Public health impact of the spread of Anopheles stephensi in the WHO Eastern Mediterranean Region countries in Horn of Africa and Yemen: need for integrated vector surveillance and control.

BACKGROUND: Anopheles stephensi is an efficient vector of both Plasmodium falciparum and Plasmodium vivax in South Asia and the Middle East. The spread of An. stephensi to countries within the Horn of Africa threatens progress in malaria control in this region as well as the rest of sub-Saharan Africa. METHODS: The available malaria data and the timeline for the detection of An. stephensi was reviewed to analyse the role of An. stephensi in malaria transmission in Horn of Africa of the Eastern Mediterranean Region (EMR) in Djibouti, Somalia, Sudan and Yemen. RESULTS: Malaria incidence in Horn of Africa of EMR and Yemen, increased from 41.6 in 2015 to 61.5 cases per 1000 in 2020. The four countries from this region, Djibouti, Somalia, Sudan and Yemen had reported the detection of An. stephensi as of 2021. In Djibouti City, following its detection in 2012, the estimated incidence increased from 2.5 cases per 1000 in 2013 to 97.6 cases per 1000 in 2020. However, its contribution to malaria transmission in other major cities and in other countries, is unclear because of other factors, quality of the urban malaria data, human mobility, uncertainty about the actual arrival time of An. stephensi and poor entomological surveillance. CONCLUSIONS: While An. stephensi may explain a resurgence of malaria in Djibouti, further investigations are needed to understand its interpretation trends in urban malaria across the greater region. More investment for multisectoral approach and integrated surveillance and control should target all vectors particularly malaria and dengue vectors to guide interventions in urban areas.

Injection practices in 2011-2015: a review using data from the demographic and health surveys (DHS).

BACKGROUND: Reuse of injection devices to give healthcare injections decreased from 39.8 to 5.5% between 2000 and 2010, but trends since 2011 have not been described. We reviewed results of Demographic and Health Surveys (DHS) to describe injection practices worldwide from 2011 to 2015. METHODS: We searched the DHS Internet site for data published on injection practices conducted in countries from 2011 to 2015, extracted information on frequency (number of healthcare injections per person in the last 12 months) and safety (proportion of syringes and needles taken from a new, unopened package). We compared gender groups and WHO regions in terms of frequency and safety. For countries with data available, we compared injection practices 2004-2010 and 2011-2015. RESULTS: Since 2011, 40 of 92 countries (43%) that conducted DHS surveys reported on injection practices. On average, the frequency of injection was 1.64 per person per year (from 3.84 in WHO Eastern Mediterranean region to 1.18 in WHO African region). Among those, 96.1% of injections reportedly used new injection devices (from 90.2% in the WHO Eastern Mediterranean region to 98.8% in the WHO Western Pacific region). On average, women received more injections per year (1.85) than men (1.41). Among 16 (40%) countries with data in 2004-2010 and 2011-2015, 69% improved in terms of safety. The annual number of unsafe injections reduced in 81% of countries. In Pakistan, the number of unsafe injections was the highest and did not decrease between 2006 and 2012. CONCLUSIONS: Injection practices have continued to improve in most countries worldwide, although the Eastern Mediterranean region in particular still faces unsafe practices that are not improving. Further efforts are needed to eliminate unsafe injection practices in health care settings, including through the use of reuse-prevention devices. Despite some limitations, DHS is an easily available method to measure progress over time.

Development, production, and postmarketing surveillance of hepatitis A vaccines in China.

