Since its first inception supporting house to house malaria campaigns in southern Africa, Reveal has been through numerous phases of growth. Originally named “mSpray,” the tool debuted in 2015 and was used exclusively to support indoor residual spraying (IRS) campaigns by using geospatial data and a suite of tools to improve coverage rates. In some cases, coverage rates improved by as much as 20-30 percent. (1)
In 2019, Akros received development funding to expand the tool and rebranded mSpray as “Reveal”—a platform to assist in the micro-planning, delivery, and management of a wide variety of health campaigns. Reveal is an open-source digital global good that uses smart maps and technology appropriate for resource-constrained settings to monitor coverage of interventions in real-time and optimize available resources.
Reveal’s mobile application spatially guides field teams to planned areas and households for service delivery. This mobile application allows offline data collection and captures indicators to inform critical field decisions. Reveal also includes a web user interface with real-time dashboards to provide program managers with helpful coverage data that informs current activities and guides teams to achieve true coverage targets.
Reveal was initially built on the OpenSRP trunk, but in late 2021 was shifted to a more appropriate backend solution. Through this monumental phase of growth, now called Reveal 3.0, the efficiency, stability, adaptability, and sustainability has improved significantly.
All in all, Reveal has impacted 3.6 million people across the 10 countries where Reveal has been deployed. (2)
Medicines and vaccines have transformed the modern world. Thanks to these innovations, diseases that used to kill large populations have been controlled over the past century, enabling more of the world’s population to live long and healthy lives and contribute to the global economy and scientific advancements. Key to the success of these tools is the science of pharmacovigilance—the detection, assessment, understanding, and prevention of any adverse effects related to the use of a specific medicine or vaccine.[1] While all medicines and vaccines undergo rigorous clinical trials, such testing environments cannot account for all factors that products will come in contact with when used by large, heterogeneous populations over long periods. Due to time restraints and limitations on the types of individuals eligible to participate in clinical trials safely (typically not individuals with concurrent diseases, young children, or pregnant women), some side effects related to vaccine or medicine use can only be detected after the products have been widely released.
Countries require robust safety surveillance systems capable of timely detection, reporting, and analysis of adverse events in order to ensure the long-term safety of drugs and vaccines once they are available on the market. Such systems implement advanced pharmacovigilance approaches to ensure healthcare workers diagnose these events, quality data is captured for each event, and teams of experts are available to review the data and take appropriate actions. Ensuring comprehensive and timely surveillance is critical to individual patient safety and an essential factor in ensuring the public trust in medicines and vaccines.
No matter the health campaign or tools used to implement the campaign, “mopping-up”–that is, bringing health resources to those people that did not receive them during the primary campaign–is critical.
“Mop-up” can be necessary for a variety of reasons, but the most common causes are inclement weather that impacted the ability to achieve the desired level of coverage, people not being at home when the field teams came knocking, or field teams ending delivery too soon. Mop up campaigns can be costly, so the need for accurate, real-time spatial data to inform these mop ups and protocols to drive them is critical. Reveal, a digital Global Good that equips field teams to reach the last mile, assists in these efforts by providing digestible maps and tables to mid- and high-level managers in near real time. Managers use these maps to understand areas which were missed in order to redeploy teams to those areas that did not receive sufficient coverage before the campaign concludes. For interventions such as indoor residual spraying (IRS) for malaria and immunization campaigns, this can mean the difference between a community attaining “herd immunity” or having gaps in coverage that render the intervention less effective.
We are thrilled to announce Akros Research has been awarded funding through Mastercard Foundation and Africa CDC’s Saving Lives and Livelihoods initiative! The Mastercard Foundation is a Canadian foundation and one of the largest in the world with more than $40 billion in assets. The Foundation was created in 2006 through the generosity of Mastercard when it became a public company. Since its inception, the Foundation has operated independently of the company. The Foundation’s policies, operations, and program decisions are determined by its Board. Africa CDC is a specialized technical institution of the African Union that strengthens the capacity and capability of Africa’s public health institutions as well as partnerships to detect and respond quickly and effectively to disease threats and outbreaks, based on data-driven interventions and programs.
