scholarly journals Evaluation of Acute Flaccid Paralysis Surveillance indicators in Sokoto State, Nigeria, 2012-2019: A secondary data analysis

2020 ◽  
Author(s):  
Ismail Abdullateef Raji ◽  
Auwal Abubakar Usman ◽  
Abdulrahman Ahmad ◽  
Saheed Gidado ◽  
Abdulhakeem Abayomi Olorukooba ◽  
...  
Keyword(s):  
Acute Flaccid Paralysis ◽  
Secondary Data ◽  
High Sensitivity ◽  
Flaccid Paralysis ◽  
World Health ◽  
Surveillance Network ◽  
Polio Virus ◽  
Acute Flaccid Paralysis Surveillance ◽  
Afp Surveillance ◽  
Health Organization

Abstract Background: Nigeria and indeed, entire Africa has been certified free of Wild Polio Virus (WPV) in 2020. However, the continent is still at risk of importation of WPV, especially in states like Sokoto in Nigeria, which has an international border. Furthermore, due to low immunity in some communities in Sokoto, outbreaks of the circulating Vaccine Derived Polio Virus (cVDPV) occur. Therefore, this paper evaluates the Acute Flaccid Paralysis (AFP) surveillance indicators in Sokoto state, Nigeria. Methods: This retrospective study was an analysis of routinely collected AFP surveillance data between 2012 and 2019 by the Sokoto state surveillance network. We assessed the Sokoto state AFP surveillance system using the AFP surveillance performance indicators. We performed all analyses using Microsoft Excel 2019.Results: Cumulatively, 3001 Acute Flaccid Paralysis (AFP) cases were reported over the evaluation period, out of which 1692 (56.4%) were males, and 2478 (82.4%) were below five years. More than half, 1773 (59.1%) had a fever at the beginning of the disease, and 1911 (63.7%) had asymmetric paralysis. The non-polio AFP rate (9.1 to 23.5%) and stool adequacy rate (92.5 to 100%) indicate high sensitivity. The proportion of cases that had stool samples collected early, timely transported to the laboratory and arrived at the laboratory in optimal condition were all above the World Health Organization (WHO) minimum standard of 80%. There was inadequate profile documentation of some suspected cases.Conclusions: Sokoto State has exceeded the WHO minimum standards in most of the AFP surveillance indicators. The performance of the system is sufficient enough to detect any reintroduction of WPV into the state. However, there is a need for improvement in data quality.

scholarly journals Evaluation of acute flaccid paralysis surveillance indicators in Sokoto state, Nigeria, 2012–2019: a secondary data analysis

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Ismail Abdullateef Raji ◽  
Auwal Usman Abubakar ◽  
Abdulrahman Ahmad ◽  
Saheed Gidado ◽  
Abdulhakeem Abayomi Olorukooba ◽  
...  
Keyword(s):  
Acute Flaccid Paralysis ◽  
Secondary Data ◽  
High Sensitivity ◽  
Flaccid Paralysis ◽  
World Health ◽  
African Region ◽  
Surveillance Network ◽  
Polio Virus ◽  
Acute Flaccid Paralysis Surveillance ◽  
Afp Surveillance

Abstract Background Nigeria, the last endemic country in the WHO African Region, was certified free of Wild Polio Virus (WPV) in 2020. However, due to low immunity in some communities in Sokoto, outbreaks of the circulating Vaccine Derived Polio Virus (cVDPV) occur. The aim of this study is to evaluate the Acute Flaccid Paralysis (AFP) surveillance indicators in Sokoto state, Nigeria. Methods This retrospective study was an analysis of routinely collected AFP surveillance data between 2012 and 2019 by the Sokoto state surveillance network. We assessed the Sokoto state AFP surveillance system using the AFP surveillance performance indicators. We performed all analyses using Microsoft Excel 2019. Results Cumulatively, 3001 Acute Flaccid Paralysis (AFP) cases were reported over the evaluation period, out of which 1692 (56.4%) were males, and 2478 (82.4%) were below five years. More than half, 1773 (59.1%), had a fever at the beginning of the disease, and 1911 (63.7%) had asymmetric paralysis. The non-polio AFP rate (9.1 to 23.5% per 100,000 children < 15 years old) and stool adequacy rate (92.5 to 100%) indicate high sensitivity. The proportion of cases that had stool samples collected early, timely transported to the laboratory and arrived at the laboratory in optimal condition were all above the World Health Organization (WHO) minimum standard of 80%. There was inadequate profile documentation of some suspected cases. Conclusions Sokoto State has exceeded the WHO minimum standards in most of the AFP surveillance indicators. The performance of the system is sufficient enough to detect any reintroduction of WPV into the state. However, there is a need for improvement in data quality.

