Review of maternal death audits in refugee camps in UNHCR East and Horn of Africa and Great Lakes Region, 2017-2019.

OBJECTIVES: To review the quality of maternal death audits and identify factors contributing to refugee maternal deaths in the East and Horn of Africa. METHODS: Maternal death audits submitted to The UN Refugee Agency (UNHCR) from 2017 to 2019 in 43 refugee camps in eight countries were analyzed for completeness, obstetric history, cause of death, and contributing factors. RESULTS: A total of 191 refugee maternal death audits were retrieved. The mean age of the deceased was 28 years (range, 15-45 years), and 13% were adolescents and 17% were of advanced maternal age. Most patients (55%) were grand multigravida (≥5 pregnancies). The majority (86%) attended antenatal care visits, with 51% attending four or more visits. Among women who delivered (n = 140), 91% were facility-based deliveries. Most (68%) deaths occurred postpartum. Obstetric hemorrhage (49%) was the leading direct cause of death (with 77 cases of postpartum hemorrhage), followed by hypertensive disorder (19%) and infection (15%). Delays in care were identified in 185 (97%) cases. Delays in receiving care were more prevalent (81%) than in seeking (61%) and reaching (26%) care. CONCLUSION: Factors contributing to delays in receiving care highlight the capacity gaps in provision of emergency obstetric care, including management of postpartum hemorrhage, requiring urgent additional investments. Audit findings also show the need for attention and action towards family planning, contraception, and adolescent sexual and reproductive health services.

Implementing a Birth Dose of Hepatitis B Vaccine in Africa: Findings from Assessments in 5 Countries.

INTRODUCTION: Few African countries have introduced a birth dose of hepatitis B vaccine (HepB-BD) despite a World Health Organization (WHO) recommendation. HepB-BD given within 24 hours of birth, followed by at least two subsequent doses, is 90% effective in preventing perinatal transmission of hepatitis B virus. This article describes findings from assessments conducted to document the knowledge, attitudes, and practices surrounding HepB-BD implementation among healthcare workers in five African countries. METHODS: Between August 2015 and November 2016, a series of knowledge, attitude and practices assessments were conducted in a convenience sample of public and private health facilities in Botswana, the Gambia, Namibia, Nigeria, and São Tomé and Príncipe (STP). Data were collected from immunization and maternity staff through interviewer-administered questionnaires focusing on HepB-BD vaccination knowledge, practices and barriers, including those related to home births. HepB-BD coverage was calculated for each visited facility. RESULTS: A total of 78 health facilities were visited: STP 5 (6%), Nigeria 23 (29%), Gambia 9 (12%), Botswana 16 (21%), and Namibia 25 (32%). Facilities in the Gambia attained high total coverage of 84% (range: 60-100%) but low timely estimates 7% (16-28%) with the median days to receiving HepB-BD of 11 days (IQR: 6-16 days). Nigeria had low total (23% [range: 12-40%]), and timely (13% [range: 2-21%]) HepB-BD estimates. Facilities in Botswana had high total (94% [range: 80-100%]), and timely (74% [range: 57-88%]) HepB-BD coverage. Coverage rates were not calculated for STP because the maternal Hepatitis B virus (HBV) status was not recorded in the delivery registers. The study in Namibia did not include a coverage assessment component. Barriers to timely HepB-BD included absence of standard operating procedures delineating staff responsible for HepB-BD, not integrating HepB-BD into essential newborn packages, administering HepB-BD at the point of maternal discharge from facilities, lack of daily vaccination services, sub-optimal staff knowledge about HepB-BD contraindications and age-limits, lack of outreach programs to reach babies born outside facilities, and reporting tools that did not allow for recording the timeliness of HepB-BD doses. DISCUSSION: These assessments demonstrate how staff perceptions and lack of outreach programs to reach babies born outside health facilities with essential services are barriers for implementing timely delivery of HepB-BD vaccine. Addressing these challenges may accelerate HepB-BD implementation in Africa.

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.

Contribution of Contact Sampling in Increasing Sensitivity of Poliovirus Detection During A Polio Outbreak-Somalia, 2013.

