Supporting national immunization technical advisory groups (NITAGs) in resource-constrained settings. New strategies and lessons learned from the Task Force for Global Health’s Partnership for influenza vaccine introduction

National Immunization Technical Advisory Groups (NITAGs) are multidisciplinary national experts who provide independent, evidence-informed vaccine policy recommendations to national health authorities. An essential NITAG function is to ensure that these decisions are grounded in the best available evidence generated through a systematic, transparent process. However, in many low- and middle-income countries (LMICs), experience with this decision making method is limited. The Task Force for Global Health manages the Partnership for Influenza Vaccine Introduction (PIVI) program in collaboration with the Centers for Disease Control and Prevention, Ministries of Health, corporate partners and others. During 2017, PIVI worked with its country partners and the World Health Organization regional and local offices to assess NITAG strengthening needs and to provide technical assistance in 7 LMIC countries (Laos Peoples Democratic Republic, Mongolia, Vietnam, Armenia, Côte d’Ivoire; Moldova and the Republic of Georgia). Our workshops supported general NITAG capacity building and the evidence-based review process using vaccines of interest to the country. For NITAGs reviewing evidence on seasonal influenza, we developed an influenza resource package to support their review and provide country-relevant information in an easy to use format. Of the seven NITAGs trained, six have applied some of the concepts learnt: revision or development of formal transparent, systematic procedures for their operations; preparation of recommendations on seasonal influenza vaccination using quality-assessed data from systematic searches and local data; and have applied the principles learned for making other new vaccine recommendations. Our experience confirms that LMIC NITAGs are considerably under-resourced without adequate technical support or access to global peer-reviewed literature. Ongoing support from NITAG partners must be secured and creative approaches might be needed to help countries achieve the GVAP 2020 target and support development of sustainable vaccine policies and programs.     

Transcatheter aortic valve replacement in the developing world: Lessons learnt and its implications for practice

BackrgroundTranscatheter aortic valve replacement (TAVR) has become an accepted modality of treatment in intermediate and high surgical risk patients of symptomatic severe calcific aortic stenosis (AS). We herein report Indian data of 84 intermediate and high-risk patients who underwent TAVR at two Armed Forces cardiac centres.MethodsMost of the patients underwent TAVR in cardiac catheterization lab by percutaneous transfemoral approach, under conscious sedation. Patients were followed up and echocardiographic parameters were assessed after six months of procedure.ResultsTotal of 84 intermediate and high-risk patients underwent TAVR between Jan 2017 and June 2021. Mean age of population was 71.5 ± 8.4 years; 28.5% of patients had bicuspid aortic valve and Mean STS score was 6.34 ± 2.08. Majority (92.8%) patients underwent the procedure under conscious sedation. Self-expanding valves were used in 72.6% and balloon expandable in 27.4% of patients. Predilatation was done in 64% patients while 13% cases underwent post dilatation. Procedural mortality was 2.3%. Rate of permanent pacemaker implantation was 4.9%. Ischemic stroke occurred in 1.1% of patents. There was no case of severe paravalvular leak. Emergency surgical aortic valve replacement was done in 2.4% patients. Procedural success in this study was 97.6%. All-cause mortality was 9.5% at 6 months.ConclusionsTAVR is an effective treatment modality in intermediate and high-risk Indian patients with severe aortic stenosis. Patients with bicuspid or previous bio prosthetic aortic valves also have a good outcome post TAVR.     

Systematic assessment of South Korea’s capabilities to control COVID-19

South Korea’s COVID-19 control strategy has been widely emulated. Korea’s ability to rapidly achieve disease control in early 2020 without a “Great Lockdown” despite its proximity to China and high population density make its achievement particularly intriguing. This paper helps explain Korea’s pre-existing capabilities which enabled the rapid and effective implementation of its COVID-19 control strategies. A systematic assessment across multiple domains demonstrates that South Korea’s advantages in controlling its epidemic are owed tremendously to legal and organizational reforms enacted after the MERS outbreak in 2015. Successful implementation of the Korean strategy required more than just a set of actions, measures and policies. It relied on a pre-existing legal framework, financing arrangements, governance and a workforce experienced in outbreak management.     

Preparing for the next public debate: universal vaccination against hepatitis B

WHO have long called for universal vaccination against hepatitis B worldwide. However, in north-western Europe low incidence of the disease has fueled debate whether targeted or universal vaccination strategies are the way to go for. Careful assessment has made it clear that the extensive targeted hepatitis B vaccination programmes in the Netherlands nevertheless fail to reach a significant part of the risk groups and have not succeeded in eliminating the disease. Modelling suggests that the public health benefits obtained through targeted programmes could be augmented considerably by universal vaccination. Therefore, the Minister of Health of the Netherlands has decided to implement universal vaccination by October 2011. We illustrate the case of the Netherlands and explore lessons, which can be learnt from the vaccination programmes against HPV and influenza A/H1N1 and how to prepare for a potential public debate that might arise when implementing universal vaccination against hepatitis B.     

