Article

Assessment of the Quality of the Reverse Cold Chain Management in the Acute Flaccid Paralysis (AFP) Surveillance System for Polio Eradication; South-south Zone, Nigeria 2015

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Abstract

Background: The Global Polio Eradication Initiative (GPEI) uses the reverse cold chain system to measure the integrity and quality of stool specimen collected and transported to the laboratory. This paper aims to determine the quality of the reverse cold chain system during stool specimen collection and transportation to the polio laboratory. Methods: A cross-sectional survey was conducted between November-December 2015 using structured questionnaires uploaded on an open data kit-collect mobile software (ODK-collect) in 56 LGAs and 332 sites in Akwa Ibom, Bayelsa, Cross River, Delta, Edo and Rivers States. The information collected from all identified respondent covered knowledge on stool sample collection, packaging, storage and transportation. The data collected using the ODK-collect mobile software was submitted to WHO server in real-time. The EPIINFO software was used to run queries on the database and to obtain the specific data sets used in this study from the WHO server. Results: A total of 165 AFP cases were reported between November and December 2015. The mothers and the DSNOs collected 77% and 15% off the stool specimens respectively. Almost all cases (98.2%) had 2 stool specimens collected 24-48hours apart (98.1%) into dry, leak proof containers (98.2%). Between January-October 2015, 1955 AFP stool specimen were sent to the polio laboratory from the 6 states in the zone. Though 80.4% of the icepacks used were frozen, power shortages still affected the production of 55.3% of these icepacks. This was coupled with the long distances travelled by the DSNOs to their respective state capitals (WHO office) for travel clearance and specimen inspection. 63% of the stool specimens were placed in the Vehicle's trunk during transport to the laboratory. Conclusions: This study identifies gaps in the reverse cold chain system; we recommend that the gaps observed in this survey be addressed systematically. This would enhance the reverse cold-chain system and the AFP surveillance system by extension as we proceed towards polio-free certification.

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... [1,2] Nigeria, Afghanistan and Pakistan remain the only countries without a polio free certification. [3,4] Nigeria was readmitted to the list of polio endemic countries following the August 2016 incident where four WPV1 was discovered in Borno state. [1] Though no new cases of WPV have been reported, Nigeria continues to implement prompt response strategies to ensure that the August 2016 scenario does not repeat itself. ...
... For all AFP cases reported, adequate stool samples must be collected and transported to a World Health Organization (WHO) accredited laboratory via a reverse cold-chain transport system for polio enterovirus isolation. [11,12] Adequate stool sample collection occurs when two stool samples are collected 24 hours apart within 14 days of paralysis onset and arrive at the laboratory within 72 hours from when the first stool sample was collected [3,13] However, AFP surveillance network is skewed to health facilities in urban and semi urban areas while special population e.g. nomadic, hard-to-reach settlements are neglected resulting in under-reporting of AFP cases. ...
Article
A weak AFP surveillance system constitutes a major threat to Nigeria's polio free certification status. This study investigates the factors that have affected AFP surveillance, case detection along the international border settlements of Oyo state, Nigeria. A cross-sectional survey was conducted between 26 th-31 th December 2018 using structured questionnaires uploaded onto Open Data Kit-collect (ODK) mobile software in 4 LGAs in Oyo state. Overall, 427 respondents (community members=420, community informants=7) participated in this study. On the average, 10% and 46% of the community members and informants could identify the various aspects of the AFP case definition. Majority of the community members weren't aware of AFP surveillance neither were they aware of their AFP focal person/DSNO or where to report AFP cases. Barriers to case reporting include, irregular movements of commercial vehicles, swampy roads during rainy seasons, rocky roads during dry seasons; poor communication networks; and poor modes of transportation. The accessibility and difficulty of terrain along these international boarders has greatly hindered surveillance activities in their corresponding communities. If steps are taken to improve accessibility in such areas, we believe that AFP case detection and reporting would also improve.
... Regarding the specimens shipped frozen, preferably with dry ice or cold frozen cubes at a temperature of -20 °c, the percentage was 31/50 (62.0%).This study result percentage lower than other study done in south-south zone, Nigeria (Bassey, et al., 2016) which found45/56 (80.4%)specimens shipped and transport via the reverse cold-chain system. The characteristic of a good condition for specimen in transportation means there is ice or a temperature indicator (showing <8°c) in the cold boxthe percentage was 32/50 (64.0%). ...
