Transmissibility and severity of COVID-19 in a humanitarian setting: First few X investigation of cases and contacts in Juba, South Sudan, 2020.

BACKGROUND: The first few 'X' (FFX) studies provide evidence to guide public health decision-making and resource allocation. The adapted WHO Unity FFX protocol for COVID-19 was implemented to gain an understanding of the clinical, epidemiological, virological and household transmission dynamics of the first cases of COVID-19 infection detected in Juba, South Sudan. METHODS: Laboratory-confirmed COVID-19 cases were identified through the national surveillance system, and an initial visit was conducted with eligible cases to identify all close contacts. Consenting cases and close contacts were enrolled between June 2020 and December 2020. Demographic, clinical information and biological samples were taken at enrollment and 14-21 days post-enrollment for all participants. RESULTS: Twenty-nine primary cases and 82 contacts were included in the analyses. Most primary cases (n = 23/29, 79.3%) and contacts (n = 61/82, 74.4%) were male. Many primary cases (n = 18/29, 62.1%) and contacts (n = 51/82, 62.2%) were seropositive for SARS-CoV-2 at baseline. The secondary attack rate among susceptible contacts was 12.9% (4/31; 95% CI: 4.9%-29.7%). All secondary cases and most (72%) primary cases were asymptomatic. Reported symptoms included coughing (n = 6/29, 20.7%), fever or history of fever (n = 4/29, 13.8%), headache (n = 3/29, 10.3%) and shortness of breath (n = 3/29, 10.3%). Of 38 cases, two were hospitalised (5.3%) and one died (2.6%). CONCLUSIONS: These findings were used to develop the South Sudanese Ministry of Health surveillance and contract tracing protocols, informing local COVID-19 case definitions, follow-up protocols and data management systems. This investigation demonstrates that rapid FFX implementation is critical in understanding the emerging disease and informing response priorities.

Early epidemiological investigations: World Health Organization UNITY protocols provide a standardized and timely international investigation framework during the COVID-19 pandemic.

BACKGROUND: The declaration of Coronavirus disease 2019 (COVID-19) as a Public Health Emergency of International Concern (PHEIC) on 30 January 2020 required rapid implementation of early investigations to inform appropriate national and global public health actions. METHODS: The suite of existing pandemic preparedness generic epidemiological early investigation protocols was rapidly adapted for COVID-19, branded the 'UNITY studies' and promoted globally for the implementation of standardized and quality studies. Ten protocols were developed investigating household (HH) transmission, the first few cases (FFX), population seroprevalence (SEROPREV), health facilities transmission (n = 2), vaccine effectiveness (n = 2), pregnancy outcomes and transmission, school transmission, and surface contamination. Implementation was supported by WHO and its partners globally, with emphasis to support building surveillance and research capacities in low- and middle-income countries (LMIC). RESULTS: WHO generic protocols were rapidly developed and published on the WHO website, 5/10 protocols within the first 3 months of the response. As of 30 June 2021, 172 investigations were implemented by 97 countries, of which 62 (64%) were LMIC. The majority of countries implemented population seroprevalence (71 countries) and first few cases/household transmission (37 countries) studies. CONCLUSION: The widespread adoption of UNITY protocols across all WHO regions indicates that they addressed subnational and national needs to support local public health decision-making to prevent and control the pandemic.

Transmission of SARS-CoV-2 in standardised first few X cases and household transmission investigations: A systematic review and meta-analysis.

