Epidemiological characteristics of a protracted and widespread measles outbreak in the Democratic Republic of Congo, 2018 - 2020.

Introduction: measles is a highly contagious viral disease. Since 2011, the Democratic Republic of Congo (DR Congo) has had the first dose measles vaccination coverage of less than 80% according to the World Health Organization - United Nations International Children's Emergency Fund (WHO-UNICEF) coverage estimates, and measles mass vaccination coverage of less than the required coverage level of 95% by survey. Starting in August 2018, the country experienced an increase in measles case reports which continued through to early 2020. Epidemiological aspects of the outbreak are described in this article. Methods: we analysed aggregate weekly passive surveillance data from the DR Congo for the years 2018 - 2020 to understand the trends of occurrence of suspected measles cases. We also analysed the measles case-based surveillance database to understand the epidemiological characteristics of confirmed cases of measles and rubella during the same period of time. Results: a total of 458,156 suspected measles cases and 8,127 deaths were reported between 1st January 2018 and 31st December 2020, with the majority of cases and deaths reported in 2019. Only 2.9% of these cases were reported through the case-based surveillance system, with 31,639 cases being confirmed as measles by the laboratory, by epidemiological linkage and on clinical compatibility. Children less than 5 years of age were most affected with a cumulative incidence of 960 cases per 1,000,000 inhabitants. Only 41% of the confirmed cases were vaccinated. Maindombe and Tshopo provinces had the highest cumulative incidence levels. There was a distinct geographic progression of the outbreak between provinces during the course of the three years. A total of 1760 lab confirmed rubella cases were confirmed in various provinces among the cases investigated with blood specimens, 93% of whom were less than 15 years of age. Conclusion: the recent gaps in vaccination coverage, the age pattern of confirmed cases and the lack of vaccination history in the majority of cases is suggestive of failure to vaccinate as the likely cause of this large and protracted outbreak. Efforts to improve vaccination coverage and the measles surveillance system are needed in order to prevent the occurrence of future outbreaks and to avert measles-related deaths.

Main challenges of the detection in the context of global health security: systematic review of Joint External Evaluation (JEE) reports.

Introduction: since 2016, Joint External Evaluation (JEE) missions have been organized in various countries. This systematic review of the JEE reports is intended to identify the main challenges (MC) of detection in WHO regions. Methods: we accessed JEE reports on the WHO website. Challenge was defined as a variable of the indicators of detection where there was a need of improvement. MC was a challenge common to at least one-third of countries in each region and globally. For consistency, we assessed challenges reported under "Areas which need strengthening/challenges" in reports. Results: we analyzed 96 JEE reports. African Region (91.7%), Eastern Mediterranean Region (80.9%) and South East Asia Region (72.7%) had the highest rates of JEE completion. The MC were 24 in European Region, 26 in Mediterranean Region, 30 in Western Pacific Region, 33 in South East Asia Region and 34 in African Region. 24 MCs were identified at global level. National laboratory system and Real time surveillance had the highest number of MC. Eleven MCs were common to all WHO regions and global level. These include insufficient capacity for core test confirmation, insufficient specimen referral system, weak quality management system, issues in laboratories licensing and accreditation, weak data management, weak electronic reporting system, absence /weak mechanism of information exchange between International Health Regulation and animal health focal points, insufficient health professional specialists, the need of workforce strategy, the need of field epidemiology and insufficient workforce retention capacity. Conclusion: the MCs identified should be addressed through a global approach.

Challenges related to resources mobilization for measles outbreak response: Madagascar experience during the 2018-2019 measles outbreak.

INTRODUCTION: on October 4th, 2018, a measles outbreak was declared in Madagascar. This study describes challenges related to resources mobilization for the outbreak response. METHODS: data were collected using minutes of coordination committee meetings, activities reports, operational action plans and situation reports. RESULTS: the total cost of the outbreak response was estimated to US$ 11,281,381. Operational cost was the leading cost driver (42.45%) followed by vaccine cost (33.74%). Cases management, epidemiological surveillance, communication and social mobilization and routine immunization strengthening represented 23.81% of the total cost. The main funder of the outbreak response was the measles and rubella initiative. CONCLUSION: good coordination, open dialogue, good use of financial resources and accountability of government and partners have enabled to gain the confidence of national and international donors.

Madagascar 2018-2019 measles outbreak response: main strategic areas.

