Provincial Intra-Action Review of the COVID-19 Vaccination Programme: Opportunities to Improve Vaccine Response in North Kivu, Democratic Republic of Congo.

Background: Low levels of COVID-19 vaccination coverage in many countries prompted the use of rapid assessments to characterize barriers to vaccination and identify corrective measures. The World Health Organization recommended the use of intra-action reviews (IARs) to identify best practices, gaps, and lessons learned to make real-time improvements to the COVID-19 vaccination response. Objective: The Democratic Republic of the Congo (DRC) implemented a national IAR in July 2021 that was poorly attended by the provincial health level, where vaccination activities are planned and implemented. To bridge this gap, we proposed sub-national IARs focused on COVID-19 vaccine program implementation at the provincial level. Methods: Using the WHO methodology, we organized a four-day provincial IAR workshop and invited national, provincial and health zone Ministry of Health (MoH) representatives and private and non-governmental organizations involved in the provincial COVID-19 vaccination response. Participants were divided into six groups based on their expertise, affiliation, and role within the health system to assess and identify lessons learned, challenges and the solutions within each of the six technical areas: (1) coordination, planning and monitoring; (2) service delivery; (3) risk communication and community engagement; (4) adverse effects following immunization (AEFI); (5) logistics; (6) and data management, monitoring and evaluation. Results: The first provincial COVID-19 IAR was conducted in Goma, North Kivu, from January 19-22, 2022. A total of 56 participants came from provincial and health zone offices, and non-governmental organizations. Through work group discussions, they identified best practices, challenges, and lessons learned, and made recommendations to improve implementation of vaccination activities and reach coverage targets. Activities were proposed to operationalize recommendations and address challenges to improve the provincial response. Conclusion: This provincial IAR was a useful tool for reviewing progress and areas of improvement, while evaluating aspects of the COVID-19 vaccine rollout. It provided a means to share information with vaccination partners on areas of intervention, tailored to the local context.

U.S. Preparedness and Response to Increasing Clade I Mpox Cases in the Democratic Republic of the Congo - United States, 2024.

Clade I monkeypox virus (MPXV), which can cause severe illness in more people than clade II MPXVs, is endemic in the Democratic Republic of the Congo (DRC), but the country has experienced an increase in suspected cases during 2023-2024. In light of the 2022 global outbreak of clade II mpox, the increase in suspected clade I cases in DRC raises concerns that the virus could spread to other countries and underscores the importance of coordinated, urgent global action to support DRC's efforts to contain the virus. To date, no cases of clade I mpox have been detected outside of countries in Central Africa where the virus is endemic. CDC and other partners are working to support DRC's response. In addition, CDC is enhancing U.S. preparedness by raising awareness, strengthening surveillance, expanding diagnostic testing capacity for clade I MPXV, ensuring appropriate specimen handling and waste management, emphasizing the importance of appropriate medical treatment, and communicating guidance on the recommended contact tracing, containment, behavior modification, and vaccination strategies.

Assessment of the integrated disease surveillance and response system implementation in health zones at risk for viral hemorrhagic fever outbreaks in North Kivu, Democratic Republic of the Congo, following a major Ebola outbreak, 2021.