... Conflicts appear to have little effect on the ability to detect AFP cases and meet standard indicators, with similar results reported in countries such as Pakistan, Afghanistan, and Nigeria [39,41,42] The program's ability to detect and report the presence or absence of poliovirus is contingent upon the laboratory's ability to isolate and identify enteroviruses from AFP samples. These are affected by the reverse cold chain, with a 10% NPEV isolation rate serving as a reference point [43]. The country met the criterion for this indicator, further establishing the credibility of the country's polio activities despite delays in stool transfer to WHO-accredited laboratories caused by erratic flight schedules and cancellations, particularly during the rainy season. ...
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Introduction: in 1988 the World Health Assembly set an ambitious target to eradicate Wild Polio Virus (WPV) by 2000, following the successful eradication of the smallpox virus in 1980. South Sudan and the entire African region were certified WPV free on August 25, 2020. South Sudan has maintained its WPV free status since 2010, and this paper reviewed the country's progress, outlined lessons learned, and describes the remaining challenges in polio eradication. Methods: secondary data analysis was conducted using the Ministry of Health and WHO polio surveillance datasets, routine immunisation coverage, polio campaign data, and surveys from 2010 to 2020. Relevant technical documents and reports on polio immunisation and surveillance were also reviewed. Data analysis was conducted using EPI Info 7 software. Results: administrative routine immunisation coverage for bivalent Oral Polio Vaccine (OPV) 3rd dose declined from 77% in 2010 to 56% in 2020. In contrast, the administrative and post-campaign evaluation coverage recorded for the nationwide supplemental polio campaigns since 2011 was consistently above 85%; however, campaigns declined in number from four in 2011 to zero in 2020. Overall, 76% of notified cases of Acute Flaccid Paralysis (AFP) received three or more doses of the oral polio vaccine. The Annualized Non-AFP rate ranged between 4.0 to 5.4 per 100,000 under 15 years populations, and stool adequacy ranged from 83% to 94%. Conclusion: South Sudan's polio-free status documentation was accepted by the ARCC in 2020, thereby enabling the African Region to be certified WPV free on August 25, 2020. However, there are concerns as the country continues to report low routine immunisation coverage and a reduction in the number of polio campaigns conducted each year. It is recommended that the country conduct high-quality nationwide supplemental polio campaigns yearly to achieve and maintain the required herd immunity. It invests in its routine immunisation program while ensuring optimal AFP surveillance performance indicators.
... Conflicts appear to have little effect on the ability to detect AFP cases and meet standard indicators, with similar results reported in countries such as Pakistan, Afghanistan, and Nigeria [39,41,42] The program's ability to detect and report the presence or absence of poliovirus is contingent upon the laboratory's ability to isolate and identify enteroviruses from AFP samples. These are affected by the reverse cold chain, with a 10% NPEV isolation rate serving as a reference point [43]. The country met the criterion for this indicator, further establishing the credibility of the country's polio activities despite delays in stool transfer to WHO-accredited laboratories caused by erratic flight schedules and cancellations, particularly during the rainy season. ...
Article
Full-text available
Introduction: in 1988 the World Health Assembly set an ambitious target to eradicate Wild Polio Virus (WPV) by 2000, following the successful eradication of the smallpox virus in 1980. South Sudan and the entire African region were certified WPV free on August 25, 2020. South Sudan has maintained its WPV free status since 2010, and this paper reviewed the country’s progress, outlined lessons learned, and describes the remaining challenges in polio eradication. Methods: secondary data analysis was conducted using the Ministry of Health and WHO polio surveillance datasets, routine immunisation coverage, polio campaign data, and surveys from 2010 to 2020. Relevant technical documents and reports on polio immunisation and surveillance were also reviewed. Data analysis was conducted using EPI Info 7 software. Results: administrative routine immunisation coverage for bivalent Oral Polio Vaccine (OPV) 3rd dose declined from 77% in 2010 to 56% in 2020. In contrast, the administrative and post-campaign evaluation coverage recorded for the nationwide supplemental polio campaigns since 2011 was consistently above 85%; however, campaigns declined in number from four in 2011 to zero in 2020. Overall, 76% of notified cases of Acute Flaccid Paralysis (AFP) received three or more doses of the oral polio vaccine. The Annualized Non-AFP rate ranged between 4.0 to 5.4 per 100,000 under 15 years populations, and stool adequacy ranged from 83% to 94%. Conclusion: South Sudan’s polio-free status documentation was accepted by the ARCC in 2020, thereby enabling the African Region to be certified WPV free on August 25, 2020. However, there are concerns as the country continues to report low routine immunisation coverage and a reduction in the number of polio campaigns conducted each year. It is recommended that the country conduct high-quality nationwide supplemental polio campaigns yearly to achieve and maintain the required herd immunity. It invests in its routine immunisation program while ensuring optimal AFP surveillance performance indicators.
