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Grant J, Diawara H, Traore S, Koita F, Myers J, Sagara I, Chandramohan D, Dicko A, Greenwood B, Webster J. Delivery strategies for malaria vaccination in areas with seasonal malaria transmission. BMJ Glob Health 2023; 8:e011838. [PMID: 37147016 PMCID: PMC10163455 DOI: 10.1136/bmjgh-2023-011838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/11/2023] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND Seasonal vaccination with the RTS,S/AS01E malaria vaccine given alongside seasonal malaria chemoprevention (SMC) substantially reduces malaria in young children. The WHO has recommended the use of RTS,S/AS01E, including seasonal vaccination, in areas with seasonal malaria transmission. This study aimed to identify potential strategies to deliver RTS,S/AS01E, and assess the considerations and recommendations for delivery of seasonal malaria vaccination in Mali, a country with highly seasonal malaria. METHODS Potential delivery strategies for RTS,S/AS01E in areas with seasonal malaria were identified through a series of high level discussions with the RTS,S/AS01E plus SMC trial investigators, international and national immunisation and malaria experts, and through the development of a theory of change. These were explored through qualitative in-depth interviews with 108 participants, including national-level, regional-level and district-level malaria and immunisation programme managers, health workers, caregivers of children under 5 years of age, and community stakeholders. A national-level workshop was held to confirm the qualitative findings and work towards consensus on an appropriate strategy. RESULTS Four delivery strategies were identified: age-based vaccination delivered via the Essential Programme on Immunisation (EPI); seasonal vaccination via EPI mass vaccination campaigns (MVCs); a combination of age-based priming vaccination doses delivered via the EPI clinics and seasonal booster doses delivered via MVCs; and a combination of age-based priming vaccination doses and seasonal booster doses, all delivered via the EPI clinics, which was the preferred strategy for delivery of RTS,S/AS01E in Mali identified during the national workshop. Participants recommended that supportive interventions, including communications and mobilisation, would be needed for this strategy to achieve required coverage. CONCLUSIONS Four delivery strategies were identified for administration of RTS,S/AS01E alongside SMC in countries with seasonal malaria transmission. Components of these delivery strategies were defined as the vaccination schedule, and the delivery system(s) plus the supportive interventions needed for the strategies to be effective. Further implementation research and evaluation is needed to explore how, where, when and what effective coverage is achievable via these new strategies and their supportive interventions.
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Affiliation(s)
- Jane Grant
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Halimatou Diawara
- Malaria Research and Training Center (MRTC), Universite des Sciences des Techniques et des Technologies de Bamako, Bamako, Mali
| | - Seydou Traore
- Malaria Research and Training Center (MRTC), Universite des Sciences des Techniques et des Technologies de Bamako, Bamako, Mali
| | - Fatoumata Koita
- Malaria Research and Training Center (MRTC), Universite des Sciences des Techniques et des Technologies de Bamako, Bamako, Mali
| | - Jessica Myers
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Issaka Sagara
- Malaria Research and Training Center (MRTC), Universite des Sciences des Techniques et des Technologies de Bamako, Bamako, Mali
| | - Daniel Chandramohan
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Alassane Dicko
- Malaria Research and Training Center (MRTC), Universite des Sciences des Techniques et des Technologies de Bamako, Bamako, Mali
| | - Brian Greenwood
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Jayne Webster
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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2
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Saxenian H, Alkenbrack S, Freitas Attaran M, Barcarolo J, Brenzel L, Brooks A, Ekeman E, Griffiths UK, Rozario S, Vande Maele N, Ranson MK. Sustainable financing for Immunization Agenda 2030. Vaccine 2022:S0264-410X(22)01450-5. [PMID: 36464542 DOI: 10.1016/j.vaccine.2022.11.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/02/2022] [Accepted: 11/17/2022] [Indexed: 12/05/2022]
Abstract
Sustainable financing for immunization refers to the sufficient and predictable allocation and use of resources to support the achievement of immunization goals within the framework of overall health financing. The Immunization Agenda 2030 (IA2030) agenda spells out four important focus areas needed for sustainable financing: (1) ensuring sufficient and predictable resources, (2) making optimal use of resources, (3) aligning partnerships, and (4) supporting sustainable transitions from external assistance. This paper summarizes the evidence and proposes interventions under each area. While immunization is one of the best investments and justifies public financing, the COVID-19 pandemic has led to the worst economic recession since the Great Depression and threatens countries' ability to mobilize funding to ensure continuity and access to essential services, including immunization. Strategies for ensuring adequate resources differ by income group but include raising more revenues, reprioritizing the budget towards health, and ensuring that health resources favor Primary Health Care (PHC) and immunization. In low- and lower-middle income countries, support from Gavi, the Vaccine Alliance, which channels the largest amount of external financing, will remain important, but some lower-middle income countries will need to prepare for transition. Countries benefitting from the Global Polio Eradication Initiative (GPEI) are also experiencing a transition from GPEI financing to domestic and other external financing. This paper outlines ways in which countries can improve the use of domestic and external resources to better incentivize high-quality PHC and immunization services and align immunization programs with health sector reforms. While governments must lead, collective action from development partners, the private sector, and civil society is needed to promote health system financing systems that ensure that the world is better prepared for future outbreaks and pandemics, while reinforcing the IA2030 vision and making progress towards universal health coverage and the Sustainable Development Goals.
