 Hi, everyone, and welcome to this second immunization webinar. We are very happy to have you all, and I hope you have noticed that there is a new format that we are experimenting a little bit. We are streaming live through the community of practice, so the communication will be a little bit different. I hope everyone can hear me, because I've been told that people cannot hear me. I can hear you. Okay, thank you. So, yeah, we are streaming live through the community of practice, which is like a new format that we are checking out. And so we would like you to be involved directly in the community of practice. Please introduce yourself, ask questions, make comments throughout the presentations. We are going to keep an eye out throughout the whole webinar. We're going to try to answer to your questions. Some of them may be like straight during the webinar. Some others maybe are going to be after the webinar. But please use it and abuse it, really. We are hoping that this conversation will be useful for the viewers today, but the most important thing is that they're going to remain in the community of practice and this way they can be used later on from people, from other people. There is also in the community of practice thread, at the moment there is also a poll with a few questions. So you are welcome to give us more information about you, your background and your experience with Tracker and in general DHIS. Today we're going to focus mostly, as you see in the first slide, on the electronic minimization registry and event certification packages. For those who were present in the DHIS annual conference in June, we had already announced that we were launching a bunch of new packages and these two were among them. But as summer goes, we were thinking that now that people are coming back for holidays and the summer is over to revamp a little bit these packages. And so we are going to discuss mostly the electronic minimization registry, but the button event certification, you will see that it's of primary importance for the data collection and can help a lot the data collection for the population information, but in general also to give more information for the routine immunization activities. Today with us we have some very well known presenters that are at the same time probably the most important presenters. So we have Kim Frost, who is like the queen of the vaccine. She's our clinical consultant and she worked very closely with both packages and she's going to give us an introduction, especially for the electronic immunization registry. And we have Brian Adorno, who is our expert of e-registries. And finally we have Adolf de Munga, who is our senior DHIS implementer at his Peruanda. So without further ado, I would like to give a microphone to Kim. Kim, I cannot hear you. I did my video, but not my voice. Okay, can you hear me now? Okay, great. Yes, if you could just go to the next slide. Yes, so as Vito has mentioned, we have published our electronic immunization registry. This is the focus of zero to 18 month immunizations for children. This work has been an ongoing process and it was actually a foundational starting point for the COVID vaccine work based on the work that we had previously done with this prior to COVID. We were able to jump in quite easily to make a COVID program. The immunization e-registry digital data package was developed in response to an express need from countries and partners to improve timeliness, accuracy of data, coverage and effectiveness. This program was designed based on the WHO position papers recommendations for routine immunizations. We also collaborated with institutions such as the Norwegian Institute of Public Health and highlighted country use cases from Zambia, Botswana and Rwanda and also literature from HAHO. With this, we were able to use an e-registry approach. An e-registry approach is something that provides clinical guidance to healthcare providers focusing on immunization schedules, contraindications and global standards. Rwanda was the first country that we worked with to adopt this package which they adopted to fit their immunization context last year. It is to note that national guideline and policy may vary and is highly recommended to adapt this package to the local context and this was what we also found in Rwanda. This is a starting point for countries to have an electronic immunization registry but it does need to have an implementation process and decision making process. Next slide. This is the structure and flow of the program that has been created. They have the immunization program within that we have birth details and immunization stage. For many children, the immunization program might be the first entry point into the health system. The EIR showcases how small additions to normal EIR workflow can make big impact on patient longitudinal data and cross-sectional data usage. It also provides an opportunity for clinical guidance and support for healthcare providers. As you can see in this program stage, you have a birth details option and an immunization. The immunization stage is where all of the scheduled vaccines for immunizations reside and then within that we were able to add a birth notification stage, which helps collaborate with the CRVS system, the civil registration and vital events. There we go. With some simple questions, we have pre-immunization questions that help give some clinical workflow based on guidelines and then we have routine immunization with high show rules and immunization schedule and override. That is a repeatable program that goes on. We have also added birth details, which is an optional stage, which only needs to be added one time, filled in one time, and it gives some basic information of a patient's birth. This will help strengthen the longitudinal data of a patient and also give information for cross-programs opportunity. Next slide. For example, birth notifications to CRVS. By adding a simple birth notification, some questions and birth details, we have the opportunity to collaborate with the CRVS system in country to help strengthen the registration process and generation of strong population statistics. Admitting settings, healthcare workers already collect much of the core information that is needed to register a birth or a death. By adding simple birth details to the immunization registry, it strengthens longitudinal patient data. And a birth notification, it creates multiple opportunities to help overcome barriers to ensuring that births are notified to the CRVS system. By adding a few notification questions to the ER system, it could create a scale response with SMS and email notifications. And then you will get a circular effect. Once it's notified within the CRVS system, all that information and data will come back as help for generation of statistics and decision making. Next slide. Click. As you can see, this is within the tracker program. We have the birth, we have birth details, immunization and adverse events. We have opened the birth details and as you can see, there's only a few important components of what the birth was. So if this is your child's first time into the health system, we have an opportunity to grab this information. And this is not to burden the healthcare provider because it's a one-time data entry that takes limited time. Next. And then once the healthcare provider opens the immunization section, you'll notice within this program you have a birth notification pre-immunization