Quantifying the indirect impact of COVID-19 pandemic on utilisation of outpatient and immunisation services in Kenya: a longitudinal study using interrupted time series analysis

The impact of the COVID-19 pandemic on urban-rural outpatient primary care utilisation in Malaysia: a retrospective time series and spatiotemporal analysis

BACKGROUND

The COVID-19 pandemic significantly affected healthcare utilisation worldwide, underscoring the importance of monitoring it to indicate whether essential health services were maintained during crises. This study explored how the pandemic affected outpatient department (OPD) utilisation in public primary care facilities in Malaysia by analysing utilisation trends and comparing it across geographical regions, including urban-rural disparities.

METHODS

Monthly OPD attendance from 1,053 public primary care health clinics in Malaysia, from January 1, 2019, to June 30, 2021, was analysed. The study duration was divided into four distinct periods: pre-pandemic, pandemic with the first lockdown implementation, pandemic after the first lockdown was lifted, and pandemic with the second lockdown implementation. An interrupted time series analysis was conducted to assess the impact of different interventions at national, regional, urban-rural, and district levels. Data were then aggregated at the district level and the utilisation changes were visualised in a choropleth map. Additionally, simple linear regression (SLR) was performed to explore the association between utilisation changes and urbanisation rates of the district, for each period.

RESULTS

Nationally, OPD utilisation dropped by nearly 13% at the onset of the first lockdown and continued to decline by almost 24% monthly thereafter. In terms of urban-rural differences, urban areas in the Central and Eastern Regions showed greater fluctuations in OPD utilisation during different periods. Results from the SLR revealed that higher urbanisation rates were associated with more pronounced changes in utilisation, although the direction of these changes varied across time periods.

CONCLUSION

The OPD utilisation was affected during the COVID-19 and sporadic urban-rural differences were observed in some areas of the country. This study offers important insights into the geographic and urban-rural patterns of healthcare utilisation during the pandemic, which are crucial in improving healthcare equity in Malaysia.

Evaluation of the impact of the state of emergency during the COVID-19 pandemic on childhood immunizations in Benguela Province, Angola

BACKGROUND

The impact of public health measures against the coronavirus disease 2019 on the rate of childhood immunization has not yet been fully defined. Particularly, measures which directly affect health-seeking behaviors (e.g., the State of Emergency; SoE) drew public health attention. We aim to describe this impact in Benguela Province, Angola, by comparing the immunization rates between infants who had their immunizations before and after the SoE, which was declared on March 27, 2020.

METHODS

We retrospectively reviewed the epidemiological data of infants born between November 2019 and February 2020 in Benguela Province, Angola. Immunization rates (i.e., the number of immunized infants divided by the number of infants in the group of same months of birth and residential areas) were calculated for 11 vaccines that infants received from at birth to the 4th month after birth. The rates for the 2nd month vaccines were compared between infants immunized before the SoE (post-SoE), and after the SoE (pre-SoE).

RESULTS

Among 9,595 infants, the overall immunization rates were higher in the post-SoE (71.9-77.8%) than in the pre-SoE groups (66.0-73.8%). The overall immunization rates were higher in the post-SoE group than in the pre-SoE group in both urban and rural municipalities, although the rates were > 20% higher in urban than in rural municipalities. The immunization rates in the recommended month showed a similar trend, except for the stratified analysis for rural municipalities, where the rates were 2.3-4.1% lower in the post-SoE than in the pre-SoE groups. The most common reason for missing immunization was vaccine unavailability at health units (19.9%, 684/3,440). Less than 10% of missed immunizations were due to the SoE, which occurred mostly in infants born in rural municipalities in February 2020 (9.8%, 52/532). Less than 2% of missed immunizations were due to health units not being open, and was highest in rural municipalities in January 2020 (1.6%, 27/1,673).

CONCLUSIONS

Our study suggested that the disruptive impacts of public health measures against pandemics on rates of childhood immunization can be mitigated, and support is needed for areas with vulnerable health systems, such as rural areas.

Economic impact of COVID-19 on patients with type 2 diabetes in Kenya and Tanzania: a costing analysis

Introduction

COVID-19 affected healthcare access, utilisation and affordability, especially for patients suffering from chronic diseases, including type 2 diabetes (T2D). This study measured the occurrence and magnitude of changes in healthcare and broader societal costs among patients with T2D before and during COVID-19 in Kenya and Tanzania to understand whether and how COVID-19 affected T2D management in countries implementing different policies during the pandemic.

Methods

A cross-sectional study was conducted in Kenya and Tanzania in March-April 2022 among 500 patients with T2D in each country. We interviewed patients on direct healthcare costs (eg, inpatient and outpatient costs), societal costs (eg, productivity loss) and patients' characteristics before and during the COVID-19 pandemic. We estimated changes over time using the Generalised Linear Model in Kenya and a two-part model in Tanzania, adjusting for patient-level covariates.

Results

The overall costs of management of T2D in most categories increased in both countries during COVID-19, but some of the increase was not significant. Transport and testing costs increased significantly in Tanzania (I$0.33, p<0.01 and I$0.85, p<0.01) but not in Kenya (I$1.69, p=0.659 and I$0.10, p=0.603). Outpatient costs increased significantly in Tanzania (I$8.84, p<0.01) but there was no significant change in Kenya (I$8.09, p=0.432). T2D medication costs did not change in Tanzania (I$0.19, p=0.197), but decreased significantly in Kenya (I$18.48, p<0.01). Productivity losses increased significantly in both countries.