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Affiliation(s)
| | - S Alkenbrack
- World Bank Group, Health, Nutrition and Population Global Practice, Washington, D.C., United States
| | | | - J Barcarolo
- Gavi, The Vaccine Alliance, Geneva, Switzerland(1)
| | - L Brenzel
- Bill & Melinda Gates Foundation, Seattle, WA, United States
| | - A Brooks
- Bridges to Development, Geneva, Switzerland
| | - E Ekeman
- World Health Organization, Geneva, Switzerland
| | - U K Griffiths
- UNICEF Programme Division, New York City, NY, United States
| | - S Rozario
- UNICEF Programme Division, New York City, NY, United States
| | | | - M K Ranson
- World Bank Group, Health, Nutrition and Population Global Practice, Geneva, Switzerland
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3
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Hodgins S, Kok M, Musoke D, Lewin S, Crigler L, LeBan K, Perry HB. Community health workers at the dawn of a new era: 1. Introduction: tensions confronting large-scale CHW programmes. Health Res Policy Syst 2021; 19:109. [PMID: 34641886 PMCID: PMC8506102 DOI: 10.1186/s12961-021-00752-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Community health worker (CHW) programmes are again receiving more attention in global health, as reflected in important recent WHO guidance. However, there is a risk that current CHW programme efforts may result in disappointing performance if those promoting and delivering them fail to learn from past efforts. This is the first of a series of 11 articles for a supplement entitled "Community Health Workers at the Dawn of a New Era". METHODS Drawing on lessons from case studies of large well-established CHW programmes, published literature, and the authors' experience, the paper highlights major issues that need to be acknowledged to design and deliver effective CHW programmes at large scale. The paper also serves as an introduction to a set of articles addressing these issues in detail. RESULTS The article highlights the diversity and complexity of CHW programmes, and offers insights to programme planners, policymakers, donors, and others to inform development of more effective programmes. The article proposes that be understood as actors within community health system(s) and examines five tensions confronting large-scale CHW programmes; the first two tensions concern the role of the CHW, and the remaining three, broader strategic issues: 1) What kind of an actor is the CHW? A lackey or a liberator? Provider of clinical services or health promoter? 2) Lay versus professional? 3) Government programme at scale or nongovernmental organization-led demonstration project? 4) Standardized versus tailored to context? 5) Vertical versus horizontal? CONCLUSION CHWs can play a vital role in primary healthcare, but multiple conditions need to be met for them to reach their full potential.
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Affiliation(s)
- Stephen Hodgins
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Maryse Kok
- Department of Global Health, KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | - David Musoke
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Simon Lewin
- Norwegian Institute of Public Health, Oslo Town, Norway
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Lauren Crigler
- Crigler Consulting, LLC, Hillsborough, NC, United States of America
| | - Karen LeBan
- Independent Consultant, Washington, DC, United States of America
| | - Henry B Perry
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America.
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Neel AH, Closser S, Villanueva C, Majumdar P, Gupta SD, Krugman D, Akinyemi OO, Deressa W, Kalbarczyk A, Alonge O. 30 years of polio campaigns in Ethiopia, India and Nigeria: the impacts of campaign design on vaccine hesitancy and health worker motivation. BMJ Glob Health 2021; 6:bmjgh-2021-006002. [PMID: 34344665 PMCID: PMC8336205 DOI: 10.1136/bmjgh-2021-006002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 06/11/2021] [Indexed: 11/10/2022] Open
Abstract
Introduction The debate over the impact of vertical programmes, including mass vaccination, on health systems is long-standing and often polarised. Studies have assessed the effects of a given vertical health programme on a health system separately from the goals of the vertical programme itself. Further, these health system effects are often categorised as either positive or negative. Yet health systems are in fact complex, dynamic and tightly linked. Relationships between elements of the system determine programme and system-level outcomes over time. Methods We constructed a causal loop diagram of the interactions between mass polio vaccination campaigns and government health systems in Ethiopia, India and Nigeria, working inductively from two qualitative datasets. The first dataset was 175 interviews conducted with policymakers, officials and frontline staff in these countries in 2011–2012. The second was 101 interviews conducted with similar groups in 2019, focusing on lessons learnt from polio eradication. Results Pursuing high coverage in polio campaigns, without considering the dynamic impacts of campaigns on health systems, cost campaign coverage gains over time in weaker health systems with many campaigns. Over time, the systems effects of frequent campaigns, delivered through parallel structures, led to a loss of frontline worker motivation, and an increase in vaccine hesitancy in recipient populations. Co-delivery of interventions helped to mitigate these negative effects. In stronger health systems with fewer campaigns, these issues did not arise. Conclusion It benefits vertical programmes to reduce the construction of parallel systems and pursue co-delivery of interventions where possible, and to consider the workflow of frontline staff. Ultimately, for health campaign designs to be effective, they must make sense for those delivering and receiving campaign interventions, and must take into account the complex, adaptive nature of the health systems in which they operate.
