Category: Health Care

A. Situation analysis

Description of the disaster

The Ministry of Health reported a confirmed case of Type 1 wild poliovirus (WPV1) in Lilongwe district, Malawi on 17February 2022. Polio virus causes irreversible paralysis mainly in children zero to fifteen years of age. It also has the potential to infect immunocompromised adults. This is the first detection of a case of WPV1 in Africa since 2016. The African continent had been declared free of wild poliovirus since 2020. Genetic sequencing of this case has linked the virus to a strain circulating in Pakistan’s Sindh Province in 2019, indicating that this is an imported virus. The detection of a single case of WPV1 outside of the world’s two remaining endemic countries, Pakistan and Afghanistan, represents an emergency that requires effective and at-scale response to prevent spread. Normally, a child would present to a health facility with acute onset of limb weakness which progresses to paralysis. If it is a leg or an arm, it may become relatively smaller (wasted) than the normal body mass and lose. Polio is a disabling and life-threatening disease. Polio is an infectious disease that can be passed from one person to another through ingestion of food or water which is contaminated with polio virus. The high-risk groups are those that are unvaccinated or those that have received fewer doses of polio vaccines, particularly among communities with poor water and sanitation infrastructure.

Following this development, the Ministry of Health, with support from partners, has put in place strategies for elimination of polio in the country. These strategies are in line with the strategies recommended by the World Health Organization (WHO) through the Global Polio End Game Strategy. Vaccines are the most effective and available prevention strategy for this disease, in addition to improved water and sanitation practices.

The Malawi Government through the Ministry of Health established the National Expanded Programme on Immunization (EPI) in 1979 to deal with vaccine preventable diseases including Polio, Measles and Neonatal Tetanus. These diseases are undergoing eradication and elimination. The Ministry has therefore intensified surveillance for these diseases in line with the WHO recommendations. Malawi has sustained good coverage of its entire vaccine antigen above 80% now for two decades and polio vaccine is no exception. Like many other countries in the world, Malawi provides polio vaccine that targets Polio virus type 1 and type 3 following the global eradication of Poliovirus type 2. The country also vaccinates its children with Inactivated Polio Virus vaccine in all the 29 districts across the country with sustained good coverage to date since introduction in 2018. The overall Vax coverage for Lilongwe is over 80% which is beyond the coverage of most districts in the country. The location where the case was registered enjoys even better coverage than some areas within Lilongwe district.

Generally, there is high number of children who are vaccinated in urban areas as compared to the rural areas of the country. In order to reduce the spread and further risks and in line with the WHO guidance and the International Health Regulations (IHR), the country is immediately putting in place additional activities to help in reducing further spread of the virus in the country. The first step is declaring this as a Public Health Emergency: The President on 17 February 2022, through the minister of Health, declared a Public Health Emergency following confirmation of an imported case of polio in in Lilongwe districts.

The Emergency Operations Committee (EOC) was immediately established where meetings and a risk assessment of the situation is being done with support from partners such as the WHO. The country is also working very closely with the neighboring countries, as diseases know no borders. As stated earlier, the laboratory results show that this is an imported virus as there is no evidence of community circulation of the virus. The Ministry of Health has assured the nation that the situation is under control and would like to encourage the public to continue observing good personal hygiene practices since the virus is spread through ingestion of contaminated food or water. The public has therefore been informed that the polio outbreak has been declared a Public Health Emergency1 by the Malawi Government.

Meanwhile, the Ministry of Health with support from The World Health Organization has called for a mass vaccination for children under 5 years across the country. There are already rumors around that the vaccination is a plan by government to increase COVID-19 vaccination. These rumours if not corrected may lead to low polio vaccine coverage. The Polio emergency is coming at a time that the country is responding to the effects of Tropical Cyclone Ana which has also greatly affected the Malawi health systems requiring more attention and resources by the ministry of health. There is therefore great need for supporting community mobilization to ensure good public awareness as well as need to support management of vaccination sites as the ministry of health still face human resources challenges in undertaking mass vaccinations.

The last polio case in Malawi was reported in 1992 meaning that this is the first case in thirty years. Malawi also obtained a Polio free status in 2005 while the WHO African region received its Polio free status certificate in the year 2020. These are remarkable milestones in the polio eradication initiative in the country. In practice, any child from zero to fifteen years of age coming with acute onset of flaccid paralysis or weakness is supposed to be reported as a suspected Polio case. The minimum standard is to report 2 non-polio AFP per 100,000 population, as well as adequate stool specimen collection capacity. Malawi has been meeting these indicators throughout the years and sustained its Polio surveillance robustly.

