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      Implementing nationwide measles supplemental immunization activities in Ethiopia in the context of COVID-19: process and lessons learnt

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          Abstract

          The COVID-19 pandemic has disrupted immunization activities in many countries, causing declines in the delivery of routine doses of antigens, and the postponement of scheduled supplemental immunization activities (SIAs). Following the declaration of the pandemic, Ethiopia postponed nationwide follow-up measles preventive vaccination campaign which was scheduled for April 2020. The disruptions to routine services and the postponement of the SIAs increased the risk for measles outbreaks. The national authorities, in consultation with the secretariat of the National COVID-19 Pandemic Prevention and Control Ministerial Coordination Committee, subnational level authorities, technical partner agencies and stakeholders, reviewed the risks for measles outbreaks and decided to implement the nationwide measles SIAs, with strict implementation of COVID prevention measures. The revised micro-plans accommodated the additional human resource and logistics needs for COVID prevention, for which partner resources were mobilized to fill the gaps. The key SIAs preparatory and implementation activities including training, logistics, social mobilization, service delivery and supervision were modified to take into consideration the COVID context. Infection prevention and control supplies were procured and distributed as a package with the bundled vaccines and other supplies. The SIAs were completed in July 2020 and reached 102.8% administrative coverage nationwide, with 78% of the 1123 woredas attaining the target of 95% coverage. The strong commitment of the leadership, the coordination role of the national and regional COVID prevention and control taskforces, the engagement of community leaders, the use of multi-channel communication, the timely availability of additional resources and modification of the service delivery approaches contributed to the success of the SIAs.

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          Routine childhood immunisation during the COVID-19 pandemic in Africa: a benefit–risk analysis of health benefits versus excess risk of SARS-CoV-2 infection

          Summary Background National immunisation programmes globally are at risk of suspension due to the severe health system constraints and physical distancing measures in place to mitigate the ongoing COVID-19 pandemic. We aimed to compare the health benefits of sustaining routine childhood immunisation in Africa with the risk of acquiring severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection through visiting routine vaccination service delivery points. Methods We considered a high-impact scenario and a low-impact scenario to approximate the child deaths that could be caused by immunisation coverage reductions during COVID-19 outbreaks. In the high-impact scenario, we used previously reported country-specific child mortality impact estimates of childhood immunisation for diphtheria, tetanus, pertussis, hepatitis B, Haemophilus influenzae type b, Streptococcus pneumoniae, rotavirus, measles, meningitis A, rubella, and yellow fever to approximate the future deaths averted before 5 years of age by routine childhood vaccination during a 6-month COVID-19 risk period without catch-up campaigns. In the low-impact scenario, we approximated the health benefits of sustaining routine childhood immunisation on only the child deaths averted from measles outbreaks during the COVID-19 risk period. We assumed that contact-reducing interventions flattened the outbreak curve during the COVID-19 risk period, that 60% of the population will have been infected by the end of that period, that children can be infected by either vaccinators or during transport, and that upon child infection the whole household will be infected. Country-specific household age structure estimates and age-dependent infection-fatality rates were applied to calculate the number of deaths attributable to the vaccination clinic visits. We present benefit–risk ratios for routine childhood immunisation, with 95% uncertainty intervals (UIs) from a probabilistic sensitivity analysis. Findings In the high-impact scenario, for every one excess COVID-19 death attributable to SARS-CoV-2 infections acquired during routine vaccination clinic visits, 84 (95% UI 14–267) deaths in children could be prevented by sustaining routine childhood immunisation in Africa. The benefit–risk ratio for the vaccinated children is 85 000 (4900–546 000), for their siblings ( 60 years) is 96 (14–307). In the low-impact scenario that approximates the health benefits to only the child deaths averted from measles outbreaks, the benefit–risk ratio to the households of vaccinated children is 3 (0–10); if the risk to only the vaccinated children is considered, the benefit–risk ratio is 3000 (182–21 000). Interpretation The deaths prevented by sustaining routine childhood immunisation in Africa outweigh the excess risk of COVID-19 deaths associated with vaccination clinic visits, especially for the vaccinated children. Routine childhood immunisation should be sustained in Africa as much as possible, while considering other factors such as logistical constraints, staff shortages, and reallocation of resources during the COVID-19 pandemic. Funding Gavi, the Vaccine Alliance; Bill & Melinda Gates Foundation.
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            Progress Toward Regional Measles Elimination — Worldwide, 2000–2018

