"Implementation of intensified COVID-19 vaccination optimization (ICVOPT) campaigns strategy in complex humanitarian emergency settings and hard-to-reach areas; a case of South Sudan".

INTRODUCTION: The COVID-19 pandemic is still a public health concern in South Sudan having caused suffering since the first case of COVID-19 was introduced on 28th February 2020. COVAX vaccines have since been introduced using a number of strategies including fixed site, temporary mobile, hit and run in flooded and conflict affected areas. We aim to describe the 2 ICVOPT campaigns that were conducted to improve the uptake and document lessons learnt during the initial rollout of the COVID-19 vaccination programin South Sudan between February 2022 and June 2022 each lasting for 7-days. METHODOLOGY: We conducted an operational cross-sectional descriptive epidemiological study of a series of the intensified COVID-19 vaccination Optimization (ICVOPT) campaigns from February 2022 to June 2022. Before the campaign, a bottom up micro-planning was conducted, validated by the County Health Departments (CHDs) and national MOH team. Each of the 2 campaigns lasted for 7 days targeting 30% of the eligible unvaccinated target population who were18 years and above. Each team consisted of 2 vaccinators, 2 recorders and 1 mobilizer. The teams employed both fixed site, temporary mobile, hit and run in flooded and conflict affected areas. The number of teams were calculated based on the daily workload per day (80 persons per team/day) for the duration of the campaigns. RESULTS: A total of 444,030 individuals were vaccinated with primary series COVID-19 vaccine (J&J) out of the targeted 635,030 persons. This represented 69.9% of target population in the selected 28 counties and 10 states of South Sudan in 7 days' ICVOPT campaigns. More eligible persons were reached in 7 days campaigns than the 9 months of rollout of the COVID-19 vaccine prior to ICVOPT campaigns using the fixed site strategy at the health facility posts. CONCLUSION: Intensified COVID-19 vaccination Optimization (ICVOPT) campaigns were vital and fast in scaling up vaccination coverages as compared to the fixed site vaccination strategies (2022 progress report on the Global Action Plan for Healthy Lives and Well-being for All Stronger collaboration for an equitable and resilient recovery towards the health-related Sustainable Development Goals, incentivizing collaboration, 2022) in complex humanitarian emergency settings and hard-to-reach areas of South Sudan.

A circulating vaccine-derived poliovirus type 2 outbreak in a chronic conflict setting: a descriptive epidemiological study in South Sudan - 2020 to 2021.

BACKGROUND: In this study, we describe the epidemiological profile of an outbreak of the circulating Vaccine Derived Polio Virus type 2 in South Sudan from 2020 to 2021. METHOD: We conducted a retrospective descriptive epidemiological study using data from the national polio/AFP surveillance database, the outbreak investigation reports, and the vaccination coverage survey databases stored at the national level. RESULTS: Between September 2020 and April 2021, 59 cases of the circulating virus were confirmed in the country, with 50 cases in 2020 and 9 cases in 2021. More cases were males (56%) under five (93%). The median age of the cases was 23.4 ± 11.9 months, ranging from 1 to 84 months. All states, with 28 out of the 80 counties, reported at least one case. Most of the cases (44, 75%) were reported from five states, namely Warrap (31%), Western Bahr el Ghazal (12%), Unity (12%), Central Equatoria (10%), and Jonglei (10%). Four counties accounted for 45.8% of the cases; these are Gogrial West with 12 (20%), Jur River with 5 (8.5%), Tonj North with 5 (8.5%), and Juba with 5 (8.5%) cases. The immunization history of the confirmed cases indicated that 14 (24%) of the affected children had never received any doses of oral polio or injectable vaccines either from routine or during supplemental immunization before the onset of paralysis, 17 (28.8%) had received 1 to 2 doses, while 28 (47.5%) had received 3 or more doses (Fig. 4). Two immunization campaigns and a mop-up were conducted with monovalent Oral Polio Vaccine type 2 in response to the outbreak, with administrative coverage of 91.1%, 99.1%, and 97% for the first, second, and mop-up rounds, respectively. CONCLUSION: The emergence of the circulating vaccine-derived poliovirus outbreak in South Sudan was due to low population immunity, highlighting the need to improve the country's routine and polio immunization campaign coverage.

Acute flaccid paralysis surveillance performance from 2011 to 2020 in Jonglei State, South Sudan: progress and challenges encountered.