INTRODUCTION: on October 4th, 2018, a measles outbreak was declared in Madagascar. This study describes the outbreak response in terms of coordination, case management, vaccination response and epidemiological surveillance. METHODS: data were collected using a line list and vaccination tally sheet. Serum samples were collected within 30 days of rash onset for laboratory testing; confirmation was made by detection of measles immunoglobulin M antibody. RESULTS: from September 2018 to May 2019, a total of 146,277 measles cases were reported which included 1394 (1%) laboratory-confirmed cases and 144,883 (99%) epidemiological link-confirmed cases. The outbreak affected equally males (72,917 cases; 49.85%) and females (73,233 cases; 50.06%). The sex was not specified for 127 (0.09%) cases. Case fatality rate and attack rate were high among children less than 5 years. Responses interventions include effective coordination, free of charge case management, reactive vaccination, strengthened real-time surveillance, communication and community engagement and the revitalization of the routine immunization. Reactive vaccination was implemented in different phases. A total of 7,265,990 children aged from 6 months to 9 years were vaccinated. Post campaign survey coverage was 95%, 96% and 97% for phase 1, 2, 3 respectively. CONCLUSION: elimination of measles will be challenging in Madagascar because of low routine immunization coverage and the absence of a second dose of measles vaccine in the routine immunization schedule.

Measles outbreak in 2018-2019, Madagascar: epidemiology and public health implications.

INTRODUCTION: In October 4th, 2018, a measles outbreak was declared in Madagascar. This study describes the epidemiology of the outbreak and determines public health implications for measles elimination in Madagascar. METHODS: Data have been collected using line list developed for the outbreak. Serum samples were collected within 30 days of rash onset for laboratory testing; confirmation was made by detection of measles immunoglobulin M (IgM) antibody. RESULTS: A total of 2,930 samples were analysed in the laboratory among which 1,086 (37%) were laboratory confirmed. Measles cases age ranged from a minimum of 1 month to a maximum of 88 years. The median and the mean were 7 years and 9 years respectively. Children between 1 to 9 years accounted for 50.6% of measles cases. Attack rate (39,014 per 1,000,000 inhabitants) and case fatality rate (1.2%) were highest among children aged 9-11 months. A total of 67.2% cases were unvaccinated. As of March 14th, 2019, all the 22 regions and 105 (92%) health districts out of 114 were affected by the measles outbreak in Madagascar. CONCLUSION: Measles outbreak in Madagascar showed that the country is not on the track to achieve the goal of measles elimination by 2020.

Surveillance des paralysies flasques aiguës en Côte d'Ivoire de 2007 à 2016 : importance et profil épidémiologique des entérovirus non poliovirus.

INTRODUCTION: Côte d'Ivoire's status as a polio-free country requires high quality surveillance of acute flaccid paralysis. Our study aims to determine the prevalence of non-poliovirus enteroviruses found in the surveillance of Acute Flaccid Paralysis (AFP) in Côte d'Ivoire and to study their distribution according to individual characteristics and associated factors. METHOD: We conducted an exhaustive descriptive and analytical cross-sectional retrospective study on 3597 cases of acute flaccid paralysis notified in the context of surveillance of AFP from 2007 to 2016 in Côte d'Ivoire. RESULTS: The mean annual rate of non-poliovirus enterovirus over the period was 11.3% over the study period with extremes of 9.2% and 15.9%. The absence of fever at the onset of illness and early age were factors associated with the occurrence of acute flaccid paralysis due to non-poliovirus enterovirus. CONCLUSION: Our study found a downward trend in non-poliovirus enteroviruses detected in AFP surveillance in Côte d'Ivoire, and identified the absence of fever and the age of the subject as being the factors associated with their occurrence. It is therefore necessary to type all cases of non-poliovirus enteroviruses detected in AFP surveillance to assess the risks of vaccine-derived polioviruses.

[Surveillance of acute flaccid paralysis in Ivory Coast between 2007 and 2016: Significance and epidemiological profile of non-poliovirus enteroviruses]. / Surveillance des paralysies flasques aiguës en Côte d'Ivoire de 2007 à 2016 : importance et profil épidémiologique des entérovirus non poliovirus.

