Building Data Triangulation Capacity for Routine Immunization and Vaccine Preventable Disease Surveillance Programs to Identify Immunization Coverage Inequities.

The Expanded Programme on Immunization (EPI) and Vaccine Preventable Disease (VPD) Surveillance (VPDS) programs generate multiple data sources (e.g., routine administrative data, VPD case data, and coverage surveys). However, there are challenges with the use of these siloed data for programmatic decision-making, including poor data accessibility and lack of timely analysis, contributing to missed vaccinations, immunity gaps, and, consequently, VPD outbreaks in populations with limited access to immunization and basic healthcare services. Data triangulation, or the integration of multiple data sources, can be used to improve the availability of key indicators for identifying immunization coverage gaps, under-immunized (UI) and un-immunized (zero-dose (ZD)) children, and for assessing program performance at all levels of the healthcare system. Here, we describe the data triangulation processes, prioritization of indicators, and capacity building efforts in Bangladesh, Nigeria, and Rwanda. We also describe the analyses used to generate meaningful data, key indicators used to identify immunization coverage inequities and performance gaps, and key lessons learned. Triangulation processes and lessons learned may be leveraged by other countries, potentially leading to programmatic changes that promote improved access and utilization of vaccination services through the identification of UI and ZD children.

Migration from Epi Info to District Health Information Software 2 for Vaccine-Preventable Disease Surveillance - World Health Organization African Region, 2019-2023.

High-quality vaccine-preventable disease (VPD) surveillance data are critical for timely outbreak detection and response. In 2019, the World Health Organization (WHO) African Regional Office (AFRO) began transitioning from Epi Info, a free, CDC-developed statistical software package with limited capability to integrate with other information systems, affecting reporting timeliness and data use, to District Health Information Software 2 (DHIS2). DHIS2 is a free and open-source software platform for electronic aggregate Integrated Disease Surveillance and Response (IDSR) and case-based surveillance reporting. A national-level reporting system, which provided countries with the option to adopt this new system, was introduced. Regionally, the Epi Info database will be replaced with a DHIS2 regional data platform. This report describes the phased implementation from 2019 to the present. Phase one (2019-2021) involved developing IDSR aggregate and case-based surveillance packages, including pilots in the countries of Mali, Rwanda, and Togo. Phase two (2022) expanded national-level implementation to 27 countries and established the WHO AFRO DHIS2 regional data platform. Phase three (from 2023 to the present) activities have been building local capacity and support for country reporting to the regional platform. By February 2024, eight of 47 AFRO countries had adopted both the aggregate IDSR and case-based surveillance packages, and two had successfully transferred VPD surveillance data to the AFRO regional platform. Challenges included limited human and financial resources, the need to establish data-sharing and governance agreements, technical support for data transfer, and building local capacity to report to the regional platform. Despite these challenges, the transition to DHIS2 will support efficient data transmission to strengthen VPD detection, response, and public health emergencies through improved system integration and interoperability.

A global comprehensive vaccine-preventable disease surveillance strategy for the immunization Agenda 2030.

As part of the Immunization Agenda 2030, a global strategy for comprehensive vaccine-preventable disease (VPD) surveillance was developed. The strategy provides guidance on the establishment of high-quality surveillance systems that are 1) comprehensive, encompassing all VPD threats faced by a country, in all geographic areas and populations, using all laboratory and other methodologies required for timely and reliable disease detection; 2) integrated, wherever possible, taking advantage of shared infrastructure for specific components of surveillance such as data management and laboratory systems; 3) inclusive of all relevant data needed to guide immunization program management actions. Such surveillance systems should generate data useful to strengthen national immunization programs, inform vaccine introduction decision-making, and reinforce timely and effective detection and response. All stakeholders in countries and globally should work to achieve this vision.

Effects of COVID-19 on Vaccine-Preventable Disease Surveillance Systems in the World Health Organization African Region, 2020.