We aimed to estimate the household secondary infection attack rate (hSAR) of SARS-CoV-2 in investigations aligned with the WHO Unity Studies Household Transmission Investigations (HHTI) protocol. We conducted a systematic review and meta-analysis according to PRISMA 2020 guidelines. We searched Medline, Embase, Web of Science, Scopus and medRxiv/bioRxiv for "Unity-aligned" First Few X cases (FFX) and HHTIs published 1 December 2019 to 26 July 2021. Standardised early results were shared by WHO Unity Studies collaborators (to 1 October 2021). We used a bespoke tool to assess investigation methodological quality. Values for hSAR and 95% confidence intervals (CIs) were extracted or calculated from crude data. Heterogeneity was assessed by visually inspecting overlap of CIs on forest plots and quantified in meta-analyses. Of 9988 records retrieved, 80 articles (64 from databases; 16 provided by Unity Studies collaborators) were retained in the systematic review; 62 were included in the primary meta-analysis. hSAR point estimates ranged from 2% to 90% (95% prediction interval: 3%-71%; I 2 = 99.7%); I 2 values remained >99% in subgroup analyses, indicating high, unexplained heterogeneity and leading to a decision not to report pooled hSAR estimates. FFX and HHTI remain critical epidemiological tools for early and ongoing characterisation of novel infectious pathogens. The large, unexplained variance in hSAR estimates emphasises the need to further support standardisation in planning, conduct and analysis, and for clear and comprehensive reporting of FFX and HHTIs in time and place, to guide evidence-based pandemic preparedness and response efforts for SARS-CoV-2, influenza and future novel respiratory viruses.

The first epidemiological and virological influenza surveillance in the Republic of Guinea revealed the predominance of influenza A/H3N2 and B Victoria viruses.

Little is known about respiratory viruses infection in Guinea. Influenza surveillance has not been implemented in Guinea mainly because of the paucity of laboratory infrastructure and capacity. This paper presents the first influenza surveillance data in Guinea.Swabs were obtained from August 2018 through December 2019 at influenza sentinel sites and transported to the Institut National de Santé Publique for testing. Ribonucleic acid was extracted and tested for the presence of influenza A and B by real-time reverse transcription-polymerase chain reaction (RT-PCR). Positive samples were further characterised to determine the subtypes and lineages of influenza viruses.A total of 862 swabs were collected and tested. Twenty-three per cent of samples tested positive for influenza A and B viruses. Characterisation of positive specimens identified influenza A/H1N1pmd09 (2.5%), influenza A/H3N2 (57.3%), influenza B/Victoria lineage (36.7%) and 7 (3.5%) influenza B with undetermined lineage. Influenza B virus activity clustered in August through November while influenza A/H3N2 displayed two clusters of activities that appeared in May through August and November through December.For the first time in Guinea, the epidemiology, diversity and period of circulation of influenza viruses were studied. The results indicate the predominance and the periods of activities of influenza B Victoria lineage and influenza A/H3N2 which are important information for preventive strategies. It is warranted to extend the influenza surveillance to other parts of Guinea to better understand the epidemiology of the viruses and monitor the emergence of influenza strains with pandemic potential.

Institut Pasteur International Network's efforts to guide control measures against the coronavirus disease 2019 (COVID-19) epidemic among healthcare workers in Africa.

During epidemic periods, HCW are vulnerable. In Africa, cohort studies implemented by the Institut Pasteur International Network in five countries showed after 3-month follow-up around 40% of the HCW have been infected by the SARS-CoV-2. So advocacy for HCW protection strategy need to be fostered and sustained by the health authorities all over the African continent.

The COVID-19 pandemic: research and health development in the World Health Organisation Africa region.

Concerns have been expressed about the view point of WHO AFRO concerning research for health in the African Region. WHO AFRO considers research a critical component in the improvement of health in the Africa region. Ensuring the effectiveness of our strategies, policies and programmes requires evidence. In the context of the ongoing COVID-19 outbreak, WHO research interests cover key areas of the response. The WHO AFRO consider research as critical in our efforts at protecting people against health emergencies and pandemics like the COVID-19 and ensuring universal access to proven interventions. In view of this, the WHO has taken steps to strengthen capacity for research in the region. The results of these efforts may take time to manifest but will surely do as we persist in our drive, with support from our partners.

The epidemiology of seasonal influenza after the 2009 influenza pandemic in Africa: a systematic review.

