Tamanu has assisted several Pacific Island Countries with their COVID-19 immunisation campaigns. In Nauru for example, the country now tracks all COVID-19 vaccines using Tamanu’s immunisation module. Nauru remains a COVID-safe environment: with fewer than ten cases cumulatively (all contained to quarantine) to May 2022, the virus has been successfully contained, there is no leakage into the community, and Nauru also boasts a high vaccination rate. Now Tamanu provides the country with a complete solution to issue internationally-recognised Vaccine Certificates to its citizens.

Digital Vaccine Certificates are an enhancement on the security and usability of the existing International Certificate of Vaccination or Prophylaxis (ICVP), commonly known as the “yellow card”, established in 1933 and used for health risk control at borders for various epidemics and pandemics since, such as cholera, meningitis, and the 2002-2004 SARS outbreak.

This is a paper document that is filled by hand and rubber-stamped with authorities’ official shields. Much like the text on passports, it has labels in only a handful of languages. Due to these aspects and the explosion of technological means in recent decades, the yellow card is almost trivially falsifiable now. There is also a desire for a document which is more compatible with the variety of languages spoken around the world, and which can be embedded in mobile phones to “get with the times” and reduce or avoid reliance on paper.

Global and inter-regional agencies have developed two major standards for this purpose: the United Nations, via its ICAO organisation, created a Visible Digital Seal specification for “Non Constrained” environments (VDS-NC), modelled on the existing ePassport infrastructure; the European Union concurrently put in place its Digital COVID-19 Certificates (DCC or EU-DCC). Tamanu supports both and offers these flexibly to countries using the platform; Nauru chose the VDS-NC standard.

Before getting too deep into the technical weeds, an overview of how such a document is obtained and used:

• All begins, of course, with a vaccination. When someone is vaccinated, this event is recorded in Tamanu by the health practitioner against the patient’s history.
• At a patient’s request, or as a matter of procedure, a vaccination document is generated. The document takes the form of a single-page PDF with a summary of the vaccinations the patient has undertaken and a QR code which contains the VDS-NC data. It is transmitted directly from Tamanu to the patient via email.
• The patient then travels outside of Nauru: at a foreign border (or at airline check-in), officials view the document, either on a mobile device or in printed form. Using barcode scanners, the VDS-NC data is accessed and locally verified.
• With the data verified, officers are able to reliably trust the information within and allow access or thoroughfare to the traveller based on their vaccination status.

As the entire purpose of the document is to be validated at the border or overseas to prove that one has been vaccinated, this verification must be watertight: it must be quick (can’t take longer than a few seconds or everyone would miss their plane!), and it must be trusted (there must be no doubt, and no possibility of forgery). The standards have been designed to ensure this.

Both standards are based on QR codes. It’s important to highlight that the format of these codes is unchanged, and that they can be read by any existing QR code reader, such that is present on every mobile phone and many verification devices in airports, such as the kiosks used by fliers in recent years to self-check-in. Only the data inside the QR codes is new, so only a software update – or specific app – is required to interpret them correctly.

The data inside the QR codes include information about the relevant vaccines the holder has received, as well as some identity details. This information is machine-readable: for example, instead of the data being text reading:

This is to certify that Pooja Fairclough-Acosta, born 23 June 1973 has received Dose 1 of the COVID-19 Pfizer Comirnaty vaccine on 11 April 2021, batch 3416BHB, at RON Hospital, Nauru.

The data instead looks like:

{“pid”:{“n”:”Pooja Fairclough-Acosta”,”dob”:”1973-06-23″},”ve”:[{

“des”:”XM68M6″,”nam”:”Comirnaty”,”dis”:”RA01.0″,”vd”:[{“dvc”:”2021-04-11″,

“seq”:1,”ctr”:”NRU”,”adm”:”RON Hospital”,”lot”:”3416BHB”}]}

Certainly that is a lot more obscure for a human to read! Yet this format means that a reader application in English can show a summary like the one above, but others in French, Japanese, or Nauruan can show the information with language-appropriate labels, without risk of misunderstanding and without requiring translation.

Alongside this data is a cryptographic “signature” and verification information. In simple terms, this uses something called asymmetric keys, complicated mathematical algorithms that provide keys made of two parts: a private key, kept secret, and a public key, which can be safely given out. They are used to provide an unforgeable proof that some data was created by the person or system that owns the secret part of the key, a fact which can be verified using only the public part of the key. These processes are called signing and verifying, and are used to protect and authenticate communications on the internet and elsewhere, such as for credit cards and airplane boarding passes.

