Pathways to care for psychosis in Malawi

People with psychosis in Malawi have very limited access to timely assessment and evidence-based care, leading to a long duration of untreated psychosis and persistent disability. Most people with psychosis in the country consult traditional or religious healers. Stigmatising attitudes are common and services have limited capacity, particularly in rural areas. This paper, focusing on pathways to care for psychosis in Malawi, is based on the Wellcome Trust Psychosis Flagship Report on the Landscape of Mental Health Services for Psychosis in Malawi. Its purpose is to inform Psychosis Recovery Orientation in Malawi by Improving Services and Engagement (PROMISE), a longitudinal study that aims to build on existing services to develop sustainable psychosis detection systems and management pathways to promote recovery.

The role of polio emergency operations centers: perspectives for future disease control initiatives in Nigeria

The Nigeria Polio Emergency Operations Centre (EOC) was established in October 2012 to strengthen coordination, provide strategic direction based on real-time data analysis, and manage all operational aspects of the polio eradication program. The establishment of seven state-level polio EOCs followed. With success achieved in the interruption of wild poliovirus (WPV) transmission as certified in 2020, the future direction of the polio EOC is under consideration. This paper describes the role of the polio EOC in other emergencies and perspectives on future disease control initiatives. A description of the functionality and operations of the polio EOC and a review of documentation of non-polio activities supported by the EOC was done. Key informant insights of national and state-level stakeholders were collected through an electronic questionnaire to determine their perspectives on the polio EOC's contributions and its future role in other public health interventions. The polio EOC structure is based on an incident management system with clear terms of reference and accountability and with full partner coordination. A decline in WPV1 cases was observed from 122 cases in 2012 to 0 in 2015; previously undetected transmission of WPV1 was confirmed in 2016 and all transmission was interrupted under the coordination of the EOCs at national and state levels. During 2014-2019, the polio EOC infrastructure and staff expertise were used to investigate and respond to outbreaks of Ebola, measles, yellow fever, and meningitis and to oversee maternal and neonatal tetanus elimination campaigns. The EOC structure at the national and state levels has contributed to the positive achievements in the polio eradication program in Nigeria and further in the coordination of other disease control and emergency response activities. The transition of the polio EOCs and their capacities to support other non-polio programs will contribute to harnessing the country's capacity for effective coordination of public health initiatives and disease outbreaks.

Deployment of novel oral polio vaccine type 2 under emergency use listing in Nigeria: the rollout experience

In 2011, a dedicated consortium of experts commenced work on the development of the novel oral poliovirus vaccine type 2 (nOPV2). After careful and rigorous analysis of data to enable early, targeted use of the vaccine, World Health Organization´s (WHO´s) Strategic Advisory Group of Experts on Immunization (SAGE) reviewed data from accelerated clinical development of nOPV2 and endorsed entering assessment under WHO´s Emergency Use Listing (EUL) procedure. In November 2020, nOPV2 received an interim recommendation for use under EUL to enable rapid field availability and potential wider rollout of the vaccine. In December 2020, Nigeria initiated preparation to meet all criteria for initial use of nOPV2 in the country and the documentation process to verify meeting them. The process entailed addressing the status of meeting 25 readiness criteria in nine categories for nOPV2 use in Nigeria for response efforts to ongoing cVDPV2 outbreaks. During January-February 2021, Nigeria submitted the required documentation for all required indicators for nOPV2 initial use. In February 2021, the country obtained approval from the GPEI nOPV2 Readiness Verification Team to introduce nOPV2 and in March 2021, rolled out the novel vaccine in mass vaccination campaigns for outbreak response in Bayelsa, Delta, Niger, Sokoto and Zamfara states, and one area council in the Federal Capital Territory (FCT). The lessons learned from this rollout experience in Nigeria are being applied as the country streamlines and strengthens the nOPV2 rollout process across the remaining states.

Measles outbreak response immunization during the COVID-19 pandemic: lessons from Borno State, Nigeria

Introduction

the COVID-19 outbreak was declared a public health emergency of international concern by the WHO on the 30^th January 2020. The occurrence of measles outbreaks in the context of COVID-19, both highly infectious respiratory illnesses, impacts additional challenges to the health system in a state with an ongoing humanitarian crisis. This article documents the implementation of an outbreak response immunization (ORI) during the COVID-19 pandemic and the implementation of global guidelines for mass vaccination.

Methods

a retrospective review of the response to measles outbreak implemented in Borno state across six local government areas (LGAs) in 2019 was conducted. This review assessed the utilization of the World Health Organization (WHO) decision making framework, measles and COVID-19 epidemiological reports and the measle's vaccination response data.

Results

an outbreak response immunization was implemented in six LGAs in Borno State, with a validated post campaign coverage of 96.3% (95% CI: 93.0 - 98.1). In total, 181,634 children aged 9 months-9 years were vaccinated with 27,961 (15.4%) receiving the measles vaccine for the first time. Prior to the interventions, 20 COVID-19 cases were reported in the six LGAs while only seven suspected cases were reported with only two cases confirmed in one of the six LGAs four weeks after the ORI.

Conclusion

the WHO decision-making framework for implementing mass vaccinations in the context of the COVID-19 Pandemic was utilized for the outbreak response immunization in Borno State, Nigeria with 181,634 children aged 9 Months-9 years vaccinated with the measles vaccine. The use of the WHO decision-making framework to assess risk benefits of initiating mass vaccination campaigns remains a very important practical tool. These types of responses in Nigeria and other low and middle income countries (LMICs), with hitherto suboptimal immunization coverage and weak health systems and other settings, affected by humanitarian emergencies is essential in the achievement of the regional measle's elimination targets.

Enhancing acute flaccid paralysis surveillance system towards polio eradication: reverse cold chain monitoring in Nigeria, 2017 to 2019

INTRODUCTION

Highly sensitive acute flaccid paralysis (AFP) surveillance is critical for detection of poliovirus circulation and documentation for polio-free certification. The reverse cold chain (RCC) is a system designed to maintain stool specimens in appropriate temperature for effective detection of poliovirus in the laboratory. We monitored the RCC of AFP surveillance in Nigeria to determine its effectiveness in maintaining viability of enterovirus.

METHODS

A descriptive cross-sectional study was conducted from November 2017 to December 2019. We included AFP cases from 151 Local Government Areas and monitored RCC of paired stool specimens from collection to arrival at laboratories. The national guideline recommends RCC temperature of +2 to +8°C and a non-polio enterovirus (NPENT) detection rate of ≥10%. We analyzed data with Epi Info 7, and presented results as frequencies and proportions, using Chi-square statistic to test for difference in enterovirus isolation.

RESULTS

Of the 1,042 tracked paired stool specimens, 1,038(99.6%) arrived at the laboratory within 72 hours of collection of second specimen, 824(79.1%) were maintained within recommended temperature range, and 271(26%) yielded enteroviruses: 200(73.8%) NPENT, 66(24.4%) Sabin, 3(1.1%) vaccine derived poliovirus type 2 and 2(0.7%) mixture of Sabin and NPENT. The NPENT and Sabin rates were 19.2% and 6.7% respectively. Twenty-five percent of 824 specimens maintained within recommended temperature range, compared with 29.8% of 218 specimens with temperature excursion yielded enteroviruses (P=0.175).

CONCLUSION

the RCC of AFP surveillance system in the study area was optimal and effective in maintaining the viability of enteroviruses. It was unlikely that poliovirus transmission was missed during the intervention.

Missed opportunities for vaccination among children aged 0-23 months visiting health facilities in a southwest State of Nigeria, December 2019

Background

Despite efforts to improve childhood immunization coverage in Nigeria, coverage has remained below the national acceptable level. In December 2019, we conducted an assessment of Missed Opportunities for Vaccination (MOV) in Ondo State, in Southwest Nigeria. The objectives were to determine the magnitude of, explore the reasons for, as well as possible solutions for reducing MOV in the State.

Methods

This was a cross-sectional study using a mixed-methods approach. We purposively selected 66 health facilities in three local government authorities, with a non-probabilistic sampling of caregivers of children 0–23 months for exit interviews, and health workers for knowledge, attitudes, and practices (KAP) surveys. Data collection was complemented with focus group discussions and in-depth interviews with caregivers and health workers. The proportion of MOV among children with documented vaccination histories were determined and thematic analysis of the qualitative data was carried out.

Results

984 caregivers with children aged 0–23 months were interviewed, of which 869 were eligible for inclusion in our analysis. The prevalence of MOV was 32.8%. MOV occurred among 90.8% of children during non-vaccination visits, and 7.3% during vaccination visits. Vaccine doses recommended later in the immunization series were given in a less timely manner. Among 41.0% of health workers, they reported their vaccination knowledge was insufficient. Additionally, 57.5% were concerned about and feared adverse events following immunization. Caregivers were found to have a low awareness about vaccination, and issues related to the organization of the health system were found to contribute towards MOV.

Conclusions

One in three children experienced a MOV during a health service encounter. Potential interventions to reduce MOV include training of health workers about immunization policies and practices, improving caregivers’ engagement and screening of vaccination documentation by health workers during every health service encounter.