questions. By adding three simple birth notification questions, can you confirm that the child has been registered into the national CRVS system? If yes, you will see it will have a dropdown that says, when was the birth registration done? And then you will have another question. Has the birth certificate been delivered to the parents? Within the civil registration system, to obtain a birth certificate and registration, there are many steps that it takes to complete this process. By adding this context into the immunization program, you have multiple chances to catch that child to make sure they complete registration. By answering these questions, it will trigger notifications to the CRVS program and possibly to the parents if it's designed that way. And it is important to note that the civil registration process is a legal process. And it is important to collaborate with the CRVS system to decide what is legally an opportunity and okay to have pushed down to the healthcare provider. A birth notification is just a simple, go ahead, go to the next slide. Birth notification is as simple as this. A birth notification for at has been completed at this or unit. Please review the birth details and from the immunization program. This is the beginning of a cascade of notification that can be done by healthcare providers without legal standing. But it is important to make sure you talk with your CRVS system and have a collaborative effort to know what can be done in country. And there are multiple ways to do this. Next slide. So what we just talked about really highlights how simple additions to the immunization program registry can strengthen cross program data and data programs. We also, using the registry modality, we have tried to provide clinical guidance and support to healthcare providers. We have highlighted a few of these avenues. We used hide show program rules. We use warning and contraindications. We use SMS notifications, vaccine card view to mimic the typical yellow card that parents are given. It was very important to healthcare providers to have working lists to help them know who has been in the program, who is coming, and who has been missed. Also a strong focus on analytics and indicators. If you could go to the next slide. For example, we're back into the tracker program. If you could hit next. Based program rules have been entered into the program based on age to help healthcare providers not to be overwhelmed by all the different options. If you you'll see that the child is currently two days old and from hit the next slide please is currently two days old. So we have some program rules. A child with less than six weeks you would should get these three different vaccines. So we will see that for BCG it says show at date of birth and hide once given. Or if child is greater than 12 months. And for OPV show at the date of birth hide once given hide when OPV one dose shows at six weeks. So as you can see there are these program rules that have been integrated to help strengthen decision-making process and to make sure that the child has received it. And it will show up again in the next the next visit if it hasn't been given. So it will show up until it's been given or until that child ages out. Next we have also added warning and validation rules based on the WHO proposition papers. As you can see we added a few pre immunization questions which then trigger warning and validation rules. So as you can see that this child is six weeks old has not received any of his or her vaccinations. So and that shows that this child is HIV positive but not on art yet. So with that we have BCG it is comes up saying it is contraindicated to give BCG vaccine if the child is HIV positive and not on art. We wanted to make sure that we didn't hide the BCG totally because we still wanted to give healthcare providers an opportunity to make their own clinical decision with some valid information. So the healthcare provider has an option at this time to make their own choice. Is it should do they agree with the warnings yes or no? They also have a high show warning for if a child is very sick or has a high temperature. And this one's a little bit less severe it says be aware it is advisable to defer vaccine until after acute infection with temperature greater than 39 degrees. So these are some of the rules that have been put in to help decision support next. It has been a very everyone is used to the yellow card and by just turning on tabular data entry within the DHS2 tracker program we were able to get something that mimics the yellow card. You can see what has been given at what time and you can also click on one of those vaccine events and it can pull up to show in further detail people have really liked this view. Next let me see what this question is and there are no dumb questions from Derek. I'm sorry but if a child is registered to the CRVS and a unique ID is assigned by the national authority is the ID persistent across all programs including the immunization program as a golden thread for this child. We will Brian will be giving a demonstration and maybe you can highlight this more but there is an opportunity for in the when you enter a child you have an opportunity to have either a national ID entered or a unique system ID entered. So that is what we are hoping to to create is a persistent golden thread for this child either if it's being depending on the country if they don't have national IDs which many don't they have the opportunity to use the system generated ID which can be used within the DHS2 programs across programs and that could also if based on country interests you could also use the national ID. Hopefully that answers your question we might be able to get into that more with the demo. Working list has been a big has been something very important for health care providers as we have talked to people and talked to health care providers about what they need in their immunization programs. So this within this program we've scripted these different working events so you can choose you can see all current immunization children immunize all current immunized immunized patients scheduled appointments for this week scheduled appointments today and missed appointments which hopefully can be very beneficial for planning next within the immunization program we also have SMS notifications preconfigured they can be changed as needed but for an example this immunization will be sent to parents to remind them of the next immunization visit and it just something simple says we want to remind you of your next immunization appointment for this child is scheduled at this clinic on this date we look forward to seeing you then please remember to bring your immunization card and you have the opportunity to decide when to send this two days before the immunization appointment 24 hours before the immunization appointment so all of these things can be configured per country needs next and I just wanted to highlight that our digital data packages are optimized for android data collection and are within are in the dhs2 capture app and there you can find them at the google play store so this is android is our offline solution so and I've been really impressed what android has been able to do for work to be able to do this data entry offline and then once you are have connection to be able to update upload the information next the one of the most interesting things okay we have a question is this tracker to be