A randomised controlled trial of SMS messaging and calendar reminders to improve vaccination timeliness in infants

"Our kids are our future": Barriers and facilitators to vaccine uptake and timeliness among Aboriginal children younger than five years in Boorloo (Perth), Western Australia

INTRODUCTION

Rates of several vaccine preventable diseases, and associated hospitalisation, are higher among Aboriginal and/or Torres Strait Islander children than non-Indigenous children. Western Australia has among the lowest childhood vaccine coverage in Australia, particularly among Aboriginal and/or Torres Strait Islander children. Delayed vaccination is also more common in this population. This project aimed to understand the barriers and facilitators to vaccine uptake and timeliness among Aboriginal and/or Torres Strait Islander children aged under five years in Boorloo (Perth).

METHODS

The Tailoring Immunisation Programs method was used to determine the barriers and facilitators to vaccination. Between March - November 2023, in-depth interviews were conducted with 18 parents/carers of Aboriginal and/or Torres Strait Islander children in Boorloo who were currently or previously overdue for one or more childhood vaccines. Qualitative data were analysed in NVivo 14 using deductive and inductive coding following the Capability-Opportunity-Motivation-Behaviour model.

RESULTS

The majority of participants believed vaccines are safe, effective and supported vaccination as a means to strengthen the next generation of Aboriginal and/or Torres Strait Islander children. Barriers to on-time vaccination related to access and ineffective reminder systems. Participants expressed limited knowledge about additional vaccines recommended for Aboriginal and/or Torres Strait Islander children under Australia's National Immunisation Program.

CONCLUSION

An increase in vaccine coverage and timeliness will optimise protection and decrease the burden of disease in Aboriginal and/or Torres Strait Islander children in Boorloo. This can be supported by policy interventions to better cater for the needs of families, including addressing transport challenges, being mindful of the wider network of kin and care relationships, ensuring the funding of Aboriginal health services, and co-designing culturally appropriate resources. The federal government should use the Centrelink system to notify all eligible families of pending vaccines due.

Effects of parental short message service reminders on infant immunisation coverage, timeliness and barriers in Nigeria: A quasi-experimental study

Introduction

This study aimed to determine the effects of parental short message service (SMS) reminders on infant immunisation coverage, timeliness and barriers and evaluate the effects of sex on immunisation outcomes in Maiduguri, Borno State, Nigeria.

Methods

This two-arm quasi-experimental study was conducted in two primary healthcare facilities selected using simple random sampling with opaque envelopes. A total of 524 participants were enrolled using purposive sampling. Data were statistically analysed using the Statistical Package for the Social Sciences version 28 with repeated-measures logistic regression analysis, the Z test for Poisson rates and the Wilcoxon signed-rank test.

Results

The parental SMS reminders significantly improved the immunisation coverage, as reported by 69 (26.3%) (P=0.001, 95% confidence interval [CI] = 12.2-40.5), 117 (44.7%) (P=0.001, 95% CI=32.6-56.9) and 116 (44.3%) participants (P=0.001, 95% CI=34.2-54.4) for the 6th-, 10th- and 14th-week schedules, respectively. Compared to mothers' involvement, fathers' involvement did not significantly affect the immunisation coverage (B=0.158, P=0.311, 95% CI=-0.148-0.464). With regard to the immunisation timeliness, the parental SMS reminders yielded a significant effect for the 6th-, 10th- and 14th-week schedules (P=0.001, 95% CI=25.9-46.7; P=0.001, 95% CI=24.2-43.0; and P=0.001, 95% CI=21.1-36.9, respectively). Compared to mothers' involvement, fathers' involvement significantly influenced the immunisation timeliness (B=0.298, P=0.038, 95% CI=0.016-0.579). Lastly, the parental SMS reminders significantly reduced the barriers to immunisation, with a P-value of 0.001.

Conclusion

Parental SMS reminders can significantly improve immunisation outcomes in Nigeria.

Mobile Phone Text Message Reminders to Improve Vaccination Uptake: A Systematic Review and Meta-Analysis

INTRODUCTION

Mobile phone text message reminders (MPTMRs) have been implemented globally to promote vaccination uptake and recall rates. This systematic review evaluated the effectiveness of MPTMRs on vaccination recall rates.

