Inequities in the deployment of COVID-19 vaccine in the WHO Eastern Mediterranean Region, 2020-2021.

The WHO Eastern Mediterranean Region (EMR) is characterised by a large range in routine immunisation coverage. We reviewed progress in access, deployment efforts, and use of COVID-19 vaccines in the EMR to identify bottlenecks and propose recommendations. We compiled and analysed data reported to WHO regarding the number of vaccines provided emergency use authorisation (EUA) in each country, the number of vaccine doses allocated and delivered by COVAX, the number of vaccine doses received bilaterally, the date of initiation of vaccination, vaccine usage rate and overall vaccination coverage. In June-July and October-November 2021, we conducted two rounds of a regional survey to assess vaccine acceptance and calculated the weighted proportion of individuals who would get vaccinated once a vaccine is available and recommended. We stratified the analysis according to four groups based on their participation status in COVAX, from the highest to lowest income, that is, (1) fully self-financing high-income countries (group 1), (2) fully self-financing upper middle-income countries (group 2), (3) Advance Market Commitment (AMC) countries not eligible to receive Gavi support (group 3) and (4) AMC countries eligible for Gavi support (group 4). As of 31 December 2021, the median number of vaccines provided with EUA was 6 for group 1, 11 for group 2, 8 for group 3 and 9 for group 4. On the same date, COVAX had delivered 179 793 310 doses to EMR countries. Vaccination started on 10 December 2020 in group 1, on 13 December 2020 in group 2, on 30 December 2020 in group 3 and on 20 January 2021 in group 4. The regional acceptance survey (first round) pointed to higher vaccine acceptance in group 1 (96%), than in others, including group 2 (73.9%), group 3 (78.8%) and group 4 (79.3%), with identical patterns in the second round (98%, 78%, 84% and 76%), respectively. Usage of vaccine allocated by COVAX to participating countries was 89% in group 1, 75% in group 2, 78% in group 3 and 42% in group 4. The full dose and partial dose coverage decreased with the income groups of countries, from 70% and 6% in group 1, to 43% and 8% in group 2, to 33% and 11% in group 3, and 20% and 8% in group 4. All 22 EMR countries introduced COVID-19 vaccines by 21 April 2021, but with major inequities in coverage. Additional efforts are needed to address the determinants of unequal vaccine coverage at all stages of the result chain to improve vaccine equity.

Prevalence of HBV and HCV infections, Bhutan, 2017: Progress and next steps.

BACKGROUND: Bhutan is committed to eliminating hepatitis B and hepatitis C, though recent baseline estimates of disease burden in the general population are unknown. In 2017, we carried out a biomarker survey in the general population to estimate the prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) biomarkers to evaluate the impact of immunization and guide further efforts. METHODS: In 2017, a cross-sectional, population-based, three-stage cluster survey was undertaken of the general population (1-17 and 20+ years of age). We visited households, collected blood specimens and administered a standard questionnaire. Specimens were collected for hepatitis B surface antigen (HBsAg) and hepatitis C virus antibody (anti-HCV) testing. We calculated prevalence of infection and selected characteristics, along with confidence intervals (CIs). RESULTS: Of 1372 individuals approached, 1358 (99%) participated. Of those, 1321 (97%) had a specimen tested for HBsAg, and among 1173 enrolled individuals 5 years of age or older, 1150 (98%) individuals were tested for anti-HCV. The prevalence of HBsAg was 2.0% in 775 persons 20 years of age or older (95% CI: 1.0-4.0) and 0.5% in 546 persons 1-17 years of age (95% CI: 0.1-1.8). The prevalence of anti-HCV was 0.3% (95% CI: 0.1-0.8) among persons ≥5 years. CONCLUSIONS: Universal hepatitis B immunization of infants has resulted in a low prevalence of chronic HBV infection in persons 1-17 years of age and the prevalence of anti-HCV is low among persons aged ≥5 years. Efforts should continue to reach high coverage of the timely birth dose along with completion of the hepatitis B vaccine series. To reduce the chronic liver disease burden among adults, HBV and HCV testing and treatment as indicated might be restricted to pregnant women, blood donors, individuals with chronic liver diseases, and other groups with history of high-risk exposures.