used at point of care I will say that it was designed to be used at point of care however we know that many countries are not ready for point of care so this can be done so you can have data entry clerks do this also you can choose when that you upload the data we just wanted to highlight the strengths of what a point of care registry tracker program can do but it can be used in different ways as your country needs EPI tracker analytics and indicators I think this is something that's very interesting when you start using a tracker program with the ability to have individual level data it enables the capture and analysts of highly granular data and adds nuance to information systems it provides opportunities for ad hoc analytics and shifting indicators over time so one of the interesting things you can do with indicators from tracker is to create cohorts rather than raw data accounts so you can make it more individualized to what your context is for example you can have a if you want to see all the children that were vaccinated from six months it will look at the child's birth date if they had it before so there's different ways that you can look at tracker cohorts and analyze the data which Brian will highlight a little bit more the indicators within this tracker program have been based on the WHO EPI aggregate program which probably many of you are familiar with and maybe have even downloaded into your country's system so we took the foundational pieces of the EPI aggregate program and created five dashboards into the metadata packages broken down into rollout age ranges dropout vaccine doses and an overall immunization package from this go ahead and do the next slide we will let Brian take over and give a demo and highlight some of the use cases from the tracker program thank you hi everyone can you hear me hope everybody can hear me yeah so my name is Brian O'Donnell I'm going to be doing a short video demo of the of the immunization registry just so that nothing nothing goes wrong I've recorded this but you can access this the same demo at the WHO-demo.dhis2.org and you can log into the demo system and explore yourself as well so I'm just going to press play here and narrate as we walk through so as Kim was mentioning we have if you go to tracker capture app and we select the immunization registry program then we go to our org unit and select a CHW unit we have a number of different working lists that would provide information on the patients that are available for the next doses and I can select a patient from there just during new one if I register a new one you'd note that there was a list of previous patients there so I'm just going to try to generate a new client that's the same name as one of those previous clients and see what happens so for example if I say that this name is Gilbert and then enter in some additional mandatory attributes such as patients contact name or sorry primary contacts first name and primary contacts last name then I try to enroll this patient then I get a top of box that says there's possible duplicates for a previous patient called Gilbert so if that's one blocker to prevent unnecessary duplication of data over if I replace this name with Gilbert and last name Sullivan then this will actually allow me to proceed because there's no primary blockers there okay so now I've opened up a new patient record for Gilbert Sullivan it's an enrollment in the electronic immunization registry program you can see that all of the the attribute details are on the right and of the birth details and immunization stage are down here in tabular data entry which is so I I will be using a some back dates just to showcase some of the functionality that are available so in the birth details stage if I enter a birth weight that is too high or too low then I will get some validation alerts that this is an incorrect state of value same goes for the gestational age to improve the equality it should be in the right range so then I would select on the birth type attendant at birth if the place of birth was at home then providing more granular detail on what the location of bullets as a village and then the mode of delivery once I complete this stage then we can move on to the immunization section or immunization stage so the date of services that we're given will actually give this as shortly after birth so we remember that the birth date is 15th of June so if we do the 23rd or the 28th of June here this is before two weeks of the past and we see the different sections that are available for us we see immunization routine is BCG 0.5 BOPV and HEPI when we say no the serous system has not been notified because it's just the night of the birth vaccination place facility there's been no history of an effective reaction we see that the allergies know pops up at the top as well as the age at visit and current days then if we say diagnosed with HIV or severe immune deficiency this is alerted to be a high risk at the very top so in future events we can also see of this child's HIV positive there is no recent infection and now we enter in all of the immunization details such as BCG 0.5 and HEPI 1 I'm going to leave these schedule overrides for the first subsequent visit so let's now generate a a new event here this is with the plus button there and I'm going to change the the dates to be about seven weeks after birth and once we do that then we can see which immunization is popular so there's the birth card that Kim mentioned earlier the yellow card we can see which immunizations were given in the previous visit as well as which that vaccinations are still awaiting within the schedule so based on the screen sometimes have to scroll a bit so the date of service is given now we're actually going to say yes the CRVS system has been notified and we will be entering the the birth registration date there and now if we also say no that this birth certificate has not been delivered now we can actually get we can actually get two different program notifications that are showing up under messages which I will be showing you later so under pre-immunization questions we can see that a history of reactions was carried over from the previous stage as well as HIV status we don't need to check off that box and but below that actually there's another one which will not be carried over which is recent infection with a temperature above 39 degrees so this time we will actually check off as a guess and here we can see the contraindication that's brought up in real time for PCV1 so based on the previous answer under immunization routine we can say that yes the child should receive BOPV1 as well as PENTA1 and will not be receiving PCV1 because of this contraindication so then once we say no we give the reason not given stock out contraindication, guardian refusal etc we say contraindication but we also say RB1 motor rates was also given so let's say that there's some other immunizations that could be given for some reasons such as there's been a recent yellow fever outbreak and we want to immunize as many people as possible for yellow fever so we would click show non-routine immunization doses here and we would provide a reason or an explanation and this then unlocks all of the possible non-routine immunizations that are available to register in the system and we see that we also marked the date in which the non-routine immunizations were unlocked so that future users could actually look up which was given so we can check