All Articles

Nick F. Hallam^*

Colposcopy Clinic, Women's Outpatients, Cumberland Infirmary, Carlisle, England, United Kingdom

This short communication reports additional research that extends the previously published article - Commentary: HPV Catch-Up Vaccination Reduces the Prevalence of HPV 16 and 18 Infections and Cervical Disease: A Retrospective Study.1 One limitation of that study was uncertainty as to whether the catch-up cohort had actually received HPV (human papillomavirus) vaccination. That information has now been obtained. 87 (59%) of the 147 patients in the catch-up cohort had received at least one dose of HPV bivalent vaccine. 69 of these (representing 79% of those vaccinated) had received three doses (as recommended at the time). Both the vaccinated and unvaccinated subsets of the catch-up cohort show a significant reduction in the prevalence of HPV 16 and/or 18 (with/without other high-risk types 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 and 68) and of high grade cervical disease compared to an earlier unvaccinated cohort. These results confirm the efficacy of HPV catch-up vaccination and the existence of herd immunity following the introduction of national HPV vaccination campaigns. However, 34 patients (23%) in the catch-up cohort had high grade disease (cervical intraepithelial neoplasia [CIN] 2 or worse), 16 of whom had been vaccinated (12 with three doses, one with two doses and three with one dose of HPV bivalent vaccine) and four of those vaccinated had HPV 16 and/or 18 (with/without other high-risk types), the rest had other HPV high risk types. This emphasises the importance of maintaining cervical screening alongside HPV vaccination.

Lisa M. James^1,2,3, Peka Christova^1,2, Rachel A. Johnson¹, Brian E. Engdahl^1,2,4, Scott M. Lewis^1,5, Adam F. Carpenter^1,5, Apostolos P. Georgopoulos^1,2,3,5*

¹Brain Sciences Center, Department of Veterans Affairs Health Care System, Minneapolis, MN, 55417, USA

²Department of Neuroscience, University of Minnesota Medical School, Minneapolis, MN 55455, USA

³Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN 55455, USA

⁴Department of Psychology, University of Minnesota Medical School, Minneapolis, MN 55455, USA

⁵Department of Neurology, University of Minnesota Medical School, Minneapolis, MN 55455, USA

Separate lines of research have documented brain atrophy and evidence of autoimmune mechanisms in Gulf War Illness (GWI), including the presence of lupus anticoagulant (LAC), in veterans with GWI. Here we evaluated the possible association of LAC and brain volume in veterans with GWI. The presence of LAC was determined using Silica Clotting Time and dilute Russell’s Viper Venom Time assays. MRI data was acquired using a Philips 3T MR scanner from which total gray matter, total cortical gray matter, total subcortical gray matter, and total cerebral white matter were derived. The results demonstrated a statistically significant reduction of brain volume in all regions tested in GWI veterans with positive LAC, as compared to those without LAC. These findings add to the literature implicating autoimmune mechanisms in GWI and point to the presence of prothrombotic antiphospholipid antibodies as contributing to brain atrophy in GWI.

Kalpana Balakrishnan^{1, 4}, Divya Sivanesan¹, Gaanappriya Mohan⁴, Sachin S Gunthe^2,3, Rama S Verma^1*

¹Department of Biotechnology, Indian Institute of Technology Madras, Chennai

²Department of Civil Engineering, Indian Institute of Technology Madras, Chennai

³Laboratory of Atmospheric and Climate Sciences, Institute of Technology Madras, Chennai

⁴Department of Biotechnology, K. S. Rangasamy College of Technology, Namakkal Tamil Nadu, India

The human microbiome plays a crucial role in health and disease conditions. These microbiomes constitute a structured, coordinated microbial network throughout the human body. The oral cavity harbors one of the extensively diverse bacteria in the human system. Although many studies emphasize bacteriome and its interaction with the host system, very little attention is given to candidate phyla radiation (CPR), fungal components, and its interkingdom interaction in the oral microecology even with advanced techniques. The interkingdom interactions among caries causing microbes trigger the pathogenesis of bacterial diseases and cause ecological shifts and affect the host system. Studying the complex relations among the diverse oral microbiome and its host, especially CPR phyla and fungi, would give a holistic view of the caries etiology. This review provides evidence on the interkingdom interaction that establishes a complex community that could help predict future oral and systemic diseases.

Lisa M. James^1,2,3, Apostolos P. Georgopoulos^1,2,3,4*

¹The HLA Research Group, Brain Sciences Center, Department of Veterans Affairs Health Care System, Minneapolis, MN, 55417, USA

²Department of Neuroscience, University of Minnesota Medical School, Minneapolis, MN 55455, USA

³Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN 55455, USA

⁴Department of Neurology, University of Minnesota Medical School, Minneapolis, MN 55455, USA 

Human leukocyte antigen (HLA), a system involved in immune response to foreign antigens and in autoimmunity, has been strongly implicated in multiple sclerosis (MS). Prior research has shown that HLA DRB1*15:01 exerts the strongest susceptibility effect, although other HLA alleles have been implicated in both susceptibility to, and protection against, MS. Here we utilized an immunogenetic epidemiological approach to evaluate correlations between the population frequencies of 127 HLA Class I and II alleles and the population prevalence of MS in 14 Continental Western European countries to identify an HLA profile for MS. The results of these analyses, which largely corroborated prior findings and revealed several novel and highly robust HLA associations with MS, revealed a larger number of protective HLA alleles than susceptibility alleles, particularly for HLA Class I. Given the role of HLA in pathogen elimination and autoimmunity, these findings point to a contributory role of exposure to pathogens in the absence of protective HLA in underlying the inflammation and autoimmunity associated with MS.

