Local discrepancies in measles vaccination opportunities: results of population-based surveys in Sub-Saharan Africa

BMC Public Health
(Accessed 22 February 2014)

Research article
Local discrepancies in measles vaccination opportunities: results of population-based surveys in Sub-Saharan Africa
Lise Grout, Nolwenn Conan, Aitana Juan Giner, Northan Hurtado, Florence Fermon, Alexandra N¿Goran, Emmanuel Grellety, Andrea Minetti, Klaudia Porten and Rebecca F Grais
Author Affiliations
BMC Public Health 2014, 14:193  doi:10.1186/1471-2458-14-193
Published: 21 February 2014

Abstract (provisional)
The World Health Organization recommends African children receive two doses of measles containing vaccine (MCV) through routine programs or supplemental immunization activities (SIA). Moreover, children have an additional opportunity to receive MCV through outbreak response immunization (ORI) mass campaigns in certain contexts. Here, we present the results of MCV coverage by dose estimated through surveys conducted after outbreak response in diverse settings in Sub-Saharan Africa. .

We included 24 household-based surveys conducted in six countries after a non-selective mass vaccination campaign. In the majority (22/24), the survey sample was selected using probability proportional to size cluster-based sampling. Others used Lot Quality Assurance Sampling.

In total, data were collected on 60,895 children from 2005 to 2011. Routine coverage varied between countries (>95% in Malawi and Kirundo province (Burundi) while <35% in N’Djamena (Chad) in 2005), within a country and over time. SIA coverage was <75% in most settings. ORI coverage ranged from >95% in Malawi to 71.4% [95%CI: 68.9-73.8] in N’Djamena (Chad) in 2005.

In five sites, >5% of children remained unvaccinated after several opportunities. Conversely, in Malawi and DRC, over half of the children eligible for the last SIA received a third dose of MCV.

Control pre-elimination targets were still not reached, contributing to the occurrence of repeated measles outbreak in the Sub-Saharan African countries reported here. Although children receiving a dose of MCV through outbreak response benefit from the intervention, ensuring that programs effectively target hard to reach children remains the cornerstone of measles control.

Research article Systematic review on what works, what does not work and why of implementation of mobile health (mHealth) projects in Africa

BMC Public Health
(Accessed 22 February 2014)

Research article
Systematic review on what works, what does not work and why of implementation of mobile health (mHealth) projects in Africa
Clara B Aranda-Jan, Neo Mohutsiwa-Dibe and Svetla Loukanova
Author Affiliations
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BMC Public Health 2014, 14:188  doi:10.1186/1471-2458-14-188
Published: 21 February 2014

Abstract (provisional)
Access to mobile phone technology has rapidly expanded in developing countries. In Africa, mHealth is a relatively new concept and questions arise regarding reliability of the technology used for health outcomes. This review documents strengths, weaknesses, opportunities, and threats (SWOT) of mHealth projects in Africa.

A systematic review of peer-reviewed literature on mHealth projects in Africa, between 2003 and 2013, was carried out using PubMed and OvidSP. Data was synthesized using a SWOT analysis methodology. Results were grouped to assess specific aspects of project implementation in terms of sustainability and mid/long-term results, integration to the health system, management process, scale-up and replication, and legal issues, regulations and standards.

Forty-four studies on mHealth projects in Africa were included and classified as: “patient follow-up and medication adherence” (n = 19), “staff training, support and motivation” (n = 2), “staff evaluation, monitoring and guidelines compliance” (n = 4), “drug supply-chain and stock management” (n = 2), “patient education and awareness” (n = 1), “disease surveillance and intervention monitoring” (n = 4), “data collection/transfer and reporting” (n = 10) and “overview of mHealth projects” (n = 2). In general, mHealth projects demonstrate positive health-related outcomes and their success is based on the accessibility, acceptance and low-cost of the technology, effective adaptation to local contexts, strong stakeholder collaboration, and government involvement. Threats such as dependency on funding, unclear healthcare system responsibilities, unreliable infrastructure and lack of evidence on cost-effectiveness challenge their implementation. mHealth projects can potentially be scaled-up to help tackle problems faced by healthcare systems like poor management of drug stocks, weak surveillance and reporting systems or lack of resources.

mHealth in Africa is an innovative approach to delivering health services. In this fast-growing technological field, research opportunities include assessing implications of scaling-up mHealth projects, evaluating cost-effectiveness and impacts on the overall health system.