BACKGROUND: The Democratic Republic of the Congo (DRC) experienced its largest Ebola Virus Disease Outbreak in 2018-2020. As a result of the outbreak, significant funding and international support were provided to Eastern DRC to improve disease surveillance. The Integrated Disease Surveillance and Response (IDSR) strategy has been used in the DRC as a framework to strengthen public health surveillance, and full implementation could be critical as the DRC continues to face threats of various epidemic-prone diseases. In 2021, the DRC initiated an IDSR assessment in North Kivu province to assess the capabilities of the public health system to detect and respond to new public health threats. METHODS: The study utilized a mixed-methods design consisting of quantitative and qualitative methods. Quantitative assessment of the performance in IDSR core functions was conducted at multiple levels of the tiered health system through a standardized questionnaire and analysis of health data. Qualitative data were also collected through observations, focus groups and open-ended questions. Data were collected at the North Kivu provincial public health office, five health zones, 66 healthcare facilities, and from community health workers in 15 health areas. RESULTS: Thirty-six percent of health facilities had no case definition documents and 53% had no blank case reporting forms, limiting identification and reporting. Data completeness and timeliness among health facilities were 53% and 75% overall but varied widely by health zone. While these indicators seemingly improved at the health zone level at 100% and 97% respectively, the health facility data feeding into the reporting structure were inconsistent. The use of electronic Integrated Disease Surveillance and Response is not widely implemented. Rapid response teams were generally available, but functionality was low with lack of guidance documents and long response times. CONCLUSION: Support is needed at the lower levels of the public health system and to address specific zones with low performance. Limitations in materials, resources for communication and transportation, and workforce training continue to be challenges. This assessment highlights the need to move from outbreak-focused support and funding to building systems that can improve the long-term functionality of the routine disease surveillance system.

Measles outbreak response immunization during the COVID-19 pandemic: lessons from Borno State, Nigeria.

Introduction: the COVID-19 outbreak was declared a public health emergency of international concern by the WHO on the 30th January 2020. The occurrence of measles outbreaks in the context of COVID-19, both highly infectious respiratory illnesses, impacts additional challenges to the health system in a state with an ongoing humanitarian crisis. This article documents the implementation of an outbreak response immunization (ORI) during the COVID-19 pandemic and the implementation of global guidelines for mass vaccination. Methods: a retrospective review of the response to measles outbreak implemented in Borno state across six local government areas (LGAs) in 2019 was conducted. This review assessed the utilization of the World Health Organization (WHO) decision making framework, measles and COVID-19 epidemiological reports and the measle's vaccination response data. Results: an outbreak response immunization was implemented in six LGAs in Borno State, with a validated post campaign coverage of 96.3% (95% CI: 93.0 - 98.1). In total, 181,634 children aged 9 months-9 years were vaccinated with 27,961 (15.4%) receiving the measles vaccine for the first time. Prior to the interventions, 20 COVID-19 cases were reported in the six LGAs while only seven suspected cases were reported with only two cases confirmed in one of the six LGAs four weeks after the ORI. Conclusion: the WHO decision-making framework for implementing mass vaccinations in the context of the COVID-19 Pandemic was utilized for the outbreak response immunization in Borno State, Nigeria with 181,634 children aged 9 Months-9 years vaccinated with the measles vaccine. The use of the WHO decision-making framework to assess risk benefits of initiating mass vaccination campaigns remains a very important practical tool. These types of responses in Nigeria and other low and middle income countries (LMICs), with hitherto suboptimal immunization coverage and weak health systems and other settings, affected by humanitarian emergencies is essential in the achievement of the regional measle's elimination targets.

Measles susceptibility in maternal-infant dyads-Bamako, Mali.

Measles is endemic in Africa; measles mortality is highest among infants. Infant measles antibody titer at birth is related to maternal immune status. Older mothers are likelier to have had measles infection, which provides higher antibody titers than vaccine-induced immunity. We investigated the relationship between maternal age and measles susceptibility in mother-infant pairs in Mali through six months of infancy. We measured serum measles antibodies in 340 mother-infant pairs by plaque reduction neutralization test (PRNT) and calculated the proportion of mothers with protective titers (>120 mIU/mL) at delivery and the proportion of infants with protective titers at birth, and at three and six months of age. We explored associations between maternal age and measles antibodies in mothers and infants at the timepoints noted. Ten percent of Malian newborns were susceptible to measles; by six months nearly all were. Maternal and infant antibody titers were highly correlated. At delivery, 11% of mothers and 10% of newborns were susceptible to measles. By three and six months, infant susceptibility increased to 72% and 98%, respectively. Infants born to younger mothers were most susceptible at birth and three months. Time to susceptibility was 6.6 weeks in infants born to mothers with measles titer >120-<430 mIU/mL versus 15.4 weeks when mothers had titers ≥430 mIU/mL. Maternal and newborn seroprotective status were positively correlated. Improved strategies are needed to protect susceptible infants from measles infection and death. Increasing measles immunization coverage in vaccine eligible populations, including nonimmune reproductive-aged women and older children should be considered.

