Making districts functional for universal health coverage attainment: lessons from Ghana

Ensuring the sub national level in the health system can function effectively is central to attainment of health results in countries. However, the current health agenda has not prioritized how districts can deploy their existing resources effectively, to maximize the efficiency equity and effectiveness in their use. Ghana initiated a self-assessment process to understand the functionality of districts to deliver on health results. The assessment was conducted by health managers in 33 districts during August-October 2022 using tools pre-developed by the World Health Organization. Functionality was explored around service provision, oversight, and management capacities, each with defined dimensions and attributes. The objective of the study was to highlight specific functionality improvements needed by districts in terms of investments and access to service delivery in achieving Universal Health Care. The results showed a lack of correlation between functionality and performance as is currently defined in Ghana; a higher functionality of oversight capacity compared to service provision or management capacities; and specifically low functionality for dimensions relating to capacity to make available quality services, responsiveness to beneficiaries and the systems and three structures for health management. The findings highlight the need to shift from quantitative outcome indicator-based performance approaches to measures of total health and wellbeing of beneficiaries. Specific functionality improvements are needed to improve the engagement and answerability to the beneficiaries, investments in access to services, and in building management architecture.

Post introduction evaluation of the malaria vaccine implementation programme in Ghana, 2021

BACKGROUND

Malaria remains a public health challenge in Sub-Saharan Africa with the region contributing to more than 90% of global cases in 2020. In Ghana, the malaria vaccine was piloted to assess the feasibility, safety, and its impact in the context of routine use alongside the existing recommended malaria control measures. To obtain context-specific evidence that could inform future strategies of introducing new vaccines, a standardized post-introduction evaluation (PIE) of the successes and challenges of the malaria vaccine implementation programme (MVIP) was conducted.

METHODS

From September to December 2021, the WHO Post-Introduction Evaluation (PIE) tool was used to conduct a mixed methods evaluation of the MVIP in Ghana. To ensure representativeness, study sites and participants from the national level, 18 vaccinating districts, and 54 facilities from six of the seven pilot regions were purposively selected. Quantitative and qualitative data were collected using data collection tools that were adapted based on the WHO PIE protocol. We performed summary descriptive statistics on quantitative data, thematic analysis on qualitative data, and triangulation of the results from both sets of analyses.

RESULTS

About 90.7% (49/54) of health workers stated that the vaccine introduction process was smooth and contributed to an overall improvement of routine immunisation services. About 87.5% (47/54) of healthcare workers, and 95.8% (90/94) of caregivers accepted RTS,S malaria vaccine. Less than half [46.3%; (25/54)] of the healthcare workers participated in the pre-vaccine introduction training but almost all [94.4%; (51/54)] were able to constitute and administer the vaccine appropriately. About 92.5% (87/94) of caregivers were aware of the RTS,S introduction but only 44.0% (44/94) knew the number of doses needed for maximum protection. Health workers believed that the MVIP has had a positive impact on under five malaria morbidity.

CONCLUSIONS

The malaria vaccine has been piloted successfully in Ghana. Intensive advocacy; community engagement, and social mobilization; and regular onsite supportive supervision are critical enablers for successful introduction of new vaccines. Stakeholders are convinced of the feasibility of a nationwide scale up using a phased subnational approach taking into consideration malaria epidemiology and global availability of vaccines.

