Deo Nshimirimana

Effectively introducing a new meningococcal A conjugate vaccine in Africa: The Burkina Faso experience

A new Group A meningococcal (Men A) conjugate vaccine, MenAfriVac™, was prequalified by the World Health Organization (WHO) in June 2010. Because Burkina Faso has repeatedly suffered meningitis epidemics due to Group A Neisseria meningitidis special efforts were made to conduct a country-wide campaign with the new vaccine in late 2010 and before the onset of the next epidemic meningococcal disease season beginning in January 2011. In the ensuing five months (July-November 2010) the following challenges were successfully managed: (1) doing a large safety study and registering the new vaccine in Burkina Faso; (2) developing a comprehensive communication plan; (3) strengthening the surveillance system with particular attention to improving the capacity for real-time polymerase chain reaction (PCR) testing of spinal fluid specimens; (4) improving cold chain capacity and waste disposal; (5) developing and funding a sound campaign strategy; and (6) ensuring effective collaboration across all partners. Each of these issues required specific strategies that were managed through a WHO-led consortium that included all major partners (Ministry of Health/Burkina Faso, Serum Institute of India Ltd., UNICEF, Global Alliance for Vaccines and Immunization, Meningitis Vaccine Project, CDC/Atlanta, and the Norwegian Institute of Public Health/Oslo). Biweekly teleconferences that were led by WHO ensured that problems were identified in a timely fashion. The new meningococcal A conjugate vaccine was introduced on December 6, 2010, in a national ceremony led by His Excellency Blaise Compaore, the President of Burkina Faso. The ensuing 10-day national campaign was hugely successful, and over 11.4 million Burkinabes between the ages of 1 and 29 years (100% of target population) were vaccinated. African national immunization programs are capable of achieving very high coverage for a vaccine desired by the public, introduced in a well-organized campaign, and supported at the highest political level. The Burkina Faso success augurs well for further rollout of the Men A conjugate vaccine in meningitis belt countries.

Reaching Every District (RED) approach: a way to improve immunization performance

In their paper, Victora et al.1 show that “child survival interventions are inequitably distributed within low- and middle-income countries”. Areas of greatest need were not prioritized, and expansion of these health programmes in more difficult areas has tended to be delayed or postponed. In response, we wish to share some results and propose a way forward based upon experiences with immunization programmes. Immunization programmes around the world have recognized and strived to reduce inequity for many years. While Universal Child Immunization (UCI) of 80% coverage was achieved in 1990, this merely emphasized the need to balance the inequalities within and between countries. Accordingly, several approaches were adopted. The “high risk approach” was designed in the mid-1990s to reach women in underserved areas with tetanus toxoid immunization using a campaign-style approach.2 District level microplanning has been the cornerstone of the polio eradication and measles elimination initiatives, to maximize the delivery of vaccines to all districts, especially underserved populations. District-level coverage and disease surveillance data are now routinely collected in most countries, with reporting of selected indicators to the global level since 2000. In 2002, the Reaching Every District (RED) approach was developed and introduced by WHO, the United Nations Children’s Fund (UNICEF) and other partners in the GAVI Alliance to improve immunization systems in areas with low coverage. Far from being a programme, or separate initiative, the approach outlines five operational components that are specifically aimed at improving coverage in every district: re-establishment of regular outreach services; supportive supervision: on-site training; community links with service delivery; monitoring and use of data for action; better planning and management of human and financial resources.3 The RED approach encourages countries to use coverage data to make an analysis of the distribution of unimmunized infants, and thereby prioritize districts with poor access and utilization of immunization, while districts are encouraged to make microplans to identify local problems and adopt corrective solutions. Since 2003, 53 developing countries have started implementing RED to various degrees, mostly in Africa and south and south-east Asia.4 All 53 countries belong to the groups of lower income and lower-middle income countries, as per World Bank classification. In 2005, an evaluation of 5 countries in Africa that had implemented RED found that, in 4 of the 5 countries, immunization coverage had increased since the implementation of RED, and that the proportion of districts with DTP3 (three-dose diphtheria, tetanus and pertussis vaccine) coverage above 80% had more than doubled.5 The number of unimmunized children in these 5 countries was reduced from 3 million in 2002 to 1.9 million in 2004. Interestingly, the report notes that outreach services, one of the five components of RED, were often used to deliver other interventions beyond immunization, such as Vitamin A, antihelminthic drugs or insecticide-treated bed nets. This indicates that implementation of RED components may start to have an impact beyond immunization services alone. An analysis of coverage data supports the findings of the evaluation in Africa. It shows that in the 53 countries that started to implement RED between 2003 and 2005, DTP3 coverage (as estimated by WHO and UNICEF) increased between 2002 and 2005 in 34 (64%) countries, and decreased in only 7 (13%).6 Although these data need to be interpreted with caution, since RED implementation has not been nationwide in many countries, they seem to indicate that where RED is implemented, it can help to reduce gaps in immunization coverage. We agree with the suggestion of Victora et al. regarding the need for information systems and training. Most of the 53 countries we refer to have functional immunization information, logistics and supply systems and have implemented district training, often using funds from the GAVI Alliance. Furthermore WHO, UNICEF and other partners at country and regional level have been closely involved in guiding countries adopting the RED approach to reach the unreached. We believe that the RED approach of district microplanning based upon local data using simple operational components and supported by supply and logistics has the potential for the successful delivery of other child health interventions, especially during outreach. ■