off yellow fever one there but there's a long list of non-routine immunizations that you can pick from and you can also break the schedule as well by clicking show all scheduled vaccinations in case maybe you missed something or you've given something out of schedule so now we're going to schedule a new event and we'll just to show off the working-less functionality we'll make that event today so we'll say September 8th and save that and now you can see the working-less was also updated with the previous the previous doses that were given now when we go to all current patients we can see govresolvena and govresolvena is also under the the scheduled appointments for today so there is also a possibility to show how this works on android if you give me just one second here I can pull up a separate video for that so if we were to create a new case on android it follows a very similar process is what we just saw earlier I think you can see you can see the screen right someone please verify for me yes okay so as long as you can see this android screen moving good so um so we select the new registration date we select all the attributes for this person and it works very much the same way as in the web version so entering the date of birth is mandatory field and the most important also the sex of the child and then the primary contacts first name and last name so then we proceed to the next phase so we can enter the birth details and then also the immunization phases but just for demonstration I'll just show some of these drop downs as follows there's some immunization yes no boxes that are available here so that's it for this for the android demo just now but I'd be happy to go into more detail about what's available on the android application as well but quickly I just want to show off some of the the dashboards that are available and I think it's actually probably easier if I just show that um show that live so let me just stop sharing really quickly and then share a different screen here so I just wanted to show the different dashboards that are available for for end users to see and start with the overall rollouts this is the sort of overall view of how is the rollout of the eir going in your context so you can see just based on the dummy data that we have here the total number of children that were reached by the system that's the number of new enrollments since the system in dhs to speak also the total number of doses that have been administered and we can we can also see some charts based on the total number of doses or children this is a first introduction to the cohort type indicators but if we wanted to look at all of the children who have passed 1.5 years of age in the system currently um as in like um as within the last 12 months they passed 18 months of age how many of them actually received the full um allotment of immunizations that they should receive and so we're actually just at 6 right now it's a headline figure um but it would also be interesting to see um at what age these children are actually being reached by the electronic immunization register so for example the age at enrollment in weeks and then also the age at the visit in weeks so you should see some more follow-up in this in this 65 weeks or a time of 13 weeks range as well as these um as these infants accumulate more visits and more doses and then finally um location of immunization service delivery we have some geographic information this is um this is the Laos board unit hierarchy we're working with here as well as um from our our breakdown of the the location of visits um you can actually see that most of them are from mass campaigns in our system here same goes for contraindications this would be very useful to see um where the reasons why children are not being vaccinated just in general and also see some some trends here so regarding refusal and contraindication type so that was the overall rollout um I want to do a couple more one more basic one and then we can go into some of the cohort indicators so here we see the vaccination doses that were just given over the last 12 months just the total raw count of the different dose types that were given and now we'll go into age ranges which are again these are cohort type indicators um so with this number of districts it's a bit hard to see but this is actually um by by district um the number of infants um with all required zero to six week doses in the last six months so of all those infants who crossed the six week threshold in the previous three months how many of them actually received all of the required doses for that period and so now you can make a sort of an assessment of the performance of different districts based on some longitudinal data analysis you're the same thing for the other windows of of immunizations such as zero to 10 weeks 14 weeks and zero to nine months and zero to 15 months et cetera um so brian just to clarify yeah those children are just the children that have been inside the tracker program right that's correct so we're not working at um any other um aggregate data or such as like population counts of the number of of infants that are under six weeks within the catchment areas that are sort of not counted by the eir but it's just all of those infants that have been enrolled within the tracker how many of them did you follow up to receive all of their doses right um so when we do go to um the last one on dropout rates um this is actually um one one way of representing the value of having longitudinal data as opposed to rock counts of the different doses so in traditional dropout rates you might just count the raw number of dpt one doses minus the number of dpt three doses and then divide that by the number of dpt one doses given to get your dpt dropout rate the problem with this is that you're actually using inconsistent cohorts because um based on the period that these doses were given and that you're using the dpt one doses and dpt three doses would have been provided to different children but now you can actually um use consistent cohorts to make sure that this dpt one and dpt three were provided to the same individuals um and so we are actually just looking at all children who have passed six months at age this period who have dbt one but not dbt three divided by all everyone who has dbt one and also passed six months at this age so that's one explanation um we can also go into bcb bcg mcb dropout rate etc um the final thing that i also wanted to uh show just in this quick demo was um going into the system notifications oh um shoot i think this proves the demo system i actually need to be a um as a different super user to see it but um you can also show um having the messages for birth notification sent to your um to your admin user so we can see earlier that a birth notification was sent to crbs for a Gilbert Sullivan um and the same after that the birth certificate was delivered for Gilbert Sullivan um so that's um all i have but i'm happy to take a question to pass it on to item now thank you so much came in brian thank you again um this has been like a super thorough and super interesting demonstration and in general presentation of the of the of the program um if you still have questions comments and such please continue posting everything in the in the threat of the community of practice and king and brian will be there answering your doubts or just curiosities um i will just give a quick mention of the birth notification program just