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Cholera is an important public health problem in Africa. AFENET is contributing to the multi-faceted efforts to reduce its impact. AFENET does this through supporting Ministries of Health and working with international and local partners. Outbreak response has been the mainstay of understanding and controlling Cholera in Africa. The work of the African Corps of Disease Detectives (ACoDD) fellows during the recent Cholera outbreak in Zimbabwe is highlighted in this issue. New initiatives hold significant promise. One initiative supported by the World Health Organization Regional Office for Africa (WHO AFRO) has over 80% of African countries committed to reducing the impact of this stubborn public health problem by 90%. By 2030. Africa is becoming healthier.

Operational gaps in the Global Polio Eradication Initiative implementation had been partly responsible for inadequate population immunity and the continued transmission of wild poliovirus in Nigeria before the African Region was declared polio-free in 2020. Missed opportunities to provide services in nomadic populations due to frequent mobility, lack of inclusion in microplans and the remoteness of their settlements were the major challenges. During May 2013 we conducted immunization outreach to nomadic and other underserved communities in Rabah LGA, Sokoto state, and Ardo Kola LGA, Taraba state, in Nigeria to identify and vaccinate children missed during supplemental immunization activities while identifying missed acute flaccid paralysis cases.An enumeration checklist and data collection instruments on Android cell phones were used to capture socio-demographic data and GPS coordinates on nomadic settlements, households, number of children aged5 years, children previously missed for vaccination and their locations. Local guides led trained enumerators to underserved communities for the enumeration and vaccination. Data were analyzed using Microsoft Excel 2007.A total of 324 settlements were listed for the two states, and 111 (34.3%) of these were identified as missed when compared with micro-planning for the most recent SIA. In these settlements, 3,533 households and 9,385 children aged5 years were listed. We administered oral poliovirus vaccine to all 1,946 missed children during the recent or any supplemental immunization activities. Of these, 527 (27.1%) had never been vaccinated. We found no missed acute flaccid paralysis cases.Nomadic populations continue to be underserved, especially for vaccination services. This results in pockets of populations with low herd immunity and increased risk for poliovirus transmission. Community leaders and nomadic settlements should be included in the micro-planning of all supplemental immunization activities to ensure all children receive vaccination services.

Public health emergency (PHE) response in sub-Saharan Africa is constrained by inadequate skilled public health workforce and underfunding. Since 2005, the African Field Epidemiology Network (AFENET) has been supporting field epidemiology capacity development and innovative strategies are required to use this workforce. In 2018, AFENET launched a continental rapid response team: the AFENET Corps of Disease Detectives (ACoDD). ACoDD comprises field epidemiology graduates and residents and was established to support PHE response. Since 2018, AFENET has deployed the ACoDD to support response to several PHEs. The main challenges faced during ACoDD deployments were financing of operations, ACoDD safety and security, resistance to interventions and distrust of the responders by some communities. Our experience during these deployments showed that it was feasible to mobilise and deploy ACoDD within 48 hours. However, the sustainability of deployments will depend on establishing strong linkages with the employers of ACoDD members. PHEs are effectively controlled when there is a fast deployment and strong linkages between the stakeholders. There are ongoing efforts to strengthen PHE preparedness and response in sub-Saharan Africa. ACoDD members are a competent workforce that can effectively augment PHE response. ACoDD teams mentored front-line health workers and community health workers who are critical in PHE response. Public health emergence response in sub-Saharan Africa is constrained by inadequacies in a skilled workforce and underfunding. ACoDD can be utilised to overcome the challenges of accessing a skilled public health workforce. To improve health security in sub-Saharan Africa, more financing of PHE response is needed.

