INTRODUCTION: the National Primary Health Care Development Agency, African Field Epidemiology Network, United States Centers for Disease Control and Prevention and the Bill and Melinda Gates Foundation are implementing a Routine Immunization (RI) Module as part of their Routine Health Data Management System based on the 2013 - 2015 Accountability Framework for RI in Nigeria. To inform planning and evidence-based decision making, a data management needs assessment was conducted in Bauchi state which was one of the states selected for the deployment of the DHIS2 RI module. METHODS: desk reviews were conducted, and a semi-structured questionnaire was administered in four Local Government Areas (LGAs) in Bauchi state that were selected based on the initial evaluation of the performance of all 20 Bauchi LGAs. Ganjuwa and Shira were selected as high-performing LGAs and Alkaleri and Bogoro as low-performing LGAs. Four Health Facilities (HF) were selected in each LGA based on rural or urban classification, type of HFs (private or public), security and accessibility. RESULTS: local Immunization Officers (LIOs) prepare monthly reports in high-performing LGAs, and Community Health Care workers are mostly (69%) responsible for report compilation at the HFs. Shira and Alkaleri met 77% and 44% of training indicator targets, respectively, in the previous 12 months. Data recording and reporting was the type of training received the most by health facility personnel. Functioning refrigerators were in all visited LGAs, working thermometer and updated temperature monitoring charts were available in all the cold chain stores. However, no health facility reported having available computers for data-related activities. CONCLUSION: this assessment provided an improved understanding of the Bauchi state Routine Health Data Management System and informed the content of the state-wide scale-up.

INTRODUCTION: a district health information system 2 tool with a customized routine immunization (RI) module and indicator dashboard was introduced in Kano State, Nigeria, in November 2014 to improve data management and analysis of RI services. We assessed the use of the module for program monitoring and decision-making, as well as the enabling factors and barriers to data collection and use. METHODS: a mixed-methods approach was used to assess user experience with the RI data module and dashboard, including 1) a semi-structured survey questionnaire administered at 60 health facilities administering vaccinations and 2) focus group discussions and 16 in-depth interviews conducted with immunization program staff members at the local government area (LGA) and state levels. RESULTS: in health facilities, a RI monitoring chart was used to review progress toward meeting vaccination coverage targets. At the LGA, staff members used RI dashboard data to prioritize health facilities for additional support. At the State level, immunization program staff members use RI data to make policy decisions. They viewed the provision of real-time data through the RI dashboard as a "game changer". Use of immunization data is facilitated through review meetings and supportive supervision visits. Barriers to data use among LGA staff members included inadequate understanding of the data collection tools and computer illiteracy. CONCLUSION: the routine immunization data dashboard facilitated access to and use of data for decision-making at the LGA, State and national levels, however, use at the health facility level remains limited. Ongoing data review meetings and training on computer skills and data collection tools are recommended.

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

In 2010, Nigeria adopted the use of web-based software District Health Information System, V.2 (DHIS2) as the platform for the National Health Management Information System. The platform supports real-time data reporting and promotes government ownership and accountability. To strengthen its routine immunisation (RI) component, the US Centers for Disease Control and Prevention (CDC) through its implementing partner, the African Field Epidemiology Network-National Stop Transmission of Polio, in collaboration with the Government of Nigeria, developed the RI module and dashboard and piloted it in Kano state in 2014. The module was scaled up nationally over the next 4 years with funding from the Bill & Melinda Gates Foundation and CDC. One implementation officer was deployed per state for 2 years to support operations. Over 60 000 RI healthcare workers were trained on data collection, entry and interpretation and each local immunisation officer in the 774 local government areas (LGAs) received a laptop and stock of RI paper data tools. Templates for national-level and state-level RI bulletins and LGA quarterly performance tools were developed to promote real-time data use for feedback and decision making, and enhance the performance of RI services. By December 2017, the DHIS2 RI module had been rolled out in all 36 states and the Federal Capital Territory, and all states now report their RI data through the RI Module. All states identified at least one government DHIS2 focal person for oversight of the system's reporting and management operations. Government officials routinely collect RI data and use them to improve RI vaccination coverage. This article describes the implementation process-including planning and implementation activities, achievements, lessons learnt, challenges and innovative solutions-and reports the achievements in improving timeliness and completeness rates.