Increased financial accessibility and targeted education messages could increase ownership and use of mosquito nets in Purulia District, West Bengal, India.

Insecticide-treated mosquito nets are effective in reducing malaria transmission and mortality, yet they are underused for prevention. In this study, 561 households in 33 clusters were surveyed to estimate the coverage of net ownership and the frequency of use according to selected characteristics. Of the 540 participating household heads, 247 (46%) owned mosquito nets. Of 1681 individuals in households with mosquito nets, 1359 (81%) used the nets. A household monthly income > or =2000 Indian rupees (US$45) was strongly associated with mosquito net ownership (prevalence ratio=12, 95% CI 7.8-82). Factors independently associated with net use in multivariate analysis included age < 35 years (P<0.001), sleeping inside (P<0.001), use of repellent (P=0.03) as well as knowledge that mosquitoes cause malaria (P=0.002) and that malaria is severe in children (P<0.001). Whilst household income is the strongest determinant of mosquito net ownership, selected knowledge elements are associated with net use. It is necessary to improve financial accessibility to nets and to communicate that malaria is a disease transmitted by mosquitoes that could be fatal in children.

Scrub typhus in Darjeeling, India: opportunities for simple, practical prevention measures.

To identify risk factors for scrub typhus in Darjeeling, India, we compared 62 scrub typhus cases (acute fever with eschar and specific IgM) with 62 neighbourhood controls. Cases were more likely to live close to bushes [matched odds ratio (MOR) 10; 95% CI 2.3-63] and wood piles (MOR 3.5; 95% CI 1.5-9.5), to work on farms (MOR 10; 95% CI 2.7-63), to observe rodents at home (MOR 3.6; 95% CI 1.4-11) and at work (MOR 9; 95% CI 2.4-57), and to rear domestic animals (MOR 2.4; 95% CI 1.1-5.7). Cases were less likely to wash after work (MOR 0.4; 95% CI 0.1-0.9) and change clothes to sleep (MOR 0.2; 95% CI 0.1-0.5). A cleaner, rodent-controlled environment may prevent exposure to scrub typhus. Personal protection measures and better hygiene could further reduce individual risk.

An urban, water-borne outbreak of diarrhoea and shigellosis in a district town in eastern India.

BACKGROUND: In September 2007, the Gayeshpur municipality reported a cluster of cases with diarrhoea. We aimed to identify the causative agent and the source of the disease. METHODS: We defined a case as the occurrence of diarrhoea (> 3 loose stools/day) with fever or bloody stools in a resident of Gayeshpur in September-October 2007. We asked healthcare facilities to report cases, collected stool specimens from patients, constructed an epidemic curve, drew a map and calculated the incidence by age and sex. We also conducted a matched case-control study (58 in each group), calculated matched odds ratio (MOR) and population attributable fraction (PAF), as well as assessed the environment. RESULTS: We identified 461 cases (attack rate: 46/1000 population) and isolated Shigella flexneri (serotype 2a and 3a) from 3 of 4 stool specimens. The attack rate was higher among females (52/1000) and those in the age group of 45-59 years (71/1000). The outbreak started on 22 September, peaked multiple times and subsided on 12 October 2007. Cases were clustered distal to a leaking pipeline that crossed an open drain to intermittently supply non-chlorinated water to taps. The 58 cases and 58 controls were matched for age and sex. Drinking tap water (MOR: 10; 95% CI: 3-32; PAF: 89%), washing utensils in tap water (MOR: 3.7; 95% CI: 1.2-11.3) and bathing in tap water (MOR: 3.5; 95% CI: 1.1-11) were associated with the illness. CONCLUSION: This outbreak of diarrhoea and Shigella flexneri dysentery was caused by contamination of tap water and subsided following repair of the pipeline. We recommended regular chlorination of the water and maintenance of pipelines.

Outbreak of waterborne hepatitis E in Hyderabad, India, 2005.