because uh between king and brian you heard mentioned it quite often and and yeah so we published also um a package for that and the main role of this of this package of course has been to increase the the availability but also the reliability of data um to expand the coverage of the core events such for example still birth births and deaths but they can also other other uh information that can be reported and big they can trigger real-time notifications either via email in in system notifications sms is directly if implemented as so directly from the point of care and then of course it's also um can be used to prove um the the foundation of some more reliable demographic uh data and in general statistical repository of the target population the way that the tracker has been um designed and implemented um it's uh to have three main uh three main stages that is the enrollment which is the general enrollment of the vital events so you just give like the personal information of the person of the person individual that is being enrolled then there is a stage that has to be selected so depending on the actual vital event that is happening so either birth or still birth or a death um is going to it's going to show a different secondary stage and then the final um stage if we can call it so that it's the notification that can be either sent to the civil registration or um can be sent to as I said in system other system via emails also to the person that is the primary contact of the of the individual that has been inserted in the in the system um and all this information of course can be used for data analysis we can provide the as usual the predefined dashboards uh there can be some in possibility of data triangulation there is the possibility to have some line lists um created in order to manage well the information that has been entered um in particular for data triangulation uh we would like to highlight that of course if you have in your instance a more than one package there can be some information that can be compared in order to get more information on the on the on the vital events that are happening so for example um the AFI tracker uh once the um national level program stage has been completed there is one option uh that it's the outcome of the AFI case and if for example that information is that patient has died this can be a triangulation that's you can triangulate it with the with the information that you can provide for the vital events and as for example if uh uh the person has been notified of the of the death same thing can happen with the as we said the electronic immunization register with COVID surveillance with the case surveillance for TB so um whenever you have in any of the tracker uh information that are regarding vital events um this can be triangulated with the with the vital events tracker of course very important to highlight these can also be integrated with known DHIS systems as needed but most importantly especially because of this information I would like to pass the the word to to adopt who's going to give us a more realistic and hands-on overview of the implementation and the way that it happened in Rwanda both for the electronic immunization registry and the vital events so Adolf to you okay thank you very much uh good afternoon to everyone as Victoria Victoria said I'm going to take you through or share with you the experience of Rwanda use case um how we have implemented the electronic immunization registry in the country and be able to make it interoperable with the the civil registration and the vital statistics systems of the country so as you are aware the the global uh uh immunization registry package uh has uh in it apart from the immunization registry it has also a bus registration and also uh uh bus registration and also vital statistics information in it so but in Rwanda while trying to implement the module we of course we did an assessment trying to apply to try to find what is existing uh what is existing in terms of systems in terms of information needed so after that one we have realized that the the government was in a plan of implementing part of the the immunization registry packages namely the bus registration and this registration so we by then that has been a little bit uh changed the plan on how we we we deploy the the module in the country so so with this uh few slides I want to try to summarize the Rwanda journey uh implementing uh this next please so so the health sector in Rwanda uh is not really big as the country size is also not big so so it has uh around uh 500 uh this is 500 health centers and 848 hospitals among of them are public owned and also others are private owned so DHIS implemented started in 2012 whereby by then the government or the ministries of health were mainly looking at a tool that can replace the existing standard application for the routine health formation system so gradually other vertical programs started joining the the process so the government started integrating program rated systems and that's when that's how also the immunization registry just comes in so as of now the immunization registry in the country is deployed across in all his facilities public and private and the SOPs for routine data management has been developed since the implementation has been there for a while however for the case-based reporting the SOPs uh haven't been finalized for to support a number of implementation that has been in the uh that has been depressed so far namely the the ETB registry the HIV registry ncd registries for ncd screening and also this uh listen to one for immunization registry so for this immunization registry the country on annual basis is targeting almost 370 000 children per annum for to be vaccinated throughout the routine immunization schedule next please so this is a quick summary of what I have explained in the previous slides so the immunization registry actually started in september 2019 that's when we are in collaboration with the EPI program we of course with the UNICEF, UIO, WHO and other partners we deployed the immunization immunization tracker in the country but the customization started a little bit in may but the the rollout in the country and the training has been completed in august and the system rolled out in september 2019 next please so initially the agenda to add also to roll out this plan so as from may to from may 2019 that's when the customization actually started uh by then we were targeting to have the immunization tracker uh implemented have birth notification tracker and uh and adverse event for immunization uh included and also have some TOTs for national facilitators and also to support the rollout and the implementation and uh have also end user training because there is there were an agency to migrate from the the aggregate from the aggregate the existing aggregate reporting form whereby data were being deported through HMIS routine reporting systems and the program was to have a separate immunization tracker to maximize to ensure that there is a full coverage of every child born in the country to make sure that they is access the immunization services uh so as phase two the plan uh was to of course after rolling out the the tracker the plan was to focus on information use and data information use and dashboards configuration and because it's starting uh we uh we didn't want to to bring every modules at once so then the IFI was planned as in the next phase doing also uh adding also