BACKGROUND: Influenza infection is a serious public health problem that causes an estimated 3 to 5 million cases and 250,000 deaths worldwide every year. The epidemiology of influenza is well-documented in high- and middle-income countries, however minimal effort had been made to understand the epidemiology, burden and seasonality of influenza in Africa. This study aims to assess the state of knowledge of seasonal influenza epidemiology in Africa and identify potential data gaps for policy formulation following the 2009 pandemic. METHOD: We reviewed articles from Africa published into four databases namely: MEDLINE (PubMed), Google Scholar, Cochrane Library and Scientific Research Publishing from 2010 to 2019. RESULTS: We screened titles and abstracts of 2070 studies of which 311 were selected for full content evaluation and 199 studies were considered. Selected articles varied substantially on the basis of the topics they addressed covering the field of influenza surveillance (n=80); influenza risk factors and co-morbidities (n=15); influenza burden (n=37); influenza vaccination (n=40); influenza and other respiratory pathogens (n=22) and influenza diagnosis (n=5). CONCLUSION: Significant progress has been made since the last pandemic in understanding the influenza epidemiology in Africa. However, efforts still remain for most countries to have sufficient data to allow countries to prioritize strategies for influenza prevention and control.

Leveraging the Global Influenza Surveillance and Response System for global respiratory syncytial virus surveillance-opportunities and challenges.

BACKGROUND: Respiratory syncytial virus (RSV)-associated acute lower respiratory infection is a common cause for hospitalization and hospital deaths in young children globally. There is urgent need to generate evidence to inform immunization policies when RSV vaccines become available. The WHO piloted a RSV surveillance strategy that leverages the existing capacities of the Global Influenza Surveillance and Response System (GISRS) to better understand RSV seasonality, high-risk groups, validate case definitions, and develop laboratory and surveillance standards for RSV. METHODS: The RSV sentinel surveillance strategy was piloted in 14 countries. Patients across all age groups presenting to sentinel hospitals and clinics were screened all year-round using extended severe acute respiratory infection (SARI) and acute respiratory infection (ARI) case definitions for hospital and primary care settings, respectively. Respiratory specimens were tested for RSV at the National Influenza Centre (NIC) using standardized molecular diagnostics that had been validated by an External Quality Assurance program. The WHO FluMart data platform was adapted to receive case-based RSV data and visualize interactive visualization outputs. RESULTS: Laboratory standards for detecting RSV by RT-PCR were developed. A review assessed the feasibility and the low incremental costs for RSV surveillance. Several challenges were addressed related to case definitions, sampling strategies, the need to focus surveillance on young children, and the data required for burden estimation. CONCLUSIONS: There was no evidence of any significant adverse impact on the functioning of GISRS which is primarily intended for virologic and epidemiological surveillance of influenza.

The covid-19 pandemic: research and health development in the World Health Organisation Africa region

Concerns have been expressed about the view point of WHO AFRO concerning research for health in the African Region. WHO AFRO considers research a critical component in the improvement of health in the Africa region. Ensuring the effectiveness of our strategies, policies and programmes requires evidence. In the context of the ongoing COVID-19 outbreak, WHO research interests cover key areas of the response. The WHO AFRO consider research as critical in our efforts at protecting people against health emergencies and pandemics like the COVID-19 and ensuring universal access to proven interventions. In view of this, the WHO has taken steps to strengthen capacity for research in the region. The results of these efforts may take time to manifest but will surely do as we persist in our drive, with support from our partners

Joint external evaluation of the International Health Regulation (2005) capacities: current status and lessons learnt in the WHO African region.