A large outbreak of hepatitis E occurred in 2005 in Hyderabad, Andhra Pradesh, India. A total of 1611 cases were reported between 1 March and 31 December 2005 (attack rate 40/100,000). The epidemic curve suggested a continuing common source outbreak. Cases were centred around open sewage drains that crossed the old city. The attack rate was significantly higher in neighbourhood blocks supplied by water supply lines that crossed open drains (203/100,000) than in blocks supplied by non-crossing water pipes with a linear trend (38/100 000, P<0.00001). Crossing water pipelines were repaired and the attack rates declined.

Injection practices in Burkina Faso in 2000.

BACKGROUND: Unsafe delivery and overuse of injections can result in the spread of hepatitis B virus, hepatitis C virus, and HIV. The aim of the present survey was to estimate the frequency of safe injection practices in Burkina Faso. METHOD: Using the new standardized World Health Organization tool to assess injection practices, we selected 80 primary health facilities with a two-stage cluster sampling method, collected information using structured observations and provider interviews, and analyzed the data using Epi-Info software. RESULTS: We observed 116 injections in 52 facilities. In 50 facilities [96%; 95% confidence interval (CI) 85-99%] injections were given with a new, single-use syringe and needle. In 29 facilities (56%; 95% CI 36-74%), staff recapped needles using two hands. All 80 facilities visited had a stock in the community to provide new, single-use syringes and needles. In 61% (95% CI 54-79%) of facilities, staff reported needlestick injuries in the last 12 months. Used needles were discarded in open containers in 66 facilities (83%; 95% CI 55-96%) and observed in the surroundings of 46 facilities (57%; 95% CI 32-80%). CONCLUSIONS: In 2000, most of the health facilities in Burkina Faso were using sterile injection equipment. However, practices were still observed that could expose patients, health care workers, and communities to risks, and that required specific interventions.

The role of child care in a community-wide outbreak of hepatitis A.

OBJECTIVE: To evaluate the role of child care centers in a community-wide hepatitis A epidemic. METHODS: We analyzed surveillance data during an epidemic in Maricopa County, Arizona, from January to October 1997 and conducted a case-control study using a sample of cases reported from June to November. Cases were physician-diagnosed and laboratory confirmed; control subjects were frequency matched by age and neighborhood. Information regarding hepatitis A risk factors, including child care-related exposures, was collected. Characteristics of all licensed child care centers in the county were obtained through review of computerized lists from the Arizona Office of Child Day Care Licensing. Surveillance data were linked to the child care list to determine which centers had reported hepatitis A cases. We conducted univariate and multivariate conditional logistic analyses and calculated population attributable risks (PAR). RESULTS: In total, 1242 cases (50/100 000 population) were reported. The highest rates occurred among people aged 0 to 4 (76/100 000), 5 to 14 (95/100 000), and 15 to 29 (79/100 000) years. The most frequently reported risk factor was contact with a hepatitis A patient (45%). However, nearly 80% of these contacts were with individuals who attended or worked in a child care center. Overall, child care center-related contact could have been the source of infection for 34% of case-patients. In the case-control study, case-patients (n = 116) and control subjects (n = 116) did not differ with respect to demographic characteristics. A total of 51% of case-patients compared with 18% of control subjects reported attending or working in a child care setting (direct contact; adjusted odds ratio [OR]: 6.0; 95% confidence interval [CI]: 2.1-23.0) or being a household contact of such a person (indirect contact; OR: 3.0; 95% CI: 1.3-8.0). In age-stratified analyses, the association between hepatitis A and direct or indirect contact with child care settings was strongest for children <6 years old and adults aged 18 to 34 years. Household contact with a person with hepatitis A also was associated with hepatitis A (OR: 9.2; 95% CI: 2.6-58.2). The presence of a child <5 years old in the household was not associated with hepatitis A. The estimated PAR for direct child care contact was 23% (95% CI: 16-34), for indirect child care contact was 21% (95% CI: 13-35), and for any child care contact was 40% (95% CI: 30-53). Information on 1243 licensed child care centers was obtained, with capacity ranging from 5 to 479 slots (mean: 87). Thirty-four (2.7%) centers reported hepatitis A cases. Centers that had a mean capacity of >50 children were more than twice as likely to have had a reported case of hepatitis A (OR: 2.6; 95% CI: 1.1-6.7). Among the 747 centers that accepted >50 children, having infant (OR: 3.7; 95% CI: 1.6-8.3), toddler (OR: 6.3; 95% CI: 2.2-20.0), or full-day service (OR; undefined; 95% CI: 1.7- ~) was associated with having a reported case of hepatitis A. CONCLUSIONS: In Maricopa County, people associated with child care settings are at increased risk of hepatitis A, and child care attendees may be an appropriate target group for hepatitis A vaccination. Considering the estimated proportion of children who attended child care and were old enough to receive hepatitis A vaccine (>/=2 years of age) and the calculated PAR, approximately 40% of cases might have been prevented if child care center attendees and staff had been vaccinated. However, epidemiologic studies indicate that the proportion of cases that are attributable to child care center exposure varies considerably among counties, suggesting that this exposure may be associated with an increased risk of hepatitis A in some communities but not in others. To prevent and control hepatitis A epidemics in communities, the Advisory Committee on Immunization Practices and the American Academy of Pediatrics have adopted a long-term strategy of routine vaccination of children who live in areas with consistently elevated hepatitis A rates. After demonstrating cost-effectiveness, a rule was implemented in January 1999 to require hepatitis A vaccination of all children who are aged 2 to 5 years and enrolled in a licensed child care facility in Maricopa County. Other communities with similar epidemiologic features might consider routine vaccination of child care center attendees as a long-term hepatitis A prevention strategy. Consistent with current recommendations, in communities with persistently elevated hepatitis A rates where child care center attendance does not play an important role in hepatitis A virus transmission in the community, child care centers may nonetheless provide a convenient access point for delivering hepatitis A as well as other routine childhood vaccinations.