Source: International Federation of Red Cross and Red Crescent Societies

On 17 February 2022, WHO received an update regarding the detection of wild poliovirus type 1 (WPV1) in Malawi which was previously notified on 31 January 2022 through an IHR notification as a case of poliovirus type 2 (PV2). The case, a child under 5 years old, from Central constituency, Lilongwe district, Central Region, developed acute flaccid paralysis (AFP) on 19 November 2021. Two stool specimens were collected for testing on 26 and 27 November, and were received at the Regional Reference Laboratory, the National Institute of Communicable Disease (NICD) in South Africa, on 14 January 2022, and then forwarded to the United States Centers for Disease Control and Prevention (US CDC).

Sequencing of the virus conducted by the NICD on 2 February, and the US CDC on 12 February confirmed this case as WPV1. Analysis shows that the current WPV1 isolate in Malawi is genetically linked to a Pakistan sequence detected in 2020 in Sindh province.

Africa was declared free of indigenous wild polio in August 2020 after eliminating all forms of wild polio from the region, and in Malawi, the last clinically confirmed WPV case was reported in 1992.

Public health response

• Global Polio Eradication Initiative (GPEI) partners, including WHO, is supporting the Malawi health authorities to carry out a risk assessment and outbreak response, including supplemental immunization. Surveillance measures are being activated and expanded in Malawi and neighbouring countries to detect potential cases.

• GPEI Rapid Response Team has been sent to Malawi to support coordination, surveillance, data management, communications, and operations. Partner organizations also sent teams to support emergency operations and innovative vaccination campaign solutions.

WHO risk assessment

Polio is a highly infectious disease, caused by a virus that invades the nervous system and can cause permanent paralysis (approximately one in 200 infections) or death (approximately 2-10% of paralyzed cases). The virus is transmitted by person-to-person, mainly through the faecal-oral route or, less frequently, by a common vehicle (for example, contaminated water or food).

Two of the three types of wild poliovirus have been eradicated (WPV2 and WPV3), with ongoing global efforts to eradicate WPV1. Currently, wild poliovirus is endemic in two countries: Pakistan and Afghanistan. The detection of WPV1 outside the two countries where the disease is endemic demonstrates the continuous risk of international spread of the disease until every corner of the world is free of WPV1.

The risk at the national level in Malawi is assessed as high given the presence of high population density, low vaccination coverage (<80%) in many districts and lack of a catch-up campaign for more than six years, accumulated susceptible populations, suboptimal AFP surveillance, and lack of environmental surveillance, that may be affecting the ability to ascertain cases. Furthermore, the switch from the trivalent Oral Polio Vaccine (OPV) to bivalent OPV in Malawi was completed on 25 April 2016, and Inactivated Polio Vaccine (IPV) was introduced on 14 December 2018. The most recent supplementary immunization activities (SIAs) with a vaccine containing type 2 vaccine were conducted in 2013.

Additionally, the country is currently affected by tropical storm Ana which may impact the country’s response capacity by impairing Polio SIAs and surveillance activities. According to the UN flash update on Malawi tropical storm Ana, as of 11 February, there have been 995 072 people affected in 19 districts, 206 people injured, 46 people reported dead, and 18 people are reported still missing. The United Nations and partners are supporting the life-saving emergency flood response

The risk at the regional level is assessed as moderate given the significant population movement between Mozambique and Malawi, suboptimal vaccination coverage in the neighbouring countries, and suboptimal AFP surveillance activities.

The risk at the global level is assessed as low given the existing response capacity in place and the moderately high global Polio coverage estimates.

WHO advice

It is important that all countries, particularly those with frequent travel and contacts with polio-affected countries and areas, strengthen the surveillance of AFP cases to rapidly detect any new poliovirus importations and to facilitate a rapid response.

Under the International Health Regulations (2005) (IHR), countries must investigate and notify any poliovirus isolate, whether the isolate is from AFP cases, AFP contacts or environmental surveillance. Local health authorities should initiate the investigation within 24 hours of a poliovirus isolate being reported.

Isolation of poliovirus in a previously non-infected area represents an event or outbreak that requires national authorities to complete an immediate risk assessment to inform the type and scale of response. Following initial investigation and risk assessment, national authorities must continue to collect detailed information to update the situation analysis and risk assessment (i.e. results from laboratory investigations, or detailed information on affected communities, etc.). Neighbouring countries/regions must also continue to update their risk assessment with support from WHO regional offices.