Conclusion

The COVID-19 pandemic is associated with increased direct costs but with a significant increase in many cost categories (transport, testing and outpatient) in Tanzania than in Kenya. A significant increase in productivity loss was observed in both countries. The minimal cost increases in Kenya may be due to the inaccessibility of services associated with lockdown measures and higher insurance coverage compared with Tanzania. Pandemic preparedness initiatives and interventions are needed to safeguard the welfare of patients with chronic conditions during pandemics.

Impact of COVID-19 on essential healthcare services in Addis Ababa, Ethiopia: Implications for future pandemics

BACKGROUND

Responding to the COVID-19 pandemic has presented an unprecedented challenge to health systems, with countries needing to balance the demands of responding directly to the pandemic, while simultaneously continuing provision of essential health services. This study aimed to explore the impact of COVID-19 on essential healthcare services in Addis Ababa, Ethiopia.

METHODS

A facility-based retrospective study was undertaken in 30 health centers in Addis Ababa which were selected using simple random sampling. Secondary data were extracted for 22 indicators on maternal and child health, communicable and non-communicable diseases, and outpatient services for the period spanning between July 2019 and October 2020. These indicators were selected based on the WHO operational guidance on maintaining essential health services during an outbreak guide, essential packages of health services in Ethiopia and expert consultation. The difference in the trends of services before and during COVID-19 was compared using linear-by-linear tests and the difference of magnitude across the indicators was compared using Autoregressive Integrated Moving Average (ARIMA) interrupted time series analysis at a 5% significance level.

RESULTS

Overall, more than 1.7 million people visited the studied facilities for outpatient services, and 18,325 mothers attended skilled delivery in the study period. The present study found that the mean number of patients treated for TB declined by 35 patients (β: -34.62; 95%CI: -50.29, -18.95) compared to the pre-COVID-19 era while the number of new patients enrolled for ART decreased by 71 patients (β: -70.62; 95%CI: -107.19, -34.05). Regarding maternal health services, the number of women who received post-natal care decreased by about 215 mothers (β: -214.87; 95%CI: -331.57, -98.17). Similarly, the mean number of clients served at inpatient services declined by 34 (β: -33.72; 95%CI: -68.55, 1.05). On the other hand, the mean number of patients screened for diabetes and hypertension during the pandemic increased by more than 1014 (β: 1014.5; 95%CI: 103.07, 1925.92) and 610 patients (β: 611.21; 95%CI: 302.42, 919.99), respectively. However, changes with regard to antenatal care, skilled birth delivery, and children immunization services did not show a statistically significant change after COVID-19 was reported in Ethiopia.

CONCLUSION

Despite the notable efforts to sustain essential health services amidst the COVID-19 pandemic, our study revealed that there were disruptions in these services. This reinforces the need to adapt strategies to ensure sustainable provision of essential health services when pandemics of COVID19 magnitude cause disruptions of the health services.

Impact of COVID-19 on Maternal Health Service Uptake and Perinatal Outcomes in Sub-Saharan Africa: A Systematic Review

Coronavirus 2019 (COVID-19) is a major global public health threat that has impeded health infrastructures in low- and middle-income countries. This systematic review examines the impact of COVID-19 on maternal health service uptake and perinatal outcomes in Sub-Saharan Africa. We searched four databases in August 2020 and updated the search on 22 December 2023: PubMed/MEDLINE, CINAHL, Maternity and Infant Care, and EMBASE. Data extraction was performed using a standardised Joana Briggs Institute data extraction format for the eligibility of articles, and any discrepancies were solved through discussion and consensus. This systematic review includes 36 studies that met the inclusion criteria. Antenatal care attendance and institutional childbirth significantly decreased during the COVID-19 pandemic, and home births increased. Fear of contracting the virus, a lack of transport, a shortage of logistic supplies, a lack of personal protective equipment, lockdown policies, economic and food security, stigmatisation of sick persons, long waiting times in the hospital, and health system weakness were barriers to accessing maternity care. The findings of this review showed a significant decrease in antenatal care attendance and institutional birth during the COVID-19 pandemic. Based on our findings, we recommend that stakeholders ensure the availability of essential medical supplies in the hospital.

COVID-19 related disruption and resilience in immunisation activities in LMICs: a rapid review

OBJECTIVES

We conducted a rapid review to determine the extent that immunisation services in low-income and middle-income countries (LMICs) were disrupted by the COVID-19 pandemic and synthesised the factors that can be used to build resilience in future.

DESIGN

Rapid review reported in accordance with the Preferred reporting for Systematic reviews and Meta-Analyses (PRISMA) guidelines.

DATA SOURCES

PubMed and Web of Science were searched through 6 October 2023.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included studies that focused on disruption to immunisation activities due to the COVID-19 pandemic in LMICs. Outcomes included routine vaccine coverage, supplementary immunisation activities, vaccine doses, timing of vaccination, supply chain changes, and factors contributing to disruption or resilience.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers used standardised methods to search, screen and code studies. Quality assessment was performed using a modified version of the Critical Appraisal Skills Programme for qualitative research. Findings were summarised qualitatively.