Priyanka Ray

Department of Chemical, Biochemical and Environmental Engineering, University of Maryland, Baltimore County, Baltimore MD, 21250, USA

Shruti Sharma^1*, Ujjawal Sharma^2#, Anupama Chaudhary³, Manisha Naithani⁴, Priyanka Naithani⁵, Saurabh Prashar², Bunty Sharma⁶, Pramod Kumar Nagar⁷, Prudhvi Lal Bhukya⁸, Unnati Bhalerao⁸, Meenakshi Singh⁹, Manjita Srivastava⁸, Muneesh Kumar Barman¹⁰, Sampan Attri², Jitender Gairolla^2,11# 

¹Department of Experimental Medicine and Biotechnology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

²Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India

³Orinin BioSystems, Karnal, India

⁴Department of Biochemistry, All India Institute of Medical Sciences, Rishikesh, India

⁵Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

⁶Chitkara School of Health Sciences, Chitkara University, Punjab, India

⁷Hematology Oncology Unit, Advance Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India

⁸National Institute of Virology, Pune, India

⁹Transplant Immunology and Immunogenetics Lab (HLA), ACTREC, Tata Memorial Centre

¹⁰Laboratory for HIV Research, National Centre for Cell Sciences, Pune-India

¹¹Department of Microbiology, All India Institute of Medical Sciences, Rishikesh, India

The global public health scenario is worsening gradually as the confirmed cases of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infections are incessantly escalating with every passing day. The pathological condition caused by SARS-CoV-2 is termed as Coronavirus disease 2019 (COVID-19). The understanding of SARS-CoV-2 transmission dynamics, immunopathogenesis, and the need for early-stage diagnosis and the effective therapeutic regime are the few immediate challenges faced by healthcare professionals worldwide. More specifically, the role of SARS-CoV-2 in the host’s immunopathogenesis response is crucial to determine the disease severity and its clinical outcome in COVID-19 patients. In the present review, we provide insights into the SARS-CoV-2 pathology, host immune responses including innate, cellular, and humoral responses, and immunomodulatory functions of SARS-CoV-2 including cytokine storm and immune evasion. We also shed light upon the present clinical and laboratory-based applications enrolled in the SARS-CoV-2 diagnosis. Taking into consideration the pathogenesis and SARS-CoV-2 immune function, in the present review, we finally provide succinct insights into the SARS-CoV-2 transmission dynamics, immunopathogenesis, with the assessment of the current diagnostic and preventive/ therapeutic strategies.

Lisa M. James^1,2,3, Apostolos P. Georgopoulos^1,2,3,4*

¹The HLA Research Group, Brain Sciences Center, Department of Veterans Affairs Health Care System, Minneapolis, MN, 55417, USA

²Department of Neuroscience, University of Minnesota Medical School, Minneapolis, MN 55455, USA

³Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN 55455, USA

⁴Department of Neurology, University of Minnesota Medical School, Minneapolis, MN 55455, USA

Human leukocyte antigen (HLA), which is critically involved in immune response to foreign antigens and in autoimmunity, has been implicated in dementia and Parkinson’s disease. Here we report on the correlations between the population frequencies of 127 HLA Class I and II alleles and the population prevalence of dementia and Parkinson’s disease in 14 Continental Western European countries, extending previous work^1,2. We used these correlations to construct and compare HLA profiles for each disease³. We found that (a) the HLA profiles of the two diseases were significantly correlated across both HLA Class I and Class II alleles, (b) negative (“protective”) HLA-disease correlations did not differ significantly for either HLA class, but (c) positive (“susceptibility”) HLA-disease correlations were significantly higher in dementia than in Parkinson’s disease for both HLA classes of alleles. These findings indicate that (a) dementia and Parkinson’s disease share immunogenetic HLA-related mechanisms, (b) HLA-related protective mechanisms (presumably against pathogens) do not differ between the two diseases, but (c) HLA-related susceptibility mechanisms (presumably underlying autoimmunity) are significantly stronger in dementia than in Parkinson’s disease.

Samuel Okiror¹*, John Ogange², Hemant Shukla³, Christine Lamoureau⁴, Mwaka Monze⁵, Amina Ismail², Anthony Kazoka⁶, Ben Nkowane³, Raoul Kamadjeu⁷, Obianuju Igweonu⁸, Joseph Okeibunor⁹, Chidiadi Nwogu¹

