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Background: Postlicensure evaluations have identified an association between rotavirus vaccination and intussusception in several high- and middle-income countries. We assessed the association between monovalent human rotavirus vaccine and intussusception in lower-income sub-Saharan African countries.Methods: Using active surveillance, we enrolled patients from seven countries (Ethiopia, Ghana, Kenya, Malawi, Tanzania, Zambia, and Zimbabwe) who had intussusception that met international (Brighton Collaboration level 1) criteria. Rotavirus vaccination status was confirmed by review of the vaccine card or clinic records. The risk of intussusception within 1 to 7 days and 8 to 21 days after vaccination among infants 28 to 245 days of age was assessed by means of the self-controlled case-series method.Results: Data on 717 infants who had intussusception and confirmed vaccination status were analyzed. One case occurred in the 1 to 7 days after dose 1, and 6 cases occurred in the 8 to 21 days after dose 1. Five cases and 16 cases occurred in the 1 to 7 days and 8 to 21 days, respectively, after dose 2. The risk of intussusception in the 1 to 7 days after dose 1 was not higher than the background risk of intussusception (relative incidence [i.e., the incidence during the risk window vs. all other times], 0.25; 95% confidence interval [CI], <0.001 to 1.16); findings were similar for the 1 to 7 days after dose 2 (relative incidence, 0.76; 95% CI, 0.16 to 1.87). In addition, the risk of intussusception in the 8 to 21 days or 1 to 21 days after either dose was not found to be higher than the background risk.Conclusions: The risk of intussusception after administration of monovalent human rotavirus vaccine was not higher than the background risk of intussusception in seven lower-income sub-Saharan African countries. (Funded by the GAVI Alliance through the CDC Foundation.). [ABSTRACT FROM AUTHOR]

Introduction: Botswana had a resurgent diarrhea outbreak in 2018, mainly affecting children under five years old. Botswana introduced rotavirus vaccine (RotarixTM) into the national immunization programme in July 2012. Official rotavirus vaccine coverage estimates averaged 77.2% over the five years following introduction., Materials and Methods: The outbreak was investigated using multiple data sources, including stool laboratory testing, immunization data review, water assessment, and vaccine storage assessment. We reviewed official reports of the routine immunization data from 2013 to 2017 and compared district-level rotavirus vaccine coverage with district-level attack rates during the outbreak., Results: During the outbreak, a total of 228 stool samples were tested at the national health laboratory and 152 (67%) of the specimens were positive for rotavirus. A portion of adequate samples (80) were selected for referral to the Regional Reference Lab. The laboratory testing of 80 samples at the Regional Reference Laboratory in South Africa showed that 91% of the stool samples were positive for rotavirus, and the dominant strain 47/80 (58.7%) was G3P[8]. The immunization data showed that rotavirus vaccine coverage varied widely among districts, and there was no correlation between districts with high attack rates and those with low immunization coverage. Water assessment showed that some water sources were contaminated with E Coli. There was no problem with vaccine storage., Conclusion: The outbreak was caused by rotavirus G3P[8], a strain that was not common in the country prior to the outbreak. Despite the significant pressure and anxiety that outbreaks cause, the number of diarrhea cases and deaths were less compared to pre-vaccine era due to the impact of vaccination. This highlights the need for continuous implementation of high impact child survival interventions., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Ltd.)

Background: Cameroon has been struggling with low Covid-19 vaccination coverage, with only 4.5 % of the population receiving the primary series as of November 2022. The COVID-19 Vaccine Delivery Partnership (CoVDP) conducted a high-level mission to Cameroon to assess progress and advocate for actions to address bottlenecks. The objective of the mission was to administer at least 3,000,000 doses of vaccines during the 5th Mass vaccination campaign. This study examines the factors contributing to the success of the campaign and uses a geographical and gender lens to assess the results., Methods: The study is a secondary analysis of data from the DHIS2 collected during the 5th mass vaccination campaign for Covid-19. Descriptive statistics were used to assess coverages per location and gender expressed in OR. sccess factors, and chi-squared tests were used to assess differences in vaccine distribution across regions and by gender., Results: This 5th vaccination campaign benefitted from a strong political commitment facilitated by CoVDP's mission, international support, collaboration, planning, supervision, and demand generation. The campaign recorded 2 019 118 administered vaccine doses, a staggering 46-fold increase in vaccinated individuals relative to the first round, with vaccination coverage reaching 10.1 % of the general population. However, the study reveals regional and gender disparities in vaccination coverage. Men had higher odds of being vaccinated than women in the three Sahel regions. Among individuals with comorbidities, the national coverage rate was only 14 %, and the Far North and East regions exhibited the lowest coverage rates. Janssen was the most used vaccine, and the total AEFI cases reported were 2 per 1000 vaccine doses., Conclusion: The 5th COVID-19 vaccination campaign in Cameroon saw a strong political commitment and was the most successful so far. Despite the gains, there was gender disparity in coverage in some regions. It is important to continue the established momentum, ensure equitable access in the Sahel regions, and reach high-priority groups with primary series and booster doses., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier Ltd.)

Problem: In 2021, Central African Republic was facing multiple challenges in vaccinating its population against coronavirus disease 2019 (COVID-19), including inadequate infrastructure and funding, a shortage of health workers and vaccine hesitancy among the population., Approach: To increase COVID-19 vaccination coverage, the health ministry used three main approaches: (i) task shifting to train and equip existing community health workers (CHWs) to deliver COVID-19 vaccination; (ii) evidence gathering to understand people's reluctance to be vaccinated; and (iii) bundling of COVID-19 vaccination with the polio vaccination programme., Local Setting: Central African Republic is a fragile country with almost two thirds of its population in need of humanitarian assistance. Despite conducting two major COVID-19 vaccination campaigns, by January 2022 only 9% (503 000 people) of the 5 570 659 general population were fully vaccinated., Relevant Changes: In the 6 months from February to July 2022, Central African Republic tripled its coverage of COVID-19 vaccination to 29% (1 615 492 out of 5 570 659 people) by August 2022. The integrated polio-COVID-19 campaign enabled an additional 136 040 and 218 978 people to be vaccinated in the first and second rounds respectively, at no extra cost. Evidence obtained through surveys and focus group discussions enabled the health ministry to develop communication strategies to dispel vaccine hesitancy and misconceptions., Lessons Learnt: Task shifting COVID-19 vaccination to CHWs can be an efficient solution for rapid scaling-up of vaccination campaigns. Building trust with the community is also important for addressing complex health issues such as vaccine hesitancy. Collaborative efforts are necessary to provide access to COVID-19 vaccines for high-risk and vulnerable populations., ((c) 2023 The authors; licensee World Health Organization.)

Background: With the evolving epidemiological parameters of COVID-19 in Africa, the response actions and lessons learnt during the pandemic's past two years, SARS-COV 2 will certainly continue to circulate in African countries in 2022 and beyond. As countries in the African continent need to be more prepared and plan to 'live with the virus' for the upcoming two years and after and at the same time mitigate risks by protecting the future most vulnerable and those responsible for maintaining essential services, WHO AFRO is anticipating four interim scenarios of the evolution of the pandemic in 2022 and beyond in the region., Objective: In preparation for the rollout of response actions given the predicted scenarios, WHO AFRO has identified ten strategic orientations and areas of focus for supporting member states and partners in responding to the COVID-19 pandemic in Africa in 2022 and beyond., Methods: WHO analysed trends of the transmissions since the first case in the African continent and reviewed lessons learnt over the past months., Results: Establishing a core and agile team solely dedicated to the COVID-19 response at the WHO AFRO, the emergency hubs, and WCOs will improve the effectiveness of the response and address identified challenges. The team will collaborate with the various clusters of the regional office, and other units and subunits in the WCOs supported with good epidemics intelligence. COVID-19 pandemic has afflicted global humanity at unprecedented levels., Conclusion: Two years later and while starting the third year of the COVID-19 response, we now need to change and adapt our strategies, tools and approaches in responding timely and effectively to the pandemic in Africa and save more lives.

