Strengthening and utilizing response groups for emergencies flagship: a narrative review of the roll out process and lessons from the first year of implementation.

The World Health Organization Regional Office for Africa (WHO/AFRO) faces members who encounter annual disease epidemics and natural disasters that necessitate immediate deployment and a trained health workforce to respond. The gaps in this regard, further exposed by the COVID-19 pandemic, led to conceptualizing the Strengthening and Utilizing Response Group for Emergencies (SURGE) flagship in 2021. This study aimed to present the experience of the WHO/AFRO in the stepwise roll-out process and the outcome, as well as to elucidate the lessons learned across the pilot countries throughout the first year of implementation. The details of the roll-out process and outcome were obtained through information and data extraction from planning and operational documents, while further anonymized feedback on various thematic areas was received from stakeholders through key informant interviews with 60 core actors using open-ended questionnaires. In total, 15 out of the 47 countries in WHO/AFRO are currently implementing the initiative, with a total of 1,278 trained and validated African Volunteers Health Corps-Strengthening and Utilizing Response Groups for Emergencies (AVoHC-SURGE) members in the first year. The Democratic Republic of Congo (DRC) has the highest number (214) of trained AVoHC-SURGE members. The high level of advocacy, the multi-sectoral-disciplinary approach in the selection process, the adoption of the one-health approach, and the uniqueness of the training methodology are among the best practices applauded by the respondents. At the same time, financial constraints were the most reported challenge, with ongoing strategies to resolve them as required. Six countries, namely Botswana, Mauritania, Niger, Rwanda, Tanzania, and Togo, have started benefiting from their trained AVoHC-SURGE members locally, while responders from Botswana and Rwanda were deployed internationally to curtail the recent outbreaks of cholera in Malawi and Kenya.

Willingness of WHO staff to work in health emergencies in the African Region: opportunity for phased deployment of staff and ensure continuity of health services.

A human resource base that ensures appropriate deployment of staff to emergencies, addressing different shock events in emergencies, without disrupting continuity of service is germane to a successful response. Consequently, the WHO Health Emergencies programme in the African Region, in collaboration with Africa Centre for Disease Control (ACDC) launched the African Volunteer Health Corps (AVoHC) and Strengthening and Utilization of Response Group for Emergencies (SURGE), an initiative aimed at ensuring a pool of timely responders. We explored the willingness of WHO staff to work in emergencies. A call for expression of interest to be part of the Elite Emergency Experts (Triple E) was published on 5th July 2022 via email and was open for 5 weeks. The responses were analyzed using simple descriptive statistics and presented with graphic illustrations. A total of 1253 WHO staff, from all the six WHO regions, cutting across all cadre, applied to the call. The applicants had various trainings and experiences in emergency and have responded to mostly disease outbreaks. Two-third of the applicants were males. This paper did not explore reasons for the willingness to work in emergencies. However, contrary to fears expressed in literature that health workers would not want to work in emergencies with potential for infections, the applicants have worked mostly in infectious emergencies. Literature identified some themes on factors that could impact on willingness of health workers to work in emergencies. These include concerns for the safety of the responders and impact of partners, child and elderly care, as well as other family obligations, which emergency planners must consider in planning emergency response.

Willingness of WHO staff to work in health emergencies in the African Region: opportunity for phased deployment of staff and ensure continuity of health services

A human resource base that ensures appropriate deployment of staff to emergencies, addressing different shock events in emergencies, without disrupting continuity of service is germane to a successful response. Consequently, the WHO Health Emergencies programme in the African Region, in collaboration with Africa Centre for Disease Control (ACDC) launched the African Volunteer Health Corps (AVoHC) and Strengthening and Utilization of Response Group for Emergencies (SURGE), an initiative aimed at ensuring a pool of timely responders. We explored the willingness of WHO staff to work in emergencies. A call for expression of interest to be part of the Elite Emergency Experts (Triple E) was published on 5th July 2022 via email and was open for 5 weeks. The responses were analyzed using simple descriptive statistics and presented with graphic illustrations. A total of 1253 WHO staff, from all the six WHO regions, cutting across all cadre, applied to the call. The applicants had various trainings and experiences in emergency and have responded to mostly disease outbreaks. Two-third of the applicants were males. This paper did not explore reasons for the willingness to work in emergencies. However, contrary to fears expressed in literature that health workers would not want to work in emergencies with potential for infections, the applicants have worked mostly in infectious emergencies. Literature identified some themes on factors that could impact on willingness of health workers to work in emergencies. These include concerns for the safety of the responders and impact of partners, child and elderly care, as well as other family obligations, which emergency planners must consider in planning emergency response.