... Additional evidence of surveillance gaps includes findings from rapid surveillance assessments conducted within the reporting period which showed knowledge gaps among key surveillance personnel, missed AFP cases, and inadequate active surveillance and documentation [7][8][9][10]. ...
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Background The tremendous progress made by Nigeria towards polio eradication has recently suffered a setback with the isolation of circulating vaccine-derived poliovirus (cVDPV) type 2 from environmental samples and confirmation of four wild poliovirus (WPV) cases from acute flaccid paralysis (AFP) cases, with dates of onset of paralysis in July and August 2016. All these viruses were confirmed from the security-challenged northeastern state of Borno. Polio-compatible cases exist in Nigeria, and they indicate surveillance failure. Surveillance, therefore, has to be strengthened for the country to achieve certification. The objective of this paper is to highlight the epidemiological profile and magnitude of polio-compatible cases in Nigeria during the reporting period, as well as immunization and surveillance response activities conducted to close immunity and surveillance gaps. Methods We conducted a retrospective review of AFP surveillance performance and polio-compatible cases in Nigeria between 2006 and 2016 from the AFP database at the World Health Organization Country Office. We also reviewed and compared key epidemiological features of polio-compatible cases with those of wild poliovirus cases during the reporting period. Results The non-polio AFP rate improved from 6.5 in 2006 to 19.5 in 2016. The corresponding figures for stool adequacy rates were 88 and 98%. The total number of polio-compatible cases reported during the reporting period was 888, with the highest number (194) of cases reported in 2006 and the least (24) in 2016. Clusters of polio-compatible cases were reported every year during the reporting period except in 2015. The highest number (65) of polio-compatible cases in clusters was reported in 2006. The key epidemiological features of polio-compatible and wild poliovirus cases were similar. Conclusion AFP surveillance performance has improved significantly during the reporting period. Surveillance gaps still existed as shown by the presence of orphan viruses and polio-compatible cases, and these gaps need to be identified and closed to achieve certification.
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To demonstrate the immunity status of children with non-polio acute flaccid paralysis (NP AFP) reported through the AFP surveillance system in the South–South region of Nigeria. A retrospective study was conducted using AFP surveillance data collected routinely between January 2011 and December 2014 by the Disease Surveillance Department of the regional health service and the World Health Organization (WHO)-accredited regional reference polio laboratory. All cases of AFP reported to the Disease Surveillance Network from all six zones during this period were included in the study. In total, 5111 cases of AFP in children aged ≤15 years were reported between 2011 and 2014. These cases were investigated and verified by WHO surveillance officers using a standard questionnaire, which captured the number of doses of oral polio vaccine (OPV) received by the child. Two stool samples were collected for each case, 24–48 h apart, within 14 days of the onset of paralysis, and transported to the national polio laboratory under reverse cold chain storage. Data retrieved were stored in an AFP database hosted by the WHO server. EPIINFO software was used to query the database and extract the information required for analysis in this study. The percentage of children who had received at least three doses of OPV (which serves as a threshold to measure immunity status) decreased from 87% in 2011 to 82% in 2014. The percentage of children who had not received any doses of OPV decreased from 2% in 2011 to 1% in 2014. Forty-eight percent of the children who had not received any doses of OPV were aged <1 year. Given the decrease in OPV immunity status, the region risks re-introduction of poliovirus. Swift steps should be taken to improve the immunization coverage, which would boost immunity status in Nigeria.
