Community Barriers, Enablers, and Normative Embedding of Second Year of Life Vaccination in Ghana: A Qualitative Study.

INTRODUCTION: Coverage rates for second year of life (2YL) vaccination still lag behind infant vaccination in most settings. We conducted a qualitative baseline study of community barriers and enablers to acceptance of 2YL vaccines in Ghana 4 years after introducing the second dose of the measles-containing vaccine. METHODS: We conducted 26 focus group discussions in 2016 with men and women caregivers from mixed urban, peri-urban, and rural areas, as well as pastoralists, using semistructured topic guides based on the Health Belief Model theory. We conducted a thematic analysis of the discussion using NVivo software. We use Normalization Process Theory to contextualize results as a snapshot of a dynamic process of community adaptation to change to a well-established routine immunization schedule following 2YL introduction. RESULTS: Routine immunization for infants enjoys resilient demand, grounded in strong community norms despite surprisingly low levels of vaccine literacy. Despite best practices like integration with the established 18-month "weighing visit," demand for 2YL vaccination is still conditional on individual awareness and competition for limited maternal time, household resources, and other health concerns. An embedded norm that children should be fully vaccinated by 12 months originally sustained Expanded Programme for Immunization goals but now discouraged some caregivers from seeking vaccines for children perceived to be "too old" to vaccinate. Caregivers cited greater costs and inconvenience of taking older, heavier children in for vaccination and anticipated criticism from both community members and health care providers for coming "too late." CONCLUSION: Closing the 2YL vaccination coverage gap will ultimately require modifying embedded norms among caregivers and health care providers alike. Time is necessary but not sufficient to reach this goal. Progress can be accelerated by increasing the level of community and institutional engagement and adapting services where possible to minimize added costs to caregivers of vaccinating older children.

Evaluation of Container Clinics as an Urban Immunization Strategy: Findings from the First Year of Implementation in Ghana, 2017-2018.

BACKGROUND: In 2017, the Expanded Programme on Immunization in Ghana opened two container clinics in Accra, which were cargo containers outfitted to deliver immunizations. At each clinic, we assessed performance and clinic acceptance during the first 12 months of implementation. METHODS: We employed a descriptive mixed-method design using monthly administrative immunization data, exit interviews with caregivers of children of <5 years (N = 107), focus group discussions (FGDs) with caregivers (n = 6 FGDs) and nurses (n = 2 FGDs), and in-depth interviews (IDIs) with community leaders (n = 3) and health authorities (n = 3). RESULTS: Monthly administrative data showed that administered vaccine doses increased from 94 during the opening month to 376 in the 12th month across both clinics. Each clinic exceeded its target doses for the 12-23 month population (second dose of measles). Almost all (98%) exit interview participants stated that the clinics made it easier to receive child health services compared to previous health service interactions. The accessibility and acceptability of the container clinics were also supported from health worker and community perspectives. CONCLUSIONS: Our initial data support container clinics as an acceptable strategy for delivering immunization services in urban populations, at least in the short term. They can be rapidly deployed and designed to serve working mothers in strategic areas.

Optimising reporting of adverse events following immunisation by healthcare workers in Ghana: A qualitative study in four regions.

INTRODUCTION: Despite the emphasis on reporting of Adverse Events Following Immunisation (AEFIs) during didactic training sessions, especially prior to new vaccine introductions, it remains low in Ghana. We explored the factors underlying the under-reporting of AEFI by healthcare workers (HCWs) to provide guidance on appropriate interventions to increase reporting. METHODS: We conducted an exploratory descriptive in-depth study of the factors contributing to low reporting of AEFI among HCWs in four regions in Ghana. Key informant interviews (KII) were held with purposively selected individuals that are relevant to the AEFI reporting process at the district, regional, and national levels. We used KII guides to conduct in-depth interviews and used NVivo 10 qualitative software to analyse the data. Themes on factors influencing AEFI reporting were derived inductively from the data, and illustrative quotes from respondents were used to support the narratives. RESULTS: We conducted 116 KIIs with the health managers, regulators and frontline HCWs and found that lack of information on reportable AEFIs and reporting structures, misunderstanding of reportable AEFIs, heavy workload, cost of reporting AEFIs, fear of blame by supervisors, lack of motivation, and inadequate feedback as factors responsible for underreporting of AEFIs. Respondents suggested that capacity building for frontline HCWs, effective supervision, the provision of motivation and feedback, simplification of reporting procedures, incentives for integrating AEFI reporting into routine monitoring and reporting, standardization of reporting procedures across regions, and developing appropriate interventions to address the fear of personal consequences would help improve AEFI reporting. CONCLUSION: From the perspectives of a broad range of key informants at all levels of the vaccine safety system, we found multiple factors (both structural and behavioural), that may impact HCW reporting of AEFI in Ghana. Improvements in line with the suggestions are necessary for increased AEFI reporting in Ghana.