The polio eradication end game: what it means for Europe

Volume 19, Issue 7, 20 February 2014

The polio eradication end game: what it means for Europe
D Heymann 1,2, Q Ahmed3
–       London School of Hygiene and Tropical Medicine, London, United Kingdom
–       Chatham House Centre on Global Health Security, London United Kingdom
–       State University of New York (SUNY) at Stony Brook, New York, United States

This edition of Eurosurveillance provides a series of articles related to polio that present a microcosm of some of the issues that have plagued polio eradication since the programme first began, and it also provides many of the solutions.

Had these and other issues been clearly understood in 1988 when the World Health Assembly passed the resolution that committed all countries to polio eradication by the year 2000, the decision to eradicate would have been more difficult. But fortunately, buoyed by the then recent success in the eradication of smallpox, active debate on whether to use inactivated or live polio vaccines, awareness that many countries had already interrupted polio transmission, and unawareness of the difficult eradication end game, the resolution was passed by consensus of the World Health Organization (WHO)’s member states [1]. Although progress towards eradication has been slower than anticipated in 1988, paralytic polio has decreased from an estimated 1,000 children per day during 1988, to approximately 400 during 2013. Today there remain only three countries with endemic polio, Afghanistan, Nigeria and Pakistan, and the recent risk assessment from the European Centre for Disease Prevention and Control (ECDC) reminds us that Europe must remain vigilant with strong surveillance and sustained laboratory capacity [2].

The series of polio articles in this edition begins with the article by Hindiyeh et al. [3] describing direct sewage testing for wild poliovirus antigen, using a multiplex quantitative reverse-transcription PCR (qRT-PCR) for rapid detection of the virus, directly on concentrated sewage samples. When compared to cell culture of the same sewage specimens, which is the initial process in the gold standard testing protocol for confirmation of polio, sensitivity and specificity of the multiplex system were shown to be high. Results were obtained in 24 to 48 hours, rather than the usual five to seven days required for the culture-based protocol.

The time from collection of a stool sample to analysis for polio virus in polio eradication programmes has often been weeks, not days, causing delays in response, more widespread transmission, and greater and more costly containment efforts. Recently though, times from specimen collection to outbreak control have decreased considerably by strengthening transport systems from the field to the laboratory, and modifying the testing protocol [4]. At the same time, there is active research and development of new testing algorithms that can provide more rapid results [5]. Hindiyeh et al. have concluded that their qRT-PCR system could be a promising application for testing of RNA extracted directly from processed stool samples from children with acute flaccid paralysis (AFP), and it remains to be seen whether further study will be conducted along these lines [3].

The article by Manor et al. [6] describes the discovery of a silent introduction of wild poliovirus, in the absence of detection of AFP in children (the standard surveillance methodology), by what they describe as an early warning system of sewage monitoring for poliovirus. They point out that this silent introduction occurred in a highly immune population in which inactivated polio vaccine (IPV) has been used exclusively since 2005, and that AFP surveillance alone had not detected this introduction and circulation. The authors suggest that there is a fundamental role for environmental surveillance in routine monitoring as an early warning system in polio-free countries, possibly more sensitive than surveillance for AFP. Shulman et al. [7] add greater perspective in their report on genetic sequencing of these wild polioviruses. It suggests that they were linked to strains that were circulating in South Asia and Egypt in 2012 and concludes that there had been one, or perhaps more than one, importation event.

