Efforts Towards Polio Eradication in Madagascar: 1997 to 2017.

BACKGROUND: In 1988, the World Health Assembly launched the Global Polio Eradication Initiative. WHO AFRO is close to achieve this goal with the last wild poliovirus detected in 2014 in Borno States in Nigeria. The certification of the WHO African Region requires that all the 47 member states meet the critical indicators for a polio free status. Madagascar started implementing polio eradication activities in 1996 and was declared polio free in June 2018 in Abuja. This study describes the progress achieved towards polio eradication activities in Madagascar from 1977-2017 and highlights the remaining challenges to be addressed. METHODS: Data were collected from the national routine immunization services, Country Acute Flaccid surveillance databases and national reports of SIAS and Mop Up campaign. Country complete polio and immunization related documentation provided detailed historical information's. RESULTS: From 1997 to 2017, Madagascar reported one wild poliovirus (WPV) outbreak and four circulating Vaccine Derived Polio Virus (cVDPV) oubreaks with a total of 21 polioviruses (1 WPV and 21 cVDPV). The last WPV and cVDPV were notified in 1997 in Antananarivo and 2015 in Sakaraha health districts respectively. Madagascar met the main polio surveillance indicators over the last ten years and made significant progress following the last cVDPV2 outbreak in 2014 -2015. In addition, the country successfully implemented the switch from trivalent Oral Polio Vaccine (tOPV) to bivalent Oral Polio vaccine (bOPV) and containment activities. Environmental Surveillance established since 2015 did not reveal any poliovirus. The administrative coverage of the 3rd dose of oral polio vaccine (OPV3) varied across the years from 55% in 1991 to a maximum of 95% in 2007 before a progressive decrease to 86% in 2017. The percentage of AFP cases with more than 3 doses of oral polio vaccines increased from 56% in 2014 to 88% in 2017. A total of 19 supplementary immunization activities (SIA) were conducted in Madagascar from 1997 to 2017, among which 3 were subnational immunization days (sNID) and 16 were national immunization days (NIDs). Poor routine coverage contributed to the occurrence of cVDPC outbreaks in the country; addressing this should remain a key priority for the country to maintain the polio free status.From 2015 to June 2017, Madagascar achieved the required criteria leading to the acceptance of the country's polio-free documentation in June 2018 by ARCC. However, continuous efforts will be needed to maintain a highly sensitive polio surveillance system with emphasis on security compromised areas. Finally strengthening the health system and governance at all levels will be necessary if these achievements are to be sustained. CONCLUSIONS: High national political commitment and support of the Global Polio Eradication Partnership were critical for Madagascar to achieve polio free status. Socio-political instability, weakness of the health system, sub-optimal routine immunization performance, insufficient SIA quality and existing security compromised areas remain critical program challenges to address in order to maintaining the polio free status. Continuous high-level advocacy should be kept in order to ensure that new government authorities maintain polio eradication among the top priorities of the country.

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.