COVID-19 vaccination rollout in the World Health Organization African region: status at end June 2022 and way forward.

In October 2021, the WHO published an ambitious strategy to ensure that all countries had vaccinated 40% of their population by the end of 2021 and 70% by mid-2022. The end of June 2022 marks 18 months of implementation of coronavirus disease 2019 (COVID-19) vaccination in the African region and provides an opportunity to look back and think ahead about COVID-19 vaccine set targets, demand and delivery strategies. As of 26 June 2022 two countries in the WHO African region have achieved this target (Mauritius and Seychelles) and seven are on track, having vaccinated between 40% and 69% of their population. By the 26 June 2022, seven among the 20 countries that had less than 10% of people fully vaccinated at the end of January 2022, have surpassed 15% of people fully vaccinated at the end of June 2022. This includes five targeted countries, which are being supported by the WHO Regional Office for Africa through the Multi-Partners' Country Support Team Initiative. As we enter the second semester of 2022, a window of opportunity has opened to provide new impetus to COVID-19 vaccination rollout in the African region guided by the four principles: Scale-up, Transition, Consolidation and Communication. Member States need to build on progress made to ensure that this impetus is not lost and that the African region does not remain the least vaccinated global region, as economies open up and world priorities change.

Impact of Rotavirus Vaccine Introduction on Rotavirus Hospitalizations Among Children Under 5 Years of Age-World Health Organization African Region, 2008-2018.

BACKGROUND: Rotavirus is the leading cause of acute gastroenteritis (AGE) among children worldwide. Prior to rotavirus vaccine introduction, over one third of AGE hospitalizations in Africa were due to rotavirus. We describe the impact of rotavirus vaccines using data from the African Rotavirus Surveillance Network (ARSN). METHODS: For descriptive analysis, we included all sites reporting to ARSN for any length of time between 2008 and 2018. For vaccine impact analysis, continuous surveillance throughout the year was required to minimize potential bias due to enrollment of partial seasons and sites had to report a minimum of 100 AGE cases per year. We report the proportion of rotavirus AGE cases by year relative to vaccine introduction, and the relative reduction in the proportion of rotavirus AGE cases reported following vaccine introduction. RESULTS: From 2008 to 2018, 97 366 prospectively enrolled hospitalized children <5 years of age met the case definition for AGE, and 34.1% tested positive for rotavirus. Among countries that had introduced rotavirus vaccine, the proportion of hospitalized AGE cases positive for rotavirus declined from 39.2% in the prevaccine period to 25.3% in the postvaccine period, a 35.5% (95% confidence interval [CI]: 33.7-37.3) decline. No declines were observed among countries that had not introduced the vaccine over the 11-year period. CONCLUSIONS: Rotavirus vaccine introduction led to large and consistent declines in the proportion of hospitalized AGE cases that are positive for rotavirus. To maximize the public health benefit of these vaccines, efforts to introduce rotavirus vaccines in the remaining countries in the region and to improve coverage should continue.

Towards universal health coverage in the WHO African Region: assessing health system functionality, incorporating lessons from COVID-19.

The move towards universal health coverage is premised on having well-functioning health systems, which can assure provision of the essential health and related services people need. Efforts to define ways to assess functionality of health systems have however varied, with many not translating into concrete policy action and influence on system development. We present an approach to provide countries with information on the functionality of their systems in a manner that will facilitate movement towards universal health coverage. We conceptualise functionality of a health system as being a construct of four capacities: access to, quality of, demand for essential services and its resilience to external shocks. We test and confirm the validity of these capacities as appropriate measures of system functionality. We thus provide results for functionality of the 47 countries of the WHO African Region based on this. The functionality of health systems ranges from 34.4 to 75.8 on a 0-100 scale. Access to essential services represents the lowest capacity in most countries of the region, specifically due to poor physical access to services. Funding levels from public and out-of-pocket sources represent the strongest predictors of system functionality, compared with other sources. By focusing on the assessment on the capacities that define system functionality, each country has concrete information on where it needs to focus, in order to improve the functionality of its health system to enable it respond to current needs including achieving universal health coverage, while responding to shocks from challenges such as the 2019 coronavirus disease. This systematic and replicable approach for assessing health system functionality can provide the guidance needed for investing in country health systems to attain universal health coverage goals.

Geospatial Clustering of Mobile Phone Use and Tuberculosis Health Outcomes Among African Health Systems.