Background. In May 2013, a wild poliovirus type 1 (WPV1) outbreak reported in Somalia provided an opportunity to examine the contribution of testing contacts to WPV detection. Methods. We reviewed acute flaccid paralysis (AFP) case-patients and linked contacts reported in the Somalia Surveillance Database from May 9 to December 31, 2013. We restricted our analysis to AFP case-patients that had ≥3 contacts and calculated the contribution of each contact to case detection. Results. Among 546 AFP cases identified, 328 AFP cases had ≥3 contacts. Among the 328 AFP cases with ≥3 contacts, 93 WPV1 cases were detected: 58 cases (62%; 95% confidence interval [CI], 52%-72%) were detected through testing stool specimens from AFP case-patients; and 35 cases (38%; 95% CI, 28%-48%) were detected through testing stool specimens from contacts, including 19 cases (20%; 95% CI, 14%-30%) from the first contact, 11 cases (12%; 95% CI, 7%-20%) from the second contact, and 5 cases (5%; 95% CI, 2%-12%) from the third contact. Among the 103 AFP cases with ≥4 contacts, 3 (6%; 95% CI, 2%-16%) of 52 WPV1 cases were detected by testing the fourth contact. No additional WPV1 cases were detected by testing >4 contacts. Conclusions. Stool specimens from 3 to 4 contacts of persons with AFP during polio outbreaks are needed to maximize detection of WPV cases.

Progress towards achieving hepatitis B control in the Cook Islands, Niue, Tokelau, and Kiribati.

BACKGROUND: Hepatitis B virus (HBV) is highly endemic in many of the Pacific Island countries. Four island countries-Cook Islands, Kiribati, Niue, and Tokelau-sought to evaluate the success of their hepatitis B vaccination programs by conducting nationally representative serosurveys among children born post-vaccine introduction. METHODS: Cook Islands, Niue, and Tokelau conducted school-based census serosurveys because of small populations. The Cook Islands tested children in second grade; Niue tested children in early childhood education through sixth grade; and Tokelau tested children in first through sixth grades. Because Kiribati has a much larger birth cohort, it conducted a one-stage stratified serosurvey among first grade students. All four countries tested children using the Alere Determine™ rapid point of care hepatitis B surface antigen (HBsAg) test. RESULTS: In the three smaller countries, no children were seropositive for HBsAg (0/245 Cook Island students, 0/183 Niuean students, 0/171 Tokelau students). In Kiribati, 39 (3.3%, 95% confidence interval 2.4-4.6%) of 1249 students were HBsAg positive. Vaccination data collected in the Cook Islands and Tokelau showed high vaccination coverage in both countries with ⩾95% birth dose coverage and 100% 3-dose coverage. CONCLUSIONS: The Cook Islands, Niue, and Tokelau have made remarkable progress in establishing strong vaccination programs and towards decreasing the burden of hepatitis B among children. Kiribati still needs to improve vaccination coverage to achieve the <1% HBsAg target established by the World Health Organization Western Pacific Region.

Contribution of polio eradication initiative to strengthening routine immunization: Lessons learnt in the WHO African region.

BACKGROUND: Important investments were made in countries for the polio eradication initiative. On 25 September 2015, a major milestone was achieved when Nigeria was removed from the list of polio-endemic countries. Routine Immunization, being a key pillar of polio eradication initiative needs to be strengthened to sustain the gains made in countries. For this, there is a huge potential on building on the use of polio infrastructure to contribute to RI strengthening. METHODS: We reviewed estimates of immunization coverage as reported by the countries to WHO and UNICEF for three vaccines: BCG, DTP3 (third dose of diphtheria-tetanus toxoid- pertussis), and the first dose of measles-containing vaccine (MCV1).We conducted a systematic review of best practices documents from eight countries which had significant polio eradication activities. RESULTS: Immunization programmes have improved significantly in the African Region. Regional coverage for DTP3 vaccine increased from 51% in 1996 to 77% in 2014. DTP3 coverage increased >3 folds in DRC (18-80%) and Nigeria from 21% to 66%; and >2 folds in Angola (41-87%), Chad (24-46%), and Togo (42-87%). Coverage for BCG and MCV1 increased in all countries. Of the 47 countries in the region, 18 (38%) achieved a national coverage for DTP3 ⩾90% for 2years meeting the Global Vaccine Action (GVAP) target. A decrease was noted in the Ebola-affected countries i.e., Guinea, Liberia and Sierra Leone. CONCLUSIONS: PEI has been associated with increased spending on immunization and the related improvements, especially in the areas of micro planning, service delivery, program management and capacity building. Continued efforts are needed to mobilize international and domestic support to strengthen and sustain high-quality immunization services in African countries. Strengthening RI will in turn sustain the gains made to eradicate poliovirus in the region.