A scorecard of progress towards measles elimination in 15 west African countries, 2001-19: a retrospective, multicountry analysis of national immunisation coverage and surveillance data

Background

The WHO Regional Office for the Africa Regional Immunization Technical Advisory Group, in 2011, adopted the measles control and elimination goals for all countries of the African region to achieve in 2015 and 2020 respectively. Our aim was to track the current status of progress towards measles control and elimination milestones across 15 west African countries between 2001 and 2019.

Methods

We did a retrospective multicountry series analysis of national immunisation coverage and case surveillance data from Jan 1, 2001, to Dec 31, 2019. Our analysis focused on the 15 west African countries that constitute the Economic Community of West African States. We tracked progress in the coverage of measles-containing vaccines (MCVs), measles supplementary immunisation activities, and measles incidence rates. We developed a country-level measles summary scorecard using eight indicators to track progress towards measles elimination as of the end of 2019. The summary indicators were tracked against measles control and elimination milestones.

Findings

The weighted average regional first-dose MCV coverage in 2019 was 66% compared with 45% in 2001. 73% (11 of 15) of the west African countries had introduced second-dose MCV as of December, 2019. An estimated 4 588 040 children (aged 12–23 months) did not receive first-dose MCV in 2019, the majority (71%) of whom lived in Nigeria. Based on the scorecard, 12 (80%) countries are off-track to achieving measles elimination milestones; however, Cape Verde, The Gambia, and Ghana have made substantial progress.

Interpretation

Measles will continue to be endemic in west Africa after 2020. The regional measles incidence rate in 2019 was 33 times the 2020 elimination target of less than 1 case per million population. However, some hope exists as countries can look at the efforts made by Cape Verde, The Gambia, and Ghana and learn from them.

Funding

None.

Association between referral source and duration of untreated psychosis in pathways to care among first episode psychosis patients in Northern Malawi

AIMS

To examine the association between referral source and duration of untreated psychosis (DUP) and explore determinants of referral source; when adjusting for pathways to care, positive and negative symptoms, diagnosis and socio-demographic characteristics.

METHODS

A total of 140 subjects with first episode psychosis (FEP) were enrolled from a pilot early intervention service for psychosis in Northern Malawi between June 2009 and September 2012. Logistic regression analyses were used to quantify the associations between variables of interest.

RESULTS

Age ranged between 18 and 65 at assessment, with median, 33. Median DUP was 12.5 months. First contact did not independently determine DUP. Long DUP (>6 months) was associated with referral from community based volunteer (CBV) or traditional healer (TH), a unit increase in severity of negative symptoms and having schizophrenia, which was also associated with referral from CBV or TH. Additionally, being unemployed was associated with referral from CBV or TH. However, a unit increase in the number of times religious advice (RA) was sought, GP was contacted and severity of positive symptoms was associated with referral by GP.

CONCLUSIONS

Mental health awareness is justified for this population and collaboration with THs in identifying and treating patients with psychosis may help reduce treatment delays. Access to mental health services ought to improve, particularly for the unemployed group. Future studies should consider adjusting for referral source when ascertaining first contact source as a predictor of DUP.

Bacterial Biofilm Formation in Milking Equipments in Lilongwe, Malawi

Background: Some microorganisms can adhere to food handling surfaces forming biofilms that pose a safety challenge. This study was done to evaluate bacterial biofilm formation in milking equipments in Lilongwe, Malawi. Methods: Pooled milk (n=54) and water (n=60) samples were collected from households and milk bulking groups in Lilongwe, Malawi. Swabbing (n=46) and rinsing (n=16) were done on milk handling containers after cleaning. Biofilm determination on the containers was done by detecting biofilm indicator bacteria, including Bacillus spp., Salmonella spp., and Pseudomonas spp. The strength of biofilm was determined by the tube method. Data were analyzed by SAS software version 9.1.3.   Results: Prevalence rates of Gram-negative rods were significantly (p<0.05) higher than the Gram-positive rods and the Gram-positive cocci. Of the 176 cases, contamination rates were 36 (20.4%), 32 (18.2%), and 18 (10.2%) for Salmonella spp., Bacillus spp., and Pseudomonas spp., respectively. The biofilm indicator organisms were significantly (p<0.05) more prevalent in dairy farmer households compared with the milk bulking centers. Fourteen out of 86 (16.3%) microbial isolates formed strong/high biofilms, whereas 18 out of 86 (20.93%) of isolates did not form any biofilm. The rate of isolates forming strong/high biofilms in households (17.6%) was significantly (p<0.05) higher than that of milk bulking centers (11.1%). Conclusion: Biofilm formation on milk handling container surfaces in Lilongwe, Malawi could serve as a source of microbial pathogens and spoilage organisms.

Effects of socio-demographic characteristics, premorbid functioning, and insight on duration of untreated psychosis in first-episode schizophrenia or schizophreniform disorder in Northern Malawi

AIM

Long duration of untreated psychosis (DUP) is prevalent and has been shown to be associated with poorer prognosis. Thus, knowledge of its determinants may help to target early interventions to reduce DUP on the needed population. Previous studies seeking to understand determinants of DUP have been inconclusive. Therefore, this study aimed to investigate the effects of socio-demographic characteristics, premorbid functioning, and insight on DUP in patients with first-episode schizophrenia or schizophreniform disorder.

METHODS

This cross-sectional study recruited 110 subjects (aged 18-65) during a pilot early intervention service for psychosis in Northern Malawi, between June 2009 and September 2012. Short DUP was defined as ≤6 months, whereas long DUP was defined as >6 months. Unadjusted and adjusted analyses were performed to identify determinants of DUP.

RESULTS

Of the 110 subjects, 99 (90%) had schizophrenia. Median DUP was 27.5 months, while mean (SD) DUP was 71.24 (92.32) months. In addition, at least 75% had long DUP, which was associated with lower level of education, poor insight, younger age at onset, and at least one parent deceased.

CONCLUSIONS

Long DUP is prevalent in Northern Malawi. Thus, early interventions to reduce DUP are warranted in this population. Although having at least one parent deceased predicted long DUP in this study, this remains speculative because factors, such as timing of parents' death and grief reactions of the patients were not assessed. Therefore, further investigations incorporating these factors are needed to ascertain this result.

Progress Toward Poliomyelitis Eradication - Nigeria, January 2018-May 2019

The number of wild poliovirus (WPV) cases in Nigeria decreased from 1,122 in 2006 to six WPV type 1 (WPV1) in 2014 (1). During August 2014-July 2016, no WPV cases were detected; during August-September 2016, four cases were reported in Borno State. An insurgency in northeastern Nigeria had resulted in 468,800 children aged <5 years deprived of health services in Borno by 2016. Military activities in mid-2016 freed isolated families to travel to camps, where the four WPV1 cases were detected. Oral poliovirus vaccine (OPV) campaigns were intensified during August 2016-December 2017; since October 2016, no WPV has been detected (2). Vaccination activities in insurgent-held areas are conducted by security forces; however, 60,000 unvaccinated children remain in unreached settlements. Since 2018, circulating vaccine-derived poliovirus type 2 (cVDPV2) has emerged and spread from Nigeria to Niger and Cameroon; outbreak responses to date have not interrupted transmission. This report describes progress in Nigeria polio eradication activities during January 2018-May 2019 and updates the previous report (2). Interruption of cVDPV2 transmission in Nigeria will need increased efforts to improve campaign quality and include insurgent-held areas. Progress in surveillance and immunization activities will continue to be reviewed, potentially allowing certification of interruption of WPV transmission in Africa in 2020.

Towards an effective poliovirus laboratory containment strategy in Nigeria

BACKGROUND

The Global Commission for the Certification of the Eradication of Poliomyelitis will declare the world free of wild poliovirus transmission when no wild virus has been found in at least 3 consecutive years, and all laboratories possessing wild poliovirus materials have adopted appropriate measures of containment. Nigeria has made progress towards poliomyelitis eradication with the latest reported WPV type 1 on 21 Aug 2016 after 2 years without any case. This milestone achievement was followed by an inventory of biomedical laboratories completed in November 2015 with the destruction of all identified infectious materials. This paper seeks to describe the poliovirus laboratory containment process in Nigeria on which an effective containment system has been built to minimize the risk of virus re-introduction into the population from the laboratories.

METHODS

A national survey of all biomedical facilities, as well as an inventory of laboratories from various sectors, was conducted from June-November 2015. National Task Force (NTF) members and staff working on polio administered an on-site questionnaire in each facility. Laboratory personnel were sensitized with all un-needed materials destroyed by autoclaving and incineration. All stakeholders were also sensitized to continue the destruction of such materials as a requirement for phase one activities.

RESULTS

A total of 20,638 biomedical facilities were surveyed with 9575 having laboratories. Thirty laboratories were found to contain poliovirus or potentially infectious materials. The 30 laboratories belonged to the ministries of health, education, defence and private organizations.

CONCLUSIONS

This article is amongst the first in Africa that relates poliovirus laboratory containment in the context of the tOPV-bOPV switch in alignment with the Global Action Plan III. All identified infectious materials were destroyed and personnel trained to continue to destroy subsequent materials, a process that needs meticulous monitoring to mitigate the risk of poliovirus re-introduction to the population.