some vaccination logistics and stock management tools was by then the the the program were using uh were using a next in base a tool for for stock and logistics uh management uh so as I previously explained we have we have in the first tool the plan was to make the AP AP tracker interoperable with the the government system for civil registration and the vital statistics system uh so that uh we we explored the the unique identifier provided by the CRS system uh into the API tracker uh as you know uh in most of these developing countries every newborn don't have an ID and they will answer any identification number to a unique official number for every newborn so the making the API tracker interoperable with the CRS was to benefit from uh the unique identifier provided by the CRS system and then later on of course as you implement the system uh it's not a static system there might be some changes there might be some uh cleaning of data and also focus on data analysis so in phase three of this uh uh journey it was to also to finally focus on capacity transfer because this system has been implemented as I mentioned with support of his provider and other uh partners namely University of Oslo and WHO and UNICEF and others so we wanted to close the project by transferring capacity uh documenting and doing some publications on this uh uh implementation and also continued some post-implementation supports next please so the the API tracker uh has uh then uh been deployed uh borrowing leave from the global package because as I mentioned the the country uh country had already some uh immunization data case-based data but also part of it uh related to birth registration and so forth so they were another system so we wanted to we started by customizing the the the module and they are doubting to the Rwanda context trying to to make sure that it is aligned to vaccination schedule in the country uh we did some trainings of course and uh plan some and also did rollouts of the system across the country in all uh uh health facilities um here I would precise that the vaccination points in Rwanda uh is being done at the health facility and also in some selected private institutions and all of those health facilities are required to or on every vaccinated child or in every newborn in the setting is immediately um has to to to leave the facility uh receiving uh after receiving uh the first those of for or vaccines as required by the vaccination schedule in the country uh the interoperability works as I previously mentioned was also necessary to make sure that the unique identifier from the national population the national the civil the national population registry uh uh uh is faced so that we show that we we we the the the program knows that every newborn is vaccinated and know that those who are missed who missed out the vaccines and so forth and also uh the the last the the other step was to look at data use for action here focusing uh focusing uh uh uh on as analyzing data to see the coverage and so forth here I would mention that despite all these listed steps that we're supposed to go through we didn't actually uh go through them all because there's multiple uh constant just comes in because as you've seen we started in September 2019 and in March 2020 that when we had the outbreak of of covid and which has a little bit slowed down most of the planned activities next please so as I mentioned talking about the AP AP the immunization the the the immunization tracker means that you are targeting every newborn so to maximize that there is a full coverage the the interoperability was uh the right option to ensure that every newborn uh uh notified in the CRS system can be uh we the program can know that that child has has received the vaccine or is under the vaccination schedule in the country so the CRS system that has been in place uh was mainly uh there to help multiple uh DHS based system here namely I can say the the course of this DHS module that has been implemented and is now interoperable with the with the the civil registration system and the verbal autopsy DHS module that is also uh uh implemented in Rwanda and it's it's it's a it's fetching the course of this from the civil registration as you can see the civil actual the civil registration system uh among the other vital events or the civil events there is a bus there's this there's marriage there is divorce there is a adortion and so forth so all those civil registration events are all captured in the CRS system it's a it's a national system that is rolled out very soon I'm going to show you how it works so when so the the registration in the civil registration in the country is at even though it has recently started it's it's now at a over the 90 percent coverage because the registration is has been now decentralized to to health facility for the birth that happened the health facility and also for the nearby cell office for the excuse me for the community uh birth next please yeah I I think I have I have updated is this the the last the last point one online yeah I think I have added some two some two slides two slides for this on CRS to explain a little bit how the CRS works if you can refresh a little bit the all allow me to to present those two slides I'm sorry sharing okay so do you see my my my screen I'm not sure if it's on the top right yeah so this this these slides explain how the the civil registration is done to is done in Rwanda for the for the facility births so you can see from your left from your left you see a birth happens in the maternity word somewhere in the health facility so the the the birth notification has been decentralized to to to health facilities officials to immediately notify a new birth so this automatically helps you see the they notify the into the system into the CRS system the new birth automatically the CRS provide a national a national a national identification number through the CRS system so if you look yeah I'm not sure if you see my pointer here uh for for the health facilities officials to after register notifying the child so for the child to be automatically registered the the the civil registrar at the the health at the health at the the sector the sector is the lowest administrative level of the country uh the civil registrar actually accepts the the the notification when the notification is accepted this automatically that charge is is registered and be able to get the the the national what they call the NIN the national information number so this information number is actually uh it's up for two things so the NIN is automatically generated by the CRS which is automatically fetched by the DHIS if you see on top left into a DHIS for to identify every newborn in the in the in the DHIS instance which is here we're talking about the AP trucker so the interoperability the interoperability for for the DHIS to I don't know for the immunization for the CRS DHIS has been complete so far for for for for birth for birth registry and death registry and also community death uh but the process are are being done for to be also done for the immunization registry because the program has been took a little bit time to because it's going to affect the way the business processes are the vaccination points so when the child is is is registered is after getting registered by C4 registrar the child can easily can easily have access to the bus registration certificate so and where you see where you see there is a rainbow this is