Countries, territories, and areas should also maintain systematically high routine immunization coverage rates (>90%) both at national and subnational levels to minimize the consequences of any new poliovirus introduction. WHO recommends that two high-quality large-scale vaccination campaigns (>90% of children vaccinated) should be completed within eight weeks of laboratory sequencing results. A mop-up round might be required as an additional step wherever monitoring suggests children have been missed in certain health districts or areas, to ensure interruption of transmission (even in the absence of new poliovirus detections). Communication and social mobilization activities should be an integrated part of reactive Polio immunization campaigns.

WHO does not recommend any restriction on travel and/or trade to Malawi based on the information available for this current event. WHO’s International Travel and Health recommends that all travelers to polio-affected areas be fully vaccinated against polio. Residents (and visitors for more than 4 weeks) from infected areas should receive an additional dose of OPV or IPV within four weeks to 12 months of travel.

As per the advice of an Emergency Committee convened under the International Health Regulations (2005), efforts to limit the international spread of poliovirus remain a Public Health Emergency of International Concern (PHEIC). Countries affected by poliovirus transmission are subject to Temporary Recommendations. To comply with the Temporary Recommendations issued under the PHEIC, any country infected by poliovirus should declare the outbreak as a national public health emergency, consider vaccination of all international travelers, ensure such travelers are provided with an international certificate of vaccination, restrict at the point of departure the international travel of any resident lacking documentation of appropriate polio vaccination, intensify cross-border efforts to substantially increase vaccination coverage of travelers, and intensify efforts to increase routine immunization coverage.

Source: World Health Organization

Lilongwe – Polio emergency response teams in Malawi are ramping up disease surveillance and deepening investigations after the country detected a case of wild poliovirus—the first of its kind in Africa since 2016. Determining the extent of the risk and searching for any further cases are among the crucial steps for an effective response to halt the virus and protect children from its debilitating impact.

The African region was declared and certified as free of indigenous wild polio in August 2020 after eliminating all forms of wild poliovirus. Laboratory analysis linked the strain detected in Malawi to the one circulating in Pakistan’s Sindh Province in 2019.

In January 2022 soon after Malawi received preliminary results of poliovirus, the Ministry of Health, with support from World Health Organization (WHO), swiftly launched response measures, collecting additional stool samples from contacts of the index case, and shipping them for further analysis, as well as actively searching for possible new cases. The country declared an outbreak of wild polio on 17 February following confirmation of the virus type. This is the first case of wild poliovirus in Malawi since 1992.

Within days of the outbreak being declared, expert teams deployed to the country to support key response measures including setting up a fully functional environmental surveillance system to complement clinical acute flaccid paralysis surveillance for possible polio cases. This entails identifying suitable wastewater locations to serve as environmental surveillance sites and training responders at national and local levels to collect and package samples for shipping and analysis.

Environmental surveillance for polioviruses has now been established in six sites in two districts. These include Lilongwe District that encompasses the capital Lilongwe where the initial, and so far the only case, was detected. Other sites are in Blantyre, Mzuzu and Zomba cities.

The polio response teams have also undertaken a risk assessment, which includes detailed disease investigation, epidemiological surveillance assessment as well as analysing factors that can hinder or ease response operations. Additionally, educating and informing the media and the public about polio is ongoing, so they can also report any suspected cases.

To support the country team, experts from the WHO Regional Office for Africa were deployed within days of Malawi declaring the outbreak. The surge team of six includes a coordinator, a technical and operations expert, surveillance experts and a data manager. The WHO team is part of a broader multi-partner Global Polio Eradication Initiative (GPEI) support to the country.

“We have all the necessary tools and all the necessary tactics to successfully stop this outbreak,” said Dr Janet Kayita, acting WHO Representative in Malawi. “Malawi has been polio-free before and can rapidly be so again. The key is to optimize operations and now ensure that every child is reached with the life-saving polio vaccine.”

Malawi has scheduled a mass supplemental polio vaccination response targeting under-five children, using the Bivalent Oral Polio Vaccine recommended by WHO and the GPEI partners for wild poliovirus (type 1). Four rounds of polio vaccination campaigns are planned. All the neighbouring countries – Mozambique, Tanzania and Zambia – have been alerted and are planning to conduct immunization campaigns as well.