Contribution of polio eradication initiative to effective new vaccine introduction in Africa, 2010-2015.

BACKGROUND: Significant progress has been made to increase access to vaccines in Africa since the 1974 launch of the Expanded Programme on Immunization (EPI). Successes include the introduction of several new vaccines across the continent and likely eradication of polio. We examined the contribution of polio eradication activities (PEI) on new vaccine introduction in the countries of the African Region. METHODS: We reviewed country specific PEI reports to identify best practices relevant to new vaccine introduction (NVI), and analyzed trends in vaccine coverage during 2010-2015 from immunization estimates provided by WHO/UNICEF. RESULTS: Of the 47 countries in African Region 35 (74%) have introduced PCV, 27 (57%) have introduced rotavirus, and 14 (30%) have introduced IPV. National introductions for HPV vaccine have been done in 5 countries, while 15 countries have held demonstration and pilot projects. In 2014, the regional coverage for the third dose of PCV (PCV3) and rotavirus vaccines was 50% and 30% respectively. By end of 2015, all countries within the meningitis belt will have introduced MenAfriVac™ vaccine. CONCLUSIONS: PEI activities had a positive effect in strengthening the process of new vaccine introduction in the African Region. The major contribution was in availing immunization funding and providing trained and experienced technical staff to introduce vaccines. More investment is needed to advocate and sustain funding levels to maintain the momentum gained in introducing new vaccines in the region.

Measles Outbreak Associated With Low Vaccine Effectiveness Among Adults in Pohnpei State, Federated States of Micronesia, 2014.

Background. A measles outbreak in Pohnpei State, Federated States of Micronesia in 2014 affected many persons who had received ≥1 dose of measles-containing vaccine (MCV). A mass vaccination campaign targeted persons aged 6 months to 49 years, regardless of prior vaccination. Methods. We evaluated vaccine effectiveness (VE) of MCV by comparing secondary attack rates among vaccinated and unvaccinated contacts after household exposure to measles. Results. Among 318 contacts, VE for precampaign MCV was 23.1% (95% confidence interval [CI], -425 to 87.3) for 1 dose, 63.4% (95% CI, -103 to 90.6) for 2 doses, and 95.9% (95% CI, 45.0 to 100) for 3 doses. Vaccine effectiveness was 78.7% (95% CI, 10.1 to 97.7) for campaign doses received ≥5 days before rash onset in the primary case and 50.4% (95% CI, -52.1 to 87.9) for doses received 4 days before to 3 days after rash onset in the primary case. Vaccine effectiveness for most recent doses received before 2010 ranged from 51% to 57%, but it increased to 84% for second doses received in 2010 or later. Conclusions. Low VE was a major source of measles susceptibility in this outbreak; potential reasons include historical cold chain inadequacies or waning of immunity. Vaccine effectiveness of campaign doses supports rapid implementation of vaccination campaigns in outbreak settings.

Notes from the Field: Tetanus Cases After Voluntary Medical Male Circumcision for HIV Prevention--Eastern and Southern Africa, 2012-2015.

Voluntary medical male circumcision (VMMC) decreases the risk for female-to-male HIV transmission by approximately 60%, and the President's Emergency Plan for AIDS Relief (PEPFAR) is supporting the scale-up of VMMC for adolescent and adult males in countries with high prevalence of human immunodeficiency virus (HIV) and low coverage of male circumcision. As of September 2015, PEPFAR has supported approximately 8.9 million VMMCs.

Measles Outbreak Associated with Vaccine Failure in Adults--Federated States of Micronesia, February-August 2014.