COVID-19 as an Accelerator of the Implementation of Emergency Medical Teams Initiative in the AFRO Region.

OBJECTIVE: This study describes the progress that the World Health Organization (WHO) African (AFRO) region has made in establishing National Emergency Medical Teams (N-EMTs), the coordination mechanisms of the EMTs, and the regional training centers. METHODS: It used a retrospective descriptive analysis of the formulation and implementation of the EMTs Initiative from an insider perspective. The analysis is based on the review of available documents such as EMTs mission reports, assessments, surveys, EMT monthly bulletins, and meeting minutes in addition to key informant interviews (n = 5) with the EMT teams' members to validate the findings and share field experiences. RESULTS: The emergence of coronavirus disease 2019 (COVID-19) acted as an accelerator for the implementation of the EMT initiative in the AFRO region. A total of 18 EMT deployments were carried out in 16 countries in the AFRO region through the WHO EMT-network during COVID-19, providing support to countries in managing severe and critical COVID-19 cases. CONCLUSIONS: A Regional Training Center for N-EMTs is being set up in Addis Ababa to train the N-EMTs and strengthen local capacity of health personnel in the region. Challenges include unavailability of mentors to support countries in implementing N-EMTs and the Regional Simulation Training Center, poor funding, and coordination in the rolling out of the N-EMTs.

Public health emergency operations centres in Africa: a cross-sectional study assessing the implementation status of core components and areas for improvement, December 2021.

OBJECTIVE: To assess implementation status of public health emergency operations centres (PHEOCs) in all countries in Africa. DESIGN: Cross-sectional. SETTING: Fifty-four national PHEOC focal points in Africa responded to an online survey between May and November 2021. Included variables aimed to assess capacities for each of the four PHEOC core components. To assess the PHEOCs' functionality, criteria were defined from among the collected variables by expert consensus based on PHEOC operations' prioritisation. We report results of the descriptive analysis, including frequencies of proportions. RESULTS: A total of 51 (93%) African countries responded to the survey. Among these, 41 (80%) have established a PHEOC. Twelve (29%) of these met 80% or more of the minimum requirements and were classified as fully functional. Twelve (29%) and 17 (41%) PHEOCs that met 60%-79% and below 60% the minimum requirements were classified as functional and partially functional, respectively. CONCLUSIONS: Countries in Africa made considerable progress in setting up and improving functioning of PHEOCs. One-third of the responding countries with a PHEOC have one fulfilling at least 80% of the minimum requirements to operate the critical emergency functions. There are still several African countries that either do not have a PHEOC or whose PHEOCs only partially meet these minimal requirements. This calls for significant collaboration across all stakeholders to establish functional PHEOCs in Africa.

Sustainable strategies for Ebola virus disease outbreak preparedness in Africa: a case study on lessons learnt in countries neighbouring the Democratic Republic of the Congo.