The World Health Organization-designated Western Pacific Region (WPR) and African Region (AFR) have the highest number of chronic hepatitis B virus (HBV) infections worldwide. The COVID-19 pandemic has disrupted childhood immunization, threatening progress toward elimination of hepatitis B by 2030. We used a published mathematical model to estimate the number of expected and excess HBV infections and related deaths after 10% and 20% decreases in hepatitis B birth dose or third-dose hepatitis B vaccination coverage of children born in 2020 compared with prepandemic 2019 levels. Decreased vaccination coverage resulted in additional chronic HBV infections that were 36,342-395,594 in the WPR and 9,793-502,047 in the AFR; excess HBV-related deaths were 7,150-80,302 in the WPR and 1,177-67,727 in the AFR. These findings support the urgent need to sustain immunization services, implement catch-up vaccinations, and mitigate disruptions in hepatitis B vaccinations in future birth cohorts.

Introduction: as of end 2021, ten different vaccines have received Emergency use listing by the World Health Organisation. The vaccination response to the COVID pandemic started in February 2021 in the WHO African Region. WHO proposed a national coverage target of fully vaccinated population of 40% by the end of December 2021. This manuscript attempts to review the progress in the roll-out of COVID-19 vaccination in the African Region., Methods: we analysed the aggregate COVID-19 vaccine uptake and utilization data from the immunisation monitoring databases set up by countries and shared with the WHO Regional Office for Africa., Results: as of 31 December 2021, a total of 340,663,156 doses of COVID-19 vaccine were received in 46 countries in the African Region. The weekly average doses administered was 4,069,934 throughout the year. In the same period, a total of 114,498,980 persons received at least one dose, and 71,862,108 people were fully vaccinated, amounting to 6.6% of the total population in the Region. Only 5 countries attained the target of 40% full vaccination coverage. Disaggregated information was not available from all countries on the number of persons vaccinated by gender, and according to the priority population groupings. A total of 102,046 cases of adverse events following immunisation (AEFIs) were reported among which 6,260 (6.1%) were labelled as severe AEFIs., Conclusion: COVID-19 vaccination coverage remains very low in the African Region, with all but 5 countries missing the 40% coverage target as of December 2021. Countries, donors and partners should mobilise political will and resources towards the attainment of the coverage targets. Countries will need to implement vaccination efforts using tailored approaches to reach unreached populations. The reporting gaps indicate the need to invest on efforts to improve the capture, analysis and use of more granular program data., Competing Interests: The authors declare no competing interests., (Copyright: Balcha Masresha et al.)

Introduction: a year after the start of COVID-19 vaccination, coverage remains very low in the African Region. Different challenges and operational barriers have been documented, but countries will need to supplement the available information with operational research in order to adequately respond to practical questions regarding how best to scale up COVID-19 vaccination. We conducted a survey among immunisation program staff working in the African Region, in order to identify the high priority operational research questions relevant to COVID-19 vaccination., Methods: proposed operational research questions categorized into six topic areas were sent to resource persons, asking them to rate according to the relevance, urgency, feasibility, and potential impact of the research questions on the progress of COVID vaccination., Results: a total of 25 research questions have been given an average weighted rating of 75% or more by the respondents. Nine of these top priority research questions were in the area of demand generation, risk communication and community engagement while 8 questions covered the area of service delivery., Conclusion: countries should plan for and coordinate stakeholders to ensure that relevant operational research is done to respond to the top priority research questions, with a view to influence policies and implementation of strategies., Competing Interests: The authors declare no competing interests., (Copyright: Balcha Masresha et al.)

Introduction: in the first year following the introduction of COVID-19 vaccines, only 6.8% of the total population in the 47 countries in the WHO African Region have received full vaccination. In an emergency context, the intra-action review helps countries to assess their progress and document what has worked and not worked., Methods: we reviewed and identified the key lessons and challenges documented in the reports from intra-action review of COVID vaccine roll out in 22 African countries., Results: all countries documented high level political commitment, but a serious shortage of COVID-19 vaccines and funding. Seven countries identified gaps in microplanning because of lack of funding or due to the unpredictability in the type and volume of vaccine supplies. The shortage of operational funding also affected training of health workers and hampered the expansion of service delivery. The countries implemented multi-channel communications and social mobilisation activities, alongside social media engagement and social listening. However, country capacity was limited in terms of timely responding to infodemics. Hesitancy among health workers and the general population was a challenge in most of the countries., Conclusion: countries have gained valuable experiences exploring various COVID-19 vaccination delivery models, including implementing the integration of COVID-19 vaccination within routine health care programs. There is a need to regularly monitor or do studies measuring public perceptions towards COVID-19 vaccination in order to drive the demand generation efforts, as well as use evidence in addressing hesitancy., Competing Interests: The authors declare no competing interests., (Copyright: Balcha Masresha et al.)

Background: The ongoing COVID-19 pandemic in Africa is an urgent public health crisis. Estimated models projected over 150,000 deaths and 4,600,000 hospitalizations in the first year of the disease in the absence of adequate interventions. Therefore, electronic contact tracing and surveillance have critical roles in decreasing COVID-19 transmission; yet, if not conducted properly, these methods can rapidly become a bottleneck for synchronized data collection, case detection, and case management. While the continent is currently reporting relatively low COVID-19 cases, digitized contact tracing mechanisms and surveillance reporting are necessary for standardizing real-time reporting of new chains of infection in order to quickly reverse growing trends and halt the pandemic., Objective: This paper aims to describe a COVID-19 contact tracing smartphone app that includes health facility surveillance with a real-time visualization platform. The app was developed by the AFRO (African Regional Office) GIS (geographic information system) Center, in collaboration with the World Health Organization (WHO) emergency preparedness and response team. The app was developed through the expertise and experience gained from numerous digital apps that had been developed for polio surveillance and immunization via the WHO's polio program in the African region., Methods: We repurposed the GIS infrastructures of the polio program and the database structure that relies on mobile data collection that is built on the Open Data Kit. We harnessed the technology for visualization of real-time COVID-19 data using dynamic dashboards built on Power BI, ArcGIS Online, and Tableau. The contact tracing app was developed with the pragmatic considerations of COVID-19 peculiarities. The app underwent testing by field surveillance colleagues to meet the requirements of linking contacts to cases and monitoring chains of transmission. The health facility surveillance app was developed from the knowledge and assessment of models of surveillance at the health facility level for other diseases of public health importance. The Integrated Supportive Supervision app was added as an appendage to the pre-existing paper-based surveillance form. These two mobile apps collected information on cases and contact tracing, alongside alert information on COVID-19 reports at the health facility level; the information was linked to visualization platforms in order to enable actionable insights., Results: The contact tracing app and platform were piloted between April and June 2020; they were then put to use in Zimbabwe, Benin, Cameroon, Uganda, Nigeria, and South Sudan, and their use has generated some palpable successes with respect to COVID-19 surveillance. However, the COVID-19 health facility-based surveillance app has been used more extensively, as it has been used in 27 countries in the region., Conclusions: In light of the above information, this paper was written to give an overview of the app and visualization platform development, app and platform deployment, ease of replicability, and preliminary outcome evaluation of their use in the field. From a regional perspective, integration of contact tracing and surveillance data into one platform provides the AFRO with a more accurate method of monitoring countries' efforts in their response to COVID-19, while guiding public health decisions and the assessment of risk of COVID-19., (©Godwin Ubong Akpan, Isah Mohammed Bello, Kebba Touray, Reuben Ngofa, Daniel Rasheed Oyaole, Sylvester Maleghemi, Marie Babona, Chanda Chikwanda, Alain Poy, Franck Mboussou, Opeayo Ogundiran, Benido Impouma, Richard Mihigo, Nda Konan Michel Yao, Johnson Muluh Ticha, Jude Tuma, Hani Farouk A Mohamed, Kehinde Kanmodi, Nonso Ephraim Ejiofor, John Kapoi Kipterer, Casimir Manengu, Francis Kasolo, Vincent Seaman, Pascal Mkanda. Originally published in JMIR mHealth and uHealth (https://mhealth.jmir.org), 17.03.2022.)