BACKGROUND: While multiple studies have documented the impacts of mobile phone use on TB health outcomes for varied settings, it is not immediately clear what the spatial patterns of TB treatment completion rates among African countries are. This paper used Exploratory Spatial Data Analysis (ESDA) techniques to explore the clustering spatial patterns of TB treatment completion rates in 53 African countries and also their relationships with mobile phone use. Using an ESDA approach to identify countries with low TB treatment completion rates and reduced mobile phone use is the first step toward addressing issues related to poor TB outcomes. METHODS: TB notifications and treatment data from 2000 through 2015 that were obtained from the World Bank database were used to illustrate a descriptive epidemiology of TB treatment completion rates among African health systems. Spatial clustering patterns of TB treatment completion rates were assessed using differential local Moran's I techniques, and local spatial analytics was performed using local Moran's I tests. Relationships between TB treatment completion rates and mobile phone use were evaluated using ESDA approach. RESULT: Spatial autocorrelation patterns generated were consistent with Low-Low and High-Low cluster patterns, and they were significant at different p-values. Algeria and Senegal had significant clusters across the study periods, while Democratic Republic of Congo, Niger, South Africa, and Cameroon had significant clusters in at least two time-periods. ESDA identified statistically significant associations between TB treatment completion rates and mobile phone use. Countries with higher rates of mobile phone use showed higher TB treatment completion rates overall, indicating enhanced program uptake (p < 0.05). CONCLUSION: Study findings provide systematic evidence to inform policy regarding investments in the use of mHealth to optimize TB health outcomes. African governments should identify turnaround strategies to strengthen mHealth technologies and improve outcomes.

Building health system resilience in the context of primary health care revitalization for attainment of UHC: proceedings from the Fifth Health Sector Directors' Policy and Planning Meeting for the WHO African Region.

BACKGROUND: The recent 2018 Declaration of Astana recognized primary health care (PHC) as a means to achieve universal health coverage (UHC) and the health-related Sustainable Development Goals (SDGs). Following this declaration, country progress on operationalization of the PHC agenda and attainment of UHC has been stalled by the new challenges posed by the COVID-19 pandemic. The pandemic has also disrupted the continuity of essential health service provision and tested the resilience of the region's health systems. METHODS: In accordance with this, the WHO Regional Office for Africa convened the Fifth Health Sector Directors' Planning and Policy Meeting across the 47 Member States of the Region. The two-day forum focused on building health system resilience to facilitate service continuity during health threats, PHC revitalization, and health systems strengthening towards UHC. RESULTS: The Regional Forum provided evidence on building resilient health systems in the WHO African Region and engaged participants in meaningful and critical discussion. It is from these discussions that four key themes emerged: (1) working multisectorally/intersectorally, (2) moving from fragmentation to integration, (3) ensuring implementation and knowledge exchange, and (4) rethinking resilience and embracing antifragility. These discussions and associated groupings by thematic areas lend themselves to recommendations for the WHO. CONCLUSIONS: This paper details the proceedings and key findings on building resilient health systems, the four themes that emerged from participant deliberation, and the recommendations that have emerged from the meeting. Deliberations from the Regional Forum are critical, as they have the potential to directly inform policy and program design, given that the meeting convenes health sector technocrats, who are at the helm of policy design, action, and implementation.

The potential effects of widespread community transmission of SARS-CoV-2 infection in the World Health Organization African Region: a predictive model.

The spread of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has been unprecedented in its speed and effects. Interruption of its transmission to prevent widespread community transmission is critical because its effects go beyond the number of COVID-19 cases and deaths and affect the health system capacity to provide other essential services. Highlighting the implications of such a situation, the predictions presented here are derived using a Markov chain model, with the transition states and country specific probabilities derived based on currently available knowledge. A risk of exposure, and vulnerability index are used to make the probabilities country specific. The results predict a high risk of exposure in states of small size, together with Algeria, South Africa and Cameroon. Nigeria will have the largest number of infections, followed by Algeria and South Africa. Mauritania would have the fewest cases, followed by Seychelles and Eritrea. Per capita, Mauritius, Seychelles and Equatorial Guinea would have the highest proportion of their population affected, while Niger, Mauritania and Chad would have the lowest. Of the World Health Organization's 1 billion population in Africa, 22% (16%-26%) will be infected in the first year, with 37 (29 - 44) million symptomatic cases and 150 078 (82 735-189 579) deaths. There will be an estimated 4.6 (3.6-5.5) million COVID-19 hospitalisations, of which 139 521 (81 876-167 044) would be severe cases requiring oxygen, and 89 043 (52 253-106 599) critical cases requiring breathing support. The needed mitigation measures would significantly strain health system capacities, particularly for secondary and tertiary services, while many cases may pass undetected in primary care facilities due to weak diagnostic capacity and non-specific symptoms. The effect of avoiding widespread and sustained community transmission of SARS-CoV-2 is significant, and most likely outweighs any costs of preventing such a scenario. Effective containment measures should be promoted in all countries to best manage the COVID-19 pandemic.