Progress and barriers towards maternal and neonatal tetanus elimination in the remaining 12 countries: a systematic review.

This systematic review assessed the progress and barriers towards maternal and neonatal tetanus elimination in the 12 countries that are yet to achieve elimination, globally. Coverage of at least 80% (the coverage level required for elimination) was assessed among women of reproductive age for five factors: (1) at least two doses of tetanus toxoid-containing vaccine, (2) protection at birth, (3) skilled birth attendance, (4) antenatal care visits, and (5) health facility delivery. A scoping review of the literature and data from Demographic and Health Surveys and Multiple Indicator Cluster Surveys provided insights into the barriers to attaining maternal and neonatal tetanus elimination. Findings showed that none of the 12 countries attained at least 80% coverage for women of reproductive age receiving at least two doses of tetanus toxoid-containing vaccine or protection at birth according to the data from Demographic and Health Surveys or Multiple Indicator Cluster Surveys. Barriers to maternal and neonatal tetanus elimination were mostly related to health systems and socioeconomic factors. Modification to existing maternal and neonatal tetanus elimination strategies, including innovations, will be required to accelerate maternal and neonatal tetanus elimination in these countries.

The impact of the COVID-19 pandemic on measles surveillance in the World Health Organisation African Region, 2020.

INTRODUCTION: following the declaration of the COVID-19 pandemic, many countries imposed restrictions on public gatherings, health workers were repurposed for COVID-19 response, and public demand for preventive health services declined due to fear of getting COVID-19 in health care settings. These factors led to the disruption in health service delivery, including childhood immunization, in the first months of the pandemic. Measles surveillance supported with laboratory confirmation, is implemented in the African Region as part of the strategies towards attaining measles elimination. World Health Organisation developed guidelines to assist countries to continue to safely provide essential health services including immunization and the surveillance of vaccine preventable diseases during the pandemic. METHODS: we analysed the measles case-based surveillance and laboratory databases for the years 2014 to 2020, to determine the impact of the COVID-19 pandemic on measles surveillance, comparing the performance in 2020 against the preceding years. RESULTS: the weekly reporting of suspected measles cases declined starting in April 2020. Twelve countries had more than 50% decline in both the number of reported cases as well as in the number of specimens collected in 2020, as compared to the mean for the years 2014-2018. In 2020, only 30% of the specimens from suspected measles cases arrived at the national laboratory within 3 days of collection. At Regional level, 86% of the districts reported suspected measles cases in 2020, while the non-measles febrile rash illness rate was 2.1 per 100,000 population, which was the lowest rate documented since 2014. Only 11 countries met the targets for the two principal surveillance performance indicators in 2020 as compared to an average of 21 countries in the years 2014-2019. CONCLUSION: the overall quality of measles surveillance has declined during the COVID pandemic in many countries. Countries should implement immediate and proactive measures to revitalise active surveillance for measles and monitor the quality of surveillance. We recommend that countries consider implementing specimen collection and testing methods that can facilitate timely confirmation of suspected measles cases in remote communities and areas with transportation challenges.

Trends in measles incidence and measles vaccination coverage in Nigeria, 2008-2018.

