Using short-message-service notification as a method to improve acute flaccid paralysis surveillance in Papua New Guinea.

BACKGROUND: High quality acute flaccid paralysis (AFP) surveillance is required to maintain polio-free status of a country. Papua New Guinea (PNG) is considered as one of the highest risk countries for polio re-importation and circulation in the Western Pacific Region (WPRO) of the World Health Organization due to poor healthcare infrastructure and inadequate performance in AFP surveillance. The Government of PNG, in collaboration with WHO, piloted the introduction of short-message-service (SMS) to sensitize pediatricians and provincial disease control officers on AFP and to receive notification of possible AFP cases to improve surveillance quality in PNG. METHODS: Ninety six health care professionals were registered to receive SMS reminders to report any case of acute flaccid paralysis. Fourteen SMS messages were sent to each participant from September 2012 to November 2013. The number of reported AFP cases were compared before and after the introduction of SMS. RESULTS: Two hundred fifty three unique responses were received with an overall response rate of 21 %. More than 80 % of responses were reported within 3 days of sending the SMS. The number of reported AFP cases increased from 10 cases per year in 2009-2012 to 25 cases per year during the study period and correlated with provincial participation of the health care professionals. CONCLUSIONS: Combined with improved sensitization of health care professionals on AFP reporting criteria and sample collection, SMS messaging provides an effective means to increase timely reporting and improve the availability of epidemiologic information on polio surveillance in PNG.

Progress and Challenges in Measles and Rubella Elimination in the WHO European Region.

The elimination of both measles and rubella remains a priority for all 53 Member States of the World Health Organization (WHO) European Region. To provide an update on the epidemiological status of measles and rubella in the Region, we reviewed surveillance data on both diseases for 2023 submitted monthly by national surveillance institutions. We analyzed the cases of measles and rubella for 2023 by age group, case classification, vaccination, hospitalization, and importation status and report on measles-related deaths. In 2023, 60,860 measles cases, including 13 fatal cases, were reported in 41 countries. Most cases (95%; n = 57,584) were reported by six countries: Azerbaijan, Kazakhstan, Kyrgyzstan, Romania, the Russian Federation, and Türkiye. Of the 60,848 cases with data on age, 19,137 (31%) were 1-4 years old and 12,838 (21%) were 5-9 years old. A total of 10,412 (17%) were 20 years and older. The genotypes identified in the Region were largely dominated by D8 variants (n = 1357) and the remainder were B3 variants (n = 221). In 2023, 345 rubella cases were reported by 17 countries, mostly from Poland, Kyrgyzstan, Tajikistan, Türkiye, and Ukraine. A total of 262 cases (76%) were classified as clinically compatible and 79 (23%) were laboratory-confirmed. To achieve the elimination of measles and rubella in the Region, political commitment needs to be revived to enable urgent efforts to increase vaccination coverage, improve surveillance and outbreak preparedness, and respond immediately to outbreaks.

Evaluating the hepatitis B vaccination impact in the Republic of Moldova: A nationwide representative serosurvey of children born in 2013.

Objectives: The WHO European Region set targets for the control of hepatitis B through immunization, including prevalence of hepatitis B surface antigen (HBsAg) at ≤0.5% in vaccinated cohorts. The Republic of Moldova implemented universal hepatitis B vaccination since 1995. We conducted a nationwide representative serosurvey to estimate HBsAg seroprevalence in children born in 2013 to validate hepatitis B control targets. Methods: We used probability-based sampling and a two-stage cluster design. All children born in 2013 and registered in primary healthcare facilities were eligible for participation. We tested blood samples of all participants for hepatitis B core antibody (anti-HBc), using Enzyme-Linked Immunosorbent Assay (ELISA). Anti-HBc-positive samples were tested for HBsAg and HBsAg-positive samples confirmed, using ELISA. We obtained information on hepatitis B vaccination from vaccination cards. Results: Of 3352 sampled children, 3064 (91%) participated. Most participating children were 7 years old (n = 3030, 99%), 1426 (48%) were girls. The weighted, national seroprevalence estimate was 3.1% (95% confidence interval = 2.1-4.5) for anti-HBc and 0.21% (95% confidence interval = 0.08-0.53) for HBsAg. Conclusion: The study demonstrated the impact of hepatitis B vaccination and allowed the Republic of Moldova to validate regional hepatitis B control targets. Other countries with high vaccination coverage could use hepatitis B serosurveys and apply for validation. Sustained efforts in the Republic of Moldova will be crucial on the path to hepatitis B elimination.

Addressing Determinants of Immunization Inequities Requires Objective Tools to Devise Local Solutions.

