Tracking Immunizations During COVID-19 Restrictions Insights from Zindagi Mehfooz (Safe Life) EIR Big Data Analysis, Sindh, Pakistan

BLN Webinar on the EIR & COVID -19 Response Apr 23, 2020

Tracking Immunizations during COVID-19 Restrictions Insights from Zindagi Mehfooz (Safe Life) EIR Big Data Analysis, Sindh, Pakistan

Subhash Chandir, MD, MPH, PhD HEALTH DEPARTMENT Director, Maternal & Child Health GOVERNMENT OF SINDH [email protected] WU82 Electronic Immunization Registries in Pakistan – Breakdown by Province

Gilgit City, GB Region Population: 1.249M

Sindh Province Population: 47.89M Piloting the Zindagi Mehfooz Electronic Immunization Registry

Zindagi Mehfooz started as a simple phone-based electronic immunization registry to improve immunization coverage and timeliness.

Seed Funding

Awarded in 2011 by United Nations Foundation through the UN Secretary General’s Innovation Working Group Zindagi Mehfooz Electronic Immunization Registry Features

QR code-based Interactive SMS identification reminders

Web interface Offline mode

Mobile based data Child entry & access registry Zindagi Mehfooz Electronic Immunization Registry Features

Built in DSS for routine & Micro-planning catch up immunization activities

Attendance & GIS Predictive tracking of Analytics vaccinators

Virtual immunization Defaulter list & certificate addition of reports on vaccinators mobile Zindagi Mehfooz Electronic Immunization Registry Features Screenshots of Zindagi Mehfooz Electronic Immunization Registry Unique Identification Quick Response (QR) Code

Unique ID assigned to each child in the form of a Quick Response Barcode which can be scanned at the time of follow up WU85 Zindagi Mehfooz Electronic Immunization Registry (ZM EIR), Sindh Province

Population of Sindh: 47.89 million EPI Centers: 258 Vaccinators: 343 EPI Centers: 221 Registered in the ZM EIR as of Oct 1, 2017 – Apr 20, 2020 Vaccinators: 319 2.9M+ 1M+ 22M+ Children Women Immunizations

*EPI Centers: 0 Vaccinators: 0

1,514 EPI Centers: 193 28 Public Vaccinators: 260 Districts Immunization EPI Centers: 202 Clinics Vaccinators: 271

EPI Centers: 334 Vaccinators: 777 462 District health 2,425 staff Vaccinators EPI Centers: 145 Vaccinators: 245 EPI Centers: 161 Vaccinators: 210

Source: Zindagi Mehfooz EIR data, EPI-Sindh/IRD WU102 Annual Live Birth Cohort Captured by ZM EIR in 27 districts of Sindh Province in 2019

1,444,773 1,198,881

EPI estimated target Birth cohort captured in ZM

83%

% Cohort enrolled Impact of COVID-19 on Immunizations across Sindh Province, Pakistan Feb 29 - Apr 21, 2020

Daily average number of Immunizations for 6 months preceding COVID-19 lockdown Enrollments Flight ban Restrictions 1000th Total: 16,649 Enrollments: 32% Follow-ups: 68% enforced enforced case Follow-ups 30,000

First 100th Public 25,000 COVID-19 case case spaces Daily average number of Immunizations closed during COVID-19 lockdown 20,000 Total: 5,836

15,000 Enrollments: 31% Follow-ups: 69%

10,000 No. of children immunizedchildren of No.