The National Stop Transmission of Polio (NSTOP) program was created in 2012 to support the Polio Eradication Initiative (PEI) in Local Government Areas (LGAs) at high risk for polio in Northern Nigeria. We assessed immunization service delivery prior to the commencement of NSTOP support in 2014 and after one year of implementation in 2015 to measure changes in the implementation of key facility-based Routine Immunization (RI) components.The pre- and post-assessment was conducted in selected health facilities (HFs) in 61 LGAs supported by NSTOP in 5 states. A standardized questionnaire was administered to the LGA and HF immunization staff by trained interviewers on key RI service delivery components.At the LGA level, an increase was observed in key components including availability of updated Reach Every Ward (REW) micro-plans with identification of hard to reach settlements (65.6% baseline, 96.8% follow-up, PR = 1.5 (95% CI 3.4 - 69.8), vaccine forecasting (77.1% baseline, 93.5% follow-up, PR =1.2 (95% CI 1.8 - 13.8), and timely delivery of monthly immunization reports (73.8% baseline, 90.2% follow-up; PR =1.2 (95% CI 1.2 - 9.0). At the HF level, there was an increase in percentage of HFs with written supervisory feedback (44.5% baseline, 82.5% follow-up, PR = 1.8 (95% CI 4.7 - 7.3), written stock records (66.5% baseline, 87.9% follow-up, PR = 1.3 (95% CI 2.9 - 4.7) and updated immunization monitoring charts (76.3% baseline, 95.6% follow-up, PR = 1.3 (95% CI 4.6 - 9.9).We observed an improvement in key RI service delivery components following implementation of NSTOP program activities in supported LGAs.

Timely and accurate data are necessary for informing sound decision-making and developing effective routine immunization (RI) programs. We launched a pilot project in Kano State to strengthen routine immunization (RI) data reporting through the immunization module of the District Health Information System version 2 (DHIS2). We examined the completeness and timeliness of reporting monthly RI data one year before and one year after DHIS2 module pilot in the State.The first phase of the DHIS2 RI module pilot in Kano included training on RI data tools in November 2014 and in January 2015 for 36 state and zonal personnels, 276 local government area (LGA) personnel, and 2,423 health facility (HF) staff. A RI-focused dashboard to display core RI accountability framework indicators, such as completeness and timeliness of reporting, planned immunization sessions conducted, coverage and dropout was implemented. Report completeness was ratio of submitted reports to number of health facilities while report timeliness was ratio of reports on the DHIS2 by 14th of the month to number of expected.Completeness of data reporting increase from 70% in 2014 to 87% in 2015, while timeliness of reporting increase from 64% to 87% over the same period. Challenges encountered during the implementation process included limited access to internet, power outages, health workers strike, staff attrition and competing state activities.The pilot implementation of the DHIS2 immunization module in Kano State led to modest improvement in the reporting of RI services. Several lessons learned were used to guide scale-up to other states in the country.

Surveillance for acute flaccid paralysis (AFP) is a fundamental cornerstone of the global polio eradication initiative (GPEI). Active surveillance (with visits to health facilities) is a critical strategy of AFP surveillance systems for highly sensitive and timely detection of cases. Because of the extensive resources devoted to AFP surveillance, multiple opportunities exist for additional diseases to be added using GPEI assets, particularly because there is generally 1 district officer responsible for all disease surveillance. For this reason, integrated surveillance has become a standard practice in many countries, ranging from adding surveillance for measles and rubella to integrated disease surveillance for outbreak-prone diseases (integrated disease surveillance and response). This report outlines the current level of disease surveillance integration in 3 countries (Nepal, India, and Nigeria) and proposes that resources continue for long-term maintenance in resource-poor countries of AFP surveillance as a platform for surveillance of vaccine-preventable diseases and other outbreak-prone diseases.

Vaccination is an important and cost-effective disease prevention and control strategy. Despite progress in vaccine development and immunization delivery systems worldwide, populations in areas of conflict (hereafter, "conflict settings") often have limited or no access to lifesaving vaccines, leaving them at increased risk for morbidity and mortality related to vaccine-preventable disease. Without developing and refining approaches to reach and vaccinate children and other vulnerable populations in conflict settings, outbreaks of vaccine-preventable disease in these settings may persist and spread across subnational and international borders. Understanding and refining current approaches to vaccinating populations in conflict and humanitarian emergency settings may save lives. Despite major setbacks, the Global Polio Eradication Initiative has made substantial progress in vaccinating millions of children worldwide, including those living in communities affected by conflicts and other humanitarian emergencies. In this article, we examine key strategic and operational tactics that have led to increased polio vaccination coverage among populations living in diverse conflict settings, including Nigeria, Somalia, and Pakistan, and how these could be applied to reach and vaccinate populations in other settings across the world.

