Oral pre-exposure prophylaxis (PrEP) reduces HIV acquisition risk from sex by 99% and from injection drug use by ≥74% when used as recommended. The Joint United Nations Programme on HIV/AIDS (UNAIDS) has set a goal of 21.2 million persons using (initiating or continuing) PrEP globally in 2025. In 2016, CDC, with the U.S. President's Emergency Plan for AIDS Relief, joined ministries of health to implement PrEP globally. PrEP is beneficial for persons at substantial risk for acquiring HIV, including but not limited to key populations, which include female sex workers, men who have sex with men, persons in prisons and other enclosed settings, persons who inject drugs, and transgender persons. Annual country targets were used to guide scale-up. In 2023, CDC supported 856,816 PrEP initiations, which represents nearly one quarter of the 3.5 million persons globally who either initiated or continued PrEP that year. During 2017-2023, CDC supported PrEP initiations for 2,278,743 persons, 96.0% of whom were in sub-Saharan Africa. More than one half (64.0%) were female and 44.9% were aged 15-24 years. Overall, CDC achieved 118.7% of its PrEP initiation targets for the 7-year period. Among PrEP initiations for key populations, the majority in sub-Saharan Africa were female sex workers, whereas in Southeast Asia, Eurasia, and the Americas, the majority were men who have sex with men. Continued rapid scale-up is needed to meet the UNAIDS goal to end HIV as a public health threat.

INTRODUCTION: Highly sensitive acute flaccid paralysis (AFP) surveillance is critical for detection of poliovirus circulation and documentation for polio-free certification. The reverse cold chain (RCC) is a system designed to maintain stool specimens in appropriate temperature for effective detection of poliovirus in the laboratory. We monitored the RCC of AFP surveillance in Nigeria to determine its effectiveness in maintaining viability of enterovirus. METHODS: A descriptive cross-sectional study was conducted from November 2017 to December 2019. We included AFP cases from 151 Local Government Areas and monitored RCC of paired stool specimens from collection to arrival at laboratories. The national guideline recommends RCC temperature of +2 to +8°C and a non-polio enterovirus (NPENT) detection rate of ≥10%. We analyzed data with Epi Info 7, and presented results as frequencies and proportions, using Chi-square statistic to test for difference in enterovirus isolation. RESULTS: Of the 1,042 tracked paired stool specimens, 1,038(99.6%) arrived at the laboratory within 72 hours of collection of second specimen, 824(79.1%) were maintained within recommended temperature range, and 271(26%) yielded enteroviruses: 200(73.8%) NPENT, 66(24.4%) Sabin, 3(1.1%) vaccine derived poliovirus type 2 and 2(0.7%) mixture of Sabin and NPENT. The NPENT and Sabin rates were 19.2% and 6.7% respectively. Twenty-five percent of 824 specimens maintained within recommended temperature range, compared with 29.8% of 218 specimens with temperature excursion yielded enteroviruses (P=0.175). CONCLUSION: the RCC of AFP surveillance system in the study area was optimal and effective in maintaining the viability of enteroviruses. It was unlikely that poliovirus transmission was missed during the intervention.

INTRODUCTION: to support polio eradication activities in Nigeria, in 2012 the National Polio Emergency Operation Center (NEOC) created the Management Support Teams (MST) to address gaps in the quality of supervision of polio vaccination teams. The National Stop Transmission of Polio (NSTOP) Program supported the polio eradication activities by deploying trained supervisors as part of the MST for polio and non-polio immunization campaigns. METHODS: trained MST members were deployed approximately 4 days before the start of the campaign to participate in pre-implementation activities and supervise vaccination teams during campaigns. Terms of reference (TOR) developed by NEOC was provided to MST members to guide their activities. Qualified MSTs that met pre-determined criteria were selected and deployed to the field to support pre, intra and post campaigns activities. RESULTS: a pool of over 400 MST personnel have been identified, trained, and repeatedly deployed from 2012 till 2016. The number of deployed MST personnel rose from 40 per campaign in October 2012 to 342 in May 2016. Of these, 270 (79%) MST personnel were deployed to 11 polio high-risk states of northern Nigeria, where campaigns are conducted between eight and ten times yearly as planned by NEOC. For measles campaigns, about 300 (75%) MST personnel were deployed for the one-off northern and southern campaigns in 2016. The results of clustered Lot Quality Assurance Sampling (LQAS) post-campaign vaccination coverage surveys, a measure of campaign quality, of which introduction into the polio program coincided with deployment of MSTs, showed improvement over time, from 10% (very poor quality) in February 2012 to about 90% (good quality) in December 2016. CONCLUSION: the deployment of MST personnel increased the number of trained supervisors in the field, frequency of supervisory visits and had a positive impact on the quality of polio campaigns.