METHODS

We included randomized controlled trials of caregivers of children, adolescents, or adults who received MPTMRs for improving vaccine uptake and recall visits. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, and Scopus to identify relevant studies published up to 24 January 2024. We used Cochrane's Risk of Bias tool to assess the included studies and reported the results as risk ratios with 95% confidence intervals, using a random effects model.

RESULTS

We identified 25 studies for inclusion. All studies were assessed as having a low risk of bias. The evidence supports MPTMRs for improving vaccination uptake compared to usual care (RR = 1.09 [95%CI: 1.06, 1.13], I2 = 76%). Intervention characteristics, country setting, country economic status, and vaccination type had no bearing on the effectiveness of the intervention.

CONCLUSIONS

MPTMRs have a positive effect, albeit relatively small, on vaccination uptake. These findings may assist public health practitioners, policymakers, and vaccine researchers in evidence-based decision making that focuses on MPTMRs and their impact on vaccination coverage.

Effectiveness of Catch-Up Vaccination Interventions Versus Standard or Usual Care Procedures in Increasing Adherence to Recommended Vaccinations Among Different Age Groups: Systematic Review and Meta-Analysis of Randomized Controlled Trials and Before-After Studies

BACKGROUND

To address the global challenge of vaccine hesitancy, the Strategic Advisory Group of Experts on Immunization strongly promotes vaccination reminder and recall interventions. Coupled with the new opportunities presented by scientific advancements, these measures are crucial for successfully immunizing target population groups.

OBJECTIVE

This systematic review and meta-analysis aims to assess the effectiveness of various interventions in increasing vaccination coverage compared with standard or usual care. The review will cover all vaccinations recommended for different age groups.

METHODS

In February 2022, 2 databases were consulted, retrieving 1850 studies. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 79 manuscripts were included after the assessment phase. These comprised 46 trials/randomized controlled trials (RCTs) and 33 before-after studies. A meta-analysis using a random-effects model was performed with STATA software (version 14.1.2). The selected outcome was the risk ratio (RR) of vaccination coverage improvement effectiveness. Additionally, meta-regression analyses were conducted for the included manuscripts.

RESULTS

The analyses showed an overall efficacy of RR 1.22 (95% CI 1.19-1.26) for RCTs and RR 1.70 (95% CI 1.54-1.87) for before-after studies when considering all interventions cumulatively. Subgroup analyses identified multicomponent interventions (RR 1.58, 95% CI 1.36-1.85) and recall clinical interventions (RR 1.24, 95% CI 1.17-1.32) as the most effective in increasing vaccination coverage for RCTs. By contrast, educational interventions (RR 2.13, 95% CI 1.60-2.83) and multicomponent interventions (RR 1.61, 95% CI 1.43-1.82) achieved the highest increases for before-after studies. Meta-regression analyses indicated that the middle-aged adult population was associated with a higher increase in vaccination coverage (RCT: coefficient 0.54, 95% CI 0.12-0.95; before-after: coefficient 1.27, 95% CI 0.70-1.84).

CONCLUSIONS

Community, family, and health care-based multidimensional interventions, as well as education-based catch-up strategies, effectively improve vaccination coverage. Therefore, their systematic implementation is highly relevant for targeting undervaccinated population groups. This approach aligns with national vaccination schedules and aims to eliminate or eradicate vaccine-preventable diseases.

SMS-based interventions for improving child and adolescent vaccine coverage and timeliness: a systematic review

BACKGROUND

The aim of this review was to investigate the impact of short message service (SMS)-based interventions on childhood and adolescent vaccine coverage and timeliness.

METHODS

A pre-defined search strategy was used to identify all relevant publications up until July 2022 from electronic databases. Reports of randomised trials written in English and involving children and adolescents less than 18 years old were included. The review was conducted in accordance with PRISMA guidelines.

RESULTS

Thirty randomised trials were identified. Most trials were conducted in high-income countries. There was marked heterogeneity between studies. SMS-based interventions were associated with small to moderate improvements in vaccine coverage and timeliness compared to no SMS reminder. Reminders with embedded education or which were combined with monetary incentives performed better than simple reminders in some settings.