Acute flaccid paralysis (AFP) surveillance intensification for polio certification in Kaduna state, Nigeria: lessons learnt, 2015-2016

Background

Nigeria has made remarkable progress in its current efforts to interrupt wild poliovirus transmission despite the re-emergence of wild poliovirus in 2016. The gains made in Nigeria have been achieved through concerted efforts by governments at all levels, traditional leaders, health workers, caregivers, and development partners. The efforts have involved an elaborate plan, coordination, and effective implementation of routine immunization services, supplemental immunization activities, and acute flaccid paralysis (AFP) surveillance.

Methods

We conducted the following activities to strengthen AFP surveillance in Kaduna state: a monetary reward for all AFP cases reported by health workers or community informants and verified as “true” AFP by a World Health Organization (WHO) cluster coordinator; training and sensitization of surveillance officers, clinicians, and community informants; recruitment of more personnel and expansion of the surveillance network; and the involvement of special populations (nomadic, hard-to-reach, and border communities) and caregivers in stool sample collection. The paired t test was used to evaluate the impact of the different initiatives implemented in Kaduna state to intensify AFP surveillance in 2016.

Results

There was increased annualized non-polio AFP rate (ANPAFPR) in 21 out of 23 Local Government Areas (LGAs) of Kaduna state 6 months after implementation of different initiatives to intensify AFP surveillance. The AFP reported by the special population increased in 15 out of 23 LGAs. Statistical analyses of mean scores of ANPAFPR before and after the interventions using the paired t test revealed a significant difference in mean scores: mean = 19.7 (standard deviation (SD) = 16.1) per 100,000 < 15 years old in July–December 2015, compared with 38.0 (SD = 21.6) per 100,000 < 15 years old in January–June 2016 (p < 0.05). Likewise, analysis of silent wards using the paired t test showed a significant difference in mean scores: mean = 4.0 (SD = 2.1) in July–December 2015 compared with 2.4 (SD = 1.8) in January–June 2016 (p < 0.05).

Conclusion

The different initiatives implemented in 23 LGAs of Kaduna state to intensify AFP surveillance may be responsible for the significant improvement in the AFP surveillance performance indicators in 2016.

AVADAR (Auto-Visual AFP Detection and Reporting): demonstration of a novel SMS-based smartphone application to improve acute flaccid paralysis (AFP) surveillance in Nigeria

Background

Eradication of polio requires that the acute flaccid paralysis (AFP) surveillance system is sensitive enough to detect all cases of AFP, and that such cases are promptly reported and investigated by disease surveillance personnel. When individuals, particularly community informants, are unaware of how to properly detect AFP cases or of the appropriate reporting process, they are unable to provide important feedback to the surveillance network within a country.

Methods

We tested a new SMS-based smartphone application (App) that enhances the detection and reporting of AFP cases to improve the quality of AFP surveillance. Nicknamed Auto-Visual AFP Detection and Reporting (AVADAR), the App creates a scenario where the AFP surveillance network is not dependent on a limited number of priority reporting sites. Being installed on the smartphones of multiple health workers (HWs) and community health informants (CHIs) makes the App an integral part of the detection and reporting system.

Results

Results from two phases of tests conducted in Nigeria point to the effectiveness of the App in the surveillance of AFP.

Conclusion

We posit that appropriate use of the App can soon bring about a worldwide eradication of poliomyelitis.

Profile of polio-compatible cases in Nigeria, 2006-2016

Background

The tremendous progress made by Nigeria towards polio eradication has recently suffered a setback with the isolation of circulating vaccine-derived poliovirus (cVDPV) type 2 from environmental samples and confirmation of four wild poliovirus (WPV) cases from acute flaccid paralysis (AFP) cases, with dates of onset of paralysis in July and August 2016. All these viruses were confirmed from the security-challenged northeastern state of Borno. Polio-compatible cases exist in Nigeria, and they indicate surveillance failure. Surveillance, therefore, has to be strengthened for the country to achieve certification. The objective of this paper is to highlight the epidemiological profile and magnitude of polio-compatible cases in Nigeria during the reporting period, as well as immunization and surveillance response activities conducted to close immunity and surveillance gaps.

Methods

We conducted a retrospective review of AFP surveillance performance and polio-compatible cases in Nigeria between 2006 and 2016 from the AFP database at the World Health Organization Country Office. We also reviewed and compared key epidemiological features of polio-compatible cases with those of wild poliovirus cases during the reporting period.

Results

The non-polio AFP rate improved from 6.5 in 2006 to 19.5 in 2016. The corresponding figures for stool adequacy rates were 88 and 98%. The total number of polio-compatible cases reported during the reporting period was 888, with the highest number (194) of cases reported in 2006 and the least (24) in 2016. Clusters of polio-compatible cases were reported every year during the reporting period except in 2015. The highest number (65) of polio-compatible cases in clusters was reported in 2006. The key epidemiological features of polio-compatible and wild poliovirus cases were similar.

Conclusion

AFP surveillance performance has improved significantly during the reporting period. Surveillance gaps still existed as shown by the presence of orphan viruses and polio-compatible cases, and these gaps need to be identified and closed to achieve certification.

Distribution pattern of poliovirus potentially infectious materials in the phase 1b medical laboratories containment in conformity with the global action plan III

Background

The containment of poliovirus infectious/potentially infectious materials in all biomedical facilities in Nigeria remain crucial to maintaining gains recorded towards polio eradication. Activities involved in the Nigerian Poliovirus type 2-laboratory containment survey in line with the 3rd Global Action Plan III (GAP III) for poliovirus containment are documented in this study. Through these activities, the overall preparedness for poliovirus eradication in Nigeria is assessed.

Method

A cross-sectional survey was conducted from 19th September-31st October 2016 using structured Laboratory survey and inventory (LSI) questionnaires uploaded onto the SPSS software package in 560 biomedical facilities classified either as high risk or medium risk facilities across the 6 zones in Nigeria.

Results

In total, 560 biomedical facilities were surveyed in Nigeria in conformity with the GAP III. In total, 86% of the facilities surveyed were with laboratories while 14% were without laboratories.

Twelve laboratories with poliovirus potentially infectious materials were identified in this exercise. In total, 50% of the 12 laboratories were under the ministry of education for research purposes. While 33% were among those laboratories surveyed in the phase 1a exercise without any recorded inventory, but have acquired some since the phase 1a survey.

A total of 13,484 poliovirus infectious materials were found in the 12 laboratories. Only 8% of the materials were immediately destroyed while the remaining materials (62%) were found in Oyo and Borno states scheduled for destruction within 3–4 months according to WHO protocol for destruction of poliovirus infectious materials.

Conclusion

This study has revealed the successful containment of all poliovirus infectious materials in the laboratories surveyed. It has also revealed some surveillance gaps. We recommend that the surveillance system be improved to maintain the gains from the containment exercise and avoid reintroduction of infectious materials into biomedical facilities. This reduces the chances of viral reintroduction to the population in general.

Mobilizing political support proved critical to a successful switch from tOPV to bOPV in Kano, Nigeria 2016

BACKGROUND

Kano is one of the high-risk states for polio transmission in Northern Nigeria. The state reported more cases of wild polioviruses (WPVs) than any other state in the country. The Nigeria Demographic and Health Survey of 2013 indicated that OPV3 coverage in the routine immunization (RI) programmewas 57.9%. Additionally, serial polio seroprevalence studies conducted from 2011 to 2015 in the eightmetropolitan LGAs indicated low immunity levels against all three polio serotypes in children below one year. Areas with sub-optimal RI coverage such as Kanothat fail to remove all tOPV during the tOPV-bOPV switchwill be at increased risk of VDPV2 circulation.

METHODS

We assessed the impact of political leadership engagement in mobilizing other stakeholders on the outcomes of the bOPV-tOPV switch in Kano State from February to May 2016 using nationally-selected planning and outcome indicators.

RESULTS

A total of 670 health facilities that provide RI services were assessed during the pre-switch activities. Health workers were aware of the switch exercise in 520 (95.1%) of the public health facilities assessed. It was found that health workers knew what to do should tOPV be found in any of the 521 (95.2%)public health facilities assessed. However, there was a wide disparity between the public and private health practitioners' knowledge on basic concepts of the switch. There was 100% withdrawal of tOPV from the state and the seven zonal cold stores. Unmarked tOPVwas found in the cold chain system in 2 (4.5%) LGAs. Only one health facility (0.8%) had tOPV in the cold chain. No tOPVwas identified outside the cold chain without the "Do not use" sticker in any of the health facilities.

CONCLUSION

The engagement of the political leadership to mobilize other key stakeholders facilitated successful implementation of the tOPV-bOPVswitch exercise and provided opportunity to strengthen partnerships with the private health sector in Kano State.