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Background Ghana recorded the last case of indigenous wild poliovirus in 1999 but suffered two more outbreaks in 2003 and 2008. Following the World Health Organization (WHO) guidelines, transmission was interrupted through high routine immunisation coverage with live-attenuated oral polio vaccine (OPV), effective acute flaccid paralysis (AFP) surveillance and supplementary immunisation activities (SIA). This article describes the results of a five-year surveillance of AFP in polio-free Ghana, evaluate the surveillance indicators and identify areas that need improvement. Methods We investigated 1345 cases of AFP from children aged less than 15 years reported to the Disease Surveillance Department from January 2009 to December 2013. Data on demographic characteristics, vaccination history, clinical presentation and virological investigation on stool specimens collected during investigation were analysed. Results Of the specimens analysed, 56% were from males and 76.3% were from children less than 5 years of age. Twenty-four percent of the children received up to 3 doses of OPV, 57% received at least 4 doses while the status of 19% was unknown. Core AFP surveillance indicators were partly met for non-polio AFP rate while the WHO target for stool adequacy and timeliness was exceeded over the period of study. All the cases were classified virologically, however no wild polio was found. Sixty-day follow-up was conducted for 56.3% of cases and 8.6% cases classified as compactible with polio. Conclusion Both laboratory and epidemiological surveillance for AFP were efficient and many WHO targets were met. However, due to the risk of poliovirus importation prior to global eradication, longterm surveillance is required to provide a high degree of confidence in prevention of poliovirus infection in Ghana. Thus, efforts should be made to strengthen regional performance and to follow–up on all AFP cases in order to establish proper diagnoses for the causes of the AFP leading to proper care.
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After being polio free for more than 10 years, an outbreak occurred in China in 2011 in Xinjiang Uygur Autonomous Region (Xinjiang) following the importation of wild poliovirus (WPV) originating from neighboring Pakistan. To strengthen acute flaccid paralysis (AFP) surveillance in Xinjiang, "zero case daily reporting" and retrospective searching of AFP cases were initiated after the confirmation of the WPV outbreak. To pinpoint all the polio cases in time, AFP surveillance system was expanded to include persons of all ages in the entire population in Xinjiang. Totally, 578 AFP cases were reported in 2011 in Xinjiang, including 21 WPV cases, 23 clinical compatible polio cases and 534 non-polio AFP cases. Of the 44 polio cases, 27 (61.4%) cases were reported among adults aged 15-53 years. Strengthening AFP surveillance resulted in an increase in the number of non-polio AFP cases in 2011 (148 children < 15 years) compared with 76 cases < 15 years in 2010. The AFP surveillance system in Xinjiang was sensitive enough to detect polio cases, with the AFP incidence of 3.28/100,000 among children < 15 years of age. Incorporating adult cases into the AFP surveillance system is of potential value to understand the overall characteristics of the epidemic and to guide emergency responses, especially in countries facing WPV outbreak following long-term polio free status. The AFP surveillance system in Xinjiang was satisfactory despite limitations in biological sample collection.
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Introduction: Acute Flaccid Paralysis (AFP) surveillance was adopted by World Health Organization (WHO) to monitor progress towards poliomyelitis eradication. South Africa Department of Health (DoH) routinely collects AFP surveillance data but has no documented evidence of its epidemiological use. The study discusses the epidemiology of AFP in South Africa from 2005-9, evaluates performance of the AFP surveillance system, and identifies components that require strengthening. Methods: A retrospective descriptive analysis was conducted on secondary AFP surveillance data for South Africa for the period 2005-2009, consisting of all children <15years reported to the DoH as AFP. AFP surveillance performance was evaluated using WHO-specified AFP surveillance indicators. Results: South Africa reported 1501 AFP cases between 2005 and 2009. Of these, 67.2% were <5years of age, and 54.3% were male. None of the cases were confirmed poliomyelitis, and ten (0.7%) were classified as polio-compatible. The national annualized non-polio AFP detection rate increased from 1.6 in 2005 to 2.1 non-polio AFP cases/100,000 children <15years in 2008-9. All performance indicators met the WHO-specified targets except two. Between 2007 and 2009, 51.5%, 55.3% and 65% of specimens, respectively, reached the laboratory within 72hours of being sent (WHO target is ≥80%). Proportion of stool specimens where non-polio enterovirus was isolated decreased from 22.5% in 2006 to <1% in 2008 and 2009 (WHO target is ≥10%). Conclusion: The AFP surveillance system met most WHO-specified epidemiological and laboratory performance standards. The surveillance programme needs to address problems of delayed specimen arrival to the laboratory and incomplete documentation of laboratory findings in the national AFP surveillance database.