            In 2010, the World Health Assembly (WHA) set the following three milestones for measles control to be achieved by 2015: 1) increase routine coverage with the first dose of measles-containing vaccine (MCV1) among children aged 1 year to ≥90% at the national level and to ≥80% in every district, 2) reduce global annual measles incidence to less than five cases per 1 million population, and 3) reduce global measles mortality by 95% from the 2000 estimate* ( 1 ). In 2012, WHA endorsed the Global Vaccine Action Plan, † with the objective of eliminating measles § in five of the six World Health Organization (WHO) regions by 2020. This report updates a previous report ( 2 ) and describes progress toward WHA milestones and regional measles elimination during 2000–2018. During 2000–2018, estimated MCV1 coverage increased globally from 72% to 86%; annual reported measles incidence decreased 66%, from 145 to 49 cases per 1 million population; and annual estimated measles deaths decreased 73%, from 535,600 to 142,300. During 2000–2018, measles vaccination averted an estimated 23.2 million deaths. However, the number of measles cases in 2018 increased 167% globally compared with 2016, and estimated global measles mortality has increased since 2017. To continue progress toward the regional measles elimination targets, resource commitments are needed to strengthen routine immunization systems, close historical immunity gaps, and improve surveillance. To achieve measles elimination, all communities and countries need coordinated efforts aiming to reach ≥95% coverage with 2 doses of measles vaccine ( 3 ). Immunization Activities WHO and the United Nations Children’s Fund (UNICEF) use data from administrative records and vaccination coverage surveys reported annually to estimate MCV1 and second dose (MCV2) coverage through routine immunization services. ¶ During 2000–2018, estimated MCV1 coverage increased globally from 72% to 86% (Table), although coverage has remained at 84%–86% since 2010, with considerable regional variation. Since 2016, MCV1 coverage has remained relatively constant in the African Region (AFR) (74%–75%), the Eastern Mediterranean Region (EMR) (82%–83%), and the South-East Asia Region (SEAR) (88%–89%); and it has remained constant since 2008 in the European Region (EUR) (93%–95%) and in the Western Pacific Region (WPR) (95%–97%). Estimated MCV1 coverage in the Region of the Americas (AMR) decreased from 92% in 2016 to 88% in 2017 and increased to 90% in 2018. TABLE Estimates of coverage with the first and second doses of measles-containing vaccine administered through routine immunization services, reported measles cases and incidence, and estimated measles cases and deaths,* by World Health Organization (WHO) region — worldwide, 2000 and 2018 WHO region/ Year (no. of countries in region) % MCV1† coverage % countries with ≥90% MCV1 coverage % MCV2† coverage % of reporting countries with 600 per million and accounted for 45% (157,239 cases) of all reported cases worldwide. The percentage of reporting countries with annual measles incidence of 100 importations in 2018 as a consequence of inadequate vaccination coverage, endemic measles virus transmission has been reestablished in the United Kingdom. Countries such as Cambodia, which, through sustained efforts, identified and closed immunity gaps to achieve elimination, but which border countries with ongoing endemic transmission, must remain vigilant to identify and stop measles outbreaks rapidly. Before international travel, travelers from all countries should ensure they have been appropriately vaccinated against measles. Progress toward measles elimination will regress without a unified effort by all communities and countries. Evaluations of routine immunization programs to identify barriers to vaccination indicate that children miss MCV1 and MCV2 doses for many reasons, including families’ limited awareness of the need for vaccination, limited access to or financial barriers to receiving vaccination; vaccine stock-outs; political instability; and vaccine hesitancy and misinformation. WHO’s Global Routine Immunization Strategies and Practices and The Guide to Tailoring Immunization Programmes provides guidance on identifying demand and supply barriers to routine vaccination and strengthening immunization programs ( 8 , 9 ). Outbreaks should serve as opportunities to investigate underlying causes of undervaccination and to design specific routine immunization strengthening activities to prevent future outbreaks. In addition, population immunity gaps should be identified through triangulation of data, including surveillance and vaccination coverage data, and should be targeted by vaccination activities. The findings in this report are subject to at least two limitations. First, large differences between estimated and reported incidence indicate overall low surveillance sensitivity, making comparisons between regions difficult to interpret. Second, the measles mortality model estimates might be affected by biases in model inputs, including vaccination coverage and surveillance data. The trends of increasing measles incidence and mortality are reversible; however, further progress toward achieving elimination goals will require 1) resource commitments to strengthen routine immunization systems, close historical immunity gaps, and improve surveillance to rapidly detect and respond to cases, and 2) a new perspective to use measles as a stimulus and guide to improving immunization programs. To achieve measles elimination, all communities and countries need coordinated efforts aiming to reach ≥95% coverage with 2 doses of measles vaccine. As the period covered by the Global Vaccine Action Plan 2012–2020 approaches its end, a new vision and strategy for accelerated progress on immunization for 2021–2030 is being developed by countries and stakeholders ( 10 ). Pillars of this evolving strategy include commitment and demand, research and innovation, life course and integration, and supply and sustainability; all of these are vital to achieving and maintaining measles elimination. This new agenda should be used to secure the necessary resource commitments to improve coverage and equity substantially and, in so doing, further progress toward achieving the measles elimination goals. Summary What is already known about this topic? In 2012, the World Health Assembly endorsed the Global Vaccine Action Plan; countries in all six World Health Organization regions have adopted goals to eliminate measles by 2020. What is added by this report? During 2000–2018, annual reported measles incidence decreased 66%, and annual estimated measles deaths decreased 73%. Since 2000, measles vaccination has prevented an estimated 23.2 million deaths globally. However, measles incidence increased in five regions during 2016–2018. What are the implications for public health practice? To achieve regional measles elimination goals, resource commitments are needed to strengthen routine immunization systems, close immunity gaps, and improve case-based surveillance.
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              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.
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                Author and article information