Saving Lives and Livelihoods is a partnership that enables the purchase of COVID-19 vaccines for at least 65 million people and supports the delivery to millions more across the continent. It will also lay the groundwork for vaccine manufacturing in Africa through a focus on human capital development, and strengthen Africa CDC. The partnership builds on the ongoing efforts of AVAT, COVAX, WHO, and local governments to provide access to vaccines to Africa and support the African Union’s goal of vaccinating 70 percent of Africa’s population by the end of 2022. This joint initiative will focus on four key areas:
Pillar 1—Purchase at least 50M COVID-19 vaccine doses
Pillar 2—Support deployment of COVID-19 vaccine doses
Pillar 3—Strengthen vaccine manufacturing of human vaccines
Pillar 4—Strengthen Africa CDC’s capacity and capabilities
Nigeria encompasses a unique and significant role in Africa. Not only is it the continent’s most populous country, clocking in at 206 million people, but it also is also the continent’s largest economy (with a total GDP of $441 billion in 2021). However, it also maintains a less desirable superlative title, which is that it bears the highest burden of malaria deaths on the continent, and 27% of all malaria deaths worldwide in 2020. In raw numbers, this amounts to an estimated 64.5 million cases annually. As a result, the public health challenge of malaria in Nigeria is enormous, and the stakes are high. Though Nigeria’s National Malaria Elimination Program (NMEP) has risen to meet this challenge consistently throughout the years, attaining the goal of reducing malaria morbidity to less than 10% parasite prevalence and mortality attributable to malaria to less than 50 deaths per 1,000 by 2025 is far from guaranteed. One key in realizing this goal is seasonal malaria chemoprevention (SMC), which typically consists of routine administration of two antimalarial drugs to children 3 to 59 months of age during the peak months of malaria transmission. Malaria Consortium and Akros worked with the Nigeria NMEP to support the planning, tracking, and delivery of SMC in six rural health facility catchments in the Shagari local government area of Sokoto State, Nigeria in 2021.
Senegal is hardly alone in experiencing challenges with their COVID-19 vaccine roll out. Like many countries, much of the challenge has been related to hesitancy and demand. Recognizing that having ready access to COVID-19 vaccination-related behavior indicators can inform a better understanding of why coverage is not reaching saturation and to whom additional resources and efforts should be directed, Akros (in collaboration with Fraym and GRID3) worked with Senegal Ministry of Health and Social Action (MSAS) departments and in-country partners to build a custom geospatial dashboard that demonstrates these data.
Hesitancy and lack of demand issues for vaccines can stem from a number of causes. For example, rural communities far from health facilities administering vaccines may require significantly extra effort and expenses to travel to get the intervention, resulting in a demand challenge. The response to this demand-driven low-coverage problem will be different than hesitancy-driven challenges and the data required to respond effectively is likewise different. In this example, understanding: 1) Which communities are farther than a reasonable traveling distance to the health facility, 2) where exactly those communities are, and 3) how many people are expected to be found there, is valuable information that can be used to maximize the chances of a successful response. However, access to these types of granular geospatial demographic and health data that promote this level of evaluation to allow progress against such bottlenecks, has not been widely available or accessible to staff needing to make critical resource prioritization decisions.
The solution—hyperlocal geospatial data for COVID-19 vaccinations
With vaccination hesitancy and demand as the major challenges to achieving higher coverage, the data prioritized for this dashboard were proxy indicators for providing more insight into these challenges. Further, in order to decentralize decision making and empower district and health facility staff to make decisions that drive up coverage, this data was made accessible through the dashboard at 1km x 1km cells that can be aggregated up to health facility and district-level indicators. The dashboard interface allows this hyperlocal data to be, quickly and easily, geospatially explored before downloading for further analysis or input into external planning tools.
This work was built upon a history of collaboration among these partners — which has had success in providing detailed microplanning services utilizing granular spatial data to government malaria and neglected tropical disease (NTD) programs, with demonstrated examples for malaria in Zambia, Nigeria, and Senegal and for NTDs in Rwanda and Kenya. Building on that technical capacity, the dashboard in Figure 1 (showing COVID-19 vulnerable populations against health facility catchment areas) was built to display modeled COVID-19 vulnerability data to enable more informed decisions within vaccination planning workflows.
The geospatial dashboard allows users to filter out key COVID-19 planning data at a granular level.
The geospatial dashboard consolidated a wide variety of data and relevant COVID-19 vulnerability and risk models into the visualization to be filtered by region, district, and health facility to inform all levels of health planning. Largely using demographic and health surveys, the data includes statistically sound high-quality, geo-tagged household survey data, satellite imagery-derived data products, health metrics, and health infrastructure. This hyperlocal data, down to 1km grid cells, allows for the visualization of the spatial distribution of priority groups and classifies individuals within priority groups using WHO-guided indicators of vulnerability. These include elderly population groups and groups that receive a high vulnerability score generated within the COVID-19 vulnerability model. Other COVID-19 indicators within this model included vaccine allocation, exposure, co-morbidities, information access, prevention activities, and vaccination likeliness — all of which were able to be filtered, displayed, and extracted for all levels of the health administration hierarchy to inform microplanning.
Digital Square at PATH is pleased to announce that Digital Square’s Board has approved eight proposals for investment—as part of Notice F—to strengthen adaptable, replicable digital tools designed to work together seamlessly to improve health outcomes and help close the health equity gap around the world.
The advancement of mature digital public goods for health (global goods) is crucial for saving lives and improving health around the world because these free and open-source digital health tools can be used across different countries and health program verticals, cutting down on fragmentation and duplication to accelerate scale and health impact.
This funding call encouraged applicants to focus on aligning to global health standards and guidance, as well as working with local teams to build capacity in health technologies in the countries and contexts where they will be used. Notice F consists of three workstreams:
Foster global goods’ uptake of World Health Organization (WHO) technical specifications and implementation guidance on developing standards-based, interoperable digital certificates for COVID-19 vaccination status.