Global emergence of the COVID-19 pandemic in 2020 curtailed vaccine-preventable disease (VPD) surveillance activities, but little is known about which surveillance components were most affected. In May 2021, we surveyed 214 STOP (originally Stop Transmission of Polio) Program consultants to determine how VPD surveillance activities were affected by the COVID-19 pandemic throughout 2020, primarily in low- and middle-income countries, where program consultants are deployed. Our report highlights the responses from 154 (96%) of the 160 consultants deployed to the World Health Organization African Region, which comprises 75% (160/214) of all STOP Program consultants deployed globally in early 2021. Most survey respondents observed that VPD surveillance activities were somewhat or severely affected by the COVID-19 pandemic in 2020. Reprioritization of surveillance staff and changes in health-seeking behaviors were factors commonly perceived to decrease VPD surveillance activities. Our findings suggest the need for strategies to restore VPD surveillance to prepandemic levels.

Comprehensive Vaccine-Preventable Disease Surveillance in the Western Pacific Region: A Literature Review on Integration of Surveillance Functions, 2000-2021.

INTRODUCTION: A strategic framework for 2021-2030 developed by the World Health Organization (WHO) Regional Office for the Western Pacific emphasizes the need for high-quality and integrated vaccine-preventable disease (VPD) surveillance. We conducted a literature review to document the barriers, enabling factors, and innovations for integrating surveillance functions for VPDs and other communicable diseases in Western Pacific Region (WPR) countries. METHODS: We searched published and gray literature on integrated VPD surveillance from 2000 to 2021. Articles in English, Spanish, or French were screened to identify those relating to VPD surveillance in a WPR country and not meeting defined exclusion criteria. We categorized articles using the 8 WHO surveillance support functions and abstracted data on the country; type of surveillance; and reported barriers, enabling factors, and best practices for integration. RESULTS: Of the 3,137 references screened, 87 met the eligibility criteria. Of the 8 surveillance support functions, the proportion of references that reported integration related to the laboratory was 56%, followed by workforce capacity (54%), governance (51%), data management and use (47%), field logistics and communication (47%), coordination (15%), program management (13%), and supervision (9%). Several references noted fragmented systems and a lack of coordination between units as barriers to integration, highlighting the importance of engagement across public health units and between the public and private sectors. The literature also indicated a need for interoperable information systems and revealed the use of promising new technologies for data reporting and laboratory testing. In some WPR countries, workforce capacity was strengthened at all administrative levels by the implementation of integrated trainings on data monitoring and use and on laboratory techniques applicable to multiple VPDs. CONCLUSION: This literature review supports integrating VPDs into broader communicable disease surveillance systems in WPR countries while ensuring that the minimal WHO-recommended standards for VPD surveillance are met.

Evaluation of Senegal's prevention of mother to child transmission of HIV (PMTCT) program data for HIV surveillance.

BACKGROUND: With the expansion of Prevention of Mother to Child Transmission (PMTCT) services in Senegal, there is growing interest in using PMTCT program data in lieu of conducting unlinked anonymous testing (UAT)-based ANC Sentinel Surveillance. For this reason, an evaluation was conducted in 2011-2012 to identify the gaps that need to be addressed while transitioning to using PMTCT program data for surveillance. METHODS: We conducted analyses to assess HIV prevalence rates and agreements between Sentinel Surveillance and PMTCT HIV test results. Also, a data quality assessment of the PMTCT program registers and data was conducted during the Sentinel Surveillance period (December 2011 to March 2012) and 3 months prior. Finally, we also assessed selection bias, which was the percentage difference from the HIV prevalence among all women enrolled in the antenatal clinic and the HIV prevalence among women who accepted PMTCT HIV testing. RESULTS: The median site HIV prevalence using routine PMTCT HIV testing data was 1.1% (IQR: 1.0) while the median site prevalence from the UAT HIV Sentinel Surveillance data was at 1.0% (IQR: 1.6). The Positive per cent agreement (PPA) of the PMTCT HIV test results compared to those of the Sentinel Surveillance was 85.1% (95% CI 77.2-90.7%), and the percent-negative agreement (PNA) was 99.9% (95% CI 99.8-99.9%). The overall HIV prevalence according to UAT was the same as that found for women accepting a PMTCT HIV test and those who refused, with percent bias at 0.00%. For several key PMTCT variables, including "HIV test offered" (85.2%), "HIV test acceptance" (78.0%), or "HIV test done" (58.8%), the proportion of records in registers with combined complete and valid data was below the WHO benchmark of 90%. CONCLUSIONS: The PPA of 85.1 was below the WHO benchmarks of 96.6%, while the combined data validity and completeness rates was below the WHO benchmark of 90% for many key PMTCT variables. These results suggested that Senegal will need to reinforce the quality of onsite HIV testing and improve program data collection practices in preparation for using PMTCT data for surveillance purposes.