INTRODUCTION: All WHO regions have set measles elimination objective for 2020. To address the specific needs of achieving measles elimination, Nigeria is using a strategy focusing on improving vaccination coverage with the first routine dose of (monovalent) measles (MCV1) at 9 months, providing measles vaccine through supplemental immunization activities (children 9-59 months), and intensified measles case-based surveillance system. METHODS: We reviewed measles immunization coverage from population-based surveys conducted in 2010, 2013 and 2017-18. Additionally, we analyzed measles case-based surveillance reports from 2008-2018 to determine annual, regional and age-specific incidence rates. FINDINGS: Survey results indicated low MCV1 coverage (54.0% in 2018); with lower coverage in the North (mean 45.5%). Of the 153,097 confirmed cases reported over the studied period, 85.5% (130,871) were from the North. Moreover, 70.8% (108,310) of the confirmed cases were unvaccinated. Annual measles incidence varied from a high of 320.39 per 1,000,000 population in 2013 to a low of 9.80 per 1,000,000 in 2009. The incidence rate is higher among the 9-11 months (524.0 per million) and 12-59 months (376.0 per million). Between 2008 and 2018, the incidence rate had showed geographical variation, with higher incidence in the North (70.6 per million) compare to the South (17.8 per million). CONCLUSION: The aim of this study was to provide a descriptive analysis of measles vaccine coverage and incidence in Nigeria from 2008 to 2018 to assess country progress towards measles elimination. Although the total numbers of confirmed measles cases had decreased over the time period, measles routine coverage remains sub-optimal, and the incidence rates are critically high. The high burden of measles in the North highlight the need for region-specific interventions. The measles program relies heavily on polio resources. As the polio program winds down, strong commitments will be required to achieve elimination goals.

Measles outbreak in complex emergency: estimating vaccine effectiveness and evaluation of the vaccination campaign in Borno State, Nigeria, 2019.

BACKGROUND: From January to May 2019, large measles outbreaks affected Nigeria. Borno state was the most affected, recording 15,237 suspected cases with the state capital of Maiduguri having 1125 cases investigated and line-listed by March 2019. In Borno state, 22 of the 27 Local Government Areas (LGAs or Districts), including 37 internally displaced persons (IDPs) camps were affected. In response to the situation, an outbreak response immunization (ORI) campaign was conducted in the 13 most affected LGAs. In addition to conventional vaccination teams, special teams were deployed in security compromised areas, areas with migrants, and for nomadic and IDPs. Here we describe the outbreak and the ORI campaign. We also assess the measles-containing vaccine (MCV) coverage and vaccine effectiveness (VE) in order to quantify the population-level impact. METHODS: We reviewed the ORI activities, and conducted an analysis of the surveillance and the outbreak investigation reports. We assessed VE of MCV by applying the screening-method. Sensitivity analyses were also conducted to assess the effect of final classification of cases on the VE of MCV. The MCV coverage was assessed by a post-campaign coverage survey after completion of the ORI through a quantitative survey in the 12 LGAs that were accessible. RESULTS: Of the total 15,237 reported measles cases, 2002 cases were line-listed and investigated, and 737 were confirmed for measles by week 9 of 2019. Of the investigated cases 67.3% (n = 1348) were between 9 and 59 months of age. Among the 737 confirmed cases, only 9% (n = 64) stated being vaccinated with at least 1 dose of MCV. The overall VE for MCV was 98.4% (95%CI: 97.8-98.8). No significant differences were observed in the VE estimates of lab-confirmed and epi-linked cases when compared to the original estimates. The aggregated weighted vaccination coverage was 85.7% (95% CI: 79.6-90.1). CONCLUSION: The experience in Borno demonstrates that adequate VE can be obtained in conflict-affected areas. In complex emergencies affected by measles outbreaks, health authorities may consider integration with other health strategies and the engagement of security personnel as part of the ORI activities.

A scorecard of progress towards measles elimination in 15 west African countries, 2001-19: a retrospective, multicountry analysis of national immunisation coverage and surveillance data.

