Gavi Support for Typhoid Conjugate Vaccines: Moving From Global Investments to Country Introduction.

Nine years elapsed between Gavi's investment decision to support typhoid conjugate vaccines (TCVs) in 2008 and Gavi support becoming available for countries to introduce TCV. The protracted path toward Gavi support for TCV highlights the challenges of vaccine development for lower-income countries and the importance of Gavi engagement as early as possible in product development processes to support the alignment of manufacturing, global policy, and program implementation. Early engagement would provide inputs to inform strategic vaccine investment decisions that transition more efficiently toward country implementation. Several countries have been approved for Gavi support to introduce TCV in 2019-2020. The paucity of generalizable typhoid epidemiological data in early introducing countries has reinforced the need for continued evidence generation regarding typhoid epidemiology and TCV impact. This has led to the development of guidance and tools to support country decision making for TCV introduction based on enhanced understanding of local typhoid burden and risk.

Transition Planning For After Polio Eradication.

The Global Polio Eradication Initiative (GPEI) has been in operation since 1988, now spends $1 billion annually, and operates through thousands of staff and millions of volunteers in dozens of countries. It has brought polio to the brink of eradication. After eradication is achieved, what should happen to the substantial assets, capabilities, and lessons of the GPEI? To answer this question, an extensive process of transition planning is underway. There is an absolute need to maintain and mainstream some of the functions, to keep the world polio-free. There is also considerable risk-and, if seized, substantial opportunity-for other health programs and priorities. And critical lessons have been learned that can be used to address other health priorities. Planning has started in the 16 countries where GPEI's footprint is the greatest and in the program's 5 core agencies. Even though poliovirus transmission has not yet been stopped globally, this planning process is gaining momentum, and some plans are taking early shape. This is a complex area of work-with difficult technical, financial, and political elements. There is no significant precedent. There is forward motion and a willingness on many sides to understand and address the risks and to explore the opportunities. Very substantial investments have been made, over 30 years, to eradicate a human pathogen from the world for the second time ever. Transition planning represents a serious intent to responsibly bring the world's largest global health effort to a close and to protect and build upon the investment in this effort, where appropriate, to benefit other national and global priorities. Further detailed technical work is now needed, supported by broad and engaged debate, for this undertaking to achieve its full potential.

Monitoring Results in Routine Immunization: Development of Routine Immunization Dashboard in Selected African Countries in the Context of the Polio Eradication Endgame Strategic Plan.

Background: To monitor immunization-system strengthening in the Polio Eradication Endgame Strategic Plan 2013-2018 (PEESP), the Global Polio Eradication Initiative identified 1 indicator: 10% annual improvement in third dose of diphtheria- tetanus-pertussis-containing vaccine (DTP3) coverage in polio high-risk districts of 10 polio focus countries. Methods: A multiagency team, including staff from the African Region, developed a comprehensive list of outcome and process indicators measuring various aspects of the performance of an immunization system. Results: The development and implementation of the dashboard to assess immunization system performance allowed national program managers to monitor the key immunization indicators and stratify by high-risk and non-high-risk districts. Discussion: Although only a single outcome indicator goal (at least 10% annual increase in DTP3 coverage achieved in 80% of high-risk districts) initially existed in the endgame strategy, we successfully added additional outcome indicators (eg, decreasing the number of DTP3-unvaccinated children) as well as program process indicators focusing on cold chain, stock availability, and vaccination sessions to better describe progress on the pathway to raising immunization coverage. Conclusion: When measuring progress toward improving immunization systems, it is helpful to use a comprehensive approach that allows for measuring multiple dimensions of the system.

Experiences and Lessons From Polio Eradication Applied to Immunization in 10 Focus Countries of the Polio Endgame Strategic Plan.

Nine polio areas of expertise were applied to broader immunization and mother, newborn and child health goals in ten focus countries of the Polio Eradication Endgame Strategic Plan: policy & strategy development, planning, management and oversight (accountability framework), implementation & service delivery, monitoring, communications & community engagement, disease surveillance & data analysis, technical quality & capacity building, and partnerships. Although coverage improvements depend on multiple factors and increased coverage cannot be attributed to the use of polio assets alone, 6 out of the 10 focus countries improved coverage in three doses of diphtheria tetanus pertussis containing vaccine between 2013 and 2015. Government leadership, evidence-based programming, country-driven comprehensive operational annual plans, community partnership and strong accountability systems are critical for all programs and polio eradication has illustrated these can be leveraged to increase immunization coverage and equity and enhance global health security in the focus countries.