China has long experience using live attenuated and inactivated vaccines against hepatitis A virus (HAV) infection. We summarize this experience and provide recent data on adverse events after immunization (AEFIs) with hepatitis A vaccines in China. We reviewed the published literature (in Chinese and English) and the published Chinese regulatory documents on hepatitis A vaccine development, production, and postmarketing surveillance of AEFI. We described the safety, immunogenicity, and efficacy of hepatitis A vaccines and horizontal transmission of live HAV vaccine in China. In clinical trials, live HAV vaccine was associated with fever (0.4%-5% of vaccinees), rash (0%-1.1%), and elevated alanine aminotransferase (0.015%). Inactivated HAV vaccine was associated with fever (1%-8%), but no serious AEFIs were reported. Live HAV vaccine had seroconversion rates of 83% to 91%, while inactivated HAV vaccine had seroconversion rates of 95% to 100%. Community trials showed efficacy rates of 90% to 95% for live HAV and 95% to 100% for inactivated HAV vaccine. Postmarketing surveillance showed that HAV vaccination resulted in an AEFI incidence rate of 34 per million vaccinees, which accounted for 0.7% of adverse events reported to the China AEFI monitoring system. There was no difference in AEFI rates between live and inactivated HAV vaccines. Live and inactivated HAV vaccines manufactured in China were immunogenic, effective, and safe. Live HAV vaccine had substantial horizontal transmission due to vaccine virus shedding; thus, further monitoring of the safety of virus shedding is warranted.

Deployment of COVID-19 vaccine in the WHO Eastern Mediterranean Region 2021-23: How do we switch to a life course approach?

In 2020-2021, all countries of the WHO Eastern Mediterranean Region [EMR] introduced COVID-19 vaccine with inequalities in coverage across countries. As for 2023, we reviewed subsequent progress in deployment, coverage, acceptance, and integration. As of 31 December 2023, coverage in EMR reached 51% for primary series and 19 % for the first booster, higher in high income countries (77 % and 44 %, respectively) than in upper middle-income countries (49 % and 20 %), Advance Market Commitment [AMC] non-Gavi eligible countries (47 % and 15 %) and AMC Gavi eligible countries (49 % and 16 %). Thirteen countries measured coverage among healthcare workers (76 % and 43 %, respectively) and 15 among elderly (69 % and 38 %, respectively). Three rounds of the regional Knowledge, Attitudes, and Practices [KAP] survey on COVID-19 vaccine acceptance in 2021-2022 indicated that acceptance increased from 20 % in June-July 2021 to 62 % in October-November 2021, and 77 % in June-July 2022. Those unvaccinated but intending to be vaccinated decreased from 60 % to 23 % and 11 %, respectively. Unvaccinated without intention to be vaccinated decreased from 15 % to 10 % and 11 %, respectively. Twenty out of 22 countries in the region had completely or partially integrated COVID-19 vaccination into the Expanded Programme on Immunization [EPI] and Primary Health Care [PHC]. Overall, challenges to reach high-risk groups persisted as the population was less concerned about Omicron variant of the SARS-CoV-2 virus. Countries should build on the trust, momentum, and lesson-learned generated from COVID-19 vaccination to get the highest risk groups vaccinated and switch from a time bound and project type approach to a sustainable and long-term approach for COVID-19 vaccine delivery that would be integrated into the routine EPI and PHC.

Seven years of the field epidemiology training programme (FETP) at Chennai, Tamil Nadu, India: an internal evaluation.

BACKGROUND: During 2001-2007, the National Institute of Epidemiology (NIE), Chennai, Tamil Nadu, India admitted 80 trainees in its two-year Field Epidemiology Training Programme (FETP). We evaluated the first seven years of the programme to identify strengths and weaknesses. METHODS: We identified core components of the programme and broke them down into input, process, output and outcome. We developed critical indicators to reflect the logic model. We reviewed documents including fieldwork reports, abstracts listed in proceedings and papers published in Medline-indexed journals. We conducted an anonymous online survey of the graduates to collect information on self-perceived competencies, learning activities, field assignments, supervision, curriculum, relevance to career goals, strengths and weaknesses. RESULTS: Of the 80 students recruited during 2001-2007, 69 (86%) acquired seven core competencies (epidemiology, surveillance, outbreaks, research, human subjects protection, communication and management) and graduated through completion of at least six field assignments. The faculty-to-student ratio ranged between 0.4 and 0.12 (expected: 0.25). The curriculum was continuously adapted with all resources available on-line. Fieldwork led to the production of 158 scientific communications presented at international meetings and to 29 manuscripts accepted in indexed, peer-reviewed journals. The online survey showed that while most graduates acquired competencies, unmet needs persisted in laboratory sciences, data analysis tools and faculty-to-student ratio. CONCLUSIONS: NIE adapted the international FETP model to India. However, further efforts are required to scale up the programme and to develop career tracks for field epidemiologists in the country.