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 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

Improving access to affordable vaccines for middle-income countries in the african region.

Despite the remarkable power of immunization reducing morbidity and mortality due to vaccine preventable diseases, one in five African children still does not receive all the basic, necessary vaccines. This is particularly true of the 10 middle-income countries (MICs) in the WHO African Region, where data demonstrates that immunization coverage is decreasing. These countries are not eligible for Gavi support in accessing new vaccines because of their relatively high per capita income level and will gradually increase with the transitioning of countries out of Gavi support. Thus, WHO was requested to facilitate access to affordable vaccines in relation to middle-income countries and those transitioning out of Gavi support in the near future. With commitment to address the issue, WHO Regional Office for Africa convened a consultative meeting from 09 to 11 April 2018 in Brazzaville, Congo to explore ways of improving access to affordable vaccines for MICs in the Region. The meeting brought together 17 low, middle and upper middle income countries in the African Region. Immunization partners and other WHO Regions also participated in the consultation to share experiences and explore ways of increasing access to affordable vaccines in MICs in the African Region. At the end of the meeting a number of solutions and action points were proposed for implementation in the Region.

Evaluation of Intussusception after Monovalent Rotavirus Vaccination in Africa.

BACKGROUND: Postlicensure evaluations have identified an association between rotavirus vaccination and intussusception in several high- and middle-income countries. We assessed the association between monovalent human rotavirus vaccine and intussusception in lower-income sub-Saharan African countries. METHODS: Using active surveillance, we enrolled patients from seven countries (Ethiopia, Ghana, Kenya, Malawi, Tanzania, Zambia, and Zimbabwe) who had intussusception that met international (Brighton Collaboration level 1) criteria. Rotavirus vaccination status was confirmed by review of the vaccine card or clinic records. The risk of intussusception within 1 to 7 days and 8 to 21 days after vaccination among infants 28 to 245 days of age was assessed by means of the self-controlled case-series method. RESULTS: Data on 717 infants who had intussusception and confirmed vaccination status were analyzed. One case occurred in the 1 to 7 days after dose 1, and 6 cases occurred in the 8 to 21 days after dose 1. Five cases and 16 cases occurred in the 1 to 7 days and 8 to 21 days, respectively, after dose 2. The risk of intussusception in the 1 to 7 days after dose 1 was not higher than the background risk of intussusception (relative incidence [i.e., the incidence during the risk window vs. all other times], 0.25; 95% confidence interval [CI], <0.001 to 1.16); findings were similar for the 1 to 7 days after dose 2 (relative incidence, 0.76; 95% CI, 0.16 to 1.87). In addition, the risk of intussusception in the 8 to 21 days or 1 to 21 days after either dose was not found to be higher than the background risk. CONCLUSIONS: The risk of intussusception after administration of monovalent human rotavirus vaccine was not higher than the background risk of intussusception in seven lower-income sub-Saharan African countries. (Funded by the GAVI Alliance through the CDC Foundation.).

Five-year experience of African Vaccination Week implemented by the WHO Regional Office.

The 5th edition of the African Vaccination Week (AVW) kicked off in Lusaka, Zambia, on 23 April 2016, the same day as did the 4th World Immunization Week (WIW), and vaccination week in other WHO regions. The theme was "Save lives, prevent disabilities, vaccinate!". The aim was to draw attention to the need to attain universal immunization coverage in the African Region by closing the immunization gap, while also celebrating the important polio eradication milestone reached in the African Region. Twenty-eight (59.6%) of the 47 countries in the African Region celebrated the AVW within the regionally set dates of 24th to 30th April 2015. However, given its flexibility, the celebration continued until September in 15 other countries in the Region. Three countries, namely Comoros, Gabon, and Cape Verde did not join the celebration for the 2015 edition of the AVW. Countries used the opportunity to introduce new vaccines into their routine immunization. Populations, hitherto unreached with basic health services were reached with needed services, such as vitamin A supplementation, deworming, and catch up immunization services. The programmes promoted awareness of the benefits of vaccines and the rights of communities to demand vaccines and immunization services to save lives and prevent disabilities. The number of participating countries rose steadily from 40 in 2011 to 43 and 46 countries in 2013 and 2014 respectively. The number ranged from one intervention integrated with AVW in 17 countries to 5 interventions integrated with the AVW in three countries. In 2015, 67.4% of the participating countries integrated other interventions with AVW activities.