The COVID-19 pandemic: broad partnerships for the rapid scale up of innovative virtual approaches for capacity building and credible information dissemination in Africa

The Corona Virus Disease 2019 (COVID-19) pandemic has rapidly spread in Africa, with a total of 474,592 confirmed cases by 11th July 2020. Consequently, all policy makers and health workers urgently need to be trained and to access the most credible information to contain and mitigate its impact. While the need for rapid training and information dissemination has increased, most of Africa is implementing public health social and physical distancing measures. Responding to this context requires broad partnerships and innovative virtual approaches to disseminate new insights, share best practices, and create networked communities of practice for all teach, and all learn. The World Health Organization (WHO)-Africa region, in collaboration with the Extension for Community Health Outcome (ECHO) Institute at the University of New Mexico Health Sciences Center (UNM HSC), the West Africa college of nurses and the East Central and Southern Africa college of physicians, private professional associations, academia and other partners has embarked on a virtual training programme to support the containment of COVID-19. Between 1st April 2020 and 10th July 2020, about 7,500 diverse health professionals from 172 locations in 58 countries were trained in 15 sessions. Participants were from diverse institutions including: central ministries of health, WHO country offices, provincial and district hospitals and private medical practitioners. A range of critical COVID-19 preparedness and response interventions have been reviewed and discussed. There is a high demand for credible information from credible sources about COVID-19. To mitigate the "epidemic of misinformation" partnerships for virtual trainings and information dissemination leveraging existing learning platforms and networks across Africa will augment preparedness and response to COVID-19.

The potential effects of widespread community transmission of SARS-CoV-2 infection in the World Health Organization African Region: a predictive model

The spread of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has been unprecedented in its speed and effects. Interruption of its transmission to prevent widespread community transmission is critical because its effects go beyond the number of COVID-19 cases and deaths and affect the health system capacity to provide other essential services. Highlighting the implications of such a situation, the predictions presented here are derived using a Markov chain model, with the transition states and country specific probabilities derived based on currently available knowledge. A risk of exposure, and vulnerability index are used to make the probabilities country specific. The results predict a high risk of exposure in states of small size, together with Algeria, South Africa and Cameroon. Nigeria will have the largest number of infections, followed by Algeria and South Africa. Mauritania would have the fewest cases, followed by Seychelles and Eritrea. Per capita, Mauritius, Seychelles and Equatorial Guinea would have the highest proportion of their population affected, while Niger, Mauritania and Chad would have the lowest. Of the World Health Organization's 1 billion population in Africa, 22% (16%-26%) will be infected in the first year, with 37 (29 - 44) million symptomatic cases and 150 078 (82 735-189 579) deaths. There will be an estimated 4.6 (3.6-5.5) million COVID-19 hospitalisations, of which 139 521 (81 876-167 044) would be severe cases requiring oxygen, and 89 043 (52 253-106 599) critical cases requiring breathing support. The needed mitigation measures would significantly strain health system capacities, particularly for secondary and tertiary services, while many cases may pass undetected in primary care facilities due to weak diagnostic capacity and non-specific symptoms. The effect of avoiding widespread and sustained community transmission of SARS-CoV-2 is significant, and most likely outweighs any costs of preventing such a scenario. Effective containment measures should be promoted in all countries to best manage the COVID-19 pandemic.

Integrated Disease Surveillance and Response (IDSR) strategy: current status, challenges and perspectives for the future in Africa

In 1998, the WHO African region adopted a strategy called Integrated Disease Surveillance and Response (IDSR). Here, we present the current status of IDSR implementation; and provide some future perspectives for enhancing the IDSR strategy in Africa. In 2017, we used two data sources to compile information on the status of IDSR implementation: a pretested rapid assessment questionnaire sent out biannually to all countries and quarterly compilation of data for two IDSR key performance indicators (KPI). The first KPI measures country IDSR performance and the second KPI tracks the number of countries that the WHO secretariat supports to scale up IDSR. The KPI data for 2017 were compared with a retrospective baseline for 2014. By December 2017, 44 of 47 African countries (94%) were implementing IDSR. Of the 44 countries implementing IDSR, 40 (85%) had initiated IDSR training at subnational level; 32 (68%) had commenced community-based surveillance; 35 (74%) had event-based surveillance; 33 (70%) had electronic IDSR; and 32 (68%) had a weekly/monthly bulletin for sharing IDSR data. Thirty-two countries (68%) had achieved the timeliness and completeness threshold of at least 80% of the reporting units. However, only 12 countries (26%) had the desired target of at least 90% IDSR implementation coverage at the peripheral level. After 20 years of implementing IDSR, there are major achievements in the indicator-based surveillance systems. However, major gaps were identified in event-based surveillance. All African countries should enhance IDSR everywhere.