BACKGROUND: From May 2018 to September 2022, the Democratic Republic of Congo (DRC) experienced seven Ebola virus disease (EVD) outbreaks within its borders. During the 10th EVD outbreak (2018-2020), the largest experienced in the DRC and the second largest and most prolonged EVD outbreak recorded globally, a WHO risk assessment identified nine countries bordering the DRC as moderate to high risk from cross border importation. These countries implemented varying levels of Ebola virus disease preparedness interventions. This case study highlights the gains and shortfalls with the Ebola virus disease preparedness interventions within the various contexts of these countries against the background of a renewed and growing commitment for global epidemic preparedness highlighted during recent World Health Assembly events. MAIN TEXT: Several positive impacts from preparedness support to countries bordering the affected provinces in the DRC were identified, including development of sustained capacities which were leveraged upon to respond to the subsequent coronavirus disease 2019 (COVID-19) pandemic. Shortfalls such as lost opportunities for operationalizing cross-border regional preparedness collaboration and better integration of multidisciplinary perspectives, vertical approaches to response pillars such as surveillance, over dependence on external support and duplication of efforts especially in areas of capacity building were also identified. A recurrent theme that emerged from this case study is the propensity towards implementing short-term interventions during active Ebola virus disease outbreaks for preparedness rather than sustainable investment into strengthening systems for improved health security in alignment with IHR obligations, the Sustainable Development Goals and advocating global policy for addressing the larger structural determinants underscoring these outbreaks. CONCLUSIONS: Despite several international frameworks established at the global level for emergency preparedness, a shortfall exists between global policy and practice in countries at high risk of cross border transmission from persistent Ebola virus disease outbreaks in the Democratic Republic of Congo. With renewed global health commitment for country emergency preparedness resulting from the COVID-19 pandemic and cumulating in a resolution for a pandemic preparedness treaty, the time to review and address these gaps and provide recommendations for more sustainable and integrative approaches to emergency preparedness towards achieving global health security is now.

Framing the future of the COVID-19 response operations in 2022 in the WHO African region.

BACKGROUND: With the evolving epidemiological parameters of COVID-19 in Africa, the response actions and lessons learnt during the pandemic's past two years, SARS-COV 2 will certainly continue to circulate in African countries in 2022 and beyond. As countries in the African continent need to be more prepared and plan to 'live with the virus' for the upcoming two years and after and at the same time mitigate risks by protecting the future most vulnerable and those responsible for maintaining essential services, WHO AFRO is anticipating four interim scenarios of the evolution of the pandemic in 2022 and beyond in the region. OBJECTIVE: In preparation for the rollout of response actions given the predicted scenarios, WHO AFRO has identified ten strategic orientations and areas of focus for supporting member states and partners in responding to the COVID-19 pandemic in Africa in 2022 and beyond. METHODS: WHO analysed trends of the transmissions since the first case in the African continent and reviewed lessons learnt over the past months. RESULTS: Establishing a core and agile team solely dedicated to the COVID-19 response at the WHO AFRO, the emergency hubs, and WCOs will improve the effectiveness of the response and address identified challenges. The team will collaborate with the various clusters of the regional office, and other units and subunits in the WCOs supported with good epidemics intelligence. COVID-19 pandemic has afflicted global humanity at unprecedented levels. CONCLUSION: Two years later and while starting the third year of the COVID-19 response, we now need to change and adapt our strategies, tools and approaches in responding timely and effectively to the pandemic in Africa and save more lives.

The role of emergency medical teams in Eswatini during the COVID-19 pandemic.

The paper documents experiences and lesson learned in responding to COVID-19 pandemic in Eswatini with the support of the Emergency Medical Teams. WHO databases, operation reports and hospitalization records were reviewed. The WHO Emergency Medical Teams built the capacity of the local response teams in Eswatini. The conclusion is that following the intervention of the WHO Emergency Medical Teams, Eswatini is better prepared to respond to the ongoing COVID-19 pandemic and future outbreaks.

Coordination and Management of COVID-19 in Africa through Health Operations and Technical Expertise Pillar: A Case Study from WHO AFRO One Year into Response.