CONCLUSION

Some SMS-based interventions appear effective for improving child vaccine coverage and timeliness in some settings. Future studies should focus on identifying which features of SMS-based strategies, including the message content and timing, are determinants of effectiveness.

Evaluating Pilot Implementation of 'PenCS Flu Topbar' App in Medical Practices to Improve National Immunisation Program-Funded Seasonal Influenza Vaccination in Central Queensland, Australia

BACKGROUND

The 'PenCS Flu Topbar' app was deployed in Central Queensland (CQ), Australia, medical practices through a pilot programme in March 2021.

METHODS

We evaluated the app's user experience and examined whether the introduction of 'PenCS Flu Topbar' in medical practices could improve the coverage of NIP-funded influenza vaccinations. We conducted a mixed-method study including a qualitative analysis of in-depth interviews with key end-users and a quantitative analysis of influenza vaccine administrative data.

RESULTS

'PenCS Flu Topbar' app users reported positive experiences identifying patients eligible for NIP-funded seasonal influenza vaccination. A total of 3606 NIP-funded influenza vaccinations was administered in the eight intervention practices, 14% higher than the eight control practices. NIP-funded vaccination coverage within practices was significantly higher in the intervention practices (31.2%) than in the control practices (27.3%) (absolute difference: 3.9%; 95% CI: 2.9%-5.0%; p < 0.001). The coverage was substantially higher in Aboriginal and Torres Strait Islander people aged more than 6 months, pregnant women and children aged 6 months to less than 5 years for the practices where the app was introduced when compared to control practices: incidence rate ratio (IRR) 2.4 (95% CI: 1.8-3.2), IRR 2.7 (95% CI: 1.8-4.2) and IRR 2.3 (1.8-2.9) times higher, respectively.

CONCLUSIONS

Our evaluation indicated that the 'PenCS Flu Topbar' app is useful for identifying the patients eligible for NIP-funded influenza vaccination and is likely to increase NIP-funded influenza vaccine coverage in the eligible populations. Future impact evaluation including a greater number of practices and a wider geographical area is essential.

Parental Reminder Strategies and the Cost Implication for Improved Immunisation Outcomes: A Systematic Review and Meta-Analysis

Getting children vaccinated amidst prevailing barriers to immunisation has been challenging in both developed and developing countries. To address these problems, studies on parental reminder strategies were conducted to improve immunisation outcomes in children. These led to the development of different parental reminder interventions. This review systematically reviews different parental interventions and their cost implication for improved immunisations. Five online databases; Medline Complete, the Cumulative Index for Nursing and Allied Health Literature [CINAHL], Academic search premier, SPORTDiscus, and Health Source Nursing/Academic were searched using search terms. A total of 24 articles that met the inclusion criteria were included in this review. Studies that provided sufficient information were included for meta-analysis using Comprehensive Meta-Analysis version three, while narrative synthesis was used for the other studies. Results indicate that a heterogeneous and low-quality certainty of evidence on parental voice calls (OR 4.752, 95% CI 1.846-12.231, p = 0.001) exists in improving immunisation coverage. Regarding immunisation timeliness, a high-quality certainty of evidence on Short Message Services (SMS)-delivered health education messages (OR 2.711 95% CI 1.387-5.299, p = 0.004) had more effect on timely immunisation uptake. The average cost of SMS-delivered parental reminder interventions for improved immunisation outcomes was USD 0.50. The study concludes that mobile technology is a promising, cost-effective strategy for improved immunisation outcomes.

Comparison of strategies for daily surveillance of international travellers quarantined in Vanuatu, October-December 2020

OBJECTIVE

To prevent importation of coronavirus disease 2019 (COVID-19) to Vanuatu, since March 2020, all travellers to the country have been required to complete a 14-day quarantine in a government-designated facility. A short message service (SMS, or "text message") system was developed to collect information on symptoms of COVID-19 among travellers in quarantine. A trial within a cohort study was conducted among travellers arriving to Vanuatu by air from 27 October to 7 December 2020 to assess SMS acceptability, efficiency and utility and whether SMS-based health monitoring was as effective as in-person monitoring in identifying people with COVID-19 symptoms.

METHODS

Control group participants received standard monitoring (daily in-person visits) and participants in the intervention group received a daily SMS text requesting a response coded for symptom development. Differences between the two groups were determined using χ² tests.