RESULTS

Of 4978 identified studies, 85 met the eligibility criteria. Included studies showed declines in immunisation activities across LMICs related to the COVID-19 pandemic. These included reductions in achieved routine coverage, cancellation or postponement of campaigns and underimmunised cohorts. Immunisation was most disrupted in the early months of the pandemic; however, recovery varied by country, age-group and vaccine. Though many countries observed partial recovery in 2020, disruption in many countries continued into 2021. It has also been noted that clinician staff shortages and vaccine stock-outs caused by supply chain disruptions contributed to immunisation delays, but that concern over COVID-19 transmission was a leading factor. Key resiliency factors included community outreach and healthcare worker support.

CONCLUSIONS

There is limited information on whether reductions in vaccination coverage or delays have persisted beyond 2021. Further research is needed to assess ongoing disruptions and identify missed vaccine cohorts.

Trust in health workers and patient-centeredness of care were strongest factors associated with vaccination for Kenyan children born between 2017-2022

Objective

Although vaccination confidence is declining globally, there is little detailed information from low- and middle-income countries about factors influencing routine vaccination behavior in these contexts.

Methods

In mid-2022, we surveyed people who gave birth in Kenya between 2017-2022, and asked them about their children's vaccination history and about hypothesized correlates of vaccination per the Behavioural and Social Drivers of Vaccination model.

Results

Of 873 children in this sample, 117 (13%) were under-vaccinated (i.e., delayed or missing vaccine dose(s)) - and under-vaccination was more common among births during the COVID-19 pandemic (2020-2022) versus pre-pandemic (2017-2019). In multi-level multivariable models, children of respondents who expressed concerns about serious side effects from vaccines had significantly higher odds of missed vaccine dose(s) (aOR 2.06, 95 % CI 1.14-3.72), and there was a strong association between having more safety concerns now versus before the COVID-19 pandemic (aOR missed dose(s) 4.44, 95 % CI 1.71-11.51; aOR under-vaccination 3.03, 95 % CI 1.28-7.19). People with greater trust in health workers had lower odds of having a child with missed vaccine dose(s) (aOR 0.85, 95 % CI 0.75-0.97). People who reported higher patient-centered quality of vaccination care had much lower odds of having children with delayed or missed vaccine dose(s) (aOR missed dose(s) 0.14, 95 % CI 0.04-0.58; aOR under-vaccination 0.27, 95 % CI 0.10-0.79).

Conclusions

These findings highlight potential strategies to improve vaccine coverage: greater focus on patient-centered quality of care, training healthcare workers on how to address safety concerns about vaccines, and building trust in the health care system and in health workers.

Evaluating the impact of COVID-19 on routine childhood immunizations coverage in Zambia

There are growing concerns about the comeback of vaccine-preventable diseases. Epidemics exert shocks which affect other health performance indicators such as routine immunizations. Early model forecasts indicate decreased use of immunization services, which puts children at greater risk. Concerns about an increase in morbidity and mortality for illnesses other than COVID-19, particularly in children missing routine vaccinations, are of public health interest. In this study, we evaluate COVID-19 effects on the uptake of routine immunization in Zambia.This was an interrupted time series study. National data on routine immunization coverage between January 2017 and December 2022 were analyzed. Interrupted time series analysis was performed to quantify changes in immunization utilization. To determine if changes in the underlying patterns of utilization of immunization service were correlated with the commencement of COVID-19, seasonally adjusted segmented Poisson regression model was utilised.Utilization of health services was similar with historical levels prior to the first case of COVID-19. There was a significant drop in immunization coverage for measles dose two (RR, 0.59; 95% CI: 0.43-0.80). A decreased slope was observed in immunization coverage of Rotavirus dose one (RR, 0.97; 95% CI: 0.96-0.98) and Rotavirus dose two (RR, 0.97; 95% CI: 0.96-0.98). A growing slope was observed for Oral Poliovirus two (RR, 1.007; 95% CI: 1.004-1.011) and Oral Poliovirus three (RR, 1.007; 95% CI: 1.002-1011). We also observed a growing slope in BCG Bacille Calmette-Guerin (BCG) (RR, 1.001; 95% CI: 1.000-1011) and Pentavalent one (RR, 1.00; 95% CI: 1.001-1008) and three (RR, 1.004; 95% CI: 1.001-1008).The COVID-19 pandemic has had a number of unintended consequences that have affected the use of immunization services. Ensuring continuity in the provision of health services, especially childhood immunization, during pandemics or epidemics is crucial. Therefore, Investing in robust healthcare infrastructure to withstand surges, training and retaining a skilled workforce capable of handling emergencies and routine services simultaneously is very cardinal to avoid vaccine-preventable diseases, causing long-term health effects especially child mortality.

The changes in health service utilisation in Malawi during the COVID-19 pandemic

INTRODUCTION

The COVID-19 pandemic and the restriction policies implemented by the Government of Malawi may have disrupted routine health service utilisation. We aimed to find evidence for such disruptions and quantify any changes by service type and level of health care.

METHODS

We extracted nationwide routine health service usage data for 2015-2021 from the electronic health information management systems in Malawi. Two datasets were prepared: unadjusted and adjusted; for the latter, unreported monthly data entries for a facility were filled in through systematic rules based on reported mean values of that facility or facility type and considering both reporting rates and comparability with published data. Using statistical descriptive methods, we first described the patterns of service utilisation in pre-pandemic years (2015-2019). We then tested for evidence of departures from this routine pattern, i.e., service volume delivered being below recent average by more than two standard deviations was viewed as a substantial reduction, and calculated the cumulative net differences of service volume during the pandemic period (2020-2021), in aggregate and within each specific facility.