Measles in rural West Bengal, India, 2005-6: low recourse to the public sector limits the use of vitamin A and the sensitivity of surveillance.

BACKGROUND: Measles is often underreported. We evaluated the sensitivity of the measles surveillance in 2 districts of West Bengal in 2005-2006. METHODS: We sampled households with children aged <5 years in village clusters selected with probability proportional to size. We searched households door to door to identify World Health Organization-defined suspected measles cases that had occurred during 12 months in 2004-2005 in Howrah and in 2006 in Purulia. We interviewed mothers about use of health care services during episodes and calculated the proportion of patients seen in the public sector. We reviewed surveillance records at all levels to estimate the proportion of cases seen in public health care facilities that had been reported to the district. We calculated the overall sensitivity of measles surveillance by multiplying these 2 proportions. RESULTS: In Howrah, we identified 240 cases of measles. Of these, 8 (3.3% [95% confidence interval {CI}, 1.5%-6.5%]) had been seen in public facilities and recorded. Of 980 cases identified in 448 public facilities in the periphery, 962 (98%) had been transmitted to the district (overall sensitivity of surveillance, 3.2%). In Purulia, we identified 167 measles cases. Of these, 39 (23.4% [95% CI, = 17.2%-30.5%]) had been seen in public facilities and recorded. Of 418 cases identified in public facilities in the periphery, 414 (99%) had been transmitted to the district (overall sensitivity of surveillance, 23.1%). CONCLUSIONS: Measles surveillance captured a minority of measles cases, but cases captured were transmitted well to the district. Surveillance must engage the private sector. Health education focusing on vitamin A treatment for measles might provide an incentive to seek care, which could increase the sensitivity of surveillance.

The heterogeneity of measles epidemiology in India: implications for improving control measures.

BACKGROUND: Measles vaccination coverage varies in India. Trainees of the Field Epidemiology Training Programme (FETP) investigated 8 outbreaks from 2004 through 2006 in Himachal Pradesh, Uttaranchal, Tamil Nadu, and West Bengal. We reviewed these outbreaks to contribute to the description of the epidemiology of measles and propose recommendations for control. METHODS: FETP trainees searched for measles cases through stimulated passive surveillance or door-to-door case search; estimated attack rates, case fatality, and the median age of case patients; interviewed mothers about vaccination status of their children; and collected serum samples for immunoglobulin M serological testing whenever possible. For 3 outbreaks, the trainees estimated the vaccine efficacy for children >12 months of age through cohort studies. RESULTS: Six of the 8 outbreaks were serologically confirmed. Compared with outbreaks in other states, outbreaks in states with vaccination coverage of >90% had a higher median age among case patients and a lower median attack rate. Six deaths (case fatality rate, 1.5%) occurred during the 5 outbreaks for which vitamin A was not used. The vaccine efficacy was 84% (95% confidence interval [CI], 74%-91%) in Himachal Pradesh. In West Bengal, it was 66% (95% CI, 44%-80%) in 2005 and 81% (95% CI, 67%-89%) in 2006. CONCLUSIONS: In states with higher coverage, attack rates were lower and case patients were older. Although states with coverage of <90% should increase 1-dose coverage and address coverage in pockets that are poorly reached, a second opportunity for measles vaccination could be considered in states such as Himachal Pradesh and Tamil Nadu. Use of vitamin A for case management needs to be generalized.

United for dignity: four strategic shifts to get to zero leprosy by 2030.

Leprosy, or Hansen's disease, is a curable infectious disease caused by the bacillus M. leprae. In 1991, the World Health Assembly WHA44.9 set the goal for "elimination of leprosy as a public health problem" as less than one case on treatment per 10 000 population by 2000. Since then, global leprosy strategies have focused on reducing the prevalence of the disease at country level and reducing transmission. Early detection and prompt treatment with multidrug therapy, the keystone for leprosy control, led to the achievement of this goal at global level by 2000, and in almost all countries, at least at the national level, by 2015.

Progress towards elimination of viral hepatitis by 2030 in the WHO Eastern Mediterranean Region, 2019.