                Journal
                Pan Afr Med J
                Pan Afr Med J
                PAMJ
                The Pan African Medical Journal
                The African Field Epidemiology Network
                1937-8688
                16 November 2020
                2020
                : 37
                : Suppl 1
                : 36
                Affiliations
                [1 ]Federal Ministry of Health, Addis Ababa, Ethiopia,
                [2 ]United Nations Children's Fund (UNICEF), Addis Ababa, Ethiopia,
                [3 ]World Health Organization, Addis Ababa, Ethiopia
                [4 ]World Health Organization, Regional Office for Africa, Brazzaville, Congo
                Author notes
                Corresponding author: Balcha Masresha, World Health Organization, Regional Office for Africa, Brazzaville, Congo. masreshab@ 123456who.int
                Article
                PAMJ-SUPP-37-1-36
                10.11604/pamj.supp.2020.37.36.26614
                7796832
                33456660
                abbe63bb-63ad-45af-8565-6faa6e647c0c
                Copyright: Mulat Nigus et al.

                The Pan African Medical Journal (ISSN: 1937-8688). This is an Open Access article distributed under the terms of the Creative Commons Attribution International 4.0 License ( https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 21 October 2020
                : 13 November 2020
                Categories
                Project Evaluation

                Medicine
                measles,immunization,covid-19,vaccination,ethiopia,africa,supplemental immunization activity
                Medicine
                measles, immunization, covid-19, vaccination, ethiopia, africa, supplemental immunization activity

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