Detection of non-polio and polio enteroviruses in Acute Flaccid Paralysis surveillance in Turkey

2021 ◽  
Author(s):  
Gulay Korukluoglu ◽  
Umit Ozdemirer ◽  
Fatma Bayrakdar ◽  
Zehra Unal ◽  
Yasemin Cosgun ◽  
...  
Keyword(s):  
Acute Flaccid Paralysis ◽  
Flaccid Paralysis ◽  
Sequencing Analysis ◽  
National Data ◽  
Polio Virus ◽  
Vaccination Rates ◽  
Acute Flaccid Paralysis Surveillance ◽  
Polio Vaccination ◽  
Afp Surveillance ◽  
Comprehensive Study

AbstractPoliomyelitis was a disease feared worldwide, striking suddenly and paralysing mainly children for life. Monitoring of suspected cases of poliomyelitis is carried out with Acute Flaccid Paralysis (AFP) surveillance in Turkey. This study examines national data of AFP surveillance and the epidemiology of enteroviruses (EV) in Turkey from 2000 to 2019 and gives an overview of the detected serotypes of EVs. A total of 13,640 samples collected from patients with 5216 AFP pre-diagnosed cases (2 samples from each patient) and 3,208 contacts, during a 20-year period (2000–2019) were investigated. All isolated polioviruses were tested for their wild or vaccine origin according to the WHO recommended protocol by PCR and sequencing analysis were performed. Enterovirus positivity was detected in a total of 915 cases, which were identified as 204 Sabin-like polio virus (SLPV) and 711 non-polio enterovirus (NPEV). Of the 204 SLPV, 141 (69.1%) AFP were detected in patients and 63 (30.9%) were detected in samples taken from their contacts. Of the 711 NPEVs, 516 (72.5%) were from AFP cases and 195 (27.5%) were detected in samples taken from their contacts. It is concluded that the reason for the higher detection rate of NPEV in samples from AFP pre-diagnosed cases is attributed to the polio vaccination rates reaching 97% between 2008 and 2019 in Turkey. The most frequently detected NPEV serotypes were Coxackie A24, B3, and Echo 30. This retrospective study is the first comprehensive study in Turkey to evaluate the results of the AFP surveillance in the last 20 years.

Performance of acute flaccid paralysis surveillance compared with World Health Organization standards

2014 ◽  
Vol 51 (2) ◽  
pp. 209-214 ◽  
Author(s):  
Shalini Desai ◽  
Tiffany Smith ◽  
Bruce R Thorley ◽  
Danielle Grenier ◽  
Nigel Dickson ◽  
...  
Keyword(s):  
World Health Organization ◽  
Acute Flaccid Paralysis ◽  
Flaccid Paralysis ◽  
World Health ◽  
Acute Flaccid Paralysis Surveillance ◽  
Health Organization

scholarly journals Genotyping of non-polio enteroviruses associated with acute flaccid paralysis in Thailand in 2013 and 2014

2021 ◽  
Vol 18 (1) ◽  
Author(s):  
Napa Onvimala ◽  
Nathamon Kosoltanapiwat ◽  
Pornpan Pumirat ◽  
Muthita Vanaporn ◽  
Suchitra Nimmanitya ◽  
...  
Keyword(s):  
Acute Flaccid Paralysis ◽  
Flaccid Paralysis ◽  
World Health ◽  
Reference Laboratory ◽  
Mouth Diseases ◽  
Circulation Patterns ◽  
The World ◽  
Afp Surveillance ◽  
Health Organization ◽  
First Time