A Comparative Study of Lymphatic Filariasis-Related Perceptions among Treated and Non-Treated Individuals in the Ahanta West Municipality of Ghana.

Background: Ghana joined the Global Programme to Eliminate Lymphatic Filariasis (GPELF), established in the year 2000, with the aim of eliminating the disease as a public health problem through annual mass treatment of entire endemic populations. Since 2001, the country has implemented mass drug administration (MDA) in endemic districts, with great reductions in the population at risk for infection. However, in many districts, the elimination programme is faced with the presence of hotspots, which may be due in part to individuals not taking part in MDA (either intentionally or unintentionally) who may serve as reservoirs to sustain transmission. This paper compares the LF-related perceptions among individuals who regularly take the MDA drugs and those who seldom or never take part in the MDA in the Ahanta West Municipality of Ghana to determine community acceptable ways to implement an intervention aimed to track, engage, and treat individuals who regularly miss MDA or to test individuals who intentionally refuse MDA and treat them if positive for LF. Methods: This was a mixed method study employing questionnaire surveys and focus group discussions (FDG) for data collection. Survey participants were randomly selected from the 2019 treatment register to stratify respondents into treated and non-treated groups. FGD participants were selected purposively such that there are at least two non-treated persons in each discussion session. Results: Over 90% of the respondents were aware of the disease. Poor hygiene/dirty environment was wrongly reported by most respondents (76.8%) as the causes. MDA awareness was very high among both treated (96.9%) and non-treated (98.6%) groups. A low sense of vulnerability to LF infection was evident by a reduction in the number of people presenting clinical manifestations of the disease in communities. Slightly more, 65 (29.0%) of the non-treated group compared to the 42 (19.4%) treated group reported ever experiencing adverse effects of the MDA drugs. Barriers to MDA uptake reported in both groups were poor planning and implementation of the MDA, lack of commitments on the part of drug distributors, and adverse drug reactions. About 51% of the non-treated group reported never taking the drugs even once in the last five years, while 61% among the treated group took the MDA drug consistently in the past five years. Respondents in both groups believed that, when engaged properly, most non-treated persons will accept to take the drug but insisted community drug distributors (CDDs) must be trained to effectively engage people and have time for those they will be engaging in dialogue. The chiefs emerged as the most influential people who can influence people to take MDA drugs. Conclusions: The reduction in risk perception among respondents, adverse reactions and the timing of MDA activities may be influencing MDA non-participation in the study area; however, respondents think that non-treated individuals will accept the interventions when engaged properly by the CDDs.

COVID-19 related perception among some community members and frontline healthcare providers for NTD control in Ghana.

INTRODUCTION: The Coronavirus Disease 2019 (COVID-19) pandemic has resulted in a major breakdown of health service provision in the fight against neglected tropical diseases (NTDs). COVID-19 may impact NTDs service delivery in varied ways. As the Ghana NTD programme planned to resume MDA activities, we examined the COVID-19 related perceptions and practices among some community members and frontline health workers for NTD control activities in the country. METHODS: The study was conducted in seven communities in the Ahanta West district of Ghana. This was a qualitative study using in-depth interviews (IDI) and focus group discussions (FGDs) for data collection. Participants were purposively selected from varied backgrounds to represent both beneficiaries and service providers directly involved in NTD programme implementation. Trained and experienced qualitative data collectors conducted the FGD and IDI sessions in the local Twi language, while health worker sessions were conducted in English. Discussions were audio-recorded and transcribed directly into English. Data was analysed using an iterative process. The transcripts were pre-coded using the broad themes, entered into a computer using Microsoft Word, and then imported into the MAXQDA software for thematic content analysis to select relevant representative narratives for presentation. RESULTS: Participants were aware of the COVID-19 pandemic and referred to it appropriately as 'coronavirus', COVID-19, and often as 'the new disease'. Though many respondents could not describe the route of transmission, most of them reported that it is transmitted through touch or sharing of common items. They reported some signs/symptoms like fever, headache and difficulty breathing, and prevention methods like the use of hand sanitiser, washing of hands and sneezing appropriately. Respondents have reported that COVID-19 has negatively affected their daily lives by limiting their movements and therefore work. It also came to light that COVID-19 has also negatively affected the NTD programme implementation, especially mass drug administration (MDA) activities, leading to the postponement of the yearly MDA. The COVID-19 pandemic has negatively affected clinic attendance; people are afraid that they may be tested for COVID-19 at the clinic. CONCLUSION: COVID-19 has negatively affected the NTD programme. Education and the provision of personal protective equipment will be required to build the confidence of frontline care providers including community drug distributors and community members in order to enhance quality service and participation in future MDA activities.