RESULTS

Evidence of disruptions were found: from April 2020 to December 2021, services delivered of several types were reduced across primary and secondary levels of care-including inpatient care (-20.03% less total interactions in that period compared to the recent average), immunisation (-17.61%), malnutrition treatment (-34.5%), accidents and emergency services (-16.03%), HIV (human immunodeficiency viruses) tests (-27.34%), antiretroviral therapy (ART) initiations for adults (-33.52%), and ART treatment for paediatrics (-41.32%). Reductions of service volume were greatest in the first wave of the pandemic during April-August 2020, and whereas some service types rebounded quickly (e.g., outpatient visits from -17.7% to +3.23%), many others persisted at lower level through 2021 (e.g., under-five malnutrition treatment from -15.24% to -42.23%). The total reduced service volume between April 2020 and December 2021 was 8 066 956 (-10.23%), equating to 444 units per 1000 persons.

CONCLUSION

We have found substantial evidence for reductions in health service delivered in Malawi during the COVID-19 pandemic which may have potential health consequences, the effect of which should inform how decisions are taken in the future to maximise the resilience of healthcare system during similar events.

Health care utilisation in Cox's Bazar district, Bangladesh, during the first year of the COVID-19 pandemic: A mixed-methods study among host communities

To respond to the COVID-19 pandemic, countries introduced public health and social measures that had indirect societal, economic consequences. Concerns during epidemics include continuity of routine health services. We investigate how healthcare utilisation and healthcare seeking behaviour changed during the first year of the COVID-19 pandemic among host communities in Cox's Bazar, Bangladesh. This mixed-methods study combines quantitative analyses of routine health data and population-based findings about healthcare seeking behaviours. Trends in consultations changed according to facility level (higher-level facilities included Upazila Health Complexes and District Hospitals; lower-level facilities included Community Clinics and Union Health and Family Welfare Centers). At the pandemic's beginning, drops were seen at higher-level health facilities for outpatient department (OPD) consultations, respiratory infections, and antenatal care. Minor reductions or increases were seen at lower-level facilities for the same services. Half of the subdistricts reported a cumulative increase in OPD and respiratory tract infection consultations. Most subdistricts reported a cumulative decrease in antenatal care. Child vaccinations dropped in all subdistricts, half of which did not catch-up, resulting in a cumulative decrease of delivered doses. Fear of contracting COVID-19 and financial constraints were the main reasons for decreased access. Drivers of healthcare seeking behaviours should be better understood to guide preparedness and service delivery modalities at primary and secondary levels.

Resilience of routine childhood immunization services in two counties in Kenya in the face of the COVID-19 pandemic

The recently emerged coronavirus disease 2019 (COVID-19) has caused considerable morbidity and mortality worldwide and disrupted health services. We describe the effect of the COVID-19 pandemic on utilization of childhood vaccination services during the pandemic. Using a mixed methods approach combining retrospective data review, a cross-sectional survey, focus group discussions among care givers and key informant interviews among nurses, we collected data between May and September 2021 in Mombasa and Nakuru counties. Overall, there was a <2 % decline in the number of vaccine doses administered during the pandemic period compared to the pre-pandemic period but this was statistically insignificant, both for the pentavalent-1 vaccine (ß = -0.013, p = 0.505) and the pentavalent-3 vaccine (ß = -0.012, p = 0.440). In government health facilities, there was 7.7 % reduction in the number of pentavalent-1 (ß = -0.08, p = 0.010) and 10.4 % reduction in the number of pentavalent-3 (ß = -0.11, p < 0.001) vaccine doses that were administered during the pandemic period. In non-government facilities, there was a 25.8 % increase in the number of pentavalent-1 (ß=0.23, p < 0.001) and 31.0 % increase in the number of pentavalent-3 (ß = -0.27, p < 0.001) vaccine doses that were administered facilities during the pandemic period. The strategies implemented to maintain immunization services during the pandemic period included providing messaging on the availability and importance of staying current with routine vaccination and conducting catch-up vaccinations and vaccination outreaches. Our findings suggest that the COVID-19 pandemic did not impact childhood vaccination services in Mombasa and Nakuru counties in Kenya. The private health facilities cushioned vaccination services against the effects of the pandemic and the strategies that were put in place by the ministry of health ensured continuation of vaccination services and encouraged uptake of the services during the pandemic period in the two counties in Kenya. These findings provide useful information to safeguard vaccination services during future pandemics.