Using Acute Flaccid Paralysis Surveillance as a Platform for Vaccine-Preventable Disease Surveillance.

Surveillance for acute flaccid paralysis (AFP) is a fundamental cornerstone of the global polio eradication initiative (GPEI). Active surveillance (with visits to health facilities) is a critical strategy of AFP surveillance systems for highly sensitive and timely detection of cases. Because of the extensive resources devoted to AFP surveillance, multiple opportunities exist for additional diseases to be added using GPEI assets, particularly because there is generally 1 district officer responsible for all disease surveillance. For this reason, integrated surveillance has become a standard practice in many countries, ranging from adding surveillance for measles and rubella to integrated disease surveillance for outbreak-prone diseases (integrated disease surveillance and response). This report outlines the current level of disease surveillance integration in 3 countries (Nepal, India, and Nigeria) and proposes that resources continue for long-term maintenance in resource-poor countries of AFP surveillance as a platform for surveillance of vaccine-preventable diseases and other outbreak-prone diseases.

Yellow Fever Outbreak - Kongo Central Province, Democratic Republic of the Congo, August 2016.

On April 23, 2016, the Democratic Republic of the Congo's (DRC's) Ministry of Health declared a yellow fever outbreak. As of May 24, 2016, approximately 90% of suspected yellow fever cases (n = 459) and deaths (45) were reported in a single province, Kongo Central Province, that borders Angola, where a large yellow fever outbreak had begun in December 2015. Two yellow fever mass vaccination campaigns were conducted in Kongo Central Province during May 25-June 7, 2016 and August 17-28, 2016. In June 2016, the DRC Ministry of Health requested assistance from CDC to control the outbreak. As of August 18, 2016, a total of 410 suspected yellow fever cases and 42 deaths were reported in Kongo Central Province. Thirty seven of the 393 specimens tested in the laboratory were confirmed as positive for yellow fever virus (local outbreak threshold is one laboratory-confirmed case of yellow fever). Although not well-documented for this outbreak, malaria, viral hepatitis, and typhoid fever are common differential diagnoses among suspected yellow fever cases in this region. Other possible diagnoses include Zika, West Nile, or dengue viruses; however, no laboratory-confirmed cases of these viruses were reported. Thirty five of the 37 cases of yellow fever were imported from Angola. Two-thirds of confirmed cases occurred in persons who crossed the DRC-Angola border at one market city on the DRC side, where ≤40,000 travelers cross the border each week on market day. Strategies to improve coordination between health surveillance and cross-border trade activities at land borders and to enhance laboratory and case-based surveillance and health border screening capacity are needed to prevent and control future yellow fever outbreaks.

Respondent-Driven Sampling in a Multi-Site Study of Black and Latino Men Who Have Sex with Men.

