Impact of periodic intensification of routine immunization within an armed conflict setting and COVID-19 outbreak in Cameroon in 2020

Overcoming challenges and achieving high HPV vaccination uptake in Cameroon: lessons learned from a gender-neutral and single-dose program and community engagement

INTRODUCTION

Human papillomavirus (HPV) is sexually transmissible and affects almost all sexually active people. The virus infects females and males, causing genital warts, cervical cancer, and oropharyngeal cancers in some. The disease burden is highest in resource-constrained countries, and it is a leading cause of cancer-related mortality in Cameroon. HPV infection is preventable by vaccination. Despite the merits of HPV vaccination, improving coverage has remained difficult in Cameroon. This paper highlights the challenges, lessons learned, and progress in HPV vaccination as part of Cameroon's gender-neutral-single-dose approach and the periodic intensification of routine immunization (PIRI).

METHODS

This ecological cross-sectional study, conducted from July to December 2023, examines the introduction of the HPV vaccine in Cameroon, along with associated challenges, strategies, and progress. Vaccination data from 2020 to 2023 were retrieved from Cameroon's District Health Information Software (DHIS2), while information on the vaccine introduction process and challenges was sourced from Expanded Programme on Immunisation (EPI) reports. Data analysis was performed using Python. The Shapiro-Wilk test assessed normality, and segmented regression analysis within an interrupted time series framework was applied to evaluate the contribution of each intervention to HPV vaccination uptake among girls. Statistical significance was set at a 95% confidence interval (CI) with a p-value < 0.05. Microsoft Excel 365 was used for calculating vaccination coverage proportions and visualizing results through figures and tables.

RESULTS

Cameroon introduced the HPV vaccine to nine-year-old girls in October 2020 amidst negative rumours. The first dose coverage stayed around 20% for three years. Following the National Immunization Technical Advisory Group recommendation, the Ministry of Health intensified communication and community engagement, switched to a single-dose vaccination for nine-year-old boys and girls in January 2023, and PIRI in households and schools in March 2023. All regions improved, with four (Adamawa, East, Far North, and North) having coverages for girls over 90% and around 40% for boys. National-level vaccination coverage for girls improved three-fold, and boys recorded 26%. Interrupted time series highlighted an immediate improvement in girls' vaccination following PIRI in 70% of regions and nationally. In contrast gender-neutral-single-dose vaccination led to immediate improvement in coverage in 30% of regions (Far North, South, South West) and at the national level, while intensified communication lacked significant contribution.

CONCLUSION

HPV vaccination in Cameroon has faced significant challenges. However, interventions such as adopting a gender-neutral, single-dose policy and implementing PIRI have greatly improved coverage across various levels of the health system since 2023.

COVID- 19 vaccine uptake and its determinants in Cameroon: a systematic review and meta-analysis (2021-2024)

BACKGROUND

COVID-19 vaccination is crucial for mitigating the pandemic's impact. However, vaccine hesitancy and access challenges have hindered global vaccination efforts. This meta-analysis aimed to estimate the pooled COVID-19 vaccine uptake proportion and identify associated determinants in Cameroon.

METHODS

This review, conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, identified articles through searches of electronic databases, including PubMed, ScienceDirect, and Google Scholar, as well as through gray literature. The search encompassed published and unpublished studies from 2021 to 2024 reporting on COVID-19 vaccine uptake and/or acceptance in Cameroon. Extracted data were compiled in a Microsoft Excel spreadsheet and analyzed using R statistical software (version 4.4.2). A random-effects model was employed when heterogeneity exceeded 50%. Publication bias was assessed using funnel plots, Egger's and Begg's tests. Meta-regression was used to explore the influence of study characteristics.

RESULTS

Twenty-two studies, encompassing 24,130 participants, were included. The pooled vaccine uptake proportion was 37.14% (95% CI: 29.24-45.05) with substantial heterogeneity (I2 = 98.2%, p < 0.001). Subgroup analyses revealed lower uptake among the general population (23.18%; 95% CI: 10.11-36.25) and in community settings (16.0%; 95% CI: 0.97-31.04) compared with healthcare workers (42.12%; 95% CI: 34.14-50.09). Younger age (OR = 0.53; 95% CI: 0.42-0.67) was inversely associated with vaccine uptake, while being in a partnership (OR = 1.59; 95% CI: 1.11-2.27) was positively associated. Higher levels of education (OR = 1.75; 95% CI: 1.56-1.97), urban residence (OR = 1.66; 95% CI: 1.21-2.29) were positively associated with vaccine acceptance.