Outbreak of human monkeypox, Democratic Republic of Congo, 1996 to 1997.

Human monkeypox is a zoonotic smallpox-like disease caused by an orthopoxvirus of interhuman transmissibility too low to sustain spread in susceptible populations. In February 1997, 88 cases of febrile pustular rash were identified for the previous 12 months in 12 villages of the Katako-Kombe Health Zone, Democratic Republic of Congo (attack rate = 22 per 1,000; case-fatality rate = 3.7%). Seven were active cases confirmed by virus isolation. Orthopoxvirus- neutralizing antibodies were detected in 54% of 72 patients who provided serum and 25% of 59 wild-caught animals, mainly squirrels. Hemagglutination-inhibition assays and Western blotting detected antibodies in 68% and 73% of patients, respectively. Vaccinia vaccination, which protects against monkeypox, ceased by 1983 after global smallpox eradication, leading to an increase in the proportion of susceptible people.

Multiple modes of hepatitis A virus transmission among methamphetamine users.

Methamphetamine users are at increased risk of hepatitis A, but modes of transmission are unclear. The authors conducted a case-control study among methamphetamine users during an outbreak in Iowa in 1997. Twenty-eight reported, laboratory-confirmed, hepatitis A cases did not differ from 18 susceptible controls with respect to age, sex, or number of doses used. When compared with controls in multivariate analysis, case-patients were more likely to have injected methamphetamine (odds ratio (OR) = 5.5, 95% confidence interval (CI): 1.1, 27), to have used methamphetamine with another case-patient (OR = 6.2, 95% CI: 0.95, 41), and to have used brown methamphetamine (OR = 5.5, 95% CI: 0.51, 59). Receptive needle sharing was reported by 10 of the 20 case-patients who injected. Methamphetamine use with another case-patient was also associated with hepatitis A in an analysis restricted to noninjectors (OR = 17, 95% CI: 1.0, 630). During this outbreak, hepatitis A may have been transmitted from person to person among methamphetamine users through the fecal-oral and the percutaneous routes. Methamphetamine users should be vaccinated against hepatitis A and should be given immune globulin if they used methamphetamine with a case-patient in the last 2 weeks. Persons who intend to continue using methamphetamine should be advised about safer practices.