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 February 16, 2017, the Ministry of Health in Zamfara State, in northwestern Nigeria, notified the Nigeria Centre for Disease Control (NCDC) of an increased number of suspected cerebrospinal meningitis (meningitis) cases reported from four local government areas (LGAs). Meningitis cases were subsequently also reported from Katsina, Kebbi, Niger, and Sokoto states, all of which share borders with Zamfara State, and from Yobe State in northeastern Nigeria. On April 3, 2017, NCDC activated an Emergency Operations Center (EOC) to coordinate rapid development and implementation of a national meningitis emergency outbreak response plan. After the outbreak was reported, surveillance activities for meningitis cases were enhanced, including retrospective searches for previously unreported cases, implementation of intensified new case finding, and strengthened laboratory confirmation. A total of 14,518 suspected meningitis cases were reported for the period December 13, 2016-June 15, 2017. Among 1,339 cases with laboratory testing, 433 (32%) were positive for bacterial pathogens, including 358 (82.7%) confirmed cases of Neisseria meningitidis serogroup C. In response, approximately 2.1 million persons aged 2-29 years were vaccinated with meningococcal serogroup C-containing vaccines in Katsina, Sokoto, Yobe, and Zamfara states during April-May 2017. The outbreak was declared over on June 15, 2017, after high-quality surveillance yielded no evidence of outbreak-linked cases for 2 consecutive weeks. Routine high-quality surveillance, including a strong laboratory system to test specimens from persons with suspected meningitis, is critical to rapidly detect and confirm future outbreaks and inform decisions regarding response vaccination.

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

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.

In September 2015, more than 1 year after reporting its last wild poliovirus (WPV) case in July 2014, Nigeria was removed from the list of countries with endemic poliovirus transmission, leaving Afghanistan and Pakistan as the only remaining countries with endemic WPV. However, on April 29, 2016, a laboratory-confirmed, circulating vaccine-derived poliovirus type 2 (cVDPV2) isolate was reported from an environmental sample collected in March from a sewage effluent site in Maiduguri Municipal Council, Borno State, a security-compromised area in northeastern Nigeria. VDPVs are genetic variants of the vaccine viruses with the potential to cause paralysis and can circulate in areas with low population immunity. The Nigeria National Polio Emergency Operations Center initiated emergency response activities, including administration of at least 2 doses of oral poliovirus vaccine (OPV) to all children aged <5 years through mass campaigns; retroactive searches for missed cases of acute flaccid paralysis (AFP), and enhanced environmental surveillance. Approximately 1 million children were vaccinated in the first OPV round. Thirteen previously unreported AFP cases were identified. Enhanced environmental surveillance has not resulted in detection of additional VDPV isolates. The detection of persistent circulation of VDPV2 in Borno State highlights the low population immunity, surveillance limitations, and risk for international spread of cVDPVs associated with insurgency-related insecurity. Increasing vaccination coverage with additional targeted supplemental immunization activities and reestablishment of effective routine immunization activities in newly secured and difficult-to-reach areas in Borno is urgently needed.

BACKGROUND: TB remains a major public health concern, even in low-incidence countries like the USA and the UK. Over the last two decades, cases of TB reported in the USA have declined, while they have increased substantially in the UK. We examined factors associated with this divergence in TB trends between the two countries. METHODS: We analysed all cases of TB reported to the US and UK national TB surveillance systems from 1 January 2000 through 31 December 2011. Negative binominal regression was used to assess potential demographic, clinical and risk factor variables associated with differences in observed trends. FINDINGS: A total of 259 609 cases were reported. From 2000 to 2011, annual TB incidence rates declined from 5.8 to 3.4 cases per 100 000 in the USA, whereas in the UK, TB incidence increased from 11.4 to 14.4 cases per 100 000. The majority of cases in both the USA (56%) and the UK (64%) were among foreign-born persons. The number of foreign-born cases reported in the USA declined by 15% (7731 in 2000 to 6564 in 2011) while native-born cases fell by 54% (8442 in 2000 to 3883 in 2011). In contrast, the number of foreign-born cases reported in the UK increased by 80% (3380 in 2000 to 6088 in 2011), while the number of native-born cases remained largely unchanged (2158 in 2000 to 2137 in 2011). In an adjusted negative binomial regression model, significant differences in trend were associated with sex, age, race/ethnicity, site of disease, HIV status and previous history of TB (p<0.01). Among the foreign-born, significant differences in trend were also associated with time since UK or US entry (p<0.01). INTERPRETATION: To achieve TB elimination in the UK, a re-evaluation of current TB control policies and practices with a focus on foreign-born are needed. In the USA, maintaining and strengthening control practices are necessary to sustain the progress made over the last 20 years.