INTRODUCTION: Côte d'Ivoire's status as a polio-free country requires high quality surveillance of acute flaccid paralysis. Our study aims to determine the prevalence of non-poliovirus enteroviruses found in the surveillance of Acute Flaccid Paralysis (AFP) in Côte d'Ivoire and to study their distribution according to individual characteristics and associated factors. METHOD: We conducted an exhaustive descriptive and analytical cross-sectional retrospective study on 3597 cases of acute flaccid paralysis notified in the context of surveillance of AFP from 2007 to 2016 in Côte d'Ivoire. RESULTS: The mean annual rate of non-poliovirus enterovirus over the period was 11.3% over the study period with extremes of 9.2% and 15.9%. The absence of fever at the onset of illness and early age were factors associated with the occurrence of acute flaccid paralysis due to non-poliovirus enterovirus. CONCLUSION: Our study found a downward trend in non-poliovirus enteroviruses detected in AFP surveillance in Côte d'Ivoire, and identified the absence of fever and the age of the subject as being the factors associated with their occurrence. It is therefore necessary to type all cases of non-poliovirus enteroviruses detected in AFP surveillance to assess the risks of vaccine-derived polioviruses.

[A plea for introduction of hepatitis B vaccination at birth in Côte d'Ivoire]. / Plaidoyer pour l?introduction du vaccin contre l?hépatite virale B à la naissance en Côte d?Ivoire.

The Côte d'Ivoire National Immunization Technical Advisory Group 2015 work plan included elaboration of an opinion on inclusion of hepatitis B vaccination at birth in the Expanded Program on Immunization (EPI) in Côte d'Ivoire. A task force was set up to conduct this assessment according to a systematized method. The task force analysed scientific articles on the burden of hepatitis B in Côte d'Ivoire, the burden of mother-child transmission, the impact of hepatitis B vaccination at birth in countries which have adopted this strategy, the efficacy and safety of hepatitis B vaccine in newborns, the cost-effectiveness of hepatitis B vaccination at birth, and the best strategy to introduce hepatitis B vaccination at birth in the EPI. The National Immunization Technical Advisory Group of Côte d'Ivoire finally recommended introduction of a dose of hepatitis B vaccine at birth in the context of the Expanded Program on Immunization with maintenance of three doses of pentavalent vaccine (DPT-HepB-Hib) at 6, 10, and 14 weeks of age.

Evaluation of introduction of the Haemophilus influenzae vaccine in Côte d'Ivoire / Évaluation de l'introduction du vaccin anti-haemophilus influenzae en Côte d'Ivoire.

Introduction: Côte d'Ivoire introduced the Haemophilus influenzae type b vaccine into the EPI in March 2009. Following this introduction, an evaluation was conducted in 2012 in order to evaluate the vaccine introduction process. Methods: Data collection methods consisted of document review, structured interviews and direct observation. This study collected information from six health region officials, 12 health districts and 36 healthcare institutions. Seventy-two mothers or child carers were also interviewed. Collected data were processed and analysed by Excel, Epi Info and SPSS. Results: A vaccine introduction plan was developed, but was not communicated at the operational level. The planned training for district health care providers was conducted eighteen months after introduction of the vaccine. None of the vaccinating centres had communication support about the new vaccine. Temperature recording was regularly performed in 92% of district deposits and 68% of vaccinating centres. Deteriorated vaccines were observed in 6% of vaccinating centres. Only 3.5% of parents had been informed about introduction of the vaccine. Increased immunization coverage for the third dose of pentavalent vaccine was observed in one half of health districts. Conclusion: Evaluation of the introduction of Haemophilus influenzae type b vaccine highlightsthe strengths and weaknesses of the health system and provides lessons for the introduction of other vaccines into the expanded programme on immunization.

[Sociodemographic factors associated with incomplete immunization of children aged 12 to 59 months in six West African countries]. / Facteurs sociodémographiques associés à la vaccination incomplète des enfants de 12 à 59 mois dans six pays d’Afrique de l’ouest.

Every year, thousands of children worldwide remain unimmunized or partially immunized, especially in developing countries. It therefore appears important to examine soda-demographic factors associated with incomplete immunization of children in West Africa. The present cross-sectional study examined factors associated with incomplete immunization of children aged 12 to 59 months in Cote d'lvoire, Ghana, Burkina Faso, Mali, Guinea, and Liberia, based on Demographic and Health Surveys data. The findings of the study showed that birth at home, absence of access of mothers to media, no religion, poverty, and illiteracy were associated with incomplete immunization of children. Health officials should take these immunization status predictors into account when making policies and immunization strategies in countries included in this study in order to achieve immunization coverage targets.