African rotavirus surveillance network: a brief overview.

With the imminent availability of new and prospective rotavirus vaccines, reliable information on burden of rotavirus diseases in the different African countries was required to enable evidence-based decision making regarding introduction of rotavirus vaccines. World Health Organization has been supporting Member States since 2006 to establish sentinel surveillance for rotavirus diarrhea in children <5 years of age using standardized guidelines. African countries are using this platform to generate high quality country specific data to document and demonstrate the burden of rotavirus gastroenteritis. The data gathered are being used by policy makers to guide decisions on appropriate intervention strategies for diarrhea control including the value and timing of the introduction of new rotavirus vaccines in the national immunization programs.

Epidemiological and Surveillance Response to Ebola Virus Disease Outbreak in Lofa County, Liberia (March-September, 2014); Lessons Learned.

Ebola Virus Disease (EVD) outbreak was confirmed in Liberia on March 31st 2014. A response comprising of diverse expertise was mobilized and deployed to the country to contain transmission of Ebola and give relief to a people already impoverished from protracted civil war. This paper describes the epidemiological and surveillance response to the EVD outbreak in Lofa County in Liberia from March to September 2014. Five of the 6 districts of Lofa were affected. The most affected districts were Voinjama/Guardu Gbondi and Foya. By 26th September, 2014, a total of 619 cases, including 19.4% probable cases, 20.3% suspected cases and 44.2% confirmed cases were recorded by the Ebola Emergency Response Team (EERT) of Lofa County. Adults (20-50 years) were the most affected. Overall fatality rate was 53.3%. Twenty two (22) cases were reported among the Health Care Workers with a fatality rate of 81.8%. Seventy eight percent (78%) of the contacts successfully completed 21 days follow-up while 134 (6.15%) that developed signs and symptoms of EVD were referred to the ETU in Foya. The contributions of the weak health systems as well as socio-cultural factors in fueling the epidemic are highlighted. Importantly, the lessons learnt including the positive impact of multi-sectorial and multidisciplinary and coordinated response led by the government and community. Again, given that the spread of infectious disease can be considered a security threat every effort has to put in place to strengthen the health systems in developing countries including the International Health Regulation (IHR)’s core capacities. Key words: Ebola virus disease, outbreak, epidemiology and surveillance, socio-cultural factors, health system, West Africa.

