Polio Outbreak Investigation and Response in The Horn of Africa: 2013-2016

Background

There has been civil strife, spanning more than two decades in some countries and recurrent natural disasters in the Horn of Africa (HoA). This has consistently maintained these countries in chronic humanitarian conditions. More important however is the fact that these crises have also denied populations of these countries access to access to lifesaving health services. Children in the difficult terrains and security compromised areas are not given the required immunization services to build their immunity against infectious diseases like the poliovirus. This was the situation in 2013 when the large outbreaks of poliovirus occurred in the HoA. This article reviews the epidemiology, risk, and programme response to what is now famed as the 2013-204 poliovirus outbreaks in the HoA and highlights the challenges that the programme faced in interrupting poliovirus transmission here.

Methods

A case of acute flaccid paralysis (AFP) was defined as a child <15 years of age with sudden onset of fever and paralysis. Polio cases were defined as AFP cases with stool specimens positive for WPV.

Results

Between 2013 and 2016, when transmission was interrupted 20,266 polio viruses were in the Horn of Africa region. In response to the outbreak, several supplementary immunization activities were conducted with oral polio vaccine (OPV) The trivalent OPV was used initially, followed subsequently by bivalent OPV, and targeting various age groups, including children aged <5 years, children aged <10 years, and individuals of any age. Other response activities were undertaken to supplement the immunization in controlling the outbreak. Some of these activities included the use of various communication strategies to create awareness, sensitize and mobilize the populations against poliovirus transmission.

Conclusions

The outbreaks were attributed to the existence of clusters of unvaccinated children due to inaccessibility to them by the health system, caused by poor geographical terrain and conflicts. The key lesson therefore is that the existence of populations with low immunity to infections will necessary constitutes breeding grounds for disease outbreak and of course reservoirs to the vectors. Though brought under reasonable control, the outbreaks indicate that the threat of large polio outbreaks resulting from poliovirus importation will remain constant unless polio transmission is interrupted in the remaining polio-endemic countries of the world.

Mortality and Disability-Adjusted Life-Years (Dalys) for Common Neglected Tropical Diseases in Ethiopia, 1990-2015: Evidence from the Global Burden of Disease Study 2015

INTRODUCTION

Neglected tropical diseases (NTDs) are important public health problems in Ethiopia. In 2013, the Federal Ministry of Health (FMOH) has launched a national NTD master plan to eliminate major NTDs of public health importance by 2020. Benchmarking the current status of NTDs in the country is important to monitor and evaluate the progress in the implementation of interventions and their impacts. Therefore, this study aims to assess the trends of mortality and Disability-adjusted Life-Years (DALY) for the priority NTDs over the last 25 years.

METHODS

We used the Global Burden of Disease (GBD) 2015 estimates for this study. The GBD 2015 data source for cause of death and DALY estimation included verbal autopsy (VA), Demographic and Health Surveys (DHS), and other disease specific surveys, Ministry of Health reports submitted to United Nations (UN) agencies and published scientific articles. Cause of Death Ensemble modeling (CODEm) and/or natural history models were used to estimate NTDs mortality rates. DALY were estimated as the sum of Years of Life Lost (YLL) due to premature mortality and Years Lived with Disability (YLD).

RESULTS

All NTDs caused an estimated of 6,293 deaths (95% uncertainty interval (UI): 3699-10,080) in 1990 and 3,593 deaths (95% UI: 2051 - 6178) in 2015, a 43% reduction over the 25 years. Age-standardized mortality rates due to schistosomiasis, STH and leshmaniasis have declined by 91.3%, 73.5% and 21.6% respectively between 1990 to 2015. The number of DALYs due to all NTDs has declined from 814.4 thousand (95% UI: 548 thousand-1.2million) in 1990 to 579.5 thousand (95%UI: 309.4 thousand-1.3 million) in 2015. Age-standardized DALY rates due to all NTDs declined by 30.7%, from 17.6 per 1000(95%UI: 12.5-26.5) in 1990 to 12.2 per 1000(95%UI: 6.5 - 27.4) in 2015. Age-standardized DALY rate for trachoma declined from 92.7 per 100,000(95% UI: 63.2 - 128.4) in 1990 to 41.2 per 100,000(95%UI: 27.4-59.2) in 2015, a 55.6% reduction between 1990 and 2015. Age-standardized DALY rates for onchocerciasis, schistosomiasis and lymphiaticfilariasis decreased by 66.2%, 29.4% and 12.5% respectively between 1990 and 2015. DALY rate for ascariasis fell by 56.8% over the past 25 years.