INTRODUCTION: following the spread of the COVID-19 pandemic to Nigeria, the Federal Government of Nigeria restricted human and vehicular movements to curb the spread of the disease. This action had a negative impact on Acute Flaccid Paralysis (AFP) surveillance, with a resultant reduction in the number of AFP cases reported. This paper describes the impact of the COVID-19 pandemic on poliovirus surveillance in Nigeria and the proactive interventions by Nigeria´s polio program to mitigate the impact of COVID-19 on polio surveillance. METHODS: nine innovative strategies were implemented in all 774 Local Government Areas (LGA) of the 36 states and Federal Capital Territory (FCT) of the country. These strategies were developed by the national surveillance officers and operationalized by sub-national surveillance officers with different strategies starting at different epidemiological weeks from week 14 to 23, 2020. Many of the strategy innovations were technology-based and included: the use of mobile phones to send the AFP case definition and video by WhatsApp or by SMS, the use of state-specific toll-free numbers and Mobile Telephone Network (MTN) (mobile service provider) CallerfeelTM to community informants (CI) who were the main targets of the interventions to increase case detection and reporting. Others included the use of abridged e-surveillance integrated supportive supervision (ISS) checklists, virtual monthly DSNO meetings, and batched AFP stool specimen transportation network. RESULTS: compared to the same period in 2019, the cumulative rate of AFP case detection and reporting had gradually declined from 39.1% in January to 16.7% before the commencement of the interventions in week 20, 2020. However, the detection and reporting increased by 57.% from week 20 to week 47 compared to the same period in 2019. This is because with COVID-19, hospital visitation dropped, and the sick remained in the communities, so the CI network was relied on to detect and report AFP cases. The cumulative proportion of AFP cases reported by community informants as of week 47 increased from 13% in 2018 to 21% in 2020. This indicates an increase of 38%. Thirty-five AFP cases were detected and reported using the MTN Caller Feel strategy, while 15 cases were reported through state-specific toll-free numbers. CONCLUSION: the implementation of the innovative strategies was able to mitigate the low AFP case detection and reporting observed at the initial stage of the COVID-19 pandemic. The use of technology facilitated reaching the CI network, which was more instrumental in detecting and reporting the cases.

INTRODUCTION: acute flaccid paralysis (AFP) surveillance is the gold standard of the Global Polio Eradication Initiative (GPEI) for detecting cases of poliomyelitis and tracking poliovirus transmission. Nigeria's AFP surveillance performance indicators are among the highest in countries of the World Health Organization (WHO) African Region. The primary AFP surveillance performance indicators are the rate of non-polio AFP among children and the proportion of timely, adequate specimen collection. The surveillance working group of the National Emergency Operations Centre assessed the quality of AFP surveillance data in some reportedly high-performing states. METHODS: we conducted a retrospective review of AFP surveillance performance indicators in Nigeria for 2010-2019. We also reviewed data in reports from four groups of surveillance peer reviews and validation visits (conducted by in-country GPEI partners) during August 2017-May 2019 in 16 states with high primary AFP surveillance indicators; the validation visits reviewed clinical information and the dates of specimen collection and onset of paralysis with caretakers. RESULTS: there were consistently increasing AFP surveillance primary performance indicators during 2010-2016, followed by declines during 2017-2019. From the data for 16 states with peer reviews conducted from August 2017-May 2019, overall concordance of reported and "true" (validated) AFP indicator data in peer review investigations was highly variable. True AFP concordance ranged from 58%-100%, and stool timeliness concordance ranged from 56%-95%. The most common clinical causes of reported AFP cases that were not true AFP were spastic paralysis, malaria, sickle cell disease, and malnutrition. All the states that participated in peer reviews developed surveillance improvement plans based on the gaps identified. CONCLUSION: Nigeria has highly sensitive AFP surveillance according to reported primary AFP performance indicators. The findings of peer reviews indicate that the AFP surveillance system needs to be strengthened and well-supervised to enhance data quality.

INTRODUCTION: novel oral poliovirus vaccine type 2 (nOPV2), designed to be more genetically stable than Sabin-strain oral poliovirus vaccine type 2 (mOPV2), is a new and key component of the Global Polio Eradication Initiative's strategy to combat outbreaks of circulating vaccine-derived poliovirus type 2 (cVDPV2). The World Health Organization´s (WHO´s) emergency use listing (EUL) requires extensive safety monitoring for Adverse Event of Special Interest (AESI) in its use. We implemented AESI active surveillance to monitor the safety of the nOPV2 in Nigeria. METHODS: a cross-sectional assessment was conducted in Nigeria during March-June 2021 in 117 local government areas (LGAs) across 6 states and the Federal Capital Area with confirmed cVDPV2 transmission. We conducted active searches for nOPV2 AESI in all health facilities. Suspected events were ascertained, and vaccination and clinical data abstracted. Events were classified using WHO causality assessment algorithm. Data were analyzed using Epi info7. RESULTS: total of 234 adverse events were reported after 21,997,300 doses of nOPV2 were administered, giving a crude reported incidence of 1 in 94,000 doses of nOPV2. Altogether, 221 of the 234 (94%) adverse events were classified. For 166 AESI ascertained to occur following a dose of nOPV2, the corrected crude incidence rate was 1 in 133,000 doses; 4 of the adverse events, were classified as consistent with casual association with nOPV2 vaccination. CONCLUSION: we found that nOPV2 had a low incidence of AESI following nOPV2 campaigns and no new or unexpected adverse event was reported. Safety monitoring should be sustained for early detection of signals and uncommon adverse events.

In 2011, a dedicated consortium of experts commenced work on the development of the novel oral poliovirus vaccine type 2 (nOPV2). After careful and rigorous analysis of data to enable early, targeted use of the vaccine, World Health Organization´s (WHO´s) Strategic Advisory Group of Experts on Immunization (SAGE) reviewed data from accelerated clinical development of nOPV2 and endorsed entering assessment under WHO´s Emergency Use Listing (EUL) procedure. In November 2020, nOPV2 received an interim recommendation for use under EUL to enable rapid field availability and potential wider rollout of the vaccine. In December 2020, Nigeria initiated preparation to meet all criteria for initial use of nOPV2 in the country and the documentation process to verify meeting them. The process entailed addressing the status of meeting 25 readiness criteria in nine categories for nOPV2 use in Nigeria for response efforts to ongoing cVDPV2 outbreaks. During January-February 2021, Nigeria submitted the required documentation for all required indicators for nOPV2 initial use. In February 2021, the country obtained approval from the GPEI nOPV2 Readiness Verification Team to introduce nOPV2 and in March 2021, rolled out the novel vaccine in mass vaccination campaigns for outbreak response in Bayelsa, Delta, Niger, Sokoto and Zamfara states, and one area council in the Federal Capital Territory (FCT). The lessons learned from this rollout experience in Nigeria are being applied as the country streamlines and strengthens the nOPV2 rollout process across the remaining states.