Lessons learnt from implementing community engagement interventions in mobile hard-to-reach (HTR) projects in Nigeria, 2014-2015

BACKGROUND

The year 2014 was a turning point for polio eradication in Nigeria. Confronted with the challenges of increased numbers of polio cases detected in rural, hard-to-reach (HTR), and security-compromised areas of northern Nigeria, the Nigeria polio program introduced the HTR project in four northern states to provide immunization and maternal and child health services in these communities. The project was set up to improve population immunity, increase oral polio vaccine (OPV) and other immunization uptake, and to support Nigeria's efforts to interrupt polio transmission by 2015. Furthermore, the project also aimed to create demand for these services which were often unavailable in the HTR areas. To this end, the program developed a community engagement (CE) strategy to create awareness about the services being provided by the project. The term HTR is operationally defined as geographically difficult terrain, with any of the following criteria: having inter-ward/inter-Local Government Area/interstate borders, scattered households, nomadic population, or waterlogged/riverine area, with no easy to access to healthcare facilities and insecurity.

METHODS

We evaluated the outcome of CE activities in Kano, Bauchi, Borno, and Yobe states to examine the methods and processes that helped to increase OPV and third pentavalent (penta3) immunization coverage in areas of implementation. We also assessed the number of community engagers who mobilized caregivers to vaccination posts and the service satisfaction for the performance of the community engagers.

RESULTS

Penta3 coverage was at 22% in the first quarter of project implementation and increased to 62% by the fourth quarter of project implementation. OPV coverage also increased from 54% in the first quarter to 76% in the last quarter of the 1-year project implementation.

CONCLUSIONS

The systematic implementation of a CE strategy that focused on planning and working with community structures and community engagers in immunization activities assisted in increasing OPV and penta3 immunization coverage.

Stopping circulatory vaccine-derived poliovirus in Kaduna state by scaling up special interventions in local government areas along rivers of interest- kamacha basin experience, 2013-2015

BACKGROUND

The Kamacha river is one of the five polio environmental surveillance sites in Kaduna State where 13 circulating vaccine-derived polioviruses (cVDPDs) were isolated between 2014 and 2015. Kamacha river accounted for 5 of all reported cVDPVs in Kaduna State between 2014 and 2015. Poor quality Supplemental Immunization Activities (SIAs) and low population immunity have been reported in the 10 LGAs with tributaries that flow into the river. We described the processes of implementing the various health interventions in these targeted LGAs along the Kamacha River and assessed the effectiveness of the interventions in stopping cVDPV in Kaduna, state, Nigeria.

METHODS

Special interventions that had been proven to be functional and effective in reaching unreached children with potent vaccines in the state were scaled up in these targeted 10 LGAs along the Kamacha River. These interventions included revision of house based microplans, scaling up of transit vaccination, scaling up of youth engagement, intensified supportive supervision, scaling up of Directly Observed Polio Vaccination (DOPV) and in-between rounds vaccination activities. We analyzed immunization plus days (IPDs) administrative tally sheet and monitoring data from 10 rounds before and 10 rounds after the special interventions.

RESULTS

The number of children immunized increased from 1,862,958 in December 2014 before the intervention to 1,922,940 in March 2016 after the intervention. Lot Quality Assurance Sampling (LQAS) results showed an increase in the proportion of LGAs accepted at coverage > 90% after the interventions, from 67% before intervention to 84% after intervention. The proportion of non-polio AFP children with > 4 doses of oral polio vaccine increased from 2 to 8% before to 93-98% after the interventions.. No new environmental cVDPV has been isolated since the introduction of the interventions in April 2015 until July 2016.

CONCLUSION

Scaling up known working interventions in the 10 LGAs with tributaries that drain to Kamacha River environmental sample site may have contributed to improved immunity and interruption of cVDPV in Kaduna state. These interventions should be replicated in LGAs and states with persistent poliovirus isolation.

Conduct of vaccination in hard-to-reach areas to address potential polio reservoir areas, 2014-2015

BACKGROUND

The Global Vaccine Action Plan (GVAP) seeks to achieve the total realization of its vision through equitable access to immunization as well as utilizing the immunization systems for delivery of other primary healthcare programs. The inequities in accessing hard-to-reach areas have very serious implications for the prevention and control of vaccine-preventable diseases, especially the polio eradication initiative. The Government of Nigeria implemented vaccination in hard-to-reach communities with support from the World Health Organization (WHO) to address the issues of health inequities in the hard-to-reach communities. This paper documents the process of conducting integrated mobile vaccination in these hard-to-reach areas and the impact on immunization outcomes.

METHODS

We conducted vaccination using mobile health teams in 2311 hard-to-reach settlements in four states at risk of sustaining polio transmission in Nigeria from July 2014 to September 2015.

RESULTS

The oral polio vaccine (OPV)3 coverage among children under 1 year of age improved from 23% at baseline to 61% and OPV coverage among children aged 1-5 years increased from 60 to 90%, while pentavalent vaccine (penta3) coverage increased from 22 to 55%. Vitamin A was administered to 78% of the target population and 9% of children that attended the session were provided with treatment for malaria.

CONCLUSIONS

The hard-to-reach project has improved population immunity against polio, as well as other routine vaccinations and delivery of child health survival interventions in the hard-to-reach and underserved communities.

Impact of engaging security personnel on access and polio immunization outcomes in security-inaccessible areas in Borno state, Nigeria

BACKGROUND

Nigeria was polio free for almost 2 years but, with the recent liberation of areas under the captivity of insurgents, there has been a resurgence of polio cases. For several years, these inaccessible areas did not have access to vaccination due to activities of Bokoharam, resulting in a concentration of a cohort of unvaccinated children that served as a polio sanctuary. This article describes the processes of engagement of security personnel to access security-compromised areas and the impact on immunization outcomes.

METHODS

We assessed routine program data from January 2016 to July 2016 in security-inaccessible areas and we evaluated the effectiveness of engaging security personnel to improve access to settlements in security-compromised Local Government Areas (LGAs) of Borno state. We thereafter evaluated the effects of this engagement on postcampaign evaluation indicators.

RESULTS

From 15 LGAs accessible to vaccination teams in January 2016, there was a 47% increase in July 2016. The number of wards increased from 131 in January to 162 in July 2016, while the settlement numbers increased from 6050 in January to 6548 in July 2016. The average percentage of missed children decreased from 8% in January to 3% in July 2016, while the number of LGAs with ≥ 80% coverage increased from 85% in January to 100% in July 2016.

CONCLUSION

The engagement of security personnel in immunization activities led to an improved access and improvement in postcampaign evaluation indicators in security-compromised areas of a Nigerian state. This approach promises to be an impactful innovation in reaching settlements in security-compromised areas.

Rate of and time to symptomatic remission in first-episode psychosis in Northern Malawi: A STROBE-compliant article

Although longer duration of untreated psychosis (DUP) is associated with poor response to antipsychotic treatment, it remains unclear whether it independently influences time to symptomatic remission in first-episode psychosis (FEP). This study examined rate of symptomatic remission, and explored if DUP, premorbid functioning, global functioning, insight and socio-demographic characteristics were independently associated with time to symptomatic remission in FEP.This prospective study enrolled 126 FEP patients (aged 18-65) between June 2009 and September 2012. Subjects were followed-up monthly over 18 months after they had received antipsychotic medication. Remission in positive and negative symptoms was defined as in the Remission in Schizophrenia Working Group (RSWG) criteria. Subjects were defined as "in symptomatic remission" if they remitted in both negative and positive symptoms. At baseline, the following explanatory variables were measured: socio-demographic characteristics; DUP as short (≤5 months) and long (>5 months); premorbid functioning as deteriorating, stable poor, and stable good according to Cannon-Spoor Premorbid Adjustment Scale; global functioning as "worst (1-10) to serious (41-50)" and "moderate (51-60) to superior (91-100)," according to the Global Assessment of Functioning Scale; and insight as poor (≤8) and good (≥9) according to the Insight Scale (Birchwood). Univariate and multivariable analyses were used to generate results.Out of 126 subjects, 98 (78%) completed follow-up, of which 70 (71.4%) achieved symptomatic remission within mean duration of 8.05 (4.54) months. Besides, having long DUP and separated/divorced/widowed (adjusted hazard ratio [aHR] = 0.07, 95%CI = [0.01, 0.46]), long DUP and poor insight (aHR = 0.18, 95%CI = [0.04, 0.89]), poor insight and separated/divorced/widowed (aHR = 0.09, 95%CI = [0.01, 0.70]), deteriorating premorbid functioning (aHR = 0.47, 95%CI = [0.23, 0.97]), family history of psychiatric disorders (aHR = 0.52, 95%CI = (0.30, 0.93]), and being male (aHR = 0.47, 95%CI = [0.24, 0.92]) delayed symptomatic remission.These results propose that psychological interventions and social support for mental health problems are warranted and may enhance better response to antipsychotic medications among separated/divorced/widowed patients with long DUP or poor insight, and poor insight patients with long DUP. Deteriorating premorbid functioning, family history of psychiatric disorders and being male continue being important risk factors for poor odds of remission.

Burden of seasonal influenza in sub-Saharan Africa: a systematic review protocol

INTRODUCTION

Measures of epidemiological burdens are an important contribution to estimating disease severity and determining the at-risk populations for seasonal influenza. In the absence of these data, it is extremely difficult for policy-makers to decide on how to distribute limited resources. This systematic review will synthesise the literature on reported burden of seasonal influenza (eg, morbidity and mortality) in sub-Saharan Africa.