The impact of COVID-19 on health financing in Kenya

Sudden shocks to health systems, such as the COVID-19 pandemic may disrupt health system functions. Health system functions may also influence the health system's ability to deliver in the face of sudden shocks such as the COVID-19 pandemic. We examined the impact of COVID-19 on the health financing function in Kenya, and how specific health financing arrangements influenced the health systems capacity to deliver services during the COVID-19 pandemic.We conducted a cross-sectional study in three purposively selected counties in Kenya using a qualitative approach. We collected data using in-depth interviews (n = 56) and relevant document reviews. We interviewed national level health financing stakeholders, county department of health managers, health facility managers and COVID-19 healthcare workers. We analysed data using a framework approach. Purchasing arrangements: COVID-19 services were partially subsidized by the national government, exposing individuals to out-of-pocket costs given the high costs of these services. The National Health Insurance Fund (NHIF) adapted its enhanced scheme's benefit package targeting formal sector groups to include COVID-19 services but did not make any adaptations to its general scheme targeting the less well-off in society. This had potential equity implications. Public Finance Management (PFM) systems: Nationally, PFM processes were adaptable and partly flexible allowing shorter timelines for budget and procurement processes. At county level, PFM systems were partially flexible with some resource reallocation but maintained centralized purchasing arrangements. The flow of funds to counties and health facilities was delayed and the procurement processes were lengthy. Reproductive and child health services: Domestic and donor funds were reallocated towards the pandemic response resulting in postponement of program activities and affected family planning service delivery. Universal Health Coverage (UHC) plans: Prioritization of UHC related activities was negatively impacted due the shift of focus to the pandemic response. Contrarily the strategic investments in the health sector were found to be a beneficial approach in strengthening the health system. Strengthening health systems to improve their resilience to cope with public health emergencies requires substantial investment of financial and non-financial resources. Health financing arrangements are integral in determining the extent of adaptability, flexibility, and responsiveness of health system to COVID-19 and future pandemics.

Impact of COVID-19 on routine childhood immunisations in low- and middle-income countries: A scoping review

Routine vaccines are critical to child health. The COVID-19 pandemic significantly impacted essential health services, particularly in low-and middle-income countries (LMICs). We reviewed literature to determine the impact of COVID-19 on service delivery and uptake of routine childhood immunisation in LMICs. We reviewed papers published between March 2020 and June 2022 using a scoping review framework, and assessed each paper across the World Health Organisation health system strengthening framework. Our search identified 3,471 publications; 58 studies were included. One-quarter of studies showed routine childhood immunisation coverage declined (10% to 38%) between 2019 to 2021. Declines in the number of vaccine doses administered (25% to 51%), timeliness (6.2% to 34%), and the availability of fixed and outreach services were also reported. Strategies proposed to improve coverage included catch-up activities, strengthening supply chain and outreach services. Re-focusing efforts on increasing coverage is critical to improve child health and reduce the likelihood of disease outbreaks.

COVID-19 impacts on healthcare access in sub-Saharan Africa: an overview

This overview aimed to describe the situation of healthcare access in sub-Saharan Africa, excluding South Africa, during the COVID-19 pandemic. A PubMed^® search from March 31, 2020, to August 15, 2022, selected 116 articles. Healthcare access and consequences of COVID-19 were assessed based on comparisons with months before its onset or an identical season in previous years. A general reduction of healthcare delivery, associated with the decline of care quality, and closure of many specialty services were reported. The impact was heterogeneous in space and time, with an increase in urban areas at the beginning of the pandemic (March-June 2020). The return to normalcy was gradual from the 3^rd quarter of 2020 until the end of 2021. The impact of COVID-19 on the health system and its use was attributed to (a) conjunctural factors resulting from government actions to mitigate the spread of the epidemic (containment, transportation restrictions, closures of businesses, and places of entertainment or worship); (b) structural factors related to the disruption of public and private facilities and institutions, in particular, the health system; and (c) individual factors linked to the increase in costs, impoverishment of the population, and fear of contamination or stigmatization, which discouraged patients from going to health centers. They have caused considerable socio-economic damage. Several studies emphasized some adaptability of the healthcare offer and resilience of the healthcare system, despite its unpreparedness, which explained a return to normal activities as early as 2022 while the COVID-19 epidemic persisted. There appears to be a strong disproportion between the moderate incidence and severity of COVID-19 in sub-Saharan Africa, and the dramatic impact on healthcare access. Several articles make recommendations for lowering the socioeconomic consequences of future epidemics to ensure better management of health issues.

The first year of the COVID-19 pandemic in humanitarian settings: epidemiology, health service utilization, and health care seeking behavior in Bangui and surrounding areas, Central African Republic

BACKGROUND

Despite increasing evidence on COVID-19, few studies have been conducted in humanitarian settings and none have investigated the direct and indirect effects of the pandemic in the Central African Republic. We studied the COVID-19 epidemiology, health service utilization, and health care seeking behavior in the first year of the pandemic in Bangui and surrounding areas.

METHODS

This mixed-methods study encompasses four components: descriptive epidemiological analysis of reported COVID-19 cases data; interrupted time series analysis of health service utilization using routine health service data; qualitative analysis of health care workers' perceptions of how health services were affected; and health care seeking behavior of community members with a household survey and focus group discussions.

RESULTS

The COVID-19 epidemiology in CAR aligns with that of most other countries with males representing most of the tested people and positive cases. Testing capacity was mainly concentrated in Bangui and skewed towards symptomatic cases, travelers, and certain professions. Test positivity was high, and many cases went undiagnosed. Decreases in outpatient department consultations, consultations for respiratory tract infections, and antenatal care were found in most study districts. Cumulative differences in districts ranged from - 46,000 outpatient department consultations in Begoua to + 7000 in Bangui 3; - 9337 respiratory tract infections consultations in Begoua to + 301 in Bangui 1; and from - 2895 antenatal care consultations in Bimbo to + 702 in Bangui 2. Consultations for suspected malaria showed mixed results while delivery of BCG vaccine doses increased. Fewer community members reported seeking care at the beginning of the pandemic compared to summer 2021, especially in urban areas. The fear of testing positive and complying with related restrictions were the main obstacles to seeking care.