The WHO Global Health Sector Strategy and hepatitis regional action plan for the WHO Eastern Mediterranean Region (EMR) proposed strategic directions for countries to progress towards the elimination of viral hepatitis by 2030. In 2019, we reviewed progress to gain a picture of current pressures and identify priority actions for member states to reach this goal. We collected data from country, regional, and global reports published in 2015-19, questionnaires completed by countries, and convened a regional consultation with programme managers and partners. We analysed these data along three thematic areas: governance and finance, strategic information, and service delivery. 15 of the 22 EMR countries completed the review. Of these, 10 (67%) had a national strategy and six (40%) allocated funds to it. 11 (73%) countries had testing and treatment guidelines in line with WHO recommendations. Ten (67%) countries had burden and coverage estimates, four (27%) reported on the cascade of care for hepatitis C virus (HCV), three (20%) reported on the cascade of care for hepatitis B (HBV), and three (20%) had mortality estimates. By 2019, the regional hepatitis B vaccination coverage among infants was 82% for the third dose and 33% for the timely birth dose. For harm reduction, 27 syringes were distributed per injecting drug user per year. Between 2015 and 2019, HCV diagnosis increased from 18% to 33% and treatment for hepatitis C increased from 12% to 26%. Within the same time period, diagnosis of HBV diagnosis increased from 2% to 14% and treatment initiation increased from less than 1% to 2%. EMR countries made progress in governance, policy development, coverage of the third dose of the hepatitis B vaccine, and testing and treatment for HCV infection. However, birth dose vaccination, injection safety, harm reduction, and testing and treatment are limited by insufficient financing. Core interventions need to be included within national universal health coverage packages as an initial move towards elimination.

Over-Prescription and Overuse of Antimicrobials in the Eastern Mediterranean Region: The Urgent Need for Antimicrobial Stewardship Programs with Access, Watch, and Reserve Adoption.

Excessive antimicrobial use contributes to the development of antimicrobial resistance. In the Eastern Mediterranean region (EMR), there is dearth of information on the prevalence of antimicrobial use in patients hospitalized in acute healthcare settings, clinical indications, types of antimicrobials prescribed, and quality indicators for prescriptions. Between September and December 2019, seven countries in the EMR conducted a standardized point prevalence survey. All patients present in the hospital wards at 8 a.m. on the day of the survey constituted the sample population. We collected data, including patient characteristics, antimicrobials received, therapeutic indication according to predefined lists, and markers of prescribing quality. The survey included data from 139 hospitals in seven countries. Among the 19,611 inpatients surveyed, 11,168 patients received at least one antimicrobial {crude prevalence: 56.9% (95%CI: 56.2-57.6%). The top three classes of antimicrobials prescribed were third-generation cephalosporins (26.7%), beta-lactam penicillins (18.1%), and imidazole derivatives (n = 1655, 9.8%). Carbapenems were most frequently prescribed for the treatment of healthcare-associated infections. Compliance with quality indicators of antimicrobial use was limited where treatment guidelines were available for 41% of antimicrobial prescriptions and targeted antimicrobial treatment represented 21% of therapeutic indications. Overall hospital antimicrobial use was high in countries of the EMR, pointing to the need to design and implement context-specific antimicrobial stewardship programs to optimize antimicrobial use and reduce antimicrobial resistance.

Worldwide prevalence of hepatitis B virus and hepatitis C virus among patients with cirrhosis at country, region, and global levels: a systematic review.