PURPOSE: Respondent-driven sampling (RDS) was used to recruit four samples of Black and Latino men who have sex with men (MSM) in three metropolitan areas to measure HIV prevalence and sexual and drug use behaviors. We compared demographic and behavioral risk characteristics of participants across sites, assessed the extent to which the RDS statistical adjustment procedure provides estimates that differ from the crude results, and summarized our experiences using RDS. METHODS: From June 2005 to March 2006 a total of 2,235 MSM were recruited and interviewed: 614 Black MSM and 516 Latino MSM in New York City, 540 Black MSM in Philadelphia, and 565 Latino MSM in Los Angeles County. Crude point estimates for demographic characteristics, behavioral risk factors and HIV prevalence were calculated for each of the four samples. RDS Analysis Tool was used to obtain population-based estimates of each sampled population's characteristics. RESULTS: RDS adjusted estimates were similar to the crude estimates for each study sample on demographic characteristics such as age, income, education and employment status. Adjusted estimates of the prevalence of risk behaviors were lower than the crude estimates, and for three of the study samples, the adjusted HIV prevalence estimates were lower than the crude estimates. However, even the adjusted HIV prevalence estimates were higher than what has been previously estimated for these groups of MSM in these cities. Each site faced unique circumstances in implementing RDS. CONCLUSIONS: Our experience in using RDS among Black and Latino MSM resulted in diverse recruitment patterns and uncertainties in the estimated HIV prevalence and risk behaviors by study site.

The Epidemiology of HIV and Prevention Needs of Men Who Have Sex with Men in Abidjan, Cote d'Ivoire.

To determine HIV prevalence and associated risk factors among men who have sex with men (MSM) in Abidjan, Côte d'Ivoire. We conducted a cross-sectional RDS survey of MSM in Abidjan from October 2011 to February 2012. Eligibility criteria included age ≥ 18 years and having had oral or anal sex with another man in the last 12 months. Weighted data analysis was conducted with RDSAT and SAS. We enrolled 603 participants, of whom 601 (99.7%) completed the questionnaire and 581 (96.7%) consented to HIV testing. HIV population prevalence was estimated as 18.0% (95% CI: 13.0-23.1); 86.4% (95% CI: 75.1-94.9) of HIV-positive MSM were unaware of their serostatus. In multivariable analysis, adjusting for age, education, and income, HIV infection was associated with unprotected sex at last sex with a woman, more than two male anal sex partners in last 12 months, inconsistent condom use during anal sex with a man, self-perceived risk of HIV, history of forced sex, history of physical abuse due to MSM status, and not receiving last HIV test result prior to study. HIV prevalence among MSM in Abidjan is more than four times as high as that of general population men. MSM engage in high-risk sexual behavior and most HIV-positive MSM are unaware of their serostatus. Greater access to HIV prevention, care, and treatment services targeted to MSM is necessary.

Global epidemiology of HIV.

The number of persons living with HIV worldwide reached approximately 35.3 million in 2012. Meanwhile, AIDS-related deaths and new HIV infections have declined. Much of the increase in HIV prevalence is from rapidly increasing numbers of people on antiretroviral treatment who are now living longer. There is regional variation in epidemiologic patterns, major modes of HIV transmission, and HIV program response. It is important to focus on HIV incidence, rather than prevalence, to provide information about HIV transmission patterns and populations at risk. Expanding HIV treatment will function as a preventive measure through decreasing horizontal and vertical transmission of HIV.

Trends in HIV prevalence and risk behavior among men who have sex with men in New York City, 2004-2011.

This study examined trends in HIV prevalence and HIV-related risk behaviors from 2004 through 2011 among men who have sex with men (MSM) in New York City. MSM were venue-sampled, interviewed, and offered HIV testing in serial cross-sectional studies. Significant differences in overall time trends were determined using the Spearman rank correlation and logistic regression models. There were 457 (2004-2005), 550 (2008), and 510 (2011) participants in each study round. There was no significant trend in HIV prevalence over time, and past 12 month unprotected anal intercourse remained steady. However, drug use and number of sex partners declined. Among those who did not self-report being HIV positive, the percentage that tested for HIV in the past 12 months increased. The results from this study suggest that from 2004 through 2011 more MSM in New York City are being tested for HIV and have declining drug use and fewer sex partners.

Homophobia is associated with sexual behavior that increases risk of acquiring and transmitting HIV infection among black men who have sex with men.