Create a set of standard implementation examples using the WHO digital adaptation kit (DAK) for antenatal care so that more digital systems will include data and health content that are consistent with WHO’s antenatal care recommendations.
Strengthen the technologies of software global goods so they can be deployed as stand-alone products, while building the capacity of new innovators and implementers.
Last month, the World Health Organization (WHO) sent joyous shock waves through the global health community and the Global South by officially recommending that the new RTS,S/AS01 (RTS,S) malaria vaccine be adopted into widespread use among children in sub-Saharan Africa and other regions with moderate to high P. falciparum malaria incidence. Now the international community, through Gavi, the Vaccine Alliance, has just stepped forward to help finance the rollout of the world’s first malaria vaccine.
A female mosquito takes a blood meal.
It has been true for some time that sub-Saharan Africa bears the largest malaria burden in the world, with children shouldering the largest proportion of deaths. Over 90% of global cases are on the continent, with children under the age of 5 years constituting a staggering two-thirds of all malaria deaths. This is due to a confluence of factors, not least because of the widespread prevalence of P. falciparum (the most deadly species of malaria parasite), and a very efficient mosquito that spreads it (Anopheles gambiae). The economic impact of malaria is estimated to cost Africa $12 billion every year—a figure that also factors in costs of healthcare, absenteeism, days lost in education, decreased productivity due to brain damage from cerebral malaria, and loss of investment and tourism. The introduction of an effective vaccine offers a beam of hope in the fight to mitigate the massive toll this centuries-old disease inflicts on Africa.
In recent years, countries within the Southern African Development Community (SADC) region of Africa have been making outstanding strides toward the challenging goal of malaria elimination. This commitment to elimination is the guiding mandate of Elimination 8 (E8), which focuses on the following countries: Angola, Botswana, Eswatini, Mozambique, Namibia, South Africa, Zambia, and Zimbabwe. Through E8, these ministerial bodies have resolved to coordinate their efforts to collaboratively work toward the shared regional goal of malaria elimination.
A Reveal UI view of the campaign in progress.
To that end, in 2017, E8 contracted with MENTOR to deliver indoor residual spray (IRS) in border districts of southern Angola. The MENTOR Initiative is a registered nonprofit organization devoted to reducing deaths and suffering from tropical diseases. In Angola, MENTOR has been a stable National Malaria Control Program (NMCP) partner supporting vector control, case management, and surveillance activities since 2004. MENTOR has established offices across Angola and has full country reach in its operations, making it the ideal partner for E8 to engage for expanded IRS interventions. Since 2017, MENTOR has implemented IRS with reported high coverage rates in all campaigns conducted. For its 2020 campaign, MENTOR aimed to improve IRS reporting systems and increase accountability to donors and NMCP. To realize this goal, they chose to pilot Reveal—a digital global good and open source spatial intelligence platform used to drive the delivery of life-saving interventions. MENTOR collaborated with Akros to configure and support the field pilot of Reveal v. 1 in Menongue District (Cuando Cubango Province).
Through Reveal, field teams and managers use detailed household and community maps, protocols, and a data-collection and dashboarding platform for decision-making support to plan, implement, and adjust interventions so they achieve the greatest impact. Akros’ partnership with MENTOR Initiative to pilot Reveal v. 1 in Menogue District to support IRS delivery first included assessment and scoping to understand three key elements: intervention and data collection and management protocols, resource availability, and the environment within which Reveal was to be implemented and sustained. Akros then conducted system configuration to align IRS standard operating procedures (SOPs) with the Reveal platform, set-up mobile application and coverage dashboards, and configured feedback loops and tasking for unique user roles. Following that, the Reveal team participated in campaign planning, including enumeration and base map preparation and work to plan and validate in-field assumptions. Finally, the Reveal team supported implementation in December 2020 and provided post-implementation support.
Maximal coverage defines the effectiveness of vaccination campaigns. Over one year after the start of the devastating COVID-19 pandemic, countries around the globe are vaccinating those ages 16 and older, while vaccine-producing companies are conducting vaccine trials for children. Positivity and hope infuse vaccine distribution efforts, but as these initiatives ensue, attention is being drawn to the challenges of vaccine distribution, namely, those left behind.
Mass vaccination campaigns are critical to the introduction of new vaccines, to providing doses to those who may have missed routine doses, and to giving a second opportunity to those who may not have developed immunity. In each instance, with greater coverage comes stronger, more resilient communities. However, zero-dose children, or children who have not received any routine vaccinations, are often missed by these campaigns. With every child left unvaccinated, communities’ vulnerability to vaccine-preventable diseases escalates. Fortunately, in bracing for future vaccination efforts, we can look to previous initiatives to guide our efforts. In particular, the potential of geospatial data and technology to ensure all, including zero-dose children, are included.
From June through to December 2020, Akros, in partnership with Johns Hopkins University, Macha Research Trust, and the Zambia Ministry of Health, utilized spatial intelligence and the Reveal platform to identify and vaccinate zero-dose children following a nationwide Zambian vaccination campaign for measles and rubella.