Introduction: South Sudan reported the last indigenous wild poliovirus (WPV) in 2001 in Unity State, while the country was part of Sudan. In addition, the country reported an imported case of WPV in 2004-2005 and 2008-2009. The WPV circulation in the state was interrupted in 2009 and the last case was reported in Ayod county. The country continues to be at risk of importation of circulating vaccine-derived poliovirus type 2 (cVDPV2). In 2014 and 2020 the country experienced an outbreak of cVDPV2, in which Jonglei state was one of the affected states. Four out of 50 (8%) cVDPV2 cases in 2020 were reported from Jonglei State. The purpose of this study is to review surveillance performance indicators of Jonglei and compare them with the WHO surveillance performance standard and other country´s surveillance performances. Methods: retrospective secondary data analysis was conducted using the Jonglei state Acute Flaccid Paralysis (AFP) surveillance case-based database from 2011 to 2020. The reason for selecting Jonglei is because it is one of the poor performing states and is chronically hit by flood and internal conflicts. Data analyses were carried out using the Microsoft Excel (2016) program, where descriptive analysis frequencies, tables, and graphs were generated. Results: the study revealed that 346 AFP cases were reported in the counties of Jonglei state from 2011 through 2020. Out of 11 counties, 11 (100%) of them have reported suspected AFP cases. Children under five years accounted for 275 (79%) of all cases. The male gender accounted for 175 (51%) of all cases. A total of 249 (72%) had received three or more doses of Oral Polio Vaccine (OPV). Non-Polio Acute Flaccid Paralysis (NPAFP) rate varies from 1.2 in 2014 to 4.4 cases per 100,000 children under 15 years in 2018. The stool adequacy ranges from 58% in 2020 to 100% in 2011. Conclusion: the performance of Jonglei´s AFP surveillance system did not meet the WHO recommended target for both major AFP surveillance indicators (non-polio AFP rate and stool adequacy) during the study period.

The sensitivity of acute flaccid paralysis surveillance - the case of South Sudan: retrospective secondary analysis of AFP surveillance data 2014-2019.

Introduction: South Sudan has made quite impressive progress in interrupting wild poliovirus and maintaining a polio-free status since the last case was reported in 2009. South Sudan introduced different complementary strategies to enhance acute flaccid paralysis (AFP) surveillance. Hence, the objective of this study is to evaluate the sensitivity of the surveillance system using the WHO recommended surveillance standard and highlight the progress and challenges over the years. Methods: we conducted a retrospective, descriptive, quantitative study design and used the available secondary AFP surveillance database. Results: the overall non-polio AFP rate was 6.2/100,000 children under 15 years old in the study period. The stool adequacy was maintained well above the certification level of surveillance. The two main surveillance performance indicators were met at the national level throughout the study period. In contrast, only five out of ten states persistently attained and maintained the two main surveillance performance indicators throughout the study period, while in 2019 all states achieved except for Jonglei state. During the analysis period, no wild poliovirus was isolated except two circulating Vaccine Derived Poliovirus Type 2 (cVDPV2) cases in 2014 and one Immunodeficiency Vaccine Derived Poliovirus Type 2 (iVDPV2) case in 2015. However, on average, three cases were classified as polio compatible with each year of the study. Conclusion: South Sudan met the two key surveillance performance indicators and had a sensitive AFP surveillance system during the period studied. We recommend intensifying surveillance activities in the former conflict-affected states and counties to maintain polio-free status.

Contribution of Auto-Visual AFP Detection and Reporting (AVADAR) on polio surveillance in South Sudan.

Introduction: the last wild polio virus in South Sudan was documented in 2009. Nonetheless, it was one of the last four countries in the WHO African region to be accepted as a polio-free country in June 2020. In line with this, to accelerate the polio-free documentation process, the country has piloted Auto Visual AFP Detection and Reporting (AVADAR) in three counties. This study examined the contribution of the AVADAR surveillance system to the traditional Acute Flaccid Paralysis (AFP) surveillance system to document lessons learnt and best practices. Methods: we performed a retrospective descriptive quantitative study design to analyze secondary AVADAR surveillance data collected from June 2018 to December 2019 and stored at the WHO AVADAR server. Results: the AVADAR community surveillance system has improved the two main AFP surveillance indicators in the piloted counties and made up 86% of the total number of true AFP cases detected in these counties. The completeness and timeliness of weekly zero reporting were 97% and 94%, respectively and maintained above the standard throughout the study, while the two main surveillance indicators in the project area were improved progressively except for the Gogrial West County. In contrast, main surveillance indicators declined in some of the none-AVADAR implementing counties. Conclusion: the AVADAR surveillance system can overcome the logistical and remoteness barriers that can hinder the early detection and reporting of cases due to insecurity, topographical, and communication barrier in rural and hard-to-reach areas to accomplish and sustain the two main surveillance indicators, along with the completeness and timeliness of weekly zero reporting. We recommend extending this application-based surveillance system to other areas with limited resources and similar challenges by incorporating other diseases of public health concern.

