Surveillance of acute flaccid paralysis in Akwa Ibom State, Nigeria 2004–2009

Introduction: The last case of wild polio virus transmission occurred in Akwa Ibom state in October 2001; however, combination high routine immunization coverage with OPV, high quality AFP surveillance, mass immunization campaign in which two doses of potent oral polio vaccine is administered to eligible children and mop-up campaigns in areas with identified immunization or surveillance gaps has help the state in maintaining a free polio status for over ten years. This study was carried out to describe the characteristics of reported acute flaccid paralysis cases between 2004 and 2009, and to evaluate the performance of the acute flaccid paralysis surveillance system using indicators recommended by the World Health Organization. Methods: A retrospective study was conducted among children, 0-15 years, by the World Health Organization (WHO) and Epidemiology unit of State Ministry of Health (SMOH), Uyo. The demographic characteristics and the results of isolation and identification of polio and other enteroviruses in stool samples sent to the WHO Polio Laboratory Ibadan for cases was analyzed. Results: A total of 521 cases of AFP (270 males and 251 females) aged 0 month to = 15 years were reported by the surveillance system between 2004 and 2009. Those below 5 years of age accounted for 82.5% of cases reported and investigated. Of the 521 cases investigated 512 (98.3%) received at least three doses of oral polio vaccine, while 9(1.7) never received any oral polio vaccine (zero-dose). In all 5.1% of the isolates were Sabin, 7.9% non polio enterovirus (NPEV) and 2.3% were classified by national expert committee as compatible with poliomyelitis. There was consistent and steady increase in three critical indicators; Non polio AFP rate in children <15 years from 4.5 to 6.4 per 100 000 population, proportion of AFP cases with 2 stool specimens collected within 14 days of onset of paralysis from 57% in 2005 to 91% in 2009 and proportion of Local Government Areas (Districts) meeting both core indicators from 23% in 2005 to 87% in 2009. The highest numbers of cases were seen in the months of March, May and September. Conclusion: This study showed high levels of surveillance performance with some challenges in reverse the cold chain system, the continuation and sustained AFP case detection, prompt investigation and response, improvement in the reserve cold chain system would achieve optimal standards recommended by WHO and might provide a good model for the eradication of poliomyelitis.Key words: Acute flaccid paralysis, Surveillance, Poliomyelitis, Nigeri

Key issues in the persistence of poliomyelitis in Nigeria: a case-control study

Background The completion of poliomyelitis eradication is a global emergency for public health. In 2012, more than 50% of the world’s cases occurred in Nigeria following an unanticipated surge in incidence. We aimed to quantitatively analyse the key factors sustaining transmission of poliomyelitis in Nigeria and to calculate clinical effi cacy estimates for the oral poliovirus vaccines (OPV) currently in use. Methods We used acute fl accid paralysis (AFP) surveillance data from Nigeria collected between January, 2001, and December, 2012, to estimate the clinical effi cacies of all four OPVs in use and combined this with vaccination coverage to estimate the eff ect of the introduction of monovalent and bivalent OPV on vaccine-induced serotype-specifi c population immunity. Vaccine effi cacy was determined using a case-control study with CIs based on bootstrap resampling. Vaccine effi cacy was also estimated separately for north and south Nigeria, by age of the children, and by year. Detailed 60-day follow-up data were collected from children with confi rmed poliomyelitis and were used to assess correlates of vaccine status. We also quantitatively assessed the epidemiology of poliomyelitis and programme performance and considered the reasons for the high vaccine refusal rate along with risk factors for a given local government area reporting a case. Findings Against serotype 1, both monovalent OPV (median 32·1%, 95% CI 26·1–38·1) and bivalent OPV (29·5%, 20·1–38·4) had higher clinical effi cacy than trivalent OPV (19·4%, 16·1–22·8). Corresponding data for serotype 3 were 43·2% (23·1–61·1) and 23·8% (5·3–44·9) compared with 18·0% (14·1–22·1). Combined with increases in coverage, this factor has boosted population immunity in children younger than age 36 months to a record high (64–69% against serotypes 1 and 3). Vaccine effi cacy in northern states was estimated to be signifi cantly lower than in southern states (p≤0·05). The proportion of cases refusing vaccination decreased from 37–72% in 2008 to 21–51% in 2012 for routine and supplementary immunisation, and most caregivers cited ignorance of either vaccine importance or availability as the main reason for missing routine vaccinations (32·1% and 29·6% of cases, respectively). Multiple regression analyses highlighted associations between the age of the mother, availability of OPV at health facilities, and the primary source of health information and the probability of receiving OPV (all p<0·05). Interpretation Although high refusal rates, low OPV campaign awareness, and heterogeneous population immunity continued to support poliomyelitis transmission in Nigeria at the end of 2012, overall population immunity had improved due to new OPV formulations and improvements in programme delivery.Funding Bill & Melinda Gates Foundation Vaccine Modeling Initiative, Royal Society.Introduction In May, 2012, after more than 20 years of mass vaccination campaigns, the 65t