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Affiliation(s)
- Abigail H Neel
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Svea Closser
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Catherine Villanueva
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Piyusha Majumdar
- SDG School of Public Health, Indian Institute of Health Management Research, Jaipur, Rajasthan, India
| | - S D Gupta
- SDG School of Public Health, Indian Institute of Health Management Research, Jaipur, Rajasthan, India
| | - Daniel Krugman
- Anthropology, Middlebury College, Middlebury, Vermont, USA
| | | | - Wakgari Deressa
- Preventive Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Anna Kalbarczyk
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Olakunle Alonge
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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5
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Haenssgen MJ, Closser S, Alonge O. Impact and effect mechanisms of mass campaigns in resource-constrained health systems: quasi-experimental evidence from polio eradication in Nigeria. BMJ Glob Health 2021; 6:bmjgh-2020-004248. [PMID: 33685940 PMCID: PMC7942242 DOI: 10.1136/bmjgh-2020-004248] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/12/2021] [Accepted: 02/10/2021] [Indexed: 12/04/2022] Open
Abstract
Background Mass campaigns are a key strategy for delivering life-saving interventions under Global Health Initiatives, especially in weak health system contexts. They are frequently designed parallel to the health system to rapidly achieve programme targets such as vaccination coverage, but we lack quantitative evidence demonstrating their impact and effect mechanisms on health system performance at sub-/national level. This longitudinal study responds to this gap through an analysis of polio eradication campaigns in Nigeria. Methods Using four rounds of Demographic and Health Surveys in Nigeria between October 2000 and December 2017, we created a longitudinal dataset containing 88 881 under-5 children/pregnancies. We estimated the relationships between individuals’ campaign exposure and health system performance indices (full RI schedule attainment, maternal healthcare services utilisation and child survival) using multilevel, mixed-effects regression models applied nationally and stratified by the six geopolitical zones in Nigeria. Results Nationally, high-frequency mass campaigns had detrimental health systems effects that potentially left 3.6 million children deprived of full immunisation. The frequency of campaigns was most concentrated in regions with weak health systems, where the operations of RI were disrupted, alongside negative effects on child survival and institutional delivery. In contrast, regions with relatively strong health systems and few campaigns experienced beneficial effects on maternal healthcare service utilisation. Conclusions As we provide evidence that well-functioning health systems can benefit from mass campaigns under Global Health Initiatives, our work also challenges the established wisdom to intensify mass campaigns in weaker health systems to bypass service provision bottlenecks. Mass campaigns do not inherently benefit or damage a health system, but frequent campaigns in weak health system contexts can impede service provision. We call for an additional burden of proof and active efforts to integrate mass campaigns into routine health services by harmonising implementation plans and service delivery in weak health system contexts.
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Affiliation(s)
- Marco J Haenssgen
- Department of Global Sustainable Development, School of Cross-Faculty Studies, University of Warwick, Coventry, UK.,Institute of Advanced Study, Milburn House, University of Warwick, Coventry, UK
| | - Svea Closser
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Olakunle Alonge
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
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6
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Omoleke SA, Getachew B, Igoh CS, Yusuf TA, Lukman SA, Loveday N. The Potential Contribution of Supplementary Immunization Activities to Routine Immunization in Kebbi State, Nigeria. J Prim Care Community Health 2021; 11:2150132720932698. [PMID: 32508212 PMCID: PMC7281641 DOI: 10.1177/2150132720932698] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Among the strategies of the Polio Eradication Initiative, the landmark interventions are routine immunization (RI) and supplementary immunization activities (SIAs). RI is the provision of vaccination service at the health facility and conducted year-round. SIAs are a community-based intervention targeting large numbers of an eligible population within a short period. Hence, the study aimed to assess the contributions of SIAs on access and utilization of RI services. Methods: We conducted the study in 10 local government areas in Kebbi State, northwestern Nigeria. We analyzed RI data from January to September 2019 and included the 4 SIAs conducted in January, April, August, and September in the same years. The number of children vaccinated, the trend of BCG, pentavalent vaccine at 6 and 10 weeks, and measles coverage and dropout rates (DORs) were analyzed. Results: For all the selected vaccines, the highest contributions to RI were recorded during the August 2019 fractional Inactivated Polio Vaccine (fIPV) campaign. On the other hand, the least contributions were noted during January SIAs. The BCG coverage showed an erratic trend with the lowest in February and highest in July 2019. The coverage for the pentavalent vaccine at 6 and 10 weeks was lowest in February and September. The pentavalent vaccine DOR pattern showed the lowest in February with value of 0% and the highest in June with 12%. Except for May and June, the Pentavalent vaccine DORs for all other months were <10%. February 2019 had the lowest measles coverage. Conclusion: Our study demonstrated that the integration of RI into SIAs could improve RI coverage. and potentially reduce DOR, especially when the integration is of good quality and conducted at short and regular intervals. Although SIAs are instrumental at increasing RI coverage, the disruption of RI services may occur due to overlapping resources and poor planning. Therefore, SIAs should be adequately planned by program managers to strengthen RI service delivery during the SIAs implementation.