In 2015, wild poliovirus (WPV) transmission was identified in only Afghanistan and Pakistan (1). The widespread use of live, attenuated oral poliovirus vaccine (OPV) has been key in polio eradication efforts. However, OPV use, particularly in areas with low vaccination coverage, is associated with the low risk for emergence of vaccine-derived polioviruses (VDPV), which can cause paralysis (2). VDPVs vary genetically from vaccine viruses and can cause outbreaks in areas with low vaccination coverage. Circulating VDPVs (cVDPVs) are VDPVs in confirmed outbreaks. Single VDPVs for which the origin cannot be determined are classified as ambiguous (aVDPVs), which can also cause paralysis. Among the three types of WPV, type 2 has been declared to be eradicated. More than 90% of cVDPV cases have been caused by type 2 cVDPVs (cVDPV2). Therefore, in April 2016, all OPV-using countries of the world are discontinuing use of type 2 Sabin vaccine by simultaneously switching from trivalent OPV (types 1, 2, and 3) to bivalent OPV (types 1 and 3) for routine and supplementary immunization. The World Health Organization recently broadened the definition of cVDPVs to include any VDPV with genetic evidence of prolonged transmission (i.e., >1.5 years) and indicated that any single VDPV2 event (a case of paralysis caused by a VDPV or isolation of a VDPV from an environmental specimen) should elicit a detailed outbreak investigation and local immunization response. A confirmed cVDPV2 detection should elicit a full poliovirus outbreak response that includes multiple supplemental immunization activities (SIAs); an aVDPV designation should be made only after investigation and response (3). Since 2005, there have been 1-8 cVDPV outbreaks and 3-12 aVDPV events per year. There are currently five active cVDPV outbreaks in Guinea, Laos, Madagascar, Myanmar, and Ukraine, and four other active VDPV events.

OBJECTIVE: To assess prevalence and occupational risk factors of latent TB infection and history of TB disease ascribed to work in a health care setting in western Kenya. METHODS: We conducted a cross-sectional survey among health care workers in western Kenya in 2013. They were recruited from dispensaries, health centers, and hospitals that offer both TB and HIV services. School workers from the health facilities' catchment communities were randomly selected to serve as the community comparison group. Latent TB infection was diagnosed by tuberculin skin testing. HIV status of participants was assessed. Using a logistic regression model, we determined the adjusted odds of latent TB infection among health care workers compared to school workers; and among health care workers only, we assessed work-related risk factors for latent TB infection. RESULTS: We enrolled 1,005 health care workers and 411 school workers. Approximately 60% of both groups were female. 22% of 958 health care workers and 12% of 392 school workers tested HIV positive. Prevalence of self-reported history of TB disease was 7.4% among health care workers and 3.6% among school workers. Prevalence of latent TB infection was 60% among health care workers and 48% among school workers. Adjusted odds of latent TB infection were 1.5 times higher among health care workers than school workers (95% confidence interval 1.2-2.0). Health care workers at all three facility types had similar prevalence of latent TB infection, (p=0.72), but increasing years of employment was associated with increased odds of LTBI (p<0.01). CONCLUSION: Health care workers at facilities in western Kenya which offer TB and HIV services are at increased risk of latent TB infection, and the risk is similar across facility types. The WHO-recommended TB infection control measures are urgently needed in health facilities to protect health care workers. This article is protected by copyright. All rights reserved.