Universal immunization substantially reduces morbidity and mortality from vaccine-preventable diseases. In recent years, routine immunization coverage has varied considerably among countries across the WHO European Region, and among different populations and districts within countries. It has even declined in some countries. Sub-optimal immunization coverage contributes to accumulations of susceptible individuals and can lead to outbreaks of vaccine-preventable diseases. The European Immunization Agenda 2030 (EIA2030) seeks to build better health in the WHO European Region by ensuring equity in immunization and supporting immunization stakeholders in devising local solutions to local challenges. The factors that influence routine immunization uptake are context specific and multifactorial; addressing immunization inequities will require overcoming or removing barriers to vaccination for underserved individuals or populations. Local level immunization stakeholders must first identify the underlying causes of inequities, and based on this information, tailor resources, or service provision to the local context, as per the organization and characteristics of the health care system in their countries. To do this, in addition to using the tools already available to broadly identify immunization inequities at the national and regional levels, they will need new pragmatic guidance and tools to address the identified local challenges. It is time to develop the necessary guidance and tools and support immunization stakeholders at all levels, especially those at the subnational or local health centre levels, to make the vision of EIA2030 a reality.

COVID-19 vaccination roll-outs in eleven small countries within the WHO European region; Lessons learned.

The development and administration of COVID-19 vaccines has been an essential element in controlling the COVID-19 pandemic. However, countries worldwide have faced challenges in planning and implementing vaccination strategies. The aim of the current paper is to describe the situation faced by small countries in the WHO European Region in implementing their national vaccination strategies during the first stages of the planned roll-out (up to May 2021). This paper uses information from the WHO Small Countries Initiative (SCI), which includes a network of 11 countries with populations of ≤ 2 million (Andorra, Cyprus, Estonia, Iceland, Latvia, Luxembourg, Malta, Monaco, Montenegro, San Marino, and Slovenia). The SCI countries faced many challenges including: a lack of appropriate vaccination centers, adequate workforce, and registration/booking systems to cope with the unprecedented vaccine storage and administration demands; difficulties for high-risk groups (e.g., older individuals and those with health problems or cognitive impairment) to access vaccination sites or use digital registration/booking systems; vaccine wastage due to canceled appointments; and inequalities in vaccine uptake. Innovative programmatic interventions were implemented to facilitate the vaccination uptake of the populations such as: the creation of non-medical vaccination sites and mobile vaccination units; on-site vaccination of people in long-term residential facilities and long-term medical wards; diversifying health workforce like redeployment of healthcare professionals and use of medical students and retired medical professionals; campaigns with clear information to the general public (in multiple languages where necessary) both offline and online; use of digital registration/booking systems and alternative (non-digital) registration/booking systems for relevant individuals; and administration of excess vaccine doses to non-priority groups to avoid wastage.

Supporting National Immunization Technical Advisory Groups in the WHO European Region in developing national COVID-19 vaccination recommendations through online communication platform.

National Immunization Technical Advisory Groups are groups of multi-disciplinary experts that provide scientific advice to policy makers to enable them to make informed immunization policy and programme decisions. NITAGs faced challengesusing their routine approach to develop recommendations for COVID-19 vaccines during the pandemic. In response, the WHORegional Office for Europe (Regional Office), with the support of theRobert Koch Institute, developedan innovative approach of a series of webinars, provision of materials, and remote technical assistance to address these challenges. Polls conducted during webinars were used to tailor future webinars and evaluate the effectiveness of these interventions. According to poll results, 76% of participants found the webinars and resources shared very useful in their work on COVID-19 vaccination.The Regional Office plans to build further upon the scope of online communication and establish a regional online platform for NITAGs to further support NITAGs and build capacity.

Analysing the characteristics of a measles outbreak in Houaphanh province to guide measles elimination in the Lao People's Democratic Republic.

INTRODUCTION: In recent years, the incidence of measles has declined in the Lao People's Democratic Republic. However, an outbreak was reported in August 2014 in Houaphanh province, which was the biggest outbreak in the country since 2008. We describe the characteristics of this outbreak and outline critical interventions for the Lao People's Democratic Republic to achieve measles elimination. METHODS: Fever and rash cases in the Khouan and Samtai districts with an onset date from 1 September to 25 October 2014 were investigated. Active case finding and health facility record reviews were carried out. Appropriate samples from the individuals with suspected measles were tested to confirm the diagnosis. RESULTS: A total of 265 suspected cases including 12 deaths were reported from eight villages in the Khouan and Samtai districts. Forty-five individuals tested positive for measles IgM. Most of the confirmed patients were male (n = 28, 62%), less than 5 years old (n = 23, 51%) and from the Hmong ethnic community (n = 44, 98%). The majority of the people with suspected measles (n = 213, 80%) and all the confirmed ones were unvaccinated. A measles vaccination campaign conducted in the eight affected villages resulted in 76% coverage of the targeted population. DISCUSSION: Low routine coverage and measles occurrence among unvaccinated individuals indicate underimmunized areas. The geographical and sociodemographic characteristics of this outbreak highlight the need for tailored vaccination strategies to close the immunity gap. A sensitive surveillance system that is able to detect, notify, investigate and guide response measures, including a second measles dose in the routine immunization schedule, will be essential for the Lao People's Democratic Republic to attain its measles elimination status.