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Affiliation(s)
- Semeeh A Omoleke
- Office of the Country Representative, World Health Organization, Abuja, Nigeria.,World Health Organization, Kebbi State Field Office, Birnin Kebbi, Nigeria
| | - Biniam Getachew
- Office of the Country Representative, World Health Organization, Abuja, Nigeria.,World Health Organization, Kebbi State Field Office, Birnin Kebbi, Nigeria
| | - Catherine S Igoh
- World Health Organization, Kebbi State Field Office, Birnin Kebbi, Nigeria
| | - Taofik A Yusuf
- World Health Organization, Kebbi State Field Office, Birnin Kebbi, Nigeria
| | | | - Nkwogu Loveday
- Office of the Country Representative, World Health Organization, Abuja, Nigeria
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7
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Matos CCDSA, Gonçalves BA, Couto MT. Vaccine hesitancy in the global south: Towards a critical perspective on global health. Glob Public Health 2021; 17:1087-1098. [PMID: 33843459 DOI: 10.1080/17441692.2021.1912138] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The complex phenomenon of vaccine hesitancy has been causing increasing global concern. This systematic review aims at analysing the state of art of scientific literature concerning vaccine hesitancy in Latin America and Africa, observing if: (i) they use the same research trends as the global North; and (ii) the parameters recommended by the World Health Organization (WHO) and taken from the experience of the global North are adequate to the Global South's context. This review analyses empirical, qualitative, quantitative, or mixed-study publications, from 2015 to 2020, available at five different databases. The studies produced in the Global South bring up important context-specific issues, such as issues of access (that are not included in the WHO's definition of vaccine hesitancy), cultural and religious issues, reactions to governments, reactions to recent episodes of vaccine tests on populations, and reactions to past of colonial violence. Initiatives to understand the phenomenon based on methodological and conceptual frameworks from the global North alone can cause wrongful conclusions.
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Portnoy A, Jit M, Helleringer S, Verguet S. Comparative Distributional Impact of Routine Immunization and Supplementary Immunization Activities in Delivery of Measles Vaccine in Low- and Middle-Income Countries. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:891-897. [PMID: 32762991 PMCID: PMC7519803 DOI: 10.1016/j.jval.2020.03.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 03/09/2020] [Accepted: 03/18/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES In many countries, measles disproportionately affects poorer households. To achieve equitable delivery, national immunization programs can use 2 main delivery platforms: routine immunization and supplementary immunization activities (SIAs). The objective of this article is to use data concerning measles vaccination coverage delivered via routine and SIA strategies to make inferences about the associated equity impact. METHODS We relied on Demographic and Health Survey and Multiple Indicator Cluster Surveys multi-country survey data to conduct a comparative analysis of routine and SIA measles vaccination status of children by wealth quintile. We estimated the value of the angle, θ, for the ratio of the difference between coverage levels of adjacent wealth quintiles by using the arc-tangent formula. For each country/year observation, we averaged the θ estimates into one summary measurement, defined as the "equity impact number." RESULTS Across 20 countries, the equity impact number summarized across wealth quintiles was greater (and hence less equitable) for routine delivery than for SIAs in the survey rounds (years) during, before, and after an SIA about 65% of the time. The equity impact numbers for routine measles vaccination averaged across wealth quintiles were usually greater than for SIA measles vaccination across country-year observations. CONCLUSIONS This analysis examined how different measles vaccine delivery platforms can affect equity. It can serve to elucidate the impact of immunization and public health programs in terms of comparing horizontal to vertical delivery efforts and in reducing health inequalities in global and country-level decision-making.