BACKGROUND: The WHO Regional Office for the Africa Regional Immunization Technical Advisory Group, in 2011, adopted the measles control and elimination goals for all countries of the African region to achieve in 2015 and 2020 respectively. Our aim was to track the current status of progress towards measles control and elimination milestones across 15 west African countries between 2001 and 2019. METHODS: We did a retrospective multicountry series analysis of national immunisation coverage and case surveillance data from Jan 1, 2001, to Dec 31, 2019. Our analysis focused on the 15 west African countries that constitute the Economic Community of West African States. We tracked progress in the coverage of measles-containing vaccines (MCVs), measles supplementary immunisation activities, and measles incidence rates. We developed a country-level measles summary scorecard using eight indicators to track progress towards measles elimination as of the end of 2019. The summary indicators were tracked against measles control and elimination milestones. FINDINGS: The weighted average regional first-dose MCV coverage in 2019 was 66% compared with 45% in 2001. 73% (11 of 15) of the west African countries had introduced second-dose MCV as of December, 2019. An estimated 4 588 040 children (aged 12-23 months) did not receive first-dose MCV in 2019, the majority (71%) of whom lived in Nigeria. Based on the scorecard, 12 (80%) countries are off-track to achieving measles elimination milestones; however, Cape Verde, The Gambia, and Ghana have made substantial progress. INTERPRETATION: Measles will continue to be endemic in west Africa after 2020. The regional measles incidence rate in 2019 was 33 times the 2020 elimination target of less than 1 case per million population. However, some hope exists as countries can look at the efforts made by Cape Verde, The Gambia, and Ghana and learn from them. FUNDING: None.

The performance of routine immunization in selected African countries during the first six months of the COVID-19 pandemic.

INTRODUCTION: following the declaration of the COVID-19 pandemic on 11 March 2020, countries started implementing strict control measures, health workers were re-deployed and health facilities re-purposed to assist COVID-19 control efforts. These measures, along with the public concerns of getting COVID-19, led to a decline in the utilization of regular health services including immunization. METHODS: we reviewed the administrative routine immunization data from 15 African countries for the period from January 2018 to June 2020 to analyze the trends in the monthly number of children vaccinated with specific antigens, and compare the changes in the first three months of the COVID-19 pandemic. RESULTS: thirteen of the 15 countries showed a decline in the monthly average number of vaccine doses provided, with 6 countries having more than 10% decline. Nine countries had a lower monthly mean of recipients of first dose measles vaccination in the second quarter of 2020 as compared to the first quarter. Guinea, Nigeria, Ghana, Angola, Gabon, and South Sudan experienced a drop in the monthly number of children vaccinated for DPT3 and/or MCV1 of greater than 2 standard deviations at some point in the second quarter of 2020 as compared to the mean for the months January-June of 2018 and 2019. CONCLUSION: countries with lower immunization coverage in the pre-COVID period experienced larger declines in the number of children vaccinated immediately after the COVID-19 pandemic was declared. Prolonged and significant reduction in the number of children vaccinated poses a serious risk for outbreaks such as measles. Countries should monitor coverage trends at national and subnational levels, and undertake catch-up vaccination activities to ensure that children who have missed scheduled vaccines receive them at the earliest possible time.

The African Region early experience with structures for the verification of measles elimination - a review.

Substantial progress has been achieved in the last two decades with the implementation of measles control strategies in the African Region. Elimination of measles is defined as the absence of endemic transmission in a defined geographical region or country for at least 12 months, as documented by a well-performing surveillance system. The framework for documenting elimination outlines five lines of evidence that should be utilized in documenting and assessing progress towards measles elimination. In March 2017, the WHO regional office for Africa developed and disseminated regional guidelines for the verification of measles elimination. As of May 2019, fourteen countries in the African Region have established national verification committees and 8 of these have begun to document progress toward measles elimination. Inadequate awareness, concerns about multiple technical committees for immunization work, inadequate funding and human resources, as well as gaps in data quality and in the implementation of measles elimination strategies have been challenges that hindered the establishment and documentation of progress by national verification committees. We recommend continuous capacity building and advocacy, technical assistance and networking to improve the work around the documentation of country progress towards measles elimination in the African Region.