Progress and challenges in measles and rubella elimination in the WHO European Region.

INTRODUCTION: Despite availability of safe and cost-effective vaccines to prevent it, measles remains one of the significant causes of death among children under five years of age globally. The World Health Organization (WHO) European Region has seen a drastic decline in measles and rubella cases in recent years, and a few of the once common measles genotypes are no longer detected. Buoyed by this success, all Member States of the Region reconfirmed their commitment in 2010 to eliminating measles and rubella, and made this a central objective of the European Vaccine Action Plan 2015-2020 (EVAP). Nevertheless, sporadic outbreaks continue, recently affecting primarily adolescents and young adults with no vaccination or an incomplete vaccination history. The European Regional Verification Commission for Measles and Rubella Elimination was established in 2011 to evaluate the status of measles and rubella elimination based on documentation submitted annually by each country's national verification committee. DISCUSSION: Each country's commitment to eliminate measles and rubella is influenced by competing health priorities, and in some cases lack of capacity and resources. All countries need to improve case-base surveillance for both measles and rubella, ensure documentation of each outbreak and strengthen the link between epidemiology and laboratory data. Achieving high coverage with measles- and rubella-containing vaccines will require a multisectoral approach to address the root causes of lower uptake in identified communities including service delivery challenges or vaccine safety concerns caused by circulating myths about vaccination. CONCLUSIONS: The WHO European Region has made steady progress towards eliminating measles and rubella and over half of the countries interrupted endemic transmission of both diseases by 2015. The programmatic challenges in disease surveillance, vaccination service delivery and communication in the remaining endemic countries should be addressed through periodic evaluation of the strategies by all stakeholders and exploring additional opportunities to accelerate the ongoing elimination activities.

Improving hepatitis B birth dose in rural Lao People's Democratic Republic through the use of mobile phones to facilitate communication.

BACKGROUND: Hepatitis B vaccine birth dose (HepB-BD) was introduced in Lao People's Democratic Republic to prevent perinatal hepatitis B virus transmission in 2008; high coverage is challenging since only 38% of births occur in a health facility. Healthcare workers report being unaware of home births and thus unable to conduct timely postnatal care (PNC) home visits. A quasi-experimental pilot study was conducted wherein mobile phones and phone credits were provided to village health volunteers (VHV) and healthcare workers (HCWs) to assess whether this could improve HepB-BD administration, as well as birth notification and increase home visits. METHODS: From April to September 2014, VHVs and HCWs in four selected intervention districts were trained, supervised, received outreach per diem for conducting home visits, and received mobile phones and phone credits. In three comparison districts, VHVs and HCWs were trained, supervised, and received outreach per diem for conducting home visits. A post-study survey compared HepB-BD coverage among children born during the study and children born one year before. HCWs and VHVs were interviewed about the study. FINDINGS: Among intervention districts, 463 study children and 406 pre-study children were enrolled in the survey; in comparison districts, 347 study children and 309 pre-study children were enrolled. In both arms, there was a significant improvement in the proportion of children reportedly receiving a PNC home visit (intervention p<0.0001, comparison p=0.04). The median difference in village level HepB-BD coverage (study cohort minus pre-study cohort), was 57% (interquartile range [IQR] 32-88%, p<0.0001) in intervention districts, compared with 20% (IQR 0-50%, p<0.0001) in comparison districts. The improvement in the intervention districts was greater than in the comparison districts (p=0.0009). CONCLUSION: Our findings suggest that the provision of phones and phone credits might be one important factor for increasing coverage. However, reasons for improvement in both arms are multifactorial and discussed.

Hepatitis B surface antigen seroprevalence among children in Papua New Guinea, 2012-2013.

