Surveys of measles vaccination coverage in eastern and southern Africa: a review of quality and methods used.

OBJECTIVE: To assess the methods used in the evaluation of measles vaccination coverage, identify quality concerns and provide recommendations for improvement. METHODS: We reviewed surveys that were conducted to evaluate supplementary measles immunization activities in eastern and southern Africa during 2012 and 2013. We investigated the organization(s) undertaking each survey, survey design, sample size, the numbers of study clusters and children per study cluster, recording of immunizations and methods of analysis. We documented sampling methods at the level of clusters, households and individual children. We also assessed the length of training for field teams at national and regional levels, the composition of teams and the supervision provided. FINDINGS: The surveys were conducted in Comoros, Eritrea, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, Swaziland, Uganda, Zambia and Zimbabwe. Of the 13 reports we reviewed, there were weaknesses in 10 of them for ethical clearance, 9 for sample size calculation, 6 for sampling methods, 12 for training structures, 13 for supervision structures and 11 for data analysis. CONCLUSION: We recommend improvements in the documentation of routine and supplementary immunization, via home-based vaccination cards or other records. For surveys conducted after supplementary immunization, a standard protocol is required. Finally, we recommend that standards be developed for report templates and for the technical review of protocols and reports. This would ensure that the results of vaccination coverage surveys are accurate, comparable, reliable and valuable for programme improvement.

Measles resurgence in southern Africa: challenges to measles elimination.

INTRODUCTION: In seven southern African countries (Botswana, Lesotho, Malawi, Namibia, South Africa, Swaziland and Zimbabwe), following implementation of a measles mortality reduction strategy starting in 1996, the number of annually reported measles cases decreased sharply to less than one per million population during 2006-2008. However, during 2009-2010, large outbreaks occurred in these countries. In 2011, a goal for measles elimination by 2020 was set in the World Health Organization (WHO) African Region (AFR). We reviewed the implementation of the measles control strategy and measles epidemiology during the resurgence in the seven southern African countries. METHODS: Estimated coverage with routine measles vaccination, supplemental immunization activities (SIA), annually reported measles cases by country, and measles surveillance and laboratory data were analyzed using descriptive analysis. RESULTS: In the seven countries, coverage with the routine first dose of measles-containing vaccine (MCV1) decreased from 80% to 65% during 1996-2004, then increased to 84% in 2011; during 1996-2011, 79,696,523 people were reached with measles vaccination during 45 SIAs. Annually reported measles cases decreased from 61,160 cases to 60 cases and measles incidence decreased to <1 case per million during 1996-2008. During 2009-2010, large outbreaks that included cases among older children and adults were reported in all seven countries, starting in South Africa and Namibia in mid-2009 and in the other five countries by early 2010. The measles virus genotype detected was predominantly genotype B3. CONCLUSION: The measles resurgence highlighted challenges to achieving measles elimination in AFR by 2020. To achieve this goal, high two-dose measles vaccine coverage by strengthening routine immunization systems and conducting timely SIAs targeting expanded age groups, potentially including young adults, and maintaining outbreak preparedness to rapidly respond to outbreaks will be needed.

Emergency, anaesthetic and essential surgical capacity in the Gambia.

OBJECTIVE: To assess the resources for essential and emergency surgical care in the Gambia. METHODS: The World Health Organization's Tool for Situation Analysis to Assess Emergency and Essential Surgical Care was distributed to health-care managers in facilities throughout the country. The survey was completed by 65 health facilities - one tertiary referral hospital, 7 district/general hospitals, 46 health centres and 11 private health facilities - and included 110 questions divided into four sections: (i) infrastructure, type of facility, population served and material resources; (ii) human resources; (iii) management of emergency and other surgical interventions; (iv) emergency equipment and supplies for resuscitation. Questionnaire data were complemented by interviews with health facility staff, Ministry of Health officials and representatives of nongovernmental organizations. FINDINGS: Important deficits were identified in infrastructure, human resources, availability of essential supplies and ability to perform trauma, obstetric and general surgical procedures. Of the 18 facilities expected to perform surgical procedures, 50.0% had interruptions in water supply and 55.6% in electricity. Only 38.9% of facilities had a surgeon and only 16.7% had a physician anaesthetist. All facilities had limited ability to perform basic trauma and general surgical procedures. Of public facilities, 54.5% could not perform laparotomy and 58.3% could not repair a hernia. Only 25.0% of them could manage an open fracture and 41.7% could perform an emergency procedure for an obstructed airway. CONCLUSION: The present survey of health-care facilities in the Gambia suggests that major gaps exist in the physical and human resources needed to carry out basic life-saving surgical interventions.

Strengthening the emergency healthcare system for mothers and children in The Gambia.

A system to improve the management of emergencies during pregnancy, childbirth, infancy and childhood in a region of The Gambia (Brikama) with a population of approximately 250,000 has been developed.This was accomplished through formal partnership between the Gambian Ministry of Health, the World Health Organisation, Maternal Childhealth Advocacy International and the Advanced Life Support Group.Since October 2006, the hospital in Brikama has been renovated and equipped and more efficiently provided with emergency medicines. An emergency ambulance service now links the community with the hospital through a mobile telephone system. Health professionals from community to hospital have been trained in obstetric, neonatal and paediatric emergency management using skills' based education. The programme was evaluated in log books detailing individual resuscitations and by external assessment.The hospital now has constant water and electricity, a functioning operating theatre and emergency room; the maternity unit and children's wards have better emergency equipment and there is a more reliable supply of oxygen and emergency drugs, including misoprostol (for treating post partum haemorrhage) and magnesium sulphate (for severe pre-eclampsia). There is also a blood transfusion service.Countrywide, 217 doctors, nurses, and midwives have undergone accredited training in the provision of emergency maternal, newborn and child care, including for major trauma. 33 have received additional education through Generic Instructor Courses and 15 have reached full instructor status. 83 Traditional Birth Attendants and 48 Village Health Workers have been trained in the recognition and initial management of emergencies, including resuscitation of the newborn. Eleven and ten nurses underwent training in peri-operative nursing and anaesthetics respectively, to address the acute shortage required for emergency Caesarean section.Between May 2007 and March 2010, 109 patients, mostly pregnant mothers, were stabilised and transported to hospital by the new emergency ambulance service.293 resuscitation attempts were documented in personal logbooks.A sustainable system for better managing emergencies has been established and is helping to negate the main obstacle impeding progress: the country's lack of available trained medical and nursing staff. However, insufficient attention was paid to improving staff morale and accommodation representing significant failings of the programme.