Applying Adult Learning Best Practices to Design Immunization Training for Health Care Workers in Ghana.

INTRODUCTION: A 2016 assessment of frontline health care workers (HCWs) in Ghana identified knowledge, skill, and attitude gaps related to immunization during the second year of life (2YL). The U.S. Centers for Disease Control and Prevention subsequently supported the Ghana Health Service Immunization Program to apply best practices of adult learning and training of trainers (TOT) for a cascade training program for 2YL. METHODS: Five districts from each of the 3 regions (Greater Accra, Northern, and Volta) were selected for the TOT based on key measles and rubella vaccination coverage indicators. The design incorporated best practices of adult learning and TOT. The curriculum integrated 3 major topical themes: technical (immunization topics), operational, and training adults. The technical and operational content was based on HCW tasks most directly affecting 2YL objectives. A cross-functional team developed all classroom, field activity, and training evaluation materials. RESULTS: Seventy-four participants attended TOT workshops in 2017. Based on a rubric defined by the course designers, 99% of the participants reported an acceptable level of confidence to apply and teach the course content. After the TOTs, participants conducted 65 workshops, 43 field visits, and 4 review meetings, reaching 1,378 HCWs within 7 months. Fifty-four percent of HCWs who received training from TOT participants reported an acceptable level of confidence in using the skills, and 92% reported they would prioritize applying the skills acquired during the training. DISCUSSION: The success factors for effective adult learning and TOT can be applied to design and implement high-quality TOT even in resource-limited settings. The factors include using a variety of approaches, spending enough class time to prepare TOT participants for their training role, setting specific expectations for cascading the training, and following up through mentorship and reporting. Strong collaboration across the administrative levels of the Ghana Health Service enabled cascade training.

Evaluation of the Impact of Immunization Second Year of Life Training Interventions on Health Care Workers in Ghana.

INTRODUCTION: As part of a suite of training interventions to improve the knowledge and practice of immunization in the second year of life (2YL), training of trainers workshops were conducted with regional and district health management teams (DHMTs) in 15 districts in 3 regions of Ghana. Using adult learning principles, DHMTs implemented several capacity-building activities at the subdistrict and health facility levels, including health facility visits, on-the-job training, and review meetings. The current evaluation investigated whether frontline health care workers (HCWs) reported or demonstrated improvements in knowledge, attitudes, and practices after training interventions. METHODS: Quantitative and qualitative methods with a utilization-focused approach guided the framework for this evaluation. A systematic random sample of 115 HCWs in 3 regions of Ghana was selected to complete a competency survey before and after training, which focused on 3 core competency areas-Expanded Programme on Immunization (EPI) policy; communication with caregivers; and immunization data management, recording, and use. Interviews and direct observations by data collectors were done to assess HCWs' knowledge, self-reported attitude, and behavior changes in practices. RESULTS: Of 115 HCWs, 102 were surveyed before and 4 months after receiving capacity-building interventions. Modest but not statistically significant improvements were found in knowledge on EPI policy, immunization data management, and communication skills with caregivers. HCWs reported that they had improved several attitudes and practices after the 2YL training. The most improved practice reported by HCWs and observed in all 3 regions was the creation of a defaulter list. DISCUSSION: Findings of this evaluation provide encouraging evidence in taking the first step toward improving HCW knowledge, attitudes, and practices for 3 core immunization competency areas. The use of learner-focused teaching methods combined with adult learning principles is helpful in solving specific performance problems (such as lack of knowledge of EPI policy).