5,000

0 14-Feb 21-Feb 28-Feb 6-Mar 13-Mar 20-Mar 27-Mar 3-Apr 10-Apr 17-Apr

Feb Mar Apr Calendar Date

Decrease in Immunization Visits Avg. number of children missed per 65% during Covid-19 10,813 day during lockdown

Source: Zindagi Mehfooz (ZM) EIR data, EPI-Sindh/IRD. Contact: [email protected] Percentage Change in Daily Average Immunization Visits across Sindh by District & Union Council from Mar 23 – Apr 21, 2020 vs. Sep 23, 2019 – Mar 22, 2020

District Union Council

65% Reduction in daily average vaccination visits across Sindh

Source: Zindagi Mehfooz EIR data, EPI-Sindh/IRD Immunization Coverage Across District Badin Pre-COVID-19 Lockdown & COVID-19 Lockdown March 1 – 22, 2020 and March 23 – April 20, 2020

Source: Zindagi Mehfooz EIR data, EPI-Sindh/IRD Children Missed in District West, Karachi during COVID-19 Lockdown March 23 – April 20, 2020

Source: Zindagi Mehfooz EIR data, EPI-Sindh/IRD Immunization Coverage District West Pre-COVID19 Lockdown & COVID-19 Lockdown March 1 – 22, 2020 and March 23 – 21 April, 2020

Source: Zindagi Mehfooz EIR data, EPI-Sindh/IRD Daily Average Immunization Visits across Sindh by District: Baseline (Sep 23, 2019 – Mar 2, 2020) VS. COVID-19 (Mar 23 – Apr 20, 2020)

Baseline Covid-19 Lockdown EPI estimated average enrollment Enrollments Follow-ups Enrollments Follow-ups target for surviving infants

Source: Zindagi Mehfooz EIR data, EPI-Sindh/IRD Daily trend of Total Antigens Administered across Sindh province Mar 2 – Apr 21, 2020

Mar Apr

Regular period Period of COVID-19 restrictions

Source: Zindagi Mehfooz EIR data, EPI-Sindh/IRD Daily Average OPV3 Immunization Visits across Sindh by District: Baseline (Sep 23, 2019 – Mar 2, 2020) vs. COVID-19 (Mar 23 – Apr 18, 2020)

250 228

200 194

173

153 156 151 148 144 150 139

121 115 106 Axis Title 100 99 100 91 94 94 93 85 80 75 79 69 70 60 60 59 62 62 59 56 54 49 47 45 44 43 43 50 38 38 26 31 32 30 29 26 28 28 21 22 21 19 20 18 17 15

0 Malir Badin Sukkur Thatta Ghotki Matiari Sujawal Korangi Kambar Larkana Khairpur Umerkot Sanghar TM Khan N Feroze Shikarpur Jamshoro T Allahyar Kashmore Tharparkar Mirpurkhas Hyderabad Jacobabad Karachi East Karachi West Karachi South S Benazirabad

Karachi Central Axis Title

Baseline COVID-19 Lockdown

Source: Zindagi Mehfooz EIR data, EPI-Sindh/IRD T8 Daily Average Measles-I Immunization Visits across Sindh by District: Baseline (Sep 23, 2019 – Mar 2, 2020) vs. COVID-19 (Mar 23 – Apr 18, 2020)

200 179 166 160 139 139 135 130 123 123 120 106 95 87 91 85 82 81 82 Axis Title 81 80 75 74 65 57 56 56 56 57 55 52 51 50 49 48 42 43 39 37 40 32 32 26 28 25 22 20 21 20 22 15 17 17 17 17 12 12 12 12 11 9

Baseline During Covid-19 Lockdown

Source: Zindagi Mehfooz EIR data, EPI-Sindh/IRD Daily Average Percentage of Follow-ups and Enrollments of Children in ZM EIR during Baseline (Sep 23-Mar 22, 2020) and COVID-19 Lockdown (Mar 23-Apr 20, 2020) periods by Urbanization in Sindh Province

Baseline period COVID-19 lockdown period Difference in COVID19 lockdown vs. Baseline Urban Rural Total Urban Rural Total Urban Rural Total % % %

Enrollments 2,359 3,020 5,379 898 979 1,877 -62% -67% -65%

- Follow-ups 5,114 6,156 11,270 1,768 2,441 4,209 -65% -60% 63 % - 63 Total 7,473 9,176 16,649 2,666 3,420 6,086 -64% -63% %