Background: following the importation of the first Coronavirus disease 2019 (COVID-19) case into Africa on 14 February 2020 in Egypt, the World Health Organisation (WHO) regional office for Africa (AFRO) activated a three-level incident management support team (IMST), with technical pillars, to coordinate planning, implementing, supervision, and monitoring of the situation and progress of implementation as well as response to the pandemic in the region. At WHO AFRO, one of the pillars was the health operations and technical expertise (HOTE) pillar with five sub-pillars: case management, infection prevention and control, risk communication and community engagement, laboratory, and emergency medical team (EMT). This paper documents the learnings (both positive and negative for consideration of change) from the activities of the HOTE pillar and recommends future actions for improving its coordination for future emergencies, especially for multi-country outbreaks or pandemic emergency responses. Method: we conducted a document review of the HOTE pillar coordination meetings' minutes, reports, policy and strategy documents of the activities, and outcomes and feedback on updates on the HOTE pillar given at regular intervals to the Regional IMST. In addition, key informant interviews were conducted with 14 members of the HOTE sub pillar. Key Learnings: the pandemic response revealed that shared decision making, collaborative coordination, and planning have been significant in the COVID-19 response in Africa. The HOTE pillar's response structure contributed to attaining the IMST objectives in the African region and translated to timely support for the WHO AFRO and the member states. However, while the coordination mechanism appeared robust, some challenges included duplication of coordination efforts, communication, documentation, and information management. Recommendations: we recommend streamlining the flow of information to better understand the challenges that countries face. There is a need to define the role and responsibilities of sub-pillar team members and provide new team members with information briefs to guide them on where and how to access internal information and work under the pillar. A unified documentation system is important and could help to strengthen intra-pillar collaboration and communication. Various indicators should be developed to constantly monitor the HOTE team's deliverables, performance and its members.

Coordination mechanisms for COVID-19 in the WHO Regional office for Africa.

AIM: This study describes the coordination mechanisms that have been used for management of the COVID 19 pandemic in the WHO AFRO region; relate the patterns of the disease (length of time between onset of coordination and first case; length of the wave of the disease and peak attack rate) to coordination mechanisms established at the national level, and document best practices and lessons learned. METHOD: We did a retrospective policy tracing of the COVID-19 coordination mechanisms from March 2020 (when first cases of COVID-19 in the AFRO region were reported) to the end of the third wave in September 2021. Data sources were from document and Literature review of COVID-19 response strategies, plans, regulations, press releases, government websites, grey and peer-reviewed literature. The data was extracted to Excel file database and coded then analysed using Stata (version 15). Analysis was done through descriptive statistical analysis (using measures of central tendencies (mean, SD, and median) and measures of central dispersion (range)), multiple linear regression, and thematic analysis of qualitative data. RESULTS: There are three distinct layered coordination mechanisms (strategic, operational, and tactical) that were either implemented singularly or in tandem with another coordination mechanism. 87.23% (n = 41) of the countries initiated strategic coordination, and 59.57% (n = 28) initiated some form of operational coordination. Some of countries (n = 26,55.32%) provided operational coordination using functional Public Health Emergency Operation Centres (PHEOCs) which were activated for the response. 31.91% (n = 15) of the countries initiated some form of tactical coordination which involved the decentralisation of the operations at the local/grassroot level/district/ county levels. Decentralisation strategies played a key role in coordination, as was the innovative strategies by the countries; some coordination mechanisms built on already existing coordination systems and the heads of states were effective in the success of the coordination process. Financing posed challenge to majority of the countries in initiating coordination. CONCLUSION: Coordinating an emergency is a multidimensional process that includes having decision-makers and institutional agents define and prioritise policies and norms that contain the spread of the disease, regulate activities and behaviour and citizens, and respond to personnel who coordinate prevention.

Assessment of COVID-19 pandemic responses in African countries: thematic synthesis of WHO intra-action review reports.

OBJECTIVES: We conducted a review of intra-action review (IAR) reports of the national response to the COVID-19 pandemic in Africa. We highlight best practices and challenges and offer perspectives for the future. DESIGN: A thematic analysis across 10 preparedness and response domains, namely, governance, leadership, and coordination; planning and monitoring; risk communication and community engagement; surveillance, rapid response, and case investigation; infection prevention and control; case management; screening and monitoring at points of entry; national laboratory system; logistics and supply chain management; and maintaining essential health services during the COVID-19 pandemic. SETTING: All countries in the WHO African Region were eligible for inclusion in the study. National IAR reports submitted by March 2021 were analysed. RESULTS: We retrieved IAR reports from 18 African countries. The COVID-19 pandemic response in African countries has relied on many existing response systems such as laboratory systems, surveillance systems for previous outbreaks of highly infectious diseases and a logistics management information system. These best practices were backed by strong political will. The key challenges included low public confidence in governments, inadequate adherence to infection prevention and control measures, shortages of personal protective equipment, inadequate laboratory capacity, inadequate contact tracing, poor supply chain and logistics management systems, and lack of training of key personnel at national and subnational levels. CONCLUSION: These findings suggest that African countries' response to the COVID-19 pandemic was prompt and may have contributed to the lower cases and deaths in the region compared with countries in other regions. The IARs demonstrate that many technical areas still require immediate improvement to guide decisions in subsequent waves or future outbreaks.