[Sociodemographic factors associated with incomplete immunization or children aged 12 to 59 months in six West African countries]. / Facteurs sociodémographiques associés à la vaccination incomplète des enfants de 12 à 59 mois dans six pays d’Afrique de l’ouest.

INTRODUCTION: Every year, thousands of children in the world remain unimmunized or partially immunized, especially in developing countries. It therefore appears important to examine sociodemographic factors associated with incomplete immunization of children in West Africa. METHODS: This cross-sectional study examined factors associated with incomplete immunization of children aged 12 to 59 months in Côte d'Ivoire, Ghana, Burkina Faso, Mali, Guinea, and Liberia based on Demographic and Health Survey data. RESULTS: The findings of the study showed that birth at home, mothers with no access to media, no religion, poverty, and illiteracy were associated with incomplete immunization of children. DISCUSSION: Health officials should take these immunization status predictors into account when developing policies and immunization strategies in countries included in this study in order to achieve immunization coverage targets.

[Knowledge, and attitudes of Civil Society Organizations in the implementation of the Expanded Program on Immunization in Côte d'Ivoire]. / Connaissances et attitudes des organisations de la sociéteé civile à la mise en oeuvre du Programme élargi de vaccination de routine en Côte d'Ivoire.

INTRODUCTION: The objective of this study was to assess the level of involvement of leaders of Civil Society Organizations (CSOs) in implementation of routine EPI activities. METHODS: This was a cross-sectional descriptive study of the knowledge and attitudes of CSOs concerning implementation of routine EPI activities in the health district of Adiaké (Côte d'Ivoire). RESULTS: This study shows that 77.1% of CSO leaders were literate and 92.9% of them were practicing Catholics or Muslims. They had a good knowledge of the existence of EPI (97.1%) and EPI target diseases, but were ignorant about the immunization schedule (82%). 90% of CSO leaders considered EPI to be an important activity for the prevention of childhood diseases. They considered the reception in immunization units to be satisfactory (60%) and believed that rumours about the sterility of women were the cause of refusal of vaccination by communities. Although 41.4% of leaders had participated in social mobilization activities, none had participated in the mobilization of resources. DISCUSSION: Vaccination was not rejected by CSO leaders, but their lack of participation in implementation of EPI could induce errors and lead them to believe the rumours and refuse vaccination of their community. CONCLUSION: The effective integration of the socio-cultural bases of communities in which immunization programmes are conducted will promote the adhesion of the people responsible for these programmes.

Establishment of a National Immunization Technical Advisory Group in Côte d'Ivoire: process and lessons learned.

In January 2010, Côte d'Ivoire became the first GAVI-eligible country in sub-Saharan Africa to establish a National Immunization Technical Advisory Group (NITAG). The Côte d'Ivoire "National Committee of Independent Experts for Vaccination and Vaccines" (CNEIV-CI) was created to strengthen national capacity for evidence-based policy decisions with regard to immunization and vaccines. The primary reasons for success in Côte d'Ivoire were a strong political will, the availability of sufficient national expertise, a step-by-step country-driven process, and the provision of technical assistance to the Ministry of Health. The challenges included operating within the socio-political crisis, and initial reluctance from some stakeholders due to the potential overlap with other existing committees. The latter rapidly dissolved over the course of numerous meetings held with the SIVAC Initiative to clarify the mandate of a NITAG.

[The quality of immunization services in community centers in Abidjan, Côte d'Ivoire]. / Qualité des prestations vaccinales des centres sociaux publics d'Abidjan, Côte d'Ivoire.

In addition to health care centers, other institutions such as community centers are also involved in providing immunization services, the purpose being to address the inadequate provision of services in this area. The purpose of this study was to assess the quality of immunization services provided by non-medical staff. A cross-sectional descriptive study was conducted over the course of two months in the 15 public community centers providing immunization services in Abidjan. Data collection was performed by two physicians using three questionnaires (one for center managers, one for vaccinators and one for vaccine recipients) and two observation checklists (to assess vaccination equipment and to observe the behaviors and practices of vaccinators). The study found that none of the centers had a generator. One community center had no refrigerator. Refrigerators were not placed in a ventilated area in 14.3 % of the centers and were not exclusively used for the storage of vaccines in 26.7 % of the centers. None of the centers had an incinerator. 21.1 % of staff did not know the correct storage temperature. In 88.9 % of cases, the swab used to stop bleeding was also used to clean the injection site. The injection site was not sterilized in 10.8 % of cases. 73.9 % of the recipients did not know what vaccine they had been administered, while 95 % of the recipients did not know the date of their next vaccination appointment. The results indicate that immunization services in public community centers have many shortcomings. To address these issues, it is necessary to implement a training policy and to provide appropriate equipment and supervision.