Abstract Background Acute flaccid paralysis (AFP) surveillance was conducted as part of the World Health Organization’s strategy for completely eradicating poliomyelitis and leaving non-polio enteroviruses NPEVs as one of the main potential causes of AFP. We aimed to detect NPEV in association with AFP. Methods We used 459 isolates reported to be Negative Polio and some NPEVs by the World Health Organization Polio Regional Reference Laboratory (Thailand), which had been obtained during polio surveillance programmes conducted in Thailand in 2013–2014. Of 459 isolates, 35 belonged to the genus Enterovirus by RT-PCR and genotyping by DNA sequencing. Results This study found 17 NPEV genotypes, with 3, 13 and 1 belonging to enterovirus (EV) species A (EV-A), EV-B, and EV-C, respectively. The EV-A types identified included coxsackievirus A2 (CA2), CA4, and EV71, typically associated with hand, foot and mouth diseases. EV-B is the most prevalent cause of AFP in Thailand, while CA21 was the only type of EV-C detected. The EV-B species (13/35; 76.5%) constituted the largest proportion of isolates, followed by EV-A (3/35; 17.6%) and EV-C (1/35; 5.9%). For the EV-B species, Echovirus (E) 30 and CVB were the most frequent isolates. E30, CVB, E14, and E6 were considered endemic strains. Conclusion NPEVs, e.g. CA4, are reported for the first time in Thailand. Despite some limitations to this study, this is the first report on the circulation patterns of NPEVs associated with AFP in Thailand. AFP surveillance has unearthed many unknown NPEVs and, the cases of death due to AFP occur annually. Therefore, it is important to study NPEVs in the wake of the eradication of poliovirus in the context of the continued incidence of paralysis.

scholarly journals Gonotyping of non-polio enteroviruses associated with acute flaccid paralysis in Thailand in 2013 and 2014

2021 ◽  
Author(s):  
Napa Onvimala ◽  
Nathamon Kosoltanapiwat ◽  
Pornpan Pumirat ◽  
Muthita Vanaporn ◽  
Suchitra Nimmanitya ◽  
...  
Keyword(s):  
Acute Flaccid Paralysis ◽  
Flaccid Paralysis ◽  
World Health ◽  
Reference Laboratory ◽  
Mouth Diseases ◽  
Circulation Patterns ◽  
The World ◽  
Afp Surveillance ◽  
Health Organization ◽  
First Time

Abstract Background Acute flaccid paralysis (AFP) surveillance was conducted as part of the World Health Organization’s strategy for completely eradicating poliomyelitis and leaving non-polio enteroviruses NPEVs as one of the main potential causes of AFP. We aimed to detect NPEV in association with AFP.Methods We used 459 isolates reported to be Negative Polio and some NPEVs by the World Health Organization Polio Regional Reference Laboratory (Thailand), which had been obtained during polio surveillance programmes conducted in Thailand in 2013–2014. Of 459 isolates, 35 belonged to the genus Enterovirus by RT-PCR and genotyping by DNA sequencing.Results This study found 17 NPEV genotypes, with 3, 13 and 1 belonging to enterovirus (EV) species A (EV-A), EV-B, and EV-C, respectively. The EV-A types identified included coxsackievirus A2 (CA2), CA4, and EV71, typically associated with hand, foot and mouth diseases. EV-B is the most prevalent cause of AFP in Thailand, while CA21 was the only type of EV-C detected. The EV-B species (13/35; 76.5%) constituted the largest proportion of isolates, followed by EV-A (3/35; 17.6%) and EV-C (1/35; 5.9%). For the EV-B species, Echovirus (E) 30 and CVB were the most frequent isolates. E30, CVB, E14, and E6 were considered endemic strains.Conclusion NPEVs, e.g. CA4, are reported for the first time in Thailand. Despite some limitations to this study, this is the first report on the circulation patterns of NPEVs associated with AFP in Thailand. AFP surveillance has unearthed many unknown NPEVs and, the cases of death due to AFP occur annually. Therefore, it is important to study NPEVs in the wake of the eradication of poliovirus in the context of the continued incidence of paralysis.

scholarly journals Evaluation of the Acute Flaccid Paralysis Surveillance System in Polio-Free Jordan, 2012-2016: Retrospective Secondary Analysis (Preprint)

2019 ◽  
Author(s):  
Fatima Zerriouh ◽  
Yousef Khader ◽  
Nabil Qasem ◽  
Kamel Abusal ◽  
Ibrahim Iblan ◽  
...  
Keyword(s):  
Surveillance System ◽  
Acute Flaccid Paralysis ◽  
Secondary Analysis ◽  
Flaccid Paralysis ◽  
Cold Chain ◽  
World Health ◽  
Eradication Strategy ◽  
Acute Flaccid Paralysis Surveillance ◽  
Afp Surveillance ◽  
Stool Specimens