RESULTS

Of the 495 eligible travellers, 423 participated; 170 were allocated to the control group and 253 to the intervention group. At least one return SMS text was received from 50% (107/212) of participants who were confirmed to have received an SMS text. Less than 2% (4/253) of the intervention group and 0% of the control group reported symptoms.

DISCUSSION

The SMS intervention had a high level of acceptability. SMS is a useful tool to monitor symptom development among people in quarantine and for broader public health programmes that require follow up.

Effect of mobile health interventions in increasing utilization of Maternal and Child Health care services in developing countries: A scoping review

Background

Mobile health (mHealth) technology is being used predominantly in low- and middle-income countries. Developing countries with low level of investment in health infrastructure can augment existing capacity by adopting low-cost affordable technology. The aim of the review was to summarize the available evidence on mHealth interventions that aimed at increasing the utilization of Maternal and Child Health (MCH) care services. Further, this review investigated the barriers which prevent the use of mHealth among both health care workers as well as beneficiaries.

Methodology

A scoping review of literature was undertaken using the five-stage framework developed by Arksey and O'Malley. The articles published between 1990 and 2021 were retrieved from three databases (PubMed, Cochrane Reviews, and Google Scholar) and grey literature for this review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist was followed to present the findings.

Result

A total of 573 studies were identified. After removing duplicates, studies not related to mHealth and MCH and publications of systematic reviews and protocols for studies, a total of 28 studies were selected for review. The study design of the research articles which appeared during the search process were mostly observational, cross-sectional, and randomized controlled trials (RCTs). We have classified the studies into four categories based on the outcomes for which the mHealth intervention was implemented: MCH care services, child immunization, nutrition services, and perceptions of stakeholders toward using technology for improving MCH outcomes.

Conclusion

This brief review concludes that mHealth interventions can improve access to MCH services. However, further studies based on large sample size and strong research design are recommended.

Short message service (SMS) reminders for childhood immunisation in low-income and middle-income countries: a systematic review and meta-analysis

Introduction

Childhood vaccine delivery services in the low- and middle-income countries (LMIC) are struggling to reach every child with lifesaving vaccines. Short message service (SMS) reminders have demonstrated positive impact on a number of attrition-prone healthcare delivery services. We aimed to evaluate the effectiveness of SMS reminders in improving immunisation coverage and timeliness in LMICs.

Methods

PubMed, Embase, Scopus, Cochrane CENTRAL, CINAHL, CNKI, PsycINFO and Web of Science including grey literatures and Google Scholar were systematically searched for randomised controlled trials (RCTs) and non-RCTs that evaluated the effect of SMS reminders on childhood immunisation and timeliness in LMICs. Risk of bias was assessed using the Cochrane Risk of Bias 2.0 assessment tool for RCTs and Cochrane Risk of Bias in Non-randomised Studies of Interventions tool for non-RCTs. Meta-analysis was conducted using random-effects models to generate pooled estimates of risk ratio (RR).

Results

18 studies, 13 RCTs and 5 non-RCTs involving 32 712 infants (17 135 in intervention groups and 15 577 in control groups) from 11 LMICs met inclusion criteria. Pooled estimates showed that SMS reminders significantly improved childhood immunisation coverage (RR=1.16; 95% CI: 1.10 to 1.21; I²=90.4%). Meta-analysis of 12 included studies involving 25 257 infants showed that SMS reminders significantly improved timely receipt of childhood vaccines (RR=1.21; 95% CI: 1.12 to 1.30; I²=87.3%). Subgroup analysis showed that SMS reminders are significantly more effective in raising childhood immunisation coverage in lower middle-income and low-income countries than in upper middle-income countries (p<0.001) and sending more than two SMS reminders significantly improves timely receipt of childhood vaccines than one or two SMS reminders (p=0.040).

Conclusion

Current evidence from LMICs, although with significant heterogeneity, suggests that SMS reminders can contribute to achieving high and timely childhood immunisation coverage.

PROSPERO registration number

CRD42021225843.