[Estimated costs of the expanded program of immunization in the health district of Grand Bassam, Cote d'Ivoire]. / Estimation des coûts du programme élargi de vaccination dans le district sanitaire de Grand Bassam, Côte d'Ivoire.

The vaccines of the Expanded Immunization Program are administered free of charge to beneficiaries. However, these vaccines are purchased by countries and partners of immunization. These costs need to be estimated to be better understood. We conducted a descriptive cross-sectional study of the costs of the Expanded Immunization Program in the health district of Grand-Bassam from January 1 to December 31, 2006, with questions aiming to understand the costs from the point of view of the state and partners. We aimed to determine costs by level of expenditure, calculate the cost per child who received 3 doses of vaccine against Diphtheria-Tetanus-Pertussis-Hepatitis B and cost per strategy. Vaccines and injection supplies accounted for 49% of recurrent costs. Vehicles and motorcycles for transport accounted for 73% of non-recurrent costs. The recurrent cost per child who received 3 doses of the vaccine was 10 797 FCFA (16 euros). The recurrent cost per dose administered was 1,041 FCFA (1,58 euros) for the fixed strategy, 4,232 FCFA (6,45 euros) for the outreach strategy and 4,058 FCFA (6,18 euros) for the mobile strategy. Because of the scarcity of financial resources, the Côte d'Ivoire government must strengthen efficient public-health measures, including vaccination.

[Determinants of street drug use in urban areas]. / Facteurs déterminant la consommation des médicaments de la rue en milieu urbain.

A descriptive and analytical cross-sectional study was conducted to assess street drug use in an urban setting. The study was conducted in Abidjan city center (Adjamé). The general aim of the study was to contribute to the fight against street drug consumption by identifying the determinants of drug use. The objectives of this paper are to describe the socio-demographic characteristics of street drug users, to determine the type of drugs purchased, and to identify the factors influencing drug purchase. Based on a sample of 300 individuals, the study found that the use of street drugs is a widespread phenomenon, as shown by its prevalence in the surveyed population (216 individuals out of a total of 300, i.e. 72% of the surveyed population). The study found that most drug users were young, male (32%) and worked in the informal sector. More than half of the drug users (58%) had a monthly income below 50,000 CFA and had no health insurance. The low cost of drugs was found to be the main reason for drug use (69%). The most commonly used drugs were analgesics (75%), antimalarial drugs (72%) and antibiotics (48%). Because of the lack of medical knowledge of drug sellers, drug users are exposed to serious health risks. The results of this study suggest the need for greater public awareness of the dangers of street drugs and emphasize the importance of promoting access to essential generic drugs.

[Estimated operational costs of vaccination campaign to combat yellow fever in Abidjan]. / Coûts de la riposte vaccinate contre la fièvre jaune à Abidjan, 2001.

A cost effectiveness study was conducted with the main objective to assess the operational costs of a vaccination campaign against yellow fever organised and implemented in Abidjan from September 21st to October 2nd, 2001. The study was carried out from the perspective of the health authorities. Data was collected retrospectively on all information related to resources needed and required activities. The justification of the monetary value of resources was provided with written proof and receipts as well as other supporting documents. The coverage achieved was 91.33% with 2 584 360 doses of vaccine having been administered. Spending on vaccines and vaccine supplies amounted to 1 123 177 128 FCFA; the average cost per dose was 539.40 FCFA. Human resource costs amounted to 2590 people who were mobilized for a total cost of 125 678 400 FCFA. The total operational cost of the vaccination campaign was 1 394 010 829 FCFA. Vaccines and supplies were the largest item of expenditure, or 80.57% of the total spent. The results of this study could serve as a tool for decision-making related to funding a vaccination campaign. Taking account of these results could contribute to the development of strategies to effectively reduce the operational cost of a vaccination campaign.