The World Health Organization African region recorded its first laboratory-confirmed coronavirus disease-2019 (COVID-19) cases on 25 February 2020. Two months later, all the 47 countries of the region were affected. The first anniversary of the pandemic occurred in a changed context with the emergence of new variants of concern (VOC) and growing COVID-19 fatigue. This study describes the epidemiological trajectory of COVID-19 in the region, summarises public health and social measures (PHSM) implemented and discusses their impact on the pandemic trajectory. As of 24 February 2021, the African region accounted for 2.5% of cases and 2.9% of deaths reported globally. Of the 13 countries that submitted detailed line listing of cases, the proportion of cases with at least one co-morbid condition was estimated at 3.3% of all cases. Hypertension, diabetes and human immunodeficiency virus (HIV) infection were the most common comorbid conditions, accounting for 11.1%, 7.1% and 5.0% of cases with comorbidities, respectively. Overall, the case fatality ratio (CFR) in patients with comorbid conditions was higher than in patients without comorbid conditions: 5.5% vs. 1.0% (P < 0.0001). Countries started to implement lockdown measures in early March 2020. This contributed to slow the spread of the pandemic at the early stage while the gradual ease of lockdowns from 20 April 2020 resulted in an upsurge. The second wave of the pandemic, which started in November 2020, coincided with the emergence of the new variants of concern. Only 0.08% of the population from six countries received at least one dose of the COVID-19 vaccine. It is critical to not only learn from the past 12 months to improve the effectiveness of the current response but also to start preparing the health systems for subsequent waves of the current pandemic and future pandemics.

Background: Rotavirus is the leading cause of acute gastroenteritis (AGE) among children worldwide. Prior to rotavirus vaccine introduction, over one third of AGE hospitalizations in Africa were due to rotavirus. We describe the impact of rotavirus vaccines using data from the African Rotavirus Surveillance Network (ARSN)., Methods: For descriptive analysis, we included all sites reporting to ARSN for any length of time between 2008 and 2018. For vaccine impact analysis, continuous surveillance throughout the year was required to minimize potential bias due to enrollment of partial seasons and sites had to report a minimum of 100 AGE cases per year. We report the proportion of rotavirus AGE cases by year relative to vaccine introduction, and the relative reduction in the proportion of rotavirus AGE cases reported following vaccine introduction., Results: From 2008 to 2018, 97 366 prospectively enrolled hospitalized children <5 years of age met the case definition for AGE, and 34.1% tested positive for rotavirus. Among countries that had introduced rotavirus vaccine, the proportion of hospitalized AGE cases positive for rotavirus declined from 39.2% in the prevaccine period to 25.3% in the postvaccine period, a 35.5% (95% confidence interval [CI]: 33.7-37.3) decline. No declines were observed among countries that had not introduced the vaccine over the 11-year period., Conclusions: Rotavirus vaccine introduction led to large and consistent declines in the proportion of hospitalized AGE cases that are positive for rotavirus. To maximize the public health benefit of these vaccines, efforts to introduce rotavirus vaccines in the remaining countries in the region and to improve coverage should continue., (Published by Oxford University Press for the Infectious Diseases Society of America 2021.)

Introduction: regular in-service training of healthcare workers within the immunization program is critical to address the program needs created by the introduction of new vaccines and technologies, as well as the expanding scope of immunisation programmes beyond infant immunization and towards a life-course approach. National immunization programs conduct in-service training of health workers depending on program needs and particularly when new program elements are introduced., Methods: we conducted a survey of national and provincial level immunization program staff in 9 countries in the World Health Organization (WHO) African Region to determine the perceived needs and preferred training methods for capacity building in immunisation., Results: nearly all of the respondents (98.3%) stated that there are skill gaps at their respective levels in the immunization program which require training, with 88% indicating that mid-level program management (MLM) training was needed to train new program staff, while 78% indicated program performance gaps and 60% of the respondents stated that refresher training is needed. Program areas identified as top priorities for training included immunisation monitoring and data quality, sustainable immunization financing, adverse events monitoring and community mobilization. More than three quarters of the respondents (78%) think that online MLM training is adequate to address program gaps. Only four of the 9 immunization program managers indicated that they regularly monitor the number of MLM trained staff within their national program., Conclusion: there is a strong need for in-service training of immunization program officers in the countries surveyed, especially at the subnational levels. Program managers should conduct regular monitoring of the training status of staff, as well as conduct detailed training needs assessments in order to tailor the training approaches and topics. Online training provides an acceptable approach for capacity building of immunization program staff., Competing Interests: The authors declare no competing interests., (Copyright: Balcha Girma Masresha et al.)

Mobile phone data collection tools are increasingly becoming very usable collecting, collating and analysing data in the health sector. In this paper, we documented the experiences with mobile phone data collection, collation and analysis in 5 countries of the East and Southern African, using Open Data Kit (ODK), where questionnaires were designed and coded on an XML form, uploaded and data collected using Android-Based mobile phones, with a web-based system to monitor data in real-time during EPI comprehensive review. The ODK interface supports in real-time monitoring of the flow of data, detection of missing or incomplete data, coordinate location of all locations visited, embedded charts for basic analysis. It also minimized data quality errors at entry level with the use of validation codes and constraint developed into the checklist. These benefits, combined with the improvement that mobile phones offer over paper-based in terms of timeliness, data loss, collation, and real-time data collection, analysis and uploading difficulties, make mobile phone data collection a feasible method of data collection that needs to be further explored in the conduct of all surveys in the organization.