Effect of Mobile Phone Text Message Reminders on the Completion and Timely Receipt of Routine Childhood Vaccinations: Superiority Randomized Controlled Trial in Northwest Ethiopia

BACKGROUND

Nonattendance at vaccination appointments is a big challenge for health workers as it is difficult to track routine vaccination schedules. In Ethiopia, 3 out of 10 children have incomplete vaccination and the timely receipt of the recommended vaccines is low. Thus, innovative strategies are required to reach the last mile where mobile technology can be effectively utilized to achieve better compliance. Despite this promising technology, little is known about the role of text message-based mobile health interventions in improving the complete and timely receipt of routine childhood vaccinations in Ethiopia.

OBJECTIVE

This trial aimed to determine the effect of mobile phone text message reminders on the completion and timely receipt of routine childhood vaccinations in northwest Ethiopia.

METHODS

A two-arm, parallel, superiority randomized controlled trial was conducted in 9 health facilities in northwest Ethiopia. A sample size of 434 mother-infant pairs was considered in this trial. Randomization was applied in selected health facilities during enrollment with a 1:1 allocation ratio by using sealed and opaque envelopes. Participants assigned to the intervention group received mobile phone text message reminders one day before the scheduled vaccination visits. Owing to the nature of the intervention, blinding of participants was not possible. Primary outcomes of full and timely completion of vaccinations were measured objectively at 12 months. A two-sample test of proportion and log-binomial regression analyses were used to compare the outcomes between the study groups. A modified intention-to-treat analysis approach was applied and a one-tailed test was reported, considering the superiority design of the trial.

RESULTS

A total of 426 participants were included for the analysis. We found that a higher proportion of infants in the intervention group received Penta-3 (204/213, 95.8% vs 185/213, 86.9%, respectively; P<.001), measles (195/213, 91.5% vs 169/213, 79.3%, respectively; P<.001), and full vaccination (176/213, 82.6% vs 151/213, 70.9%, respectively; P=.002; risk ratio 1.17, 95% lower CI 1.07) compared to infants in the usual care group. Similarly, a higher proportion of infants in the intervention group received Penta-3 (181/204, 88.7% vs 128/185, 69.2%, respectively; P<.001), measles (170/195, 87.1% vs 116/169, 68.6%, respectively; P<.001), and all scheduled vaccinations (135/213, 63.3% vs 85/213, 39.9%, respectively; P<.001; risk ratio 1.59, 95% lower CI 1.35) on time compared to infants in the usual care group. Of the automatically sent 852 mobile phone text messages, 764 (89.7%) were delivered successfully to the participants.

CONCLUSIONS

Mobile phone text message reminders significantly improved complete and timely receipt of all recommended vaccines. Besides, they had a significant effect in improving the timely receipt of specific vaccines. Thus, text message reminders can be used to supplement the routine immunization program in resource-limited settings. Considering different contexts, studies on the implementation challenges of mobile health interventions are recommended.

TRIAL REGISTRATION

Pan African Clinical Trial Registry PACTR201901533237287; https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=5839.

Barriers to influenza vaccination of children hospitalised for acute respiratory illness: A cross-sectional survey

AIM

To identify barriers to influenza vaccination of children hospitalised for acute respiratory illness in Australia.

METHODS

A total of 595 parents of children hospitalised with acute respiratory illness across five tertiary hospitals in 2019 participated in an online survey. Multivariate logistic regression identified factors most strongly associated with influenza vaccination barriers.

RESULTS

Odds of influenza vaccination were lower with lack of health-care provider (HCP) recommendation (adjusted odds ratio (aOR) 0.18; 95% confidence interval (CI): 0.08-0.38); if parents had difficulties (aOR 0.19; 95% CI: 0.08-0.47) or were 'neutral' (aOR 0.23; 95% CI: 0.06-0.82) in remembering to make an appointment; and if parents had difficulties (aOR 0.21; 95% CI: 0.07-0.62) or were 'neutral' (aOR 0.24; 95% CI: 0.07-0.79) regarding getting an appointment for vaccination. Odds were also lower if parents did not believe (aOR 0.27; 95% CI: 0.08-0.90) or were 'neutral' (aOR 0.15; 95% CI: 0.04-0.49) regarding whether the people most important to them would have their child/ren vaccinated against influenza. Children had lower odds of vaccination if parents did not support (aOR 0.09; 95% CI: 0.01-0.82) or were ambivalent (aOR 0.09; 95% CI: 0.01-0.56) in their support for influenza vaccination. Finally, lack of history of influenza vaccination of child (aOR 0.38; 95% CI: 0.18-0.81) and respondent (aOR 0.25; 95% CI: 0.11-0.56) were associated with lack of receipt of influenza vaccine before admission for acute respiratory infection.