On May 15, 2014, CDC was notified of two laboratory-confirmed measles cases in the Federated States of Micronesia (FSM), after 20 years with no reported measles. FSM was assisted by the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), and CDC in investigating suspected cases, identify contacts, conduct analyses to guide outbreak vaccination response, and review vaccine cold chain practices. During February­August, three of FSM's four states reported measles cases: Kosrae (139 cases), Pohnpei (251), and Chuuk (3). Two thirds of cases occurred among adults aged ≥20 years; of these, 49% had received ≥2 doses of measles-containing vaccine (MCV). Apart from infants aged <12 months who were too young for routine vaccination, measles incidence was lower among children than adults. A review of current cold chain practices in Kosrae revealed minor weaknesses; however, an absence of historical cold chain maintenance records precluded an evaluation of earlier problems. Each state implemented vaccination campaigns targeting children as young as age 6 months through adults up to age 57 years. The preponderance of cases in this outbreak associated with vaccine failure in adults highlights the need for both thorough case investigation and epidemiologic analysis to guide outbreak response vaccination. Routine childhood vaccination coverage achieved in recent years limited the transmission of measles among children. Even in areas where transmission has not occurred for years, maintaining high 2-dose MCV coverage through routine and supplemental immunization is needed to prevent outbreaks resulting from increased measles susceptibility in the population.

Etiology and Incidence of Viral Acute Respiratory Infections Among Refugees Aged 5 Years and Older in Hagadera Camp, Dadaab, Kenya.

We used the Centers for Disease Control and Prevention-Kenya Medical Research Institute Acute Respiratory Infection (ARI) Surveillance System data to estimate severe acute respiratory infection (SARI) hospitalization rates, viral etiology, and associated complaints of influenza-like illnesses (ILI) and SARI conditions among those aged 5 years and older in Hagadera, Dadaab refugee camp, Kenya, for 2010-2012. A total of 471 patients aged ≥ 5 years met the case definition for ILI or SARI. SARI hospitalization rates per 10,000 person-years were 14.7 (95% confidence interval [CI] = 9.1, 22.2) for those aged 5-14 years; 3.4 (95% CI = 1.6, 7.2) for those aged 15-24 year; and 3.8 (95% CI = 1.6, 7.2) for those aged ≥ 25 years. Persons between the ages of 5 and 14 years had 3.5 greater odds to have been hospitalized as a result of SARI than those aged ≥ 25 years (odds ratio [OR] = 3.5, P < 0.001). Among the 419 samples tested, 169 (40.3%) were positive for one or more virus. Of those samples having viruses, 36.9% had influenza A; 29.9% had adenovirus; 20.2% had influenza B; and 14.4% had parainfluenza 1, 2, or 3. Muscle/joint pain was associated with influenza A (P = 0.002), whereas headache was associated with influenza B (P = 0.019). ARIs were responsible for a substantial disease burden in Hagadera camp.

Progress toward polio eradication--Worldwide, 2013-2014.

In 1988, the World Health Assembly of the World Health Organization (WHO) resolved to interrupt wild poliovirus (WPV) transmission worldwide, and in 2012, the World Health Assembly declared the completion of global polio eradication a programmatic emergency for public health. By 2013, the annual number of WPV cases had decreased by >99% since 1988, and only three countries remained that had never interrupted WPV transmission: Afghanistan, Nigeria, and Pakistan. This report summarizes global progress toward polio eradication during 2013-2014 and updates previous reports. In 2013, a total of 416 WPV cases were reported globally from eight countries, an 86% increase from the 223 WPV cases reported from five countries in 2012. This upsurge in 2013 was caused by a 60% increase in WPV cases detected in Pakistan, and by outbreaks in five previously polio-free countries resulting from international spread of WPV. In 2014, as of May 20, a total of 82 WPV cases had been reported worldwide, compared with 34 cases during the same period in 2013. Polio cases caused by circulating vaccine-derived poliovirus (cVDPV) were detected in eight countries in 2013 and in two countries so far in 2014. To achieve polio eradication in the near future, further efforts are needed to 1) address health worker safety concerns in areas of armed conflict in priority countries, 2) to prevent further spread of WPV and new outbreaks after importation into polio-free countries, and 3) to strengthen surveillance globally. Based on the international spread of WPV to date in 2014, the WHO Director General has issued temporary recommendations to reduce further international exportation of WPV through vaccination of persons traveling from currently polio-affected countries.