An outbreak of hospital-acquired hepatitis B virus infection among patients receiving chronic hemodialysis.

OBJECTIVE: To investigate a cluster of hepatitis B virus (HBV) infections between December 1995 and May 1996 among chronic hemodialysis patients in one county. SETTING: Two dialysis centers (A and B) and a hospital (C) in one county. PATIENTS: Six case-patients who were dialyzed in one of two centers, A and B, and had all been hospitalized between January and February 1996 at hospital C. METHODS: Patient 1, usually dialyzed in center A, sero-converted to hepatitis B surface antigen (HBsAg) in December 1995 and could have been the source of infection for the others, who seroconverted between March and April 1996. Two cohort studies were conducted: one among patients dialyzed in center A, to determine where transmission had occurred, and one among patients dialyzed at hospital C at the time patient 1 was hospitalized, to identify factors associated with infection. RESULTS: Four (15%) of the 26 susceptible patients dialyzed at center A became infected with HBV. Hospitalization at hospital C when patient 1 was hospitalized was associated with infection (P = .002). A cohort study of the 10 susceptible patients dialyzed at hospital C during the time patient 1 was hospitalized did not identify specific risk factors for infection. However, supplies and multidose vials were shared routinely among patients, providing opportunities for transmission. CONCLUSION: When chronic hemodialysis patients require dialysis while hospitalized, their HBsAg status should be reviewed, and no instrument, supplies, or medications should be shared among them.

Injections given in healthcare settings as a major source of acute hepatitis B in Moldova.

BACKGROUND: Reported rates of acute hepatitis B are high in many former Soviet Union republics and modes of transmission are not well defined. METHODS: Two case-control studies were undertaken in Moldova to identify risk factors for acute hepatitis B in people aged 2-15 years (children) and > or =15 years (adults). Serologically confirmed acute hepatitis B cases occurring between 1 January 1994 and 30 August 30 1995, were matched on age, sex, and district of residence to three potential controls who were tested for hepatitis B markers to exclude the immune. Stratified odds ratios (SOR) were calculated using bivariate and multivariate methods. RESULTS: In multivariate analysis, compared with the 175 controls, the 70 adult cases (mean age 25 years, 66% male) were more likely to report receiving injections in the 6 months before illness during a dental visit (SOR = 21; 95% CI: 3.7-120), a hospital visit (SOR = 35; 95% CI: 7.2-170), or a visit to the polyclinic (SOR = 13; 95% CI: 2.4-74). Among children, receiving injections during a hospital visit (SOR = 5.2; 95% CI: 1.2-23) was the only exposure reported significantly more often by the 19 cases (mean age 8 years, 68% male) compared with the 81 controls. CONCLUSION: These results, along with reported unsafe injection practices in Moldova, suggest that injections are a major source of hepatitis B virus transmission and highlight the importance of proper infection-control procedures in preventing transmission of blood-borne infections.

PIP: Two case-control studies were conducted between January 1994 and August 1995 to determine the relative importance of injections and other exposures as a source of acute hepatitis B in Moldova among adults (aged 15 years) and children (aged 2-15 years). Results showed that injections in various health care settings were associated with acute hepatitis B and showed a higher proportion among adults compared with children. Contact with an HBsAg-positive person was also associated with illnesses; however, there was no statistically significant association between acute hepatitis B and other exposures. The risk of HBV transmission following percutaneous exposure is high (at least 30%). Calculation of the population attributable to risk suggests that injections associated with acute hepatitis B cases occurred in adults (52%) and children (21%). Adverse effects of injections may not be apparent in causing chronic infections. Transmission of blood-borne pathogens through unsafe injection practices is a problem increasingly identified worldwide.

Identifying target groups for a potential vaccination program during a hepatitis A communitywide outbreak.

OBJECTIVES: This study sought to identify groups for targeted vaccination during a communitywide hepatitis A outbreak in 1996. METHODS: Residents of the Sioux City, Iowa, metropolitan area reported with hepatitis A between September 1995 and August 1996 were sampled and compared with population-based controls. RESULTS: In comparison with 51 controls, the 40 case patients were more likely to inject methamphetamine, to attend emergency rooms more often than other health care facilities, and to have a family member who used the Special Supplemental Nutrition Program for Women, Infants, and Children. CONCLUSIONS: Groups at increased risk of hepatitis A can be identified that might be [corrected] accessed for vaccination during communitywide outbreaks.