The impact of a prolonged ebola outbreak on measles elimination activities in Guinea, Liberia and Sierra Leone, 2014-2015.

INTRODUCTION: Guinea, Sierra Leone and Liberia have attained significant reduction in measles incidence between 2004 and 2013. The Ebola outbreak in 2014-2015 in West Africa caused significant disruption of the health service delivery in the three worst affected countries. The magnitude of the impact on the immunization program has not been well documented. METHODS: We reviewed national routine immunization administrative coverage data as well as measles surveillance performance and measles epidemiology in the years before, during and after the EVD outbreak in Guinea, Liberia, Sierra Leone. RESULTS: Both Liberia and Guinea experienced a sharp decline of more than 25% in the monthly number of children vaccinated against measles in 2014 and 2015 as compared to the previous years, while there was no reported decline in Sierra Leone. Guinea and Liberia experienced a decline in measles surveillance activity and performance indicators in 2014 and 2015. During this period, there was an increase in measles incidence and a decline in the mean age of measles cases reported in Liberia and Sierra Leone. Guinea started reporting high measles incidence in 2016. All three countries organized measles supplemental immunization activities by June 2015. Liberia achieved 99% administrative coverage, while Guinea and Sierra Leone attained 90.6% and 97.2% coverage respectively. There were no severe adverse events reported during these mass vaccination activities. The disruptive effect of the Ebola outbreak on immunization services was especially evident in Guinea and Liberia. Our review of the reported administrative vaccination coverage at national level does not show significant decline in measles first dose vaccination coverage in Sierra Leone as compared to other reports. This may be due to inaccuracies in coverage monitoring and data quality problems. The increases in measles transmission and incidence in these three countries can be explained by the rapid accumulation of susceptible children. Despite the organization of mass vaccination activities, measles incidence through 2017 has remained higher than the pre-Ebola period in all three countries. CONCLUSION: The Ebola outbreak in West Africa significantly affected measles vaccination coverage rates in two of the three worst affected countries, and led to persistent gaps in coverage, along with high measles incidence that was documented until two years after the end of the Ebola outbreak. Liberia and Sierra Leone have demonstrated coverage improvements after the end of the Ebola outbreak.

Performance of National Measles Case-Based Surveillance Systems in The WHO African Region. 2012 - 2016.

Case based surveillance for measles is implemented in the African Region integrated with Acute Flaccid Paralysis (AFP) surveillance. In 2011, the Region adopted a measles elimination goal to be achieved by 2020, which included coverage, incidence and surveillance performance targets. We reviewed measles case-based surveillance data and surveillance performance from countries in the African Region for the years 2012 - 2016. During this period, a total of 359,019 cases of suspected measles were reported from the 44 of 47 (94%) countries using the case based surveillance system. Of these, 202,126 (56%) had specimens collected for laboratory testing. A total of 39,806 measles cases and 25,679 rubella cases were confirmed by IgM serology. Twelve countries met the two principal surveillance performance indicators for each year during the period and four countries met neither indicator over the period. At the Regional level, both surveillance targets were met in 3 of the 5 years in the period of study; however performance varies widely by country. Surveillance performance did not improve across the Region during the 5 years period. High quality surveillance performance is critical to support the achievement of the regional measles elimination goal. Better integrating implementation with AFP surveillance, securing predictable long-term funding sources, and conducting detailed evaluations at country level to identify and address the root cause of performance gaps is recommended.

Congenital Rubella Syndrome in The African Region - Data from Sentinel Surveillance.

