Implementation of an outbreak response vaccination campaign with typhoid conjugate vaccine - Harare, Zimbabwe, 2019.

Introduction: Typhoid fever is a public-health problem in Harare, the capital city of Zimbabwe, with seasonal outbreaks occurring annually since 2010. In 2019, the Ministry of Health and Child Care (MOHCC) organized the first typhoid conjugate vaccination campaign in Africa in response to a recurring typhoid outbreak in a large urban setting. Method: As part of a larger public health response to a typhoid fever outbreak in Harare, Gavi approved in September 2018 a MOHCC request for 340,000 doses of recently prequalified Typbar-TCV to implement a mass vaccination campaign. To select areas for the campaign, typhoid fever surveillance data from January 2016 until June 2018 was reviewed. We collected and analyzed information from the MOHCC and its partners to describe the vaccination campaign planning, implementation, feasibility, administrative coverage and financial costs. Results: The campaign was conducted in nine high-density suburbs of Harare over eight days in February-March 2019 and targeted all children aged 6 months-15 years; however, the target age range was extended up to 45 years in one suburb due to the past high attack rate among adults. A total of 318,698 people were vaccinated, resulting in overall administrative coverage of 85.4 percent. More than 750 community volunteers and personnel from the MOHCC and the Ministry of Education were trained and involved in social mobilization and vaccination activities. The MOHCC used a combination of vaccination strategies (i.e., fixed and mobile immunization sites, a creche and school-based strategy, and door-to-door activities). Financial costs were estimated at US$ 2.39 per dose, including the vaccine and vaccination supplies (US$ 0.79 operational costs per dose excluding vaccine and vaccination supplies). Conclusion: A mass targeted campaign in densely populated urban areas in Harare, using the recently prequalified typhoid conjugate vaccine, was feasible and achieved a high overall coverage in a short period of time.

The challenges of detecting and responding to a Lassa fever outbreak in an Ebola-affected setting.

OBJECTIVES: Lassa fever (LF), a priority emerging pathogen likely to cause major epidemics, is endemic in much of West Africa and is difficult to distinguish from other viral hemorrhagic fevers, including Ebola virus disease (EVD). Definitive diagnosis requires laboratory confirmation, which is not widely available in affected settings. The public health action to contain a LF outbreak and the challenges encountered in an EVD-affected setting are reported herein. METHODS: In February 2016, a rapid response team was deployed in Liberia in response to a cluster of LF cases. Active case finding, case investigation, contact tracing, laboratory testing, environmental investigation, risk communication, and community awareness raising were undertaken. RESULTS: From January to June 2016, 53 suspected LF cases were reported through the Integrated Disease Surveillance and Response system (IDSR). Fourteen cases (26%) were confirmed for LF, 14 (26%) did not have a sample tested, and 25 (47%) were classified as not a case following laboratory analysis. The case fatality rate in the confirmed cases was 29%. One case of international exportation was reported from Sweden. Difficulties were identified in timely specimen collection, packaging, and transportation (in confirmed cases, the time from sample collection to sample result ranged from 2 to 64 days) and a lack of response interventions for early cases. CONCLUSIONS: The delay in response to this outbreak could have been related to a number of challenges in this EVD-affected setting: a need to strengthen the IDSR system, develop preparedness plans, train rapid response teams, and build laboratory capacity. Prioritizing these actions will aid in the timely response to future outbreaks.

Infection prevention and control in health facilities in post-Ebola Liberia: don't forget the private sector!

Setting: Recognising the importance of infection prevention and control (IPC), a minimum standards tool (MST) was developed in Liberia to guide the safe (re-) opening and provision of care in health facilities. Objectives: To analyse the implementation of specific IPC measures after the 2014 Ebola virus outbreak between June 2015 and May 2016, and to compare the relative improvements in IPC between the public and private sectors. Design: A retrospective comparative cohort study. Results: We evaluated 723 (94%) of the 769 health facilities in Liberia. Of these, 437 (60%) were public and 286 (40%) were private. There was an overall improvement in the MST scores from a median of 13 to 14 out of a maximum possible score of 16. While improvements were observed in all aspects of IPC in both public and private health facilities, IPC implementation was systematically higher in public facilities. Conclusions: We demonstrate the feasibility of monitoring IPC implementation using the MST checklist in post-Ebola Liberia. Our study shows that improvements were made in key aspects of IPC after 1 year of evaluations and tailored recommendations. We also highlight the need to increase the focus on the private sector to achieve further improvements in IPC.

