Strengthening acute flaccid paralysis surveillance post Ebola virus disease outbreak 2015 - 2017: the Liberia experience.

INTRODUCTION: Liberia remains at high risk of poliovirus outbreaks due to importation. The country maintained certification level acute flaccid paralysis (AFP) surveillance indicators each year until 2014 due to Ebola outbreak. During this time, there was a significant drop in non-polio AFP rate to (1.2/100,000 population under 15 years) in 2015 from 2.9/100, 000 population in 2013, due to a variety of reasons including suspension on shipment of acute flaccid paralysis stool specimen to the polio regional lab in Abidjan, refocusing of surveillance officers attention solely on Ebola virus disease (EVD) surveillance, inactivation of national polio expert committee (NPEC) and National Certification Committee (NCC). The Ministry of Health (MOH) supported by partners worked to restore AFP surveillance post EVD outbreak and ensure that Liberia maintains its polio free certification. METHODS: We conducted a desk review to summarize key activities conducted to restore acute flaccid paralysis (AFP) surveillance based on World Health Organization (WHO) AFP surveillance guidelines for Africa region. We also reviewed AFP surveillance indicators and introduction of new technologies. Data sources were from program reports, scientific and gray literature, AFP database, auto visual AFP detection and reporting (AVADAR) and ONA Servers. Data analysis was done using Microsoft excel and access spread sheets, ONA software and Geographic Information System (Arc GIS). RESULTS: AFP surveillance indicators improved with a rebound of non-polio AFP rate (NPAFP) rate from 1.2/100, 000 population under 15 years in 2015 to 4.3 in 2017. The stool adequacy rate at the national level also improved from 79% in 2016 to 82% in 2017, meeting the global target. The percentage of counties meeting the two critical AFP surveillance indicators NPAFP rate and stool adequacy improved from 47% in 2016 to 67% in 2017.The Last polio case reported in Liberia was in late 2010. CONCLUSION: There was significant improvement in the key AFP surveillance indicators such as NPAFP rate and stool adequacy with a 3.5 fold increase in NPAFP from 2014 to 2017. By 2017, the stool adequacy rate was up to target levels compared to 2016, which was below target level of 80%. The number of counties meeting target for the two critical AFP surveillance indicators also increased by 20% points between 2016 and 2017. Similarly there was approximately two-fold increase in the oral polio vaccines (OPV) coverage for the reported AFP cases between 2015 and 2017. Strategies employed to address gaps in AFP surveillance included enhanced active case search for AFP, re-instatement of laboratory testing, supportive supervision in addition to facilitating enhanced community engagement in surveillance activities. New technologies such as AVADAR Pilot, electronic integrated supportive supervision (ISS) and electronic surveillance (eSurv) tools were introduced to improve real time AFP case reporting. However, there remain residual gaps in AFP surveillance in the country especially at the sub-national level. Similarly, the newly introduced technologies will require continued funding and capacity building for MOH staff to ensure sustainability of the initiatives.

Rapid response to meningococcal disease cluster in Foya district, Lofa County, Liberia January to February 2018.

INTRODUCTION: Early detection of disease outbreaks is paramount to averting associated morbidity and mortality. In January 2018, nine cases including four deaths associated with meningococcal disease were reported in three communities of Foya district, Lofa County, Liberia. Due to the porous borders between Lofa County and communities in neighboring Sierra Leone and Guinea, the possibility of epidemic spread of meningococcal disease could not be underestimated. METHODS: The county incidence management system (IMS) was activated that coordinated the response activities. Daily meetings were conducted to review response activities progress and challenges. The district rapid response team (DRRT) was the frontline responders. The case based investigation form; case line list and contacts list were used for data collection. A data base was established and analysed daily for action. Tablets Ciprofloxacin were given for chemoprophylaxis. RESULTS: Sixty-seven percent (67%) of the cases were males and also 67% of the affected age range was 3 to 14 years and attending primary school. The attack rate was 7/1,000 population and case fatality rate was 44.4 % with majority of the deaths occurring within 24-48 hours of symptoms onset. Three of the cases tested positive for Neisseria Meningitidis sero-type W while six cases were Epi-linked. None of the cases had recent meningococcal vaccination and no health-worker infections were registered. CONCLUSION: This cluster of cases of meningococcal disease during the meningitis season in a country that is not traditionally part of the meningitis belt emphasized the need for strengthening surveillance, preparedness and response capacity to meningitis.