CONCLUSIONS

Assisting parents in remembering and accessing influenza vaccination and encouraging health-care providers to recommend vaccination may increase uptake.

One Digital Health: A Unified Framework for Future Health Ecosystems

One Digital Health is a proposed unified structure. The conceptual framework of the One Digital Health Steering Wheel is built around two keys (ie, One Health and digital health), three perspectives (ie, individual health and well-being, population and society, and ecosystem), and five dimensions (ie, citizens’ engagement, education, environment, human and veterinary health care, and Healthcare Industry 4.0). One Digital Health aims to digitally transform future health ecosystems, by implementing a systemic health and life sciences approach that takes into account broad digital technology perspectives on human health, animal health, and the management of the surrounding environment. This approach allows for the examination of how future generations of health informaticians can address the intrinsic complexity of novel health and care scenarios in digitally transformed health ecosystems. In the emerging hybrid landscape, citizens and their health data have been called to play a central role in the management of individual-level and population-level perspective data. The main challenges of One Digital Health include facilitating and improving interactions between One Health and digital health communities, to allow for efficient interactions and the delivery of near–real-time, data-driven contributions in systems medicine and systems ecology. However, digital health literacy; the capacity to understand and engage in health prevention activities; self-management; and collaboration in the prevention, control, and alleviation of potential problems are necessary in systemic, ecosystem-driven public health and data science research. Therefore, people in a healthy One Digital Health ecosystem must use an active and forceful approach to prevent and manage health crises and disasters, such as the COVID-19 pandemic.

Effects of a short message service (SMS) by cellular phone to improve compliance with fasting guidelines in patients undergoing elective surgery: a retrospective observational study

Background

Contemporary perioperative fasting guidelines aim to alleviate patient discomfort before surgery and enhance postoperative recovery whilst seeking to reduce the risk of pulmonary aspiration during anesthesia. The impact of a short message service (SMS) reminder on fasting guideline compliance is unknown. Therefore, we performed a retrospective observational study and quality improvement project aiming to quantify the extent of excessive and prolonged fasting, and then assessed the impact of a SMS reminder in reducing fasting times.

Methods

After ethics committee approval we performed a retrospective observational study investigating preoperative fasting times of adult patients undergoing elective surgery. First, we assessed whether the fasting guideline times were adhered to (Standard Care group). All patients received internationally recommended fasting guidelines in the form of a written hospital policy document. We then implemented an additional prompt via a mobile phone SMS 1 day prior to surgery containing a reminder of fasting guideline times (SMS group). The primary aims were to compare fasting times between the Standard Care group and the SMS group.

Results

The fasting times of 160 patients in the Standard Care group and 110 patients in the SMS group were evaluated. Adherence to the fasting guidelines for solids occurred in 14 patients (8.8%) in the Standard Care group vs. Twenty-two patients (13.6%) in the SMS group (p=0.01). Adherence to the fasting guidelines for fluids occurred in 4 patients (2.5%) in the Standard Care group vs. Ten patients (6.3%) in the SMS group (p=0.023). Patients in the Standard Care group had a longer median (inter-quartile range (IQR)) fasting time for fluids compared the SMS group [6.5 h (IQR 4.5:11) vs 3.5 h (IQR 3:8.5), p< 0.0001]. Median fasting times for solids were 11 h (IQR 7:14) in the Standard Care group and 11.5 h (IQR 7:13.5) in the SMS group (p=0.756).

Conclusion

Adherence to internationally recommended fasting guidelines for patients undergoing elective surgery is poor. The introduction of a fasting guideline reminder via a mobile phone SMS in addition to a written hospital policy improved adherence to fasting advice and reduced the fasting times for fluids but not for solids. The use of an SMS reminder of fasting guidelines is a simple, feasible, low-cost, and effective tool in minimising excessive fasting for fluids among elective surgical patients.

Trial registration

ACTRN12619001232123 (Australia New Zealand Clinical Trials Registry). Registered 6th September 2019 (retrospectively registered).