Public Health Surveillance in Pilot Drinking Water Contamination Warning Systems

Objective

This paper describes the lessons learned from operation and maintenance of the public health surveillance (PHS) component of five pilot city drinking water contamination warning systems (CWS) including: Cincinnati, New York, San Francisco, Philadelphia, and Dallas.

Introduction

The U.S. Environmental Protection Agency (EPA) designed a program to pilot multi-component contamination warning systems (CWSs), known as the “Water Security initiative (WSi).” The Cincinnati pilot has been fully operational since January 2008, and an additional four pilot utilities will have their own, custom CWSs by the end of 2012. A workshop amongst the pilot cities was conducted in May 2012 to discuss lessons learned from the design, implementation, operation, maintenance, and evaluation of each city’s PHS component.

Methods

When evaluating potential surveillance tools to integrate into a drinking water contamination warning system, it is important to consider design decisions, dual use applications/considerations, and the unique capabilities of each tool. The pilot cities integrated unique surveillance tools, which included a combination of automated event detection tools and communication and coordination procedures into their respective PHS components. The five pilots performed a thorough, technical evaluation of each component of their CWS, including PHS.

Results

Four key lessons learned were identified from implementation of the PHS component in the five pilot cities. First, improved communication and coordination between public health and water utilities was emphasized as an essential goal even if it were not feasible to implement automated surveillance systems. The WSi pilot project has helped to strengthen this communication pathway through the process of collaborating to develop the component, and through the need to investigate PHS alerts.Second, the approximate location of specific cases associated with PHS alerts was found to be an essential feature that allowed a cross-comparison to water pressure zones when attempting to locate the source of possible contamination. More specific location data (e.g., latitude and longitude) leads to a more efficient investigation, however, just narrowing the case location down to a specific hydraulic region within the water distribution system is extremely useful.Third, the ability to quickly visualize spatial distribution of cases via a visual interface was reported to be valuable to investigators during alert investigations. Most pilots implemented a CWS dashboard, in the form of a central graphical display, which presents the alerts and was used by the water utility and public health to obtain an understanding of geospatial relationships between cases, alerts and water pressure zones.Finally, public health and water utility representatives from several of the WSi pilots acknowledged that their automated surveillance tools currently have limited capabilities for detection of chemical contaminants (which may result in a sudden onset of symptoms), with the main deficiency being the timeliness of the alerts relative to the window of opportunity to respond in a meaningful and effective manner. While they currently focus on detection of traditional waterborne diseases, these tools could potentially be adapted to also detect chemical contaminants.

Conclusions

The results of the pilots have demonstrated that it is important to construct and formalize standard operating procedures, so that public health personnel and water utilities have a standard communication protocol. As a basic step to a PHS component, it is important to establish a relationship between utilities and public health. In addition to the efforts of the WSi pilots, research is currently being conducted by the U.S. EPA to analyze health seeking behavior of symptomatic individuals, because all PHS tools rely on data generated from behavior pursued by the affected population during a public health incident. Results from analysis of both emergency department data and poison control center follow-up phone data are currently underway.     

新疆维吾尔自治区2011年输入脊髓灰质炎野病毒并引起局部传播的调查处置经验和教训

2011年,新疆维吾尔自治区（新疆）发生输入I型脊髓灰质炎（脊灰）野病毒（Type 1 Wild Poliovirus,WPV1）并引起局部传播,共报告实验室确诊脊灰21例,分布在和田地区、喀什地区、巴音郭楞蒙古自治州（巴州）和阿克苏地区。经世界卫生组织全球脊灰实验室网络协查,此次输入的病毒源自巴基斯坦。卫生部和新疆维吾尔自治区人民政府立即启动II级应急响应,建立了与国际组织、部门之间的协作机制,加强急性弛缓性麻痹（Acute Flaccid Paralysis,AFP）病例监测,开展5轮口服脊灰减毒活疫苗应急免疫活动,其接种4300万人次。通过迅速采取正确有效的措施,阻断了输入WPV1的传播。新疆输入WPV1事件的发生,提示中国维持无脊灰存在着薄弱地区和薄弱环节,需要大力加强常规免疫服务和AFP病例监测工作。