Children in low-and middle-income countries, including Rwanda, experience a greater burden of rotavirus disease relative to developed countries. Evolutionary mechanisms leading to multiple reassortant rotavirus strains have been documented over time which influence the diversity and evolutionary dynamics of novel rotaviruses. Comprehensive rotavirus whole-genome analysis was conducted on 158 rotavirus group A (RVA) samples collected pre- and post-vaccine introduction in children less than five years in Rwanda. Of these RVA positive samples, five strains with the genotype constellations G4P[4]-I1-R2-C2-M2-A2-N2-T1-E1-H2 (n = 1), G9P[4]-I1-R2-C2-M2-A1-N1-T1-E1-H1 (n = 1), G12P[8]-I1-R2-C2-M1-A1-N2-T1-E2-H3 (n = 2) and G12P[8]-I1-R1-C1-M1-A2-N2-T2-E1-H1 (n = 1), with double and triple gene reassortant rotavirus strains were identified. Phylogenetic analysis revealed a close relationship between the Rwandan strains and cognate human RVA strains as well as the RotaTeq ® vaccine strains in the VP1, VP2, NSP2, NSP4 and NSP5 gene segments. Pairwise analyses revealed multiple differences in amino acid residues of the VP7 and VP4 antigenic regions of the RotaTeq ® vaccine strain and representative Rwandan study strains. Although the impact of such amino acid changes on the effectiveness of rotavirus vaccines has not been fully explored, this analysis underlines the potential of rotavirus whole-genome analysis by enhancing knowledge and understanding of intergenogroup reassortant strains circulating in Rwanda post vaccine introduction.

The Corona Virus Disease 2019 (COVID-19) pandemic has rapidly spread in Africa, with a total of 474,592 confirmed cases by 11 th July 2020. Consequently, all policy makers and health workers urgently need to be trained and to access the most credible information to contain and mitigate its impact. While the need for rapid training and information dissemination has increased, most of Africa is implementing public health social and physical distancing measures. Responding to this context requires broad partnerships and innovative virtual approaches to disseminate new insights, share best practices, and create networked communities of practice for all teach, and all learn. The World Health Organization (WHO)-Africa region, in collaboration with the Extension for Community Health Outcome (ECHO) Institute at the University of New Mexico Health Sciences Center (UNM HSC), the West Africa college of nurses and the East Central and Southern Africa college of physicians, private professional associations, academia and other partners has embarked on a virtual training programme to support the containment of COVID-19. Between 1 st April 2020 and 10 th July 2020, about 7,500 diverse health professionals from 172 locations in 58 countries were trained in 15 sessions. Participants were from diverse institutions including: central ministries of health, WHO country offices, provincial and district hospitals and private medical practitioners. A range of critical COVID-19 preparedness and response interventions have been reviewed and discussed. There is a high demand for credible information from credible sources about COVID-19. To mitigate the "epidemic of misinformation" partnerships for virtual trainings and information dissemination leveraging existing learning platforms and networks across Africa will augment preparedness and response to COVID-19., Competing Interests: The authors declare no competing interests., (Copyright: Ambrose Otau Talisuna et al.)

The World Health Organization (WHO) African regional training course for mid-level managers (MLM) of immunization programs launched in 2004, has undergone revisions across the years, to accommodate new developments in the field. In 2016, the WHO African regional office conducted a thorough review of the course materials and delivery methods to document lessons to help improve the course. Some of the gaps included inappropriate selection of trainees, inadequate focus on skills development, heavy reliance on text and presentations, as well as resource limitations to reach a critical mass of learners. The regional office worked with Bull City Learning to redesign the course materials along carefully crafted course objectives and curricula, and to assist facilitators to better deliver the course. In addition, the materials were converted into online learning tools. Within 10 months, a total of 3011 learners were enrolled in the online MLM training platform and earned a total of 9209 certificates. The MLM course will continue to be highly relevant as the immunization area of work expands significantly, with the addition of new vaccines, introduction of new technologies, and expanding opportunities for online learning., Competing Interests: The authors declare no competing interests., (Copyright: Balcha Masresha et al.)

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., Competing Interests: The authors declare no competing interests., (Copyright: Balcha Girma Masresha et al.)

Despite the implementation of effective conjugate vaccines against the three main bacterial pathogens that cause meningitis, Streptococcus pneumoniae , Haemophilus influenzae type b (Hib), and Neisseria meningitidis serogroup A, the burden of meningitis in West Africa remains high. The relative importance of other bacterial, viral, and parasitic pathogens in central nervous system infections is poorly characterized. Cerebrospinal fluid (CSF) specimens were collected from children younger than 5 years with suspected meningitis, presenting at pediatric teaching hospitals across West Africa in five countries including Senegal, Ghana, Togo, Nigeria, and Niger. Cerebrospinal fluid specimens were initially tested using bacteriologic culture and a triplex real-time polymerase chain reaction (PCR) assay for N. meningitidis , S. pneumoniae , and H. influenzae used in routine meningitis surveillance . A custom TaqMan Array Card (TAC) assay was later used to detect 35 pathogens including 15 bacteria, 17 viruses, one fungus, and two protozoans. Among 711 CSF specimens tested, the pathogen positivity rates were 2% and 20% by the triplex real-time PCR (three pathogens) and TAC (35 pathogens), respectively. TAC detected 10 bacterial pathogens, eight viral pathogens, and Plasmodium . Overall, Escherichia coli was the most prevalent (4.8%), followed by S. pneumoniae (3.5%) and Plasmodium (3.5%). Multiple pathogens were detected in 4.4% of the specimens. Children with human immunodeficiency virus (HIV) and Plasmodium detected in CSF had high mortality. Among 220 neonates, 17% had at least one pathogen detected, dominated by gram-negative bacteria. The meningitis TAC enhanced the detection of pathogens in children with meningitis and may be useful for case-based meningitis surveillance.

Background: In 1997, The Gambia introduced three primary doses of Haemophilus influenzae type b (Hib) conjugate vaccine without a booster in its infant immunisation programme along with establishment of a population-based surveillance on Hib meningitis in the West Coast Region (WCR). This surveillance was stopped in 2002 with reported elimination of Hib disease. This was re-established in 2008 but stopped again in 2010. We aimed to re-establish the surveillance in WCR and to continue surveillance in Basse Health and Demographic Surveillance System (BHDSS) in the east of the country to assess any shifts in the epidemiology of Hib disease in The Gambia., Methods: In WCR, population-based surveillance for Hib meningitis was re-established in children aged under-10 years from 24 December 2014 to 31 March 2017, using conventional microbiology and Real Time Polymerase Chain Reaction (RT-PCR). In BHDSS, population-based surveillance for Hib disease was conducted in children aged 2-59 months from 12 May 2008 to 31 December 2017 using conventional microbiology only. Hib carriage survey was carried out in pre-school and school children from July 2015 to November 2016., Results: In WCR, five Hib meningitis cases were detected using conventional microbiology while another 14 were detected by RT-PCR. Of the 19 cases, two (11%) were too young to be protected by vaccination while seven (37%) were unvaccinated. Using conventional microbiology, the incidence of Hib meningitis per 100 000-child-year (CY) in children aged 1-59 months was 0.7 in 2015 (95% confidence interval (CI) = 0.0-3.7) and 2.7 (95% CI = 0.7-7.0) in 2016. In BHDSS, 25 Hib cases were reported. Nine (36%) were too young to be protected by vaccination and five (20%) were under-vaccinated for age. Disease incidence peaked in 2012-2013 at 15 per 100 000 CY and fell to 5-8 per 100 000 CY over the subsequent four years. The prevalence of Hib carriage was 0.12% in WCR and 0.38% in BHDSS., Conclusions: After 20 years of using three primary doses of Hib vaccine without a booster Hib transmission continues in The Gambia, albeit at low rates. Improved coverage and timeliness of vaccination are of high priority for Hib disease in settings like Gambia, and there are currently no clear indications of a need for a booster dose., Competing Interests: Competing interests: All authors have completed the ICMJE uniform disclosure form at http://www.icmje.org/disclosure.pdf (available upon request from the corresponding author) and declare no conflicts of interest., (Copyright © 2020 by the Journal of Global Health. All rights reserved.)