Acute flaccid paralysis (AFP) pictorial surveillance reminder cards (AFP cards) could aid AFP case identification during supplementary immunization activities (SIAs). We assessed the availability and utilization of AFP cards among vaccination teams during the December 2014 polio SIAs in Jigawa State, Nigeria.We conducted a cross-sectional survey of a convenience sample of 95 vaccination team supervisors. We used a semi-structured interviewer-administered questionnaire to collect information on socio-demographics, knowledge of AFP cases, availability and utilization of the AFP cards for case identification and investigation and non-compliance resolution by vaccination teams. Univariate and bivariate analyses were performed using Epi Info version 3.5.1.Of the 95 supervisors interviewed, 86 (91%) reported that vaccinators properly displayed the AFP cards, 90 (95%) reported use of cards for AFP case identification, 88 (93%) reported use of cards to resolve non-compliance with polio vaccination and 77 (81%) reported use of cards to ask caregivers six key questions to prevent missed children. Fifty-eight (61%) supervisors knew the AFP case definition. A total of 21 possible AFP cases were identified by vaccination team members with the aid of the cards, of which 17 (81%) were referred to the nearest health facility.The survey demonstrated usefulness of reminder cards for identification and follow-up of AFP cases. Based on these findings, use of AFP cards was implemented in all Nigerian States and similar cards were developed and implemented for measles surveillance during SIAs.

On August 10, 2016, 2 years after the most recent wild poliovirus (WPV) case was reported in Nigeria (in July 2014) (1), two WPV cases were reported in the northeastern state of Borno, which has been severely affected by insurgency-related insecurity since 2013. On September 9 and 26, 2016, two additional WPV cases were reported in Borno in children whose families migrated from security-compromised, inaccessible areas of the state. All four cases were WPV serotype 1 (WPV1), with genetic differences indicating prolonged undetected transmission. A large-scale emergency response plan was developed and implemented. The plan initially called for vaccination of 815,791 children during August 15-18 in five local government areas (LGAs) in the immediate vicinity of the first two WPV cases. Subsequently, the plan was expanded to regionally synchronized supplementary immunization activities (SIAs), conducted during August 27-December 6 in five Lake Chad basin countries at increased risk for national and regional WPV1 transmission (Cameroon, Central African Republic, Chad, Niger, and Nigeria). In addition, retrospective searches for missed cases of acute flaccid paralysis (AFP), enhanced environmental surveillance for polioviruses, and polio surveillance system reviews were conducted. Prolonged undetected WPV1 transmission in Borno State is a consequence of low population immunity and severe surveillance limitations associated with insurgency-related insecurity and highlights the risk for local and international WPV spread (2). Increasing polio vaccination coverage and implementing high-quality polio surveillance, especially among populations in newly secured and difficult-to-access areas in Borno and other Lake Chad basin areas are urgently needed.

Background: The need to understand the contribution of bovine tuberculosis (BTB) to the general tuberculosis burden in a poor resource setting is paramount. The aim of this study is to determine the burden of BTB among herdsmen and cattle in the North Tongu district of Volta Region in Ghana.Materials and Methods: A cross- sectional study was conducted in the North Tongu District of the Volta Region between the period of October 2011- March 2012. A well-structured questionnaire was used to collect socio-demographic information and possible risk factor information on cattle from participants. Sputum samples from 68 herdsmen and blood samples from 200 cattle belonging to these herdsmen were also collected. Sputum samples were analyzed using Ziehl- Neelsen staining while Anigen Rapid BTB Test was used for Cattle blood samples.Results: Ninety percent (61/68) of respondents were also found to consume fresh milk while 84% (57/68) do not use protective clothing. Of a total of 1580 cattle owned by the herdsmen, 200 cattle consisting of 14 bulls and 186 cows were screened where the prevalence of bovine TB was 19% (38/200) and those affected were all females. All (100%) human sample tested negative for Acid- Fast Bacilli (AFB). However, the seropositivity of cattle and kraal density were statistically associated (p= 0.001).Conclusion: Bovine TB is prevalent in cattle in North Tongu district. Although herdsmen indulge in risky lifestyles that expose them to BTB, a zero prevalence of BTB was observed, further study is envisaged using a larger sample size.Key words: Bovine tuberculosis, Ghana, Herdsmen, North Tongu.