METHOD AND ANALYSIS

We will include published epidemiological studies that capture the burden estimation of seasonal influenza between 1 January 2000 and 31 August 2018. Studies that have reported disease burden estimates associated to influenza-like illness, acute respiratory illness, acute lower respiratory illness, severe acute respiratory illness and severe or very severe pneumonia using laboratory-confirmed influenza cases will be included. We will perform a multiple electronic database search in PubMed, Embase, African Journals Online, Cochrane, Web of science, CINAHL and Google scholar for eligible studies. The reference lists of relevant studies will also be hand-searched for potentially eligible studies. The titles and abstracts of identified records will be screened independently by two authors. The full-text articles of potentially eligible studies will be assessed independently by two authors. Discrepancies will be resolved by discussion, and by a third author if the first two authors fail to come to a consensus. The measures of the burden of influenza will be aggregated using a meta-analysis for homogeneous studies and narrative synthesis if the studies are heterogeneous. The strength of the evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation approach.

ETHICS AND DISSEMINATION

This systematic review will use publicly available data; and as such, no formal ethical review is required. Our findings will be published in a peer-reviewed journal and also disseminated through conferences and stakeholder meetings.

PROSPERO REGISTRATION NUMBER

CRD42017074091.

Developing a multisectoral National Action Plan for Health Security (NAPHS) to implement the International Health Regulations (IHR 2005) in Tanzania

The Ebola outbreak in West Africa precipitated a renewed momentum to ensure global health security through the expedited and full implementation of the International Health Regulations (IHR) (2005) in all WHO member states. The updated IHR (2005) Monitoring and Evaluation Framework was shared with Member States in 2015 with one mandatory component, that is, States Parties annual reporting to the World Health Assembly (WHA) on compliance and three voluntary components: Joint External Evaluation (JEE), After Action Reviews and Simulation Exercises. In February 2016, Tanzania, was the first country globally to volunteer to do a JEE and the first to use the recommendations for priority actions from the JEE to develop a National Action Plan for Health Security (NAPHS) by February 2017. The JEE demonstrated that within the majority of the 47 indicators within the 19 technical areas, Tanzania had either 'limited capacity' or 'developed capacity'. None had 'sustainable capacity'. With JEE recommendations for priority actions, recommendations from other relevant assessments and complementary objectives, Tanzania developed the NAPHS through a nationwide consultative and participatory process. The 5-year cost estimate came out to approximately US$86.6 million (22 million for prevent, 50 million for detect, 4.8 million for respond and 9.2 million for other IHR hazards and points of entry). However, with the inclusion of vaccines for zoonotic diseases in animals increases the cost sevenfold. The importance of strong country ownership and committed leadership were identified as instrumental for the development of operationally focused NAPHS that are aligned with broader national plans across multiple sectors. Key lessons learnt by Tanzania can help guide and encourage other countries to translate their JEE priority actions into a realistic costed NAPHS for funding and implementation for IHR (2005).

Effectiveness of a girls' empowerment programme on early childbearing, marriage and school dropout among adolescent girls in rural Zambia: study protocol for a cluster randomized trial

Background

Adolescent pregnancies pose a risk to the young mothers and their babies. In Zambia, 35% of young girls in rural areas have given birth by the age of 18 years. Pregnancy rates are particularly high among out-of-school girls. Poverty, low enrolment in secondary school, myths and community norms all contribute to early childbearing. This protocol describes a trial aiming to measure the effect on early childbearing rates in a rural Zambian context of (1) economic support to girls and their families, and (2) combining economic support with a community intervention to enhance knowledge about sexual and reproductive health and supportive community norms.

Methods/design

This cluster randomized controlled trial (CRCT) will have three arms. The clusters are rural schools with surrounding communities. Approximately 4900 girls in grade 7 in 2016 will be recruited from 157 schools in 12 districts. In one intervention arm, participating girls and their guardians will be offered cash transfers and payment of school fees. In the second intervention arm, there will be both economic support and a community intervention. The interventions will be implemented for approximately 2 years. The final survey will be 4.5 years after recruitment. The primary outcomes will be “incidence of births within 8 months of the end of the intervention period”, “incidence of births before girls’ 18th birthday” and “proportion of girls who sit for the grade 9 exam”. Final survey interviewers will be unaware of the intervention status of respondents. Analysis will be by intention-to-treat and adjusted for cluster design and confounders. Qualitative process evaluation will be conducted.

Discussion

This is the first CRCT to measure the effect of combining economic support with a community intervention to prevent adolescent childbearing in a low- or middle-income country. We have designed a programme that will be sustainable and feasible to scale up. The findings will be relevant for programmes for adolescent reproductive health in Zambia and similar contexts.

Trial registration

ISRCTN registry: ISRCTN12727868, (4 March 2016).

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1682-9) contains supplementary material, which is available to authorized users.

Enhancing transit polio vaccination in collaboration with targeted stakeholders in Kaduna State, Nigeria: Lessons learnt: 2014-2015

INTRODUCTION

In Kaduna State of Nigeria, the high influx of people from neighboring states with eligible children for polio vaccination represents a significant proportion of the target population. Many of these children are often missed by the vaccination team. The purpose of the study was to determine the contribution of targeted stakeholders in transit polio vaccination.

METHODS

We used the trends of vaccinated children at transit points, motor parks and markets, well as total children vaccinated by transit teams in Chikun, Igabi and Sabon Gari Local Government Areas (LGAs) of Kaduna State, Nigeria, four rounds before and after the introduction of transit polio vaccination with targeted stakeholders in Kaduna State.

RESULTS

A total of 87,502 under-5 children were vaccinated by the various transit teams in the three LGAs, which accounted for 3.2% of the total 2,781,162 children vaccinated by the three LGAs. For transit point vaccination, the number of vaccinated children increased from 1026 to 19,289 (302%), while motor park vaccination increased from 1289 to 4106 (318%) and market vaccination increased from 10,488 to 14,511 (138%), four rounds after the introduction of transit polio vaccination with targeted stakeholders.

CONCLUSION

Engagement of targeted stakeholders significantly enhanced transit polio vaccination in Kaduna State, Nigeria.

Strategies for Improving Polio Surveillance Performance in the Security-Challenged Nigerian States of Adamawa, Borno, and Yobe During 2009-2014

BACKGROUND

The security-challenged states of Adamawa, Borno, and Yobe bear most of the brunt of the Boko Haram insurgency in Nigeria. The security challenge has led to the killing of health workers, destruction of health facilities, and displacement of huge populations. To identify areas of polio transmission and promptly detect possible cases of importation in these states, polio surveillance must be very sensitive.

METHODS

We conducted a retrospective review of acute flaccid paralysis surveillance in the security-compromised states between 2009 and 2014, using the acute flaccid paralysis database at the World Health Organization Nigeria Country Office. We also reviewed the reports of surveillance activities conducted in these security-challenged states, to identify strategies that were implemented to improve polio surveillance.

RESULTS

Environmental surveillance was implemented in Borno in 2013 and in Yobe in 2014. All disease surveillance and notification officers in the 3 security-challenged states now receive annual training, and the number of community informants in these states has dramatically increased. Media-based messaging (via radio and television) is now used to sensitize the public to the importance of surveillance, and contact samples have been regularly collected in both states since 2014.

CONCLUSIONS

The strategies implemented in the security-challenged states improved the quality of polio surveillance during the review period.

Contribution of Environmental Surveillance Toward Interruption of Poliovirus Transmission in Nigeria, 2012-2015

BACKGROUND

Cases of paralysis caused by poliovirus have decreased by >99% since the 1988 World Health Assembly's resolution to eradicate polio. The World Health Organization identified environmental surveillance (ES) of poliovirus in the poliomyelitis eradication strategic plan as an activity that can complement acute flaccid paralysis (AFP) surveillance. This article summarizes key public health interventions that followed the isolation of polioviruses from ES between 2012 and 2015.

METHODS

The grap method was used to collect 1.75 L of raw flowing sewage every 2-4 weeks. Once collected, samples were shipped at 4 °C to a polio laboratory for concentration. ES data were then used to guide program implementation.

RESULTS

From 2012 to 2015, ES reported 97 circulating vaccine-derived polioviruses (cVDPV2) and 14 wild polioviruses. In 2014 alone, 54 cVDPV type 2 cases and 1 WPV type 1 case were reported. In Sokoto State, 58 cases of AFP were found from a search of 9426 households. A total of 2 252 059 inactivated polio vaccine and 2 460 124 oral polio vaccine doses were administered to children aged <5 year in Borno and Yobe states.

CONCLUSIONS

This article is among the first from Africa that relates ES findings to key public health interventions (mass immunization campaigns, inactivated polio vaccine introduction, and strengthening of AFP surveillance) that have contributed to the interruption of poliovirus transmission in Nigeria.

Revised Household-Based Microplanning in Polio Supplemental Immunization Activities in Kano State, Nigeria. 2013-2014

BACKGROUND

Remarkable progress had been made since the launch of the Global Polio Eradication Initiative in 1988. However endemic wild poliovirus transmission in Nigeria, Pakistan, and Afghanistan remains an issue of international concern. Poor microplanning has been identified as a major contributor to the high numbers of chronically missed children.