CONCLUSION

This meta-analysis revealed a suboptimal pooled COVID-19 vaccine uptake required to ensure a herd immunity. The results of this meta-analysis underline the crucial need to step up efforts to improve vaccination coverage, particularly among the most vulnerable populations. Identifying and addressing the factors underlying this low coverage is imperative if public health objectives are to be met. Public health interventions should be tailored to address the specific concerns and needs of different age groups and marital statuses.

Navigating vaccine procurement and financing challenges in Cameroon: Insights and recommendations from a mixed-methods study (2015-2020)

OBJECTIVES

Vaccine stockouts at the national level has been recognized as a critical challenge in ensuring sustained and equitable immunization coverage. These stockouts often arise from inherent issues within countries, including delays in government funding, suboptimal forecasting and stock management practices, and inefficiencies in the procurement process amongst others. Understanding the complexities and barriers within vaccine procurement and financing systems is crucial for developing effective strategies to enhance vaccine availability and strengthen immunization programs. This is particularly relevant in the context of reaching zero dose children and transitioning from Gavi. This study aimed to comprehensively assess the vaccine procurement and financing landscape in Cameroon from 2015 to 2020.

STUDY DESIGN

This was a descriptive cross-sectional study.

METHODS

Employing a mixed-methods approach, we conducted a desk review of pertinent documents and engaged in in-depth interviews with key stakeholders involved in the procurement and funding mobilization processes. Through data collection and analysis using Microsoft Excel 365 and Dedoose software, we delineated the intricacies of the procurement process and pinpointed specific barriers that have contributed to vaccine stockouts.

RESULTS

The mapping of vaccine procurement processes revealed complexity, protracted timelines, and the involvement of multiple stakeholders. The Expanded Program on Immunization (EPI) faced a USD 4 million funding deficit for vaccine procurement between 2016 and 2019. Consequently, the program experienced delays in acquiring 20 million vaccine doses, leading to 41 months of stockout for at least one antigen. Major bottlenecks identified by key stakeholders in vaccine procurement and financing encompassed delayed fund mobilization, inefficient and lengthy processes for fund mobilization and disbursement, poor data utilization, and discrepancies between forecasted, allocated, and mobilized funds.

CONCLUSION

The findings of this research hold significant implications for many EPIs. By elucidating procurement and financing challenges, we can formulate evidence-based recommendations aimed at optimizing resource allocation, streamlining procurement processes, and bolstering vaccine availability. These insights are essential for fostering collaboration between government agencies, technical partners, and financial partners to achieve sustainable vaccine access in Cameroon. Establishing a joint procurement working group could streamline processes, potentially reducing stockouts and improving vaccine coverage.

Impact of Ebola and COVID-19 on maternal, neonatal, and child health care among populations affected by conflicts: a scoping review exploring demand and supply-side barriers and solutions

INTRODUCTION

Armed conflicts have a severe impact on the health of women and children. Global health emergencies such as pandemics and disease outbreaks further exacerbate the challenges faced by vulnerable populations in accessing maternal, neonatal, and child healthcare (MNCH). There is a lack of evidence that summarizes the challenges faced by conflict-affected pregnant women, mothers, and children in accessing MNCH services during global health emergencies, mainly the Ebola and COVID-19 pandemics. This scoping review aimed to analyze studies evaluating and addressing barriers to accessing comprehensive MNCH services during Ebola and COVID-19 emergencies in populations affected by conflict.

METHODS

The search was conducted on PubMed, Scopus, and Web of Science databases using terms related to Ebola and COVID-19, conflicts, and MNCH. Original studies published between 1990 and 2022 were retrieved. Articles addressing the challenges in accessing MNCH-related services during pandemics in conflict-affected settings were included. Thematic analysis was performed to categorize the findings and identify barriers and solutions.

RESULTS

Twenty-nine studies met the inclusion criteria. Challenges were identified in various MNCH domains, including antenatal care, intrapartum care, postnatal care, vaccination, family planning, and the management of childhood illnesses. Ebola-related supply-side challenges mainly concerned accessibility issues, health workforce constraints, and the adoption of stringent protocols. COVID-19 has resulted in barriers related to access to care, challenges pertaining to the health workforce, and new service adoption. On the demand-side, Ebola- and COVID-19-related risks and apprehensions were the leading barriers in accessing MNCH care. Community constraints on utilizing services during Ebola were caused by a lack of trust and awareness. Demand-side challenges of COVID-19 included fear of disease, language barriers, and communication difficulties. Strategies such as partnerships, strengthening of health systems, service innovation, and community-based initiatives have been employed to overcome these barriers.