Efforts to Reach More Children with Effective Vaccines Through Routine Immunization in The WHO African Region: 2013-2015.

BACKGROUND: Some progress has been made in expanding immunization in the African Region over the last four decades. However, an estimated 22% of the eligible children in the African Region, located in four countries of the African Region (Democratic Republic of the Congo, Ethiopia, Nigeria and South Africa), continue to miss vaccination services for various reasons. This paper documents the status of routine immunization in the African Region. METHODS: Programme records, reports and statistics were reviewed for this paper. RESULTS: Challenges remain in reaching an estimated 20-30% of children across the Region. In addition to the traditional vaccines (DTP, measles, polio and tuberculosis) newer ones, such as for Pneumococcal conjugate vaccine (PCV) and rotavirus, are being rolled out in the Region but uptake and coverage are slow and patchy both within and between countries. CONCLUSION: The new regional strategic plan for immunization 2014-2020 is intended to provide policy and programmatic guidance to Member States, in line with the 2011-2020 Global Vaccine Action Plan (GVAP), in order to optimize immunization services and assist countries to further strengthen their immunization programmes.

IMMUNIZATION AND VACCINE DEVELOPMENT: Progress towards High and Equitable Immunization Coverage in the Africa Region.

OBJECTIVE: This paper gives a brief update on the status of the immunization and vaccine development in the WHO African Region. It also highlights the progress on the control, elimination or eradication of vaccine preventable diseases in the African Region. METHOD: The paper reviews national immunization programme data as well as WHO-UNICEF Estimates for Immunization Coverage (WUENIC) in the African Region from 2012-2016. RESULTS: It revealed that there has been considerable success with the development and introduction of new vaccines in the Region. However, uptake of these vaccines has not matched the level of success in new vaccine introduction. This has made the goal of reaching high and equitable immunization coverage a mirage in the Region. Multiple barriers have been blamed for this, chief among which are inadequate commitment of national governments and weak community engagement to immunization service delivery in the Region. Steps are taken to address these issues, including sensitization of government of the African Region to prioritize Universal Access to Immunization as a Cornerstone for Health and Development in Africa. This is because it is argued that development efforts are link to the human beings for whom progress is targeted and/or agents that bring about development. CONCLUSION: Saving human lives therefore is critical to the realization of development goals. It is important that immunization coverage is universal to achieve the control/elimination of vaccine preventable diseases.

Towards a Strategy for Reducing Missed Opportunities for Vaccination in Malawi: Implications of a Qualitative Health Facility Assessment.

BACKGROUND: Missed opportunities for vaccination (MOVs), estimated to be about 32-47% of child healthcare clinic visits in various settings globally, contribute to unfulfilled childhood vaccination coverage targets in the African region. OBJECTIVE: We assessed the extent of MOVs, identify local drivers and test interventions to reduce MOVs in Malawi. METHODS: We conducted in-depth and key informant interviews with administrators of district hospitals and officers in charge of community health facilities. Focus group discussions were held with health workers and caregivers of children under 24 months of age who received services from study health facilities in Malawi. Coverage rates were collected from the health facility records. RESULTS: Vaccination is appreciated in the communities, but coverage is generally below targets. In some facilities, reported coverage was less than 50%. Opportunities to provide up-to-date vaccination for children were missed due to lack of awareness and knowledge of health workers and caregivers, attitude and priority of health workers, long waiting time, poor coordination and referral of eligible children by clinicians and nurses and overall lack of a team approach to vaccination perceived as a responsibility of health surveillance assistants. Other notable issues included limited time of caregivers labouring on estate farms, unavailability of vaccines resulting from poorly functioning of cold chain equipment and limited transport and failure to appreciate the impact of MOV on poor immunization coverage. CONCLUSION: Simple, low-cost, pragmatic and community-driven interventions that may reduce MOVs and improve vaccine coverage.

