Center for Disease Control

Aug 23, 2016

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Photo: CDC. Paper data collection.

Photo: CDC. Paper data collection for an immunization data quality study conducted in Lusaka and Southern Province, Zambia.

Photo: Kristie Clarke,

Photo: Dr. Kristie Clarke.

Dr. Kristie Clarke is a medical epidemiologist working on the Global Immunization Division at the Centres for Disease Control (CDC). CDC sponsors the SmartCare electronic health record system, which has an immunization component included, and operates in some of the facilities where BID Initiative is rolling out the new electronic immunization registry. As part of an effort to improve vaccination data quality in Zambia, the author and investigative team explored existing paper and electronic record-keeping systems.  This post is a preliminary overview of the results.

Optimizing immunisation coverage in Zambia is an important goal, achievable with Ministry of Health leadership and close collaboration among partners. Implementation of appropriate technology could help to increase coverage, but new technology is not a solution in itself.  The skill and engagement of users are critical elements for the success of any innovation.

Through a joint project with the Ministry of Health, we asked facility staff members their opinions on immunisation record-keeping in Zambia.  For this exploratory cross-sectional, mixed-methods study, we visited a diverse selection of 10 facilities in Lusaka and Southern Province, conducting interviews with facility staff.

The team shared preliminary results with Zambia BID Initiative leadership within one week of completing data collection.  This study was an excellent opportunity to learn lessons about successes and challenges with electronic records of immunizations, and to share with others so that we can all have greater success in reaching every child in need of vaccination.

Photo: CDC. Electronic data collection conducted in a study in Lusaka and Southern Province, Zambia.

Photo: CDC. Electronic data collection for an immunization data quality study conducted in Lusaka and Southern Province, Zambia.

Key findings from the study include the following:

  • Current electronic collection of individual-level immunisation data (through SmartCare) is very limited due to logistical barriers (see below) and the need for smoother integration of data collection into provider workflow
  • Power outages continue to be a major barrier to electronic data collection; new innovations must address this challenge
  • Poor data quality on paper forms was found frequently; such issues, if not addressed, could translate into similar problems in any electronic system
  • Data quality problems (with both paper and electronic records) were more frequent in the following areas, which should be key areas of focus for improvement:
    • Vaccines administered to older children (MCV1 as compared to Penta1)
    • Vaccines given in the outreach setting
  • When redundant data collection systems (multiple paper forms, or parallel paper and electronic systems) were in place, vaccinations were often recorded in one, but not all, systems
  • Most facility staff were supportive of electronic data collection for immunisation. However, staff expressed several concerns:
    • Sustainability: Some facilities had used systems in the past that were later phased out, creating a barrier to full engagement with future electronic data systems
    • Workflow: An electronic system must facilitate workflow and meet provider needs. Wait time is an important concern; any increased time demanded by a system needs to be clearly justified by the benefits
    • Logistical barriers: The need for reliable electricity, sufficient hardware and readily available technical support were frequent concerns
    • Training: Staff stated that many staff members per facility would need initial and refresher trainings, to avoid problems due to staff leave or turnover
  • When asked about using tablets for recording immunisations, staff stated that tablets may address the challenges of inconsistent electricity and mobility to outreach sites. However, concerns with loss or theft were frequent and some were less comfortable using mobile touchscreen technology.

A final report with comprehensive findings and a full explanation of methods will be published and disseminated later this year.

The CDC team is excited to continue collaboration with BID Initiative in Zambia.  In particular, concerns about sustainability highlight the opportunity to collaborate on immunisation data standards and ensuring interoperability of any innovation with digital systems already used by health facilities, such as SmartCare.  By pulling together towards a common goal in partnership with the Ministry of Health, we can accelerate progress towards a time where every Zambian child has a healthier future through immunisation.

The findings and conclusions in this article are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention.

Co-Principal Investigators:
Dr. Caroline Phiri, Director of Mother Child Health, Zambia Ministry of Health
Dr. Idongesit Essiet-Gibson, Deputy Associate Director for Health Information and Epidemiology, CDC-Zambia
Dr. Kristie E.N. Clarke, Medical Epidemiologist, CDC Global Immunization Division
Dr. Francis Mwansa, Child Health Specialist, Zambia Ministry of Health
Andrew Kashoka, Assistant Director for Information Communication Technology Unit, Zambia Ministry of Health
Maggy Kwendakwape, Project Coordinator, AFENET/CDC
Dr. Adam MacNeil, Strategic Information Team Lead, CDC Global Immunization Division 
Data collection team:
Sara Andrist, Monitoring and Evaluation Specialist, CDC Global Immunization Division
Dr. Daniel Rhee, Epidemic Intelligence Officer, CDC Division for Global Health Protection

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