Enrollments (first vaccination) Follow-ups Rural areas have a 5% higher Urban areas have a 5% higher Key Takeaways 67% decrease than Urban areas 65% decrease than rural areas (65% (67% vs. 62%). Younger ages vs. 60%). Older ages are more are more affected affected

Difference in COVID19 Baseline period COVID-19 lockdown period lockdown vs. Baseline Slum Non-slum Total Slum Non-slum Total Slum Non-slum Total %% %

Enrollments 1,644 241 1,885 63 12 75 -96% -95% -96%

Follow-ups 3,580 610 4,190 1,385 213 1,598 -61% -65% -62%

Total 5,224 851 6,075 1,448 225 1,673 -72% -74% -73%

Follow-ups Enrollments (first vaccination) Non-slum UCs have 4% higher Slums & Non-slum UCs are Key Takeaways 96% almost equally affected 65% decrease than slums areas (65% (96% vs. 95%) vs. 61%). Older ages are more affected

*Karachi and Hyderabad data only. Limitation: Union Councils (UCs) with complete or partial slum areas are considered as slums. Revisions will be made with actual slum areas only. Source: Zindagi Mehfooz EIR data, EPI-Sindh/IRD Daily Updates Number of Centers showing operation and client flow by District* As of April 21, 2020

Khairpur 65 46 0 Badin 44 27 5 Open Centres Hyderabad 50 26 0 West 60 13 1 Shaheed Benazirabad 51 15 3 Open Centres Shikarpur 41 22 3 with no Client Sanghar 36 22 5 Flow Sukkur 39 21 3 Mirpurkhas 39 22 0 Closed EPI Centre Naushahro Feroze 52 9 0 Central 47 8 3 Larkana 24 27 3

Districts Umerkot 28 22 0 Tharparkar 39 10 1 Malir 40 6 2 Ghotki 27 20 0 Korangi 34 4 8 Kambar 26 17 2 Kashmore 18 25 0 South 30 7 0 Sujawal 15 8 12 Jamshoro 14 18 2 Thatta 23 5 6 Tando Allahyar 20 8 1 Tando Muhammad Khan 20 8 0 East 5 22 0 20 40 60 80 100 120

Number of EPI Centres

Source: District Field reports - Zindagi Mehfooz Program, IRD * Ghotki and Jacobabad information is pending Attendance Percentage of Vaccinators in Sindh, by District Apr 21, 2020

Vaccinator attendance on ZM, by District [% of working days from Apr 2, 2020]

>80% Kambar 100 Badin 100 70 - 79% Naushero Feroz 99 Larkana 99 60 - 69% Tharparkar 98 Tando Allahyar 97 <60% Khairpur 97 Matiari 97 Malir 96 Shikarpur 95 Shaheed Benazirabad 95 Karachi West 94 Sanghar 94 Mirpurkhas 93 Umerkot 93 Tando Muhammad Khan 91 Hyderabad 91 Ghotki 91 Karachi Central 90 Thatta 88 Karachi South 86 Kashmore 85 Sujawal 83 Sukkur 79 Korangi 73 Jacobabad 61 Avg: 90 % Jamshoro 57 *Vaccinator attendance does not account for 0 20406080100120 the total time spent at the Immunization Center throughout the day Source: Zindagi Mehfooz EIR data, EPI-Sindh/IRD Impact of COVID-19 on Immunizations across Sindh province, Pakistan (Feb 29 - Apr 18, 2020)

Response strategies

1 2 3 PPE training for Ensure vaccine Geo-spatial Vaccinators and stocks analysis to identify Support staff high risk areas

4 5 6 Prepare Revise workflows for Accelerated defaulter lists by physical distancing, Outreach Activities Center’s hand hygiene, referring to cover missed catchment area COVID-19 suspects children

7 8 Mobile Deployment of Immunizations Chatbot and 2-way vans as fixed sites SMS reminders in High risk areas Thank you

Picture: Deployment of ZM mobile immunization van as a fixed site in high risk Union Council during COVID-19 Lockdown