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Defeatingmeningitisby2030:aglobalroadmapFromregionalimplementationtoimpactincountries

EighthmeetingoftheTechnicalTaskforce(TTF)

Geneva,13–15December2022

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Contents

Opening 3

Globalupdateandnextsteps 3

Fromregionalimplementationtoimpactincountries(1) 3

Regionalupdate:South-EastAsiaRegion 3

Regionalupdate:RegionoftheAmericas 4

Processandmaterialstodevelopnationalplanstodefeatmeningitisby2030 5

Regionalupdate:AfricanRegion 6

UpdateonBurkinaFaso 6

UpdateonNiger 7

Regionalupdate:WesternPacificRegion 7

Partnerupdates 8

Developmentofdiagnostictests 8

TheroleofPATH 9

UpdateonGroupBStreptococcus 10

Acutemeningitisandsequelae 10

Fromregionalimplementationtoimpactincountries(2) 10

Howtomoveforwardspecificactivitiesincountries–breakthroughgroups 10

Group1:Surveillanceandlaboratory 11

Group2:Clinicaldiagnosisandtreatmentincludingrecognitionofsequelaeandlong-termcare 11

Group3:Increasingawarenessandadvocacyonmeningitisanditsimpactincommunities 11

Globalupdate 12

Implementingtheroadmapfordefeatingmeningitisthroughtheuniversalhealthcoverage/primary

healthcare(PHC)approach 12

Strengtheninglinkswiththedisabilityagenda 12

GlobalMeningitisGenomePartnership 13

ConfederationofMeningitisOrganizations(CoMO)/MRF:WorldMeningitisDay 14

TheMeningstopandMenMapprojects:strengtheningthesurveillanceofinvasivebacterialinfectionsin

NorthAfricaandtheMiddleEast 15

RoadmapInvestmentCaseandcommunication 15

Investmentcase 15

Keythematicareasoftheinvestmentcase 16

Fromregionalimplementationtoimpactincountries(3) 17

Regionalupdate:EasternMediterraneanRegion 17

Mobilizingresources 18

Developingsynergies–learningfromotherinitiatives(4) 18

Developingsynergies:learningfromotherinitiativesforwidercoverage 18

Improvingdiagnosis,treatmentandmanagementofacutebraininfections 18

Healthpromotionandaccesstocare 19

Financialaccesstoqualityhealthcare 20

Monitoringandevaluation 21

GlobalM&ECommitee 21

Monitoringandevaluationframeworkfornationalimplementationandindicators 21

Closureofthemeeting 22

Annex1.Agenda 23

Annex2.Listofparticipants 26

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Opening

TheeighthmeetingoftheTechnicalTaskforce(TTF)ontheGlobalroadmapfordefeatingmeningitisby2030tookplaceattheheadquartersoftheWorldHealthOrganization(WHO)on13–15December2022.MembersoftheTTFandothermeetingparticipantswerewelcomedbyDrKatherineO’Brien,DirectorofWHO’sDepartmentofImmunization,VaccinesandBiologicalswhonotedthatsincetheGlobalroadmapwasapprovedbytheWorldHealthAssemblyin2020,theprocesstowardsdefeatingthisdiseaseismovingforwardthanksinlargeparttothetaskforce.TheworkonmeningitisisoneofWHO’scoreglobalstrategies,anddefeatingthediseasewillnotonlysavehugenumbersoflivesbutwillhelptostrengthenhealthsystemsworldwide.

TheTTFChair,ProfessorBrianGreenwoodoftheUnitedKingdom,andtheco-ChairDrSambaSowofMaliaddedtheirwelcomestoparticipants.OnDay1ProfessorSowtookthechairandwelcomedthecontributionoftheTTF’seffortstostrengtheningprimaryhealthcare.MeetingparticipantsthenintroducedthemselvesaroundthetableandalsoovertheInternet.

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Annex1containstheagendaofthemeetingandAnnex2hasthelistofparticipants.