INTRODUCTION: in August 2020, the World Health Organization African Region was certified free of wild poliovirus (WPV) when Nigeria became the last African country to interrupt wild poliovirus transmission. The National Polio Emergency Operations Center instituted in 2012 to coordinate and manage Nigerian polio eradication efforts reviewed the epidemiology of WPV cases during 2000-2020 to document lessons learned. METHODS: we analyzed reported WPV cases by serotype based on age, oral poliovirus vaccine immunization history, month and year of reported cases, and annual geographic distribution based on incidence rates at the Local Government Area level. The observed trends of cases were related to major events and the poliovirus vaccines used during mass vaccination campaigns within the analysis period. RESULTS: a total of 3,579 WPV type 1 and 1,548 WPV type 3 laboratory-confirmed cases were reported with onset during 2000-2020. The highest WPV incidence rates per 100,000 population in Local Government Areas were 19.4, 12.0, and 11.3, all in 2006. Wild poliovirus cases were reported each year during 2000-2014; the endemic transmission went undetected throughout 2015 until the last cases in 2016. Ten events/milestones were highlighted, including insurgency in the northeast which led to a setback in 2016 with four cases from children previously trapped in security-compromised areas. CONCLUSION: Nigeria interrupted WPV transmission despite the challenges faced because of the emergency management approach, implementation of mass vaccination campaigns, the commitment of the government agencies, support from global polio partners, and special strategies deployed to conduct vaccination and surveillance in the security-compromised areas.

INTRODUCTION: in Nigeria, supportive supervision of Supplementary Immunization Activities (SIA) is a quality improvement strategy for providing support to vaccination teams administering the poliovirus vaccines to children under 5 years of age. Supervision activities were initially reported in paper forms. This had significant limitations, which led to Open Data Kit (ODK) technology being adopted in March 2017. A review was conducted to assess the impact of ODK for supervision reporting in place of paper forms. METHODS: issues with paper-based reporting and the benefits of ODK were recounted. We determined the average utilization of ODK per polio SIA rounds and assessed the supervision coverage over time based on the proportion of local government areas with ODK geolocation data per round. RESULTS: a total of 17 problematic issues were identified with paper-based reporting, and ODK addressed all the issues. Open Data Kit-based supervision reports increased from 3,125 in March 2017 to 51,060 in February 2020. Average ODK submissions for national rounds increased from 84 in March 2017 to 459 in February 2020 and for sub-national rounds increased from 533 in July 2017 to 1,596 in October 2019. Supportive supervision coverage improved from 42.5% in March 2017 to 97% in February 2020. CONCLUSION: the use of digital technologies in public health has comparative advantages over paper forms, and the adoption of ODK for supervision reporting during polio SIAs in Nigeria experienced the advantages. The visibility and coverage of supportive supervision improved, consequentially contributing to the improved quality of polio SIAs.

INTRODUCTION: in 2016, a switch from trivalent oral poliovirus vaccine (OPV) (containing serotypes 1,2,3) to bivalent OPV (types 1,3) was implemented globally. We assessed the seroprevalence of poliovirus antibody levels in selected Nigerian states, before and after the switch, documented poliovirus type2 outbreak responses conducted and ascertained factors associated with immunity gaps based on seroprevalence rates. METHODS: we conducted a secondary analysis of stored serum samples from the 2018 Nigeria National HIV/AIDS Indicator and Impact Survey. Serum from 1,185 children aged 0-119 months residing in one southern and four northern states were tested for serotype-specific PV neutralizing antibodies; seropositivity was a reciprocal titer ≥8. We conducted regression analysis to determine sociodemographic risk factors associated with low seroprevalence using SAS 9.4. RESULTS: children aged 24-119 months (pre-switch cohort) had seroprevalence against PV1, PV2, and PV3, of 97.3% (95% CI:96.4-98.2), 93.8% (95% CI:92.2-95.5), and 91.3% (95% CI:89.2-93.4), while children aged <24 months (post-switch) had seroprevalence of 86.0% (95% CI:81.2-90.8), 55.6% (95% CI: 47.7-63.4), and 77.2% (95% CI:71.0-83.4) respectively. Regression analysis showed age <24 months was associated with lower seroprevalence against all PV serotypes, (p<0.0001); females had lower seroprevalence against PV1 (p=0.0184) and PV2 (p=0.0354); northern states lower seroprevalence against PV1 (p=0.0039), while well-water source lower seroprevalence against PV3 (p=0.0288). CONCLUSION: this study showed high seroprevalence rates against PV 1, 2, and 3 in pre-switch children (aged 24-119 months). However, post-switch children (<24 months) had low immunity against PV2 despite outbreak responses. Strategies to increase routine immunization coverage and high-quality polio campaigns can increase immunity against polio virus.