INTRODUCTION: Rubella is a mild febrile rash illness caused by the rubella virus. The most serious consequence of rubella is congenital rubella syndrome (CRS), which occurs if the primary rubella infection occurs during early pregnancy, with subsequent infection of the placenta and the developing fetus. METHODS: WHO supported countries to set up sentinel surveillance for CRS using standard case definitions, protocols, and case classification scheme. This descriptive analysis summarises the data from 5 countries which have been regularly reporting. RESULTS: A total of 383 suspected cases of CRS were notified from the 5 countries as of December 2016, of which 52 cases were laboratory confirmed and 67 were confirmed on clinical grounds.The majority (43%) of confirmed CRS cases were in the age group 6 - 11 months. The most common major clinical manifestation (Group A) among the confirmed cases is congenital heart disease (72%) followed by cataracts (32%) and glaucoma (10%). DISCUSSION AND CONCLUSIONS: The number of years of reporting from these sentinel sites is too short to describe trends in CRS occurrence across the years. However, the limited surveillance data has yielded comparable information with other developing countries prior to introduction of rubella vaccine. As more countries introduce rubella vaccine into their immunisation programs, there is a need to ensure that all rubella outbreaks are thoroughly investigated and documented, to expand sentinel surveillance for CRS in more countries in the Region, and to complement this with retrospective record reviews for CRS cases in selected countries.

The Impact of Recent Rubella Vaccine Introduction in 5 Countries in The African Region.

The World Health Organization (WHO) recommends that countries introduce rubella containing vaccines (RCVs) to reduce rubella circulation and the occurrence of congenital rubella syndrome (CRS). As of June 2017, a total of 18 countries have already introduced or are in the process of introducing RCV in routine child vaccination programs. RCV introduction during 2013 - 2014 in five countries in the Region resulted in a reduction of rubella incidence of 48% to 96% in the post-introduction period as compared to the average incidence in the years before introduction. These results suggest that initial mass vaccination campaigns and introduction of RCVs in routine immunization programs result in significant reduction in rubella incidence and a reduced potential for the occurrence of CRS.

Introduction of the Second Dose of Measles Containing Vaccine in the Childhood Vaccination Programs Within the WHO Africa Region - Lessons Learnt.

BACKGROUND: WHO recommends all countries to include a second routine dose of measles containing vaccine (MCV2) in their national routine vaccination schedules regardless of the level of coverage with the first routine dose of measles containing vaccine (MCV1). As of Dec 2016, 26 countries in the African Region have introduced MCV2. METHODS: We reviewed the WHO UNICEF coverage estimates for MCV1 and MCV2 in these countries, and the reports of the post introduction evaluation of MCV2 from 11 countries. RESULTS: Twenty three countries have WHO/UNICEF estimates of MCV2 coverage available in 2015. Of these, 2 countries have coverage of ≥ 95% for both MCV1 and MCV2 while 5 countries have coverage of > 80% for both doses. Dropout rates of >20% MCV1 - MCV2 exist in 12 countries. Post-MCV2 introduction evaluations done in 11 countries from 2012 to 2015 showed that inadequate health worker training, insufficient sensitization and awareness generation among parents and suboptimal dose recording practices were common programmatic weaknesses that contributed to the low MCV2 coverage in these countries. CONCLUSION: MCV2 coverage remains low as reflected in large drop-out rates in most countries. Higher MCV2 coverage is necessary to sustainably achieve the regional measles elimination goal. National immunization programs must improve implementation of MCV2 using the standard introduction and evaluation guidelines available for EPI program planning.

Status of Measles Elimination in Eleven Countries with High Routine Immunisation Coverage in The WHO African Region.