¹WHO Horn of Africa Coordination Office (HOA), Nairobi, Kenya

²World Health Organization, Kenya Country Office

³WHO Headquarters, Geneva

⁴Independent Consultant

⁵Polio Laboratory, Zambia

⁶World Health Organization, Tanzania Country Office

⁷UNICEF, New York

⁸University of Nigeria, Nsukka

⁹WHO Regional Office for Africa (WHO AFRO) Brazzaville, Congo

Background: The risk for importation and reintroduction wild poliovirus in areas that have been cleared of the wild poliovirus in the Horn of Africa will remain if the surveillance systems are weak and porous. Methods: Consequently, the Horn of Africa Polio Coordinating Office in Nairobi, together with partners conducted surveillance reviews for some of the countries in the Horn of Africa, especially Ethiopia, Kenya and Somalia to identify gaps in the polio surveillance and provided recommendations for improved surveillance. Structured questionnaires collected information about acute flaccid paralysis (AFP) surveillance resources, training, data monitoring, and supervision at provincial, district, and health facility levels. Other information collected included resource availability, management and monitoring of AFP surveillance.Results: The result revealed that although AFP surveillance systems were well established in these countries, a number of gaps and constraints existed. Widespread deficiencies and inefficient resource flow systems were observed and reported at all levels. There were also deficiencies related to provider knowledge, funding, training, and supervision, and were particularly evident at the health facility level. These weaknesses were corroborated with the sustained transmission of polioviruses in the region, where the surveillance systems were not sensitive enough to pick the viruses. Conclusion: The review teams made useful recommendations that led to strengthening of the surveillance systems in these countries, including the formation and use of village polio volunteers in the south and central zones of Somalia, where security was heavily compromised and surveillance officers lacked regular access to the communities.

Bernard Ntsama¹, Ado Bwaka², Reggis Katsande³, Regis Maurin Obiang⁴, Daniel Rasheed Oyaole⁵, Pascal Mkanda⁵, Joseph Okeibunor⁵

¹Data Manager, IST West Africa

²IVD/PEP Focal Point, IST West Africa

³Data Manager, AFRO

⁴Data Manager, IST Central Africa

⁵Data Manager, WHO Nigeria

The polio Eradication Initiative (PEI) is one of the most important public health interventions in Africa.  Quality data is necessary to monitor activities and key performance indicators and access year by year progress made. This process has been possible with a solid polio health information system that has been consolidated over the years.

This study describes the whole process to have data for decision making.  The main components are the data flow, the role of the different levels, data capture and tools, standards and codes, the data cleaning process, the integration of data from various sources, the introduction of innovative technologies, feedback and information products and capacity building. The results show the improvement in the timeliness of reporting data to the next level, the availability of quality data for analysis to monitor key surveillance performance indicators, the output of the data cleaning exercise pointing out data quality gaps, the integration of data from various sources to produce meaningful outputs and feedback for information dissemination.

From the review of the process, it is observed an improvement in the quality of polio data resulting from a well-defined information system with standardized tools and Standard Operating Procedures (SOPs) and the introduction of innovative technologies. However, there is room for improvement; for example, multiple data entries from the field to the surveillance unit and the laboratory. Innovative technologies are implemented for the time being in areas hard to reach due to the high cost of the investment. 

A strong information system has been put in place from the community level to the global level with a link between surveillance, laboratory and immunization coverage data. To maintain standards in Polio Information system, there is need for continuous training of the staff on areas of surveillance, information systems, data analysis and information sharing. The use of innovative technologies on web-based system and mobile devices with validation rules and information check will avoid multiple entries. 

Adele Daleke Lisi Aluma¹*, Sam Koulmini², Souley Kalilou², Obianuju Igweonu³, Felix Amadou Kouassi⁴, Mohamed Alimou Traore², Benoit Ntezayabo⁴, Laurel Zomahoun Delayo⁵, Aboubacar Barry², Aime Matela Esanga², Adama Nanko Bagayoko², Don Jethro Mavungu Landu², Abdel Aziz Kadai², Bondoro Toyma², Djibrine Abakar Sedick², Penaling Nathei², Daouda Mahamat², Philbert Bohoussou², Joseph Okeibunor⁶, Narcisse de Medeiros⁷, Bakoly Rabenarivo², Fabien Diomande², Sam Okiror⁸ 

¹Independent Consultant

²Ministry of Health Chad

³University of Nigeria, Nsukka

⁴WHO Chad

⁵WHO Headquarters, Geneva

⁶WHO Regional Office for Africa (WHO AFRO), Brazzaville, Congo

⁷UNICEF, Dakar

⁸WHO Horn of Africa Coordination Office (HOA), Nairobi KENYA

Background: One of the four key strategies of the Global Polio Eradication Initiative (GPEI) is high immunization coverage, with oral polio vaccine as part of routine immunization schedules. However, given the weak routine immunization structures in the African Region, coverage is enhanced with supplemental immunization activities (SIAs), and mop-up immunizations. Unfortunately, anecdotal information show that vaccination teams sometimes omit some catchments areas without immunization. This paper thus describes the use of “Call Centers” in detecting missed populations and taking prompt corrective action.

Method: The study was based on review of call records during polio supplemental immunization campaigns in Bol Districts in Chad from February to May 2018.  The immunization coverage resulting from these campaigns was compared with that of February 2018.  A compilation of data – details on communities, community leaders, and their phone numbers was performed. On the eve of the campaign, community leaders were alerted on the vaccinators’ visitThe community leaders were called on the eve of the campaign to alert them on the visit of the vaccinators. At the end of each day, activities (visits as well) were reviewed at the coordination centres Vaccinators were asked to return to any community where community leaders did not confirm visits).