CONCLUSIONS

A large underestimation of infections and decreased health care utilization characterized the first year of the COVID-19 pandemic in Bangui and surrounding area. Improved decentralized testing capacity and enhanced efforts to maintain health service utilization will be crucial for future epidemics. A better understanding of health care access is needed, which will require strengthening the national health information system to ensure reliable and complete data. Further research on how public health measures interact with security constraints is needed.

Investigating rapid diagnostic testing in Kenya's health system, 2018-2020: validating non-reporting in routine data using a health facility service assessment survey

BACKGROUND

Understanding the availability of rapid diagnostic tests (RDTs) is essential for attaining universal health care and reducing health inequalities. Although routine data helps measure RDT coverage and health access gaps, many healthcare facilities fail to report their monthly diagnostic test data to routine health systems, impacting routine data quality. This study sought to understand whether non-reporting by facilities is due to a lack of diagnostic and/or service provision capacity by triangulating routine and health service assessment survey data in Kenya.

METHODS

Routine facility-level data on RDT administration were sourced from the Kenya health information system for the years 2018-2020. Data on diagnostic capacity (RDT availability) and service provision (screening, diagnosis, and treatment) were obtained from a national health facility assessment conducted in 2018. The two sources were linked and compared obtaining information on 10 RDTs from both sources. The study then assessed reporting in the routine system among facilities with (i) diagnostic capacity only, (ii) both confirmed diagnostic capacity and service provision and (iii) without diagnostic capacity. Analyses were conducted nationally, disaggregated by RDT, facility level and ownership.

RESULTS

Twenty-one per cent (2821) of all facilities expected to report routine diagnostic data in Kenya were included in the triangulation. Most (86%) were primary-level facilities under public ownership (70%). Overall, survey response rates on diagnostic capacity were high (> 70%). Malaria and HIV had the highest response rate (> 96%) and the broadest coverage in diagnostic capacity across facilities (> 76%). Reporting among facilities with diagnostic capacity varied by test, with HIV and malaria having the lowest reporting rates, 58% and 52%, respectively, while the rest ranged between 69% and 85%. Among facilities with both service provision and diagnostic capacity, reporting ranged between 52% and 83% across tests. Public and secondary facilities had the highest reporting rates across all tests. A small proportion of health facilities without diagnostic capacity submitted testing reports in 2018, most of which were primary facilities.

CONCLUSION

Non-reporting in routine health systems is not always due to a lack of capacity. Further analyses are required to inform other drivers of non-reporting to ensure reliable routine health data.

Pattern of OPD utilisation during the COVID-19 pandemic under the Universal Coverage Scheme in Thailand: what can 850 million records tell us?

BACKGROUND

Out-patient department (OPD) is a crucial component of the healthcare systems in low- and middle-income countries including Thailand. A considerable impact of coronavirus disease 2019 (COVID-19) pandemic and its control measures, especially the lockdown, on utilisation of OPD services was expected. This study thus aims to estimate the pattern of OPD utilisation during the COVID-19 pandemic in Thailand including overall utilisation and within each sub-groups including diagnostic group, age group, and health region.

METHODS

This study was a secondary data analysis of aggregated outpatient data from patients covered under the Universal Coverage Scheme (UCS) in Thailand over a 4-year period (2017-2020). Interrupted time series analyses and segmented Quasi-Poisson regression were used to examine the impact of COVID-19 on the overall OPD utilisation including the impact on each diagnostic group, age groups, health regions, and provinces.

RESULTS

Analysis of 845,344,946 OPD visits in this study showed a seasonal pattern and increasing trend in monthly OPD visits before the COVID-19 pandemic. A 28% (rate ratio (RR) 0.718, 95% confidence interval (CI): 0.631-0.819) and 11% (RR 0.890, 95% CI: 0.811-0.977) reduction in OPD visits was observed during the lockdown and post-lockdown periods, respectively, when compared to the pre-lockdown period. Diseases of respiratory system were most affected with a RR of 0.411 (95% CI: 0.320-0.527), while the number of visits for non-communicable diseases (ICD-10: E00-E90, I00-I99) and elderly (> 60 years) dropped slightly. The post-lockdown trend in monthly OPD visits gradually increased to the pre-pandemic levels in most groups.

CONCLUSIONS

Thailand's OPD utilisation rate during the COVID-19 lockdown decreased in some diseases, but the service for certain group of patients appeared to remain available. After the COVID-19 lockdown, the rate returned to the pre-pandemic level in a timely manner. Equipped with a knowledge of OPD utilisation pattern during COVID-19 based on a national real-world database could aid with a better preparation of healthcare system for future pandemics.

[Impact of COVID-19 on public health in sub-Saharan Africa]

Objective

This work aimed to assess the impact of COVID-19 on healthcare supply in sub-Saharan Africa except South Africa.

Method

A search through PubMed® between April 2020 and August 2022 selected 135 articles. The impact of COVID-19 was assessed on comparisons with the months prior to the onset of COVID-19 or an identical season in previous years.