Concerns have been expressed about the view point of WHO AFRO concerning research for health in the African Region. WHO AFRO considers research a critical component in the improvement of health in the Africa region. Ensuring the effectiveness of our strategies, policies and programmes requires evidence. In the context of the ongoing COVID-19 outbreak, WHO research interests cover key areas of the response. The WHO AFRO consider research as critical in our efforts at protecting people against health emergencies and pandemics like the COVID-19 and ensuring universal access to proven interventions. In view of this, the WHO has taken steps to strengthen capacity for research in the region. The results of these efforts may take time to manifest but will surely do as we persist in our drive, with support from our partners., Competing Interests: The authors declare no competing interests., (© Matshidiso Moeti et al.)

Introduction: Guinea, Sierra Leone and Liberia have attained significant reduction in measles incidence between 2004 and 2013. The Ebola outbreak in 2014-2015 in West Africa caused significant disruption of the health service delivery in the three worst affected countries. The magnitude of the impact on the immunization program has not been well documented., Methods: We reviewed national routine immunization administrative coverage data as well as measles surveillance performance and measles epidemiology in the years before, during and after the EVD outbreak in Guinea, Liberia, Sierra Leone., Results: Both Liberia and Guinea experienced a sharp decline of more than 25% in the monthly number of children vaccinated against measles in 2014 and 2015 as compared to the previous years, while there was no reported decline in Sierra Leone. Guinea and Liberia experienced a decline in measles surveillance activity and performance indicators in 2014 and 2015. During this period, there was an increase in measles incidence and a decline in the mean age of measles cases reported in Liberia and Sierra Leone. Guinea started reporting high measles incidence in 2016. All three countries organized measles supplemental immunization activities by June 2015. Liberia achieved 99% administrative coverage, while Guinea and Sierra Leone attained 90.6% and 97.2% coverage respectively. There were no severe adverse events reported during these mass vaccination activities. The disruptive effect of the Ebola outbreak on immunization services was especially evident in Guinea and Liberia. Our review of the reported administrative vaccination coverage at national level does not show significant decline in measles first dose vaccination coverage in Sierra Leone as compared to other reports. This may be due to inaccuracies in coverage monitoring and data quality problems. The increases in measles transmission and incidence in these three countries can be explained by the rapid accumulation of susceptible children. Despite the organization of mass vaccination activities, measles incidence through 2017 has remained higher than the pre-Ebola period in all three countries., Conclusion: The Ebola outbreak in West Africa significantly affected measles vaccination coverage rates in two of the three worst affected countries, and led to persistent gaps in coverage, along with high measles incidence that was documented until two years after the end of the Ebola outbreak. Liberia and Sierra Leone have demonstrated coverage improvements after the end of the Ebola outbreak., Competing Interests: The authors declare no competing interests., (© Balcha Girma Masresha et al.)

Substantial progress has been achieved in the last two decades with the implementation of measles control strategies in the African Region. Elimination of measles is defined as the absence of endemic transmission in a defined geographical region or country for at least 12 months, as documented by a well-performing surveillance system. The framework for documenting elimination outlines five lines of evidence that should be utilized in documenting and assessing progress towards measles elimination. In March 2017, the WHO regional office for Africa developed and disseminated regional guidelines for the verification of measles elimination. As of May 2019, fourteen countries in the African Region have established national verification committees and 8 of these have begun to document progress toward measles elimination. Inadequate awareness, concerns about multiple technical committees for immunization work, inadequate funding and human resources, as well as gaps in data quality and in the implementation of measles elimination strategies have been challenges that hindered the establishment and documentation of progress by national verification committees. We recommend continuous capacity building and advocacy, technical assistance and networking to improve the work around the documentation of country progress towards measles elimination in the African Region., Competing Interests: The authors declare no competing interests., (© Balcha Masresha et al.)

Meningococcal meningitis remains a significant public health threat, especially in the African meningitis belt where Neisseria meningitidis serogroup A historically caused large-scale epidemics. With the rollout of a novel meningococcal serogroup A conjugate vaccine (MACV) in the belt, the World Health Organization recommended case-based meningitis surveillance to monitor MACV impact and meningitis epidemiology. In 2014, the MenAfriNet consortium was established to support strategic implementation of case-based meningitis surveillance in 5 key countries: Burkina Faso, Chad, Mali, Niger, and Togo. MenAfriNet aimed to develop a high-quality surveillance network using standardized laboratory and data collection protocols, develop sustainable systems for data management and analysis to monitor MACV impact, and leverage the surveillance platform to perform special studies. We describe the MenAfriNet consortium, its history, strategy, implementation, accomplishments, and challenges., (Published by Oxford University Press for the Infectious Diseases Society of America 2019. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Background: A novel meningococcal serogroup A conjugate vaccine (MACV [MenAfriVac]) was developed as part of efforts to prevent frequent meningitis outbreaks in the African meningitis belt. The MACV was first used widely and with great success, beginning in December 2010, during initial deployment in Burkina Faso, Mali, and Niger. Since then, MACV rollout has continued in other countries in the meningitis belt through mass preventive campaigns and, more recently, introduction into routine childhood immunization programs associated with extended catch-up vaccinations., Methods: We reviewed country reports on MACV campaigns and routine immunization data reported to the World Health Organization (WHO) Regional Office for Africa from 2010 to 2018, as well as country plans for MACV introduction into routine immunization programs., Results: By the end of 2018, 304 894 726 persons in 22 of 26 meningitis belt countries had received MACV through mass preventive campaigns targeting individuals aged 1-29 years. Eight of these countries have introduced MACV into their national routine immunization programs, including 7 with catch-up vaccinations for birth cohorts born after the initial rollout. The Central African Republic introduced MACV into its routine immunization program immediately after the mass 1- to 29-year-old vaccinations in 2017 so no catch-up was needed., Conclusions: From 2010 to 2018, successful rollout of MACV has been recorded in 22 countries through mass preventive campaigns followed by introduction into routine immunization programs in 8 of these countries. Efforts continue to complete MACV introduction in the remaining meningitis belt countries to ensure long-term herd protection., (© The Author(s) 2019. Published by Oxford University Press for the Infectious Diseases Society of America.)

Despite the remarkable power of immunization reducing morbidity and mortality due to vaccine preventable diseases, one in five African children still does not receive all the basic, necessary vaccines. This is particularly true of the 10 middle-income countries (MICs) in the WHO African Region, where data demonstrates that immunization coverage is decreasing. These countries are not eligible for Gavi support in accessing new vaccines because of their relatively high per capita income level and will gradually increase with the transitioning of countries out of Gavi support. Thus, WHO was requested to facilitate access to affordable vaccines in relation to middle-income countries and those transitioning out of Gavi support in the near future. With commitment to address the issue, WHO Regional Office for Africa convened a consultative meeting from 09 to 11 April 2018 in Brazzaville, Congo to explore ways of improving access to affordable vaccines for MICs in the Region. The meeting brought together 17 low, middle and upper middle income countries in the African Region. Immunization partners and other WHO Regions also participated in the consultation to share experiences and explore ways of increasing access to affordable vaccines in MICs in the African Region. At the end of the meeting a number of solutions and action points were proposed for implementation in the Region., (Copyright © 2019. Published by Elsevier Ltd.)