CONCLUSION

Global health emergencies amplify the barriers to accessing MNCH services faced by conflict-affected populations. Cultural, linguistic, and supply-side factors are key challenges affecting various MNCH domains. Community-sensitive initiatives enhancing primary health care (PHC), mobile clinics, or outreach programs, and the integration of MNCH into PHC delivery should be implemented. Efforts should prioritize the well-being and empowerment of vulnerable populations. Addressing these barriers is crucial for achieving universal health coverage and the Sustainable Development Goals.

Factors associated with a measles outbreak in three health districts of Cameroon in 2019: a cross-sectional study

Introduction

measles is an infectious viral disease that affects susceptible individuals of all ages. It is a leading cause of death among young children globally due to suboptimal vaccination coverage. In 2019, measles outbreaks affected several parts of the world, including three health districts (HDs) of Cameroon's South West Region (SWR) experiencing armed conflict. Herein, we assessed the factors associated with the outbreak in the SWR.

Methods

we conducted a comparative study from March to August 2020. Data on study participants were compared between the three HDs that experienced a measles outbreak and three other HDs of the region that reported a case of measles but did not get into an outbreak. Records on vaccination between 2015 and 2019 were reviewed.

Results

information was obtained from 56 participants with known measles status, 32 from outbreak districts, and 24 from non-outbreak districts. The population in the outbreak group was more likely to have traveled from an area in a measles outbreak (OR 2, 95%CI 1.1-11.20). There was a suboptimal availability of measles vaccines in both categories of districts compared to the needs, and there was a downward trend in vaccination coverage in both groups. In addition, vaccines were more exposed to extreme temperatures in HDs with the outbreak (P<0.01) from 2015 to 2019. We found no statistically significant difference between both groups concerning the preexisting comorbidities of participants.

Conclusion

there is an urgent need to improve the cold chain and intensify vaccination activities in these districts.

Does armed conflict lead to lower prevalence of maternal health-seeking behaviours: theoretical and empirical research based on 55 683 women in armed conflict settings

BACKGROUND

Women and children bear a substantial burden of morbidity and mortality due to armed conflict. Life-saving maternal and child health (MCH) services are low-quality in most conflict-affected regions. Previous studies on armed conflict and MCH services have been mostly cross-sectional, and a causal relationship between armed conflict and MCH services utilisation cannot be inferred.

METHODS

First, we constructed a utility equation for maternal health-seeking behaviour. Next, we extracted MCH data from the Multiple Indicator Cluster Survey led by the UNICEF. Armed conflict data were obtained from the Uppsala Conflict Data Programme; 55 683 women aged 15-49 from Chad, the Central African Republic, the Democratic Republic of Congo (DRC) and the Republic of Iraq were selected as participants. We fitted a difference-in-differences (DID) model, taking before or after the conflict started as an exposure variable to estimate the effects of armed conflict on maternal health-seeking behaviours.

RESULTS

According to the results of the DID model, in the regional sample, armed conflict had a positive effect on tetanus vaccination (β=0.055, 95% CI 0.004 to 0.106, p<0.05), and had a negative effect on antenatal care at least eight visits (ANC8+) (β=-0.046, 95% CI -0.078 to -0.015, p<0.01). And, the effects of armed conflict on ANC, ANC4+, institutional delivery and early initiation of breast feeding (EIB) were not statistically significant. As for the country sample, we found that armed conflict had a negative effect on EIB (β=-0.085, 95% CI -0.184 to 0.015, p<0.1) in Chad. In Iraq, armed conflict had positive impacts on ANC (β=0.038, 95% CI -0.001 to 0.078, p<0.1) and tetanus vaccination (β=0.059, 95% CI 0.012 to 0.107, p<0.05), whereas it had a negative effect on ANC8+ (β=-0.039, 95% CI -0.080 to 0.002, p<0.1). No statistically significant associations were discovered in DRC based on the DID model.

CONCLUSIONS

There might be a mixed effect of armed conflict on maternal health-seeking behaviours. In the absence of humanitarian assistance, armed conflict reduces certain maternal health-seeking behaviours, such as ANC8+. When practical humanitarian health assistance is provided, the damage can be alleviated, and even the prevalence of maternal health-seeking behaviours can be improved, such as tetanus vaccination. Providing humanitarian assistance to conflict-affected regions improved the accessibility of MCH services for women living in those areas. However, the goals of saving lives and alleviating suffering still need to be achieved. In conflict-affected regions, humanitarian assistance on ANC, institutional delivery and breast feeding need strengthening.