BACKGROUND: Empirical, updated country-level estimates on the proportion of cirrhosis attributable to viral hepatitis are required. We estimated the prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection in patients with cirrhosis at country, regional, and global levels as an approximation for the fractions of cirrhosis attributable to viral hepatitis. METHODS: In this systematic review, we searched MEDLINE, Embase, Web of Science, and Scielo between Jan 1, 1993, and Aug 1, 2021. Studies were eligible if they reported on the prevalence of both HBV and HCV infection in representative studies of at least 20 patients with cirrhosis. Studies were excluded if they used first-generation HCV assays or were from a selected population of patients with cirrhosis (eg, patients selected based on specific causes, veterans, injecting drug users). Two authors (CJA and CdM) selected and extracted aggregated data from the selected publications. Data were extracted for study recruitment period, age, sex, and cause of cirrhosis, among others. Data about heavy alcohol consumption and non-alcoholic fatty liver disease (NAFLD) were also extracted when available. Aggregated data from studies from key publications were requested from the authors of the original study if selection of patients was unclear or information on causes was missing. We estimated the country-specific prevalence of causes of cirrhosis by pooling study-level data from the same country using a random-effects model. Subsequently, we estimated the regional (WHO region and UN subregion) and global prevalence by weighting the country-specific prevalence by the number of new liver cancer cases that occurred in 2020, as estimated in GLOBOCAN. The study was registered with PROSPERO, CRD42020149323. FINDINGS: Our database searches identified 21 338 records, and a further nine records were identified by scanning references of key publications. After excluding duplicates and assessing full-text articles for eligibility, 520 publications from 86 countries or territories (and reporting on 1 376 503 patients with cirrhosis) were included in the systematic review. The prevalence of HBV infection was lower among patients with cirrhosis in Europe, the Americas, and Oceania (UN subregional prevalence ranges 3-14%) than in Africa and Asia (8-61%). HCV infection prevalence was heterogenous, even within regions (12-83%). The combined prevalence of HBV and HCV infection exceeded 50% in most Asian and African regions. Globally, among patients with cirrhosis, 42% had HBV infection and 21% had HCV infection. The contribution of heavy alcohol use was highest in Europe (country range 16-78%), the Americas (17-52%), and Oceania (15-37%) and lowest in Asia (0-41%). Data on NAFLD were limited. INTERPRETATION: HBV and HCV could account for almost two thirds of the global burden of cirrhosis. With the availability of effective interventions for the prevention or treatment of HBV and HCV, the data presented in this study will help to effectively allocate resources towards viral hepatitis elimination and to design interventions at the country level. FUNDING: International Agency for Research on Cancer, World Health Organization.

Five pond-centred outbreaks of cholera in villages of West Bengal, India: evidence for focused interventions.

In rural West Bengal, outbreaks of cholera are often centred around ponds that is a feature of the environment. Five investigations of laboratory-confirmed, pond-centred outbreaks of cholera were reviewed. Case-control odds ratios were approximated with relative risks (RRs) as the incidence was low. The environment was investigated to understand how the pond(s) could have become contaminated and could have infected villagers. The five outbreaks of cholera in 2004-2008 led to 277 cases and three deaths (median attack rate: 51/1,000 people; case fatality: 1.1%; median age of case-patients: 22 years; median duration: 13 days, range: 6-15 days). Factors significantly (p<0.05) associated with cholera in the case-control (n=4) and cohort investigations (n=1) included washing utensils in ponds (4 outbreaks of cholera, RR range: 6-12), bathing (3 outbreaks of cholera, RR range: 3.5-9.3), and exposure to pond water, including drinking (2 outbreaks of cholera, RR range: 2.1-3.2), mouth washing (1 outbreak of cholera, RR: 4.8), and cooking (1 outbreak of cholera, RR: 3.0). Initial case-patients contaminated ponds through washing soiled clothes (n=4) or defaecation (n=1). Ubiquitous ponds used for many purposes transmit cholera in West Bengal. Focused health education, hygiene, and sanitation must protect villagers, particularly following the occurrence of an index case in a village that has ponds.

The global hepatitis delta virus (HDV) epidemic: what gaps to address in order to mount a public health response?

BACKGROUND: Co-infection between hepatitis B virus (HBV) and hepatitis delta virus (HDV) causes the severest chronic hepatitis and is associated with a high risk of cirrhosis and hepatocellular carcinoma (HCC). The Global Health Sector Strategy on Viral Hepatitis called for the elimination of hepatitis (- 65% mortality and - 90% incidence) by 2030. Our aims were to summarize key points of knowledge and to identify the gaps that need to be addressed to mount a public health response to HDV. METHODS: We performed a current literature review in terms of epidemiology by WHO regions, genotypes distribution and their pathogenicity, factors associated with HDV infection, mortality due to HDV infection, testing strategies and treatment. RESULTS: Prevalence of infection and genotypes are heterogeneous distributed, with highest prevalence in foci around the Mediterranean, in the Middle East, and in Central, Northern Asia and Eastern Asia. Persons who inject drugs (PWID) and migrants from highly endemic areas are highly affected. While antibody detection tests are available, HDV RNA tests of current infection are not standardized nor widely available. The few therapeutic options, including lofartinib, are not widely available; however several new and promising agents have entered clinical trials. CONCLUSION: HDV infection is an poorly known cause of chronic liver disease. To mount a public health response, we need a better description of the HDV epidemic, standardized testing strategies and better treatment options.