“The quality of the vaccination campaign is essential to interrupt transmission of poliovirus from child to child. Therefore it is critical to ensure that the vaccination rounds reach every child,” said Deputy Minister of Health, Honourable Enock Phale. “We ask all our political leaders, religious leaders and community leaders to support the government in encouraging our communities to take part in the polio eradication activities by taking their children for the routine polio immunization.”

An immediate-response public awareness campaign has been launched by the Ministry of Health and partners to alert the public of the outbreak, describe the planned response and provide information about polio and the vaccine.

Malawians are treating the outbreak with due urgency.

“I am ready to do whatever it takes to protect my children including getting the polio vaccine. We do not want to see polio paralysing children again as it was 30-plus years ago,” said a resident of Area 24 in Lilongwe, who wished to remain anonymous.

Polio is a highly infectious disease caused by a virus. It invades the nervous system and can cause total paralysis within hours, particularly among children under five. The virus is transmitted from person to person mainly through faecal matter or, less frequently, through contaminated water or food, and multiplies in the intestine. While there is no cure for polio, the disease can be prevented through administration of a safe, simple and effective vaccine.

“Malawi is now considered a polio-affected country. We are working tirelessly with the government and our GPEI partners to reverse this. The WHO African Region’s status as wild polio-free remains intact. However, our work now is to quickly prevent any in-country spread of wild poliovirus and keep children safe,” said Dr Christopher Kamugisha, the GPEI Coordinator.

Source: World Health Organization

Malawi has received nearly 300,000 doses of the AstraZeneca COVID-19 vaccine under COVAX, the global initiative founded to foster equitable access to COVID-19 vaccines. This is the first vaccine donation this year, after the country’s stocks were depleted in December. The donation from Japan Saturday is part of about 2 million doses of AstraZeneca Japan is prepared to send to Malawi.

Health authorities in Malawi say the donation is the first COVID-19 vaccine consignment from Japan to a country in sub-Saharan Africa.

Malawi’s health minister, Khumbize Kandodo-Chiponda, says Malawi feels honored to receive the vaccine donation when it is needed most.

“This is so timely because we have over about 700,000 Malawians who have already received the first dose of AstraZeneca. You are aware that we had our last consignment in December. By 31 December, we finished all the doses of the AstraZeneca which we had. So we haven’t had AstraZeneca from 1 January,” said Kandodo-Chiponda.

So far, Malawi administers three types of COVID-19 vaccine: Johnson &Johnson, Pfizer and AstraZeneca.

However, the country has so far vaccinated only about 7% of the population amid continued vaccine hesitancy largely stemming from misconceptions and doubts over its efficacy.

However, the frequency of shipment of the 1.9 million doses Japan is keeping for Malawi will depend on Malawi’s commitment in increasing vaccine use.

Kandodo-Chiponda said the condition is in line with the government’s new arrangement.

“You remember that last year, in March, we had over 20,000 doses expiring on us. So, what we have agreed with COVAX is that we should be getting them in parts. Otherwise, as government, we have already made procurement of over 2 million doses but we are saying ‘we don’t want anything to expire on us, our consumption rate is still very, very low,” she said.

Maziko Matemba, Malawi’s national ambassador on health, says the condition on the forthcoming vaccine donations should be a wakeup call to the Malawi government to make sure it does not lose vaccine donations from other countries.

“This is the first time the donor has put a condition on the COVID vaccines which Malawi received as a donation. And this just shows that our partners who are supporting us with these vaccines, they have noted that maybe we are not doing much in terms of demand creation but also uptake,” he said.

The World Health Organization has called for each country to vaccinate at least 70% of their population by June.

Malawi announced last month that it has set itself a target of vaccinating 50% by June.

“As a country, we are behind our projections because we would have loved that at least by this time, we would have been taking about at least 15% of the eligible people to have been vaccinated. But we are way behind. This is mainly [because of] vaccine hesitancy. It is still there, some people still not yet convinced that they need to get the vaccine. So, it is work in progress,” said Kandodo-Chiponda.

A recent U.N. report says although the COVAX facility has helped increase vaccine supplies in Africa, the continent is struggling to expand rollout, with only 11% of the population fully vaccinated so far.

But Kandodo-Chiponda said the Malawi government is devising a plan to increase its vaccine uptake which includes increasing an ongoing door-to-door vaccination campaign.

Source: Voice of America

Experts are calling for increased investment in Africa’s health care infrastructure to support data collection, research and development related to the COVID-19 pandemic and its subsequent impact on African economies.