METHODS

We assessed the contribution of the revised household-based microplanning process implemented in Kano State from September 2013 to April 2014 to the outcomes of subsequent polio supplemental immunization activities using used preselected planning and outcome indicators.

RESULTS

There was a 38% increase in the number of settlements enumerated, a 30% reduction in the number of target households, and a 54% reduction in target children. The reported number of children vaccinated and the doses of oral polio vaccine used during subsequent polio supplemental immunization activities showed a decline. Postvaccination lot quality assurance sampling and chronically missed settlement reports also showed a progressive reduction in the number of children and settlements missed.

CONCLUSIONS

We observed improvement in Kano State's performance based on the selected postcampaign performance evaluation indicators and reliability of baseline demographic estimates after the revised household-based microplanning exercise.

Premature adult mortality in urban Zambia: a repeated population-based cross-sectional study

OBJECTIVES

To measure the sex-specific and community-specific mortality rates for adults in Lusaka, Zambia, and to identify potential individual-level, household-level and community-level correlates of premature mortality. We conducted 12 survey rounds of a population-based cross-sectional study between 2004 and 2011, and collected data via a structured interview with a household head.

SETTING

Households in Lusaka District, Zambia, 2004-2011.

PARTICIPANTS

43,064 household heads (88% female) who enumerated 123,807 adult household members aged between 15 and 60 years.

PRIMARY OUTCOME

Premature adult mortality.

RESULTS

The overall mortality rate was 16.2/1000 person-years for men and 12.3/1000 person-years for women. The conditional probability of dying between age 15 and 60 (45q15) was 0.626 for men and 0.537 for women. The top three causes of death for men and women were infectious in origin (ie, tuberculosis, HIV and malaria). We observed an over twofold variation of mortality rates between communities. The mortality rate was 1.98 times higher (95% CI 1.57 to 2.51) in households where a family member required nursing care, 1.44 times higher (95% CI 1.22 to 1.71) during the cool dry season, and 1.28 times higher (95% CI 1.06 to 1.54) in communities with low-cost housing.

CONCLUSIONS

To meet Zambia's development goals, further investigation is needed into the factors associated with adult mortality. Mortality can potentially be reduced through focus on high-need households and communities, and improved infectious disease prevention and treatment services.

Strengthening Routine Immunization in Areas of Northern Nigeria at High Risk for Polio Transmission During 2012-2014

Background. Following the 2012 declaration by World Health Organization (WHO) Regional Director for Africa and the WHO Executive Board to ramp up routine immunization (RI) activities, began to intensify activities to strengthen RI. This study assessed how the intensification of RI helped strengthen service delivery in local government areas (LGAs) of northern Nigeria at high risk for polio transmission.

Methods. A retrospective study was performed by analyzing RI administrative data and findings from supportive supervisory visits in 107 high-risk LGAs.

Results. Our study revealed that administrative coverage with 3rd dose of diphtheria-pertussis-tetanus vaccine in the 107 high-risk LGAs improved from a maximum average coverage of 33% during the preintensification period of 2009–2011 to 74% during the postintensification period of 2012–2014.

Conclusions. Routine immunization could be strengthened in areas where coverage is low, and RI has been identified to be weak when certain key routine activities are intensified.

Intensified Local Resource Mobilization for the Polio Eradication Initiative: The Experience of World Health Organization in Nigeria During 2008-2015

Background. Since the World Health Assembly (WHA) resolved in 1988 to eradicate poliovirus, several rounds of immunization campaigns have been conducted by member states. By 2000, with the support of the Global Polio Eradication Initiative (GPEI) partners, the number of polio cases decreased by 99%. Eradicating the remaining 1% proved to be more challenging. Although the GPEI, being the largest public health project, required >$9 billion between 1988 and 2012, economic analysis showed the estimated incremental net benefits of $40 billion–$50 billion between 1988 and 2035. In 2012, the WHA declared that the completion of poliovirus eradication is a programmatic emergency for global public health. Nigeria, as one of 3 remaining polio-endemic countries, developed an emergency plan to interrupt the transmission of poliovirus. The plan included the introduction or scale-up of various new innovations and strategies, which had substantial financial implication.

Methods. This is a retrospective study to document the intensified resource mobilization efforts made by the World Health Organization (WHO) in Nigeria to meet the increased financial requirements and bridge the remaining gap in funding. In addition to the established coordination platforms, the WHO Nigeria Country Office team directly engaged with national authorities, donors, and partners throughout the process of resource requirement analysis, project appraisals, proposal development, and implementation of activities, joint monitoring, and evaluation exercises. The office strengthened its capacity for direct funds disbursement and systematic implementation of a rigorous accountability framework.

Results. Between 2008 and May 2015, $538 million was mobilized locally, of which 82% was mobilized since 2012. The percentage of the total funding requirements that were locally mobilized averaged 31% between 2008 and 2011 and increased to 70% between 2012 and May 2015. During the same period, the WHO Nigeria Country Office team produced and submitted 102 grant reports and facilitated >20 joint project assessment exercises.

Discussion. The polio program in Nigeria has achieved unprecedented gains, despite prevailing security and operational challenges, with no case of wild poliovirus infection since July 2014. Through rigorous, transparent, and accountable funds management practice, the WHO country office in Nigeria gained donors' confidence. The locally mobilized funds have made a remarkable contribution to the successful implementation of the strategies set out in the polio emergency plan. We face the challenges of a narrow donor-base, donor fatigue, and competition among other emerging agencies joining the polio eradication initiative efforts over the last few years. We actively engage the national authorities and partners for effective coordination of the polio eradication initiative program and harmonization of resources, using the existing platforms at national, state, and local levels. We recommend strengthening the local resource mobilization machinery and broadening the donor base, to support the polio endgame strategy. Such efforts should also be adopted to support routine immunization, introduction of new vaccines, and strengthening of health systems in the country as part of polio legacy planning.

Strategic Engagement of Technical Surge Capacity for Intensified Polio Eradication Initiative in Nigeria, 2012-2015

Background. Following the 65th World Health Assembly (WHA) resolution on intensification of the Global Poliomyelitis Eradication Initiative (GPEI), the Nigerian government, with support from the World Health Organization (WHO) and other partners, implemented a number of innovative strategies to curb the transmission of wild poliovirus (WPV) in the country. One of the innovations successfully implemented since mid 2012 is the WHO's engagement of surge capacity personnel.

Methods. The WHO reorganized its functional structure, adopted a transparent recruitment and deployment process, provided focused technical and management training, and applied systematic accountability framework to successfully manage the surge capacity project in close collaboration with the national counterparts and partners. The deployment of the surge capacity personnel was guided by operational and technical requirement analysis.

Results. Over 2200 personnel were engaged, of whom 92% were strategically deployed in 11 states classified as high risk on the basis of epidemiological risk analysis and compromised security. These additional personnel were directly engaged in efforts aimed at improving the performance of polio surveillance, vaccination campaigns, increased routine immunization outreach sessions, and strengthening partnership with key stakeholders at the operational level, including community-based organizations.

Discussion. Programmatic interventions were sustained in states in which security was compromised and the risk of polio was high, partly owing to the presence of the surge capacity personnel, who are engaged from the local community. Since mid-2012, significant programmatic progress was registered in the areas of polio supplementary immunization activities, acute flaccid paralysis surveillance, and routine immunization with the support of the surge capacity personnel. As of 19 June 2015, the last case of WPV was reported on 24 July 2014. The surge infrastructure has also been instrumental in building local capacity; supporting other public health emergencies, such as the Ebola outbreak response and measles and meningitis outbreaks; and strengthening the integrated disease surveillance and response. Due to weak health systems in the country, it is vital to maintain a reasonable level of the surge capacity for successful implementation of the 2013–2018 global polio endgame strategy and beyond.

The Role of the Polio Program Infrastructure in Response to Ebola Virus Disease Outbreak in Nigeria 2014

BACKGROUND

The current West African outbreak of the Ebola virus disease (EVD) began in Guinea in December 2013 and rapidly spread to Liberia and Sierra Leone. On 20 July 2014, a sick individual flew into Lagos, Nigeria, from Monrovia, Liberia, setting off an outbreak in Lagos and later in Port Harcourt city. The government of Nigeria, supported by the World Health Organization and other partners, mounted a response to the outbreak relying on the polio program experiences and infrastructure. On 20 October 2014, the country was declared free of EVD.

METHODS

We examined the organization and operations of the response to the 2014 EVD outbreak in Nigeria and how experiences and support from the country's polio program infrastructure accelerated the outbreak response.

RESULTS

The deputy incident manager of the National Polio Emergency Operations Centre was appointed the incident manager of the Ebola Emergency Operations Centre (EEOC), the body that coordinated and directed the response to the EVD outbreak in the country. A total of 892 contacts were followed up, and blood specimens were collected from 61 persons with suspected EVD and tested in designated laboratories. Of these, 19 (31%) were positive for Ebola, and 11 (58%) of the case patients were healthcare workers. The overall case-fatality rate was 40%. EVD sensitization and training were conducted during the outbreak and for 2 months after the outbreak ended. The World Health Organization deployed its surveillance and logistics personnel from non-Ebola-infected states to support response activities in Lagos and Rivers states.