Results

The decline of health services, associated with a reduction in their quality, and the closure of specialized health units have been reported. Many control programs and public health interventions have been interrupted, with the risk of an increase of the corresponding diseases. Social disorganization has generated mental health issues among the population, including health personnel. The impact was heterogeneous in space and time. The main causes were attributed to containment measures (transport restrictions, trade closures) and the lack of human and material resources. The increase in costs, in addition to the impoverishment of the population, and the fear of being contaminated or stigmatized have discouraged patients from going to health centres. The studies mention the gradual return to normal after the first epidemic wave and the resilience of the healthcare system.

Conclusion

Several articles make recommendations aimed at reducing the impact of future epidemics: support for community workers, training of health workers and reorganization of services to improve the reception and care of patients, technological innovations (use of telephones, drones, etc.) and better information monitoring.

Effects of the COVID-19 pandemic on essential health and nutrition service utilisations in Ghana: interrupted time-series analyses from 2016 to 2020

OBJECTIVES

This study aimed to assess the national-level and subnational-level effects of the COVID-19 pandemic on essential health and nutrition service utilisation in Ghana.

DESIGN

Interrupted time-series.

SETTING AND PARTICIPANTS

This study used facility-level data of 7950 governmental and non-governmental health facilities in Ghana between January 2016 and November 2020.

OUTCOME MEASURES

As the essential health and nutrition services, we selected antenatal care (ANC); institutional births, postnatal care (PNC); first and third pentavalent vaccination; measles vaccination; vitamin A supplementations (VAS); and general outpatient care. We performed segmented mixed effects linear models for each service with consideration for data clustering, seasonality and autocorrelation. Losses of patient visits for essential health and nutrition services due to the COVID-19 pandemic were estimated as outcome measures.

RESULTS

In April 2020, as an immediate effect of the COVID-19 pandemic, the number of patients for all the services decreased except first pentavalent vaccine. While some services (ie, institutional birth, PNC, third pentavalent and measles vaccination) recovered by November 2020, ANC, VAS and outpatient services had not recovered to prepandemic levels. The total number of lost outpatient visits in Ghana was estimated to be 3 480 292 (95% CI: -3 510 820 to -3 449 676), followed by VAS (-180 419, 95% CI: -182 658 to -177 956) and ANC (-87 481, 95% CI: -93 644 to -81 063). The Greater Accra region was the most affected region by COVID-19, where four out of eight essential services were significantly disrupted.

CONCLUSION

COVID-19 pandemic disrupted the majority of essential healthcare services in Ghana, three of which had not recovered to prepandemic levels by November 2020. Millions of outpatient visits and essential ANC visits were lost. Furthermore, the immediate and long-term impacts of the COVID-19 pandemic on service utilisation varied by service type and region.

The impact of the COVID-19 pandemic on vaccine coverage in Kilifi, Kenya: A retrospective cohort study

The COVID-19 pandemic caused unprecedented disruption in health service delivery, globally. This study sought to provide evidence on the impact of the pandemic on vaccine coverage in Kilifi County, Kenya. We conducted a vaccine coverage survey between April and June 2021 within the Kilifi Health and Demographic Surveillance System (KHDSS). Simple random sampling was used to identify 1500 children aged 6 weeks-59 months. Participants were grouped into three retrospective cohorts based on when they became age-eligible for vaccination: before the pandemic, during the first year, or during the second year of the pandemic. Survival analysis with Cox regression was used to evaluate the association between the time-period at which participants became age-eligible for vaccination and the rate of vaccination within a month of age-eligibility for the third dose of pentavalent vaccine (Pentavalent-3) and within three months of age-eligibility for the first dose of Measles vaccine (MCV-1). A total of 1,341 participants were included in the survey. Compared to the pre-COVID-19 baseline period, the rate of vaccination within a month of age-eligibility for Pentavalent-3 was not significantly different in the first year of the pandemic (adjusted hazard ratio [aHR] 1.03, 95 % confidence interval [CI] 0.90-1.18) and was significantly higher during the second year of the pandemic (aHR 1.33, 95 % CI 1.07-1.65). The rate of vaccination with MCV-1 within three months of age-eligibility was not significantly different among those age-eligible for vaccination during the first year of the pandemic (aHR 1.04, 95 % CI 0.88-1.21) and was 35 % higher during the second year of the pandemic (95 % CI 1.11-1.64), compared to those age-eligible pre-COVID-19. After adjusting for known determinants of vaccination, the COVID-19 pandemic did not adversely affect the rate of vaccination within the KHDSS.

Geographic accessibility to public and private health facilities in Kenya in 2021: An updated geocoded inventory and spatial analysis

Objectives

To achieve universal health coverage, adequate geographic access to quality healthcare services is vital and should be characterized periodically to support planning. However, in Kenya, previous assessments of geographic accessibility have relied on public health facility lists only, assembled several years ago. Here, for the first time we assemble a geocoded list of public and private health facilities in 2021 and make use of this updated list to interrogate geographical accessibility to all health providers.

Methods

Existing health provider lists in Kenya were accessed, merged, cleaned, harmonized, and assigned a unique geospatial location. The resultant master list was combined with road network, land use, topography, travel barriers and healthcare-seeking behavior within a geospatial framework to estimate travel time to the nearest (i) private, (ii) public, and (iii) both (public and private-PP) health facilities through a travel scenario involving walking, bicycling and motorized transport. The proportion of the population within 1 h and outside 2-h was computed at 300 × 300 spatial resolution and aggregated at subnational units used for decision-making. Areas with a high disease prevalence for common infections that were outside 1-h catchment (dual burden) were also identified to guide prioritization.