Vaccine Certificates use a two-tier signature scheme. The data in the QR code is signed with a private key that Tamanu has access to, and both the public key and this signature are distributed alongside the original data. The keys that Tamanu uses are further signed by a Signing Authority that represents the country, in this case Nauru.

The country’s public key is shared with other countries via direct agreements between countries, or, more commonly, with a service of the International Civil Aviation Organisation (a branch of the UN), the Public Key Directory (PKD).

At the end point of all this is a customs agent in another country: upon scanning a QR code, the reader’s software verifies the data through the signature and against Tamanu’s public key, which are both provided alongside the data in the QR code. Then, it retrieves Nauru’s public key from the PKD and verifies Tamanu’s public key, thus establishing a chain of trust which ensures the data is not a forgery.

The public keys of all participating countries are long-lived: they last for over a decade. Therefore, airports, checker applications, and other agents can retrieve the entire list of country public keys at once every so often, and are then able to stay offline to check QR codes, if necessary. The entire checking process is almost instant: it takes less than a second to perform all of these steps.

The digital certificates can be verified by apps available on Google Play and the App Store.

Through our journey integrating these systems in Tamanu, we’ve been very grateful for the assistance and lent expertise of the Australian Department of Foreign Affairs and Trade, the Australian Passport Office, ICAO and our partner governments.

We are excited to be deploying this system to other countries in the Pacific to help them provide their population with the means to safely travel overseas. Nauru, Tuvalu and Samoa are all live with the system in place.

If you’re interested in learning more about how our tools can support your travel health certifications needs, you can learn more about Tamanu or reach out to the team at Beyond Essential Systems.

Earlier this year, the beautiful island nation of Kiribati joined the ranks of those battling COVID outbreaks. Until January 2022, Kiribati had recorded only two COVID cases throughout the entire pandemic – an incredible achievement made possible by both its remote location and a robust public health response.

But unfortunately, when the first international flight in 10 months arrived, it brought with it 36 positive cases which inevitably led to community transmission. Acting quickly, the government declared a state of disaster and the island of South Tarawa went into lockdown.

At BES, we had both a long-standing relationship with Kiribati and tried-and-tested tools to help track COVID outbreaks. When the Ministry of Health and Medical Services requested support from neighbours, we were more than happy to join the deployment team including DFAT, WHO, and SPC to respond to the outbreak.

From left to right, Dr Revite Kirition, public health physician SPC, Ms Margaret Leong, infection control specialist SPC, Dr Lamour Hansell, intensivist/anaesthetist SPC, Mr Tociro Kataki biomedical technician SPC, Mr Tebuka Toatu, laboratory specialist SPC, Carla Tolson, laboratory specialist CHS, Aislinn Healy health information systems project manager and registered nurse, BES.

Testing on arrival

Our greatest tool in this pandemic (from the BES toolbox) is our electronic medical record Tamanu. Designed specifically for remote settings in the Pacific like Kiribati, Tamanu is an offline-first system, with syncing capabilities allowing users to work seamlessly in settings with unreliable internet access. It is easy to use on both mobile and desktop, allowing health workers or anyone managing COVID testing to record patient information in a range of settings, including health clinics, testing centres, hotels, and in the field.

Upon arrival, our very own Project Manager Aislinn Healy got to be on the patient end of the COVID testing functionality for the first time. So here is how the process works: when you’re tested, you are given a COVID testing record, lab request ID number, and a QR code to access the result. When the test result is processed through Tamanu (allowing about 24 hours on the lab side), you can follow the link to easily see the result online – saving everyone time waiting on hold to confirm by phone.

Training and building local capacity

Of course, Aislinn wasn’t only visiting Kiribati to get her own COVID tests. Armed with tablets to be distributed amongst labs, and laptops on their way, Aislinn worked with the local teams to conduct training on how to enter PCR test results into Tamanu.

In South Tarawa, the most heavily populated area of Kiribati, PCR tests are being processed at three locations: the lab of the main hospital, a tuberculosis testing lab, and a COVID isolation facility set up in a shipping container donated by New Zealand’s MFAT. Kiribati’s Health Information Unit also designated a Tamanu officer, who was upskilled in all facets of Tamanu’s COVID testing functionality who can troubleshoot issues as they arise and continue training in-country as the rollout continues.