Background: In 2015, the World Health Organization (WHO) updated the global methodology for assessing and reducing missed opportunities for vaccination (MOV), when eligible children have contact with the health system but are not vaccinated. This paper presents the results of two pilot assessments conducted in Chad and Malawi., Methods: Using the ten-step global WHO MOV strategy, we purposively selected districts and health facilities, with non-probabilistic sampling of <24 month old children for exit interviews of caregivers and self-administered knowledge, attitudes, and practices (KAP) surveys of health workers. MOV were calculated based on a child's documented vaccination history (i.e., from a home-based record (HBR) or a health facility vaccination register), including selected vaccines in the national schedule., Results: Respondents included caregivers of 353 children in Chad and of 580 children in Malawi. Among those with documented vaccination history, 82% (195/238) were eligible for vaccination in Chad and 47% (225/483) in Malawi. Among eligible children, 51% (99/195) in Chad, and 66% (149/225) in Malawi had one or more MOV on the survey date. During non-vaccination visits, 77% (24/31) of children eligible for vaccination in Chad and 92% (119/129) in Malawi had a MOV compared to 46% (75/164) and 31% (30/96) during vaccination visits, respectively. Among health workers, 92% in Chad and 88% in Malawi were unable to correctly identify valid contraindications for vaccination., Conclusion: The new MOV tool was able to characterize the type and potential causes of MOV. In both countries, the findings of the assessments point to two major barriers to full vaccination of eligible children-a lack of coordination between vaccination and curative health services and incomplete vaccination during vaccination visits. National immunization programs should explore tailored efforts to improve health worker practices and to increase vaccine delivery by making better use of existing health service contacts., Competing Interests: The authors have declared that no competing interests exist.

Tetanus is a vaccine-preventable disease of significant public health importance especially in developing countries. The WHO strategy for the elimination of maternal and neonatal tetanus recommends the promotion of clean delivery practices, systematic immunization of pregnant women and those in the reproductive age (15-49 years) and surveillance for neonatal tetanus. Implementation of the recommended strategy with the support of WHO, UNICEF and other partners has led to significant decline in number of cases and deaths due to NT over the last decades. The coverage with the second or more dose of tetanus toxoid-containing vaccines (TT2+) a proxy for Protection at Birth (PAB) for the WHO African region has risen from 62% in 2000 to 77% by 2015 Reported cases of NT declined from 5175 in 2000 to 1289 in 2015. The goal of eliminating maternal and neonatal tetanus by 2015 was missed, but some progress has been made. By the end of 2016, 37 out of 47 (79%) of the WHO AFR member states achieved elimination. The 10 member states remaining need additional support by all partners to achieve and maintain the goal of MNTE. Innovative ways of implementing the recommendations need to be urgently considered.

Introduction: Few African countries have introduced a birth dose of hepatitis B vaccine (HepB-BD) despite a World Health Organization (WHO) recommendation. HepB-BD given within 24 hours of birth, followed by at least two subsequent doses, is 90% effective in preventing perinatal transmission of hepatitis B virus. This article describes findings from assessments conducted to document the knowledge, attitudes, and practices surrounding HepB-BD implementation among healthcare workers in five African countries., Methods: Between August 2015 and November 2016, a series of knowledge, attitude and practices assessments were conducted in a convenience sample of public and private health facilities in Botswana, the Gambia, Namibia, Nigeria, and São Tomé and Príncipe (STP). Data were collected from immunization and maternity staff through interviewer-administered questionnaires focusing on HepB-BD vaccination knowledge, practices and barriers, including those related to home births. HepB-BD coverage was calculated for each visited facility., Results: A total of 78 health facilities were visited: STP 5 (6%), Nigeria 23 (29%), Gambia 9 (12%), Botswana 16 (21%), and Namibia 25 (32%). Facilities in the Gambia attained high total coverage of 84% (range: 60-100%) but low timely estimates 7% (16-28%) with the median days to receiving HepB-BD of 11 days (IQR: 6-16 days). Nigeria had low total (23% [range: 12-40%]), and timely (13% [range: 2-21%]) HepB-BD estimates. Facilities in Botswana had high total (94% [range: 80-100%]), and timely (74% [range: 57-88%]) HepB-BD coverage. Coverage rates were not calculated for STP because the maternal Hepatitis B virus (HBV) status was not recorded in the delivery registers. The study in Namibia did not include a coverage assessment component. Barriers to timely HepB-BD included absence of standard operating procedures delineating staff responsible for HepB-BD, not integrating HepB-BD into essential newborn packages, administering HepB-BD at the point of maternal discharge from facilities, lack of daily vaccination services, sub-optimal staff knowledge about HepB-BD contraindications and age-limits, lack of outreach programs to reach babies born outside facilities, and reporting tools that did not allow for recording the timeliness of HepB-BD doses., Discussion: These assessments demonstrate how staff perceptions and lack of outreach programs to reach babies born outside health facilities with essential services are barriers for implementing timely delivery of HepB-BD vaccine. Addressing these challenges may accelerate HepB-BD implementation in Africa., Competing Interests: Conflict of Interest None

Objective: This paper assesses and describes the estimated coverage of the Measles Rubella (MR) campaign in each district; the national estimate of coverage for Human Papilloma Virus (HPV) vaccination campaign and Vitamin A supplementation simultaneously implemented in 2013., Methods: We applied descriptive statistics and epidemiological tools to the outcomes of the campaigns to assess the coverage achieved on the different child and maternal health interventions. We also assessed the Adverse Events following Immunization (AEFI) where the evaluation was used at the same time to assess the routine immunization performance coverage for children 12-24 months for all childhood antigens, Tetanus Toxoid coverage among mothers of infants, combined with routine immunization performance evaluation, skilled delivery and bed nets use in Rwanda., Results: Results indicated that among the eligible targets, 97.5% received MR vaccine, 91% received HPV doses, and 83% got Vitamin A. The integrated vaccination of MR with HPV did not result in any serious AEFI. Coverage for antigens and doses given early in life was above 95% with card retention of 80%. BCG to measles dropout by card was 8.5%. Main reasons for non-vaccination indicated need for more specific immunization education. About 96.8% of mothers delivered in health institutions and 95% of the mothers slept under bed nets the night before the survey., Conclusion: Rwanda successfully implemented an integrated coverage evaluation survey of the integrated vaccination campaign and routine immunization with statistically valid estimates. We drew lessons that information on routine immunization can be collected during post campaign survey evaluations. The district estimates should guide the programme performance improvement.

Case based surveillance for measles is implemented in the African Region integrated with Acute Flaccid Paralysis (AFP) surveillance. In 2011, the Region adopted a measles elimination goal to be achieved by 2020, which included coverage, incidence and surveillance performance targets. We reviewed measles case-based surveillance data and surveillance performance from countries in the African Region for the years 2012 - 2016. During this period, a total of 359,019 cases of suspected measles were reported from the 44 of 47 (94%) countries using the case based surveillance system. Of these, 202,126 (56%) had specimens collected for laboratory testing. A total of 39,806 measles cases and 25,679 rubella cases were confirmed by IgM serology. Twelve countries met the two principal surveillance performance indicators for each year during the period and four countries met neither indicator over the period. At the Regional level, both surveillance targets were met in 3 of the 5 years in the period of study; however performance varies widely by country. Surveillance performance did not improve across the Region during the 5 years period. High quality surveillance performance is critical to support the achievement of the regional measles elimination goal. Better integrating implementation with AFP surveillance, securing predictable long-term funding sources, and conducting detailed evaluations at country level to identify and address the root cause of performance gaps is recommended., Competing Interests: Conflict of Interest None

Background: Some progress has been made in expanding immunization in the African Region over the last four decades. However, an estimated 22% of the eligible children in the African Region, located in four countries of the African Region (Democratic Republic of the Congo, Ethiopia, Nigeria and South Africa), continue to miss vaccination services for various reasons. This paper documents the status of routine immunization in the African Region., Methods: Programme records, reports and statistics were reviewed for this paper., Results: Challenges remain in reaching an estimated 20-30% of children across the Region. In addition to the traditional vaccines (DTP, measles, polio and tuberculosis) newer ones, such as for Pneumococcal conjugate vaccine (PCV) and rotavirus, are being rolled out in the Region but uptake and coverage are slow and patchy both within and between countries., Conclusion: The new regional strategic plan for immunization 2014-2020 is intended to provide policy and programmatic guidance to Member States, in line with the 2011-2020 Global Vaccine Action Plan (GVAP), in order to optimize immunization services and assist countries to further strengthen their immunization programmes.