In September 2015, more than 1 year after reporting its last wild poliovirus (WPV) case in July 2014 (1), Nigeria was removed from the list of countries with endemic poliovirus transmission,* leaving Afghanistan and Pakistan as the only remaining countries with endemic WPV. However, on April 29, 2016, a laboratory-confirmed, circulating vaccine-derived poliovirus type 2 (cVDPV2) isolate was reported from an environmental sample collected in March from a sewage effluent site in Maiduguri Municipal Council, Borno State, a security-compromised area in northeastern Nigeria. VDPVs are genetic variants of the vaccine viruses with the potential to cause paralysis and can circulate in areas with low population immunity. The Nigeria National Polio Emergency Operations Center initiated emergency response activities, including administration of at least 2 doses of oral poliovirus vaccine (OPV) to all children aged

Introduction : rabies is a viral zoonotic disease caused by lyssavirus of the family Rhabdoviridea, characterized by acute encephalitis. Worldwide, 55,000 rabies deaths occur annually with 56% occurring in Africa and 44% in Asia. Humans get infected with rabies through contact with the saliva of an infected animal (bite, scratches, licks on broken skin and mucous membranes). We investigated a suspected outbreak of rabies in Nyive Community in the Ho Municipality of Volta Region, Ghana, to confirm exposure, perform descriptive epidemiology, contain the outbreak and help implement control and preventive measures, where possible using the one-health approach. Methods : a cross sectional study was conducted from 29 th of April to 2 nd May 2013. Active case search was conducted in the community to obtain a line list of case patients. The index case was a 26 years old lady who was bitten by a dog on 19 March 2013 and died on 20 April 2013 after developing furious rabies. Results : a line list of eight patients was generated. There was one human death giving a Case Fatality of 1 (12.50%) of 8 patients. Sixty-three percent (5/8) patients were males. The median age of patients was 30.5 years. The youngest was 1.5 years old. Public health response leads to vaccination of two thousand pets and 5 persons against rabies in the community. Conclusion : there was an outbreak of rabies in Nyive Community. Public education was organized on rabies both in the community and on air. Yearly vaccination of pets against rabies was recommended in the area.

BACKGROUND Unvaccinated children contribute to accumulation of susceptible persons and the continued transmission of wild poliovirus in Nigeria. In September 2012, the Expert Review Committee (ERC) on Polio Eradication and Routine Immunization in Nigeria recommended that social research be conducted to better understand why children are missed during supplementary immunization activities (SIAs), also known as "immunization plus days (IPDs)" in Nigeria. METHODS Immediately following the SIA in October 2012, polio eradication partners and the government of Nigeria conducted a study to assess why children are missed. We used semistructured questionnaires and focus group discussions in 1 rural and 1 urban local government area (LGA) of Katsina State. RESULTS Participants reported that 61% of the children were not vaccinated because of poor vaccination team performance: either the teams did not visit the homes (25%) or the children were reported absent and not revisited (36%). This lack of access to vaccine was more frequently reported by respondents from scattered/nomadic communities (85%). In 1 out of 4 respondents (25%), refusal was the main reason their child was not vaccinated. The majority of respondents reported they would have consented to their children being vaccinated if the vaccine had been offered. CONCLUSIONS Poor vaccination team performance is a major contributor to missed children during IPD campaigns. Addressing such operational deficiencies will help close the polio immunity gap and eradicate polio from Nigeria.