Enhancing capacity of Zimbabwe’s health system to respond to climate change induced drought: a rapid nutritional assessment

Introduction:&nbsp;Zimbabwe experienced the negative effects of the devastating cyclone Idai which affected several districts in the country, and the drought due to low rainfall that has affected the whole country. As a result of these catastrophes, the food and nutrition security situation in the country has deteriorated. For this reason, we carried out a rapid assessment of the health facilities in 19 sampled high global acute malnutrition and high food insecurity districts from the ten provinces of Zimbabwe to ascertain the preparedness of the facilities to respond to drought effects. Methods:&nbsp;we conducted a rapid nutritional assessment in 19 purposely selected districts with highest rates of global acute malnutrition from the 10 provinces of Zimbabwe. From these districts, we selected a district hospital and a rural health facility with high number of acute malnutrition cases. We adapted and administered the WHO recommended checklist (Multi-Cluster/Sector Initial Rapid Assessment (MIRA) as the assessment tool. We used STATA to generate frequencies, and proportions. Results:&nbsp;about 94% (16/19) of the districts had less than 50% health workers trained to manage acute malnutrition. A total of 26% (5/19) of the district hospitals and 32% (6/19) of the primary health care facilities were not admitting according to integrated management of acute malnutrition (IMAM) protocol. Twelve districts (63%) had none of their staff trained in infant and young child feeding (IYCF), 58% (11/19) had no staff trained in growth monitoring and 63% (12/19) of the districts had no trained staff in baby friendly hospital initiative (BFHI). A total of 60% of the provinces did not have combined mineral vitamin mix stocks, 80% had no resomal stocks, 20% did not have micronutrient powder stocks and 30% had no ready to use supplementary food stocks in all their assessed facilities. Fifty percent (50%) of the health facilities were not adequately stocked with growth monitoring cards. Manicaland had the least (20%) number of health facility with a registration system to notify cases of malnutrition. Conclusion:&nbsp;we concluded that the Zimbabwe health delivery system is not adequately prepared to respond to the effects of the current drought as most health workers had inadequate capacity to manage acute malnutrition, the nutrition surveillance was weak and inadequate stocks of commodities and anthropometric equipment was noted. Following this, health workers from six of ten provinces were trained on management of acute malnutrition, procurement of some life -saving therapeutic and supplementary foods was done. We further recommend food fortification as a long-term plan, active screening for early identification of malnutrition cases and continuous training of health workers

Implementing infection prevention and control capacity building strategies within the context of Ebola outbreak in a "Hard-to-Reach" area of Liberia

Introduction:&nbsp;in August 2014, WHO declared that Ebola outbreak ravaging West Africa including Liberia had become a Public Health Emergency of International Concern (PHEIC). Infection prevention and control (IPC) among healthcare workers was pivotal in reducing healthcare worker infection and containing the recent EVD outbreak. Hard to reach areas (HTRA) presents peculiar challenges in public health emergencies. We present the result of IPC capacity building strategies deployed in Gbarpolu County: an HTRA of Liberia. Methods:&nbsp;between April to October 2015, we conducted IPC training and mentorship at the county, district and facility levels in a selected HTRA of Liberia using the keep Safe, Keep Serving manual and the WHO core components of infection control. Serial follow-up assessments and mentoring using the Liberian Minimum standard tool for safe care in Liberian health facilities (MST) were done. Results:&nbsp;180 (100%) facility based healthcare workers were trained: including 59 clinicians (32%) and 121 (67%) non-clinicians. 100% of the healthcare workers in four selected very HTRAs were trained and underwent facility based-mentorship. Compliance with IPC practice increased: the MST score increased from 75% to 90% and for the MST score for waste management and isolation increased 60% to 87%. Conclusion:&nbsp;strengthening the capacity of healthcare workers for IPC was instrumental for containing the EVD epidemic but also critical for routine safe and quality services. A culture of IPC among healthcare workers in HTRA can be implemented through capacity building and training