The Nigeria Polio Emergency Operations Centre (EOC) was established in October 2012 to strengthen coordination, provide strategic direction based on real-time data analysis, and manage all operational aspects of the polio eradication program. The establishment of seven state-level polio EOCs followed. With success achieved in the interruption of wild poliovirus (WPV) transmission as certified in 2020, the future direction of the polio EOC is under consideration. This paper describes the role of the polio EOC in other emergencies and perspectives on future disease control initiatives. A description of the functionality and operations of the polio EOC and a review of documentation of non-polio activities supported by the EOC was done. Key informant insights of national and state-level stakeholders were collected through an electronic questionnaire to determine their perspectives on the polio EOC's contributions and its future role in other public health interventions. The polio EOC structure is based on an incident management system with clear terms of reference and accountability and with full partner coordination. A decline in WPV1 cases was observed from 122 cases in 2012 to 0 in 2015; previously undetected transmission of WPV1 was confirmed in 2016 and all transmission was interrupted under the coordination of the EOCs at national and state levels. During 2014-2019, the polio EOC infrastructure and staff expertise were used to investigate and respond to outbreaks of Ebola, measles, yellow fever, and meningitis and to oversee maternal and neonatal tetanus elimination campaigns. The EOC structure at the national and state levels has contributed to the positive achievements in the polio eradication program in Nigeria and further in the coordination of other disease control and emergency response activities. The transition of the polio EOCs and their capacities to support other non-polio programs will contribute to harnessing the country's capacity for effective coordination of public health initiatives and disease outbreaks.

Nigeria made a coordinated effort to be certified by the World Health Organization's African Region for interrupting endemic transmission of wild poliovirus type-1 (WPV1) in August 2020 as a response to the resurgence of WPV1 cases in August 2016 after going two years without a case. The NEOC Data Working Group (DWG) was instrumental in providing quality and timely surveillance and campaign information for decision-making in order to interrupt WPV1 transmission and provide data toward documentation of its elimination for regional certification. The polio pre-campaign dashboard was used to assess the level of preparedness for Oral Poliovirus Vaccine (OPV) polio supplementary immunization activities (SIA) at three weeks, two weeks, one week, and three days to the start of each campaign implemented during 2016-2020. The administrative tally sheet, independent monitoring survey, and Lot Quality Assurance Sampling (LQAS) survey data collected and shared from the implementation level were analyzed by the EOC DWG to provide information by person, place, and time. Using a 90% threshold in LQAS surveys defining quality SIAs, the proportion of Local Government Areas (LGAs) in Nigeria's states in which post-SIA LQAS surveys were conducted that met this threshold were assessed over time. The highest level of preparedness attained by 3 days to a polio campaign during August 2016-February 2020 was 95% and the lowest attained was 77%. The admin, independent monitoring, and LQAS data analysis results were given to EOC working groups for assessing the performance and quality of each campaign. Twenty-twenty five percent of LGAs that failed LQAS were identified for repeat vaccination. Further, acute flaccid paralysis and environmental surveillance data and laboratory results were analyzed and shared with NEOC and partners. The government and partners used the information generated by the Data Working Group to take evidence-based action including determining the scope of the polio campaign, intensification of surveillance and routine immunization activities, and special intervention activities. On average, 12% of the 774 LGAs were identified as polio high risk LGAs for intervention using selected surveillance, routine immunization (RI), SIAs, and other relevant data sets. National Emergency Operation Centre Data Working Group provided quality and timely information that supported decision-making processes for the polio program in Nigeria. The quality and timely information enabled the NEOC to make evidence-based and timely decisions that contributed to gap identification and decision-making.

INTRODUCTION: ultimately detected in 2016, wild poliovirus (WPV) transmission continued undetected after 2011 in Northeast Nigeria Borno and Yobe States in security-compromised areas, inaccessible due to armed insurgency. Varying inaccessibility prevented children aged <5 years in these areas from polio vaccination interventions and surveillance, while massive population displacements occurred. We examined progress in access over time to provide data supporting a very low probability of undetected WPV circulation within remaining trapped populations after 2016. METHODS: to assess the extent of inaccessibility in security-compromised areas, we obtained empirical historical data in 2020 on a quarterly and annual basis from relevant polio eradication staff for the period 2010-2020. The extent of access to areas for immunization by recall was compared to geospatial data from vaccinator tracking. Population estimates over time in security-compromised areas were extracted from satellite imagery. We compared the historical access data from staff with tracking and population esimates. RESULTS: access varied during 2010-2020, with inaccessibility peaking during 2014-2016. We observed concurrent patterns between historical recalled data on inaccessibility and contemporaneous satellite imagery on population displacements, which increased confidence in the quality of recalled data. CONCLUSION: staff-recalled access was consistent with vaccinator tracking and satellite imagery of population displacments. Despite variability in inaccessibility over time, innovative immunization initiatives were implemented as access allowed and surveillance initiatives were initiated to search for poliovirus transmission. Along with escape and liberation of residents by the military in some geographic areas, these initiatives resulted in a massive reduction in the size of the unvaccinated population remaining resident.

PURPOSE: Population-based prevalence surveys are essential for decision-making on interventions to achieve trachoma elimination as a public health problem. This paper outlines the methodologies of Tropical Data, which supports work to undertake those surveys. METHODS: Tropical Data is a consortium of partners that supports health ministries worldwide to conduct globally standardised prevalence surveys that conform to World Health Organization recommendations. Founding principles are health ministry ownership, partnership and collaboration, and quality assurance and quality control at every step of the survey process. Support covers survey planning, survey design, training, electronic data collection and fieldwork, and data management, analysis and dissemination. Methods are adapted to meet local context and needs. Customisations, operational research and integration of other diseases into routine trachoma surveys have also been supported. RESULTS: Between 29(th) February 2016 and 24(th) April 2023, 3373 trachoma surveys across 50 countries have been supported, resulting in 10,818,502 people being examined for trachoma. CONCLUSION: This health ministry-led, standardised approach, with support from the start to the end of the survey process, has helped all trachoma elimination stakeholders to know where interventions are needed, where interventions can be stopped, and when elimination as a public health problem has been achieved. Flexibility to meet specific country contexts, adaptation to changes in global guidance and adjustments in response to user feedback have facilitated innovation in evidence-based methodologies, and supported health ministries to strive for global disease control targets.