An assessment of hepatitis B vaccine introduction in India: Lessons for roll out and scale up of new vaccines in immunization programs.

BACKGROUND: Hepatitis B vaccine was introduced in the Universal Immunization Program (UIP) of 10 states of India in the year 2007-08. This assessment was planned and conducted to ascertain the reasons for low reported coverage of Hepatitis B (Hep B) vaccine in comparison of similarly timed diphtheria, pertussis, and tetanus (DPT) vaccine; to identify operational and programmatic challenges in new vaccine introductions, and to derive lessons for scale up of Hep B vaccination (or for introduction of any new vaccine) in UIP of India. MATERIALS AND METHODS: Purposive sampling with both quantitative and qualitative data collection. Two districts each were purposively selected from 5 of the 10 states, which introduced Hep B vaccine, in the year 2007-08, in India. A protocol was devised and data was collected through desk review, in-depth interviews and on-site observation at state, districts and facility levels. The assessment was completed in December 2009. RESULTS: Coverage with three doses of Hep B vaccine was lower than similarly timed three doses of DPT vaccine. Poor stock management ("stock outs or nil stocks" at various levels), incomplete recording and reporting, perceived costly vaccine & related fear of wastage of vaccine in 10 dose vial, and incomplete knowledge amongst health functionaries about vaccination schedule were the main reasons cited for reported lower coverage. Hep B vaccine birth dose was introduced in only 3 of 5 states evaluated. The additional reasons for low Hep B birth dose coverage were lack of knowledge amongst Health Workers about birth dose administration, no mechanism for recording birth dose, and insufficient trainings, official communications, and coordination at various levels. CONCLUSIONS: There had been a few challenges in the introduction of Hepatitis B vaccination in India, however, this provide opportunity to learn for future scale up. For successful introduction and expansion of any new vaccine in national or state immunization program; clear and timely central level instructions and oversight and improved stock management is required. At state and district levels; quality trainings, effective supervision and monitoring, improving data recording and reporting are key factor for success. The additional focus on Hep B birth dose administration may help in improving coverage.

A long-lasting measles epidemic in Maroua, Cameroon 2008-2009: mass vaccination as response to the epidemic.

BACKGROUND: A measles outbreak occurred in Maroua, Cameroon, from January 2008 to April 2009. In accordance with recent World Health Organization guidelines, an outbreak-response immunization (ORI) was conducted in January 2009. The aim of this study was to investigate the causes of the epidemic in order to guide vaccination strategies. METHODS: We performed a stratified household-based survey using cluster sampling to determine measles vaccination coverage in children aged 9 months to 15 years. We defined 3 strata based on measles incidence. Next, we performed a case-control study to measure vaccine effectiveness (VE). Cases were obtained from health center registries. Controls were selected among respondents to the coverage survey. RESULTS: The vaccination-coverage survey included 2963 children in total. The overall routine vaccination coverage was 74.1% (95% confidence interval [CI]: 70.0%-78.3%). Measles incidence was inversely proportional to routine vaccination coverage, with high incidence associated with coverage of 71% and low incidence associated with coverage of 84%. The overall VE was 94% (95% CI, 86.7%-97.4%). After the ORI in January 2009, the coverage was >90% in all strata and measles incidence declined rapidly. DISCUSSION: Our results confirm that insufficient vaccination coverage was the main reason for this epidemic. The ORI conducted in January 2009 contributed both to control the epidemic and to increase the vaccination coverage to desirable levels.

Seroprevalence of measles and natural rubella antibodies among children in Bangui, Central African Republic.