Contexte : En reconnaissance de l'importance de la prévention et contrôle de l'infection (PCI), le Liberia a élaboré le « minimum standards tool ¼ (MST) afin de guider en toute sécurité l'ouverture/réouverture des structures de santé et la prestation de soins.Objectifs : Analyser la mise en œuvre des mesures spécifiques de PCI après la flambée épidémique d'Ebola en 2014, entre juin 2015 et mai 2016, et comparer les améliorations relatives de la PCI entre le secteur public et privé.Schéma : Une étude rétrospective comparative de cohorte.Résultats : Nous avons évalué 723 (94%) des 769 structures de santé au Liberia. Parmi elles, 437 (60%) étaient publiques et 286 (40%), privées. Il y a eu une amélioration générale des scores MST depuis une médiane de 13 à 14, avec un score maximal de 16. Des améliorations ont été observées dans tous les aspects de la PCI à la fois dans les structures de santé publiques et privées, mais la mise en œuvre de la PCI a été systematiquement plus élevée dans les structures publiques.Conclusions: Nous avons démontré la faisabilité du suivi de la mise en œuvre de la PCI grâce à la check-list de la MST dans le Liberia d'après Ebola. Nous avons montré des améliorations dans des aspects clés de la PCI après une année d'évaluation et adapté les recommandations de la PCI. Nous mettons également en lumière le besoin d'accorder davantage d'attention au secteur privé, de manière à faire davantage de progrès dans la PCI.

Marco de referencia: Al reconocer la importancia de las medidas de prevención y control de las infecciones (PCI), se elaboró en Liberia un instrumento de normas mínimas encaminado a orientar la apertura o reapertura y la prestación de servicios en los establecimientos de atención de salud de manera segura.Objetivos: Analizar la ejecución de medidas específicas de PCI después de la epidemia del Ébola del 2014, entre junio del 2015 y mayo del 2016, y comparar los progresos relativos en la materia entre el sector público y el sector privado.Método: Un estudio retrospectivo de cohortes comparativo.Resultados: Se evaluaron 723 de los 769 establecimientos de salud de Liberia (94%). De estos, 437 pertenecían al sector público (60%) y 286 (40%) al sector privado. Se observó una mejoría global en las puntuaciones del instrumento de normas mínimas de una mediana de 13 a 14, sobre una puntuación máxima de 16. Hubo progresos en todos los aspectos de PCI en los establecimientos del sector público y privado, pero su aplicación fue sistemáticamente más alta en los centros del sector público.Conclusiones: El presente estudio puso en evidencia la factibilidad de vigilar la ejecución de las medidas de PCI utilizando la lista de verificación del instrumento de normas mínimas, después de la epidemia del Ébola en Liberia. Los resultados revelaron progresos en aspectos primordiales, después de un año de evaluaciones y recomendaciones adaptadas en materia de PCI. Se destacó además la necesidad de aumentar la atención prestada al sector privado, con el fin de promover mayores progresos en este campo.

Clustered lot quality assurance sampling: a pragmatic tool for timely assessment of vaccination coverage.

OBJECTIVES: To evaluate oral poliovirus vaccine (OPV) coverage of the November 2009 round in five Northern Nigeria states with ongoing wild poliovirus transmission using clustered lot quality assurance sampling (CLQAS). METHODS: We selected four local government areas in each pre-selected state and sampled six clusters of 10 children in each Local Government Area, defined as the lot area. We used three decision thresholds to classify OPV coverage: 75-90%, 55-70% and 35-50%. A full lot was completed, but we also assessed in retrospect the potential time-saving benefits of stopping sampling when a lot had been classified. RESULTS: We accepted two local government areas (LGAs) with vaccination coverage above 75%. Of the remaining 18 rejected LGAs, 11 also failed to reach 70% coverage, of which four also failed to reach 50%. The average time taken to complete a lot was 10 h. By stopping sampling when a decision was reached, we could have classified lots in 5.3, 7.7 and 7.3 h on average at the 90%, 70% and 50% coverage targets, respectively. CONCLUSIONS: Clustered lot quality assurance sampling was feasible and useful to estimate OPV coverage in Northern Nigeria. The multi-threshold approach provided useful information on the variation of IPD vaccination coverage. CLQAS is a very timely tool, allowing corrective actions to be directly taken in insufficiently covered areas.

Amodiaquine, sulfadoxine/pyrimethamine, and combination therapy for treatment of uncomplicated falciparum malaria in Kampala, Uganda: a randomised trial.

