Rubella transmission and the risk of congenital rubella syndrome in Liberia: a need to introduce rubella-containing vaccine in the routine immunization program.

BACKGROUND: Rubella is an RNA virus in the genus Rubivirus within the Matonaviridae family. Rubella remains a leading vaccine-preventable cause of birth defects. Most African countries including Liberia do not currently provide rubella-containing vaccine (RCV) in their immunization program. We analyzed the existing surveillance data to describe rubella cases and identify the at-risk population. METHODS: We conducted a retrospective descriptive statistics on the suspected-measles case-based surveillance data that obtained from the national database. Suspected-measles cases who were negative and indeterminate for measles IgM and tested for rubella IgM were extracted from the database. We used only rubella IgM positive cases to calculate trends and percentages by person, place and time. The cumulative-percent curve was used to visually describe the age distribution of rubella cases. RESULTS: During 2017-2018, a total of 2027 suspected-measles cases with known laboratory results were reported; of which, 1307 were tested for rubella IgM. Among tested cases, 472 (36%) were positive, 769 (59%) were negative and 66 (5%) were indeterminate for rubella IgM. Female contributed 269 (57%) of the confirmed rubella cases respectively. The median age was 7 years with an interquartile range of 5-10 years. From the total rubella cases, 6 (1%) were under 1 year, 109 (23%) were 1-4 years, 207 (44%) were 5-9 years, 87 (18%) were 10-14 years and 56 (12%) were more than or equal to 15 years. Women in their reproductive-age contributed 23 (5%) of rubella cases with 17% positivity rate. Two-thirds or 307 (65%) of the cases were reported from February to May which is dry season in Liberia. CONCLUSIONS: Our analysis revealed that rubella was widely circulating in Liberia. Majority of the cases were reported among children < 15 years. However, rubella was also reported among women of reproductive age and infants < 1 year with no report of congenital rubella syndrome (CRS). Detail investigation of rubella cases among infants of < 1 year and women of reproductive age is important to uncover CRS. Establishment of CRS surveillance and the introduction of RCV in the immunization program are crucial to prevent rubella infection and avert the risk of CRS.

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.

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.

Lesson learned from the investigation and response of Lassa fever outbreak, Margibi County, Liberia, 2018: case report.

BACKGROUND: Lassa fever (LF) is a viral hemorrhagic disease caused by the Lassa virus (LASV) and endemic in West African countries with an estimation of 300,000 to 500,000 cases and 5,000 deaths annually. The Margibi County Health Team of Liberia received a report of an unidentified febrile illness case from the Kakata district. We conducted the investigation to identify the causative agent and the source of infection to support treatment, control and prevention interventions. CASE PRESENTATION: We identified LASV in the blood specimens' of two patients by Reverse Transcriptase Polymerase Chain Reaction (RT-PCR). Both the confirmed cases have manifested respiratory distress, weakness, and difficulty of swallowing, muscle, joint and back pains, and vomiting with blood. The symptoms started with mild fever and gradually developed. Initially, the primary health facilities have miss-diagnosed the patients as malaria and respiratory tract infections. The primary health facilities have referred the patients to the referral hospital as the patients have failed to respond to antimalarial and antibiotics. The hospital suspected LF and sent blood specimens to the National Reference Laboratory while the patients were on supportive treatment in the isolation room. At the time when the laboratory result returned to the hospital, the patients died of LF illness before ribavirin administered. CONCLUSIONS: Our investigation revealed that the two hospitalized and deceased febrile cases were associated with LASV. The primary health facilities have failed to recognize the cases as suspected LF at the earliest time possible. The clinicians and health facilities, especially primary health facilities, need to consider LF as a differential diagnosis when the patient failed to respond to anti-malaria and broad-spectrum antibiotics.