Polio eradication in a chronic conflict setting lessons from the Republic of South Sudan, 2010-2020.

Introduction: in 1988 the World Health Assembly set an ambitious target to eradicate Wild Polio Virus (WPV) by 2000, following the successful eradication of the smallpox virus in 1980. South Sudan and the entire African region were certified WPV free on August 25, 2020. South Sudan has maintained its WPV free status since 2010, and this paper reviewed the country's progress, outlined lessons learned, and describes the remaining challenges in polio eradication. Methods: secondary data analysis was conducted using the Ministry of Health and WHO polio surveillance datasets, routine immunisation coverage, polio campaign data, and surveys from 2010 to 2020. Relevant technical documents and reports on polio immunisation and surveillance were also reviewed. Data analysis was conducted using EPI Info 7 software. Results: administrative routine immunisation coverage for bivalent Oral Polio Vaccine (OPV) 3rd dose declined from 77% in 2010 to 56% in 2020. In contrast, the administrative and post-campaign evaluation coverage recorded for the nationwide supplemental polio campaigns since 2011 was consistently above 85%; however, campaigns declined in number from four in 2011 to zero in 2020. Overall, 76% of notified cases of Acute Flaccid Paralysis (AFP) received three or more doses of the oral polio vaccine. The Annualized Non-AFP rate ranged between 4.0 to 5.4 per 100,000 under 15 years populations, and stool adequacy ranged from 83% to 94%. Conclusion: South Sudan's polio-free status documentation was accepted by the ARCC in 2020, thereby enabling the African Region to be certified WPV free on August 25, 2020. However, there are concerns as the country continues to report low routine immunisation coverage and a reduction in the number of polio campaigns conducted each year. It is recommended that the country conduct high-quality nationwide supplemental polio campaigns yearly to achieve and maintain the required herd immunity. It invests in its routine immunisation program while ensuring optimal AFP surveillance performance indicators.

Characteristics of wild polio virus outbreak investigation and response in Ethiopia in 2013-2014: implications for prevention of outbreaks due to importations.

BACKGROUND: Ethiopia joined the Global Polio Eradication Initiative (GPEI) in 1996, and by the end of December 2001 circulation of indigenous Wild Polio Virus (WPV) had been interrupted. Nonetheless, the country experienced multiple importations during 2004-2008, and in 2013. We characterize the 2013 outbreak investigations and response activities, and document lessons learned. METHOD: The data were pulled from different field investigation reports and from the national surveillance database for Acute Flaccid Paralysis (AFP). RESULTS: In 2013, a WPV1 outbreak was confirmed following importation in Dollo zone of the Somali region, which affected three Woredas (Warder, Geladi and Bokh). Between July 10, 2013, and January 5, 2014, there were 10 children paralyzed due to WPV1 infection. The majorities (7 of 10) were male and below 5 years of age, and 7 of 10 cases was not vaccinated, and 72% (92/129) of < 5 years of old children living in close proximity with WPV cases had zero doses of oral polio vaccine (OPV). The travel history of the cases showed that seven of the 10 cases had contact with someone who had traveled or had a travel history prior to the onset of paralysis. Underserved and inaccessibility of routine immunization service, suboptimal surveillance sensitivity, poor quality and inadequate supplemental immunization were the most crucial gaps identified during the outbreak investigations. CONCLUSION: Prior to the 2013 outbreak, Ethiopia experienced multiple imported polio outbreaks following the interruption of indigenous WPV in December 2001. The 2013 outbreak erupted due to massive population movement and was fueled by low population immunity as a result of low routine immunization and supplemental Immunization coverage and quality. In order to avert future outbreaks, it is critical that surveillance sensitivity be improved by establishing community-based surveillance systems and by assigning surveillance focal points at all level particularly in border areas. In addition, it is vital to set up in hard to reach areas a functional immunization service delivery system using the "Reaching Every Child" approach, including periodic routine immunization intensification and supplemental immunization activities.

Health care seeking behavior of parents with acute flaccid paralysis child.