BACKGROUND: Passively acquired maternal antibodies are necessary to protect infants against circulating measles virus until they reach the eligible age of vaccination. Likewise, high levels of population immunity must be achieved and maintained to reduce measles virus transmission. This study was undertaken to (1) assess the presence of maternally acquired measles-specific IgG antibodies among infants less than 9 months of age in Bangui, Central African Republic and (2) determine the immune status of vaccination-age children and the concordance with reported vaccination status. A secondary objective was to describe the presence of rubella-specific IgG antibody in the study population. METHODS: Vaccination history and blood samples were collected from 395 children using blotting paper. Samples were analyzed for the presence of measles-specific IgG antibodies using commercial ELISA kits. RESULTS: Measles-specific IgG antibodies were detected in 51.3% of vaccinated children and 27.6% of non-vaccinated children. Maternally derived measles IgG antibodies were present in only 14.8% of infants aged 0-3 months and were absent in all infants aged 4-8 months. The presence of IgG-specific measles antibodies varied among children of vaccination age, from 57.3% for children aged 9 months to 5 years, to 50.6% for children aged 6-9 years and 45.6% for chidren aged 10 years and above. The overall prevalence of rubella-specific IgG was 55.4%, with a high prevalence (87.4%) among children over 10 years of age. CONCLUSION: The findings suggest that despite efforts to accelerate measles control by giving a second dose of measles vaccine, a large number of children remain susceptible to measles virus. Further research is required to determine the geographic extent of immunity gaps and the factors that influence immunity to measles virus in the Central African Republic.

Cluster survey evaluation of a measles vaccination campaign in Jharkhand, India, 2012.

INTRODUCTION: India was the last country in the world to implement a two-dose strategy for measles-containing vaccine (MCV) in 2010. As part of measles second-dose introduction, phased measles vaccination campaigns were conducted during 2010-2013, targeting 131 million children 9 months to <10 years of age. We performed a post-campaign coverage survey to estimate measles vaccination coverage in Jharkhand state. METHODS: A multi-stage cluster survey was conducted 2 months after the phase 2 measles campaign occurred in 19 of 24 districts of Jharkhand during November 2011-March 2012. Vaccination status of children 9 months to <10 years of age was documented based on vaccination card or mother's recall. Coverage estimates and 95% confidence intervals (95% CI) for 1,018 children were calculated using survey methods. RESULTS: In the Jharkhand phase 2 campaign, MCV coverage among children aged 9 months to <10 years was 61.0% (95% CI: 54.4-67.7%). Significant differences in coverage were observed between rural (65.0%; 95% CI: 56.8-73.2%) and urban areas (45.6%; 95% CI: 37.3-53.9%). Campaign awareness among mothers was low (51.5%), and the most commonly reported reason for non-vaccination was being unaware of the campaign (69.4%). At the end of the campaign, 53.7% (95% CI: 46.5-60.9%) of children 12 months to <10 years of age received ≥ 2 MCV doses, while a large proportion of children remained under-vaccinated (34.0%, 95% CI: 28.0-40.0%) or unvaccinated (12.3%, 95% CI: 9.3-16.2%). CONCLUSIONS: Implementation of the national measles campaign was a significant achievement towards measles elimination in India. In Jharkhand, campaign performance was below the target coverage of ≥ 90% set by the Government of India, and challenges in disseminating campaign messages were identified. Efforts towards increasing two-dose MCV coverage are needed to achieve the recently adopted measles elimination goal in India and the South-East Asia region.

A new tool for malaria prevention?: Results of a trial of permethrin-impregnated bedsheets (shukas) in an area of unstable transmission.

BACKGROUND: Despite gains in malaria control through impregnated treated nets (ITN), malaria remains a major concern. Netting is expensive and impractical for many communities. Here we present the findings of a community-based trial of impregnated bedsheets (shukas) in Kenya. METHODS: A total of 472 individuals were enrolled in a randomized community trial where the unit of randomization was the hamlet (manyatta). Baseline data included socio-demographic data, parasite prevalence data from thick and thin blood smears, and clinical measures of malaria. The intervention involved the dipping of shukas owned by the experimental group in permethrin. FINDINGS: The prevalence of malaria in the study population (based on laboratory results) was considerably lower than that used for the power calculation based on clinical estimates (2.2% versus 20%). For those aged 6 or over, the rate of malaria cases (events per 10 000 person-days at risk) was 1.41 in the experimental group versus 7.49 in the control group (incidence rate ratio 0.187, 95% CI: 0.046- 0.770). For children

Examining the determinants of mosquito-avoidance practices in two Kenyan cities.