A malaria outbreak in Naxalbari, Darjeeling district, West Bengal, India, 2005: weaknesses in disease control, important risk factors.

An outbreak of malaria in Naxalbari, West Bengal, India, in 2005 was investigated to understand determinants and propose control measures. Malaria cases were slide-confirmed. Methods included calculation of annual blood examination rates (ABER, number of slides examined/population), collection of water specimens from potential vector-breeding sites, sorting of villages in categories depending on the number of abandoned wells within two kilometers radius and review of the DDT spray coverage. Cases were compared with matched neighbourhood controls in terms of personal protection using matched odds ratios (MOR). 7,303 cases and 17 deaths were reported between April 2005 and March 2006 with a peak during October rains (Attack rate: 50 per 1,000, case fatality: 0.2%). The attack rate increased according to the number of abandoned wells within 2 kilometres radius (P < 0.0001, Chi-square for trend). Abandoned wells were Anopheles breeding sites. Compared with controls, cases were more likely to sleep outdoors (MOR: 3.8) and less likely to use of mosquito nets and repellents (MOR: 0.3 and 0.1, respectively). DDT spray coverage and ABER were 39% and 3.5%, below the recommended 85% and 10%, respectively. Overall, this outbreak resulted from weaknesses in malaria control measures and a combination of factors, including vector breeding, low implementation of personal protection and weak case detection.

Persistence of diphtheria, Hyderabad, India, 2003-2006.

During 2003-2006, diphtheria rates in Hyderabad, India, were higher among persons 5-19 years of age, women, and Muslims than among other groups. Vaccine was efficacious among those who received >/=4 doses. The proportion of the population receiving boosters was low, especially among Muslims. We recommend increasing booster dose coverage.

How far are we from viral hepatitis elimination service coverage targets?

INTRODUCTION: In 2016, the Global Health Sector Strategy (GHSS) on viral hepatitis called for elimination of viral hepatitis as a major public health threat by 2030 (i.e. 90% reduction in incidence and 65% in mortality). In 2017, WHO's first-ever Global Hepatitis Report presented the baseline values for each of the core indicators of the strategy. We review the challenges and opportunities that lie ahead in order to reach the 2030 service coverage targets. DISCUSSION: Three-dose coverage of hepatitis B vaccine in infancy reached 84% in 2015 (2030 target: 90%); however, only 39% received the timely birth dose (2030 target: 90%). Blood safety (97% of blood units screened with quality assurance, 2030 target: 100%) and injection safety (5% unsafe injections, 2030 target: 0%) had made substantial progress while harm reduction fell short (27 syringe and needle sets distributed per person who injects drugs per year, 2030 target: 300). Worldwide, 9% and 20% of the HBV- and HCV-infected population respectively, were aware of their status (2030 targets: 90%). In the short term, to reach the 2020 target of diagnosing 50% of those infected, 107 million HBV infected persons and 15 million HCV infected persons should be urgently diagnosed. Overall, in 2015, less than 10% of known infected persons were on HBV treatment or had started HCV treatment (2030 targets: 80%). CONCLUSIONS: The prevention component of elimination is on track with respect to hepatitis B vaccination, blood safety, and injection safety. However, coverage of the hepatitis B vaccine timely birth dose requires a substantial increase, particularly in sub-Saharan Africa, and harm reduction needs to be taken to scale as injecting drug use accounts for a third of mortality from HCV infection. A promising but limited start in hepatitis testing and treatment needs to be followed by immediate and sustained action so that we reach the service coverage targets required to achieve elimination by 2030. Treating persons coinfected with HIV and hepatitis viruses is particularly urgent and needs to be promoted in the context of the HIV response.