Result: Telephone calls allowed the verification and confirmation of the vaccinators visits in 92% of cases. Villages where vaccination was planned but which were not reached were revisited. More than 1,011 children were caught up through this approach in 10 villages in the Bol district.

Conclusion: In conclusion, call centers played significantly higher role in generating covering more children with immunization during immunization campaign.

Samuel Okiror¹*, Hemant Shukla², Bob Davis³, Brigitte Toure⁴, Rustum Hydarov⁴, John Burton⁵, Subroto Mukherjee⁶, Bal Ram Bhui⁸, Mercy Lutukai⁸, Chidiadi Nwogu¹, Joseph Okeibunor⁷

¹WHO Horn of Africa Coordination Office (HOA), Nairobi KENYA

²WHO Headquarters, Geneva

³American Red Cross, Nairobi Kenya

⁴UNICEF, Nairobi Kenya

⁵UNHCR, Nairobi Kenya

⁶USAID Technical Officer

⁷WHO Regional Office for Africa, Brazzaville, Congo

⁸CORE Group Regional Office Nairobi

Background: The WPV1, first detected in Somalia in April 2013, quickly spread to Kenya and Ethiopia and triggered a multi-country coordinated effort. In February 2014, a formal HoA Polio Outbreak Coordination Office was established by WHO AFRO and WHO EMRO in Nairobi to provide technical and managerial leadership. An independent assessment was conducted to ascertain the usefulness of the HoA Coordination in response to the outbreaks.

Methods: The independent assessment team conducted desk review of the rules and guidelines forming the HoA Coordination office and committee. It also reviewed minutes of meetings and interviewed various stakeholders at the Regional levels.

Results: This independent review of the work of the office, in September 2016, showed that the office was fully functional and had benefited from financial and technical support from regional and global GPEI partners. The office is based in the WHO Kenya Country Office which also provides administrative, logistics and until August 2016, data management support. The close working relationship with technical partners ensured alignment and close coordination of outbreak response activities. The mechanism also allowed partners to identify areas of work based on their expertise and avoided duplication of efforts at the local level. Overall, the office was effective in close monitoring of implementation of the outbreak response, strengthening of cross-border activities, monitoring implementation of the TAG recommendations, improving SIA planning and quality, and expanding independent monitoring in Somalia and South Sudan. Key constraints included limited office space for day-to-day operations, and disruption of some activities due to interruption of contracts of technical staff. However, the closure of the HoA outbreak in August 2015 led to some complacency, resulting in a lost sense of urgency, negatively impacting the coordination.

Conclusions:The HoA Coordination Office should continue to function into the foreseeable future. To ensure sustainability of activities, the technical staff should be given contracts for a minimum of 12 months. The Office should re-introduce and schedule the Joint Polio Outbreak Response team meetings at least once every three months.

Joseph Okeibunor

WHO Regional Office for Africa, Brazzaville, Congo

Isah Mohammed Bello¹*, Abubakar Sadiq Umar², Godwin Ubong Akpan², Joseph Okeibunor¹, Chukwudi Shibeshi², Messeret Eshetu¹, Chakauya Jethro Magwati¹, Teshager Fasil¹, Daniel Fussum¹, Richard Mihigo², Pascal Mkanda²

¹WHO East & Southern Africa Support Team (WHO ESA IST)
²WHO Regional Office for Africa (WHO AFRO)

Mobile phone data collection tools are increasingly becoming very usable collecting, collating and analysing data in the health sector. In this paper, we documented the experiences with mobile phone data collection, collation and analysis in 5 countries of the East and Southern African, using Open Data Kit (ODK), where questionnaires were designed and coded on an XML form, uploaded and data collected using Android-Based mobile phones, with a web-based system to monitor data in real-time during EPI comprehensive review. The ODK interface supports in real-time monitoring of the flow of data, detection of missing or incomplete data, coordinate location of all locations visited, embedded charts for basic analysis. It also minimized data quality errors at entry level with the use of validation codes and constraint developed into the checklist. These benefits, combined with the improvement that mobile phones offer over paper-based in terms of timeliness, data loss, collation, and real-time data collection, analysis and uploading difficulties, make mobile phone data collection a feasible method of data collection that needs to be further explored in the conduct of all surveys in the organization.

Mamadou Diallo¹*, Alimou Traore², Myk Mwanza Nzioki¹, Ayangma Richelot¹, Kouryana Stephane³, Joseph Okeibunor¹, Mkanda Pascal¹, Samuel Okiror⁴, Johnson Ticha¹

¹WHO Regional Office for Africa (WHO AFRO), Brazzaville, Congo

²WHO Headquarters, Geneva

³WHO Chad

⁴WHO Horn of Africa Coordination Office (HOA), Nairobi KENYA

Marcellin Mengouo Nimpa¹, Noëline Ravelomanana Razafiarivao², Annick Robinson³, Mamy Randriatsarafara Fidiniaina⁴, Richter Razafindratsimandresy⁵, Yolande Vuo Masembe¹, Christiane Ramonjisoa Bodohanta⁶, Isidore Koffi Kouadio¹, Issa Kana kode Nyazy¹, Moussa Simpore¹, Charlotte Faty Ndiaye¹, Joseph Chukwudi Okeibunor^1.