the e-government services portal where every citizen can go with the the NIN and some credentials given to the person to automatically download the the the bus registration or this certificate and so forth this is for the case of a bus that happens in the health facility so with regards to so with regards to bus that happens in the in the community uh for the child to be vaccinated or to be brought to the health facility for vaccination of course through the community health workers the the the mother the mother and the child are brought to any nearby civil registrar this is the sector office uh the sector office for for registration so this this uh so this civil registrar notify a child and also register a child after registration the child the mother can go back with the NIN so this NIN can be uh be shared to the health facility when the child is is being uh brought to the facility for vaccination services of course the civil registration does everything through the civil registration system which is automatically connected to the national population registry where all best records are automatically being pushed and the civil registration and these ones provide a little bit more information on who access who are the beneficiaries of this civil registration uh database namely the national city of statistics for best rated information and of course whether born from the health facility or being born from being born in the community after registration uh parents can go to Irembo this is e-government services they can automatically generate or download the bus certificate of course which has a national edification number so this year of this comes in here to address the the constraints because initially the national population registry had population from uh age of 16 upwards so so there were a gap of under 16 of not having the unique identifier so the service is also coming to sort out to sort to solve the issue of under 16 people or children without the the unique identifier so the need is being provided to the child so and it becomes a unique identifier across all services being learned to the child uh until the child gets to 16 so because this is at its every stage uh it's not yet clear yet whether this need is going to or become the the the the national id number or whether the the the person will get a new uh a new uh a new number for id uh in the charts i'm not sure if there are questions to me probably not so that's that that's how the the community that's how the civil registrations are being done and that's how information are being shared across to the DHS instances of the ministry of health especially focusing on best records and this is helps to have like a to have a population data when it comes to calculate coverage indicators memory for vaccination for nutrition and for and other services for for give result for maternal and child health so the so coming back to the the AP registry the the the the immunization schedule in ronda a child at birth uh is being uh is being given bcg and after i've been so so the schedule is so at birth a child can have for a bcg or polio vaccine so this is the schedule so you can sorry so this is the schedule for vaccination for at birth for six weeks uh 10 weeks 14 weeks so and there are a list of antigens being given to the chart for every visit so the the immunization tracker in ronda has been customized based on this a a vaccination schedule uh where but we we have uh the profile information and also the vaccination stage which is more repeatable and captures information depending on the the age after the administration so this is a little bit the screenshots of of uh the last recorded cases for for this my my river health centers this is date of uh this august so the vaccination is not done on every day that's for one or some of the reasons to make sure that they they they are no they are no uh vials they are no and they are no uh wastage for open vials of course especially for open vials where they vaccinate children and maybe they fail to get enough children to vaccinate to find some of the doses are wasted so this is like the screenshot of the last uh of the recent work work list of vaccination list of this a health facility uh and for you this is also some screenshots from the system they listened to them uh took yesterday on on uh children is on the main as a children this is like a dashboard so i think they are since we have uh developed this immunization tracker as i mentioned just covid came in in in March so uh the program didn't have much time to work with his to fully finalize the the dashboards and and to work out on most of program indicators and the most of the other indicators and also focus on data use so that's those are the activities that are still in the plan mainly what those were in phase two as a previously explained and also phase three most of the cases has been as has not been covered implementing uh this epi epi tracker it's not a straightforward process of course you build on what is existing and also you look at the the possible opportunities in place and build on those ones so here i try to to this term of for the strengths of the opportunities that we i can share with the audience first of all uh there were a program the epi program way to to migrate from the aggregate to this case-based reporting uh that that is really that that is a very key when you want to deploy any case-based reporting so there has to be uh the the readiness of the the the the beneficiaries has to be very high uh we we also as you've seen uh Rwanda has been implementing DHIS since 2012 so they are already a well-structured staffing uh from the national wide to facility so the facilities house the term managers and in each other vaccination in every case facility and the good thing these all these staffs are on the government payroll so which means if you train people despite the movement of staff but you you have a quite number of stable uh staff uh staff uh supporting the rollout and also system use uh the country uh from the health facilities uh from this facility upwards uh all for health facilities are piped with laptops and most of them have uh uh if i can say 4g antenna to for a very good speed of internet for for data management where the 4g internet connection is not that they have models so because the the internet coverage in the country is over 90 so you find most of these facilities are well connected on the internet and have electricity the implementing this AP tracker sometimes the program runs uh outreach programs and moving around with laptops it's okay but if you have tablets which they do have a very good uh uh uh they can keep power for a long time so the tablets uh the government funded funded uh the purchase of tablets and monthly air times for for for for the in charge of vaccination in health facilities this is also a very good opportunity to support these rollouts and uh the the AP program was really very enthusiastic to be fully digitalized as they they have they have a feeling that uh the implementing this digitalization this this tool will reduce the running and the printing cost of the printing cost of of the vaccination cuts and also the running cost of this program and also the use of tablets and outreach interventions it was also a favoring uh was also uh seen as a an opportunity to make sure that every vaccination charge is automatically registered uh is directly registered into the system and at the end of the day