A multistate, foodborne outbreak of hepatitis A. National Hepatitis A Investigation Team.

BACKGROUND: We investigated a large, foodborne outbreak of hepatitis A that occurred in February and March 1997 in Michigan and then extended the investigation to determine whether it was related to sporadic cases reported in other states among persons who had consumed frozen strawberries, the food suspected of causing the outbreak. METHODS: The cases of hepatitis A were serologically confirmed. Epidemiologic studies were conducted in the two states with sufficient numbers of cases, Michigan and Maine. Hepatitis A virus RNA detected in clinical specimens was sequenced to determine the relatedness of the virus from outbreak-related cases and other cases. RESULTS: A total of 213 cases of hepatitis A were reported from 23 schools in Michigan and 29 cases from 13 schools in Maine, with the median rate of attack ranging from 0.2 to 14 percent. Hepatitis A was associated with the consumption of frozen strawberries in a case-control study (odds ratio for the disease, 8.3; 95 percent confidence interval, 2.1 to 33) and a cohort study (relative risk of infection, 7.5; 95 percent confidence interval, 1.1 to 53) in Michigan and in a case-control study in Maine (odds ratio for infection, 3.4; 95 percent confidence interval, 1.0 to 14). The genetic sequences of viruses from 126 patients in Michigan and Maine were identical to one another and to those from 5 patients in Wisconsin and 7 patients in Arizona, all of whom attended schools where frozen strawberries from the same processor had been served, and to those in 2 patients from Louisiana, both of whom had consumed commercially prepared products containing frozen strawberries from the same processor. CONCLUSIONS: We describe a large outbreak of hepatitis A in Michigan that was associated with the consumption of frozen strawberries. We found apparently sporadic cases in other states that could be linked to the same source by viral genetic analysis.

Prevalence of hepatitis B, D and C virus infections among children and pregnant women in Moldova: additional evidence supporting the need for routine hepatitis B vaccination of infants.

Rates of acute hepatitis B are high in Moldova, but the prevalence of chronic infection is unknown. In 1994, we surveyed children and pregnant women, collected demographic information, and drew blood for laboratory testing. Among the 439 children (mean age, 5 years), the prevalence of antibody to hepatitis B core antigen (anti-HBc) and hepatitis B surface antigen (HBsAg) were 17.1 and 6.8%, respectively. Among the 1098 pregnant women (mean age, 26 years), 52.4% were anti-HBc-positive and 9.7% were HBsAg-positive. Of the HBsAg-positive pregnant women, 35.6% were hepatitis B e antigen (HBeAg) positive and 18.3% had antibodies to hepatitis D virus. The prevalence of antibody to hepatitis C virus was 1.4% in children and 2.3% in pregnant women. The high HBeAg prevalence among HBsAg-positive pregnant women and the high anti-HBc prevalence among children indicate that both perinatal and early childhood transmission contribute to the high hepatitis B virus endemicity in Moldova.

Risk factors for intestinal microsporidiosis in patients with human immunodeficiency virus infection: a case-control study.

A prospective unmatched case-control study was conducted to determine risk factors for intestinal microsporidiosis in persons infected with human immunodeficiency virus (HIV) who had < or = 200 CD4 cells/mm3. In multivariate analysis, case-patients (n = 30) were more likely than were control-subjects (n = 56) to have < or = 100 CD4 cells/mm3 (odds ratio [OR], 6.5; 95% confidence interval [CI], 1-42), to report male homosexual preference (OR, 7.6; 95% CI, 1-59.5), and to report swimming in a pool in the previous 12 months (OR, 9.2; 95% CI, 2.1-38.9). In summary, intestinal microsporidiosis in persons with HIV infection and < or = 200/mm3 CD4 cells is associated with male homosexuality and swimming in pools, suggesting fecal-oral transmission, including sexual and waterborne routes.