Globalupdateandnextsteps

DrMarie-PierrePreziosinoteddramaticprogressonmeningitisintheWHOregionsandstressedthat2023wouldbeapivotalyearforglobaleffortstodefeatmeningitisby2030.TheTTFleadsandcoordinatestheimplementationoftheframeworkforactiontodefeatmeningitis.ThepresentmeetinginvolvedstafffromallWHOregions–aswellasfromtheLondonSchoolofHygieneandTropicalMedicine(LSHTM),MédecinssansFrontières(MSF),Epicentre,theMeningitisResearchFoundation(MRF),PATH,theUnitedStatesCentersforDiseaseControlandPrevention(CDC),theUnitedNationsChildren’sFund(UNICEF)andindividualexpertsfromtheBill&MelindaGatesFoundation,theInstitutPasteur,theNorwegianNationalInstituteofPublicHealth,UniversityCollegeLondonandtheUniversityofCambridge.HealthexpertsandscientistsfromBurkinaFaso,Chad,GhanaandNiger,aswellasexpertsfromGavi,GlobalHealthVisionsandtheUniversityofLiverpoolalsoparticipatedinthis8thTTFmeeting.InFebruary2023,thefirstmeetingoftheStrategySupportGroup(SSG)wouldtakeplacecomprisingrepresentativesfromministriesofhealth(onefromeachofthesixWHOregions),sixcivilsocietyorganizationswithregionalandglobalrepresentation,aswellasdonorrepresentativesatglobalandregionallevels,includingbilateralormultilateralgovernmentagenciesandphilanthropicfoundations.Progressreportsondefeatingmeningitisby2030wouldalsobeontheagendasofthe152ndsessionoftheWHOExecutiveBoardinFebruary2023andoftheSeventy-sixthWorldHealthAssemblyinMay2023.

2023willseecontinueddevelopmentoftheregionalimplementationframeworksandnationalplans.Inmid-2023,apledgingeventwilltakeplacetocoincidewiththeofficiallaunchoftheinvestmentcasefortheglobalroadmap.

Fromregionalimplementationtoimpactincountries(1)

Regionalupdate:South-EastAsiaRegion

DrManishKakkarreportedonprogresstowardsdefeatingmeningitisinWHO’sSouth-EastAsiaRegion.Theregionalvaccineactionplan2000–2030hasbeenadopted,includingthegoalof

1TTFChairProfessorBrianGreenwoodwasunabletoreachGenevaasplannedonthefirstdayofthemeetingduetotransportdelaysandjoinedviatheInternet.Hewasabletochairthemeetinginpersonondays2and3.

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increasingequitableaccessanduseofnewandexistingvaccines.MemberStateshadbeeninformedoftheGlobalroadmapfordefeatingmeningitisandinAugust2022theRegionalImmunizationTechnicalAdvisoryGroupmeetingincludedaninformationsessionondefeatingmeningitis.MemberStateswereasktointegratemeningitisvaccinesintotheirnationalimmunizationstrategiesand/orcomprehensivemulti-yearplans.ArepresentativeoftheMinistryofHealthofaMemberStateintheregionhasbeenproposedasamemberoftheStrategySupportGroup(SSG)oftheGlobalroadmap,andregionalstrategicroadmapsforhealthsecurityandfordiagnosticpreparednesshavebeenendorsedbytheRegionalCommittee.Termsofreference(ToRs)havebeenfinalizedforaconsultanttoassistwithalandscapeanalysisandtodrafttheregionalframeworkfordefeatingmeningitis.

AllcountriesintheregionareusingHibaspartofapentavalentvaccine,andpneumococcalconjugatevaccine(PCV)isnowusedinanumberofcountries.Surveillanceisbeingstrengthenedandtheimportanceoftheroleofimmunizationandsurveillanceindefeatingmeningitishasbeenrecognized.Nevertheless,challengesremain–includingcompetingprioritiesduetotheCOVID-19pandemicresponse,concernsastocoordinationbetweendifferentdepartmentsintheregionalofficeandinsufficienttechnicalsupportforregionaladaptationoftheroadmap.AnimmediatenextstepistoidentifyasuitablecandidatetosupportthedevelopmentoftheregionalimplementationframeworkfortheGlobalmeningitisroadmap.

Discussion

Indiscussion,theregionwascongratulatedontheprogressmadesofarandwasurgedtocompleteitsimplementationframeworkassoonaspossible.Intermsofinterdepartmentalcollaboration,TTFmembersstressedtheimportanceofincludingrepresentativesofthementalhealthteam,andparticularlythebrainhealthunit,intheefforttodefeatmeningitis.