Analyses of the performance of the Ebola virus disease alert management system in South Sudan: August 2018 to November 2019.

South Sudan implemented Ebola virus disease preparedness interventions aiming at preventing and rapidly containing any importation of the virus from the Democratic Republic of Congo starting from August 2018. One of these interventions was a surveillance system which included an Ebola alert management system. This study analyzed the performance of this system. A descriptive cross-sectional study of the Ebola virus disease alerts which were reported in South Sudan from August 2018 to November 2019 was conducted using both quantitative and qualitative methods. As of 30 November 2019, a total of 107 alerts had been detected in the country out of which 51 (47.7%) met the case definition and were investigated with blood samples collected for laboratory confirmation. Most (81%) of the investigated alerts were South Sudanese nationals. The alerts were identified by health workers (53.1%) at health facilities, at the community (20.4%) and by screeners at the points of entry (12.2%). Most of the investigated alerts were detected from the high-risk states of Gbudwe (46.9%), Jubek (16.3%) and Torit (10.2%). The investigated alerts commonly presented with fever, bleeding, headache and vomiting. The median timeliness for deployment of Rapid Response Team was less than one day and significantly different between the 6-month time periods (K-W = 7.7567; df = 2; p = 0.0024) from 2018 to 2019. Strengths of the alert management system included existence of a dedicated national alert hotline, case definition for alerts and rapid response teams while the weaknesses were occasional inability to access the alert toll-free hotline and lack of transport for deployment of the rapid response teams which often constrain quick response. This study demonstrates that the Ebola virus disease alert management system in South Sudan was fully functional despite the associated challenges and provides evidence to further improve Ebola preparedness in the country.

The COVID-19 pandemic: broad partnerships for the rapid scale up of innovative virtual approaches for capacity building and credible information dissemination in Africa.

The Corona Virus Disease 2019 (COVID-19) pandemic has rapidly spread in Africa, with a total of 474,592 confirmed cases by 11th July 2020. Consequently, all policy makers and health workers urgently need to be trained and to access the most credible information to contain and mitigate its impact. While the need for rapid training and information dissemination has increased, most of Africa is implementing public health social and physical distancing measures. Responding to this context requires broad partnerships and innovative virtual approaches to disseminate new insights, share best practices, and create networked communities of practice for all teach, and all learn. The World Health Organization (WHO)-Africa region, in collaboration with the Extension for Community Health Outcome (ECHO) Institute at the University of New Mexico Health Sciences Center (UNM HSC), the West Africa college of nurses and the East Central and Southern Africa college of physicians, private professional associations, academia and other partners has embarked on a virtual training programme to support the containment of COVID-19. Between 1st April 2020 and 10th July 2020, about 7,500 diverse health professionals from 172 locations in 58 countries were trained in 15 sessions. Participants were from diverse institutions including: central ministries of health, WHO country offices, provincial and district hospitals and private medical practitioners. A range of critical COVID-19 preparedness and response interventions have been reviewed and discussed. There is a high demand for credible information from credible sources about COVID-19. To mitigate the "epidemic of misinformation" partnerships for virtual trainings and information dissemination leveraging existing learning platforms and networks across Africa will augment preparedness and response to COVID-19.

The Transmission Chain Analysis of 2014-2015 Ebola Virus Disease Outbreak in Koinadugu District, Sierra Leone: An Observational Study.

