Factors Associated with Reliable Contact Tracing During the 2021 Ebola Virus Disease Outbreak in Guinea

BACKGROUND

In 2021, an Ebola virus disease (EVD) outbreak was declared in Guinea, linked to persistent virus from the 2014-2016 West Africa Epidemic. This paper analyzes factors associated with contact tracing reliability (defined as completion of a 21-day daily follow-up) during the 2021 outbreak, and transitively, provides recommendations for enhancing contact tracing reliability in future.

METHODS

We conducted a descriptive and analytical cross-sectional study using multivariate regression analysis of contact tracing data from 1071 EVD contacts of 23 EVD cases (16 confirmed and 7 probable).

RESULTS

Findings revealed statistically significant factors affecting contact tracing reliability. Unmarried contacts were 12.76× more likely to miss follow-up than those married (OR = 12.76; 95% CI [3.39-48.05]; p < 0.001). Rural-dwelling contacts had 99% lower odds of being missed during the 21-day follow-up, compared to those living in urban areas (OR = 0.01; 95% CI [0.00-0.02]; p < 0.01). Contacts who did not receive food donations were 3× more likely to be missed (OR = 3.09; 95% CI [1.68-5.65]; p < 0.001) compared to those who received them. Contacts in health areas with a single team were 8× more likely to be missed (OR = 8.16; 95% CI [5.57-11.96]; p < 0.01) than those in health areas with two or more teams (OR = 1.00; 95% CI [1.68-5.65]; p < 0.001). Unvaccinated contacts were 30.1× more likely to be missed compared to vaccinated contacts (OR = 30.1; 95% CI [5.12-176.83]; p < 0.001).

CONCLUSION

Findings suggest that contact tracing reliability can be significantly influenced by various demographic and organizational factors. Considering and understanding these factors-and where possible addressing them-may be crucial when designing and implementing contact tracing strategies during future outbreaks in low-resource settings.

Willingness of WHO staff to work in health emergencies in the African Region: opportunity for phased deployment of staff and ensure continuity of health services

A human resource base that ensures appropriate deployment of staff to emergencies, addressing different shock events in emergencies, without disrupting continuity of service is germane to a successful response. Consequently, the WHO Health Emergencies programme in the African Region, in collaboration with Africa Centre for Disease Control (ACDC) launched the African Volunteer Health Corps (AVoHC) and Strengthening and Utilization of Response Group for Emergencies (SURGE), an initiative aimed at ensuring a pool of timely responders. We explored the willingness of WHO staff to work in emergencies. A call for expression of interest to be part of the Elite Emergency Experts (Triple E) was published on 5th July 2022 via email and was open for 5 weeks. The responses were analyzed using simple descriptive statistics and presented with graphic illustrations. A total of 1253 WHO staff, from all the six WHO regions, cutting across all cadre, applied to the call. The applicants had various trainings and experiences in emergency and have responded to mostly disease outbreaks. Two-third of the applicants were males. This paper did not explore reasons for the willingness to work in emergencies. However, contrary to fears expressed in literature that health workers would not want to work in emergencies with potential for infections, the applicants have worked mostly in infectious emergencies. Literature identified some themes on factors that could impact on willingness of health workers to work in emergencies. These include concerns for the safety of the responders and impact of partners, child and elderly care, as well as other family obligations, which emergency planners must consider in planning emergency response.

Analysing the implementation of infection prevention and control measures in health care facilities during the COVID-19 pandemic in the African Region

BACKGROUND

The declaration of SARS-CoV-2 as a public health emergency of international concern in January 2020 prompted the need to strengthen infection prevention and control (IPC) capacities within health care facilities (HCF). IPC guidelines, with standard and transmission-based precautions to be put in place to prevent the spread of SARS-CoV-2 at these HCFs were developed. Based on these IPC guidelines, a rapid assessment scorecard tool, with 14 components, to enhance assessment and improvement of IPC measures at HCFs was developed. This study assessed the level of implementation of the IPC measures in HCFs across the African Region during the COVID-19 pandemic.

METHOD

An observational study was conducted from April 2020 to November 2022 in 17 countries in the African Region to monitor the progress made in implementing IPC standard and transmission-based precautions in primary-, secondary- and tertiary-level HCFs. A total of 5168 primary, secondary and tertiary HCFs were assessed. The HCFs were assessed and scored each component of the tool. Statistical analyses were done using R (version 4.2.0).

RESULTS

A total of 11 564 assessments were conducted in 5153 HCFs, giving an average of 2.2 assessments per HCF. The baseline median score for the facility assessments was 60.2%. Tertiary HCFs and those dedicated to COVID-19 patients had the highest IPC scores. Tertiary-level HCFs had a median score of 70%, secondary-level HCFs 62.3% and primary-level HCFs 56.8%. HCFs dedicated to COVID-19 patients had the highest scores, with a median of 68.2%, followed by the mixed facilities that attended to both COVID-19 and non-COVID-19 patients, with 64.84%. On the components, there was a strong correlation between high IPC assessment scores and the presence of IPC focal points in HCFs, the availability of IPC guidelines in HCFs and HCFs that had all their health workers trained in basic IPC.