BACKGROUND: This study assesses the behavioural and socio-economic factors associated with avoiding mosquitoes and preventing malaria in urban environments in Kenya. METHODS: Data from two cities in Kenya were gathered using a household survey and a two-stage cluster sample design. The cities were stratified based on planning and drainage observed across the urban areas. This helped control for the strong environmental and topographical variation that we assumed influences mosquito ecology. Individual interviews given to each household included questions on socio-economic status, education, housing type, water source, rubbish disposal, mosquito-prevention practices and knowledge of mosquitoes. In multivariate regression, factors measuring wealth, education level, and the communities' level of planning and drainage were used to estimate the probability that a household engages in multiple mosquito-avoidance activities, or has all members sleeping under a bed net. RESULTS: Our analysis shows that people from wealthier, more educated households were more likely to sleep under a net, in Kisumu (OR = 6.88; 95% CI = 2.56,18.49) and Malindi (OR = 3.80; 95% CI = 1.91,7.55). Similarly, the probability that households use several mosquito-prevention activities was highest among the wealthiest, best-educated households in Kisumu (OR = 5.15; 95% CI = 2.04,12.98), while in Malindi household wealth alone is the major determinant. CONCLUSION: We demonstrate the importance of examining human-mosquito interaction in terms of how access to resources may enhance human activities. The findings illustrate that the poorest segments of society are already doing many things to protect themselves from being bitten, but they are doing less than their richer neighbours.

Case based measles surveillance in Pune: evidence to guide current and future measles control and elimination efforts in India.

BACKGROUND: According to WHO estimates, 35% of global measles deaths in 2011 occurred in India. In 2013, India committed to a goal of measles elimination by 2020. Laboratory supported case based measles surveillance is an essential component of measles elimination strategies. Results from a case-based measles surveillance system in Pune district (November 2009 through December 2011) are reported here with wider implications for measles elimination efforts in India. METHODS: Standard protocols were followed for case identification, investigation and classification. Suspected measles cases were confirmed through serology (IgM) or epidemiological linkage or clinical presentation. Data regarding age, sex, vaccination status were collected and annualized incidence rates for measles and rubella cases calculated. RESULTS: Of the 1011 suspected measles cases reported to the surveillance system, 76% were confirmed measles, 6% were confirmed rubella, and 17% were non-measles, non-rubella cases. Of the confirmed measles cases, 95% were less than 15 years of age. Annual measles incidence rate was more than 250 per million persons and nearly half were associated with outbreaks. Thirty-nine per cent of the confirmed measles cases were vaccinated with one dose of measles vaccine (MCV1). CONCLUSION: Surveillance demonstrated high measles incidence and frequent outbreaks in Pune where MCV1 coverage in infants was above 90%. Results indicate that even high coverage with a single dose of measles vaccine was insufficient to provide population protection and prevent measles outbreaks. An effective measles and rubella surveillance system provides essential information to plan, implement and evaluate measles immunization strategies and monitor progress towards measles elimination.

Rolling out insecticide treated nets in Eritrea: examining the determinants of possession and use in malarious zones during the rainy season.

OBJECTIVE: This paper describes determinants of insecticide treated net (ITN) ownership and use in malarious areas of Eritrea. With ITN distribution and re-treatment now free for all living in these areas, we examine barriers (other than cost) to access and use of ITNs. We explore the differences between use of an ITN as a proportion of all households in the survey (the roll back malaria indicator), and use of an ITN as a proportion of those households who already own an ITN. METHODS: A modified two-stage cluster design was used to collect data from a sample of households (n = 2341) in the three most malarious administrative zobas (zones or provinces). Logistic regression was used to analyse the data. RESULTS: Our findings suggest environmental heterogeneity among zobas (including program effects specific to each zoba), perception of risk, and proximity to a clinic are important predictors of ITN possession and use. Among households with at least one ITN, 17.0% reported that children under five were not under an ITN the night before the survey, while half of all such households did not have all occupants using them the night before the survey. The number of ITNs, as well as zoba, was also significant determinants of use in these households with at least one ITN. CONCLUSION: Current efforts to disseminate ITNs to vulnerable populations in Eritrea are working, as suggested by high ITN ownership and net-to-person ratios inside households. However, the gap between ITN ownership and use, given ownership, is large, and may represent lost opportunities to prevent infection. Closing this gap requires concerted efforts to change behaviour to ensure that all household members use ITNs as consistently and correctly as possible during and following the rains.