Improving influenza surveillance in sub-Saharan Africa

PROBLEM

Little is known about the burden of influenza in sub-Saharan Africa. Routine influenza surveillance is key to getting a better understanding of the impact of acute respiratory infections on sub-Saharan African populations.

APPROACH

A project known as Strengthening Influenza Sentinel Surveillance in Africa (SISA) was launched in Angola, Cameroon, Ghana, Nigeria, Rwanda, Senegal, Sierra Leone and Zambia to help improve influenza sentinel surveillance, including both epidemiological and virological data collection, and to develop routine national, regional and international reporting mechanisms. These countries received technical support through remote supervision and onsite visits. Consultants worked closely with health ministries, the World Health Organization, national influenza laboratories and other stakeholders involved in influenza surveillance.

LOCAL SETTING

Influenza surveillance systems in the target countries were in different stages of development when SISA was launched. Senegal, for instance, had conducted virological surveillance for years, whereas Sierra Leone had no surveillance activity at all.

RELEVANT CHANGES

Working documents such as national surveillance protocols and procedures were developed or updated and training for sentinel site staff and data managers was organized.

LESSONS LEARNT

Targeted support to countries can help them strengthen national influenza surveillance, but long-term sustainability can only be achieved with external funding and strong national government leadership.

Diverse genotypes of Kaposi's sarcoma associated herpesvirus (KSHV) identified in infant blood infections in African childhood-KS and HIV/AIDS endemic region

Kaposi's sarcoma-associated herpesvirus (KSHV or HHV-8) has been associated with several neoplasias, including childhood endemic Kaposi's sarcoma (KS). It is possible that strain genotypes could contribute to the differences in regional presentation (mainly sub-Saharan Africa), childhood infection, lack of male sex bias, distinct disseminated forms and rapid fatality observed for childhood endemic KS. Early studies, at the advent of the HIV/AIDS epidemic, identified only the K1-A5 genotype in childhood KS biopsies as well as blood of a few HIV positive and negative febrile infants in Zambia, a highly endemic region. This current enlarged study analyses blood infections of 200 hospitalized infants (6–34 months age) with symptoms of fever as well as upper respiratory tract infection, diarrhoea, rash or rhinitis. KSHV and HIV viraemia and were prevalent in this group, 22% and 39%, respectively. Multiple markers at both variable ends of the genome (K1, K12, and K14.1/K15) were examined, showing diverse previously adult-linked genotypes (K1 A2, A5, B, C3, D, with K12 B1 and B2 plus K14.1/K15 P or M) detected in both HIV positive and negative infants, demonstrating little restriction on KSHV genotypes for infant/childhood transmission in a childhood endemic KS endemic region. This supports the interpretation that the acquisition of childhood KSHV infections and subsequent development of KS are due to additional co-factors. J. Med. Virol. 79:1555–1561, 2007. © 2007 Wiley-Liss, Inc.

Antigenic and genetic analyses of influenza B viruses isolated in Lusaka, Zambia in 1999

Previous studies of the hemagglutinin (HA) genes of various influenza B virus isolates demonstrated the existence of two antigenically distinct virus lineages represented by B/Victoria/2/87 and B/Yamagata/16/88, respectively. Here, we investigated the antigenic and genetic characteristics of influenza B viruses isolated from children living in Lusaka, Zambia between January and May 1999. Antigenic analysis with chicken antiviral sera showed that all the Zambian isolates had the HA protein belonging to B/Yamagata/16/88-related lineage. Furthermore, phylogenetic analyses of the eight RNA segments performed by using the total or partial nucleotide sequences of the two representative Zambian strains (B/Lusaka/270/99 and B/Lusaka/432/99) as well as the previously reported sequences suggested that the Zambian viruses are closely related to the recently circulating reassortants represented by B/Shiga/T30/98 and B/Yamanashi/166/98 which acquired the genes coding for three polymerase proteins (PB2, PB1, and PA), HA, nucleoprotein, and matrix protein from a B/Yamagata/16/88-like parent and the gene encoding nonstructural proteins (NS1 and NS2) from a B/Guandong/8/93-like parent.