¹World Health Organization Regional Office for Africa, Congo

²Faculté de Médécine d’Anatanarivo, Madagascar

³Centre Hospitalier Universitaire Mère Enfant Tsaralalana (CHUMET) -Antananarivo

⁴Direction Centrale du Service Militaire d’Antanarivo

⁵Institut Pasteur de Madagascar

⁶Expanded Programme of Immunization, Madagascar

Background: In 1988, the World Health Assembly launched the Global Polio Eradication Initiative. WHO AFRO is close to achieve this goal with the last wild poliovirus detected in 2014 in Borno States in Nigeria. The certification of the WHO African Region requires that all the 47 member states meet the critical indicators for a polio free status. Madagascar started implementing polio eradication activities in 1996 and was declared polio free in June 2018 in Abuja. This study describes the progress achieved towards polio eradication activities in Madagascar from 1977- 2017 and highlights the remaining challenges to be addressed.

Methods: Data were collected from the national routine immunization services, Country Acute Flaccid surveillance databases and national reports of SIAS and Mop Up campaign. Country complete polio and immunization related documentation provided detailed historical information’s.

Results: From 1997 to 2017, Madagascar reported one wild poliovirus (WPV) outbreak and four circulating Vaccine Derived Polio Virus (cVDPV) oubreaks with a total of 21 polioviruses (1 WPV and 21 cVDPV). The last WPV and cVDPV were notified in 1997 in Antananarivo and 2015 in Sakaraha health districts respectively. Madagascar met the main polio surveillance indicators over the last ten years and made significant progress following the last cVDPV2 outbreak in 2014 -2015. In addition, the country successfully implemented the switch from trivalent Oral Polio Vaccine (tOPV) to bivalent Oral Polio vaccine (bOPV) and containment activities. Environmental Surveillance established since 2015 did not reveal any poliovirus. The administrative coverage of the 3rd dose of oral polio vaccine (OPV3) varied across the years from 55% in 1991 to a maximum of 95% in 2007 before a progressive decrease to 86% in 2017. The percentage of AFP cases with more than 3 doses of oral polio vaccines increased from 56% in 2014 to 88% in 2017. A total of 19 supplementary immunization activities (SIA) were conducted in Madagascar from 1997 to 2017, among which 3 were subnational immunization days (sNID) and 16 were national immunization days (NIDs). Poor routine coverage contributed to the occurrence of cVDPC outbreaks in the country; addressing this should remain a key priority for the country to maintain the polio free status.

From 2015 to June 2017, Madagascar achieved the required criteria leading to the acceptance of the country’s polio-free documentation in June 2018 by ARCC. However, continuous efforts will be needed to maintain a highly sensitive polio surveillance system with emphasis on security compromised areas. Finally strengthening the health system and governance at all levels will be necessary if these achievements are to be sustained.

Conclusions: High national political commitment and support of the Global Polio Eradication Partnership were critical for Madagascar to achieve polio free status. Socio-political instability, weakness of the health system, sub-optimal routine immunization performance, insufficient SIA quality and existing security compromised areas remain critical program challenges to address in order to maintaining the polio free status. Continuous high-level advocacy should be kept in order to ensure that new government authorities maintain polio eradication among the top priorities of the country.

Abubakar Sadiq Umar¹*, Isah Mohammed Bello², Joseph Chukwudi Okeibunor ¹, Pascal Mkanda¹, Godwin Ubong Akpan¹, Daudi Manyanya², Shibeshi Messeret Eshetu², Masvikeni Brine², Matapo Belem², Masumbu Penelope², Daniel Fussum² 

¹WHO Regional Office for Africa (WHO AFRO)

²WHO East & Southern Africa Support Team (WHO ESA IST)

The use of online Integrated Supportive Supervision (ISS) is aimed to improve the quality of services provided by front line health workers. This work is aimed to document the effects of ISS on the performance of health workers in Zambia using selected key surveillance and immunization process indicators. ISS data on WHO ODK server of all Integrated Supportive Supervisory (ISS) visits that were conducted in Zambia between 1^st January 2018 to 30^th September 2018 were analysed to determine the Percentage point difference between the first and the most recent ISS visits in order to determine whether an observed gap during first ISS visit had persisted during the most recent ISS visit. Our study demonstrated that ISS has remarkable percentage point increase between the first and the most recent ISS visits on availability of an updated monitoring chart, health workers knowledge of AFP case definition and AFP case files. However, there exist variations in the frequency of ISS visits across the provinces of the country. Future research effort should consider assessing the quality of the ISS data through periodic data validation missions.

Abdi H. Ahmed¹*, Gedi Mohamed¹, Joseph Okeibunor², Iheoma Onuekwusi¹, Pascal Mkanda², Samuel Okiror³

¹WHO, Nairobi Kenya

²WHO Regional Office for Africa (WHO AFRO), Brazzaville, Congo

³WHO Horn of Africa Coordination Office (HOA), Nairobi KENYA

Background:

Poliomyelitis, often called polio is a viral paralytic disease caused by Polioviruses. Although all susceptible individuals are at risk of getting infected, only about 1% become paralyzed. During the 2013 Polio Outbreak in Garissa County in Kenya, 50% of the confirmed cases were from the nomadic population although it comprises of only less than 20% of the total population in the county. Following concerns from the Horn of Africa Polio Technical Advisory Group (TAG) regarding inadequate vaccine coverage of nomadic population, several strategies were put in place to improve coverage and Acute Flaccid Paralysis case reporting among nomads in the rest of the planned 2014 polio vaccination campaigns. We describe strategies initiated from April 2014 by the Ministry of Health and partners to reach children in nomadic settlements in the two sub-counties of Dadaab and Fafi of Garissa County.