Unfortunately, the impacts of COVID were not limited solely to South Tarawa. To ensure that health clinics in the outer islands were also well-equipped to record tests and monitor outbreaks, Aislinn also travelled further afield to conduct training sessions.

Although getting to North Tarawa isn’t as easy as it looks, our team is familiar with the unique travel systems of the Pacific islands. Travelling on boats and wading through the water, tablets safely in bags, they made it to North Tarawa. Here, they trained nursing and health staff to use Tamanu to record rapid tests and results.

Training in the outer islands is really important, as it allows positive case data to be viewed immediately by the Response Team in South Tarawa. This way, they can make planning decisions in response to accurate, real-time data and offer support to any patients who need referral.

Tracking outbreaks in real-time

In the initial days of the outbreak, the Health Information Unit that provides daily case updates was receiving little to no information from the outer islands. Information coming in from South Tarawa was often a photo of their paper records, sent through an online messaging service, and manually entered into spreadsheets by the Health Information Unit.

Tamanu was able to streamline this process, with data digitally recorded at all COVID testing sites across the country including the main hospital, labs, hotels for new arrivals, and health clinics on outer islands.

Now, that information reaches the Health Information Unit immediately. Not only does that speed up the daily case number updates, but they can now also produce weekly test reports showing analysed data and test positivity rates. These reports make it easier to make informed decisions and direct resources as needed.

The data from Tamanu also feeds into Tupaia, our data analysis and visualisation platform designed for low-income settings. Like Tamanu, Tupaia is open-source and offline-first, making it perfect for disseminating information in places with inconsistent internet connectivity.

On the live maps, decision-makers can see positive COVID cases broken down by district and sub-district. Colour-coded visuals help them to identify outbreaks as they happen, informing their next interventions and planning to prevent future spread of the virus.

Australian High Commissioner and Kiribati Minister for Health farewell the team

As it stands, Kiribati’s first COVID outbreak seems to have been contained. Cases only reached just over 3000, a testament to the rapid and coordinated response by the Ministry of Health. Given the success of Tamanu for tracking COVID-19 patients, we would love to roll out the software to support other patient interactions across the health system – although we hope future COVID outbreaks are few and far between.

To explore the live maps of health systems across the Pacific, visit Tupaia.org

To learn more about Tamanu, our EMR for remote settings, click here

As COVID cases rise across the Pacific, Tamanu is being used to help manage the COVID-19 testing programs in Fiji and Palau. Tamanu is a free, open-source EMR designed specifically for low-resource and remote settings in the Indo-Pacific region.

Using both the Mobile and Desktop versions of Tamanu, staff are recording COVID-19 tests, along with lab results and disseminating this information quickly to contact tracing teams. The system also allows patients to get their results instantly, as soon as they are published by labs. In Fiji, over 50,000 tests have been entered via the system over the last 6 months, whilst in Palau they are one week in and already entering hundreds of tests each day.

As COVID-19 outbreaks spread in countries that were previously COVID free, the system is providing a hugely valuable tool for secure information management. Its ability to collect data offline (syncing when internet becomes available across desktop and mobile) makes it perfectly suited for the Pacific setting.

Our analytics shows that there have been over 60,000 visits to our online results checking tool in Fiji alone, which has therefore saved over 60,000 calls to the national call centre from people trying to find their COVID-19 test result.

The online test results widget in Fiji has been accessed more than 60,000 times

Features of Tamanu for COVID-19 testing:

• Swab teams can record the results of RDTs (rapid tests) using their mobile devices even when offline
• Swab teams can request PCR tests and capture all the details on patient swab forms using their mobile devices, even when offline
• Any laboratory in the country can receive a lab request once it is synced up and enter results using Tamanu Desktop – even if the laboratory loses internet after receiving the request. Results can include all details, including swab type, test type, technician, verification data, status, date/time and additional notes
• Patients can receive their results via a Certificate that is automatically generated
• Patients can check their results or verify it to external parties by using our online widget tool and entering a unique code they are given when being tested
• We can push results via an API to external systems or encode the data in Visible Digital Seals (QR Codes) in accordance with international standards

Like all Tamanu modules, the system is completely free and open-source, with funding support from DFAT’s Indo-Pacific Centre for Health Security. Tamanu can also be used to manage active COVID-19 patients across inpatient and home settings, collect contact tracing information and has a complete immunization module to record COVID-19 vaccines.

Please contact us for a demo or to join upcoming webinars.

This project is proudly supported by the Australian Government.