Regionalupdate:RegionoftheAmericas

DrLúciadeOliveirareportedthatthePanAmericanHealthOrganization(PAHO)hadconductedalandscapeanalysisandaMemberStates’workshopfordevelopingaregionalroadmaptodefeatmeningitis.Thelandscapeanalysiswasbasedonareviewofliteratureandsecondarydatasources,withariskassessmentthatlookedatindicatorsofhealthservicesandtheburdenofdisease.TTFmemberswereinformedthatmeningococcalvaccineshadreducedinfectionincountriesoftheAmericaswhentheywereusedwidelyinapopulation.Unfortunately,itwasnotalwayspossibletoreach80%coverage.ThecountriesmostatriskareHaiti,DominicanRepublic,Guatemala,Bolivia,Honduras,Venezuela,Paraguay,Suriname,BrazilandArgentina.

RegionalactivitiesinsupportoftheGlobalroadmaphaveincludedPAHOinterdepartmentalmeetingstodiscussstrategy,thelandscapeanalysistobuildanevidencebaseforselectingcountriestobetargeted,aPAHOwebpageonmeningococcus,andthelaunchoftheregionalroadmapinSeptember2021.Avirtualcourseonmeningococcalmeningitiswasorganizedwith300participantsfrom20countries,andameetingwitheightselectedcountriesfocusedonsentinelsurveillancedataforinvasivebacterialdiseases.Inaddition,aworkshopwith60participantsfrom12countrieswasheldinLima,Peru,todeveloptheregionalroadmapforLatinAmericancountries.

During2023–2024,theregionalroadmapondefeatingmeningitiswillbefurtherdevelopedonthebasisofcountryinputs.Activitieswillaimtoachieveregionalandnationalcommitmentandpoliticalwilltodefeatmeningitis,andwillstrengthentheengagementofpublic-privatepartnershipsandcivilsociety.Itwillbenecessarytoensuretherearesufficienttechnical,humanandfinancialresourcestoachieveroadmapgoals.Ateamofconsultantswillbeformedtoprovidedirectsupporttocountries.Countryvisitsareplannedinordertoprepareroadmapsaccordingtonationalspecificities.Itwas

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stressedthat,althoughtargetedcountrieshavebeenselectedonthebasisoftheirneeds,allcountriesshouldworktowardsadvancingtheroadmap.Ministriesofhealthwillhaveplansformonitoringactivitiesandevaluatingindicators.Communicationandriskmanagementplanswillbedevelopedtosupporttheimplementationofroadmapactivities.

Discussion

Duringdiscussion,thecollaborativeworkshopwasdescribedasasignificantstepforwardforachievingimplementationoftheroadmap.DifferentcountrieshavedifferentapproachesandthePAHOworkshophelpedtobringthemtogetherandencouragedcooperation.TheTTFfeltthatmoresuchmeetingsinotherregionswouldbehelpful.

ItwasnotedthatsurveillancevariesconsiderablybetweencountriesintheAmericas.TTFmembersstressedtheimportanceofcommunityinvolvementinsupportofsurveillance.ThereisalackofconsistencybetweenthehealthinformationsystemsofcountriesintheAmericas,andaunifiedsystemisneededbothregionallyandglobally.Itwassuggestedthatglobalunificationofhealthinformationsystemsshouldcomefirstandshouldthenbeadjustedtoregionalneeds.Inanswertoaquestiononwhethertohavenationalchampionsfordefeatingmeningitis,theresponsewastobecarefulbecausehigh-profilepersonsatnationalleveloftentendtohavestrongpoliticalviewswhichmaybeinappropriateforPAHOandWHO.

Processandmaterialstodevelopnationalplanstodefeatmeningitisby2030

DrLorenzoPezzolipointedoutthatanactionframeworkexists,severalregionalframeworksarecompleteandothersareinprogress,anditistimetomoveaheadtodevelopnationalplans.HispresentationaimedtoshowideasonthewayforwardandtogatherfeedbackfrommembersoftheTTF.Hedescribedthestrategicplanasa“livingdocument”thatcouldchangeastimeprogressesandasfeedbackisgathered.Thestrategicplanwillbefollowedbyoperationalplansthatwillalignwithotherglobalinitiativessuchasimmunizationstrategiesandprimaryhealthcare(PHC)andwillultimatelyhaveanimpactbeyondmeningitis.Henotedtwomainaimsoftheprocesstodevelopnationalplans,namely:1)tohaveadescriptionofobjectives,activitiesandmilestoneswithrelatedtimelines,budgetandresponsibleorganizations(i.e.technicaloutput);and2)toengagestakeholdersatalllevels(i.e.politicaloutput).Eachcountryneedsastrategicplanwithfoundationactivities,operationalbuildingblocksandsupportfunctions.