INTRODUCTION: Sierra Leone experienced an unprecedented Ebola virus disease (EVD) outbreak in all its districts. Koinadugu District was the last to report an EVD case. Several outbreak response strategies were implemented. As part of lessons learnt, we conducted an observational study to describe the transmission chain in the district and the impact of the control measures implemented to contain the outbreak. METHODS: We reconstructed the transmission chain, positioning both confirmed and probable cases, described the distribution of the EVD confirmed cases in the context of the routes of transmission (Community, Funeral or Health facility setting) and assessed the impact of control measures using the surveillance data collected during the outbreak. RESULTS: All 142 confirmed and probable EVD cases registered were fully resolved in the transmission chain. 72.5% of all the EVD cases in the district were exposed in the community, 26.1% exposed during funerals, and 1.4% exposed in the health facility setting. Health-care workers contributed little to the EVD outbreak. 71.1% of EVD transmission occurred among family members. Female EVD cases generated more secondary cases than their male counterparts (P = 0.03). With removal of EVD cases from the community and admission to the community care center (CCC), the EVD transmission in the community decreased to substantially lower rates. In addition, transmission due to exposure in health facilities was further reduced with the implementation of full infection and prevention controls. CONCLUSION: This study details the transmission chain of EVD in a rural district setting and the public health interventions implemented to successfully limit the outbreak to just one of 11 chiefdoms. Heightened community-based surveillance for early case detection, swift isolation of suspect cases, efficient contact tracing and monitoring, and good infection prevention and control measures in health facilities were highly effective in limiting transmission and, eventually, breaking the transmission chain. CCCs were also instrumental in achieving early isolation and basic care for suspect cases, while ensuring that their family members who were close contacts remained in the community for easy contact tracing and monitoring. These were very useful lessons learnt that would inform the management of future outbreaks.

Incident Management Systems Are Essential for Effective Coordination of Large Disease Outbreaks: Perspectives from the Coordination of the Ebola Outbreak Response in Sierra Leone.

BACKGROUND: Response to the 2014-2015 Ebola virus disease (EVD) outbreak in Sierra Leone overwhelmed the national capacity to contain it and necessitated a massive international response and strong coordination platform. Consequently, the Sierra Leone Government, with support of the international humanitarian community, established and implemented various models for national coordination of the outbreak. In this article, we review the strengths and limitations of the EVD outbreak response coordination systems in Sierra Leone and propose recommendations for improving coordination of similar outbreaks in the future. CONCLUSION: There were two main frameworks used for the coordination of the outbreak; the Emergency Operation Center (EOC) and the National Ebola Response Center (NERC). We observed an improvement in outbreak coordination as the management mechanism evolved from the EOC to the NERC. Both coordination systems had their advantages and disadvantages; however, the NERC coordination mechanism appeared to be more robust. We identified challenges, such as competition and duplication of efforts between the numerous coordination groups, slow resource mobilization, inadequate capacity of NERC/EOC staff for health coordination, and an overtly centralized coordination and decision-making system as the main coordination challenges during the outbreak. RECOMMENDATIONS: We recommend the establishment of EOCs with simple incident management system-based coordination prior to outbreaks, strong government leadership, decentralization of coordination systems, and functions to the epicenter of outbreaks, with clear demarcation of roles and responsibilities between different levels, regular training of key coordination leaders, and better community participation as methods to improve coordination of future disease outbreaks.

High coverage of vitamin A supplementation and measles vaccination during an integrated Maternal and Child Health Week in Sierra Leone.

BACKGROUND: In May 2012, the twice-yearly Maternal and Child Health Week (MCHW) integrated vitamin A supplementation (VAS) and supplementary measles vaccination to reach all children 6-59 months in Sierra Leone. Following the MCHW, a post event coverage survey was conducted to validate VAS coverage and assess adverse events following immunization. METHODS: Using the WHO Expanded Program on Immunization sampling methodology, 30 clusters were randomly selected using population proportionate to size sampling. Fourteen caregivers of children 6-59 months were interviewed per cluster for precision of ±5%. Responses were collected via mobile phones using EpiSurveyor. RESULTS: Overall VAS and measles coverage was 91.9% and 91.6%, respectively, with no significant differences by age group, sex, religion or occupation. Major reasons given for not receiving VAS and measles vaccination were not knowing about the MCHW or being out of the area. Significantly more mild adverse events (fever, pain at injection site) were reported via the post event coverage survey (29.1%) than MCHW (0.01%) (p<0.0001). CONCLUSION: The MCHW reached >90% of children in Sierra Leone with equitable coverage. Increased reporting of mild adverse events during the survey may be attributed to delayed onset after measles vaccination and/or direct inquiry from enumerators. Even mild adverse events following immunization requires strengthened reporting during and after vaccination campaigns.