BACKGROUND As part of the polio-eradication strategy, the World Health Organization (WHO) has established a global acute flaccid paralysis (AFP) surveillance system. AFP surveillance has successfully helped Jordan achieve polio-free certification. However, there is a substantial risk of polio importation from neighboring countries including Syria and Iraq. OBJECTIVE This study aimed to evaluate the AFP surveillance in Jordan and identify areas that need improvement. METHODS This retrospective study is a secondary analysis of data that were routinely collected between 2012 and 2016 by Jordan’s Expanded Program on Immunization. The WHO’s minimum performance indicators were used to evaluate the AFP surveillance. RESULTS Cumulatively, 328 AFP cases had been reported. Almost half (n=168, 51.3%) of the patients were aged 1-5 years, and 55.8% (n=183) were male. All cases were discarded (classified as a nonpolio case). The most common cause of AFP was Guillain-Barre Syndrome (n=115, 35.1%). The annualized nonpolio AFP rate increased from 1.4/100,000 children below 15 years of age in 2012 to 4.3 in 2016. National and subnational sensitivities were not met in 2012 and 2013. Adequacy of stool specimens and timeliness of specimens arriving at and processed in the laboratory were constantly above the minimum target. Timeliness of the investigation met the expected target but with a decreasing trend. The nonpolio enterovirus isolation rate was below the target, except in 2016. CONCLUSIONS The AFP surveillance system in Jordan is performing well; however, additional efforts are needed to strengthen the subnational sensitivity. The cold chain from sample collection to laboratory testing has to be maintained to ensure the reliability of stool specimens required for isolation of the nonpolio enterovirus.

scholarly journals Evaluation of the Acute Flaccid Paralysis Surveillance System in Polio-Free Jordan, 2012-2016: Retrospective Secondary Analysis

10.2196/14217 ◽  
2019 ◽  
Vol 5 (3) ◽  
pp. e14217
Author(s):  
Fatima Zerriouh ◽  
Yousef Khader ◽  
Nabil Qasem ◽  
Kamel Abusal ◽  
Ibrahim Iblan ◽  
...  
Keyword(s):  
Surveillance System ◽  
Acute Flaccid Paralysis ◽  
Secondary Analysis ◽  
Flaccid Paralysis ◽  
Cold Chain ◽  
World Health ◽  
Eradication Strategy ◽  
Acute Flaccid Paralysis Surveillance ◽  
Afp Surveillance ◽  
Stool Specimens

Background As part of the polio-eradication strategy, the World Health Organization (WHO) has established a global acute flaccid paralysis (AFP) surveillance system. AFP surveillance has successfully helped Jordan achieve polio-free certification. However, there is a substantial risk of polio importation from neighboring countries including Syria and Iraq. Objective This study aimed to evaluate the AFP surveillance in Jordan and identify areas that need improvement. Methods This retrospective study is a secondary analysis of data that were routinely collected between 2012 and 2016 by Jordan’s Expanded Program on Immunization. The WHO’s minimum performance indicators were used to evaluate the AFP surveillance. Results Cumulatively, 328 AFP cases had been reported. Almost half (n=168, 51.3%) of the patients were aged 1-5 years, and 55.8% (n=183) were male. All cases were discarded (classified as a nonpolio case). The most common cause of AFP was Guillain-Barre Syndrome (n=115, 35.1%). The annualized nonpolio AFP rate increased from 1.4/100,000 children below 15 years of age in 2012 to 4.3 in 2016. National and subnational sensitivities were not met in 2012 and 2013. Adequacy of stool specimens and timeliness of specimens arriving at and processed in the laboratory were constantly above the minimum target. Timeliness of the investigation met the expected target but with a decreasing trend. The nonpolio enterovirus isolation rate was below the target, except in 2016. Conclusions The AFP surveillance system in Jordan is performing well; however, additional efforts are needed to strengthen the subnational sensitivity. The cold chain from sample collection to laboratory testing has to be maintained to ensure the reliability of stool specimens required for isolation of the nonpolio enterovirus.