The International Health Regulations (IHR, 2005) are an essential vehicle for addressing global health security. Here, we report the IHR capacities in the WHO African from independent joint external evaluation (JEE). The JEE is a voluntary component of the IHR monitoring and evaluation framework. It evaluates IHR capacities in 19 technical areas in four broad themes: 'Prevent' (7 technical areas, 15 indicators); 'Detect' (4 technical areas, 13 indicators); 'Respond' (5 technical areas, 14 indicators), points of entry (PoE) and other IHR hazards (chemical and radiation) (3 technical areas, 6 indicators). The IHR capacity scores are graded from level 1 (no capacity) to level 5 (sustainable capacity). From February 2016 to March 2019, 40 of 47 WHO African region countries (81% coverage) evaluated their IHR capacities using the JEE tool. No country had the required IHR capacities. Under the theme 'Prevent', no country scored level 5 for 12 of 15 indicators. Over 80% of them scored level 1 or 2 for most indicators. For 'Detect', none scored level 5 for 12 of 13 indicators. However, many scored level 3 or 4 for several indicators. For 'Respond', none scored level 5 for 13 of 14 indicators, and less than 10% had a national multihazard public health emergency preparedness and response plan. For PoE and other IHR hazards, most countries scored level 1 or 2 and none scored level 5. Countries in the WHO African region are commended for embracing the JEE to assess their IHR capacities. However, major gaps have been identified. Urgent collective action is needed now to protect the WHO African region from health security threats.

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.

Strengthening immunization service delivery post Ebola virus disease (EVD) outbreak in Liberia 2015-2017.

INTRODUCTION: The Ebola virus disease (EVD) outbreak in Liberia from 2014-2015 setback the already fragile health system which was recovering from the effects of civil unrest. This led to significant decline in immunization coverage and key polio free certification indicators. The Liberia investment plan was developed to restore immunization service delivery and overall health system. METHODS: We conducted a desk review to summarize performance of immunization coverage, polio eradication, measles control, new vaccines and technologies. Data sources include program reports, scientific and grey literature, District Health Information System (DHIS2), Integrated Diseases Surveillance and Response (IDSR) database, auto visual AFP detection and reporting (AVADAR) and ONA Servers. Data analysis was done using Microsoft excel spreadsheets, ONA software and Arc GIS. RESULTS: There was a 36% increase in national coverage for Penta 3 in 2017 compared to 2014 from WUENIC data. Penta 3 dropout rate reduced by 2.5 fold from 15.3% in 2016 to 6.4% in 2017; while MCV1 coverage improved by 23% from 64% in 2015 to 87% in 2017. There was a rebound of non-polio AFP rate (NPAFP) rate from 1.2 in 2015 to 4.3 in 2017. Furthermore, there was a 2-fold increase in the number of AFP cases receiving 3 or more doses of OPV from 36% in 2015 to 61% in 2017. CONCLUSION: Liberia demonstrated strong rebound of immunization services following the largest and most devastating EVD outbreak in West Africa in 2014 - 2015. Immunization coverage improved and dropout rates reduced. However, there are still opportunities for improvement in the immunization program both at national and sub-national levels.

Risk communication during disease outbreak response in post-Ebola Liberia: experiences in Sinoe and Grand Kru counties.

INTRODUCTION: Lessons learned from the Ebola virus disease (EVD) outbreak enabled Liberia to develop a health plan for strengthening public health capacity against potential public health threats. risk communication is one of the core pillars that provide life-saving information and knowledge for the public to take preventive and proactive actions against public health threats. These were applied in response to the post-ebola meningococcal septicemia and meningitis outbreaks in Sinoe and Grand Kru counties. This paper documents risk communication experiences in these post-ebola outbreaks in Liberia. METHODS: Risk Communication and health promotion strategies were deployed in developing response plans and promptly disseminating key messages to affected communities to mitigate the risks. Other strategies included engagement of community leaders, partnership with the media and dissemination of messages through the community radios, active monitoring community risk perceptions and compliance, rumor management, mobile stage and interpersonal communication (IPC) during the Meningococcal disease outbreaks in Sinoe and Grand Kru counties. RESULTS: In Sinoe, about 36,891 households or families in 10 health districts were reached through IPC and dialogue. Circulating rumors such as "Ebola" was the cause of deaths was timely and promptly mitigated. There was increased trust and adherence to health advice including prompt reporting of sick people to the nearest health facility in the two counties. CONCLUSION: Risk communication and health promotion encouraged community support and involvement in any response to public threats and events. No doubt, risk communication and health promotion play an important role in preparedness and response to public health emergencies.