Establishing Ebola Virus Disease (EVD) diagnostics using GeneXpert technology at a mobile laboratory in Liberia: Impact on outbreak response, case management and laboratory systems strengthening.

The 2014-16 Ebola Virus Disease (EVD) outbreak in West Africa highlighted the necessity for readily available, accurate and rapid diagnostics. The magnitude of the outbreak and the re-emergence of clusters of EVD cases following the declaration of interrupted transmission in Liberia, reinforced the need for sustained diagnostics to support surveillance and emergency preparedness. We describe implementation of the Xpert Ebola Assay, a rapid molecular diagnostic test run on the GeneXpert platform, at a mobile laboratory in Liberia and the subsequent impact on EVD outbreak response, case management and laboratory system strengthening. During the period of operation, site coordination, management and operational capacity was supported through a successful collaboration between Ministry of Health (MoH), World Health Organization (WHO) and international partners. A team of Liberian laboratory technicians were trained to conduct EVD diagnostics and the laboratory had capacity to test 64-100 blood specimens per day. Establishment of the laboratory significantly increased the daily testing capacity for EVD in Liberia, from 180 to 250 specimens at a time when the effectiveness of the surveillance system was threatened by insufficient diagnostic capacity. During the 18 months of operation, the laboratory tested a total of 9,063 blood specimens, including 21 EVD positives from six confirmed cases during two outbreaks. Following clearance of the significant backlog of untested EVD specimens in November 2015, a new cluster of EVD cases was detected at the laboratory. Collaboration between surveillance and laboratory coordination teams during this and a later outbreak in March 2016, facilitated timely and targeted response interventions. Specimens taken from cases during both outbreaks were analysed at the laboratory with results informing clinical management of patients and discharge decisions. The GeneXpert platform is easy to use, has relatively low running costs and can be integrated into other national diagnostic algorithms. The technology has on average a 2-hour sample-to-result time and allows for single specimen testing to overcome potential delays of batching. This model of a mobile laboratory equipped with Xpert Ebola test, staffed by local laboratory technicians, could serve to strengthen outbreak preparedness and response for future outbreaks of EVD in Liberia and the region

Timely Detection of SARS-CoV-2 in Limited Resource Settings: The Role of the Laboratory in Zimbabwe

The recommended approach for response to severe acute respiratory syndrome coronavirus 2, was to test to enable timely detection, isolation and contact tracing so as to reduce the rapid spread of the disease. This highlighted that the laboratory as one of the core capacities of the International Health Regulations and key technical area in the International Health Security was critical in curbing the spread of the virus. Zimbabwe embarked on testing for SARS-CoV-2 in February 2020 following the guidance and support from WHO leveraging the existing testing capacity. Testing was guided by a laboratory pillar which constituted members from different organizations partnering with the Ministry of Health and Child Care. SARS-CoV-2 testing expansion was based on a phased approach using a tiered system in which laboratory staff from lower tiers were seconded to test for coronavirus using RT-PCR with National Microbiology Reference Laboratory (NMRL) being the hub for centralized consolidation of all results. As the pandemic grew nationally, there was an increase in testing per day and reduction in turnaround time as five laboratories were fully capacitated to test using RT-PCR open platforms, thirty-three provincial and district laboratories to test using TB GeneXpert and 5 provincial laboratories to use Abbott platforms

Ebola virus disease in West Africa — the first 9 Months of the epidemic and forward projections