WHOisdevelopingaguidancemanualonDefeatingmeningitisby2030:aguidetodevelopingnationalplans.ThepublicationwasstillinapreliminaryversionatthetimeoftheTTFmeeting,butitwilldescribethreephasesofplandevelopment–1)apreparationphase(withasituationalanalysisbasedonmeningitisriskassessment,landscapeanalysisandstakeholdermapping);2)anactivityplanningphase(withbrainstormingaboutactivitiesandinterventions,creativethinkingintechnicalareas,andgoalsbrokendownintoachievablestepsofadetailedplan);and3)animplementationphase(withprocessesfordevelopingtheplan,forvalidatingandendorsingit,andforreportingonprogress).Theimplementationphaserequirestheuseofbuildingblockstobuildonwhatalreadyexists.Itwillincludeestablishingaprocessforreviewoftheplanatkeystagesontheroadto2030.Goalsandfocuscanbeadjustedasneeded.Itwasstressedthatthewholeprocessshouldbecountry-led(toidentifythegapsanddefineobjectives,activitiesandresources)butwithamulti-levelandmulti-disciplinaryapproach(includingdecision-makersandfieldworkers,andnotlimitedonlytotraditionalmeningitisexpertsandplayers).

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Discussion

Anumberofissueswereraised–suchaswhetherformalprocessesshouldbedefinedtosupportcountriesindevelopingplans,whetherthiswouldbenefitcountries,andwhatsupportpartnerscanprovide.TTFmemberswerestronglyinfavouroflettingcountriesdecide,ratherthantellingthemwhattodo,althoughitwasalsofeltthatitcanhelptodecideifyouhaveastartingpointtoguideyou.Aclearnationalframeworkcanhelpfacilitatefunding,andmanycountriesarealreadyworkinginglobalpartnershipswithdonorsandaidrecipients.Itwouldbeimportanttoestablishclearlywhoisaccountableforeachnationalplan.Ifaccountabilityisclearandformalprocessesarefollowed,donorsaremorelikelytosupportaprogramme.ItishopedthatadraftofWHO’smanualwillbesharedearlyin2023.Civilsocietyisakeyelementinanynationalpartnershipandshouldbeinvolvedearlyintheprocess.Meningitisisclearlyaglobaldisease,anditisimportanttokeepthisinmindwhenplanning.

Regionalupdate:AfricanRegion

DrAndersonLattandProfessorAndreBitareportedthattheRegionalimplementationframeworktodefeatmeningitisinAfricaby2030waslaunchedinSeptember2022bytheRegionalDirectorofWHO’sAfricanRegion.Anupdateonimplementationoftheframeworkwasprovidedduringthe19thannualmeningitismeetingandatthe9thmeetingofMenAfriNetpartnerson8–9November2022(duringwhichtherewasalsoaside-meetingdedicatedtotheregionalframework).Theregion’sfirstworkshoponthedevelopmentofnationalstrategicplanstodefeatmeningitisby2030for15targetedcountrieswasheldon28–30November2022.Thereweretwopriorbriefingsessionswiththe15countries:oneonadvocacy,stakeholdersensitizationandtheformationofcountryteams,andoneontheuseofatemplatetodoananalysisofthefightagainstmeningitisplusapre-workshop.Countriesathighandmediumriskwereconsideredpriorities.

ChallengestodefeatingmeningitisintheAfricanRegionincludecompetingpublichealthprioritiessuchastheongoingCOVID-19pandemic,anoutbreakofEbolavirusdiseaseinUgandaandavarietyofhumanitariancrises.Inthepasttwoyears,theneedtocombatCOVID-19interruptedothervaccinationprogrammessuchasthoseforPCV.Chad,Guinea,SomaliaandSouthSudanwerementionedinthisregard.Additionally,thereisalackofstandardizedguidanceforidentifyingandmanagingsequelae,fundsstillneedtobemobilized,and10high-riskcountriesstilldonotyethavethemonovalentmeningococcalAconjugatevaccine(MenACV)intheirroutineimmunizationschedules.