Sequence analyses of human herpesvirus-8 strains from both African human immunodeficiency virus-negative and -positive childhood endemic Kaposi's sarcoma show a close relationship with strains identified in febrile children and high variation in the K1 glycoprotein

Human herpesvirus-8 (HHV-8) DNA sequences have been identified in all forms of Kaposi's sarcoma (KS), a cancer found primarily in adult AIDS patients. We have identified HHV-8 strains in a rare human immunodeficiency virus (HIV)-negative form of KS, which is endemic in children in parts of sub-Saharan Africa. This was shown in Zambia, where we also had identified HHV-8 sequences in blood from HIV-negative febrile children without KS. In order to investigate the relationship of these Zambian strains to each other and to those from other forms of KS, we compared them to strains we have characterized from European AIDS KS (Denmark) and all published sequences from all forms of KS. Four distinct genomic regions were examined by PCR and sequencing: ORF26, ORF75, gH and K1. The results showed a distinct grouping of strains from both sets of Zambian children in all genomic regions studied, but which was most pronounced in the K1 glycoprotein gene. This gene was highly variable, encoding up to 25% amino acid sequence variation. In contrast, the Zambian groups were closely related to each other, with only 2% variation. Similar results were found in comparisons to the K1 sequences from HIV-positive febrile infants or KS children. The data raise the possibility that in areas where rare childhood endemic KS occurs, geographical variation in HHV-8 may relate to differences in virulence or transmission.

Characterization of VP6 subgroup, VP7 and VP4 genotype of rotavirus strains in Lusaka, Zambia

In a previous study, rotavirus infection was determined in young children at the University Teaching Hospital in Lusaka. In this study, selected rotavirus strains were characterized by monoclonal antibody assay to the VP6 subgroup antigen present and by hybridization analysis of the VP7 and VP4 genes carried by the virus. The majority of the strains were characterized as a VP6 subgroup II, VP7 serotype G1 strain with a long electropherotype and bearing the VP4 P8 genotype. A further four minor rotavirus strains with a long RNA electropherotype and subgroup II antigen were also observed to be circulating bearing G1 or G4 VP7 genes and the VP4 P8 genotype. Two electrophoretic strains with differing short RNA electropherotypes and subgroup I antigenicity were also present. These strains hybridized to the VP7 type G2 and VP4 P4 genotype probes.

Laboratory diagnosis of acute measles infections in hospitalized children in Zambia

Laboratory diagnosis of measles infection is rarely performed in developing countries and tends to depend on clinical symptoms alone. We evaluated detection of immunoglobulin M (IgM) antibodies for confirmation of acute measles infection in Zambia. In 149 hospitalized children with clinical diagnosis of measles, IgM antibodies were detected in 88.6% (132/149). The IgM-positive rate increased with time after onset of skin rash and all samples were positive after 4 days. In addition to IgM antibody test, virus isolations from throat swabs using B95a cells were also performed. These were positive in only 20.9% (14/67), and both IgM and virus isolation in combination increased the positive rate to 92.5% (62/67). Vaccinated children had higher neutralizing (Nt) antibody responses and, among IgM-negative patients, all 4 vaccinated children had high Nt antibodies while all 10 unvaccinated children had negative or low Nt results. The IgM antibody test was proved to be a sensitive method for laboratory confirmation of measles virus infection in developing countries.