Background : On the 28 th of October, 12 students from a Senior -High-School (SHS) in the Akwapim North-District-Ghana, reported to the district hospital with abdominal cramps, diarrhea and vomiting. We investigated to identify the cause, the source of infection and to recommend control measures. Methods: We conducted a descriptive investigation; with activ

Background Despite recent success towards controlling poliovirus transmission, Nigeria has struggled to achieve uniformly high routine vaccination coverage. A lack of reliable vaccination coverage data at the operational level makes it challenging to target program improvement. To reliably estimate vaccination coverage, we conducted district-level vaccine coverage surveys using a pre-existing infrastructure of polio technical staff in northern Nigeria. Methods Household-level cluster surveys were conducted in 40 polio high risk districts of Nigeria during 2014–2015. Global positioning system technology and intensive supervision by a pool of qualified technical staff were used to ensure high survey quality. Vaccination status of children aged 12–23 months was documented based on vaccination card or caretaker’s recall. District-level coverage estimates were calculated using survey methods. Results Data from 7,815 children across 40 districts were analyzed. District-level coverage with the third dose of diphtheria-pertussis-tetanus vaccine (DPT3) ranged widely from 1–63%, with all districts having DPT3 coverage below the target of 80%. Median coverage across all districts for each of eight vaccine doses (1 Bacille Calmette-Guerin dose, 3 DPT doses, 3 oral poliovirus vaccine doses, and 1 measles vaccine dose) was

Background: A snake bite is an injury caused by a bite from a snake, often resulting in puncture wounds, amputations and sometimes envenomation. Envenoming resulting from snake bite is a particularly important public health problem in rural areas of tropical and sub-tropical countries in Africa. This paper reports the incidence of snake bites and its associated mortality in the Western Region of Ghana. Method: The study was a descriptive cross-sectional review of 2006 - 2010 snake bite secondary data generated by the Western Regional Health Information Office in Ghana. Data was extracted from the District Health Information Management System (DHIMS) database. Data was managed and analyzed using SPSS Version 16.0. Univariate analyses were expressed as percentages and graphs. Results: The year 2009 recorded the highest incidence of Snake bites in the Western Region with Juabeso district recording the highest incidence of snake bites over the study period. Over the period about 55% of the incidence was between 50 – 100 per 100,000 population. The total number of snake bites recorded in the region for the period was 7,275, of which 52% (3,776) were males. About 60% of the patients were of the age group 15-49 years. A total of 12 reported snake bite deaths were recorded, of which 67% were men. This study recommends to the Districts Health Directorates in the Western Region to regularly organize community education on snake bite and the use of protective clothing by the farmers. Funding: None declared Keywords: Snake bite, Envenomation, Incidence, District Health Information Management System, Western Region, Ghana

Objective To evaluate the appropriateness and intermediate outcomes of telemetry admissions. Methods We abstracted demographic and clinical data from records of all new telemetry admissions during a 2-month period. To determine appropriateness, 2 authors classified patients using the American College of Cardiology (ACC) guidelines and our telemetry policy. Other utilization and outcome measures were assessed. Agreement between both guidelines was computed ( k coefficient). Categorical group covariates were compared using c 2 test. Variations in telemetry length of stay (LOS) were compared using Mann-Whitney and Kruskal-Wallis tests. LOS predictors were ascertained by multiple regression analysis. Results Of the 120 patients, appropriate admission was 81.6% (ACC criteria) and 83% by our criteria. Guidelines interrater reliability was .89 ( k ). Telemetry events incidence was 33.3%, with 5.8% major and 27.5% minor. LOS was longer among major than minor events group (7.8 vs 3.4 days, p = .01). Type of telemetry event was a predictor of LOS (p = .0001). The occurrence of a major telemetry event was associated with cardiology consultation (p = .03). Conclusions Appropriate telemetry admission was observed in more than 80% of cases. Our telemetry policy had very good agreement with standard guideline. However, the low rate of major telemetry events in all patient groups suggests current guidelines might have considerable limitations.