CONCLUSIONS

Ethiopia has made a remarkable progress in reducing the DALY rates for most of the NTDs over the last 25 years. The rapid scale of interventions and broader system strengthening may have a lasting impact on achieving the 2020 goal of elimination of most of NTDs. Ethiopia should strengthen the coverage of integrated interventions of NTD through proper coordination with other health programs and sectors and community participation to eliminate NTDs by 2020.

Contribution of Contact Sampling in Increasing Sensitivity of Poliovirus Detection During A Polio Outbreak—Somalia, 2013

Background.  In May 2013, a wild poliovirus type 1 (WPV1) outbreak reported in Somalia provided an opportunity to examine the contribution of testing contacts to WPV detection.

Methods.  We reviewed acute flaccid paralysis (AFP) case-patients and linked contacts reported in the Somalia Surveillance Database from May 9 to December 31, 2013. We restricted our analysis to AFP case-patients that had ≥3 contacts and calculated the contribution of each contact to case detection.

Results.  Among 546 AFP cases identified, 328 AFP cases had ≥3 contacts. Among the 328 AFP cases with ≥3 contacts, 93 WPV1 cases were detected: 58 cases (62%; 95% confidence interval [CI], 52%–72%) were detected through testing stool specimens from AFP case-patients; and 35 cases (38%; 95% CI, 28%–48%) were detected through testing stool specimens from contacts, including 19 cases (20%; 95% CI, 14%–30%) from the first contact, 11 cases (12%; 95% CI, 7%–20%) from the second contact, and 5 cases (5%; 95% CI, 2%–12%) from the third contact. Among the 103 AFP cases with ≥4 contacts, 3 (6%; 95% CI, 2%–16%) of 52 WPV1 cases were detected by testing the fourth contact. No additional WPV1 cases were detected by testing &gt;4 contacts.

Conclusions.  Stool specimens from 3 to 4 contacts of persons with AFP during polio outbreaks are needed to maximize detection of WPV cases.

Adherence to anti-tuberculosis treatment in Tigray, Northern Ethiopia

SETTING

Tuberculosis (TB) patients in Mekelle Zone, Tigray Region, in Ethiopia.

OBJECTIVE

To investigate adherence to anti-tuberculosis treatment.

DESIGN

A cross-sectional study in health facilities providing anti-tuberculosis treatment was conducted. Adherence was measured in three ways: through self-reported missed doses, by visual analogue scale whereby patients rate their own adherence and by record review. A patient was considered to be adherent if 90% or more of the prescribed medication was taken.

RESULT

Of 278 TB patients included, 101 were in the intensive and 177 in the continuation phase. Respectively 67 (24.1%), 130 (46.8%) and 80 (28.8%) patients had smear-positive, smear-negative and extra-pulmonary TB. Self-report of missed doses and record review indicated adherence of respectively 273 (97.3%) and 271 (97.5%) patients. By visual analogue scale, 250 (91.6%) patients rated themselves as adherent. History of drug side effects (aOR 0.25, 95%CI 0.08-0.77) and knowledge about TB prevention (aOR 0.19, 95%CI 0.05-0.8) were independently associated with being adherent in this setting.

CONCLUSION

Adherence to anti-tuberculosis treatment was high in our study. Adherence support should be given to the poor, the elderly, patients co-infected with the human immunodeficiency virus, alcohol abusers and smokers. Health education on TB prevention should be given to all TB patients regularly.

Immunizing nomadic children and livestock--Experience in North East Zone of Somalia

Nomads and pastoralists represent around 30% of the population of North East zone of Somalia (Puntland) and have very limited access to basic health including immunization. During the 2013-2014 polio outbreak in Somalia, an increase number of polio cases notified health services among these underserved communities highlighted the urgent need to devise innovative strategies to reach them. Harnessing the high demand for veterinary services among pastoralist communities, the Ministry of Health and the Ministry of Livestock, with support from UNICEF, WHO and FAO launched an integrated human and animal vaccination campaign on 19 October 2014. Over 30 days, 20 social mobilizers conducted shelter to shelter social mobilization and interpersonal communication for nomadic/pastoralist hamlets, 20 human vaccination teams, accompanied by local community elders, traveled with animal vaccination teams to administer polio and measles vaccination to pastoralist communities in the 5 regions of Puntland. 26,393 children (0 to 10 years) received Oral Polio Vaccine (OPV) out of which 34% for the first time ever; 23,099 were vaccinated against measles. and 12,556 Vitamin A. Despite various operational challenges and a significantly higher operational cost of $6.2 per child reached with OPV, the integrated human and animal vaccination campaign was effective in reaching the unvaccinated children from nomadic and pastoralist communities of Somalia.