Indeed, environmental monitoring in sewage has been used by many countries during the past decade, and it has identified wild poliovirus imported in 2007 to Switzerland from Chad, and in 2013 to Egypt from Pakistan [8,9]. Environmental surveillance has been a mainstay of polio eradication in several developing countries as well, for example in Egypt and India, and its wider role in the polio eradication end game continues to be assessed [10].
Van der Maas et al. [11] and Yakovenko et al. [12] discuss the importance of maintaining high polio immunity levels in order to prevent re-establishment of circulation of wild poliovirus, and the vulnerability of countries with lower than optimal population immunity in the general population or with pockets of low coverage such as those in certain religious and other groups. They clearly call attention to the fact that the circulation of wild poliovirus in one country is a threat to all others, and that vaccination coverage, using either IVP or oral polio vaccine (OPV), must be maintained until the circulation of all wild poliovirus has been interrupted. Yakovenko et al. also underscore the fact that adults are at risk from imported polio virus, having isolated wild poliovirus from adults with AFP in the Tajikistan outbreak [12].
A recent polio outbreak also provided a clear demonstration that adults are at risk of paralytic polio during outbreaks. Because adult populations in Namibia had not been vaccinated against polio in the period before independence, and had not developed immunity by exposure to poliovirus because of high quality water and sanitation systems, an importation of wild poliovirus led to an outbreak of paralytic polio in adults in 2006 [13].
Other issues that have been important to polio eradication such as circulating vaccine derived poliovirus (cVDPD) are not discussed in this series, although the ease with which the poliovirus recombines in nature was demonstrated by studies of viral sequences in the Tajikistan outbreak [12]. However, this omission from the series does not minimise the importance of cVDPV as a challenge to polio eradication that the end game will take into account [14]. The decision in Israel to reintroduce OPV after failure to interrupt transmission with IPV, foretells the complexity the end game will face in the event of a reintroduction after eradication has occurred. Outbreak containment strategies for all countries are actively being assessed for application during the post-eradication period [15].
Although solutions to most of the technical problems in polio eradication are either available or under development, risk communication and gaining trust in polio vaccination in the absence of paralytic disease remain a major challenge. This is clearly demonstrated by the experience described by Kaliner et al. [16] in developing trust and paving the way for the supplementary immunisation activities that reintroduce OPV several years after having switched to IPV in routine vaccination programmes.
The importance of trust and risk communication has likewise been clearly demonstrated in the past, when in 2003 polio vaccination was stopped in northern Nigeria because of false rumours, many of which were circulating on the world wide web, that the vaccine was being used in a plot by some Western nations to permanently sterilise young Muslim girls, and in some instances that it was associated with the introduction of AIDS [17]. Although there may have been other reasons than concern over vaccine safety, the governor of one northern state in Nigeria interrupted polio eradication activities, and other northern Nigerian states followed. Within months, polio had spread from Nigeria to neighbouring countries, to Saudi Arabia and Yemen, and from there on to Indonesia [18].

All of the countries affected were members of the Organization of the Islamic Conference who, at their October 2003 summit in Malaysia, adopted a resolution that endorsed and promoted stronger polio eradication activities [19]. Religious leaders became involved as well, and promoted polio vaccination through a series of fatwas and other declarations. Countries that had been free of polio, again had children paralysed by poliovirus, and increased their surveillance and conducted supplementary immunisation activities to prevent the virus from becoming endemic again. They were successful in containing wild poliovirus and interrupting its transmission, but at great financial cost to the countries and the polio partnership.

This series of articles on polio is a timely reminder that polio eradication has not yet been completed, and they confirm that eradication is technically feasible. But obstacles to polio eradication remain. Killings of polio workers in Pakistan and northern Nigeria have caused fear among polio workers, and pose a risk to the life of those who vaccinate door to door. These incidents have prompted a call for action from the Muslim world to counter opposition to the polio eradication programme recently published in The Lancet [20].

Civil unrest, such as that caused by the killing of polio workers, has occurred in the past, but was never targeted specifically at polio eradication. In Sudan in 2005, for example, the United Nations called for days of tranquillity so that polio and other vaccinations could continue [21].      But the solution to violence targeted at the global eradication of polio and at vaccination programmes in general, requires more than vaccine supplies, door-to-door vaccination, and meticulous surveillance. It requires collective ownership and solidarity by all countries, and it may need a prominent and accepted figure in all countries where opposition has been observed, to step forward as a leader and bring polio eradication to completion.

