For the past year, VillageReach has been working in 14 countries to reduce the time it takes for stool samples from suspected polio cases to reach the lab where they can be tested. The sooner the lab can determine whether an acute flaccid paralysis (AFP) case is caused by poliovirus, the sooner the Ministry of Health, with support from Global Polio Eradication Initiative (GPEI) partners, can respond to any new outbreaks to stop the spread of polio.
Why focus on sample transport?
Globally, very few polio cases are confirmed nowadays, but national surveillance systems must be sensitive and efficient enough to detect those cases fast – because the goal is eradication by 2026. Malawi knows this well. In 2022, Malawi detected its first case of wild poliovirus in 30 years – the first in Africa in five years – leading to a public health emergency response in Malawi and neighboring countries to stop any further spread.
This response placed heightened attention on sample transport. GPEI’s global target is that polio samples collected from patients in even the most remote areas should reach the testing lab within 72 hours. But in Malawi and many other countries, this wasn’t happening – in some cases, it was taking weeks for samples to get to the lab. Any delays mean more time for polio to silently spread before anyone knows it’s there and can respond. Our job is to shorten the lab sample transport timeline and to do so quickly.
Visibility into transport timelines
Data plays a central role in our Polio Lab Sample Transport program. Figuring out how to shorten sample transport timelines means we need to know exactly when and where delays happen. Are samples sitting at the health facility for days after being collected because no one is available to transport them? Or are they leaving the health facility quickly but getting stuck somewhere else on the way? Identifying bottlenecks enables us to address them.
This is challenging in Malawi because data isn’t recorded at many points along the samples’ journey to Lilongwe, where all samples stop briefly before being shipped internationally to the testing lab. The only two time points regularly recorded are when the sample is collected in the community or at the health facility and when it arrives in Lilongwe, which can be hundreds of miles away. We don’t typically know when the samples leave the facility or where they stop along the way, or the reason for any delays.
Moreover, data isn’t available until the sample reaches the Ministry of Health’s Expanded Programme on Immunization (EPI) team in Lilongwe. All information about the sample, including where and when it was collected, is written on a paper form that travels with the sample. Only once it arrives in Lilongwe does EPI have a record of when the sample was collected, but at that point, it’s too late to do anything to speed up timelines if the sample gets stuck somewhere along the way.
The bigger risk is that if a sample never makes it to Lilongwe, EPI might never know that a health worker suspected a patient might have polio (if not alerted via phone). The health worker won’t get test results back. Hopefully, this doesn’t happen often, but there may be samples collected that aren’t transported – it’s often busy health workers who have to transport samples, which means time away from their patients. Before we started the project, there was no way to know if or how big of a problem this was.
Simple changes can have a big impact
Over the past nine months, we’ve been working with EPI and the 29 health districts to strengthen the polio lab sample transport system by introducing on-demand courier transport and better tracking sample movements to see and respond to bottlenecks when they occur.
We’ve introduced two major data system changes.
First and foremost, we introduced a centralized national AFP sample notification system and trained all 800+ health facilities countrywide on it. Every time an AFP sample is collected, health workers are directed to notify instantly through a free texting (USSD) system implemented by R4H. The USSD system doesn’t require smartphones and is free for health workers to use. This alerts designated people within EPI, WHO, health districts, and transport couriers that they should expect the samples in a day or two. If the samples don’t arrive, these notifications let us know whom to follow up with immediately. Within one month of training on this texting system, about half of AFP samples were notified this way – and we are aiming to reach 100% by November 2023.
Second, we introduced new tools to gather detailed data on sample movements to help us better identify bottlenecks. A paper chain of custody form now travels with samples and collects more information about where each sample stops on its way to Lilongwe and who is transporting it for each leg of the trip. Over time, this will allow us to see more detailed patterns about which portions of the trip are most prone to delays. In case forms aren’t always used, a new temporary sample identifier allows us to reference each sample as it moves to Lilongwe.
For even more granular data, we send a subset of samples with a digital Tec4Med tracker that gives us the sample’s real-time GPS location (and monitors temperature), allowing us to see patterns over time and address any delays as they occur.
We know that uptake of these changes will take some time – implementation requires the cooperation of thousands of health workers, who have many other urgent tasks to complete and many patients to see. But we are already starting to see more complete and more granular data that we can use for decision-making. And the good news is that samples are reaching Lilongwe much more quickly than they were a year ago. Together, the local and global community of partners has rallied to support the Malawi Ministry of Health to contain polio for good.