Detection of vaccine-derived poliovirus circulation by environmental surveillance in the absence of clinical cases.

BACKGROUND: On August 25, 2019, the Noguchi Memorial Institute for Medical Research notified the confirmation of a circulating-vaccine-derived poliovirus type-2 (cVDPV2) from the Agbogbloshie environmental surveillance (AES) site, in the Greater Accra Region. A field investigation of the outbreak was conducted to describe the results of epidemiological and laboratory investigations, and control efforts. METHODS: We conducted a descriptive investigation, records review, and active-case-search. Caregivers were interviewed on the vaccination status of their children; knowledge, attitude, and practices on polio prevention; water, sanitation and hygiene practices, and health-seeking behaviors. Stool from healthy children <5 y and sewage samples were taken for laboratory diagnosis. RESULTS: cVDPV2 genetically similar to the cVDPV2 diagnosed recently in the Northern Region of Ghana and Nigeria was identified. 2019 half-year coverage of OPV and IPV was 22%. Fully immunized children were 49% (29/59). Most health workers (70%) had a fair knowledge of polio and acute flaccid paralysis (AFP). Forty-six percent of care-givers admitted to using the large drain linked to the site where the cVDPV2 was isolated as their place of convenience and disposing of the fecal matter of their children. No AFP case was identified. Stool samples from 40 healthy children yielded non-polio enteroviruses while 75% (3/4) of the additional sewage samples yielded cVDPV2. CONCLUSION: cVDPV2 was isolated from the AES site. No AFP or poliovirus was identified from healthy children. There is a need to improve health workers' knowledge on AFP and to address the dire sanitation conditions in the Agbogbloshie market and its environs.

Barriers to healthcare workers reporting adverse events following immunization in four regions of Ghana.

Despite didactic training on adverse events following immunization (AEFI) in Ghana, the reporting ratio of AEFI was 1.56 per 100,000 surviving infants in 2015, below the minimum reporting ratio of 10. We aimed to estimate the proportion of health care workers (HCWs) reporting AEFI and to identify barriers to reporting. We conducted a cross-sectional survey of HCWs in four regions in Ghana. A simple random sample of 176 health facilities was selected and up to two HCWs were randomly selected per facility. We used the Rao-Scott Chi-squared test to compare factors associated with reporting of AEFI in the last year. We used an open-ended question to identify reasons for low reporting. One supervisor from each facility, responsible for overall reporting and management of AEFI, was also interviewed. A total of 306 HCWs from 169 facilities were interviewed. Of these, 176 (57.5%) reported they had ever encountered an AEFI. Of the 120 who had encountered an AEFI in the last year, 66 (55.0%) indicated they had reported the AEFI, and 38 (31.7%) completed a reporting form. HCWs (n = 120) reported multiple barriers to reporting of AEFI; the most common barriers were fear of personal consequences (44.1%), lack of knowledge or training (25.2%), and not believing an AEFI was serious enough to report (22.2%). Discussion of AEFI during the last supervisory visit was significantly associated with reporting in the past year (OR 7.39; p < .001). Of 172 supervisors interviewed, 65 (37.8%) mentioned their facilties had ever encountered an AEFI; over 90% of facilities had reporting forms. We identified low reporting of AEFI and multiple barriers to reporting among HCWs in the four selected regions of Ghana. Discussing AEFI during supervisory visits with HCWs might improve reporting. Additionally, strategies to address fear of personal consequences as a barrier to reporting of AEFI are needed.

Poliovirus neutralizing antibody levels among individuals in three regions of Ghana.