We investigated whether the experience of homophobic events increases the odds of engaging in unprotected anal intercourse (UAI) among black men who have sex with men (MSM) and whether social integration level buffered the association. Participants (N = 1,154) reported homophobic events experienced in the past 12 months. Social integration measures included social support, closeness with family members and friends, attachment to the black gay community, openness about sexuality within religious communities, and MSM social network size. Logistic regression analyses indicated that experiencing homophobia was associated with (1) UAI among men not previously diagnosed with HIV and (2) sexual HIV transmission risk behavior among men who knew they were HIV-infected. None of the social integration measures buffered these associations. Homophobia may promote acquisition and transmission of HIV infection among black MSM. Interventions are needed to reduce homophobia experienced by black MSM.

Reciprocal sex partner concurrency and STDs among heterosexuals at high-risk of HIV infection.

Inconsistent findings on the relationship of sex partner concurrency to infection with HIV and other sexually transmitted diseases (STDs) may result from differences in how sex partner concurrency is conceptualized. We examine the relationship of reciprocal sex partner concurrency (RSPC) to diagnosed STDs among heterosexuals. Heterosexually active adults (N = 717) were recruited for a cross-sectional study using respondent-driven sampling (RDS) from high-HIV-risk areas in New York City (NYC, 2006-2007) and interviewed about their sexual risk behaviors, number of sex partners, last sex partners, and STD diagnoses (prior 12 months). RSPC was when both the participant and her/his last sex partner had sex with other people during their sexual relationship. Odds ratios (OR), adjusted odds ratios (aOR), and 95 % confidence intervals (95%CI) were estimated by logistic regression. The sample was 52.4 % female, 74.3 % Black; median age was 40 years. RSPC was reported by 40.7 % and any STD diagnoses by 23.4 %. Any STDs was reported by 31.5 % of those reporting RSPC vs. 17.9 % of those who did not (OR = 2.11, 95%CI = 1.49-3.0). Any STDs was independently associated with RSPC (aOR = 1.54, 95%CI = 1.02-2.32), female gender (aOR = 2.15, 95%CI = 1.43-3.23), having more than three sex partners (aOR = 1.72, 95%CI = 1.13-2.63), and unprotected anal sex (aOR = 1.65, 95%CI = 1.12-2.42). Heterosexuals in high-HIV-risk neighborhoods in sexual partnerships that involve RSPC are at greater risk of STDs and, potentially, HIV. RSPC, in addition to sexual risk behaviors and the number of sex partners, may facilitate the heterosexual spread of HIV through STD cofactors and linkage into larger STD/HIV sexual transmission networks.

The use of epidemiological data to inform the PEPFAR response.

The history of the HIV epidemic and the response to the epidemic is fundamentally a history of an emergency response to a global crisis. Trends and projections from initially available data were instrumental in establishing the President's Emergency Plan for AIDS Relief (PEPFAR) and in determining the direction of the program. Additionally, PEPFAR was built on data and the potential impact of interventions, and required the constant monitoring of the epidemic to report on the progress of the program. The response to the HIV epidemic saw the development of international guidelines and recommendations for data collection and epidemiological modeling. Although it is true that the urgency of the response often meant that data from data-poor countries suffered from incompleteness and bias, fortunately, as the response matured, the quality of the data and the infrastructure supporting data collection also matured. PEPFAR investments in surveillance and surveys were and remain critical for responding to the epidemic. The future of the response is reflected in growing country capacities to collect valid and reliable data, and using those data for decision making.

Estimating HIV incidence and the correlates of recent infection in venue-sampled men who have sex with men in New York City.