2009 Pandemic Influenza A Virus Subtype H1N1 Vaccination in Africa—Successes and Challenges

To provide vaccination against infection due to 2009 pandemic influenza A virus subtype H1N1 (A[H1N1]pdm09) to resource-constrained countries with otherwise very little access to the A(H1N1)pdm09 vaccine, the World Health Organization (WHO) coordinated distribution of donated vaccine to selected countries worldwide, including those in Africa. From February through November 2010, 32.2 million doses were delivered to 34 countries in Africa. Of the 19.2 million doses delivered to countries that reported their vaccination activities to WHO, 12.2 million doses (64%) were administered. Population coverage in these countries varied from 0.4% to 11%, with a median coverage of 4%. All countries targeted pregnant women (median proportion of all vaccine doses administered [mpv], 21% [range, 4%-72%]) and healthcare workers (mpv, 9% [range, 1%-73%]). Fourteen of 19 countries targeted persons with chronic conditions (mpv, 26% [range, 5%-66%]) and 10 of 19 countries vaccinated children (mpv, 54% [range, 17%-75%]). Most vaccine was distributed after peak A(H1N1)pdm09 transmission in the region. The frequency and severity of adverse events were consistent with those recorded after other inactivated influenza vaccines. Pandemic preparedness plans will need to include strategies to ensure more-rapid procedures to identify vaccine supplies and distribute and import vaccines to countries that may bear the brunt of a future pandemic.

Control of viral hepatitis infection in Africa: Are we dreaming?

BACKGROUND At least five different types of viral hepatitis cause problems of significant public health importance in Africa, where together they constitute a huge burden of disease. But until now, efforts to control the infections have been largely piecemeal. Analysis of the strategies needed to control each virus, however, reveals major overlaps. PROPOSAL We propose that the control of these infections in the WHO African Region should start with the common strategies rather than with each disease. But this approach presents potentially huge problems to overcome, such as the difficulty of integrating multiple health service elements - the track record for successful integration of such services is not good. This is despite encouraging rhetoric from donors and national leaders alike. And to succeed, disparate programmes must work closely together. But we believe that the time is right to create new opportunities for prevention and treatment of hepatitis, including increasing education, and promoting screening and treatment for more than 500 million people already infected with hepatitis B and C viruses. IMPACT The impact of these efforts on decreasing mortality and morbidity will be significant because of the high burden of disease from these infections, and also because the effect will spill over to benefit the control of other communicable diseases and health systems strengthening. Such a project will inevitably involve multiple strategies that will vary somewhat according to the epidemiology of the diseases and the location.

Trend in proportions of missed children during polio supplementary immunization activities in the African Region: evidence from independent monitoring data 2010-2012.

This is a comparative analysis of independent monitoring data collected between 2010 and 2012, following the implementation of supplementary immunization activities (SIAs) in countries in the three sub regional blocs of World Health Organization in the African Region. The sub regional blocs are Central Africa, West Africa, East and Southern Africa. In addition to the support for SIAs, the Central and West African blocs, threatened with importation and re-establishment of polio transmission received intensive coordination through weekly teleconferences. The later, East and Southern African bloc with low polio threats was not engaged in the intensive coordination through teleconferences. The key indicator of the success of SIAs is the proportion of children missed during SIAs. The results showed that generally there was a decrease in the proportion of children missed during SIAs in the region, from 7.94% in 2010 to 5.95% in 2012. However, the decrease was mainly in the Central and West African blocs. The East and Southern African bloc had countries with as much as 25% missed children. In West Africa and Central Africa, where more coordinated SIAs were conducted, there were progressive and consistent drops, from close to 20-10% at the maximum. At the country and local levels, steps were undertaken to ameliorate situation of low immunization uptake. Wherever an area is observed to have low coverage, local investigations were conducted to understand reasons for low coverage, plans to improve coverage are made and implemented in a coordinated manner. Lessons learned from close monitoring of polio eradication SIAs are will be applied to other campaigns being conducted in the African Region to accelerate control of other vaccine preventable diseases including cerebrospinal meningitis A, measles and yellow fever.