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Affiliation(s)
- Allison Portnoy
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Mark Jit
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, England, UK; Modelling and Economics Unit, Public Health England, London, England, UK
| | - Stéphane Helleringer
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Stéphane Verguet
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
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9
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Ateudjieu J, Yakum MN, Goura AP, Tembei AM, Ingrid DK, Bita'a Landry B, Kenfack B, Amada L, Tadzong I, Bissek AC. EPI immunization coverage, timeliness and dropout rate among children in a West Cameroon health district: a cross sectional study. BMC Public Health 2020; 20:228. [PMID: 32054484 PMCID: PMC7020570 DOI: 10.1186/s12889-020-8340-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 02/10/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Monitoring of the expanded program on immunization's performance is not only limited to routine periodic reports but equally includes surveys. Based on unpublished national EPI surveillance data from the past 5 years in Cameroon, the Foumban health district has reported a high number of vaccine preventable disease suspected cases. Contradictory information on the immunization coverage in this district exists from both administrative data and published literature. As a result, the objective of this study was to estimate the immunization coverage and dropout rate in age group 12-23 months and timeliness in age group 0-59 months among children in Foumban Health District (Cameroon), in 2018. METHOD This was a descriptive cross-sectional study targeting randomly selected children aged 0-59 months from Foumban health district. Data were collected by trained and supervised surveyors using a pretested questionnaire to describe the immunization coverage, timeliness and dropout rate in eighty clusters of about thirty buildings selected by stratified random sampling in July 2018. RESULTS In total, 80 clusters covering 2121 buildings were selected and all were reached (100%). A total of 1549 (81.2%) households accepted to participate in the survey and 1430 children aged 0-59 months including 294 (20.6%) aged 12-23 months were enrolled into the study. Of these 1430 children, 427 [29.9 (27.4-32.2)%] aged 0-59 months were vaccinated with evidence. In the age group 12-23 months, the immunization coverage with evidence of BCG, DPT-Hi + Hb 3 and measles/rubella were 28.6(23.4-33.9)%, 22.8 (18.1-27.6)% and 14.3 (10.3-18.1)% respectively. Within age group 0-59 months; the proportion of children who missed their vaccination appointments increased from 23.3 to 31.7% for the vaccine planned at birth (BCG) and last vaccine planned (Measles/Rubella) for the EPI program respectively. In age group 12-23 months; the specific (DPT-Hi + Hb1-3) and general (BCG-Measles/Rubella) dropout rates of vaccination with evidence were 14.1 and 50.0% respectively. CONCLUSION Documented immunization coverage, dropout rate and timeliness in Foumban Health district are lower than that targeted by the Cameroon EPI. Competent health authorities have to take necessary actions to ensure the implementation of national guidelines with regards to children access to immunization. Also, studies have to be conducted to identify determinants of low immunization coverage and delays in immunization schedules as well as high dropout rates.
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Affiliation(s)
- Jérôme Ateudjieu
- M.A. SANTE (Meilleuraccès aux soins de Santé), P.O. Box 33490, Yaoundé, Cameroon.,Department of Biomedical Sciences, University of Dschang, Cameroon, P.O. Box 067, Dschang, Cameroon.,Dschang District Hospital, Dschang West region of Cameroon, Dschang, Cameroon
| | | | - André Pascal Goura
- M.A. SANTE (Meilleuraccès aux soins de Santé), P.O. Box 33490, Yaoundé, Cameroon
| | - Ayok Maureen Tembei
- M.A. SANTE (Meilleuraccès aux soins de Santé), P.O. Box 33490, Yaoundé, Cameroon
| | | | - Beyala Bita'a Landry
- M.A. SANTE (Meilleuraccès aux soins de Santé), P.O. Box 33490, Yaoundé, Cameroon
| | - Bruno Kenfack
- Department of Biomedical Sciences, University of Dschang, Cameroon, P.O. Box 067, Dschang, Cameroon.,Dschang District Hospital, Dschang West region of Cameroon, Dschang, Cameroon
| | - Lapia Amada
- M.A. SANTE (Meilleuraccès aux soins de Santé), P.O. Box 33490, Yaoundé, Cameroon
| | - Isaac Tadzong
- M.A. SANTE (Meilleuraccès aux soins de Santé), P.O. Box 33490, Yaoundé, Cameroon
| | - Anne Cecile Bissek
- Division of Health Operations Research, Ministry of Public Health, Yaoundé, Cameroon
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10
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Pallas SW, Ahmeti A, Morgan W, Preza I, Nelaj E, Ebama M, Levin A, Lafond KE, Bino S. Program cost analysis of influenza vaccination of health care workers in Albania. Vaccine 2020; 38:220-227. [PMID: 31669063 PMCID: PMC10621071 DOI: 10.1016/j.vaccine.2019.10.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 10/01/2019] [Accepted: 10/09/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Since 2012, WHO has recommended influenza vaccination for health care workers (HCWs), which has different costs than routine infant immunization; however, few cost estimates exist from low- and middle-income countries. Albania, a middle-income country, has self-procured influenza vaccine for some HCWs since 2014, supplemented by vaccine donations since 2016 through the Partnership for Influenza Vaccine Introduction (PIVI). We conducted a cost analysis of HCW influenza vaccination in Albania to inform scale-up and sustainability decisions. METHODS We used the WHO's Seasonal Influenza Immunization Costing Tool (SIICT) micro-costing approach to estimate incremental costs from the government perspective of facility-based vaccination of HCWs in Albania with trivalent inactivated influenza vaccine for the 2018-19 season based on 2016-17 season data from administrative records, key informant consultations, and a convenience sample of site visits. Scenario analyses varied coverage, vaccine presentation, and vaccine prices. RESULTS In the baseline scenario, 13,377 HCWs (70% of eligible HCWs) would be vaccinated at an incremental financial cost of US$61,296 and economic cost of US$161,639. Vaccine and vaccination supplies represented the largest share of financial (89%) and economic costs (44%). Per vaccinated HCW financial cost was US$4.58 and economic cost was US$12.08 including vaccine and vaccination supplies (US$0.49 and US$6.76 respectively without vaccine and vaccination supplies). Scenarios with higher coverage, pre-filled syringes, and higher vaccine prices increased total economic and financial costs, although the economic cost per HCW vaccinated decreased with higher coverage as some costs were spread over more HCWs. Across all scenarios, economic costs were <0.07% of Albania's estimated government health expenditure, and <5.07% of Albania's estimated immunization program economic costs. CONCLUSIONS Cost estimates can help inform decisions about scaling up influenza vaccination for HCWs and other risk groups.