Methods:

The strategies involved improving the mapping and tracking of the nomadic population by establishing lists of nomadic settlements obtained from local clan leaders and government administrators, their <5-year-old populations and focal persons. Focal persons were used to mobilise residents in their respective settlements and guide vaccination teams during campaigns. Settlement leaders were sensitised to report cases of Acute Flaccid Paralysis. In remote hamlets, trained community health volunteers were used as vaccinators. In such places drugs for common illness were also provided during the campaigns. A tracking tool to monitor nomadic population movement and special tally sheets to capture data were created. Training of vaccination personnel and intense social mobilisation activities was done.

Results and conclusion

About 2,000 additional children, from both nomadic and non-nomadic areas were reached when the new initiatives were started. For the first time, an actual number of nomadic children accessed was documented. Suspected AFP cases continued to be reported from nomadic settlements, and the number of zero dose children among the nonpolio AFP cases dropped. With modification and improvement, these strategies may be used to take health services such as routine immunisation to nomadic communities and reduce their vulnerability to vaccine preventable disease outbreaks.

Samuel Okiror¹*, Brigitte Toure², Bob Davis³, Rustum Hydarov², Bal Ram⁴, Joseph Okeibunor⁵, Chidiadi Nwogu¹

¹WHO Horn of Africa Coordination Office (HOA), Nairobi KENYA

²UNICEF, Nairobi Kenya

³American Red Cross, Nairobi Kenya

⁴CORE Group Regional Office Nairobi

⁵WHO Regional Office for Africa (WHO AFRO), Brazzaville, Congo

Following the outbreak of poliovirus in the countries in the Horn of Africa, Somalia, Kenya and Ethiopia, in two WHO regions, an outbreak response involving the WHO Africa and WHO East and Mediterranean Regions and partner agencies like the UNICEF in East and Southern African was developed. This paper documents response to polio virus outbreak in the Horn of Africa and the lessons learnt for the interregional and inter-agency collaboration on the response. This collaboration led to speedy interruption of the outbreak and within a period of one year the total virus load of 217 in 2013 was brought down to mere six. This resulted from collaborative planning and implementation of activities to boost the hitherto low immunity in the countries andimprove surveillance among others. A number of lesson were generated from the process. Some of the lessons is critical role such collaboration plays in ensuring simultaneous immunity boosting, information and resources sharing, among other. Some challenges were equally encountered, chiefly in the appropriation of authorities. In conclusion, however, one is safe to note that the collaboration was very fruitful given the timely interruption of transmission.

Rustam Hydarav¹, Obianuju Igweonu²*, Saumya Anand¹, Mwakisha Jemimah³, Almaz Merdekios¹, Leila Abrar¹, Joseph Okeibunor⁴, Sam Okiror⁵

¹UNICEF, Nairobi Kenya

²University of Nigeria, Nsukka

³WHO, Nairobi, Kenya

⁴WHO AFRO, Brazzaville, Congo

⁵WHO Horn of Africa Coordination Office (HOA), Nairobi KENYA

Background: Between 2013 and 2014, the Horn of Africa countries experienced a severe and prolonged outbreak of polio viruses. It started in one district in Somalia but quickly became a national and even international disaster, crossing international boundaries into Kenya and Ethiopia. This paper documents experiences in the establishment and contributions of the Polio Communication Network (PCN) to the polio outbreak response in the outbreak countries of Somalia, Kenya and Ethiopia from 2013 to 2015. Process: The establishment of the PCN network of partnerships and technical assistance was designed to implement a strategic communication response. Various strategies were used to establish the PCN. Some of these strategies included partnerships with faith-based organizations; involvement of local leaders in microplanning; social mobilization committees and research, monitoring, evaluation and documentation structures. Major Outcomes: PCN contributions through sustained high levels of community awareness of polio rounds were demonstrated. The contributions of the context-sensitive approaches included significant gains in reaching traditionally missed, hard-to-reach, pastoral communities with polio information, improved communication capacity, and successful closure of the outbreak within the expected timeline. This PCN experience provides important communication lessons relevant to polio eradication and other public health programmes. The focus on building capacity in areas such as monitoring, and data collection generated social data that led to the communication approaches making a significant impact. PCN contributed to a better understanding of the behavioral and environmental factors affecting the demand for, and uptake of, health services in the HoA which can be extended to most of the countries in the HoA with the same demographic and epidemiological realities. Conclusion: The use of the PCN helped bring the 2013-2014 polio outbreak under control and illustrates how the PCN can help drive progress towards the realization of the agenda of the universal health coverage and vision 2030 agenda in the African Region and elsewhere.