Lessons learned from detecting and responding to recurrent measles outbreak in Liberia post Ebola-Epidemic 2016-2017.

INTRODUCTION: Measles is an acute viral disease that remains endemic in much of sub-Sahara Africa, including Liberia. The 2014 Ebola epidemic disrupted an already fragile health system contributing to low uptake of immunization services, population immunity remained low thus facilitating recurrent outbreaks of measles in Liberia. We describe lessons learnt from detecting and responding to recurrent outbreaks of measles two years post the 2014 Ebola epidemic in Liberia. METHODS: We conducted a descriptive study using the findings from Integrated Diseases Surveillance and Response (IDSR) 15 counties, National Public Health Institute of Liberia (NPHIL), National Public Health Reference Laboratory (NPHRL) and District Health Information Software (DIHS2) data conducted from October to December, 2017. We perused the outbreaks line lists and other key documents submitted by the counties to the national level from January 2016 to December 2017. RESULTS: From January 2016 to December 2017, 2,954 suspected cases of measles were reported through IDSR. Four hundred sixty-seven (467) were laboratory confirmed (IgM-positive), 776 epidemiologically linked, 574 clinically confirmed, and 1,137 discarded (IgM-negative). Nine deaths out of 1817 cases were reported, a case fatality rate of 0.5%; 49% were children below the age of 5 years. Twenty-two percent (405/1817) of the confirmed cases were vaccinated while the vaccination status of 55% (994/1817) was unknown. CONCLUSION: Revitalization of IDSR contributed to increased detection and reporting of suspected cases of measles thus facilitating early identification and response to outbreaks. Priority needs to be given to increasing the uptake of routine immunization services, introducing a second dose of measles vaccine in the routine immunization program and conducting a high-quality supplementary measles immunization campaign for age group 1 to 10 years to provide protection for a huge cohort of susceptible.

Integrated disease surveillance and response implementation in Liberia, findings from a data quality audit, 2017.

INTRODUCTION: in spite of the efforts and resources committed by the division of infectious disease and epidemiology (DIDE) of the national public health institute of Liberia (NPHIL)/Ministry of health to strengthening integrated disease surveillance and response (IDSR) across the country, quality data management system remains a challenge to the Liberia NPHIL/MoH (Ministry of health), with incomplete and inconsistent data constantly being reported at different levels of the surveillance system. As part of the monitoring and evaluation strategy for IDSR continuous improvement, data quality assessment (DQA) of the IDSR system to identify successes and gaps in the disease surveillance information system (DSIS) with the aim of ensuring data accuracy, reliability and credibility of generated data at all levels of the health system; and to inform an operational plan to address data quality needs for IDSR activities is required. METHODS: multi-stage cluster sampling that included stage 1: simple random sample (SRS) of five counties, stage 2: simple random sample of two districts and stage 3: simple random sample of three health facilities was employed during the study pilot assessment done in Montserrado County with Liberia institute of bio medical research (LIBR) inclusive. A total of thirty (30) facilities was targeted, twenty nine (29) of the facilities were successfully audited: one hospital, two health centers, twenty clinics and respondents included: health facility surveillance focal persons (HFSFP), zonal surveillance officers (ZSOs), district surveillance officers (DSOs) and County surveillance officers (CSOs). RESULTS: the assessment revealed that data use is limited to risk communication and sensitization, no examples of use of data for prioritization or decision making at the subnational level. The findings indicated the following: 23% (7/29) of health facilities having dedicated phone for reporting, 20% (6/29) reported no cell phone network, 17% (5/29) reported daily access to internet, 56.6% (17/29) reported a consistent supply of electricity, and no facility reported access to functional laptop. It was also established that 40% of health facilities have experienced a stock out of laboratory specimens packaging supplies in the past year. About half of the surveyed health facilities delivered specimens through riders and were assisted by the DSOs. There was a large variety in the reported packaging process, with many staff unable to give clear processes. The findings during the exercise also indicated that 91% of health facility staff were mentored on data quality check and data management including the importance of the timeliness and completeness of reporting through supportive supervision and mentorship; 65% of the health facility assessed received supervision on IDSR core performance indicator; and 58% of the health facility officer in charge gave feedback to the community level. CONCLUSION: public health is a data-intensive field which needs high-quality data and authoritative information to support public health assessment, decision-making and to assure the health of communities. Data quality assessment is important for public health. In this review completeness, accuracy, and timeliness were the three most-assessed attributes. Quantitative data quality assessment primarily used descriptive surveys and data audits, while qualitative data quality assessment methods include primarily interviews, questionnaires administration, documentation reviews and field observations. We found that data-use and data-process have not been given adequate attention, although they were equally important factors which determine the quality of data. Other limitations of the previous studies were inconsistency in the definition of the attributes of data quality, failure to address data users' concerns and a lack of triangulation of mixed methods for data quality assessment. The reliability and validity of the data quality assessment were rarely reported. These gaps suggest that in the future, data quality assessment for public health needs to consider equally the three dimensions of data quality, data use and data process. Measuring the perceptions of end users or consumers towards data quality will enrich our understanding of data quality issues. Data use is limited to risk communication and sensitization, no examples of use of data for prioritization or decision making at the sub national level.