the synchronization can be done and at the nationwide you can know how many children has been vaccinated across the country of course we had some uh challenges because even though this module has been customized and reviewed by a number of by so many experts uh the tool is designed as a as a general as a general mode to serve everyone so that has to be contextualized to every country context so it's not a plug and a play tool so it has to be adapted to the context and sometimes uh and and sometimes uh you you need to to to to accommodate to what to accommodate uh what is existing so we found there is some existing AP system and the extra data has to be imported and also uh by then the the government has already before having this global module the the AP program has itself started thinking of having a trucker module so by then a module has been there so it has to be uh enhanced and improved and also but we will be uh as you understand you you you don't replace your actual integrates of course the other challenge uh it was to while deploying this you find the technology you ask you to have to add some of the new information namely the vaccination namely the the id namely the phone number and you find on the existing vaccination cards and registry there are no columns or free is resolved to those information that are very key uh for for for the immunization for the e trucker especially uh phone number whereby the notification has to be sent to remind or to thanks the the mothers who brought their child they brought their child to for vaccination of course uh implementing a system with a multiple stage uh there are data completeness issues whereby people sometimes people forget to uh to update or to create new stages to update new visits so that contributes to to data completeness issues uh also by covid 19 uh uh didn't it wasn't really favoring the the mentorship supervision as you understand the covid just comes in came in came in while the system was at its early stage so whereby people were needed to have active mentorship supervision and a close follow up so we it wouldn't happen because people were in the lockdowns and so forth and also some planned activities were not completed because of lockdowns and uh of course uh as hisp we we we've been supporting the program uh but the program safe didn't have a a well-dedicated staff to or to respond to end users requests uh as your uh for for any uh troubleshooting any technical uh assistance that is needed that's uh what i can say for for now as a rwanda experience it's time for if we still have time we can ask you some few questions and that's it thank you thank you so much adult this is like it's always super important to have an overview of how things really happen once the packages are out there we say um we actually still have a few minutes um that we're online so i don't know uh kim or or brian is there any questions that you think it would be worth it to share a little bit more with the general public while we're still live just looking at some of the questions uh from the c o p um it looks like um one question that was for adult the question was just one second does the tracker implementation in rwanda integrate with the r h i e shared client record for example and also can you talk a little bit about adverse event monitoring at all that maybe you can answer that yes okay thank you kim yeah the the the the the musician truck uh it doesn't integrate with the uh with the you mentioned the health the health the health the health exchange the health information exchange this is what you're talking about right hello kim are you talking about the oh sorry the r h i e shared client record yes in rwanda we we haven't yet implemented the shared health records so the only so all the information that is currently shared across all health systems uh uh this information from the national population especially for case-based reporting systems so that's i can say is currently shared across with uh health related systems and also government services related systems but for for health shared health records uh uh that's not yet implemented and anything about adverse events adverse events no not yet it's in the plan but as i mentioned uh COVID has paralyzed everything so we most program is much more focused on no on COVID vaccinations but before then it was already looks down so uh so we couldn't introduce new interventions so we're actually maintaining what has been implemented great and i'd also just want to say thank you again from our side it's been a great opportunity to work with rwanda on this uh immunization program and birth registration rwanda is an interesting use case because your crvs system is so advanced and highly functioning it was an interesting process to see um kind of the opportunities for the crvs system to go into dhs to versus dhs to uh pushing information to the crv basic information to the crvs so i think that has been a very uh interesting use case and also the ability says you have such a high vaccine program to be able to use um information from the crvs system as an m&e tool um and then also to see the work um that you've done with the immunization package and getting it working on the ground has been quite impressive the you're right it's not a plug and play and i think you and team have done a great job uh having these high-level conversations on deciding what is the rwanda context and how do you want to integrate that what works for rwanda um from my point of view i will say uh i there's multiple ways to do adverse event uh monitoring i i remember two years ago when we went to your um when we went to rwanda there was one data element that said you know it has the child had an adverse event in the last 30 minutes which i'm sure we're all used to now with the covid context um and then you had an option to trigger some response i will say that we have published uh from uio on our website an adverse events program that you can look into um a lot of this information can be found on dhs to dot org immunizations uh i'll go ahead and turn the time back over to victoria so marty doll and and came also for wrapping up these uh it is in data like super important as well to highlight um um i'm like uh to um wrap up these this webinar reminding everyone that with this new format uh the the thread will remain open and you can continue posting questions especially to to adults or about general questions of the programs to to kim bryan and andy of course so even if tomorrow you you come up with a question please be free to continue dropping questions doubts comments um we continue answering them in the thread and talking about comments uh you also find um a comment about a registration to a webinar um that is about bna school cards and other apps so feel free to register to that one as well and um and a reminder that we will continue to offer these uh immunization webinars in uh in english of course and in french and the one about this same topic in french will be tomorrow reminder in case you want forward the information to your french colleagues and uh and yes i think this is a wrap up thank you so much everyone uh the presenters has been a fantastic cd a lot of work that has been that has been produced and and everyone showed up to listen to us in our and our presentations and in case for ronda uh have a lovely day and even depending on who you are and uh and yes try to continue the the the threads whenever you want cheers bye okay bye bye bye