Epidemiology of influenza virus infections in children with acute respiratory infections in Zambia

A viral aetiological and epidemiological study of acute respiratory infections (ARI) in children was carried out in Lusaka, Zambia between June 1993 and September 1995. A total of 3,760 throat swab specimens were collected for virus isolation from children under 5 years of age who had ARI and were attending three health centres in Lusaka. Between June and November 1993, 52 cases of the influenza A/H3N2 viruses were isolated. Between May and July 1994, 34 influenza B cases were isolated. In 1995, one A/H3N2 influenza virus was isolated in January and then the same type of influenza virus was isolated from 55 samples between June and August. The isolation rate of influenza virus was highest at 14.3% (20/139) in August 1993, at 15.1% (18/119) in June 1994 and at 25.4% (43/169) in July 1995. This is the first report of a consecutive study of influenza virus infections in Zambia and the results reveal that influenza virus infections are one of the most important pathogens of ARI in children in the cool, dry season (June-August) in this country.

Infection with AIDS-related herpesviruses in human immunodeficiency virus-negative infants and endemic childhood Kaposi's sarcoma in Africa

Novel herpesviruses have been described recently. These include human herpesviruses 6, 7 and 8 (HHV-6, -7, -8). HHV-6 has at least two strain groups, variants A and B. The B strains are predominant in the West and can account for over 97% of infections in infants. In contrast, the A strains are rare and the few well-characterized isolates have been from adult African AIDS patients. It is not clear whether the HHV-6 variant A strains are AIDS-related and/or whether they can also be acquired as childhood infections and may reactivate later during adulthood. What contribution geographical variation plays has yet to be assessed. HHV-8 has been associated with AIDS-related epidemic Kaposi's sarcoma (KS), but has also been identified in endemic KS. In regions of Africa where KS is endemic, the onset of AIDS has led to increased prevalence of KS. In this report, we examine in Zambia, an AIDS epidemic and KS endemic region, infection with these novel herpesviruses during infancy. In blood samples from human immunodeficiency virus-negative infants with first febrile episode, both semi-quantitative PCR and sequence analyses were used to identify HHV-8 in 8% and HHV-6 in 30%, with 44% of these variant A; in childhood endemic KS biopsies HHV-8 was detected in 100% and HHV-6 in none. The high viral-DNA loads in the infant blood samples were consistent with viraemia. This is the first demonstration that HHV-6 variant A and HHV-8 may be acquired as common childhood infections.

An outbreak of influenza A/H3N2 in a Zambian school dormitory

There was an outbreak of "a mysterious disease" at a Zambian school dormitory in September, 1993. Investigation with questionnaire and collection of throat swab specimens for virus isolation were carried out on 46 patients to identify the causative agent. In this outbreak, most of the patients showed similar symptoms such as fever, headache, sore throat, cough, etc. The disease had spread to all dormitories within a couple of days after the onset of the first cases. From these patients, 13 influenza viruses A/H3N2 were isolated on MDCK cell line. This was a first ever confirmed outbreak of influenza virus infection in Zambia.

Association of rotavirus and human immunodeficiency virus infection in children hospitalized with acute diarrhea, Lusaka, Zambia

In Lusaka, Zambia, rotavirus (RV) and human immunodeficiency virus (HIV) infection commonly coexist; 132 (25%) of 537 consecutively studied infants < 5 years old hospitalized with diarrhea were positive for both viral infections. Infants with RV infection were younger than those who were RV-negative (P > .05), and infants with both viruses more frequently experienced dehydration (P < .05). HIV-infected children more often exhibited respiratory symptoms on admission to the study (P < .0001) and were more frequently underweight (P < .0001) than were HIV-negative children, independent of RV infection. The mortality rate was highest in HIV-positive infants (P < .05), and coinfection with RV did not increase the risk of fatality. This study demonstrates that while RV and HIV infections commonly coexist in one region of Africa, RV infection is no more common nor is the illness more severe in HIV-positive infants.