The 5 th edition of the African Vaccination Week (AVW) kicked off in Lusaka, Zambia, on 23 April 2016, the same day as did the 4th World Immunization Week (WIW), and vaccination week in other WHO regions. The theme was "Save lives, prevent disabilities, vaccinate!". The aim was to draw attention to the need to attain universal immunization coverage in the African Region by closing the immunization gap, while also celebrating the important polio eradication milestone reached in the African Region. Twenty-eight (59.6%) of the 47 countries in the African Region celebrated the AVW within the regionally set dates of 24 th to 30 th April 2015. However, given its flexibility, the celebration continued until September in 15 other countries in the Region. Three countries, namely Comoros, Gabon, and Cape Verde did not join the celebration for the 2015 edition of the AVW. Countries used the opportunity to introduce new vaccines into their routine immunization. Populations, hitherto unreached with basic health services were reached with needed services, such as vitamin A supplementation, deworming, and catch up immunization services. The programmes promoted awareness of the benefits of vaccines and the rights of communities to demand vaccines and immunization services to save lives and prevent disabilities. The number of participating countries rose steadily from 40 in 2011 to 43 and 46 countries in 2013 and 2014 respectively. The number ranged from one intervention integrated with AVW in 17 countries to 5 interventions integrated with the AVW in three countries. In 2015, 67.4% of the participating countries integrated other interventions with AVW activities., Competing Interests: Conflict of Interest Authors have no conflict of interest to declare.

Introduction: Rubella is a mild febrile rash illness caused by the rubella virus. The most serious consequence of rubella is congenital rubella syndrome (CRS), which occurs if the primary rubella infection occurs during early pregnancy, with subsequent infection of the placenta and the developing fetus., Methods: WHO supported countries to set up sentinel surveillance for CRS using standard case definitions, protocols, and case classification scheme. This descriptive analysis summarises the data from 5 countries which have been regularly reporting., Results: A total of 383 suspected cases of CRS were notified from the 5 countries as of December 2016, of which 52 cases were laboratory confirmed and 67 were confirmed on clinical grounds.The majority (43%) of confirmed CRS cases were in the age group 6 - 11 months. The most common major clinical manifestation (Group A) among the confirmed cases is congenital heart disease (72%) followed by cataracts (32%) and glaucoma (10%)., Discussion and Conclusions: The number of years of reporting from these sentinel sites is too short to describe trends in CRS occurrence across the years. However, the limited surveillance data has yielded comparable information with other developing countries prior to introduction of rubella vaccine. As more countries introduce rubella vaccine into their immunisation programs, there is a need to ensure that all rubella outbreaks are thoroughly investigated and documented, to expand sentinel surveillance for CRS in more countries in the Region, and to complement this with retrospective record reviews for CRS cases in selected countries., Competing Interests: Conflict of Interest None

Background: Measles elimination is defined as the absence of endemic measles virus transmission in a defined geographic area for at least 12 months in the presence of a well-performing surveillance system. The WHO framework for verification of measles elimination indicates that the achievement of measles and/or rubella elimination should be verified for individual countries., Objective: We identified 11 high performing countries based on their first dose measles vaccination coverage, and looked at their performance across the various programmatic parameters, to see if they are ready to undertake the verification of measles elimination., Methods: We identified 11 countries with >90% measles first dose coverage for the most recent 5 years according to the WHO UNICEF estimates of national immunisation coverage. We analysed vaccination coverage and surveillance performance in these countries., Results: Algeria, Botswana, Gambia, Mauritius, Rwanda, Seychelles have maintained measles first dose (MCV1) coverage of 95% or more since 2011. In 2015, only Algeria, Cape Verde and Seychelles had coverage of 95% or more for the second dose of measles vaccine (MCV2). Of the 22 supplemental immunisation activities (SIAs) among the 11 countries, only 6 had administrative coverage of less than 95%. Only Rwanda and Lesotho attained the case-based surveillance performance targets in all the five years., Conclusion: Despite their high routine first dose measles immunisation coverage, all of the 11 countries have some program gaps indicating that they do not meet all the criteria to undergo verification of elimination at this point. It is recommended for these countries to set up national verification committees as per the WHO framework for verification of measles elimination, in order to initiate the documentation and monitoring of progress, and to address programmatic gaps in the coming years., Competing Interests: Conflict of Interest None

Background: Missed opportunities for vaccination (MOVs), estimated to be about 32-47% of child healthcare clinic visits in various settings globally, contribute to unfulfilled childhood vaccination coverage targets in the African region., Objective: We assessed the extent of MOVs, identify local drivers and test interventions to reduce MOVs in Malawi., Methods: We conducted in-depth and key informant interviews with administrators of district hospitals and officers in charge of community health facilities. Focus group discussions were held with health workers and caregivers of children under 24 months of age who received services from study health facilities in Malawi. Coverage rates were collected from the health facility records., Results: Vaccination is appreciated in the communities, but coverage is generally below targets. In some facilities, reported coverage was less than 50%. Opportunities to provide up-to-date vaccination for children were missed due to lack of awareness and knowledge of health workers and caregivers, attitude and priority of health workers, long waiting time, poor coordination and referral of eligible children by clinicians and nurses and overall lack of a team approach to vaccination perceived as a responsibility of health surveillance assistants. Other notable issues included limited time of caregivers labouring on estate farms, unavailability of vaccines resulting from poorly functioning of cold chain equipment and limited transport and failure to appreciate the impact of MOV on poor immunization coverage., Conclusion: Simple, low-cost, pragmatic and community-driven interventions that may reduce MOVs and improve vaccine coverage., Competing Interests: Conflict of Interest None

Objective: This paper gives a brief update on the status of the immunization and vaccine development in the WHO African Region. It also highlights the progress on the control, elimination or eradication of vaccine preventable diseases in the African Region., Method: The paper reviews national immunization programme data as well as WHO-UNICEF Estimates for Immunization Coverage (WUENIC) in the African Region from 2012-2016., Results: It revealed that there has been considerable success with the development and introduction of new vaccines in the Region. However, uptake of these vaccines has not matched the level of success in new vaccine introduction. This has made the goal of reaching high and equitable immunization coverage a mirage in the Region. Multiple barriers have been blamed for this, chief among which are inadequate commitment of national governments and weak community engagement to immunization service delivery in the Region. Steps are taken to address these issues, including sensitization of government of the African Region to prioritize Universal Access to Immunization as a Cornerstone for Health and Development in Africa. This is because it is argued that development efforts are link to the human beings for whom progress is targeted and/or agents that bring about development., Conclusion: Saving human lives therefore is critical to the realization of development goals. It is important that immunization coverage is universal to achieve the control/elimination of vaccine preventable diseases.