Globally, children aged <5 years, including those living with HIV who are not receiving antiretroviral treatment (ART), experience disproportionately high mortality. Global mortality among children living with HIV aged <5 years receiving ART is not well described. This report compares mortality and related clinical measures among infants aged <1 year and children aged 1-4 years living with HIV with those among older persons aged 5-14, 15-49, and ≥50 years living with HIV receiving ART services at all clinical sites supported by the U.S. President's Emergency Plan for AIDS Relief. During October 2020-September 2022, an average of 11,980 infants aged <1 year and 105,510 children aged 1-4 years were receiving ART each quarter; among these infants and children receiving ART, 586 (4.9%) and 2,684 (2.5%), respectively, were reported to have died annually. These proportions of infants and children who died ranged from four to nine times higher in infants aged <1 year, and two to five times higher in children aged 1-4 years, than the proportions of older persons aged ≥5 years receiving ART. Compared with persons aged ≥5 years living with HIV, the proportions of children aged <5 years living with HIV who experienced interruptions in treatment were also higher, and the proportions who had a documented HIV viral load result or a suppressed viral load were lower. Prioritizing and optimizing HIV and general health services for children aged <5 years living with HIV receiving ART, including those recommended in the WHO STOP AIDS Package, might help address these disproportionately poorer outcomes.

In 2016, World Health Organization (WHO) introduced global targets for the care and management of hepatitis C virus (HCV) infection to eliminate hepatitis C as a public health threat by 2030. Despite significant improvements in testing and treatment, in 2020 only 23% of all persons infected with HCV globally were diagnosed. We explore examples from global hepatitis C programs in Georgia, Rwanda, and Nigeria that have used decentralized and integrated models to increase access to HCV testing. Georgia established the world's first national hepatitis C elimination program in 2015. In 2022, 2.6 million people (80% of the adults) have been screened for antibodies for HCV infection, and 80,000 persons with HCV virus detected were treated. To achieve these results, Georgia implemented HCV core antigen (HCVcAg) testing, utilization of point-of-care HCV RNA, and simplification of HCV viremia detection by qualitative HCV RNA. Rwanda was the first country in sub-Saharan Africa to commit to HCV elimination in 2018, and as of 2022 it has achieved its screening target of 7 million people and initiated approximately 60,000 patients on hepatitis C treatment by rapid decentralization and integration of HCV services. In Nigeria, the integrated near-point-of-care testing approach in Nasarawa state has been effective in expanding access to HCV viremia testing and enabling the possibility of same-day testing and treatment initiation. Examples of decentralization and integration of HCV testing and linkage to care in Georgia, Rwanda and Nigeria could help inform effective strategies to reach 2030 hepatitis C elimination goals in other countries.

This study examined the impact of armed conflict on public health surveillance systems, the limitations of traditional surveillance in this context, and innovative strategies to overcome these limitations. A qualitative case study was conducted to examine the factors affecting the functioning of poliovirus surveillance in conflict-affected areas of Borno state, Nigeria using semi-structured interviews of a purposeful sample of participants. The main inhibitors of surveillance were inaccessibility, the destroyed health infrastructure, and the destroyed communication network. These three challenges created a situation in which the traditional polio surveillance system could not function. Three strategies to overcome these challenges were viewed by respondents as the most impactful. First, local community informants were recruited to conduct surveillance for acute flaccid paralysis in children in the inaccessible areas. Second, the informants engaged in local-level negotiation with the insurgency groups to bring children with paralysis to accessible areas for investigation and sample collection. Third, GIS technology was used to track the places reached for surveillance and vaccination and to estimate the size and location of the inaccessible population. A modified monitoring system tracked tailored indicators including the number of places reached for surveillance and the number of acute flaccid paralysis cases detected and investigated, and utilized GIS technology to map the reach of the program. The surveillance strategies used in Borno were successful in increasing surveillance sensitivity in an area of protracted conflict and inaccessibility. This approach and some of the specific strategies may be useful in other areas of armed conflict.

BACKGROUND: In 2017, UNAIDS estimated that 140,000 children aged 0-14 years are living with HIV in Nigeria, but only 35% have been diagnosed and are receiving antiretroviral therapy. Children are tested primarily in outpatient clinics, which show low HIV-positive rates. To demonstrate efficient facility-based HIV testing among children aged 0-14 years, we evaluated pediatric HIV-positivity rates in points of service in select health facilities in Nigeria. METHODS: We conducted a retrospective analysis of HIV testing and case identification among children aged 0-14 years at all points of service at nine purposively sampled hospitals (November 2016-March 2017). Points of service included family index testing, pediatric outpatient department (POPD), tuberculosis (TB) clinics, immunization clinics, and pediatric inpatient ward. Eligibility for testing at POPD was done using a screening tool while all children with unknown status were eligible for HIV test at other points of service. The main outcome was HIV positivity rates stratified by the testing point of service and by age group. Predictors of an HIV-positive result were assessed using logistic regression. All analyses were done using Stata 15 statistical software. RESULTS: Of 2,180 children seen at all facility points of service with unknown HIV status, 1,822 (83.6%) were tested for HIV, of whom 43 (2.4%) tested HIV positive. The numbers of children tested by age group were <1 years = 230 (12.6%); 1-4 years = 752 (41.3%); 5-9 years = 520 (28.5%); and 10-14 years = 320 (17.6%). The number of children tested by point of service were POPD = 906 (49.7%); family index testing = 693 (38.0%); pediatric inpatient ward = 192 (10.5%); immunization clinic = 16 (0.9%); and TB clinic = 15 (0.8%). HIV positivity rates by point of service were TB clinic = 6.7% (95% Confidence Interval (CI): 0.9-35.2%); pediatric inpatient ward = 4.7% (95%CI: 2.5-8.8%); family index testing = 3.5% (95%CI: 2.3-5.1%); POPD = 1.0% (95%CI: 0.5-1.9%); and immunization clinic = 0%. The percentage contribution to total HIV positive children found by point of services was: family index testing = 55.8% (95%CI: 40.9-69.8%); POPD = 20.9% (95%CI: 11.3-35.6%); inpatient ward = 20.9 (95%CI: 11.3-35.6%) and TB Clinic = 2.3% (95%CI: 0.3-14.8%). Compared with the POPD, the adjusted odds ratio (95% CI) for finding an HIV positive child by point of service were TB clinic = 7.2 (95% CI: 0.9-60.9); pediatric inpatient ward = 4.9 (95% CI: 1.9-12.8); and family index testing = 3.7 (95% CI: 1.5-8.8). HIV-positivity rates did not significantly differ by age group. CONCLUSION: In Nigeria, to improve facility-based HIV positivity rates among children aged 0-14 years, an increased focus on HIV testing among children seeking care in pediatric inpatient wards, through family index testing, and perhaps TB clinics is appropriate.