scholarly journals Sensitivity of the acute flaccid paralysis surveillance system for poliovirus in South Africa, 2016–2019

2021 ◽  
Vol 70 (10) ◽  
Author(s):  
Wayne Howard ◽  
Shelina Moonsamy ◽  
Lerato Seakamela ◽  
Sabelle Jallow ◽  
Faith Modiko ◽  
...  
Keyword(s):  
South Africa ◽  
Surveillance System ◽  
Environmental Samples ◽  
Acute Flaccid Paralysis ◽  
Flaccid Paralysis ◽  
World Health ◽  
Surveillance Programme ◽  
Acute Flaccid Paralysis Surveillance ◽  
Afp Surveillance ◽  
Type 3

Introduction. Global poliovirus eradication is a public health emergency of international concern. The acute flaccid paralysis (AFP) surveillance programme in South Africa has been instrumental in eliminating polioviruses and keeping the country poliovirus free. Gap statement. The sensitivity of surveillance for polioviruses by every African country is of global interest in the effort to ensure global health security from poliovirus re-emergence. Aim. To describe the epidemiology of polioviruses from AFP cases and environmental samples in South Africa and to report the performance of the AFP surveillance system for the years 2016–2019 against targets established by the World Health Organization (WHO). Methods. Stool specimens from AFP or suspected AFP cases were received and tested as per WHO guidelines. Environmental samples were gathered from sites across the Gauteng province using the grab collection method. Concentration was effected by the two-phase polyethylene glycol method approved by the WHO. Suspected polioviruses were isolated in RD and/or L20B cell cultures through identification of typical cytopathic effects. The presence of polioviruses was confirmed by intratypic differentiation PCR. All polioviruses were sequenced using the Sanger method, and their VP1 gene analysed for mutations. Results. Data from 4597 samples (2385 cases) were analysed from the years 2016–2019. Two cases of immunodeficiency-associated vaccine-derived poliovirus (iVDPV) type 3 were detected in 2017 and 2018. A further 24 Sabin type 1 or type 3 polioviruses were detected for the 4 years. The national surveillance programme detected an average of 3.1 cases of AFP/100 000 individuals under 15 years old (2.8/100 000–3.5/100 000). The stool adequacy of the samples received was 53.0 % (47.0–55.0%), well below the WHO target of 80 % adequacy. More than 90 % of results were released from the laboratory within the turnaround time (96.6 %) and non-polio enteroviruses were detected in 11.6 % of all samples. Environmental surveillance detected non-polio enterovirus in 87.5 % of sewage samples and Sabin polioviruses in 12.5 % of samples. Conclusion. The AFP surveillance programme in South Africa is sensitive to detect polioviruses in South Africa and provided no evidence of wild poliovirus or VDPV circulation in the country.

scholarly journals Performance of Acute Flaccid Paralysis surveillance in Bauchi State, Nigeria, 2016

2017 ◽  
Vol 9 (1) ◽  
Author(s):  
Luka M. Ibrahim ◽  
Adamu Ningi ◽  
Jalal-Eddeen Saleh
Keyword(s):  
Stool Specimen ◽  
Acute Flaccid Paralysis ◽  
Case Definition ◽  
Flaccid Paralysis ◽  
World Health ◽  
Polio Virus ◽  
Specimen Collection ◽  
Afp Surveillance ◽  
Stool Samples ◽  
Definition Of