Reasons and circumstances for the late notification of Acute Flaccid Paralysis (AFP) cases in health facilities in Luanda

Introduction As the polio eradication effort enters the end game stage, surveillance for Acute Flaccid Paralysis in children becomes a pivotal tool. Thus given the gaps in AFP surveillance as identified in the cases of late notification, this study was designed to explore the reasons and circumstances responsible for late notification of AFP and collection of inadequate stools (more than 14 days of onset of paralysis until collection of the 2nd stool specimen) of AFP cases in health facilities equipped to manage AFP cases. Methods Eleven AFP cases with inadequate stools were reported from January 2 to July 8, 2012 - Epidemiological Weeks 1-27. The families of these cases were interviewed with an in-depth interview guide. The staff of the seven health units, where they later reported, was also enlisted for the study which used in-depth interview guide in eliciting information from them. Results Ignorance and wrong perception of the etiology of the cases as well as dissatisfaction with the health units as the major reasons for late reporting of AFP cases. The first port of call is usually alternative health care system such as traditional healers and spiritualists because the people hold the belief that the problem is spiritually induced. The few, who make it to health units, are faced with ill equipped rural health workers who wait for the arrival of more qualified staff, who may take days to do so. Conclusion An understanding of the health seeking behavior of the population is germane to effective AFP surveillance. There is thus a need to tailor AFP surveillance to the health seeking behavior of the populations and expand it to community structures.

Outbreak of Type 1 Wild Poliovirus Infection in Adults, Namibia, 2006

A paralytic poliomyelitis outbreak occurred in Namibia in 2006, almost exclusively among adults. Nineteen cases were virologically confirmed as due to wild poliovirus type 1 (WPV1), and 26 were classified as polio compatible. Eleven deaths occurred among confirmed and compatible cases (24%). Of the confirmed cases, 97% were aged 15-45 years, 89% were male, and 71% lived in settlement areas in Windhoek. The virus was genetically related to a virus detected in 2005 in Angola, which had been imported earlier from India. The outbreak is likely due to immunity gaps among adults who were inadequately vaccinated during childhood. This outbreak underscores the ongoing risks posed by poliovirus importations, the importance of maintaining strong acute flaccid paralysis surveillance even in adults, and the need to maintain high population immunity to avoid polio outbreaks in the preeradication period and outbreaks due to vaccine-derived polioviruses in the posteradication era.

Documentation of polio eradication initiative best practices: Experience from WHO African Region

BACKGROUND The African Region is set to achieving polio eradication. During the years of operations, the Polio Eradication Initiative [PEI] in the Region mobilized and trained tremendous amount of manpower with specializations in surveillance, social mobilization, supplementary immunization activities [SIAs], data management and laboratory staff. Systems were put in place to accelerate the eradication of polio in the Region. Standardized, real-time surveillance and response capacity were established. Many innovations were developed and applied to reaching people in difficult and security challenged terrains. All of these resulted in accumulation of lessons and best practices, which can be used in other priority public health intervention if documented. METHODS The World Health Organization Regional Office for Africa [WHO/AFRO] developed a process for the documentation of these best practices, which was pretested in Uganda. The process entailed assessment of three critical elements [effectiveness, efficiency and relevance] five aspects [ethical soundness, sustainability, involvement of partners, community involvement, and political commitment] of best practices. A scored card which graded the elements and aspects on a scale of 0-10 was developed and a true best practice should score >50 points. Independent public health experts documented polio best practices in eight countries in the Region, using this process. The documentation adopted the cross-sectional design in the generation of data, which combined three analytical designs, namely surveys, qualitative inquiry and case studies. For the selection of countries, country responses to earlier questionnaire on best practices were screened for potential best practices. Another criterion used was the level of PEI investment in the countries. RESULTS A total of 82 best practices grouped into ten thematic areas were documented. There was a correlation between the health system performances with DPT3 as proxy, level of PEI investment in countries with number of best practice. The application of the process for the documentation of polio best practices in the African Region brought out a number of advantages. The triangulation of data collected using multiple methods and the collection of data from all levels of the programme proved useful as it provided opportunity for data verification and corroboration. It also helped to overcome some of the data challenge.