Results

The combined database contained 13,579 health facilities, both in the public (55.5%) and private-for-profit sector (44.5%) in 2021. The private health facilities' distribution was skewed toward the urban counties. Nationally, average travel time to the nearest health facility was 130, 254, and 128 min while the population within 1-h was 89.4, 80.5, and 89.6% for the public, private and PP health facility, respectively. The population outside 2-h were 6% for public and PP and 11% for the private sector. Mean travel time across counties was heterogeneous, while the population within 1-h ranged between 38 and 100% in both the public sector and PP. Counties in northwest and southeast Kenya had a dual burden.

Conclusion

Continuous updating and geocoding of health facilities will facilitate an improved understanding of healthcare gaps for planning. Heterogeneities in geographical access continue to persist, with some areas having a dual burden and should be prioritized toward reducing health inequities and attaining universal health coverage.

Transmission networks of SARS-CoV-2 in Coastal Kenya during the first two waves: A retrospective genomic study

Background

Detailed understanding of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) regional transmission networks within sub-Saharan Africa is key for guiding local public health interventions against the pandemic.

Methods

Here, we analysed 1139 SARS-CoV-2 genomes from positive samples collected between March 2020 and February 2021 across six counties of Coastal Kenya (Mombasa, Kilifi, Taita Taveta, Kwale, Tana River, and Lamu) to infer virus introductions and local transmission patterns during the first two waves of infections. Virus importations were inferred using ancestral state reconstruction, and virus dispersal between counties was estimated using discrete phylogeographic analysis.

Results

During Wave 1, 23 distinct Pango lineages were detected across the six counties, while during Wave 2, 29 lineages were detected; 9 of which occurred in both waves and 4 seemed to be Kenya specific (B.1.530, B.1.549, B.1.596.1, and N.8). Most of the sequenced infections belonged to lineage B.1 (n = 723, 63%), which predominated in both Wave 1 (73%, followed by lineages N.8 [6%] and B.1.1 [6%]) and Wave 2 (56%, followed by lineages B.1.549 [21%] and B.1.530 [5%]). Over the study period, we estimated 280 SARS-CoV-2 virus importations into Coastal Kenya. Mombasa City, a vital tourist and commercial centre for the region, was a major route for virus imports, most of which occurred during Wave 1, when many Coronavirus Disease 2019 (COVID-19) government restrictions were still in force. In Wave 2, inter-county transmission predominated, resulting in the emergence of local transmission chains and diversity.

Conclusions

Our analysis supports moving COVID-19 control strategies in the region from a focus on international travel to strategies that will reduce local transmission.

Funding

This work was funded by The Wellcome (grant numbers: 220985, 203077/Z/16/Z, 220977/Z/20/Z, and 222574/Z/21/Z) and the National Institute for Health and Care Research (NIHR), project references: 17/63/and 16/136/33 using UK Aid from the UK government to support global health research, The UK Foreign, Commonwealth and Development Office. The views expressed in this publication are those of the author(s) and not necessarily those of the funding agencies.

Virtual Faculty Development in Simulation in Sub-Saharan Africa: A Pilot Training for Pediatricians in Kisumu, Kenya

INTRODUCTION

Simulation is an effective educational tool increasingly being utilized in medical education globally and across East Africa. Globally, pediatric patients often present with low frequency, high acuity disease and simulation-based training in pediatric emergencies can equip physicians with the skills to recognize and intervene. Northwestern University (NU) in Chicago, IL, USA, and Maseno University (MU), in Kisumu, Kenya launched a predominantly virtual partnership in 2020 to utilize the Jaramogi Oginga Odinga Teaching & Referral Hospital (JOOTRH) simulation center for MU faculty development in simulation based medical education (SBME) for medical students.

MATERIALS AND METHODS

Educational goals, learning objectives, and educational content were collaboratively developed between MU and NU faculty. Virtual sessions were held for didactic education on simulation pedagogy, case development, and debriefing. Mixed educational methods were used including virtual mentored sessions for deliberate practice, piloted case facilitation with medical students, and mentored development of MU identified cases. Trained faculty had the summative experience of an intensive simulation facilitation with graduating MU students. MU faculty and students were surveyed on their experiences with SBME and MU faculty were scored on facilitation technique with a validated tool.

RESULTS

There were four didactic sessions during the training. Seven cases were developed to reflect targeted educational content for MU students. Six virtually mentored sessions were held to pilot SBME with MU students. In July 2021, fifty students participated in a week-long SBME course led by the MU trained faculty with virtual observation and mentorship from NU faculty. MU faculty reported positive experience with the SBME training and demonstrated improvement in debriefing skills after the training. The overwhelming majority of MU students reported positive experiences with SBME and endorsed desire for earlier and additional sessions.

DISCUSSION AND CONCLUSIONS

This medical education partnership, developed through virtual sessions, culminated in the implementation of an independently run simulation course by three trained MU faculty. SBME is an important educational tool and faculty in a resource constrained setting were successfully, virtually trained in its implementation and through collaborative planning, became a unique tool to address gaps for medical students.