In the meantime, European countries must continue to maintain high levels of polio vaccination coverage, and sustained surveillance of AFP with laboratory support, in order to ensure that wild poliovirus, if imported, is rapidly detected and completely contained.

Note from the editors: Polio – good news and bad news
by Eurosurveillance editorial team

Research articles
Development and validation of a real time quantitative reverse transcription-polymerase chain reaction (qRT-PCR) assay for investigation of wild poliovirus type 1-South Asian (SOAS) strain reintroduced into Israel, 2013 to 2014
by MY Hindiyeh, J Moran-Gilad, Y Manor, D Ram, LM Shulman, D Sofer, E Mendelson

Molecular epidemiology of silent introduction and sustained transmission of wild poliovirus type 1, Israel, 2013
by LM Shulman, E Gavrilin, J Jorba, J Martin, CC Burns, Y Manor, J Moran-Gilad, D Sofer, MY Hindiyeh, R Gamzu, E Mendelson, I Grotto, for the Genotype – Phenotype Identification (GPI) group

Immunity against poliomyelitis in the Netherlands, assessed in 2006 to 2007: the importance of completing a vaccination series
by NA van der Maas, L Mollema, GA Berbers, DM van Rooijen, HG van der Avoort, MA Conyn-Van Spaendonck, HE de Melker, FR van der Klis

Surveillance and outbreak reports
Intensified environmental surveillance supporting the response to wild poliovirus type 1 silent circulation in Israel, 2013
by Y Manor, LM Shulman, E Kaliner, M Hindiyeh, D Ram, D Sofer, J Moran-Gilad, B Lev, I Grotto, R Gamzu, E Mendelson

The 2010 outbreak of poliomyelitis in Tajikistan: epidemiology and lessons learnt
by ML Yakovenko, AP Gmyl, OE Ivanova, TP Eremeeva, AP Ivanov, MA Prostova, OY Baykova, OV Isaeva, GY Lipskaya, AK Shakaryan, OM Kew, JM Deshpande, VI Agol

Silent reintroduction of wild-type poliovirus to Israel, 2013 – risk communication challenges in an argumentative atmosphere
by E Kaliner, J Moran-Gilad, I Grotto, E Somekh, E Kopel, M Gdalevich, E Shimron, Y Amikam, A Leventhal, B Lev, R Gamzu

Expanding the scope of medical mission volunteer groups to include a research component

Globalization and Health
[Accessed 22 February 2014]

Expanding the scope of medical mission volunteer groups to include a research component
John Rovers, Michael Andreski, John Gitua, Abdoulaye Bagayoko and Jill DeVore
Author Affiliations
Globalization and Health 2014, 10:7  doi:10.1186/1744-8603-10-7
Published: 20 February 2014

Abstract (provisional)
Serving on volunteer groups undertaking medical mission trips is a common activity for health care professionals and students. Although volunteers hope such work will assist underserved populations, medical mission groups have been criticized for not providing sustainable health services that focus on underlying health problems. As members of a volunteer medical mission group, we performed a bed net indicator study in rural Mali. We undertook this project to demonstrate that volunteers are capable of undertaking small-scale research, the results of which offer locally relevant results useful for disease prevention programs. The results of such projects are potentially sustainable beyond the duration of a mission trip.

Volunteers with Medicine for Mali interviewed 108 households in Nana Kenieba, Mali during a routine two-week medical mission trip. Interviewees were asked structured questions about family demographics, use of insecticide treated bed nets the previous evening, as well as about benefits of net use and knowledge of malaria. Survey results were analyzed using logistic regression.

We found that 43.7% of households had any family member sleep under a bed net the previous evening. Eighty seven percent of households owned at least one ITN and the average household owned 1.95 nets. The regression model showed that paying for a net was significantly correlated with its use, while low perceived mosquito density, obtaining the net from the public sector and more than four years of education in the male head of the household were negatively correlated with net use. These results differ from national Malian data and peer-reviewed studies of bed net use.