Discussion

ThenextstepsforAfricawillbetosupportthefirstbatchof15targetedcountriestofinalizeandimplementtheirplans,tomobilizeresourcestosupportcountriestoimplementtheirplans,andtoorganizeasecondworkshop(for15additionaltargetedcountries)onthedevelopmentofnationalstrategicplanstodefeatmeningitisby2030.ThisisscheduledforApril2023.Thetargetoftheregionalframeworkisfor80%ofcountriestobeusingPCVintimetoreporttothe73rdRegionalCommitteeinAugust2023.Duringdiscussion,itwasnotedthatPCVisincreasinglybeingusedandisbeingencouragedintheremainingcountries.

UpdateonBurkinaFaso

ProfessorMahamoudouSanoutoldtheTTFthatBurkinaFasoisinthecentreofAfrica’smeningitisbelt.Everyyearinthedryseasonthereisariseinthenumberofcases.However,thenumberofcasesandfatalitiesfromserogroupAdecreasedafter2010whenMenACVwasintroduced.This

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vaccinehasshowngoodprotectionofyoungchildren.After2011,thenumberoftotalcasesanddeathsfellwithregularvaccinationandtherewereminimalcasesofserogroupA.However,thenumberofcasesofserogroupsXandYhasgrown.In2019,therewasanoutbreakofmeningitisofserogroupCinBurkinaFasoneartheborderwithNiger.

Discussion

TTFmembersnotedthenecessityofcontinuingtomobilizemobilizingresourcesagainstmeningitisandurgedlargeruseofvaccinesagainstserogroupsA,C,W,XandY.TheChairreinforcedtheneedforthispentavalentvaccine,pointingoutthattherearemanyvillagesinthemeningitisbeltwheretheresidentscangoforayearormorewithouteverbeingabletoseeacommunityhealthworker.

UpdateonNiger

DrAndréBitareportedonaworkshopinwhichcountryrepresentativeswereaskedasetoffourquestions–onprogresstowardsdevelopmentofnationalworkplans,innovativeactivities,collaborationwithneighbouringcountries,andchallenges.Therewere90representativesofcountriesattheworkshop.Nigerreportedthatithadafirstdraftofanationalplan.Nigeralongwithothercountriesattheworkshopreportedtheyhadplansthatcoveredthefivepillarsofthemeningitisframework.

Discussion

TTFmembersraisedtheissueofsurveillanceforsequelaealthoughitwasfeltthatitwasdifficultformanycountriestodothis.Itwasnotedthat,inAfrica,meningitisisthesecondcauseofneurologicalconditionsafterstroke.Therewasdiscussionastowhatthepurposeofconductingsurveillanceforsequelaewouldbe–woulditbetomeasuretheburdenofmeningitisortoestimatetheneedsforclinicalcare?Itwaspointedoutthatthereislittleevidence,intheplaceswheresurveillanceofsequelaehasbeenattempted,thatpatientshaveaccesstoneurodevelopmentalcare.ItwasagreedthatthisissueshouldbeconsideredbytheWHORegionalOfficeforAfrica.Itwassuggestedthatthatcaremightbemorelikelyifonecliniccantakecareofallthepossiblesequelaethatmeningitispatientsexperience.ItwasagreedthatPHCisagoodmodelonwhichtobasesuchservices,withmeningitisbeingconsiderednotonlyintermsofthemortalityitcausesbutalsointermsofthemorbiditylinkedtosequelae.Ifthereisnoattempttofollowuppeoplewhohavehadmeningitisbecausecareisnotavailable,theycanbelosttofollow-upevenifcarebecomesavailableseveralyearslater.Thisfurtherledtothequestionofwhetherillnessesarereallysequelaeofmeningitis.Atrainingpackagewouldbeneededtodealwiththis.Anadditionalissueraisedwasthattherearewidelydifferingattitudestothesafetyandusefulnessoflumbarpunctureandwhoshouldbeallowedtoperformthis,andthatthissituationshouldbeclarified.