Establishing a national influenza sentinel surveillance system in a limited resource setting, experience of Sierra Leone.

BACKGROUND: Acute respiratory infections remain a leading cause of morbidity and mortality in Sierra Leone; however, similar to other African countries, little is known regarding the contribution of influenza. Routine influenza surveillance is thus a key element to improve understanding of the burden of acute respiratory infections in Africa. In 2011, the World Health Organization (WHO) funded the Strengthening Influenza Sentinel Surveillance in Africa (SISA) project with the goal of developing and strengthening influenza surveillance in eight countries in sub-Saharan Africa, including Sierra Leone. This paper describes the process of establishing a functional Influenza Sentinel Surveillance (ISS) system in Sierra Leone, a post-conflict resource-poor country previously lacking an influenza monitoring system. METHODS: Sierra Leone utilized a systematic approach, including situational assessment, selection of sentinel sites, preparation of implementation plan, adaptation of the standard operating procedures, supervision and training of staff, and monitoring of influenza surveillance activities. The methods used in Sierra Leone were adapted to its specific context, using the Integrated Disease Surveillance and Response (IDSR) strategy as a platform for establishing ISS. RESULTS: The ISS system started functioning in August 2011 with subsequent capacity to contribute surveillance activity data to global influenza databases, FluID and FluNet, demonstrating a functional influenza surveillance system in Sierra Leone within the period of the WHO SISA project support. Several factors were necessary for successful implementation, including a systematic approach, national ownership, appropriate timing and external support. CONCLUSIONS: The WHO SISA project demonstrated the feasibility of building a functional influenza surveillance system in Sierra Leone, integrated into existing national IDSR system. The ISS system, if sustained long-term, would provide valuable data to determine epidemiological and virological patterns and seasonal trends to assess the influenza disease burden that will ultimately guide national control strategies.

Intervene before leaving: clustered lot quality assurance sampling to monitor vaccination coverage at health district level before the end of a yellow fever and measles vaccination campaign in Sierra Leone in 2009.

BACKGROUND: In November 2009, Sierra Leone conducted a preventive yellow fever (YF) vaccination campaign targeting individuals aged nine months and older in six health districts. The campaign was integrated with a measles follow-up campaign throughout the country targeting children aged 9-59 months. For both campaigns, the operational objective was to reach 95% of the target population. During the campaign, we used clustered lot quality assurance sampling (C-LQAS) to identify areas of low coverage to recommend timely mop-up actions. METHODS: We divided the country in 20 non-overlapping lots. Twelve lots were targeted by both vaccinations, while eight only by measles. In each lot, five clusters of ten eligible individuals were selected for each vaccine. The upper threshold (UT) was set at 90% and the lower threshold (LT) at 75%. A lot was rejected for low vaccination coverage if more than 7 unvaccinated individuals (not presenting vaccination card) were found. After the campaign, we plotted the C-LQAS results against the post-campaign coverage estimations to assess if early interventions were successful enough to increase coverage in the lots that were at the level of rejection before the end of the campaign. RESULTS: During the last two days of campaign, based on card-confirmed vaccination status, five lots out of 20 (25.0%) failed for having low measles vaccination coverage and three lots out of 12 (25.0%) for low YF coverage. In one district, estimated post-campaign vaccination coverage for both vaccines was still not significantly above the minimum acceptable level (LT = 75%) even after vaccination mop-up activities. CONCLUSION: C-LQAS during the vaccination campaign was informative to identify areas requiring mop-up activities to reach the coverage target prior to leaving the region. The only district where mop-up activities seemed to be unsuccessful might have had logistical difficulties that should be further investigated and resolved.