In a recent discussion on VOA’s Straight Talk Africa program titled COVID-19 in Africa: Virus, Variants and Vaccines, experts pointed out that the global health crisis exposed poor health infrastructure on the continent.

Mo Ibrahim, the billionaire founder and chair of the London-based foundation that bears his name, spoke about inequality in vaccine distribution at the height of the pandemic.

“The vaccine apartheid did not help the situation for Africa,” Ibrahim said. However, he said he remains “quite optimistic that the pandemic in a strange way will help us move forward.”

“Going forward, we need to manufacture our own vaccines,” he said. “We should not rely on the goodwill or the sensible behavior of others.”

Last Friday, the World Health Organization announced that six African nations would be the first on the continent to receive the technology necessary to produce mRNA vaccines. The countries are Egypt, Kenya, Nigeria, Senegal, South Africa and Tunisia.

Health experts around the world have raised concerns over the unequal distribution of vaccines. More than 80% of the African continent’s population has yet to receive a single dose of the COVID-19 vaccine, according to WHO.

“Much of this inequity has been driven by the fact that globally, vaccine production is concentrated in a few mostly high-income countries,” WHO Director-General Dr. Tedros Adhanom Ghebreyesus said at a European Union-African Union summit last week.

On the panel, Ibrahim highlighted Africa’s weak and overstretched health care system while stressing the lack of adequate investments and the effects of brain drain on health care.

Amid the COVID-19 crisis, more affluent countries in the Organization for Economic Co-operation and Development have lured migrant doctors and nurses with measures such as higher pay, temporary licensing and eased entry, the OECD has reported.

WHO recommends at least one physician for every thousand people. Some African countries, such as Ghana and Chad, had as few as 0.1 medical doctors per thousand in 2019, according to World Bank data.

Panelist Aloysius Uche Ordu dispelled the assumption that infectious diseases always come from poor countries.

“We tend to look at Africa as the place where infectious diseases start. Well, that did not happen with COVID,” said Ordu, who directs the Africa Growth Initiative at Brookings Institution, a Washington-based think tank. “COVID started with a rich country and spread to other rich countries. In fact, Africa came into the picture later on.”

An official with the Africa Centers for Disease Control and Prevention said the continent has done a laudable job of dealing with the virus.

“We have kept the numbers low. We have mobilized our political leadership from the very top all the way down to our technical teams,” said Dr. Ahmed Ogwell Ouma, deputy director of the Africa CDC. “We have mobilized the public, and Africa has largely addressed this pandemic as a group. And this is unprecedented, and I will give us a very, very good mark.”

But the dean of health sciences at the University of Witwatersrand in South Africa disagrees.

Professor Sabir Madhi noted that his country’s disproportionately high COVID-19 death toll is largely due to “much more robust” contact tracing and data collation tools than other African nations.

South Africans “constitute less than 5% of the African population yet have contributed 45% of all (COVID-19-related) deaths on the African continent,” he said.

The country of nearly 60 million people has Africa’s highest number of recorded infections and deaths — a total of 3.6 million cases and nearly 99,000 deaths as of this week, according to the Johns Hopkins University’s Coronavirus Resource Center. The center has recorded more than 420 million COVID-19 cases globally and nearly 6 million deaths.

South Africa is emerging from a fourth wave of the pandemic, largely driven by the omicron variant. According to local scientists, the variant no longer leads to high hospitalization rates and deaths in the country, a huge relief for a population reeling under lockdown fatigue.

Madhi told VOA the continent has failed to learn from experiences with the 2009 swine flu, which emphasized the need for good data collection.

He added that “the impact of the pandemic on Africa will, unfortunately, be realized only after the pandemic has passed.”

US support

The United States has committed to helping the world combat the virus. President Joe Biden pledged to donate over 1.2 billion doses through COVAX, the international vaccine-sharing initiative supported by the U.N. and the health organizations Gavi and CEPI. The initiative aims to ensure the equitable distribution of vaccines to developing countries.

So far, the U.S. has donated more than 450 million doses globally, with more than 120 million doses going to 43 countries in sub-Saharan Africa, according to the State Department.

Ordu said it has become imperative to strengthen STEM (Science, Technology, Engineering and Mathematics) in Africa. This, he contended, would be a sure way to overcome any future health crisis.

“Because of the growing youthful population in Africa, it is important that STEM education is an area of focus, particularly for women and girls,” he said.

Source: Voice of America