The implementation of integrated disease surveillance and response in Liberia after Ebola virus disease outbreak 2015-2017.

INTRODUCTION: Although Liberia adapted the integrated diseases surveillance and response (IDSR) in 2004 as a platform for implementation of International Health Regulation (IHR (2005)), IDSR was not actively implemented until 2015. Some innovations and best practices were observed during the implementation of IDSR in Liberia after Ebola virus disease outbreak. This paper describes the different approaches used for implementation of IDSR in Liberia from 2015 to 2017. METHODS: We conducted a cross-sectional study using the findings from IDSR supervisions conducted from September to November 2017 and perused the outbreaks linelists submitted by the counties to the national level from January to December 2017 and key documents available at the national level. RESULTS: In 2017, the country piloted the use of mobile phones application to store and send data from the health facilities to the national level. In addition, an electronic platform for acute flaccid paralysis (AFP) surveillance called Auto-Visual AFP Detection and Reporting (AVADAR) was piloted in Montserrado County during the first semester of 2017. The timeliness and completeness of reports submitted from the counties to national level were above the target of 80% stable despite the challenges like insufficient resources, including skilled staff. CONCLUSION: IDSR is being actively implemented in Liberia since 2015. Although the country is facing the same challenges as other countries during the early stages of implementation of IDSR, the several innovations were implemented in a short time. The surveillance system reveled to be resilient, despite the challenges.

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.

Enhancing laboratory capacity during Ebola virus disease (EVD) heightened surveillance in Liberia: lessons learned and recommendations.

INTRODUCTION: Following a declaration by the World Health Organization that Liberia had successfully interrupted Ebola virus transmission on May 9th, 2015; the country entered a period of enhanced surveillance. The number of cases had significantly reduced prior to the declaration, leading to closure of eight out of eleven Ebola testing laboratories. Enhanced surveillance led to an abrupt increase in demand for laboratory services. We report interventions, achievements, lessons learned and recommendations drawn from enhancing laboratory capacity. METHODS: Using archived data, we reported before and after interventions that aimed at increasing laboratory capacity. Laboratory capacity was defined by number of laboratories with Ebola Virus Disease (EVD) testing capacity, number of competent staff, number of specimens tested, specimen backlog, daily and surge testing capacity, and turnaround time. Using Stata 14 (Stata Corporation, College Station, TX, USA), medians and trends were reported for all continuous variables. RESULTS: Between May and December 2015, interventions including recruitment and training of eight staff, establishment of one EVD laboratory facility, implementation of ten Ebola GeneXpert diagnostic platforms, and establishment of working shifts yielded an 8-fold increase in number of specimens tested, a reduction in specimens backlog to zero, and restoration of turn-around time to 24 hours. This enabled a more efficient surveillance system that facilitated timely detection and containment of two EVD clusters observed thereafter. CONCLUSION: Effective enhancement of laboratory services during high demand periods requires a combination of context-specific interventions. Building and ensuring sustainability of local capacity is an integral part of effective surveillance and disease outbreak response efforts.