Background: Tuberculosis (TB) preventive therapy (TPT), including isoniazid preventive therapy (IPT), has been implemented within the Nigerian human immunodeficiency virus (HIV) programme since 2014. However, drug procurement and logistic support has remained the responsibility of the National Tuberculosis and Leprosy Control Programme. The US President's Emergency Plan for AIDS Relief-Nigeria (PEPFAR Nigeria) reviewed the key bottlenecks to TPT implementation in 2016. Method: The logistics of delivery of isoniazid (INH) were integrated with the antiretroviral (ARV) logistics management and information system (LMIS). Drug order and requisition forms at the facility level were revised to include INH, along with training on appropriate quantification and requisition of INH with ARVs. Support was provided for last mile delivery of INH directly to every implementing site, alongside ARV. Reults: We observed an increasing trend in TPT uptake between the pre-and-post intervention periods: 6% in fiscal year (FY) 2015, 7% in FY2016 and 12% in FY2017. Overall, the logistical changes in the LMIS to include INH in 2016 led to a 69% increase in TPT by the end of FY2017; this was statistically significant. Conclusion: Addressing logistical challenges to TPT implementation will ensure that the TB and HIV programmes can tackle the increasing burden of TB infection in people living with HIV. We recommended that the provider-to-client stage of TPT implementation be driven by the HIV programme and that cross-communication between the two programmes be improved.

The number of wild poliovirus (WPV) cases in Nigeria decreased from 1,122 in 2006 to six WPV type 1 (WPV1) in 2014 (1). During August 2014-July 2016, no WPV cases were detected; during August-September 2016, four cases were reported in Borno State. An insurgency in northeastern Nigeria had resulted in 468,800 children aged <5 years deprived of health services in Borno by 2016. Military activities in mid-2016 freed isolated families to travel to camps, where the four WPV1 cases were detected. Oral poliovirus vaccine (OPV) campaigns were intensified during August 2016-December 2017; since October 2016, no WPV has been detected (2). Vaccination activities in insurgent-held areas are conducted by security forces; however, 60,000 unvaccinated children remain in unreached settlements. Since 2018, circulating vaccine-derived poliovirus type 2 (cVDPV2) has emerged and spread from Nigeria to Niger and Cameroon; outbreak responses to date have not interrupted transmission. This report describes progress in Nigeria polio eradication activities during January 2018-May 2019 and updates the previous report (2). Interruption of cVDPV2 transmission in Nigeria will need increased efforts to improve campaign quality and include insurgent-held areas. Progress in surveillance and immunization activities will continue to be reviewed, potentially allowing certification of interruption of WPV transmission in Africa in 2020.

BACKGROUND: Four wild polio-virus cases were reported in Borno State, Nigeria 2016, 1 year after Nigeria had been removed from the list of polio endemic countries by the World Health Organization. Resulting from Nigeria's decade long conflict with Boko Haram, health officials had been unable to access as much as 60% of the settlements in Borno, hindering vaccination and surveillance efforts. This lack of accessibility made it difficult for the government to assess the current population distribution within Borno. This study aimed to use high resolution, visible band satellite imagery to assess the habitation of inaccessible villages in Borno State. METHODS: Using high resolution (31-50 cm) imagery from DigitalGlobe, analysts evaluated the habitation status of settlements in Borno State identified by Nigeria's Vaccination Tracking System. The analysts looked at imagery of each settlement and, using vegetation (overgrowth vs. cleared) as a proxy for human habitation, classified settlements into three categories: inhabited, partially abandoned, and abandoned. Analysts also classified the intact percentage of each settlement starting at 0% (totally destroyed since last assessment) and increasing in 25% intervals through 100% (completely intact but not expanded) up to 200+% (more than doubled in size) by looking for destroyed buildings. These assessments were then used to adjust previously established population estimates for each settlement. These new population distributions were compared to vaccination efforts to determine the number of children under 5 unreached by vaccination teams. RESULTS: Of the 11,927 settlements assessed 3203 were assessed as abandoned (1892 of those completely destroyed), 662 as partially abandoned, and 8062 as fully inhabited as of December of 2017. Comparing the derived population estimates from the new assessments to previous assessment and the activities of vaccination teams shows that an estimated 180,155 of the 337,411 under five children who were unreached in 2016 were reached in 2017 (70.5% through vaccination efforts in previously inaccessible areas, 29.5% through displacement to accessible areas). CONCLUSIONS: This study's methodology provides important planning and situation awareness information to health workers in Borno, Nigeria, and may serve as a model for future data gathering efforts in inaccessible regions.