Regionalupdate:WesternPacificRegion

DrHardeepSandhunotedthatWPROistrailingotherregionsindevelopingnationalplanstodefeatmeningitis.Aregionalframeworkhasbeendevelopedforvaccine-preventablediseases(VPDs)andimmunizationintheWesternPacificRegionandwasendorsedbytheSeventy-firstsessionoftheRegionalCommittee.Theframeworkinvolves18strategiesandaimstoachievethreestrategicobjectives,namely:1)strengtheningandexpandingtheimmunizationsystemsandprogrammes;2)preparingforandrespondingtopublichealthemergencies;and3)managinghealthintelligenceonVPDsandimmunization.However,therealburdenofmeningococcaldiseaseintheregionisunknownandmeningitisisnotgenerallyconsideredapriorityamongcountriesintheWesternPacific.Thereisalackofdataonthediseaseburdenandthereisunder-reportingduetoweak

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surveillance,lackofguidelinesandinconsistentcasedefinitions.Asof2020,meningococcalvaccinationwasapartofstandardimmunizationonlyinAustraliaandChina.

Thestrategicdirectionsidentifiedbytheregionalofficeforcounteringmeningococcaldiseaseare:1)topreventandcontroloutbreaksthroughdevelopmentandenhancedaccesstoaffordablevaccines,effectiveprophylacticstrategiesandtargetedcontrolinterventions;2)establish,sustainandstrengthensurveillance;3)improvediagnosticcapacityatalllevelsofhealthcare;and4)ensurepromptandeffectivemanagementandtreatment.DrSandhusummarizedthemainsurveillancesystemsintheregion–chieflyforpolio,measles/rubella,invasivebacterialdiseases(IBD),Japaneseencephalitis(JE)androtavirus–whichreportdataregularlytotheregionaloffice.Surveillanceisveryunevenandonlynineofthe13countrieswhereJEisendemichaveactuallyintroducedaJEvaccine.SinceJEisanimportantdiseaseintheWesternPacificRegion,andthereispressuretoincreaseJEsurveillance,itwassuggestedthatitcouldbeworthwhiletoincludesurveillanceformeningitistoo.Asof2021,fourcountriesoftheregionhadstillnotintroducedPCV.

Strategiesproposedare:1)tointroducePCVintheremainingcountries,prioritizingcountrieswithhighchildhoodmortality;2)toachieveandsustainhighimmunizationcoveragewithPCVthroughouttheregion;3)establish,strengthenandsustainsurveillanceforinvasivepneumococcaldisease;4)strengthenlaboratorycapacitytodetectpneumococcalisolatesfrompatients;and5)conductnasopharyngealcarriagesurveysandmonitorchangesindiseasecirculationaftertheintroductionofPCV.ItwasreportedthatToRsarebeingpreparedforaconsultanttocarryoutthelandscapeanalysisandsupportthedevelopmentoftheimplementationplanfortheroadmap.InformalconsultationshavebegunwithotherWHOunits,andaMemberStaterepresentativefortheSSGhasbeenidentified.

Discussion

TherewasacommentthatthelowrateofIBDintheregionwaslikelytobeduetothewideuseofantibioticsmakingitdifficulttoobtainpositivecultures.However,itwasalsonotedthat,evenwhentryingtodiagnoseverysickchildren,parentsandhealthcareprovidersresistedtheuseoflumbarpuncture,sothatdiagnosiscouldnotbedoneintimetoaffectthecourseofthedisease.Evenifpatientortheirfamilyagreestoalumbarpuncture,thishappensonlyattertiary-levelhospitalswhichmeanswaitingforareferralandduringthewaitingperiodadoctorislikelytogivethechildanantibiotic.Meningitisinchildrenisoftenaconsequenceofsystemicbacterialinfections,anditwasconfirmedthattheapproachintheWesternPacificistotakea“pan-bacterial”approach,testingforallinvasiveinfections.InWestAfricaitisnow10or12yearssinceMenAfriVacimmunizationbeganandduringthattimeparentsandhealthworkershavecometorecognizethevalueoflumbarpuncture.IntheWesternPacificRegionthisprocessisonlyjustbeginning.

Partnerupdates

Developmentofdiagnostictests

DrKatyaFernandezaddressedthedevelopmentofmeningitisdiagnostickits.Anexpertmeetingin2018identifiedthreeneeds,namely:1)inthemeningitisbelt,toidentifythecausativeorganismrapidlyatperipherallevelforthepurposeofoutbreakdetection(usecase1);2)todifferentiateatthepointofcarebetweenbacterialandviralinfections(usecase2);and3)t