We completed a bed net study that provided results that were specific to our service area. Since these results were dissimilar to peer-reviewed literature and Malian national level data on bed net use, the results will be useful to develop locally specific teaching materials on malaria prevention. This preventive focus is potentially more sustainable than clinical services for malaria treatment. Although we were not able to demonstrate that our work is sustainable, our study shows that volunteer groups are capable of undertaking research that is relevant to their service area.

Regional variation in the allocation of development assistance for health

Globalization and Health
[Accessed 22 February 2014]

Short report
Regional variation in the allocation of development assistance for health
Michael Hanlon, Casey M Graves, Benjamin PC Brooks, Annie Haakenstad, Rouselle Lavado, Katherine Leach-Kemon and Joseph L Dieleman
Author Affiliations
Globalization and Health 2014, 10:8  doi:10.1186/1744-8603-10-8
Published: 20 February 2014

Abstract (provisional)
The Global Burden of Disease (GBD) 2010 Study has published disability-adjusted life year (DALY) data at both regional and country levels from 1990 to 2010. Concurrently, the Institute for Health Metrics and Evaluation (IHME) has published estimates of development assistance for health (DAH) at the country-disease level for this same period of time.

We use disease burden data from the GBD 2010 study and financing data from IHME to calculate ratios of DAH to DALYs across regions and diseases. We examine the magnitude of these ratios and how they have varied over time. We hypothesize that the variation in this ratio across regions would be relatively small. However, from 2006 to 2010, we find there was considerable variation in the levels of DAH per DALY across regions. For total funding, the relative standard deviation (standard deviation as a percentage of the mean) across regions was 50%. For DAH specific to HIV/AIDS, malaria and tuberculosis, the relative standard deviations were 50%, 200% and 60%, respectively. While these deviations are high, with the exception of malaria, they have decreased since the 1990s.

There are no evident explanations for so much variation in funding across regions, especially holding the purpose of the funding constant. This suggests donors’ allocation processes have not been particularly sensitive to disease burdens. To maximize health gains, donors should explicitly incorporate new disease burden data along with the relative costs and efficacy of interventions into their allocation process.

Meningococcal vaccine introduction in Mali through mass campaigns and its impact on the health system

Global Health: Science and Practice (GHSP)
February 2014 | Volume 2 | Issue 1

Meningococcal vaccine introduction in Mali through mass campaigns and its impact on the health system
Sandra Mounier-Jacka, Helen Elizabeth Denise Burchetta, Ulla Kou Griffithsa, Mamadou Konateb, Kassibo Sira Diarrab
Author Affiliations
aLondon School of Hygiene & Tropical Medicine, London, UK
bIndependent Consultant, Bamako, Mali
The meningococcal A vaccine campaign led to major disruption of routine vaccination services and reduced other services, notably antenatal care.

Objective: To evaluate the impact of the meningococcal A (MenA) vaccine introduction in Mali through mass campaigns on the routine immunization program and the wider health system.

Methods: We used a mixed-methods case-study design, combining semi-structured interviews with 31 key informants, a survey among 18 health facilities, and analysis of routine health facility data on number of routine vaccinations and antenatal consultations before, during, and after the MenA vaccine campaign in December 2010. Survey and interview data were collected at the national level and in 2 regions in July and August 2011, with additional interviews in January 2012.

Findings: Many health system functions were not affected—either positively or negatively—by the MenA vaccine introduction. The majority of effects were felt on the immunization program. Benefits included strengthened communication and social mobilization, surveillance, and provider skills. Drawbacks included the interruption of routine vaccination services in the majority of health facilities surveyed (67%). The average daily number of children receiving routine vaccinations was 79% to 87% lower during the 10-day campaign period than during other periods of the month. Antenatal care consultations were also reduced during the campaign period by 10% to 15%. Key informants argued that, with an average of 14 campaigns per year, mass campaigns would have a substantial cumulative negative effect on routine health services. Many also argued that the MenA campaign missed potential opportunities for health systems strengthening because integration with other health services was lacking.

Conclusion: The MenA vaccine introduction interrupted routine vaccination and other health services. When introducing a new vaccine through a campaign, coverage of routine health services should be monitored alongside campaign vaccine coverage to highlight where and how long services are disrupted and to mitigate risks to routine services.