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Enteroviruses are among the most common viruses infecting humans worldwide. Human enteroviruses are enterically transmitted and cause a wide spectrum of both common and uncommon illnesses among infants and children. The objectives of this study is to isolate Non-Polio Enteroviruses from stool specimens obtained from children aged less than 15 years from different Egyptian governorates and characterize the different serotypes of it using both immunological and molecular methods according to World Health Organization recommended protocols. Non-Polio Enteroviruses were isolated from 1000 stool samples on RD-A (human rhabdomyosarcoma) cell line and was characterized to the different serotypes using neutralization by antiserum pools and RT-PCR methods. A total of 176 (17.6%) Non-Polio enteroviruses (NPEV) strains were isolated from different Egyptian governorates. The highest percentage of positive cases was found in El Menya Governorate (49 %) followed by El Fayoum (47%) then Giza (42%) while Port Said, Matrouh, South Sinai and Alwadi Algadid had no positive cases (0%). Seasonal variation of NPEV isolated from different Egyptian governorates showed the highest percentage of NPEV was recorded in the month of May (46%) followed by April (42%) then June (36%). The least percentage was found in the month of January (12%) followed by December (16%) then November (19%). There is no significant difference on the number of isolates between summer and winter months. Echoviruses (EV) had the highest prevalence in Egypt (37%). EV-14 was the most prevalent EV in Egypt (14%). The isolates (n =58) found untypable by the antiserum pools were confirmed as NPEV by PCR using Pan-Enterovirus primers. In conclusion: Study on NPEV serotypes circulating in Egypt help to formulate more effective strategies. A better knowledge of the transmission and the implications of NPEV in diseases may also justify the future studies on their molecular epidemiology. High prevalence of non-typable enteroviruses (NTEV) isolates in Egypt reflects the needs for further typing and molecular analysis.
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The last case of wild polio virus transmission occurred in Akwa Ibom state in October 2001; however, combination high routine immunization coverage with OPV, high quality AFP surveillance, mass immunization campaign in which two doses of potent oral polio vaccine is administered to eligible children and mop-up campaigns in areas with identified immunization or surveillance gaps has help the state in maintaining a free polio status for over ten years. This study was carried out to describe the characteristics of reported acute flaccid paralysis cases between 2004 and 2009, and to evaluate the performance of the acute flaccid paralysis surveillance system using indicators recommended by the World Health Organization. A retrospective study was conducted among children, 0-15 years, by the World Health Organization (WHO) and Epidemiology unit of State Ministry of Health (SMOH), Uyo. The demographic characteristics and the results of isolation and identification of polio and other enteroviruses in stool samples sent to the WHO Polio Laboratory Ibadan for cases was analyzed. A total of 521 cases of AFP (270 males and 251 females) aged 0 month to=15 years were reported by the surveillance system between 2004 and 2009. Those below 5 years of age accounted for 82.5% of cases reported and investigated. Of the 521 cases investigated 512 (98.3%) received at least three doses of oral polio vaccine, while 9(1.7) never received any oral polio vaccine (zero-dose). In all 5.1% of the isolates were Sabin, 7.9% non polio enterovirus (NPEV) and 2.3% were classified by national expert committee as compatible with poliomyelitis. There was consistent and steady increase in three critical indicators; Non polio AFP rate in children <15 years from 4.5 to 6.4 per 100,000 population, proportion of AFP cases with 2 stool specimens collected within 14 days of onset of paralysis from 57% in 2005 to 91% in 2009 and proportion of Local Government Areas (Districts) meeting both core indicators from 23% in 2005 to 87% in 2009. The highest numbers of cases were seen in the months of March, May and September. This study showed high levels of surveillance performance with some challenges in reverse the cold chain system, the continuation and sustained AFP case detection, prompt investigation and response, improvement in the reserve cold chain system would achieve optimal standards recommended by WHO and might provide a good model for the eradication of poliomyelitis.
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