INTRODUCTION: Despite the tremendous increase in the number of modern health institutions, traditional medical practices still remain alternative places of health care service delivery and important sites for disease notification in the disease surveillance system. The objectives of this study are to describe the patterns and factors associated with health care seeking behavior of parents and care takers with acute flaccid paralysis child and see how the traditional practice affect the surveillance system. METHODS: A cross-sectional descriptive study was conducted to assess the health seeking behavior of parents with an acute flaccid paralysis child. Data were collected throughout the country as a routine surveillance program. RESULTS: Of 1299 families analyzed, 907(69.3%) of families with AFP child first went to health institutions to seek medical care, while. 398 (30.7%) of parents took their child first to other traditional sites, including holy water sites (11.8%), traditional healers (9.1%) and prayer places (5.4%). Over half of the parents with AFP child reported practicing home measures before first seeking health service from modern health institutions. Home measures (OR, 0.1202, 95% CI 0.0804-0.1797), decision by relatives (OR, 0.5595, 95% CI 0.3665-0.8540) and More than 10km distance from health facility (OR, 0.5962, 95% CI, 0.4117-0.8634) were significantly associated to first seeking health service from health institutions (p<0.05). CONCLUSION: Program strategies must certainly be developed to expand and capture all traditional sites in the surveillance network, and intensify sensitization and active surveillance visit in these areas.

Measles outbreak investigation in Guji zone of Oromia Region, Ethiopia.

INTRODUCTION: Despite the increase of immunization coverage (administrative) of measles in the country, there are widespread outbreaks of measles. In this respect, we investigated one of the outbreaks that occurred in hard to reach kebeles of Guji Zone, Oromia region, to identify the contributing factors that lead to the protracted outbreak of measles. METHODS: We used a cross-sectional study design to investigate a measles outbreak in Guji zone, Oromia region. Data entry and analysis was performed using EPI-Info version 7.1.0.6 and MS-Microsoft Excel. RESULTS: In three months' time a total of 1059 suspected cases and two deaths were reported from 9 woredas affected by a measles outbreak in Guji zone. The cumulative attack rate of 81/100,000 population and case fatality ratio of 0.2% was recorded. Of these, 821 (77.5%) cases were < 15 years of age, and 742 (70%) were zero doses of measles vaccine. Although, all age groups were affected under five years old were more affected 495 (48%) than any other age groups. In response to the outbreak, an outbreak response immunization was organized at the 11th week of the epidemic, when the epidemic curve started to decline. 6 months to14 years old were targeted for outbreak response immunization and the overall coverage was 97 % (range: 90-103%). Case management with vitamin A supplementation, active case search, and health education was some of the activities carried out to curb the outbreak. CONCLUSION: We conclude that low routine immunization coverage in conjunction with low access to routine immunization in hard to reach areas, low community awareness in utilization of immunization service, inadequate cold chain management and delivery of a potent vaccine in hard to reach woredas/kebeles were likely contributed to the outbreak that's triggered a broad spread epidemic affecting mostly children without any vaccination. We also figured that the case-based surveillance lacks sensitivity and timely confirmation of the outbreak, which as a result outbreak response immunization were delayed. We recommend establishing reaching every child (REC) strategy in Guji zone with particular emphasis too hard reach areas to enhance the current immunization service, and furthermore to conduct data quality self-assessment or cluster coverage survey to verify the reported high vaccination coverage in some kebeles. We also recommend conducting the second opportunity as a form of supplemental immunization activities in 2-3 year interval or consider the national second dose introduction in the routine immunization system to improve population immunity. We further recommend that there is a need to boost the sensitivity of case-based surveillance system to be able to early detect, confirm and react to future epidemics.

Analysis of acute flaccid paralysis surveillance in Ethiopia, 2005-2015: progress and challenges.

INTRODUCTION: Ethiopia joined the global effort to eradicate polio in 1996, and interrupted indigenous wild poliovirus transmission by December 2001. However, the country experienced numerous separate importations during 2003-2013. Sensitive Acute Flaccid (AFP) surveillance is critical to rule out undetected circulation of WPV and VDPVs. METHODS: In this study described, we used a retrospective descriptive study design to characterize the surveillance performance from 2005 to 2015. RESULTS: The none-polio AFP rate improved from 2.6/100,000 children <15 years old in 2005 to 3.1 in 2015, while stool adequacy has also improved from 78.5% in 2005 to 92 % in 2015. At the national level, most AFP surveillance performance indicators are achieved and maintained over the years, however, AFP surveillance performance at sub-national level varies greatly particularly in pastoralist regions. In addition, the minimum standard for non-polio enterovirus isolation rate (10%) was not achieved except in 2007 and 2009. Nevertheless, the proportion of cases investigated within 2 days of notification and the proportion of specimens arriving in good condition within 3 days to the laboratory were maintained throughout all the years reviewed. CONCLUSION: We found that the AFP surveillance system was efficient and progressively improved over the past 10 years in Ethiopia. However, the subnational AFP surveillance performance varies and were not maintained, particularly in pastoralist regions, and the non-polio enterovirus isolation rate declined since 2010. We recommend the institution of community-based surveillance in pastoralist regions and conduct detail review of the laboratory sensitivity and the reverse cold chain system.