INTRODUCTION: Ghana was declared polio-free in 2015 after the last polio case in 2008. We determined the poliovirus neutralizing antibody levels among individuals to identify possible immunity gaps. METHODS: A cross-sectional, hospital-based study was undertaken in Northern, Ashanti and Greater Accra regions of Ghana. Individuals referred for haematology at the teaching hospitals' laboratories were invited to participate in our study. Neutralizing-antibody titers to poliovirus serotypes 1,2 & 3 were assayed by WHO-standards. Antibody titers of ≥8 were considered protective. Bivariate and multivariate analyses were conducted on subject characteristics to assess potential factors for failure to seroconvert. P-values < 0.05 were considered statistically significant. RESULTS: Poliovirus (PV) neutralizing-antibody serotypes 1, 2 and 3 were detected in 86.0% (264/307), 84% (258/307) and 75% (230/307) of samples respectively. 60.1% (185/307) were seropositive for the three poliovirus serotypes. Neutralizing poliovirus antibodies for PV1 and PV2 were higher than for PV3. Seroprevalence of poliovirus-neutralizing antibodies among males (PV1=51.9%, PV2= 51.6% and PV3= 52.6%) were higher than in females. Seroprevalence rates of poliovirus-neutralizing antibodies (PV1, PV2, and PV3) were highest in the Northern region (90%, 81%, and 77%). Poliovirus neutralizing-antibodies (PV1and PV2) decreased with age [p< 0.001]. Low seroprevalence of poliovirus-neutralizing antibodies was significantly associated with low school attendance of mothers (p<0.001). CONCLUSION: Our study population has some protection from polio. However, immunity appears to be lower with a higher age or low Mother's education. This may suggest the need for young-adult booster-dose to minimize the risk of wild poliovirus infection. FUNDING: WHO Country Office Ghana.

Poliovirus antibody levels and lameness among individuals in three regions of Ghana.

Introduction: Ghana recorded the last case of poliomyelitis caused by wild poliovirus in 2008 and the country was declared polio-free in 2015. Polio-neutralizing-antibody levels in the population of three geographically representative regions of Ghana was determined, to identify possible immunity gaps. Methods: Cross-sectional, hospital (1-70 years old) and school (primary, 1-15 years old)-based studies were undertaken in three regions in 2016. Individuals who visited the three teaching hospitals of the regions and were referred for haematology investigations were invited to participate in our study. Neutralizing-antibody titers to polio serotypes P1, P2, and P3 were assayed by WHO-standards. Antibody titers of ≥8 were considered protective. In the school lameness survey, clinical and epidemiological data were obtained from parents and their lamed children. Bivariate and multivariate analyses were conducted on subject characteristics, to assess potential factors for failure to seroconvert. P-values < 0.05 were considered statistically significant. Results: Neutralizing-antibodies against poliovirus types 1, 2 and 3 were detected in 86% (264/307), 84% (258/307) and 75% (230/307) of the samples, respectively. Overall, 60.1% (185/307) were seropositive for the three polio serotypes and 2.9% (9/307) were seronegative. Polio neutralizing-antibodies (P1and P2) decreased with age (p < .001). Low seroprevalence of polio-neutralizing-antibodies was significantly associated with low school attendance of mothers (p < .001). Prevalence of residual paralysis was <1.0/1,000 among the school children. Conclusion: Our study population is moderately protected against the three poliovirus serotypes. However, immunity appears to be lower with a higher age and low mother's education. This may suggest the need for young-adult booster-dose to minimize the risk of wild poliovirus infection.

Poliovirus neutralizing antibody levels among individuals in three regions of Ghana

Introduction: Ghana was declared polio-free in 2015 after the last polio case in 2008. We determined the poliovirus neutralizing antibody levels among individuals to identify possible immunity gaps. Methods: A cross-sectional, hospital-based study was undertaken in Northern, Ashanti and Greater Accra regions of Ghana. Individuals referred for haematology at the teaching hospitals' laboratories were invited to participate in our study. Neutralizing-antibody titers to poliovirus serotypes 1,2 & 3 were assayed by WHO-standards. Antibody titers of ≥8 were considered protective. Bivariate and multivariate analyses were conducted on subject characteristics to assess potential factors for failure to seroconvert. P-values < 0.05 were considered statistically significant. Results: Poliovirus (PV) neutralizing-antibody serotypes 1, 2 and 3 were detected in 86.0% (264/307), 84% (258/307) and 75% (230/307) of samples respectively. 60.1% (185/307) were seropositive for the three poliovirus serotypes. Neutralizing poliovirus antibodies for PV1 and PV2 were higher than for PV3. Seroprevalence of poliovirus-neutralizing antibodies among males (PV1=51.9%, PV2= 51.6% and PV3= 52.6%) were higher than in females. Seroprevalence rates of poliovirus-neutralizing antibodies (PV1, PV2, and PV3) were highest in the Northern region (90%, 81%, and 77%). Poliovirus neutralizing-antibodies (PV1and PV2) decreased with age [p< 0.001]. Low seroprevalence of poliovirus-neutralizing antibodies was significantly associated with low school attendance of mothers (p<0.001). Conclusion: Our study population has some protection from polio. However, immunity appears to be lower with a higher age or low Mother's education. This may suggest the need for young-adult booster-dose to minimize the risk of wild poliovirus infection

Pneumococcal meningitis outbreak and associated factors in six districts of Brong Ahafo region, Ghana, 2016.