Tamanu is a patient-level electronic medical record (EMR) designed for both desktop and mobile. It enables health workers to track individual patients, provide clinical support and ensure consistent management of patients through the continuum of care. The system is offline-first, with syncing capabilities, allowing users to work seamlessly in both offline and online modes so they can easily work in the most remote locations.

We knew when COVID-19 started to affect Pacific Island Countries that Tamanu was positioned to assist not only in the initial response but in delivering vaccinations. When Samoa approached Beyond Essential Systems (BES), we were ready to assist. We had the core software ready to deploy but acknowledged that for software to translate to valuable patient and health system outcomes there was more work to do.

We immediately embarked on a process to rapidly but carefully adapt Tamanu to the evolving Samoan situation. With travel all but impossible an additional challenge was providing international software technical support remotely.

The success of this process has both highlighted Tamanu as a Pacific-owned product but also challenged our usual operating model. Tamanu’s design and implementation has been locally driven; the Samoan Ministry of Health has successfully rolled out cutting edge, fit-for-purpose, open-source software in the midst of a pandemic.

The system is now being used to successfully track the COVID-19 vaccine roll-out for all vaccine recipients.

Vaccinations started on the 18th of April, with over 10,000 entries made into the system in the first 3 weeks, The program continues to accelerate, and to date 25,040 people have received their first dose of the COVID-19 vaccine.

All 215,000 people in Samoa were pre-entered into Tamanu and can be found using their first name, last name, DOB, village or ID. The system is being used to record information for each of these individuals receiving a vaccine. Tamanu captures essential details on the vaccine used, batch, injection site and the team administering the dose, provides decision support and can be used to record adverse events for individuals.
The data from each individual is then deidentified and aggregated into Tupaia, BES’ data aggregation, analysis and visualisation platform that

helps map health systems in low and middle-income countries. The platform is used to track the vaccine roll-out in real-time across metrics such as % coverage (to the village level), age and sex summaries.

What is unique about Tamanu’s functionality is that data can be entered on a desktop application, but most entries are via our mobile application, which teams can use out in the field or in vaccination centres anywhere in the country. Data can be captured offline and will sync back-and-forth whenever an internet connection is available. This navigates the patchy connectivity that can confront primary health care workers in delivering services to remote villages in the Pacific and Samoa specifically.

Enhancements and improvements continue to be made in the system responding to evolving circumstances, user experience and feedback. This demonstrates the importance of working closely and directly with governments to ensure the system works for them, and their citizens. For example, patient identification was improved in Samoa after health workers fed back that there were challenges in searching for patients that were already in the system due to inconsistencies in family surnames and father’s surnames, a traditional form of identification.

With the success of the Tamanu Immunisation Module roll-out, planning is already underway to scale up use of Tamanu to include NCD screening in Samoa.

“Tupaia and Tamanu have been critical tools in our fight against COVID-19 – we are grateful to DFAT for all their support. Fa’afetai!”

Lenara Tupa’i-Fui, A.CEO

Health Information Technology & Communications

Samoa Ministry of Health

The response in the Pacific however has been exceptional. Most Pacific Island Countries moved swiftly to shut-down international travel and in countries such as Fiji, which experienced early cases, the initial response of authorities seems – for now – to have been highly effective in preventing widespread community transmission. Elsewhere, in countries such as Tonga, Samoa, Kiribati, Solomon Islands and Vanuatu, whilst no cases have been detected, the spectre of COVID-19 looms large and preparedness work has been continuing apace. Most countries now have the capacity to undertake laboratory testing for COVD-19 locally – this has been achieved especially with the support of Australia and New Zealand, alongside other donors.

Tupaia is supporting health decision making related to COVID-19 in a number of Pacific Island Countries and elsewhere. Our staff, like everyone else, have been frustrated at our inability to travel and support face-to-face like we would usually be doing but we are providing as much remote support as we possibly can and we’ll be back travelling as soon as it is appropriate to do so.

Whilst very busy, our thoughts are also with everyone affected by the current situation, whether people have lost their livelihoods, their loved ones or their own health.

Data visualisations

As a data aggregation and visualisation platform, with the support of DFAT, we have been able to support countries to prepare for the potential onset of a COVID-19 outbreak.  In a demonstration of the data display possibilities, we have also developed a new module in Tupaia to show visualisations of the data related to the COVID-19 outbreak in Australia – these include data on confirmed cases, testing and deaths at the national and state levels.