Ajiri Atagbaza¹*, Joseph Okeibunor¹, Felix Amadou², Souley Kalilou³, Aime Matela Esanga³, Adama Nanko Bagayoko³, Philbert Bohoussou³, Obianuju Igweonu⁴, Mahamat Mbodou Seid³, Ahmad Jibril Aliyu³, Elizabeth Benoit Ntezayabo⁵, Mohamed Alimou Traore⁶, Mwanza Nzioki¹, Adebola Olaleye³, Adele Daleke Lisi Aluma⁷, Djibrine Abakar Sedick³, Adam Mahamat Seid³, Mahamat Saleh Tahir³, Narcisse de Medeiros⁸, Bakoly Rabenarivo⁹, Fabien Diomande¹⁰, Pascal Mkanda¹

¹WHO Regional Office for African (WHO AFRO), Brazzaville, Congo

²WHO Consultant Lake Chad

³Ministry of Health, Chad

⁴University of Nigeria, Nsukka

⁵WHO, Chad

⁶WHO Headquarters, Geneva

⁷Independent Consultant

⁸UNICEF Dakar

⁹UNICEF, Cameroon

¹⁰CDC Atlanta

Introduction: Chad is a country within the Lake Chad sub region, currently at risk for poliovirus infection. The Lake Chad Task Team on polio eradication in this sub region made significant efforts to reduce the risk of polio transmission in Chad by tacking immunization teams in the Island Settlement using a Geographic Information System (GIS) technology. This article demonstrates the application of GIS technology to track vaccination teams to monitor immunization coverage in the Island settlements, reduce the number of missed settlements, to provide evidence for vaccination implementation and accountability and improve team performance.

Methods: In each district 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: In 2018, tracking covered 30 immunization days, in six rounds. Approximately average of 1173 Island settlements were tracked and covered in each of the six rounds. A total of 806,999 persons aged 0-10 years were immunized, out of which 4273 were zero dose cases at the point of their immunization. Tracking activities were conducted. 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 and Island settlements ensured useful information for planning and implementation of polio campaigns and enabled supervisors to evaluate performance of vaccination teams

Atagbaza Ajiri¹*, Joseph Okeibunor¹, Samuel Aiyeoribe², Benoit Ntezayabo³, Melinda Mailhot⁴, Mwanza Nzioki¹, Alimou Traore⁴, Abdelrahim Khalid², Mamadou Diallo¹, Michel Ilboudo³, Bekele Mengistu Mikeyas¹, Dhoud Samba⁵, Twite Mulunda⁶, Narcisse De Medeiros⁷, Bakoly Rabenarivo⁸, Fabien Diomande⁵, Sam Okiror⁹

¹WHO Regional Office for African (WHO AFRO), Brazzaville, Congo

²EHealth Africa

³WHO, Chad

⁴WHO, Headquarters, Geneva

⁵CDC, Atlanta

⁶Mcking Consulting Corporation

⁷UNICEF, Dakar

⁸UNICEF, Cameroon

⁹WHO Horn of Africa Coordination Office (HOA), Nairobi KENYA

The geographic information system (GIS) mapping was used to improve the efficiency of vaccination teams. This paper documents the process in the deployment of geographical information system in response to polio eradication in Chad. It started with a careful review of government official documents as well as review of literature and online resources on Chad, which confirmed that official boundaries existed at two levels, namely Regions and Districts. All settlement locations in the target Districts were identified by manual feature extraction of high-resolution, recent satellite imagery, and map layers created for the following categories: hamlets, hamlet areas, small settlements, and built-up areas (BUAs). This clearly improved microplanning and provided valuable feedback in identifying missed settlements, leading to increased coverage and fewer missed children.

Samuel Okiror¹*, Abraham Mulugeta², Iheoma Onuekwusi³, Fiona Braka⁴, Sylvesta Malengemi⁵, John Burton⁶, Rustam Hydarav⁷, Brigitte Toure⁷, Bob Davis⁸, Carolyn Gathenji¹, Chidiadi Nwogu¹, Joseph Okeibunor⁹

¹WHO Horn of Africa Coordination Office (HOA), Nairobi KENYA

²WHO, EMRO Amman

³WHO, Nairobi Kenya

⁴WHO Country Office, Nigeria

⁵WHO, Juba South Sudan

⁶UNHCR, Nairobi Kenya

⁷UNICEF, Nairobi Kenya

⁸American Red Cross, Nairobi Kenya

⁹WHO Regional Office for Africa (WHO AFRO)

Background:

There has been civil strife, spanning more than two decades in some countries and recurrent natural disasters in the Horn of Africa (HoA). This has consistently maintained these countries in chronic humanitarian conditions. More important however is the fact that these crises have also denied populations of these countries access to access to lifesaving health services. Children in the difficult terrains and security compromised areas are not given the required immunization services to build their immunity against infectious diseases like the poliovirus. This was the situation in 2013 when the large outbreaks of poliovirus occurred in the HoA. This article reviews the epidemiology, risk, and programme response to what is now famed as the 2013-204 poliovirus outbreaks in the HoA and highlights the challenges that the programme faced in interrupting poliovirus transmission here.

Methods:

A case of acute flaccid paralysis (AFP) was defined as a child <15 years of age with sudden onset of fever and paralysis. Polio cases were defined as AFP cases with stool specimens positive for WPV.