CONCLUSIONS

The support from the polio program infrastructure, particularly the coordination mechanism adopted (the EEOC), the availability of skilled personnel in the polio program, and lessons learned from managing the polio eradication program greatly contributed to the speedy containment of the 2014 EVD outbreak in Nigeria.

Role of Serial Polio Seroprevalence Studies in Guiding Implementation of the Polio Eradication Initiative in Kano, Nigeria: 2011-2014

BACKGROUND

Nigeria was one of 3 polio-endemic countries before it was de-listed in September 2015 by the World Health Organization, following interruption of transmission of the poliovirus. During 2011-2014, Nigeria conducted serial polio seroprevalence surveys (SPS) in Kano Metropolitan Area, comprising 8 local government areas (LGAs) in Kano that is considered very high risk (VHR) for polio, to monitor performance of the polio eradication program and guide the program in the adoption of innovative strategies.

METHODS

Study subjects who resided in any of the 8 local government areas of Kano Metropolitan Area and satisfied age criteria were recruited from patients at Murtala Mohammed Specialist Hospital (Kano) for 3 seroprevalence surveys. The same methods were used to conduct each survey.

RESULTS

The 2011 study showed seroprevalence values of 81%, 75%, and 73% for poliovirus types 1, 2, and 3, respectively, among infants aged 6-9 months age. Among children aged 36-47 months, seroprevalence values were greater (91%, 87%, and 85% for poliovirus types 1, 2, and 3, respectively).In 2013, the results showed that the seroprevalence was unexpectedly low among infants aged 6-9 months, remained high among children aged 36-47 months, and increased minimally among children aged 5-9 years and those aged 10-14 years. The baseline seroprevalence among infants aged 6-9 months in 2014 was better than that in 2013.

CONCLUSIONS

The results from the polio seroprevalence surveys conducted in Kano Metropolitan Area in 2011, 2013, and 2014 served to assess the trends in immunity and program performance, as well as to guide the program, leading to various interventions being implemented with good effect, as evidenced by the reduction of poliovirus circulation in Kano.

Demand Creation for Polio Vaccine in Persistently Poor-Performing Communities of Northern Nigeria: 2013-2014

Introduction. Poliomyelitis remains a global threat despite availability of oral polio vaccine (OPV), proven to reduce the burden of the paralyzing disease. In Nigeria, children continue to miss the opportunity to be fully vaccinated, owing to factors such as unmet health needs and low uptake in security-compromised and underserved communities. We describe the implementation and evaluation of several activities to create demand for polio vaccination in persistently poor-performing local government areas (LGAs).

Methods. We assessed the impact of various polio-related interventions, to measure the contribution of demand creation activities in 77 LGAs at very high risk for polio, located across 10 states in northern Nigeria. Interventions included provision of commodities along with the polio vaccine.

Results. There was an increasing trend in the number of children reached by different demand creation interventions. A total of 4 819 847 children were vaccinated at health camps alone. There was a reduction in the number of wards in which >10% of children were missed by supplementary immunization activities due to noncompliance with vaccination recommendations, a rise in the proportion of children who received ≥4 OPV doses, and a decrease in the proportion of children who were underimmunized or unimmunized.

Conclusions. Demand creation interventions increased the uptake of polio vaccines in persistently poor-performing high-risk communities in northern Nigeria during September 2013–November 2014.

Implementation of a Systematic Accountability Framework in 2014 to Improve the Performance of the Nigerian Polio Program

Background. An accountability framework is a central feature of managing human and financial resources. One of its primary goals is to improve program performance through close monitoring of selected priority activities. The principal objective of this study was to determine the contribution of a systematic accountability framework to improving the performance of the World Health Organization (WHO)–Nigeria polio program staff, as well as the program itself.

Methods. The effect of implementation of the accountability framework was evaluated using data on administrative actions and select process indicators associated with acute flaccid paralysis (AFP) surveillance, routine immunization, and polio supplemental immunization activities. Data were collected in 2014 during supportive supervision, using Magpi software (a company that provides service to collect data using mobile phones). A total of 2500 staff were studied.

Results. Data on administrative actions and process indicators from quarters 2–4 in 2014 were compared. With respect to administrative actions, 1631 personnel (74%) received positive feedback (written or verbal commendation) in quarter 4 through the accountability framework, compared with 1569 (73%) and 1152 (61%) during quarters 3 and 2, respectively. These findings accorded with data on process indicators associated with AFP surveillance and routine immunization, showing statistically significant improvements in staff performance at the end of quarter 4, compared with other quarters.

Conclusions. Improvements in staff performance and process indicators were observed for the WHO-Nigeria polio program after implementation of a systematic accountability framework.

The Journalists Initiatives on Immunisation Against Polio and Improved Acceptance of the Polio Vaccine in Northern Nigeria 2007-2015

BACKGROUND

The polio eradication initiative had major setbacks in 2003 and 2007 due to media campaigns in which renowned scholars and Islamic clerics criticized polio vaccines. The World Health Organization (WHO) partnered with journalists in 2007 to form the Journalists Initiatives on Immunisation Against Polio (JAP), to develop communication initiatives aimed at highlighting polio eradication activities and the importance of immunization in northern Nigeria.

METHODS

We evaluated the impact of JAP activities in Kaduna State by determining the total number of media materials produced and the number of newspaper clips and bulletins published in support of polio eradication. We also determined the number of households in noncompliant communities that became compliant with vaccination during 2015 supplementary immunization activities (SIAs) after JAP interventions and compared caregivers' sources of information about SIAs in 2007 before and after the JAP was formed.

RESULTS

Since creation of the JAP, >500 reports have been published and aired, with most portraying polio vaccine positively. During June 2015 SIAs in high-risk wards of Kaduna STATE, JAP interventions resulted in vaccination of 5122 of 5991 children (85.5%) from noncompliant households. During early 2007, the number of caregivers who had heard about SIA rounds from the media increased from 26% in January, before the JAP was formed, to 33% in March, after the initiation of JAP activities.

CONCLUSIONS

The formation of the JAP resulted in measurable improvement in the acceptance of polio vaccine in northern Nigeria.

Rural-urban differentials in pregnancy-related mortality in Zambia: estimates using data collected in a census

Background

The use of census data to measure maternal mortality is a recent phenomenon, implemented in settings with non-functional vital registration systems and driven by needs for trend data. The 2010 round of population and housing censuses recorded a significant increase in the number of countries collecting maternal mortality data. The objective of this study was to estimate rural-urban differentials in pregnancy-related mortality in Zambia using census data.

Methods

We used data from the Zambia 2000 and 2010 censuses. Both censuses recorded the female population by age, the number of children ever born, and live births 12 months prior to the census. The 2010 census further recorded, by age, household, and pregnancy-related deaths 12 months prior to the census. We evaluated and adjusted recorded live births using the cohort Parity Fertility ratio method, and household deaths using deaths distribution methods (General Growth Balance and Synthetic Extinct Generation). Adult female mortality and pregnancy-related mortality for rural and urban areas were estimated for the period October 2009 to October 2010.

Results

Data evaluation showed errors in recorded population age, age-at-death, live births, and deaths, and appropriate adjustments were made. Adjusted adult female mortality was high; an adolescent aged 15 years had a one-in-three chance of dying before her 50th birthday in rural areas and one-in-four chance in urban areas. Pregnancy-related deaths comprised 15.3 % of all deaths among reproductive-age women overall; 17.9 % in rural areas and 9.8 % in urban areas. The pregnancy-related mortality ratio for the period was 789 deaths/100,000 live births overall: 960/100,000 live births in rural areas and 470/100,000 live births in urban areas.

Conclusions

Census-based estimates show very high adult female mortality and particularly high pregnancy-related mortality in both rural and urban areas of Zambia 12 months prior to the 2010 census. Future censuses should pay greater attention to strategies for improving data quality.

Youth Group Engagement in Noncompliant Communities During Supplemental Immunization Activities in Kaduna, Nigeria, in 2014

INTRODUCTION

One of the major challenges being faced in the Global Polio Eradication Initiative program is persistent refusal of oral polio vaccine (OPV) and harassment of vaccination team members by youths. The objective of the study was to describe the strategy of collaborating with recognized youth groups to reduce team harassment during vaccination campaigns and improve vaccination coverage in noncompliant communities.

METHODS

We assessed data from polio vaccination activities in OPV-refusing communities in the Igabi and Zaria local government areas (LGAs) of Kaduna State in Nigeria. We evaluated the following factors to determine trends: enhanced independent monitoring data on the proportion of children missed by vaccination activities (hereafter, "missed children"), lot quality assurance surveys, and vaccination team harassment.

RESULTS

The proportion of missed children decreased in both LGAs after the intervention. In Igabi LGA and Zaria LGA, the lowest proportions of missed children before and after the intervention decreased from 7% to 2% and from 5% to 1%, respectively. Lot quality assurance survey trends showed an improvement in immunization coverage 1 year after youth groups' engagement in both LGAs.

CONCLUSIONS

Systematic engagement of youth groups has a great future in polio interruption as we approach the endgame strategy for polio eradication. It promises to be a veritable innovation in reaching chronically missed children in OPV-refusing communities.