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Affiliation(s)
| | | | | | - Iria Preza
- Institute of Public Health, Tirana, Albania
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Portnoy A, Campos NG, Sy S, Burger EA, Cohen J, Regan C, Kim JJ. Impact and Cost-Effectiveness of Human Papillomavirus Vaccination Campaigns. Cancer Epidemiol Biomarkers Prev 2019; 29:22-30. [DOI: 10.1158/1055-9965.epi-19-0767] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 09/13/2019] [Accepted: 10/23/2019] [Indexed: 11/16/2022] Open
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Mensah K, Heraud JM, Takahashi S, Winter AK, Metcalf CJE, Wesolowski A. Seasonal gaps in measles vaccination coverage in Madagascar. Vaccine 2019; 37:2511-2519. [PMID: 30940486 PMCID: PMC6466641 DOI: 10.1016/j.vaccine.2019.02.069] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 02/17/2019] [Accepted: 02/20/2019] [Indexed: 10/29/2022]
Abstract
INTRODUCTION Measles elimination depends on the successful deployment of measles containing vaccine. Vaccination programs often depend on a combination of routine and non-routine services, including supplementary immunization activities (SIAs) and vaccination weeks (VWs), that both aim to vaccinate all eligible children regardless of vaccination history or natural infection. Madagascar has used a combination of these activities to improve measles coverage. However, ongoing massive measles outbreak suggests that the country was in a "honeymoon" period and that coverage achieved needs to be re-evaluated. Although healthcare access is expected to vary seasonally in low resources settings, little evidence exists to quantify temporal fluctuations in routine vaccination, and interactions with other immunization activities. METHODS We used three data sources: national administrative data on measles vaccine delivery from 2013 to 2016, digitized vaccination cards from 49 health centers in 6 health districts, and a survey of health workers. Data were analyzed using linear regressions, analysis of variance, and t-tests. FINDINGS From 2013 to 2016, the footprint of SIAs and VWs is apparent, with more doses distributed during the relevant timeframes. Routine vaccination decreases in subsequent months, suggesting that additional activities may be interfering with routine services. The majority of missed vaccination opportunities occur during the rainy season. Health facility organization and shortage of vaccine contributed to vaccination gaps. Children born in June were the least likely to be vaccinated on time. DISCUSSION Evidence that routine vaccination coverage varies over the year and is diminished by other activities suggests that maintaining routine vaccination during SIAs and VWs is a key direction for strengthening immunization programs, ensuring population immunity and avoiding future outbreaks. FUNDING Wellcome Trust Fund, Burroughs Wellcome Fund, Gates Foundation, National Institutes of Health.
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Affiliation(s)
- K Mensah
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, USA.