Rotavirus is a leading cause of severe pediatric diarrhea globally, estimated to have caused 120,000 deaths among children aged <5 years in sub-Saharan Africa in 2013 (1). In 2009, the World Health Organization (WHO) recommended rotavirus vaccination for all infants worldwide (2). Two rotavirus vaccines are currently licensed globally: the monovalent Rotarix vaccine (RV1, GlaxoSmithKline; 2-dose series) and the pentavalent RotaTeq vaccine (RV5, Merck; 3-dose series). This report describes progress of rotavirus vaccine introduction (3), coverage (using estimates from WHO and the United Nations Children's Fund [UNICEF]) (4), and impact on pediatric diarrhea hospitalizations in the WHO African Region. By December 2016, 31 (66%) of 47 countries in the WHO African Region had introduced rotavirus vaccine, including 26 that introduced RV1 and five that introduced RV5. Among these countries, rotavirus vaccination coverage (completed series) was 77%, according to WHO/UNICEF population-weighted estimates. In 12 countries with surveillance data available before and after vaccine introduction, the proportion of pediatric diarrhea hospitalizations that were rotavirus-positive declined 33%, from 39% preintroduction to 26% following rotavirus vaccine introduction. These results support introduction of rotavirus vaccine in the remaining countries in the region and continuation of rotavirus surveillance to monitor impact.

The Polio Eradication and Endgame Strategic plan outlines the phased removal of oral polio vaccines (OPVs), starting with type 2 poliovirus-containing vaccine and introduction of inactivated polio vaccine in routine immunization to mitigate against risk of vaccine-associated paralytic polio and circulating vaccine-derived poliovirus. The objective includes strengthening routine immunization as the primary pillar to sustaining high population immunity. After 2 years without reporting any wild poliovirus (July 2014-2016), the region undertook the synchronized switch from trivalent OPV (tOPV) to bivalent OPV (bOPV) as recommended by the Strategic Advisory Group of Experts on Immunization. Consequently the 47 countries of the World Health Organization (WHO) African Region switched from the use of tOPV to bOPV within the stipulated period of April 2016. Planning started early, routine immunization was strengthened, and technical and financial support was provided for vaccine registration, procurement, destruction, logistics, and management across countries by WHO in collaboration with the United Nations Children's Fund (UNICEF) and partners. National commitment and ownership, as well as strong coordination and collaboration between UNICEF and WHO and with partners, ensured success of this major, historic public health undertaking., (© The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America.)

Background: To monitor immunization-system strengthening in the Polio Eradication Endgame Strategic Plan 2013-2018 (PEESP), the Global Polio Eradication Initiative identified 1 indicator: 10% annual improvement in third dose of diphtheria- tetanus-pertussis-containing vaccine (DTP3) coverage in polio high-risk districts of 10 polio focus countries., Methods: A multiagency team, including staff from the African Region, developed a comprehensive list of outcome and process indicators measuring various aspects of the performance of an immunization system., Results: The development and implementation of the dashboard to assess immunization system performance allowed national program managers to monitor the key immunization indicators and stratify by high-risk and non-high-risk districts., Discussion: Although only a single outcome indicator goal (at least 10% annual increase in DTP3 coverage achieved in 80% of high-risk districts) initially existed in the endgame strategy, we successfully added additional outcome indicators (eg, decreasing the number of DTP3-unvaccinated children) as well as program process indicators focusing on cold chain, stock availability, and vaccination sessions to better describe progress on the pathway to raising immunization coverage., Conclusion: When measuring progress toward improving immunization systems, it is helpful to use a comprehensive approach that allows for measuring multiple dimensions of the system., (© The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America.)

The World Health Organization (WHO) African Region has approximately 100 million people with chronic hepatitis B virus (HBV) infection. This review describes the status of hepatitis B control in the Region. We present hepatitis B vaccine (HepB) coverage data and from available data in the published literature, the impact of HepB vaccination on hepatitis B surface antigen (HBsAg) prevalence, a marker of chronic infection, among children, HBsAg prevalence in pregnant women, and risk of perinatal transmission. Lastly, we describe challenges with HepB birth dose (HepB-BD) introduction reported in the Region, and propose strategies to increase coverage. In 2015, regional three dose HepB coverage was 76%, and 16(34%) of 47 countries reported ≥ 90% coverage. Overall, 11 countries introduced HepB-BD; only nine provide universal HepB-BD, and of these, five reported ≥ 80% coverage. From non-nationally representative serosurveys among children, HBsAg prevalence was lower among children born after HepB introduction compared to those born before HepB introduction. However, some studies still found HBsAg prevalence to be above 2%. From limited surveys among pregnant women, the median HBsAg prevalence varied by country, ranging from 1.9% (Madagascar) to 16.1% (Niger); hepatitis B e antigen (HBeAg) prevalence among HBsAg-positive women ranged from 3.3% (Zimbabwe) to 28.5% (Nigeria). Studies in three countries indicated that the risk of perinatal HBV transmission was associated with HBeAg expression or high HBV DNA viral load. Major challenges for timely HepB-BD administration were poor knowledge of or lack of national HepB-BD vaccination guidelines, high prevalence of home births, and unreliable vaccine supply. Overall, substantial progress has been made in the region. However, countries need to improve HepB3 coverage and some countries might need to consider introducing the HepB-BD to help achieve the regional hepatitis B control goal of < 2% HBsAg prevalence among children < 5 years old by 2020. To facilitate HepB-BD introduction and improve timely coverage, strategies are needed to reach both facility-based and home births. Strong political commitment, clear policy recommendations and staff training on HepB-BD administration are also required. Furthermore, high quality nationally representative serosurveys among children are needed to inform decision makers about progress towards the regional control goal.

Immunization has made significant contribution to public health in the African Region, including elimination, eradication and control of life threatening diseases. Hospitalization due to vaccine preventable diseases has been drastically reduced due to introduction of new effective vaccines. However, optimizing the benefits of immunization by achieving high universal coverage has met with many challenges. The Regional immunization coverage, though raised from its low 57% in 2000 to 76% in 2015 has remained below expected target. Worse still, it has stagnated around 70% for a prolonged period. Cases of inequity in access to immunization service continue to exist in the region. This paper therefore explored the different challenges to immunization in the African Region. Some of the challenges it identifies and discusses include issues of sustainable funding and resources for immunization, vaccine stock-outs, and logistics. Others include data issues and laboratory infrastructure. The paper also attempted some possible solutions.

Periodic measles supplemental immunisation activities (SIAs) increase population immunity and thereby reduce the pool of accumulated susceptible children. They are typically conducted every 2 - 4 years, and most often target children up to five years of age. Between 2012 and 2015, after surveillance data indicated a shift in the epidemiological profile of measles towards older age groups, 11 countries were supported to conduct wide age range SIAs based on their local epidemiological patterns. Six other countries conducted SIAs with measles-rubella vaccines targeting ages 9 months to 14 years as an initial step of introducing rubella vaccine into the immunization program. In subsequent years, the incidence of confirmed measles dropped significantly in 13 of the 17 countries reviewed. The findings emphasize the importance of well-functioning surveillance systems, and the benefits of using of surveillance data to determine the specific target age-range for periodic SIAs to accelerate progress towards measles elimination.