Approximately 8% of the population in Papua New Guinea (PNG) has chronic hepatitis B virus (HBV) infection. To decrease the burden of chronic HBV infection, a national 3-dose infant hepatitis B vaccination program was implemented starting in 1989, with a birth dose (BD) added to the schedule in 1992. To assess the impact of the hepatitis B vaccination program, we conducted a serosurvey among children born after vaccine introduction. During 2012-2013, a cross-sectional stratified four-stage cluster survey was conducted to estimate hepatitis B surface antigen (HBsAg) prevalence among children 4-6 years of age. We collected demographic data, vaccination history, and tested children for HBsAg. Of 2,133 participants, 2,130 children had vaccination data by either card or recall: 28% received a BD; 81% received ≥ 3 vaccine doses. Of 2,109 children providing a blood sample, 60 (2.3%) tested positive for HBsAg. This is the largest, most geographically diverse survey of hepatitis B vaccination and HBsAg seroprevalence done in PNG. Progress has been made in PNG toward the Western Pacific Regional goal to reduce the prevalence of chronic HBV infection to < 1% by 2017 among 5-year-old children. Vaccination efforts should be strengthened, including increasing BD coverage and completing the 3-dose series.

Integrated package approach in delivering interventions during immunisation campaigns in a complex environment in Papua New Guinea: a case study.

Papua New Guinea's difficult and varied topography, poor transport infrastructure, changing dynamics of population and economy in recent times and understaffed and poorly financed health service present major challenges for successful delivery of vaccination and other preventative health interventions to both the rural majority and urban populations, thereby posing risks for vaccine preventable disease outbreaks in the country. The country has struggled to meet the vaccination coverage targets required for the eradication of poliomyelitis and elimination of measles. Escalation of inter and intra country migration resulting from major industrial developments, particularly in extraction industries, has substantially increased the risk of infectious disease importation. This case study documents the evolution of immunisation programmes since the introduction of supplementary immunisation activities (SIAs). Single antigen SIAs have advantages and disadvantages. In situations in which the delivery of preventative health interventions is difficult, it is likely that the cost benefit is greater for multiple than for single intervention. The lessons learned from the conduct of single antigen SIAs can be effectively used for programmes delivering multiple SIA antigens, routine immunisations, and other health interventions. This paper describes a successful and cost effective multiple intervention programme in Papua New Guinea. The review of the last SIA in Papua New Guinea showed relatively high coverage of all the interventions and demonstrated the operational feasibility of delivering multiple interventions in resource constrained settings. Studies in other developing countries such as Lesotho and Ethiopia have also successfully integrated health interventions with SIA. In settings such as Papua New Guinea there is a strong case for integrating supplementary immunisation activity with routine immunisation and other health interventions through a comprehensive outreach programme.

Pertussis outbreak in Papua New Guinea: the challenges of response in a remote geo-topographical setting.

INTRODUCTION: A large outbreak of pertussis was detected during March 2011 in Goilala, a remote district of the Central Province in Papua New Guinea, characterized by rugged topography with no road access from the provincial headquarters. This outbreak investigation highlights the difficulties in reporting and responding to outbreaks in these settings. METHOD: The suspected pertussis cases, reported by health workers from the Ononge health centre area, were investigated and confirmed for the presence of Bordetella pertussis DNA using the polymerase chain reaction (PCR) method. RESULTS: There were 205 suspected pertussis cases, with a case-fatality rate (CFR) of 3%. All cases were unvaccinated. The Central Province conducted a response vaccination programme providing 65% of children less than five years of age with diphtheria-pertussis-tetanus-HepB-Hib vaccine at a cost of US$ 12.62 per child. DISCUSSION: The incurred cost of vaccination in response to this outbreak was much higher than the US$ 3.80 per child for routine outreach patrol. To prevent further outbreaks of vaccine-preventable diseases in these areas, local health centres must ensure routine vaccination is strengthened through the "Reaching Every District" initiative of the National Department of Health.

Surveillance and molecular characterization of group A rotaviruses in Goroka, Papua New Guinea.

In this study, we investigated the molecular epidemiology of group A rotaviruses in cases of acute gastroenteritis in Goroka, Papua New Guinea. From April 2008 through November 2010, 813 diarrheal stool samples were collected from children < 5 years of age hospitalized with acute gastroenteritis. Rotavirus antigen was detected in 31.2% of samples using a commercial enzyme-linked immunosorbent assay. Genotyping revealed the presence of the globally circulating strains G1P[8] (50.0%), G3P[8] (23.0%), and G2P[4] (8.2%). The globally emerging strains G9 and G12 were detected in 1.2% and 6.1% of samples, respectively. Mixed infections were detected in a high proportion of samples (11.9%), with 9.0% and 3.7% of samples displaying multiple G and P genotypes, respectively.