| | - J M Heraud
- Virology Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar
| | - S Takahashi
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, USA
| | - A K Winter
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, USA
| | - C J E Metcalf
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, USA; Woodrow Wilson School of Public Affairs, Princeton University, Princeton, NJ, USA
| | - A Wesolowski
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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The impact of supplementary immunization activities on routine vaccination coverage: An instrumental variable analysis in five low-income countries. PLoS One 2019; 14:e0212049. [PMID: 30763389 PMCID: PMC6375584 DOI: 10.1371/journal.pone.0212049] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Accepted: 01/25/2019] [Indexed: 12/12/2022] Open
Abstract
Background Countries deliver vaccines either through routine health services or supplementary immunization activities (SIAs), usually community-based or door-to-door immunization campaigns. While SIAs have been successful at increasing coverage of vaccines in low- and middle-income countries, they may disrupt the delivery of routine health services. We examine the impact of SIAs on routine vaccine coverage in five low-income countries. Methods Data on the number and timing of SIAs conducted in various countries was compiled by WHO and obtained through UNICEF. Information on the coverage of vaccines not targeted by SIAs (e.g., DPT) was extracted from the Demographic and Health Surveys. We focus on SIAs that took place between 1996 and 2013 in Bangladesh, Senegal, Togo, Gambia, and Cote d’Ivoire, and examine outcomes for children aged 12–59 months. To avoid biases resulting from non-random placement and timing of SIAs, we use age of a child at her first SIA as an instrumental variable for total exposure to SIAs. Results We find that SIA exposure reduced the likelihood of receiving routine vaccines in all the countries included in the study; the coefficients of interest are however statistically insignificant for Gambia and Cote d’Ivoire. In countries that witnessed statistically significant SIA-induced declines in the likelihood of obtaining DPT 3, measles as well as BCG, reductions ranged from 1.3 percentage points (Senegal) to 5.5 percentage points (Bangladesh). Conclusion SIA exposure reduced routine vaccination rates in study countries. Efforts should be made to limit the detrimental impact of SIAs on the services provided by routine health systems.
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Factors influencing the performance of routine immunization in urban areas: A comparative case study of two cities in Cameroon: Douala and Yaoundé. Vaccine 2018; 36:7549-7555. [DOI: 10.1016/j.vaccine.2018.10.048] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 10/12/2018] [Accepted: 10/15/2018] [Indexed: 11/23/2022]
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Postolovska I, Helleringer S, Kruk ME, Verguet S. Impact of measles supplementary immunisation activities on utilisation of maternal and child health services in low-income and middle-income countries. BMJ Glob Health 2018; 3:e000466. [PMID: 29755760 PMCID: PMC5942424 DOI: 10.1136/bmjgh-2017-000466] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 12/21/2017] [Accepted: 03/11/2018] [Indexed: 11/25/2022] Open
Abstract
Background Measles supplementary immunisation activities (SIAs) are an integral component of measles elimination in low-income and middle-income countries (LMICs). Despite their success in increasing vaccination coverage, there are concerns about their negative consequences on routine services. Few studies have conducted quantitative assessments of SIA impact on utilisation of health services. Methods We analysed the impact of SIAs on utilisation of selected maternal and child health services using Demographic and Health Surveys and Multiple Indicator Cluster Surveys from 28 LMICs, where at least one SIA occurred over 2000–2014. Logistic regressions were conducted to investigate the association between SIAs and utilisation of the following services: facility delivery, postnatal care and outpatient sick child care (for fever, diarrhoea, cough). Results SIAs do not appear to significantly impact utilisation of maternal and child services. We find a reduction in care-seeking for treatment of child cough (OR 0.67; 95% CI 0.48 to 0.95); and a few significant effects at the country level, suggesting the need for further investigation of the idiosyncratic effects of SIAs in each country. Conclusion The paper contributes to the debate on vertical versus horizontal programmes to ensure universal access to vaccination. Measles SIAs do not seem to affect care-seeking for critical conditions.
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Affiliation(s)
- Iryna Postolovska
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Stéphane Helleringer
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Margaret E Kruk
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Stéphane Verguet
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Impact of measles supplementary immunization activities on reaching children missed by routine programs. Vaccine 2017; 36:170-178. [PMID: 29174680 DOI: 10.1016/j.vaccine.2017.10.080] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 09/25/2017] [Accepted: 10/26/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Measles supplementary immunization activities (SIAs) are vaccination campaigns that supplement routine vaccination programs with a recommended second dose opportunity to children of different ages regardless of their previous history of measles vaccination. They are conducted every 2-4 years and over a few weeks in many low- and middle-income countries. While SIAs have high vaccination coverage, it is unclear whether they reach the children who miss their routine measles vaccine dose. Determining who is reached by SIAs is vital to understanding their effectiveness, as well as measure progress towards measles control. METHODS We examined SIAs in low- and middle-income countries from 2000 to 2014 using data from the Demographic and Health Surveys. Conditional on a child's routine measles vaccination status, we examined whether children participated in the most recent measles SIA. RESULTS The average proportion of zero-dose children (no previous routine measles vaccination defined as no vaccination date before the SIA) reached by SIAs across 14 countries was 66%, ranging from 28% in São Tomé and Príncipe to 91% in Nigeria. However, when also including all children with routine measles vaccination data, this proportion decreased to 12% and to 58% when imputing data for children with vaccination reported by the mother and vaccination marks on the vaccination card across countries. Overall, the proportions of zero-dose children reached by SIAs declined with increasing household wealth. CONCLUSIONS Some countries appeared to reach a higher proportion of zero-dose children using SIAs than others, with proportions reached varying according to the definition of measles vaccination (e.g., vaccination dates on the vaccination card, vaccination marks on the vaccination card, and/or self-reported data). This suggests that some countries could improve their targeting of SIAs to children who miss other measles vaccine opportunities. Across all countries, SIAs played an important role in reaching children from poor households.