BACKGROUND: Little is known on the occurrence and identity of Cryptosporidium species in sheep and goats in Algeria. This study aimed at investigating the occurrence of Cryptosporidium species in lambs and goat kids younger than 4 weeks. METHODS: A total of 154 fecal samples (62 from lambs and 92 from kid goats) were collected from 13 sheep flocks in Medea, Algeria and 18 goat flocks across Algiers and Boumerdes. They were screened for Cryptosporidium spp. by nested-PCR analysis of a fragment of the small subunit (SSU) rRNA gene, followed by restriction fragment length polymorphism and sequence analyses to determine the Cryptosporidium species present. Cryptosporidium parvum and C. ubiquitum were further subtyped by sequence analysis of the 60 kDa glycoprotein gene. RESULTS: Cryptosporidium spp. were detected in 17 fecal samples (11.0%): 9 from lambs (14.5%) and 8 from goat kids (8.7%). The species identified included C. parvum in 3 lambs, C. xiaoi in 6 lambs and 6 goat kids, and C. ubiquitum in 2 goat kids. Cryptosporidium infections were detected mostly in animals during the first two weeks of life (7/8 for goat kids and 7/9 for lambs) and in association with diarrhea occurrence (7/17 or 41.2% goat kids and 7/10 or 70.0% lambs with diarrhea were positive for Cryptosporidium spp.). Subtyping of C. parvum and C. ubiquitum isolates identified the zoonotic IIaA13G2R1 and XIIa subtype families, respectively. Minor differences in the SSU rRNA gene sequences were observed between C. xiaoi from sheep and goats. CONCLUSIONS: Results of this study indicate that three Cryptosporidium species occur in lambs and goat kids in Algeria, including zoonotic C. parvum and C. ubiquitum. They are associated with the occurrence of neonatal diarrhea.

Nearly three decades after the World Health Assembly launched the Global Polio Eradication Initiative in 1988, four of the six World Health Organization (WHO) regions have been certified polio-free (1). Nigeria is one of three countries, including Pakistan and Afghanistan, where wild poliovirus (WPV) transmission has never been interrupted. In September 2015, after >1 year without any reported WPV cases, Nigeria was removed from WHO's list of countries with endemic WPV transmission (2); however, during August and September 2016, four type 1 WPV (WPV1) cases were reported from Borno State, a state in northeastern Nigeria experiencing a violent insurgency (3). The Nigerian government, in collaboration with partners, launched a large-scale coordinated response to the outbreak (3). This report describes progress in polio eradication activities in Nigeria during January-December 2017 and updates previous reports (3-5). No WPV cases have been reported in Nigeria since September 2016; the latest case had onset of paralysis on August 21, 2016 (3). However, polio surveillance has not been feasible in insurgent-controlled areas of Borno State. Implementation of new strategies has helped mitigate the challenges of reaching and vaccinating children living in security-compromised areas, and other strategies are planned. Despite these initiatives, however, approximately 130,000-210,000 (28%-45%) of the estimated 469,000 eligible children living in inaccessible areas in 2016 have not been vaccinated. Sustained efforts to optimize surveillance and improve immunization coverage, especially among children in inaccessible areas, are needed.

On August 10, 2016, 2 years after the most recent wild poliovirus (WPV) case was reported in Nigeria (in July 2014), 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. 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.

PURPOSE: To complete the baseline trachoma map worldwide by conducting population-based surveys in an estimated 1238 suspected endemic districts of 34 countries. METHODS: A series of national and sub-national projects owned, managed and staffed by ministries of health, conduct house-to-house cluster random sample surveys in evaluation units, which generally correspond to "health district" size: populations of 100,000-250,000 people. In each evaluation unit, we invite all residents aged 1 year and older from h households in each of c clusters to be examined for clinical signs of trachoma, where h is the number of households that can be seen by 1 team in 1 day, and the product h x c is calculated to facilitate recruitment of 1019 children aged 1-9 years. In addition to individual-level demographic and clinical data, household-level water, sanitation and hygiene data are entered into the purpose-built LINKS application on Android smartphones, transmitted to the Cloud, and cleaned, analyzed and ministry-of-health-approved via a secure web-based portal. The main outcome measures are the evaluation unit-level prevalence of follicular trachoma in children aged 1-9 years, prevalence of trachomatous trichiasis in adults aged 15 + years, percentage of households using safe methods for disposal of human feces, and percentage of households with proximate access to water for personal hygiene purposes. RESULTS: In the first year of fieldwork, 347 field teams commenced work in 21 projects in 7 countries. CONCLUSION: With an approach that is innovative in design and scale, we aim to complete baseline mapping of trachoma throughout the world in 2015.