Progress toward polio eradication--Somalia, 1998-2013

Since the 1988 resolution of the World Health Assembly to eradicate polio, significant progress has been made toward achieving this goal, with the result that only Afghanistan, Nigeria, and Pakistan have never successfully interrupted endemic transmission of wild poliovirus. However, one of the greatest challenges of the Global Polio Eradication Initiative has been that of maintaining the polio-free status of countries in unstable regions with weak healthcare infrastructure, a challenge exemplified by Somalia, a country in the Horn of Africa region. Somalia interrupted indigenous transmission of wild poliovirus in 2002, 4 years after the country established its national polio eradication program. But political instability and protracted armed conflict, with significant disruption of the healthcare system, have left Somalia vulnerable to 2 imported outbreaks of wild poliovirus. The first occurred during 2005-2007, resulting in >200 cases of paralytic polio, whereas the second, which began in 2013, is currently ongoing. Despite immense challenges, the country has a sensitive surveillance system that has facilitated prompt detection of outbreaks, but its weak routine immunization system means that supplementary immunization activities constitute the primary strategy for reaching children with polio vaccines. Conducting vaccination campaigns in a setting of conflict has been at times hazardous, but the country's polio program has demonstrated resilience in overcoming many obstacles to ensure that children receive lifesaving polio vaccines. Regaining and maintaining Somalia's polio-free status will depend on finding innovative and lasting solutions to the challenge of administering vaccines in a setting of ongoing conflict and instability.

Effectiveness of oral polio vaccination against paralytic poliomyelitis: a matched case-control study in Somalia

BACKGROUND

After the last case of type 1 wild poliovirus (WPV1) was reported in 2007, Somalia experienced another outbreak of WPV1 (189 cases) in 2013.

METHODS

We conducted a retrospective, matched case-control study to evaluate the vaccine effectiveness (VE) of oral polio vaccine (OPV). We retrieved information from the Somalia Surveillance Database. A case was defined as any case of acute flaccid paralysis (AFP) with virological confirmation of WPV1. We selected two groups of controls for each case: non-polio AFP cases ("NPAFP controls") matched to WPV1 cases by age, date of onset of paralysis and region; and asymptomatic "neighborhood controls," matched by age. Using conditional logistic regression, we estimated the VE of OPV as (1-odds ratio)×100.

RESULT

We matched 99 WPV cases with 99 NPAFP controls and 134 WPV1 cases with 268 neighborhood controls. Using NPAFP controls, the overall VE was 70% (95% confidence interval [CI], 37-86), 59% (2-83) among 1-3 dose recipients, 77% (95% CI, 46-91) among ≥4 dose recipients. In neighborhood controls, the overall VE was 95% (95% CI, 84-98), 92% (72-98) among 1-3 dose recipients, and 97% (89-99) among ≥4 dose recipients. When the analysis was limited to cases and controls ≤24 months old, the overall VE in NPAFP and neighborhood controls was 95% (95% CI, 65-99) and 97% (95% CI, 76-100), respectively.

CONCLUSIONS

Among individuals who were fully vaccinated with OPV, vaccination was effective at preventing WPV1 in Somalia.

Polio outbreak investigation and response in Somalia, 2013

BACKGROUND

For >2 decades, conflicts and recurrent natural disasters have maintained Somalia in a chronic humanitarian crisis. For nearly 5 years, 1 million children <10 years have not had access to lifesaving health services, including vaccination, resulting in the accumulation by 2012 of the largest geographically concentrated cohort of unvaccinated children in the world. This article reviews the epidemiology, risk, and program response to what is now known as the 2013 wild poliovirus (WPV) outbreak in Somalia and highlights the challenges that the program will face in making Somalia free of polio once again.

METHODS

A case of acute flaccid paralysis (AFP) was defined as a child <15 years of age with sudden onset of fever and paralysis. Polio cases were defined as AFP cases with stool specimens positive for WPV.

RESULTS

From 9 May to 31 December 2013, 189 cases of WPV type 1 (WPV1) were reported from 46 districts of Somalia; 42% were from Banadir region (Mogadishu), 60% were males, and 93% were <5 years of age. All Somalian polio cases belonged to cluster N5A, which is known to have been circulating in northern Nigeria since 2011. In response to the outbreak, 8 supplementary immunization activities were conducted with oral polio vaccine (OPV; trivalent OPV was used initially, followed subsequently by bivalent OPV) targeting various age groups, including children aged <5 years, children aged <10 years, and individuals of any age.

CONCLUSIONS

The current polio outbreak erupted after a polio-free period of >6 years (the last case was reported in March 2007). Somalia interrupted indigenous WPV transmission in 2002, was removed from the list of polio-endemic countries a year later, and has since demonstrated its ability to control polio outbreaks resulting from importation. This outbreak reiterates that the threat of large polio outbreaks resulting from WPV importation will remain constant unless polio transmission is interrupted in the remaining polio-endemic countries.