Results:

Between 2013 and 2016, when transmission was interrupted 20,266 polio viruses were in the Horn of Africa region. In response to the outbreak, several supplementary immunization activities were conducted with oral polio vaccine (OPV) The trivalent OPV was used initially, followed subsequently by bivalent OPV, and targeting various age groups, including children aged <5 years, children aged <10 years, and individuals of any age. Other response activities were undertaken to supplement the immunization in controlling the outbreak. Some of these activities included the use of various communication strategies to create awareness, sensitize and mobilize the populations against poliovirus transmission.

Conclusions:

The outbreaks were attributed to the existence of clusters of unvaccinated children due to inaccessibility to them by the health system, caused by poor geographical terrain and conflicts. The key lesson therefore is that the existence of populations with low immunity to infections will necessary constitutes breeding grounds for disease outbreak and of course reservoirs to the vectors. Though brought under reasonable control, the outbreaks indicate that the threat of large polio outbreaks resulting from poliovirus importation will remain constant unless polio transmission is interrupted in the remaining polio-endemic countries of the world.

Samuel Okiror¹*, Chidiadi Nwogu¹, Obianuju Igweonu², Rustam Hydarov³, Djiboui Karim⁴, Farkhard Imambakiev⁵, John Ogange⁶, Annet Kisakye⁷, Joseph Okeibunor⁸, Hemant Shukla⁹

¹WHO Horn of Africa Coordination Office (HOA), Nairobi KENYA

²University of Nigeria, Nsukka

³UNICEF, Nairobi

⁴WHO headquarters, Geneva

⁵UNICEF New York

⁶World Health Organization, Kenya Country Office

⁷WHO, Uganda

⁸WHO Regional Office for Africa (WHO AFRO) Brazzaville, Congo

⁹WHO Headquarters, Geneva

Background:

Poliovirus importations and related outbreaks occurred in the Horn of Africa (HoA) following an initial outbreak, which started in Somalia, spread into Kenya within ten days and later into Ethiopia and gradually to other countries in the region. National preparedness plans for responding to poliovirus introduction were insufficient in many countries of the Region. We describe a series of polio outbreak simulation exercises that were implemented to formally test polio outbreak preparedness plans in the HoA countries, as a step to interrupting further transmission.

Methods:

The Polio Outbreak Simulation Exercises (POSEs) were designed and implemented. The results were evaluated and recommendations made. The roles of outbreak simulation exercises in maintaining regional polio-free status were assessed. In addition, we performed a comprehensive review of the national plans of all for seven countries in the HoA Region.

Results:

Seven simulation exercises, delivered between 2016 and 2017 revealed that participating countries were generally prepared for poliovirus introduction, but the level of preparedness needed improvement. The areas in particular need of strengthening were national preparedness plans, initial response, plans for securing vaccine supply, and communications.

Conclusions:

Polio outbreak simulation exercises can be valuable tools to help maintain polio-free status and should be extended to other high-risk countries and subnational areas in the HoA Region and elsewhere. There is also need to standardize the process and methods for conducting POSE for comparability.

Chidiadi Nwogu¹*, Johnny Musyoka², Carolyne Gathenji ¹, Rosemary Nzunza⁴, Iheoma Onuekwusi³, Joseph Okeibunor⁵, Pascal Mkanda⁵, Hemant Shukla¹, Shaikh Humayun Kabir¹, Sam O Okiror¹

¹¹WHO Horn of Africa Coordination Office (HOA), Nairobi, Kenya

²Ministry of Health (MoH), Nairobi, Kenya

³WHO, Nairobi, Kenya

⁴Kenya Medical Research Institute (KEMRI), Nairobi, Kenya

⁵WHO Regional Office for Africa, Brazzaville, Congo

Background:

Globally, tremendous improvement has been made in Polio eradication since its inception in 1988. For the third time in a decade, Kenya has experienced a Polio outbreak along the border with Somalia. The affected areas were in Garissa County, replete with previous occurrences in 2006 and 2012. This article, give an account of series of events and activities that were used to stop the transmission within 13 weeks, an interval between the first and the last case of the 2013 outbreak.

Methods:

In an attempt to stop further transmission and time bound closure of the outbreak, many activities were brought to fore: the known traditional methods, innovative approaches, improved finances and surge capacity. These assisted in case detection, implementation, and coordination of activities. The external outbreak assessments and the six-monthly technical advisory group recommendations were also employed.

Result:

There were increased case detections of >=2/100,000, stool adequacy >=80%, due to enhanced surveillance, timely feedbacks from laboratory investigation and diagnosis. Sustained coverage in supplemental immunisation of > 90%, ensured that immune profile of >=3 polio vaccine doses was quickly attained to protect the targeted population, prevent further polio infection and eventual reduction of cases coming up with paralysis.

Conclusion:

Overall, the outbreak was stopped within the 120 days of the first case using 14 rounds of supplemental immunisation activities.

Vijairam Selvaraj^1,2*, Anneliese Beaubrun^1,2, Shenjun Zhu^1,2, Kwame Dapaah-Afriyie^1,2

¹Division of Hospital Medicine, The Miriam Hospital, Providence, Rhode Island.

²Warren Alpert Medical School of Brown University, Providence, Rhode Island.