BACKGROUND: Measles elimination is defined as the absence of endemic measles virus transmission in a defined geographic area for at least 12 months in the presence of a well-performing surveillance system. The WHO framework for verification of measles elimination indicates that the achievement of measles and/or rubella elimination should be verified for individual countries. OBJECTIVE: We identified 11 high performing countries based on their first dose measles vaccination coverage, and looked at their performance across the various programmatic parameters, to see if they are ready to undertake the verification of measles elimination. METHODS: We identified 11 countries with >90% measles first dose coverage for the most recent 5 years according to the WHO UNICEF estimates of national immunisation coverage. We analysed vaccination coverage and surveillance performance in these countries. RESULTS: Algeria, Botswana, Gambia, Mauritius, Rwanda, Seychelles have maintained measles first dose (MCV1) coverage of 95% or more since 2011. In 2015, only Algeria, Cape Verde and Seychelles had coverage of 95% or more for the second dose of measles vaccine (MCV2). Of the 22 supplemental immunisation activities (SIAs) among the 11 countries, only 6 had administrative coverage of less than 95%. Only Rwanda and Lesotho attained the case-based surveillance performance targets in all the five years. CONCLUSION: Despite their high routine first dose measles immunisation coverage, all of the 11 countries have some program gaps indicating that they do not meet all the criteria to undergo verification of elimination at this point. It is recommended for these countries to set up national verification committees as per the WHO framework for verification of measles elimination, in order to initiate the documentation and monitoring of progress, and to address programmatic gaps in the coming years.

Progress Toward Measles Elimination - African Region, 2013-2016.

In 2011, the 46 World Health Organization (WHO) African Region (AFR) member states established a goal of measles elimination* by 2020, by achieving 1) ≥95% coverage of their target populations with the first dose of measles-containing vaccine (MCV1) at national and district levels; 2) ≥95% coverage with measles-containing vaccine (MCV) per district during supplemental immunization activities (SIAs); and 3) confirmed measles incidence of <1 case per 1 million population in all countries (1). Two key surveillance performance indicator targets include 1) investigating ≥2 cases of nonmeasles febrile rash illness per 100,000 population annually, and 2) obtaining a blood specimen from ≥1 suspected measles case in ≥80% of districts annually (2). This report updates the previous report (3) and describes progress toward measles elimination in AFR during 2013-2016. Estimated regional MCV1 coverage† increased from 71% in 2013 to 74% in 2015.§ Seven (15%) countries achieved ≥95% MCV1 coverage in 2015.¶ The number of countries providing a routine second MCV dose (MCV2) increased from 11 (24%) in 2013 to 23 (49%) in 2015. Forty-one (79%) of 52 SIAs** during 2013-2016 reported ≥95% coverage. Both surveillance targets were met in 19 (40%) countries in 2016. Confirmed measles incidence in AFR decreased from 76.3 per 1 million population to 27.9 during 2013-2016. To eliminate measles by 2020, AFR countries and partners need to 1) achieve ≥95% 2-dose MCV coverage through improved immunization services, including second dose (MCV2) introduction; 2) improve SIA quality by preparing 12-15 months in advance, and using readiness, intra-SIA, and post-SIA assessment tools; 3) fully implement elimination-standard surveillance††; 4) conduct annual district-level risk assessments; and 5) establish national committees and a regional commission for the verification of measles elimination.

The effect of targeted wide age range SIAs in reducing measles incidence in the African Region.

Periodic measles supplemental immunisation activities (SIAs) increase population immunity and thereby reduce the pool of accumulated susceptible children. They are typically conducted every 2 - 4 years, and most often target children up to five years of age. Between 2012 and 2015, after surveillance data indicated a shift in the epidemiological profile of measles towards older age groups, 11 countries were supported to conduct wide age range SIAs based on their local epidemiological patterns. Six other countries conducted SIAs with measles-rubella vaccines targeting ages 9 months to 14 years as an initial step of introducing rubella vaccine into the immunization program. In subsequent years, the incidence of confirmed measles dropped significantly in 13 of the 17 countries reviewed. The findings emphasize the importance of well-functioning surveillance systems, and the benefits of using of surveillance data to determine the specific target age-range for periodic SIAs to accelerate progress towards measles elimination.