BACKGROUND On March 23, 2014, the World Health Organization (WHO) was notified of an outbreak of Ebola virus disease (EVD) in Guinea. On August 8, the WHO declared the epidemic to be a "public health emergency of international concern." METHODS By September 14, 2014, a total of 4507 probable and confirmed cases, including 2296 deaths from EVD (Zaire species) had been reported from five countries in West Africa - Guinea, Liberia, Nigeria, Senegal, and Sierra Leone. We analyzed a detailed subset of data on 3343 confirmed and 667 probable Ebola cases collected in Guinea, Liberia, Nigeria, and Sierra Leone as of September 14. RESULTS The majority of patients are 15 to 44 years of age (49.9% male), and we estimate that the case fatality rate is 70.8% (95% confidence interval [CI], 69 to 73) among persons with known clinical outcome of infection. The course of infection, including signs and symptoms, incubation period (11.4 days), and serial interval (15.3 days), is similar to that reported in previous outbreaks of EVD. On the basis of the initial periods of exponential growth, the estimated basic reproduction numbers (R-0) are 1.71 (95% CI, 1.44 to 2.01) for Guinea, 1.83 (95% CI, 1.72 to 1.94) for Liberia, and 2.02 (95% CI, 1.79 to 2.26) for Sierra Leone. The estimated current reproduction numbers (R) are 1.81 (95% CI, 1.60 to 2.03) for Guinea, 1.51 (95% CI, 1.41 to 1.60) for Liberia, and 1.38 (95% CI, 1.27 to 1.51) for Sierra Leone; the corresponding doubling times are 15.7 days (95% CI, 12.9 to 20.3) for Guinea, 23.6 days (95% CI, 20.2 to 28.2) for Liberia, and 30.2 days (95% CI, 23.6 to 42.3) for Sierra Leone. Assuming no change in the control measures for this epidemic, by November 2, 2014, the cumulative reported numbers of confirmed and probable cases are predicted to be 5740 in Guinea, 9890 in Liberia, and 5000 in Sierra Leone, exceeding 20,000 in total. CONCLUSIONS These data indicate that without drastic improvements in control measures, the numbers of cases of and deaths from EVD are expected to continue increasing from hundreds to thousands per week in the coming months

Outbreak of Type 2 Vaccine-Derived Poliovirus in Nigeria: Emergence and Widespread Circulation in an Underimmunized Population

Wild poliovirus has remained endemic in northern Nigeria because of low coverage achieved in the routine immunization program and in supplementary immunization activities (SIAs). An outbreak of infection involving 315 cases of type 2 circulating vaccine-derived poliovirus (cVDPV2; >1% divergent from Sabin 2) occurred during July 2005–June 2010, a period when 23 of 34 SIAs used monovalent or bivalent oral poliovirus vaccine (OPV) lacking Sabin 2. In addition, 21 “pre-VDPV2” (0.5%–1.0% divergent) cases occurred during this period. Both cVDPV and pre-VDPV cases were clinically indistinguishable from cases due to wild poliovirus. The monthly incidence of cases increased sharply in early 2009, as more children aged without trivalent OPV SIAs. Cumulative state incidence of pre-VDPV2/cVDPV2 was correlated with low childhood immunization against poliovirus type 2 assessed by various means. Strengthened routine immunization programs in countries with suboptimal coverage and balanced use of OPV formulations in SIAs are necessary to minimize risks of VDPV emergence and circulation

Reduced evolutionary rate in reemerged Ebola virus transmission chains

On 29 June 2015, Liberia’s respite from Ebola virus disease (EVD) was interrupted for the second time by a renewed outbreak (“flare-up”) of seven confirmed cases. We demonstrate that, similar to the March 2015 flare-up associated with sexual transmission, this new flare-up was a reemergence of a Liberian transmission chain originating from a persistently infected source rather than a reintroduction from a reservoir or a neighboring country with active transmission. Although distinct, Ebola virus (EBOV) genomes from both flare-ups exhibit significantly low genetic divergence, indicating a reduced rate of EBOV evolution during persistent infection. Using this rate of change as a signature, we identified two additional EVD clusters that possibly arose from persistently infected sources. These findings highlight the risk of EVD flare-ups even after an outbreak is declared over