Background By September 2014, an outbreak of Ebola Viral Disease (EVD) in West African countries of Guinea, Liberia, Sierra Leone, Senegal and Nigeria, had recorded over 4500 and 2200 probable or confirmed cases and deaths respectively. EVD, an emerging infectious disease, can create fear and panic among patients, contacts and relatives, which could be a risk factor for psychological distress. Psychological distress among this subgroup could have public health implication for control of EVD, because of potential effects on patient management and contact tracing. We determined the Prevalence, pattern and factors associated with psychological distress among survivors and contacts of EVD and their relatives. Methods In a descriptive cross sectional study, we used General Health Questionnaire to assess psychological distress and Oslo Social Support Scale to assess social support among 117 participants who survived EVD, listed as EVD contacts or their relatives at Ebola Emergency Operation Center in Lagos, Nigeria. Factors associated with psychological distress were determined using chi square/odds ratio and adjusted odds ratio. Results The mean age and standard deviation of participants was 34 +/ - 9.6 years. Of 117 participants, 78 (66.7 %) were females, 77 (65.8 %) had a tertiary education and 45 (38.5 %) were health workers. Most frequently occurring psychological distress were inability to concentrate (37.6 %) and loss of sleep over worry (33.3 %). Losing a relation to EVD outbreak (OR = 6.0, 95 % CI, 1.2–32.9) was significantly associated with feeling unhappy or depressed while being a health worker was protective (OR = 0.4, 95 % CI, 0.2–0.9). Adjusted Odds Ratio (AOR) showed losing a relation (AOR = 5.7, 95 % CI, 1.2–28.0) was a predictor of “feeling unhappy or depressed”, loss of a relation (AOR = 10.1, 95 % CI, 1.7–60.7) was a predictor of inability to concentrate. Conclusions Survivors and contacts of EVD and their relations develop psychological distress. Development of psychological distress could be predicted by loss of family member. It is recommended that psychiatrists and other mental health specialists be part of case management teams. The clinical teams managing EVD patients should be trained on recognition of common psychological distress among patients. A mental health specialist should review contacts being monitored for EVD for psychological distress or disorders.

Background Transmission of wild poliovirus (WPV) has never been interrupted in Afghanistan, Pakistan, and Nigeria. Since 2003, infections with WPV of Nigerian origin have been detected in 25 polio-free countries. In 2012, the Nigerian government created an emergency operations center and implemented a national emergency action plan to eradicate polio. The 2013 revision of this plan prioritized (1) improving the quality of supplemental immunization activities (SIAs), (2) implementing strategies to reach underserved populations, (3) adopting special approaches in security-compromised areas, (4) improving outbreak response, (5) enhancing routine immunization and activities implemented between SIAs, and (6) strengthening surveillance. This report summarizes implementation of these activities during a period of unprecedented insecurity and violence, including the killing of health workers and the onset of a state of emergency in the northeast zone. Methods This report reviews management strategies, innovations, trends in case counts, vaccination and social mobilization activities, and surveillance and monitoring data to assess progress in polio eradication in Nigeria. Results Nigeria has made significant improvements in the management of polio eradication initiative (pei) activities with marked improvement in the quality of SIAs, as measured by lot quality assurance sampling (LQAS). Comparing results from February 2012 with results from December 2013, the proportion of local government areas (LGAs) conducting LQAS in the 11 high-risk states at the ≥90% pass/fail threshold increased from 7% to 42%, and the proportion at the 80%-89% threshold increased from 9% to 30%. During January-December 2013, 53 polio cases were reported from 26 LGAs in 9 states in Nigeria, compared with 122 cases reported from 13 states in 2012. No cases of WPV type 3 infection have been reported since November 2012. In 2013, no polio cases due to any poliovirus type were detected in the northwest sanctuaries of Nigeria. In the second half of 2013, WPV transmission was restricted to Kano, Borno, Bauchi, and Taraba states. Despite considerable progress, 24 LGAs in 2012 and 7 LGAs in 2013 reported ≥2 cases, and WPV continued to circulate in 8 LGAs that had cases in 2012. Campaign activities were negatively impacted by insecurity and violence in Borno and Kano states. Conclusions Efforts to interrupt transmission remain impeded by poor SIA implementation in localized areas, anti-polio vaccine sentiment, and limited access to vaccinate children because of insecurity. Sustained improvement in SIA quality, surveillance, and outbreak response and special strategies in security-compromised areas are needed to interrupt WPV transmission in 2014.