BACKGROUND: Meningitis, a disease of the Central Nervous System is described as inflammation of the covering of the brain and spinal cord (meninges). It is characterised by fever, severe headache, nausea, vomiting, stiff neck, photophobia, altered consciousness, convulsion/seizures and coma. In December, 2015, twelve suspected cases of meningitis were reported in Tain district in Brong Ahafo region (BAR). Subsequently, dozens of suspected cases were hospitalized in five district hospitals in BAR. We investigated to determine the magnitude, causative agent and risk factors for the disease transmission. METHODS: A community-based 1:2 case-control study (with 126 individuals) was conducted form 10/12/15 to 26/4/16 in 27 districts of Brong-Ahafo Region, Ghana. We defined suspected meningitis cases as people presenting with sudden headache and fevers (Temp> 38.0 °C) in combination with one of the following signs: neck stiffness, altered consciousness, convulsions, bulging fontanelle (infants) and other meningeal signs. Controls were selected from the same neighbourhood and defined as individuals with no overt meningitis signs/symptoms. We collected CSF samples and performed serological testing using Pastorex-Meningitis-Kit and culture for bacterial isolation. Moreover, structured questionnaires were used to collect data on socio-demographics, living conditions, health status and other risk factors. We conducted univariate data analysis and logistic regressions to study disease-exposure associations using Stata 15. RESULTS: A total of 969 suspected cases with 85 deaths (CFR = 9.0%) were recorded between December, 2015 and March, 2016. Majority, 55.9% (542/969) were females aged between 10 months-74 years (median 20 years, IQR; 14-34). Of the 969 cases, 141 were confirmed by Laboratory test with Streptococcus pneumoniae identified as the causative agent. Cases were reported in 20 districts but 6 of these districts reported cases above threshold levels. The outbreak peaked in week 6 with 178 cases. Overall attack rate (AR) was 235.0/100,000 population. District specific ARs were; Tain; 143.6/100,000, Wenchi; 110.0/100,000, Techiman; 46.6/100,000, Jaman North; 382.3/100,000 and Nkoranza South; 86.4/100,000. Female and male specific ARs were 251.3/100,000 and 214.5/100,000 respectively. Age group 10-19 years were most affected 33.8% (317/940). We identified sore throat [aOR = 5.2, 95% (CI 1.1-26.1)] and alcohol use [aOR = 9.1, 95%(CI 1.4-55.7)] as factors associated with the disease transmission. CONCLUSION: Meningitis outbreak due to Streptococcus pneumoniae was established in BAR. Upper respiratory tract infection and alcohol use were associated with the outbreak. Mass campaigns on healthy living habits, signs and symptoms of meningitis as well as the need for early reporting were some of the control measures instituted. Moreover, we recommend Pneumococcal vaccination in BAR to prevent future outbreaks.

Country Immunization Information System Assessments - Kenya, 2015 and Ghana, 2016.

The collection, analysis, and use of data to measure and improve immunization program performance are priorities for the World Health Organization (WHO), global partners, and national immunization programs (NIPs). High quality data are essential for evidence-based decision-making to support successful NIPs. Consistent recording and reporting practices, optimal access to and use of health information systems, and rigorous interpretation and use of data for decision-making are characteristics of high-quality immunization information systems. In 2015 and 2016, immunization information system assessments (IISAs) were conducted in Kenya and Ghana using a new WHO and CDC assessment methodology designed to identify root causes of immunization data quality problems and facilitate development of plans for improvement. Data quality challenges common to both countries included low confidence in facility-level target population data (Kenya = 50%, Ghana = 53%) and poor data concordance between child registers and facility tally sheets (Kenya = 0%, Ghana = 3%). In Kenya, systemic challenges included limited supportive supervision and lack of resources to access electronic reporting systems; in Ghana, challenges included a poorly defined subdistrict administrative level. Data quality improvement plans (DQIPs) based on assessment findings are being implemented in both countries. IISAs can help countries identify and address root causes of poor immunization data to provide a stronger evidence base for future investments in immunization programs.

Meningitis Outbreak Caused by Vaccine-Preventable Bacterial Pathogens - Northern Ghana, 2016.