BACKGROUND: Cryptosporidiosis is an important cause for chronic diarrhea and death in HIV/AIDS patients. Among common Cryptosporidium species in humans, C. parvum is responsible for most zoonotic infections in industrialized nations. Nevertheless, the clinical significance of C. parvum and role of zoonotic transmission in cryptosporidiosis epidemiology in developing countries remain unclear. METHODOLOGY/PRINCIPAL FINDINGS: In this cross-sectional study, 520 HIV/AIDS patients were examined for Cryptosporidium presence in stool samples using genotyping and subtyping techniques. Altogether, 140 (26.9%) patients were positive for Cryptosporidium spp. by PCR-RFLP analysis of the small subunit rRNA gene, belonging to C. parvum (92 patients), C. hominis (25 patients), C. viatorum (10 patients), C. felis (5 patients), C. meleagridis (3 patients), C. canis (2 patients), C. xiaoi (2 patients), and mixture of C. parvum and C. hominis (1 patient). Sequence analyses of the 60 kDa glycoprotein gene revealed a high genetic diversity within the 82 C. parvum and 19 C. hominis specimens subtyped, including C. parvum zoonotic subtype families IIa (71) and IId (5) and anthroponotic subtype families IIc (2), IIb (1), IIe (1) and If-like (2), and C. hominis subtype families Id (13), Ie (5), and Ib (1). Overall, Cryptosporidium infection was associated with the occurrence of diarrhea and vomiting. Diarrhea was attributable mostly to C. parvum subtype family IIa and C. hominis, whereas vomiting was largely attributable to C. hominis and rare Cryptosporidium species. Calf contact was identified as a significant risk factor for infection with Cryptosporidium spp., especially C. parvum subtype family IIa. CONCLUSIONS/SIGNIFICANCE: Results of the study indicate that C. parvum is a major cause of cryptosporidiosis in HIV-positive patients and zoonotic transmission is important in cryptosporidiosis epidemiology in Ethiopia. In addition, they confirm that different Cryptosporidium species and subtypes are linked to different clinical manifestations.

Molecular characterizations of Cryptosporidium spp. in dairy cattle in industrialized nations have mostly shown a dominance of Cryptosporidium parvum, especially its IIa subtypes in pre-weaned calves. Few studies, however, have been conducted on the distribution of Cryptosporidium species and C. parvum subtypes in various age groups of dairy cattle in developing countries. In this study, we examined the prevalence and molecular characteristics of Cryptosporidium in dairy cattle in four Nile River delta provinces in Egypt. Modified Ziehl-Neelsen acid-fast microscopy was used to screen for Cryptosporidium oocysts in 1974 fecal specimens from animals of different ages on 12 farms. Positive fecal specimens were identified from all studied farms with an overall prevalence of 13.6%. By age group, the infection rates were 12.5% in pre-weaned calves, 10.4% in post-weaned calves, 22.1% in heifers, and 10.7% in adults. PCR-RFLP and DNA sequence analyses of microscopy-positive fecal specimens revealed the presence of four major Cryptosporidium species. In pre-weaned calves, C. parvum was most common (30/69 or 43.5%), but Cryptosporidium ryanae (13/69 or 18.8%), Cryptosporidium bovis (7/69 or 10.2%), and Cryptosporidium andersoni (7/69 or 10.2%) were also present at much higher frequencies seen in most industrialized nations. Mixed infections were seen in 12/69 (17.4%) of genotyped specimens. In contrast, C. andersoni was the dominant species (193/195 or 99.0%) in post-weaned calves and older animals. Subtyping of C. parvum based on sequence analysis of the 60kDa glycoprotein gene showed the presence of subtypes IIdA20G1 in nine specimens, IIaA15G1R1 in 27 specimens, and a rare subtype IIaA14G1R1r1b in one specimen. The common occurrence of non-C. parvum species and IId subtypes in pre-weaned calves is a distinct feature of cryptosporidiosis transmission in dairy cattle in Egypt. The finding of the same two dominant IIa and IId C. parvum subtypes recently found in humans in Egypt suggests calves can be potential reservoirs of zoonotic cryptosporidiosis.

Abstract. Human immunodeficiency virus (HIV)-infected persons are commonly infected with Cryptosporidium species and Enterocytozoon bieneusi in both developed and developing countries, particularly patients with CD4+ cell counts below 200 cells/muL; 285 HIV-infected patients on highly active antiretroviral therapy (HAART) were enrolled in this study, and both stool and blood specimens were collected from participants. The stool specimens were analyzed and typed for E. bieneusi and Cryptosporidium spp. by polymerase chain reaction (PCR) and DNA sequencing. CD4 count was analyzed using flow cytometry. E. bieneusi and Cryptosporidium were detected in 18 (6.3%) and 4 (1.4%) patients, respectively. The E. bieneusi detected mostly belonged to a new genotype group that, thus far, has only been found in a few humans: genotype Nig4 in 2 patients and two new genotypes related to Nig4 in 12 patients. The Cryptosporidium detected included C. hominis (two patients), C. parvum (one patient), and C. felis (one patient), with the two C. hominis infections belonging to an unusual subtype family. Additional studies are required to determine whether some E. bieneusi genotypes and C. hominis subtypes are more prevalent in HIV patients on HAART.

Little is known about the diversity and public health significance of Cryptosporidium species in water buffaloes. In this study, we examined the distribution of Cryptosporidium spp. in water buffalo calves in Egypt. Rectal fecal specimens from 179 calves and 359 adults were screened microscopically for Cryptosporidium oocysts using modified Ziehl-Neelsen stain. Cryptosporidium spp. in 17 microscopy-positive specimens from calves were genotyped by DNA sequence analysis of the small-subunit rRNA gene, and Cryptosporidium parvum was subtyped by sequence analysis of the 60kDa glycoprotein gene. Cryptosporidium ryanae was found in 10 specimens and C. parvum in 7 specimens, with the former belonging to the newly identified C. ryanae buffalo variant and the latter belonging to the subtypes IIdA20G1 (in 5 specimens) and IIaA15G1R1 (in 2 specimens). The prevailing occurrence of C. ryanae and the subtype family IId of C. parvum and the absence of C. bovis and C. andersoni represent some features of Cryptosporidium transmission in water buffaloes in Egypt.