In a cross-sectional study, MSM aged ≥18 years were venue-sampled in New York City in 2008, interviewed, and tested for HIV using oral fluids. Participants who reported testing HIV negative at their last test in the previous 24 months were analyzed (n = 287 of 550 sampled). Those testing positive at the interview were defined as recently infected. HIV incidence was estimated using person-time at-risk methods and correlates of recent infection using proportional hazards regression. Thirty-two (11.1%) were recently infected. HIV incidence was 5.67/100 person-years at-risk. Independent correlates included: study recruitment in parks vs. bars, and in other venues vs. bars; black vs. non-black race/ethnicity; and reporting a last sex partner with a positive or unknown vs. negative HIV status. When assay-based methods are not feasible, cross-sectional HIV test results and self-reported HIV testing history and risk factor data can be used to estimate HIV incidence and the correlates of recent infection.

Recruitment-adjusted estimates of HIV prevalence and risk among men who have sex with men: effects of weighting venue-based sampling data.

OBJECTIVES: We investigated the impact of recruitment bias within the venue-based sampling (VBS) method, which is widely used to estimate disease prevalence and risk factors among groups, such as men who have sex with men (MSM), that congregate at social venues. METHODS: In a 2008 VBS study of 479 MSM in New York City, we calculated venue-specific approach rates (MSM approached/MSM counted) and response rates (MSM interviewed/MSM approached), and then compared crude estimates of HIV risk factors and seroprevalence with estimates weighted to address the lower selection probabilities of MSM who attend social venues infrequently or were recruited at high-volume venues. RESULTS: Our approach rates were lowest at dance clubs, gay pride events, and public sex strolls, where venue volumes were highest; response rates ranged from 39% at gay pride events to 95% at community-based organizations. Sixty-seven percent of respondents attended MSM-oriented social venues at least weekly, and 21% attended such events once a month or less often in the past year. In estimates adjusted for these variations, the prevalence of several past-year risk factors (e.g., unprotected anal intercourse with casual/exchange partners, ≥5 total partners, group sex encounters, at least weekly binge drinking, and hard-drug use) was significantly lower compared with crude estimates. Adjusted HIV prevalence was lower than unadjusted prevalence (15% vs. 18%), but not significantly. CONCLUSIONS: Not adjusting VBS data for recruitment biases could overestimate HIV risk and prevalence when the selection probability is greater for higher-risk MSM. While further examination of recruitment-adjustment methods for VBS data is needed, presentation of both unadjusted and adjusted estimates is currently indicated.

Continuing HIV risk in New York City injection drug users: the association of syringe source and syringe sharing.

Sterile syringe access is an important means to reduce HIV risk, but many injection drug users (IDU) who obtain syringes from sterile sources continue to share syringes. We examined the factors associated with continuing syringe sharing in New York City. We recruited 500 active IDU in 2005 through respondent-driven sampling. In multiple logistic regression, not obtaining all syringes in the past year exclusively from sterile sources was associated with increased syringe sharing. Ensuring adequate syringe availability as well as engaging and retaining nonusers and inconsistent users in sterile syringe services may increase sterile syringe access and decrease syringe sharing.

Patterns of exchange sex and HIV infection in high-risk heterosexual men and women.

Heterosexual partnerships involving the trade of money or goods for sex are a well-described HIV risk factor in Africa and Southeast Asia, but less research has been conducted on exchange partnerships and their impact on HIV infection in the United States. In our study, men and women were recruited from high-risk risk neighborhoods in New York City through respondent-driven sampling in 2006-2007. We examined the factors associated with having an exchange partner in the past year, the relationship between exchange partnerships and HIV infection, and the risk characteristics of those with exchange partners by the directionality of payment. Overall, 28% of men and 41% of women had a past-year exchange partner. For men, factors independently associated with exchange partnerships were older age, more total sexual partners, male partners, and frequent non-injection drug use. For women, factors were homelessness, more total sexual partners, more unprotected sex partners, and frequent non-injection drug use. Exchange partnerships were associated with HIV infection for both men and women, although the relationships were substantially confounded by other behavioral risks. Those who both bought and sold sex exhibited the highest levels of risk with their exchange and non-exchange partners. Exchange partnerships may be an HIV risk both directly and indirectly, given the overlap of this phenomenon with other risk factors that occur with both exchange and non-exchange partners.