Bacterial meningitis is a severe, acute infection of the fluid surrounding the brain and spinal cord that can rapidly lead to death. Even with recommended antibiotic treatment, up to 25% of infected persons in Africa might experience neurologic sequelae (1). Three regions in northern Ghana (Upper East, Northern, and Upper West), located in the sub-Saharan "meningitis belt" that extends from Senegal to Ethiopia, experienced periodic outbreaks of meningitis before introduction of serogroup A meningococcal conjugate vaccine (MenAfriVac) in 2012 (2,3). During December 9, 2015-February 16, 2016, a total of 432 suspected meningitis cases were reported to health authorities in these three regions. The Ghana Ministry of Health, with assistance from CDC and other partners, tested cerebrospinal fluid (CSF) specimens from 286 patients. In the first 4 weeks of the outbreak, a high percentage of cases were caused by Streptococcus pneumoniae; followed by an increase in cases caused by Neisseria meningitidis, predominantly serogroup W. These data facilitated Ghana's request to the International Coordinating Group* for meningococcal polysaccharide ACW vaccine, which was delivered to persons in the most affected districts. Rapid identification of the etiologic agent causing meningitis outbreaks is critical to inform targeted public health and clinical interventions, including vaccination, clinical management, and contact precautions.

Immunization delivery in the second year of life in Ghana: the need for a multi-faceted approach.

INTRODUCTION: in 2012, pneumococcal conjugate vaccine (PCV), rotavirus vaccine and a second dose of measles-containing vaccine (MCV2) were introduced into the Expanded Program on Immunization (EPI) in Ghana. According to Ghana's EPI schedule, PCV and rotavirus vaccine are given in the first year of life and MCV2 in the second year of life (2YL) at 18 months. Although coverage with the last doses of PCV and rotavirus vaccine reached almost 90% coverage within four years of introduction, MCV2 coverage did not rise above 70%. The World Health Organization Global Measles and Rubella Strategic Plan established a 2020 milestone to achieve at least 95% coverage with the first and second doses of measles-containing vaccine in each district and nationally. We developed a project to address challenges to delivery of immunizations and other child health services at the 18-month visit and throughout the 2YL. METHODS: from March to April 2016, we conducted a cluster survey of households (HHs) with children 24-35 months of age in three regions in Ghana to assess knowledge, attitudes and beliefs among caregivers about immunization during the 2YL and to collect childhood vaccination history data using vaccination cards. Three independent samples were selected from the Northern (NR), Volta (VR), and Greater Accra (GAR) regions. A survey and direct observations were performed a ta representative sample of health facilities (HFs) providing immunization services in the same regions to further characterize barriers to immunization access, utilization and delivery in the 2YL. RESULTS: data on a total of 464 children ages 24-35 months were collected in the HH survey: 211 in NR, 153 in VR, and 100 in GAR (response rate > 99%). First dose of measles-containing vaccine (MCV1) coverage was (NR: 87%, VR: 96%, GAR: 99%); however, MCV2 coverage was lower (NR: 60%, VR: 83%, GAR: 70%). MCV1 to MCV2 dropout was 32% in NR, 14% in VR, and 31% in GAR. Caregiver awareness of immunization against measles was 69% in NR, 75% in VR, and 68% in GAR yet less than half knew the recommended ages for receiving the vaccine, (NR: 4%, VR: 9%, GAR: 44%). Among 160 HFs participating in the survey (>50 in each region), most lacked a defaulter tracing system (NR: 94%,VR: 76%,GAR: 85%). A varying proportion of HCWs correctly indicated how to record a catch-up first dose of MCV administered to an 18-month-old child in the 12-23 month immunization register (NR: 38%, VR: 55%, GAR: 67%) and on the vaccination card (NR: 54%, VR: 53%, GAR: 76%). Although more than half of caregivers would accept text messages, (NR: 57%, VR: 78%, GAR: 96%) including reminders, related to their child's immunizations, < 10% HFs were utilizing this practice. CONCLUSION: challenges encountered with the establishment of an immunization visit beyond the first year of life included knowledge gaps among caregivers, high dropout rates between MCV1 and MCV2 in all study regions, and a lack of defaulter tracing systems in most healthcare facilities providing childhood immunizations. Targeted strategies that promote behavioral, cultural, and policy changes are needed to strengthen 2YL child health service delivery and improve vaccination coverage.