BACKGROUND Persistent wild poliovirus transmission in Nigeria constitutes a major obstacle to global polio eradication. In August 2012, the Nigerian national polio program implemented a strategy to conduct outreach to underserved communities within the context of the country's polio emergency action plans. METHODS A standard operating procedure (SOP) for outreach to underserved communities was developed and included in the national guidelines for management of supplemental immunization activities (SIAs). The SOP included the following key elements: (1) community engagement meetings, (2) training of field teams, (3) field work, and (4) acute flaccid paralysis surveillance. RESULTS Of the 46,437 settlements visited and enumerated during the outreach activities, 8607 (19%) reported that vaccination teams did not visit their settlements during prior SIAs, and 5112 (11.0%) reported never having been visited by polio vaccination teams. Fifty-two percent of enumerated settlements (23,944) were not found in the existing microplan used for the immediate past SIAs. CONCLUSIONS During a year of outreach to >45,000 scattered, nomadic, and border settlements, approximately 1 in 5 identified were missed in the immediately preceding SIAs. These missed settlements housed a large number of previously unvaccinated children and potentially served as reservoirs for persistent wild poliovirus transmission in Nigeria.

The concept of animal and human health experts working together toward a healthier world has been endorsed, but challenges remain in identifying concrete actions to move this one health concept from vision to action. In 2008, as a result of avian influenza outbreaks in West Africa, international donor support led to a unique opportunity to invest in Field Epidemiology and Laboratory Training Programs (FELTPs) in the region that engaged the animal and human health sectors to strengthen the capacity for prevention and control of zoonotic diseases. The FELTPs mixed 25% to 35% classroom and 65% to 75% field-based training and service for cohorts of physicians, veterinarians, and laboratory scientists. They typically consisted of a 2-year course leading to a master's degree in field epidemiology and public health laboratory management for midlevel public health leaders and competency-based short courses for frontline public health surveillance workers. Trainees and graduates work in multidisciplinary teams to conduct surveillance, outbreak investigations, and epidemiological studies for disease control locally and across borders. Critical outcomes of these programs include development of a cadre of public health leaders with core skills in integrated disease surveillance, outbreak investigation, vaccination campaigns, laboratory diagnostic testing, and epidemiological studies that address priority public health problems. A key challenge exists in identifying ways to successfully scale up and transform this innovative donor-driven program into a sustainable multisectoral one health workforce capacity development model.

Poliomyelitis is a highly-infectious viral disease affecting children under 15 years. One in 200 infections leads to irreversible paralysis and in 5 to 10% of such case, patients die from paralyzed breathing muscles. Ghana is at the verge of polio certification and the only reported case of wild polio virus in the Eastern Region was in 2003. We reviewed AFP data in the Eastern-Region to assess the progress towards interruption of polio virus transmission and identified opportunities for surveillance improvement. We reviewed records and conducted secondary data analysis of all AFP cases reported to the Region from 1997 to 2010. We assessed data quality, calculated AFP surveillance indicators, and described AFP cases by person, place, time and polio vaccination status. Completeness of case-based-forms was 90%. Of 306 AFP-cases reported, one wild polio virus was recorded; 59.2% were males aged < 5 years; 26.5% had right lower limb paralysis; 14% occurred in October and 52.6% had received 4 doses of oral polio-vaccine. The non-polio AFP rate ranged from 0.12 to 4.3/100,000 population and stool adequacy from 60 to 100%. The period prevalence of non-polio entero-viruses was 8.5% (26/306). There is sustained progress towards interruption of polio virus transmission in the region. However, opportunity remains to improve the completeness of case-based forms and the non-polio AFP rate. Key words: Acute flaccid paralysis, poliomyelitis, surveillance, eradication, vaccination, Ghana.

As of 2010 sub-Saharan Africa had approximately 865 million inhabitants living with numerous public health challenges. Several public health initiatives [e.g., the United States (US) President’s Emergency Plan for AIDS Relief and the US President’s Malaria Initiative] have been very successful at reducing mortality from priority diseases. A competently trained public health workforce that can operate multi-disease surveillance and response systems is necessary to build upon and sustain these successes and to address other public health problems. Sub-Saharan Africa appears to have weathered the recent global economic downturn remarkably well and its increasing middle class may soon demand stronger public health systems to protect communities. The Epidemic Intelligence Service (EIS) program of the US Centers for Disease Control and Prevention (CDC) has been the backbone of public health surveillance and response in the US during its 60 years of existence. EIS has been adapted internationally to create the Field Epidemiology Training Program (FETP) in several countries. In the 1990s CDC and the Rockefeller Foundation collaborated with the Uganda and Zimbabwe ministries of health and local universities to create 2-year Public Health Schools Without Walls (PHSWOWs) which were based on the FETP model. In 2004 the FETP model was further adapted to create the Field Epidemiology and Laboratory Training Program (FELTP) in Kenya to conduct joint competencybased training for field epidemiologists and public health laboratory scientists providing a master’s degree to participants upon completion. The FELTP model has been implemented in several additional countries in sub-Saharan Africa. By the end of 2010 these 10 FELTPs and two PHSWOWs covered 613 million of the 865 million people in sub-Saharan Africa and had enrolled 743 public health professionals. We describe the process that we used to develop 10 FELTPs covering 15 countries in sub-Saharan Africa from 2004 to 2010 as a strategy to develop a locally trained public health workforce that can operate multi-disease surveillance and response systems.Key words: Field epidemiology, laboratory management, multi-disease surveillance and response systems, public health workforce capacity building