We are also working with flutracking.net to visualise their crowd-sourced, weekly syndromic surveillance data at the postcode, LGA and state levels – this year, flutracking is also collecting data relating to COVID-19, which may help health authorities spot localised outbreaks more quickly than laboratory testing.

Australian COVID-19 data displays in Tupaia

Tonga

After seeing the data displays implemented in Tupaia for Australia, Tonga requested support to use Tupaia for COVID-19 related data collection and visualisations as part of their readiness planning and response activities. A facility assessment tool was developed and loaded into Tupaia MediTrak allowing Tonga to rapidly implement assessment of all facilities in Tongatapu for COVID-19 readiness. This enabled a quick stocktake of the commodities that would be of use to the facilities in the event that they were faced with COVID-19 cases (e.g. soap, alcohol hand sanitizer, face masks). This allowed facilities that had items out of stock to be prioritised for re-supply and/or allocation of additional essential resources. A picture of the Island group’s capacity for ICU admission and isolation admissions could also be mapped by asking facilities how many of each type of bed they have. Plans are currently underway to roll-out the Tupaia facility readiness assessments in the outer islands.

The results are displayed in Tupaia dashboards and map overlays, allowing the Ministry of Health easy access to the data, helping inform decision making around COVID-19 preparedness.

Tonga COVID-19 data displays in Tupaia

Samoa

Samoa have also been working with us on their COVID-19 preparedness needs, developing their own data collection tools for use in Tupaia MediTrak. They have developed surveys to conduct facility assessments, household assessments, clinical surveillance and contact tracing with respect to COVID-19 readiness. We are continuing to work with them to meet their requests for data visualisation support during this time.

Tupaia’s contact tracing tool is a basic mechanism allowing health authorities to create Index Cases and survey unlimited ‘Contact Cases’, linking each back to the original index case. It was designed specifically for the Pacific context and works across all notifiable diseases – we have made adaptations to meet the COVID-19 tracing needs in Samoa and Tonga (though neither have recorded confirmed cases yet).

Laos schools

We have been engaged in Laos to present aggregated data relating to their education system, as part of their role as the education cluster lead – this work allows data capture and visualisation across over 14,000 schools. This work pulls data from multiple education data sources to assist with decision making around the availability of clean water and infection control commodities, quarantine sites and which schools are open and closed during the pandemic.

Sample data visualisations from Laos education sector

General

A suite of surveys have been added to Tupaia MediTrak, which can be used by any country requesting access. If a country would like to proceed with data collection, we can build map overlays and dashboards specifically designed to display the information collected.

• Facility assessments and Facility Management System (including both data collection on-site and data aggregation from existing databases)
• Suspected COVID-19 cases
  • Allows countries to document and display the number of suspected cases, to monitor the likely source of cases (e.g. overseas travel), track location of infected patients.
  • It became necessary to include robust monitoring around suspected cases as countries closed borders it became difficult for them to outsource laboratory support due to a lack of flights to transport samples.
• Confirmed COVID-19 cases, including automated epi-curves.
• National Health System Readiness Assessment
  • A high-level assessment of the health system’s capacity to test for and respond to a local COVID-19 outbreak.

Pacific Syndromic Surveillance System

With the support of the Indo-Pacific Centre for Health Security and the WHO sub-regional office for the Pacific, we are re-building the Pacific Syndromic Surveillance System to optimise it for the Pacific context. This will allow participating countries to automatically sync national-level surveillance data to the platform and for real-time visualisation of data down to the primary healthcare facility or village level. We are also building tools to allow countries to more easily digitize data collection down at the facility level and enabling data to be more easily routed into national health data warehouses.

Supply Chain Support

With international travel heavily reduced and the shutdown of many manufacturing industries across the world we are also implementing ways to support Pacific Island Countries in anticipation of delays to stock arriving.

Preparing stock for pandemic response is a difficult task, as the tools used for quantification during normal times become inadequate. We have developed a calculator that countries can use to assist in predicting the amount of personal protective equipment (PPE), infection prevention and control (IPC) products, and diagnostics consumables they would need to meet the needs of their country based on the population and size of the health workforce.

We are supporting NZ and Australia in planning their supply chain responses by liaising with countries on medicines and consumables availability, providing fortnightly updates between countries and donors.

Finally, we are building a regional ‘emergency commodity’ platform in partnership with the mSupply Foundation to track critical commodities across all countries in real-time to help prevent stock-outs.

For any questions about our new capabilities or ability to support COVID-19 programming, please get in touch with us at contact@tupaia.org