Integrated Disease Surveillance and Response (IDSR) strategy: current status, challenges and perspectives for the future in Africa.

In 1998, the WHO African region adopted a strategy called Integrated Disease Surveillance and Response (IDSR). Here, we present the current status of IDSR implementation; and provide some future perspectives for enhancing the IDSR strategy in Africa. In 2017, we used two data sources to compile information on the status of IDSR implementation: a pretested rapid assessment questionnaire sent out biannually to all countries and quarterly compilation of data for two IDSR key performance indicators (KPI). The first KPI measures country IDSR performance and the second KPI tracks the number of countries that the WHO secretariat supports to scale up IDSR. The KPI data for 2017 were compared with a retrospective baseline for 2014. By December 2017, 44 of 47 African countries (94%) were implementing IDSR. Of the 44 countries implementing IDSR, 40 (85%) had initiated IDSR training at subnational level; 32 (68%) had commenced community-based surveillance; 35 (74%) had event-based surveillance; 33 (70%) had electronic IDSR; and 32 (68%) had a weekly/monthly bulletin for sharing IDSR data. Thirty-two countries (68%) had achieved the timeliness and completeness threshold of at least 80% of the reporting units. However, only 12 countries (26%) had the desired target of at least 90% IDSR implementation coverage at the peripheral level. After 20 years of implementing IDSR, there are major achievements in the indicator-based surveillance systems. However, major gaps were identified in event-based surveillance. All African countries should enhance IDSR everywhere.

Revitalization of integrated disease surveillance and response in Sierra Leone post Ebola virus disease outbreak.

BACKGROUND: The Ministry of Health and Sanitation (MOHS) in Sierra Leone partially rolled out the implementation of Integrated Disease Surveillance and Response (IDSR) in 2003. After the Ebola virus disease outbreak in 2014-2015, there was need to strengthen IDSR to ensure prompt detection and response to epidemic-prone diseases. We describe the processes, successes and challenges of revitalizing public health surveillance in a country recovering from a protracted Ebola virus disease outbreak. METHODS: The revitalization process began with adaptation of the revised IDSR guidelines and development of customized guidelines to suit the health care systems in Sierra Leone. Public health experts defined data flow, system operations, case definitions, frequency and channels of reporting and dissemination. Next, phased training of IDSR focal persons in each health facility and the distribution of data collection and reporting tools was done. Monitoring activities included periodic supportive supervision and data quality assessments. Rapid response teams were formed to investigate and respond to disease outbreak alerts in all districts. RESULTS: Submission of reports through the IDSR system began in mid-2015 and by the 35th epidemiologic week, all district health teams were submitting reports. The key performance indicators measuring the functionality of the IDSR system in 2016 and 2017 were achieved (WHO Africa Region target ≥80%); the annual average proportion of timely weekly health facility reports submitted to the next level was 93% in 2016 and 97% in 2017; the proportion of suspected outbreaks and public health events detected through the IDSR system was 96% (n = 87) in 2016 and 100% (n = 85) in 2017. CONCLUSION: With proper planning, phased implementation and adequate investment of resources, it is possible to establish a functional IDSR system in a country recovering from a public health crisis. A functional IDSR system requires well trained workforce, provision of the necessary tools and guidelines, information, communication and technology infrastructure to support data transmission, provision of timely feedback as well as logistical support.