ObjectiveTo identify and address gaps in acute flaccid surveillance for polioeradication in Buchi stateIntroductionPoliomyelitis a disease targeted for eradication since 19881still pose public health challenge. The Eastern Mediterranean andAfrican Regions out of the six World Health Organization (WHO)Regions are yet to be certified polio free2. The certification of theWHO Africa region is largely dependent on Nigeria, while the WHOEastern Mediterranean is dependent on Pakistan and Afghanistan.Surveillance for acute flaccid paralysis (AFP) is one of the criticalelements of the polio eradication initiative. It provides the neededinformation to alert health managers and clinician to timely initiateactions to interrupt transmission of the polio disease and evidence forthe absence of the wild polio virus.3,4One of the core assignments ofthe certification committee in all regions is to review documentationto verify the absence of wild poliovirus.5Good and completedocumentation is the proxy indication of the quality of the systemwhile poor documentation translates to possibilities of missing wildpoliovirus in the past. We evaluated the performance of the AFPsurveillance system in Bauchi, which is among the 11 high risks statesfor wild polio virus in Nigeria to identify and address gaps in thesurveillance system.MethodsWe conducted a cross-sectional study in Bauchi State. We assessedthe material and documentations on AFP surveillance in eighteen of thetwenty Local Government Areas (LGAs). We assessed the knowledgeof the clinician at focal and non-focal sites on case definition of AFP,the number and method of stool specimen collection to investigate acase and types of training received for AFP surveillance. We verifiedAFP case investigations for the last three years: The caregivers(mothers) were interviewed to authenticate the reported informationof AFP cases, the method used for stool specimen collection andfeedbacks. Community leaders’ knowledge on AFP surveillance wasalso assessed. Data was entered and analyzed in excel spread sheet.ResultsReview of the expected deliverables of 18 out of the 20 LGAdisease surveillance and notification officers (DSNO) revealed thatonly 2(11%), 5(28%), 6(33%) and 7(39%) had evidence of poliooutbreak investigation, supervisory reports, minutes of meeting andsurveillance work plan respectively. Of the 31 AFP cases investigated,correct and complete information was 39% for birth day, 26% forbirth month of the child, 23% for date of onset of paralysis and 23%for date of investigation. Contacts of informants, AFP 001-3 weredeficient in the focal and non-focal sites. The non-focal also lackedguidelines for integrated disease surveillance and response (IDSR)and terms of reference for surveillance focal person.Knowledge of case definition of AFP was 71% and 30% amongclinician at the focal and non-focal sites, respectively and 88% and55% for method of stool collection among clinician at focal and non-focal sites. Among the 38 care givers (mothers) interviewed 16 (42%)did not remember the day or month the investigation for the AFPwas conducted, 36(95%) gave the correct number of stool samples,15(40%) mentioned that the stool samples were collected 24 hoursapart and only 12 (32%) received feedbacks. Majority (79%) of thecommunity leaders interviewed were aware of AFP and knew thatstool was the specimen for investigation of the AFP but 21% did notknow whom to report a case of AFP in their communityConclusionsOur study revealed knowledge and documentations gaps in AFPsurveillance for certification of polio-free in Nigeria. The stateministry of health and the WHO consultants in the polio eradicationunit should update the knowledge of the health care workers at theoperational levels on AFP surveillance. The state ministry of healthand the WHO consultants should also provide all essential documentsrequired for quality AFP surveillance and ensure their judicious use.

scholarly journals Enterovirus D68 Subclade B3 Circulation in Senegal, 2016: Detection from Influenza-like Illness and Acute Flaccid Paralysis Surveillance

2019 ◽  
Vol 9 (1) ◽  
Author(s):  
Amary Fall ◽  
Ndack Ndiaye ◽  
Mamadou Malado Jallow ◽  
Mamadou Aliou Barry ◽  
Cheikh Saad Bou Touré ◽  
...  
Keyword(s):  
Active Surveillance ◽  
Acute Flaccid Paralysis ◽  
Flaccid Paralysis ◽  
Influenza Like Illness ◽  
Acute Flaccid Paralysis Surveillance ◽  
Afp Surveillance ◽  
Enterovirus D68 ◽  
Low Levels ◽  
Respiratory Specimens ◽  
Children Under 5

Abstract Following the 2014 outbreak, active surveillance of the EV-D68 has been implemented in many countries worldwide. Despite subsequent EV-D68 outbreaks (2014 and 2016) reported in many areas, EV-D68 circulation remains largely unexplored in Africa except in Senegal, where low levels of EV-D68 circulation were first noted during the 2014 outbreak. Here we investigate subsequent epidemiology of EV-D68 in Senegal from June to September 2016 by screening respiratory specimens from ILI and stool from AFP surveillance. EV-D68 was detected in 7.4% (44/596) of patients; 40 with ILI and 4 with AFP. EV-D68 detection was significantly more common in children under 5 years (56.8%, p = 0.016). All EV-D68 strains detected belonged to the newly defined subclade B3. This study provides the first evidence of EV-D68 B3 subclade circulation in Africa from patients with ILI and AFP during a 2016 outbreak in Senegal. Enhanced surveillance of EV-D68 is needed to better understand the epidemiology of EV-D68 in Africa.

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