Child malnutrition in Tigray, northern Ethiopia

OBJECTIVE

Estimate levels of and identify factors contributing to child malnutrition in Tigray, Northern Ethiopia.

DESIGN

Cross-sectional survey.

SETTING

Rural communities from four zones of Tigray.

SUBJECTS

Three hundred and eighteen under five children representing 587 randomly selected households were included.

RESULTS

Among the children surveyed, 46.9%, 33.0% and 11.6% were stunted,underweight and wasted, respectively. Older children were more likely to be undernourished. Stunting increases from 16% in the second half of the first year to 53% in children 24 months and older. Similarly, underweight increases from 10% in the first six months to 36.5% in children aged 24 months and older. A very high proportion of the mothers (80%) initiated feeding of newborns with pre-lacteal feeds primarily butter or water. Family foods and cereal-based porridge were the main complementary foods after six months. Child age, maternal anthropometric characteristics, inadequate complementary foods, the use of prelacteal feeds and area of residence were the main contributing factors to child undernutrition.

CONCLUSION

Undernutrition gets worse as the children grow older. The energy and nutrient density of the complementary foods are low as the foods were prepared from a limited number of local staple cereals without the addition of sugar, fat/oil or animal products. More importantly, these foods are diluted with water to reduce their viscosity. This makes the quality and quantity of the foods insufficient to prevent stunting and underweight. Promotion of traditional household technologies such as germination and fermentation may be affordable measures to improve the quality of the complementary foods. Thus, sustained nutrition education programmes focusing on appropriate complementary feeding practices are recommended.

Somalia: supporting the child survival agenda when routine health service is broken

Somalia, one of the most unstable countries in the world, has been without a permanent government for nearly 2 decades. With a health system in total disarray, coverage of basic health interventions remains low and, maternal and child mortality is among the highest in the world. Health partners jointly outlined an integrated package of critical child survival interventions to be delivered through a population-based delivery strategy known as Child Health Days (CHDs), to reduce child mortality. Using this strategy, key child survival interventions are delivered to the community with an objective of reaching children <5 years and women of childbearing age in all districts of Somalia every 6 months. Through this strategy, immunization services were reached in remote areas, and coverage disparity between the urban and rural areas was reduced from 17% (42% urban and 25% rural) to 10% (50% urban and 60% rural). In addition, infants were reached with a third dose of diphtheria-pertussis-tetanus vaccine, achieving 51% coverage during 2009 and 66% in 2010. This paper summarizes the challenges of scaling up child interventions in the troubled context of Somalia by reviewing the planning, implementation, and achievements of CHDs as well as reflecting on challenges for the future of child survival in Somalia.

Measles control and elimination in Somalia: the good, the bad, and the ugly

Despite enormous challenges, Somalia has been successfully implementing accelerated measles control activities since 2005. Through innovative strategies and with the support of local and international partners, the country has shown potentials of implementing measles mortality reduction activities in complex emergencies. Measles incidence has been reduced by >80% after the measles catch-up campaigns of 2005-2007, and national reported measles routine immunization coverage with first dose measles containing vaccine has reached 59% for the first time in 2009. However, the near collapse of the health care system and the ongoing insecurity continue to hamper the implementation of recommended measles control and elimination strategies in some parts of the country, making these achievements fragile. Somalia exemplifies the challenges in meeting measles elimination goals in the World Health Organization Eastern Mediterranean region. As the region is entering its 2010 measles elimination goals, it appears necessary to establish realistic and flexible interim goals for measles control in Somalia that will take into consideration the specificities of the country. Maintaining flexibility in conducting field operations, securing financial resources, multiplying opportunities for measles vaccination, and improving disease monitoring systems will remain vital to sustain and improve current achievements.

Embryonal rhabdomyosarcoma of the orbit in a 38-year-old woman

Primary embryonal rhabdomyosarcoma of the orbit is an extremely rare tumor in adults. A 38 year old female patient with immunohistochemically proved embryonal rhabdomyosarcoma of the right orbit is reported. The histologic types, diagnosis, management and out come of rhabdomyosarcoma is discussed.

Giant molluscum contagiosum presenting as a tumour in an HIV-infected patient: case report

Molluscum contagiosum (MC) has been reported commonly in immunocompromised patients. Below is described a case of atypical molluscum contagiosum of a patient who was seropositive for HIV. Possible differential diagnosis and management are discussed. Biopsy is suggested to distinguish between confusing molluscum lesions and their cutaneous simulants.