Tracking Vaccination Teams During Polio Campaigns in Northern Nigeria by Use of Geographic Information System Technology: 2013-2015

INTRODUCTION

Nigeria is among the 3 countries in which polio remains endemic. The country made significant efforts to reduce polio transmission but remains challenged by poor-quality campaigns and poor team performance in some areas. This article demonstrates the application of geographic information system technology to track vaccination teams to monitor settlement coverage, reduce the number of missed settlements, and improve team performance.

METHODS

In each local government area where tracking was conducted, global positioning system-enabled Android phones were given to each team on a daily basis and were used to record team tracks. These tracks were uploaded to a dashboard to show the level of coverage and identify areas missed by the teams.

RESULTS

From 2012 to June 2015, tracking covered 119 immunization days. A total of 1149 tracking activities were conducted. Of these, 681 (59%) were implemented in Kano state. There was an improvement in the geographic coverage of settlements and an overall reduction in the number of missed settlements.

CONCLUSIONS

The tracking of vaccination teams provided significant feedback during polio campaigns and enabled supervisors to evaluate performance of vaccination teams. The reports supported other polio program activities, such as review of microplans and the deployment of other interventions, for increasing population immunity in northern Nigeria.

Impact of Pregnancy-Related Deaths on Female Life Expectancy in Zambia: Application of Life Table Techniques to Census Data

INTRODUCTION

Since 2000, the world has been coalesced around efforts to reduce maternal mortality. However, few studies have estimated the significance of eliminating maternal deaths on female life expectancy. We estimated, based on census data, the potential gains in female life expectancy assuming complete elimination of pregnancy-related mortality in Zambia.

METHODS

We used data on all-cause and pregnancy-related deaths of females aged 15-49 reported in the Zambia 2010 census, and evaluated, adjusted and smoothed them using existing and verified techniques. We used associated single decrement life tables, assuming complete elimination of pregnancy-related deaths to estimate the potential gains in female life expectancy at birth, at age 15, and over the ages 15-49. We compared these gains with the gains from eliminating deaths from accidents, injury, violence and suicide.

RESULTS

Complete elimination of pregnancy-related deaths would extend life expectancy at birth among Zambian women by 1.35 years and life expectancy at age 15 by 1.65 years. In rural areas, this would be 1.69 years and 2.19 years, respectively, and in urban areas, 0.78 years and 0.85 years. An additional 0.72 years would be spent in the reproductive age group 15-49; 1.00 years in rural areas and 0.35 years in urban areas. Eliminating deaths from accidents, injury, suicide and violence among women aged 15-49 would cumulatively contribute 0.55 years to female life expectancy at birth.

CONCLUSION

Eliminating pregnancy-related mortality would extend female life expectancy in Zambia substantially, with more gains among adolescents and females in rural areas. The application of life table techniques to census data proved very valuable, although rigorous evaluation and adjustment of reported deaths and age was necessary to attain plausible estimates. The collection of detailed high quality cause-specific mortality data in future censuses is indispensable.

Progress toward poliomyelitis eradication--Nigeria, January 2013-September 2014

In 1988, the World Health Assembly resolved to interrupt wild poliovirus (WPV) transmission worldwide. By 2013, only three countries remained that had never interrupted WPV transmission: Afghanistan, Nigeria, and Pakistan. Since 2003, northern Nigeria has been a reservoir for WPV reintroduction into 26 previously polio-free countries. In May 2014, the World Health Organization declared the international spread of polio a Public Health Emergency of International Concern. Nigeria's main strategic goal is to interrupt WPV type 1 (WPV1) transmission by the end of 2014, which is also a main objective of the Global Polio Eradication Initiative's Polio Eradication and Endgame Strategic Plan for 2013-2018. This report updates previous reports (4-6) and describes polio eradication activities and progress in Nigeria during January 2013-September 30, 2014. Only six WPV cases had been reported in 2014 through September 30 compared with 49 reported cases during the same period in 2013. The quality of supplemental immunization activities (SIAs) improved during this period; the proportion of local government areas (LGAs) within 11 high-risk states with estimated oral poliovirus vaccine (OPV) campaign coverage at or above the 90% threshold increased from 36% to 67%. However, the number of reported circulating vaccine-derived poliovirus type 2 (cVDPV2) cases increased from four in 2013 to 21 to date in 2014, and surveillance gaps are suggested by genomic sequence analysis and continued detection of WPV1 by environmental surveillance. Interrupting all poliovirus circulation in Nigeria is achievable with continued attention to stopping cVDPV2 transmission, improving the quality of acute flaccid paralysis (AFP) surveillance, increasing vaccination coverage by strengthened routine immunization services, continuing support from all levels of government, and undertaking special initiatives to provide vaccination to children in conflict-affected areas in northeastern Nigeria.

Monitoring prevention or emergence of HIV drug resistance: results of a population-based foundational survey of early warning indicators in mainland Tanzania

BACKGROUND

In Tanzania, routine individual-level testing for HIV drug resistance (HIVDR) using laboratory genotyping and phenotyping is not feasible due to resource constraints. To monitor the prevention or emergence of HIVDR at a population level, WHO developed generic strategies to be adapted by countries, which include a set of early warning indicators (EWIs).

METHODS

To establish a baseline of EWIs, we conducted a retrospective longitudinal survey of 35 purposively sampled care and treatment clinics in 17 regions of mainland Tanzania. We extracted data relevant for four EWIs (ART prescribing practices, patients lost to follow-up 12 months after ART initiation, retention on first-line ART at 12 months, and ART clinic appointment keeping in the first 12 months) from the patient monitoring system on patients who initiated ART at each respective facility in 2010. We uploaded patient information into WHO HIVResNet excel-based tool to compute national and facility averages of the EWIs and tested for associations between various programmatic factors and EWI performance using Fisher's Exact Test.

RESULTS

All sampled facilities met the WHO EWI target (100%) for ART prescribing practices. However, the national averages for patients lost to follow-up 12 months after ART initiation, retention on first-line ART at 12 months, and ART clinic appointment keeping in the first 12 months fell short, at 26%, 54% and 38%, respectively, compared to the WHO targets ≤ 20%, ≥ 70%, and ≥ 80%. Clinics with fewer patients lost to follow-up 12 months after ART initiation and more patients retained on first-line-ART at 12 months were more likely to have their patients spend the longest time in the facility (including wait-time and time with providers), (p = 0.011 and 0.007, respectively).

CONCLUSION

Tanzania performed very well in EWI 1a, ART prescribing practices. However, its performance in other three EWIs was far below the WHO targets. This study provides a baseline for future monitoring of EWIs in Tanzania and highlights areas for improvement in the management of ART patients in order not only to prevent emergence of HIVDR due to programmatic factors, but also to improve the quality of life for ART patients.

Adjuvant potential of low dose all-trans retinoic acid during oral typhoid vaccination in Zambian men

There is an urgent need to identify ways of enhancing the mucosal immune response to oral vaccines. Rotavirus vaccine protection is much lower in Africa and Asia than in industrialized countries, and no oral vaccine has efficacy approaching the best systemic vaccines. All-trans retinoic acid (ATRA) up-regulates expression of α4β7 integrin and CCR9 on lymphocytes in laboratory animals, increasing their gut tropism. The aim of this study was to establish the feasibility of using ATRA as an oral adjuvant for oral typhoid vaccination. In order to establish that standard doses of oral ATRA can achieve serum concentrations greater than 10 nmol/l, we measured ATRA, 9-cis and 13-cis retinoic acid in serum of 14 male volunteers before and 3 h after 10 mg ATRA. We then evaluated the effect of 10 mg ATRA given 1 h before, and for 7 days following, oral typhoid vaccine in eight men, and in 24 men given various control interventions. We measured immunoglobulin (Ig)A directed against lipopolysaccharide (LPS)and protein preparations of vaccine antigens in whole gut lavage fluid (WGLF) and both IgA and IgG in serum, 1 day prior to vaccination and on day 14. Median [interquartile range (IQR)] C(max) was 26·2 (11·7-39·5) nmol/l, with no evidence of cumulation over 8 days. No adverse events were observed. Specific IgA responses to LPS (P = 0·02) and protein (P = 0·04) were enhanced in WGLF, but no effect was seen on IgA or IgG in serum. ATRA was well absorbed, well tolerated and may be a promising candidate oral adjuvant.

Prevalence of HIV drug resistance before and 1 year after treatment initiation in 4 sites in the Malawi antiretroviral treatment program

Since 2004, the Malawi antiretroviral treatment (ART) program has provided a public health-focused system based on World Health Organization clinical staging, standardized first-line ART regimens, limited laboratory monitoring, and no patient-level monitoring of human immunodeficiency virus drug resistance (HIVDR). The Malawi Ministry of Health conducts periodic evaluations of HIVDR development in prospective cohorts at sentinel clinics. We evaluated viral load suppression, HIVDR, and factors associated with HIVDR in 4 ART sites at 12-15 months after ART initiation. More than 70% of patients initiating ART had viral suppression at 12 months. HIVDR prevalence (6.1%) after 12 months of ART was low and largely associated with baseline HIVDR. Better follow-up, removal of barriers to on-time drug pickups, and adherence education for patients 16-24 years of age may further prevent HIVDR.