BACKGROUND: Increasing Plasmodium falciparum resistance to chloroquine in sub-Saharan Africa necessitates use of alternative antimalarial agents. Affordable alternative treatments include sulfadoxine/pyrimethamine and amodiaquine. Combination of antimalarial agents can increase therapeutic efficacy and delay emergence of drug resistance. We compared the efficacy of sulfadoxine/pyrimethamine, amodiaquine, and an amodiaquine/sulfadoxine/pyrimethamine combination for treatment of uncomplicated malaria in a region of high chloroquine resistance. METHODS: Patients with symptoms of uncomplicated falciparum malaria and confirmed disease in Kampala, Uganda, were randomly assigned to receive sulfadoxine/pyrimethamine (25 mg/kg sulfadoxine, and 1.25 mg/kg pyrimethamine) plus placebo; amodiaquine (25 mg/kg) plus placebo; or amodiaquine plus sulfadoxine/pyrimethamine. Patients were followed up for 14 days, and clinical and parasitological outcomes were assessed. FINDINGS: 90% (400/445) of patients enrolled in the study successfully completed 14 days of follow-up. Treatment failure based on clinical criteria occurred in 13 of 131 (10%) patients on sulfadoxine/ pyrimethamine, nine of 131 (7%) on amodiaquine, and four of 138 (3%) on amodiaquine/sulfadoxine/pyrimethamine. Based on parasitological criteria, treatment failed in 26%, 16%, and 10% of these patients, respectively. Amodiaquine/sulfadoxine/pyrimethamine was significantly more effective than sulfadoxine/pyrimethamine alone in children aged younger than 5 years (clinical failure in 3.5% vs 13.9%, respectively, risk difference 10.4% [95% CI, 1.6-19.3] p=0.021; parasitological failure in 12.8% vs 26.4%, risk difference 13.6% [1.2-26.0] p=0.041). INTERPRETATION: Sulfadoxine/pyrimethamine, amodiaquine, and amodiaquine/sulfadoxine/pyrimethamine were all effective for treatment of uncomplicated falciparum malaria in Uganda. The amodiaquine/sulfadoxine/pyrimethamine combination was the most effective, and could be the optimum low-cost alternative to chloroquine in Africa.

The comparative efficacy of chloroquine and sulfadoxine-pyrimethamine for the treatment of uncomplicated falciparum malaria in Kampala, Uganda.

Chloroquine (CQ) remains the first-line treatment for uncomplicated malaria in much of Africa despite the growing problem of resistance to this drug. Sulfadoxine-pyrimethamine (SP) is often used after CQ treatment failure and has replaced CQ as the first-line treatment in parts of Africa. To compare the efficacy of these 2 regimens, we evaluated, in March-August 1999, clinical and parasitological responses over 28 days in 214 children and adults from Kampala, Uganda, with uncomplicated falciparum malaria. Compared to SP, significantly more patients treated with CQ developed early or late clinical failure (54% vs 11%, P < 0.001) and parasitological failure (72% vs 30%, P < 0.001) during 14 days of follow-up. The risk of treatment failure occurring after day 14 was similar between the 2 treatment groups. Among those treated with CQ, children aged < 5 years were at higher risk of clinical failure than older individuals (76% vs 28%, P < 0.001), an association not seen with SP (11% vs 10%, P = 0.91). Although early parasite clearance was significantly better in the SP group (P = 0.001), fever clearance at day 3 was the same (CQ 85%, SP 86%). These and other recent findings suggest that consideration be given to replacing CQ as the first-line therapy for uncomplicated malaria in Uganda, particularly in young children.

Amodiaquine; sulfadoxine/pyrimethamine; and combination therapy for treatment of uncomplicated falciparum malaria in Kampala; Uganda:a randomised trial

Increasing Plasmodium falciparum resistance to chloroquine in sub-Saharan Africa necessitates use of alternative antimalarial agents. Affordable alternative treatments inlude sulfadoxine/pyrimethamine and amodiaquine. Combination of antimalarial agents can increase thepeutic resistance. We compared the efficacy of sulfadoxine/pryrimethamine; amodiaquine; and an amodiaquine/sulfadoxine/pyrimethamine combination for treatment of uncomplicated malaria in a region of high chloroquine resistance. Methods: Patients with symptoms of uncomplicated falciparum malaria and confirmed disease in Kampala; Uganda; were randomly assigned to receive sulfadoxine/pyrimethamine) plus placebo; amodiaquine (25mg/kg) sulfadoxine and 1.25mg/kg prymethamine) plus placebo; or amodiaquine plus sulfadoxine/pyrimethamine. Patients were followed up for 14 days; and clinical and parasitological outcomes were assessed. Findings: 90(400/445) of patients enrolled in the study successfully completed 14 days of follow-up. Treatment failure based on clinical criteria occurred in 13 of 131 (10) patients on sulfadoxine/pyrimethamine. Based on parasitological criteria; treatment failed in 26; 16; and 10of these patients; respectively. Amodiaquine/sulfadoxine/pyrimethamine was significantly more effective than sulfadoxine/pyrimethamine alone in children aged younger than 5 years (clinical failure in 3.5vs 13.9; respectively; risk difference 10.4[95CI; 1.6-19.3] p=0.021; parasitological failure in 12.8vs 26.4; risk difference 13.61.2-26.0] p=0.041) Interpretation Sulfadoxine/pyrimethamine; amodiaquine; and amodiaquine/sulfadoxine/pyrimethamine were all effective for treatment of uncomplicated falciparum malaria in Uganda. The amodiaquine/sulfadoxine/pyrimethamine combination was the most effective; and could be the optimum low-cost alternative to chloroquine in Africa