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Wallace AS, Bohara R, Stewart S, Subedi G, Anand A, Burnett E, Giri J, Shrestha J, Gurau S, Dixit S, Rajbhandari R, Schluter WW. Impact of an Intervention to Use a Measles, Rubella, and Polio Mass Vaccination Campaign to Strengthen Routine Immunization Services in Nepal. J Infect Dis 2017; 216:S280-S286. [PMID: 28838201 PMCID: PMC5771484 DOI: 10.1093/infdis/jix164] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background The potential to strengthen routine immunization (RI) services through supplementary immunization activities (SIAs) is an important benefit of global measles and rubella elimination and polio eradication strategies. However, little evidence exists on how best to use SIAs to strengthen RI. As part the 2012 Nepal measles-rubella and polio SIA, we developed an intervention package designed to improve RI processes and evaluated its effect on specific RI process measures. Methods The intervention package was incorporated into existing SIA activities and materials to improve healthcare providers' RI knowledge and practices throughout Nepal. In 1 region (Central Region) we surveyed the same 100 randomly selected health facilities before and after the SIA and evaluated the following RI process measures: vaccine safety, RI planning, RI service delivery, vaccine supply chain, and RI data recording practices. Data collection included observations of vaccination sessions, interviews with the primary healthcare provider who administered vaccines at each facility, and administrative record reviews. Pair-matched analytical methods were used to determine whether statistically significant changes in the selected RI process measures occurred over time. Results After the SIA, significant positive changes were measured in healthcare provider knowledge of adverse events following immunization (11% increase), availability of RI microplans (+17%) and maps (+12%), and awareness of how long a reconstituted measles vial can be used before it must be discarded (+14%). For the SIA, 42% of providers created an SIA high-risk villages list, and >50% incorporated this information into RI outreach session site planning. Significant negative changes occurred in correct knowledge of measles vaccination contraindications (-11%), correct definition for a measles outbreak (-21%), and how to treat a child with a severe adverse event following immunization (-10%). Twenty percent of providers reported cancelling ≥1 RI sessions during the SIA. Many RI process measures were at high proportions (>90%) before the SIA and remained high afterward, including proper vaccine administration techniques, proper vaccine waste management, and availability of vaccine carriers and vaccine registers. Conclusions Focusing on activities that are easily linked between SIAs and RI services, such as using SIA high-risk village list to strengthen RI microplanning and examining ways to minimize the impact of an SIA on RI session scheduling, should be prioritized when implementing SIAs.
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Affiliation(s)
- Aaron S Wallace
- Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Steven Stewart
- Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Abhijeet Anand
- Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eleanor Burnett
- Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | | | - Sameer Dixit
- Center for Molecular Development Network, Kathamandu, Nepal
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van den Ent MMVX, Mallya A, Sandhu H, Anya BP, Yusuf N, Ntakibirora M, Hasman A, Fahmy K, Agbor J, Corkum M, Sumaili K, Siddique AR, Bammeke J, Braka F, Andriamihantanirina R, Ziao AMC, Djumo C, Yapi MD, Sosler S, Eggers R. Experiences and Lessons From Polio Eradication Applied to Immunization in 10 Focus Countries of the Polio Endgame Strategic Plan. J Infect Dis 2017; 216:S250-S259. [PMID: 28838187 PMCID: PMC5853381 DOI: 10.1093/infdis/jix047] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Nine polio areas of expertise were applied to broader immunization and mother, newborn and child health goals in ten focus countries of the Polio Eradication Endgame Strategic Plan: policy & strategy development, planning, management and oversight (accountability framework), implementation & service delivery, monitoring, communications & community engagement, disease surveillance & data analysis, technical quality & capacity building, and partnerships. Although coverage improvements depend on multiple factors and increased coverage cannot be attributed to the use of polio assets alone, 6 out of the 10 focus countries improved coverage in three doses of diphtheria tetanus pertussis containing vaccine between 2013 and 2015. Government leadership, evidence-based programming, country-driven comprehensive operational annual plans, community partnership and strong accountability systems are critical for all programs and polio eradication has illustrated these can be leveraged to increase immunization coverage and equity and enhance global health security in the focus countries.
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Affiliation(s)
| | - Apoorva Mallya
- Polio Team, Bill and Melinda Gates Foundation, Seattle, Washington
| | | | | | - Nasir Yusuf
- UNICEF East and Southern Africa Regional Office, Nairobi, Kenya
| | | | | | - Kamal Fahmy
- WHO Eastern Mediterranean Regional Office, Cairo, Egypt
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