Implementation of Rotavirus Surveillance and Vaccine Introduction - World Health Organization African Region, 2007-2016.

Rotavirus is a leading cause of severe pediatric diarrhea globally, estimated to have caused 120,000 deaths among children aged <5 years in sub-Saharan Africa in 2013 (1). In 2009, the World Health Organization (WHO) recommended rotavirus vaccination for all infants worldwide (2). Two rotavirus vaccines are currently licensed globally: the monovalent Rotarix vaccine (RV1, GlaxoSmithKline; 2-dose series) and the pentavalent RotaTeq vaccine (RV5, Merck; 3-dose series). This report describes progress of rotavirus vaccine introduction (3), coverage (using estimates from WHO and the United Nations Children's Fund [UNICEF]) (4), and impact on pediatric diarrhea hospitalizations in the WHO African Region. By December 2016, 31 (66%) of 47 countries in the WHO African Region had introduced rotavirus vaccine, including 26 that introduced RV1 and five that introduced RV5. Among these countries, rotavirus vaccination coverage (completed series) was 77%, according to WHO/UNICEF population-weighted estimates. In 12 countries with surveillance data available before and after vaccine introduction, the proportion of pediatric diarrhea hospitalizations that were rotavirus-positive declined 33%, from 39% preintroduction to 26% following rotavirus vaccine introduction. These results support introduction of rotavirus vaccine in the remaining countries in the region and continuation of rotavirus surveillance to monitor impact.

Building Health System Capacity Through Implementation Research: Experience of INSPIRE-A Multi-country PMTCT Implementation Research Project.

BACKGROUND: The INSPIRE-Integrating and Scaling Up PMTCT through Implementation REsearch-initiative was established as a model partnership of national prevention of mother-to-child transmission of HIV (PMTCT) implementation research in 3 high HIV burden countries-Malawi, Nigeria, and Zimbabwe. INSPIRE aimed to link local research groups with Ministries of Health (MOH), build local research capacity, and demonstrate that implementation research may contribute to improving health care delivery and respond to program challenges. METHODOLOGY: We used a mixed methods approach to review capacity building activities, as experienced by health care workers, researchers, and trainers conducted in the 6 INSPIRE projects before and during study implementation. RESULTS: Between 2011 and 2016, over 3400 health care workers, research team members, and community members participated in INSPIRE activities. This included research prioritization exercises, proposal development, good clinical practice and research ethics training, data management and analysis workshops, and manuscript development. Health care workers in clinics and district health offices acknowledged the value of hosting implementation research projects and how the quality of services improved. Research teams acknowledged the opportunities that projects provided for personal development and the value of participating in a multicountry research network. DISCUSSION: INSPIRE provided an opportunity for African-led research in which researchers worked closely with national MOH to identify priority research questions and implement studies. Close partnerships between research teams and local implementers facilitated project responsiveness to local program issues. Consequently, processes and training needed for study implementation also improved local program management and service delivery. Additional benefits included improved data management, publications, and career development.

Challenges of immunization in the African Region.

Immunization has made significant contribution to public health in the African Region, including elimination, eradication and control of life threatening diseases. Hospitalization due to vaccine preventable diseases has been drastically reduced due to introduction of new effective vaccines. However, optimizing the benefits of immunization by achieving high universal coverage has met with many challenges. The Regional immunization coverage, though raised from its low 57% in 2000 to 76% in 2015 has remained below expected target. Worse still, it has stagnated around 70% for a prolonged period. Cases of inequity in access to immunization service continue to exist in the region. This paper therefore explored the different challenges to immunization in the African Region. Some of the challenges it identifies and discusses include issues of sustainable funding and resources for immunization, vaccine stock-outs, and logistics. Others include data issues and laboratory infrastructure. The paper also attempted some possible solutions.

Contribution of polio eradication initiative to strengthening routine immunization: Lessons learnt in the WHO African region.