The lack of highly trained field epidemiologists in the public health system in Ghana has been known since the 1970s when the Planning Unit was established in the Ghana Ministry of Health. When the Public Health School was started in 1994, the decision was taken to develop a 1 academic-year general MPH course. The persisting need for well-trained epidemiologists to support the public health surveillance, outbreak investigation and response system made the development of the Field Epidemiology and Laboratory Training Programme (FELTP) a national priority. The School of Public health and the Ministry of Health therefore requested the technical and financial assistance of the United States Centers for Disease Control and Prevention (CDC) in organizing the Programme. The collaboration started by organizing short courses in disease outbreak investigations and response for serving Ghana Health Service staff. The success of the short courses led to development of the FELTP. By October 2007, the new FELTP curriculum for the award of a Masters of Philosophy in Applied Epidemiology and Disease Control was approved by the Academic Board of the University of Ghana and the programme started that academic year. Since then five cohorts of 37 residents have been enrolled in the two tracks of the programme. They consist of 12 physicians, 12 veterinarians and 13 laboratory scientists. The first two cohorts of 13 residents have graduated. The third cohort of seven has submitted dissertations and is awaiting the results. The fourth cohort has started the second year of field placement while the fifth cohort has just started the first semester. The field activities of the graduates have included disease outbreak investigations and response, evaluation of disease surveillance systems at the national level and analysis of datasets on diseases at the regional level. The residents have made a total of 25 oral presentations and 39 poster presentations at various regional and global scientific conferences. The Ghana FELTP (GFELTP) has promoted the introduction of the One Health concept into FELTP. It hosted the first USAID–supported workshop in West Africa to further integrate and strengthen collaboration of the animal and human health sectors in the FETP model. GFELTP has also taken the lead in hosting the first AFENET Center for Training in Public Health Leadership and Management, through which the short course on Management for Improving Public Health Interventions was developed for AFENET member countries. The GFELTP pre-tested the Integrated Avian Influenza Outbreak and Pandemic Influenza course in preparation for introducing the materials into the curriculum of other FELTP in the network. The leadership positions to which the graduates of the program have been appointed in the human and animal Public Health Services, improvement in disease surveillance, outbreak investigation and response along with the testimony of the health authorities about their appreciation of the outputs of the graduates at various fora, is a strong indication that the GFELTP is meeting its objectives.

An outbreak of respiratory diphtheria occurred among highly-vaccinated trainees at a Latvian military academy in August-September 2000. We reviewed immunization, clinical and laboratory records and administered a questionnaire to obtain data on exposure factors. Among 207 trainees, 45 (22%) diphtheria cases and 79 (38%) carriers of toxigenic Corynebacterium diphtheriae were identified. All patients survived; 1 had severe myocarditis. Sharing cups was a risk factor for infection. Over 85% of trainees had receivedor =5 doses of diphtheria toxoid. Neither infection nor disease was associated with the number of doses or interval since last dose. However, the risk of disease was lower and diphtheria antitoxin levels were higher among trainees who received their last booster dose with higher-antigen diphtheria toxoid (DT) instead of lower-antigen Td. Outbreaks of mild diphtheria can occur among highly-vaccinated persons living in crowded conditions with intense exposure; high-antigen diphtheria booster-vaccination might provide better protection under these conditions.