BACKGROUND: Important investments were made in countries for the polio eradication initiative. On 25 September 2015, a major milestone was achieved when Nigeria was removed from the list of polio-endemic countries. Routine Immunization, being a key pillar of polio eradication initiative needs to be strengthened to sustain the gains made in countries. For this, there is a huge potential on building on the use of polio infrastructure to contribute to RI strengthening. METHODS: We reviewed estimates of immunization coverage as reported by the countries to WHO and UNICEF for three vaccines: BCG, DTP3 (third dose of diphtheria-tetanus toxoid- pertussis), and the first dose of measles-containing vaccine (MCV1).We conducted a systematic review of best practices documents from eight countries which had significant polio eradication activities. RESULTS: Immunization programmes have improved significantly in the African Region. Regional coverage for DTP3 vaccine increased from 51% in 1996 to 77% in 2014. DTP3 coverage increased >3 folds in DRC (18-80%) and Nigeria from 21% to 66%; and >2 folds in Angola (41-87%), Chad (24-46%), and Togo (42-87%). Coverage for BCG and MCV1 increased in all countries. Of the 47 countries in the region, 18 (38%) achieved a national coverage for DTP3 ⩾90% for 2years meeting the Global Vaccine Action (GVAP) target. A decrease was noted in the Ebola-affected countries i.e., Guinea, Liberia and Sierra Leone. CONCLUSIONS: PEI has been associated with increased spending on immunization and the related improvements, especially in the areas of micro planning, service delivery, program management and capacity building. Continued efforts are needed to mobilize international and domestic support to strengthen and sustain high-quality immunization services in African countries. Strengthening RI will in turn sustain the gains made to eradicate poliovirus in the region.

Contribution of polio eradication initiative to effective new vaccine introduction in Africa, 2010-2015.

BACKGROUND: Significant progress has been made to increase access to vaccines in Africa since the 1974 launch of the Expanded Programme on Immunization (EPI). Successes include the introduction of several new vaccines across the continent and likely eradication of polio. We examined the contribution of polio eradication activities (PEI) on new vaccine introduction in the countries of the African Region. METHODS: We reviewed country specific PEI reports to identify best practices relevant to new vaccine introduction (NVI), and analyzed trends in vaccine coverage during 2010-2015 from immunization estimates provided by WHO/UNICEF. RESULTS: Of the 47 countries in African Region 35 (74%) have introduced PCV, 27 (57%) have introduced rotavirus, and 14 (30%) have introduced IPV. National introductions for HPV vaccine have been done in 5 countries, while 15 countries have held demonstration and pilot projects. In 2014, the regional coverage for the third dose of PCV (PCV3) and rotavirus vaccines was 50% and 30% respectively. By end of 2015, all countries within the meningitis belt will have introduced MenAfriVac™ vaccine. CONCLUSIONS: PEI activities had a positive effect in strengthening the process of new vaccine introduction in the African Region. The major contribution was in availing immunization funding and providing trained and experienced technical staff to introduce vaccines. More investment is needed to advocate and sustain funding levels to maintain the momentum gained in introducing new vaccines in the region.

Prioritizing the PMTCT implementation research agenda in 3 African countries: INtegrating and Scaling up PMTCT through Implementation REsearch (INSPIRE).

Countries with high HIV prevalence face the challenge of achieving high coverage of antiretroviral drug regimens interventions including for the prevention of mother-to-child transmission of HIV (PMTCT). In 2011, the World Health Organization and the Department of Foreign Affairs, Trade and Development, Canada, launched a joint implementation research (IR) initiative to increase access to effective PMTCT interventions. Here, we describe the process used for prioritizing PMTCT IR questions in Malawi, Nigeria, and Zimbabwe. Policy makers, district health workers, academics, implementing partners, and persons living with HIV were invited to 2-day workshops in each country. Between 42 and 70 representatives attended each workshop. Using the Child Health Nutrition Research Initiative process, stakeholder groups systematically identified programmatic barriers and formulated IR questions that addressed these challenges. IR questions were scored by individual participants according to 6 criteria: (1) answerable by research, (2) likely to reduce pediatric HIV infections, (3) addresses main barriers to scaling-up, (4) innovation and originality, (5) improves equity among underserved populations, and (6) likely value to policy makers. Highest scoring IR questions included health system approaches for integrating and decentralization services, ways of improving retention-in-care, bridging gaps between health facilities and communities, and increasing male partner involvement. The prioritized questions reflect the diversity of health care settings, competing health challenges and local and national context. The differing perspectives of policy makers, researchers, and implementers illustrate the value of inclusive research partnerships. The participatory Child Health Nutrition Research Initiative approach effectively set national PMTCT IR priorities, promoted country ownership, and strategically allocated research resources.