CONCLUSION

In conclusion, a functional IPC programme with a dedicated focal person is a prerequisite for implementing improved IPC measures at the HCF level. In the absence of an epidemic, the general IPC standards in HCFs are low, as evidenced by the low scores in the non-COVID-19 treatment centres.

The Chronic Cholera Situation in Africa: Why Are African Countries Unable to Tame the Well-Known Lion?

Seven years to the Global Taskforce on Cholera Control's target of reducing cholera cases and deaths by 90% by 2030, Africa continues to experience a high incidence of the disease. In the last 20 years, more than 2.6 million cases and 60 000 deaths of the disease have been recorded, mostly in sub-Saharan Africa. Case Fatality Ratio remains consistently above the WHO-recommended 1% with a yearly average of 2.2%. Between 1 January 2022 and 16 July 2023, fourteen African countries reported 213 443 cases and 3951 deaths (CFR, 1.9%) of the disease. In this perspective article, based on available literature and the authors' field experiences in Africa, we discuss the underlying reasons for the sustained transmission of the disease. We posit that in addition to the well-known risk factors for the disease, the chronic cholera situation in Africa is due to the poor socioeconomic development status, weak household and community resilience, low literacy levels, weak capacity of African countries to implement the 2005 International Health Regulation and the pervasively weak health system on the continent. Stemming this tide requires good leadership, partnership, political commitment, and equity in access to health services, water, and sanitation. Therefore, we recommend that African governments and stakeholders recognize and approach cholera prevention and control from the long-term development lens and leverage the current cholera emergency preparedness and response efforts on the continent to strengthen the affected countries' health, water, and sanitation systems. We call on international organizations such as WHO and the Africa Centres for Diseases Control to support African governments in scaling up research and innovations aimed at better characterizing the epidemiology of cholera and developing evidence-based, context-specific, and innovative strategies for its prevention and control. These recommendations require long-term multisectoral and multidisciplinary approaches.

Improving global health security through implementation of the National Action Plan for Health Security in Sierra Leone, 2018-2021: lessons from the field

BACKGROUND

All countries are required to implement International Health Regulations (IHR) through development and implementation of multi-year National Action Plans for Health Security (NAPHS). IHR implementation requires annual operational planning which involves several tools such as NAPHS, State Party Annual Report (SPAR), Joint External Evaluation (JEE) and WHO IHR Benchmarks tool. Sierra Leone has successfully improved IHR capacities across the years through successful annual operational planning using the above tools. We conducted a study to document and share the country's unique approach to implementation of NAPHS.

METHODS

This was an observational study where the process of implementing and monitoring NAPHS in Sierra Leone was observed at the national level from 2018 to 2021. Data was obtained through review and analysis of NAPHS annual operational plans, quarterly review reports and annual IHR assessment reports. Available data was supplemented by information from key informants. Qualitative data was captured as notes and analysed for various themes while quantitative data was analyzed mainly for means and proportions.

RESULTS

The overall national IHR Joint External Evaluation self-assessment score for human health improved from 44% in 2018 to 51% in 2019 and 57% in 2020. The score for the animal sector improved from 32% in 2018 to 43% in 2019 and 52% in 2020. A new JEE tool with new indicators was used in 2021 and the score for both human and animal sectors declined slightly to 51%. Key enablers of success included strong political commitment, whole-of-government approach, annual assessments using JEE tool, annual operational planning using WHO IHR Benchmarks tool and real time online monitoring of progress. Key challenges included disruption created by COVID-19 response, poor health infrastructure, low funding and inadequate health workforce.

CONCLUSION

IHR annual operational planning and implementation using evidence-based data and tools can facilitate strengthening of IHR capacity and should be encouraged.

What are the research priorities for strengthening public health emergency preparedness and response in Africa?

BACKGROUND

Research evidence is needed to strengthen capacities in emergency preparedness and response (EPR). However, the absence of a clear research agenda limits the optimal use of research evidence. This paper reports on the prioritization of research questions and topics that could contribute to evidence-informed strengthening of EPR capacities in the African region.

METHODS

The priority-setting consisted of desk review and stakeholder consultation workshop. Twenty-nine people participated in the workshop, including representatives from WHO regional office and EPR focal points in Africa, representatives of research institutions, and partners from Science for Africa Foundation, United Nations Children's Fund and Africa Center for Disease Control. Modified Delphi technique was used to systematically arrive at specific and cross-cutting research priorities in the three broad areas of the EPR, which are program Implementation, Clinical and Epidemiology. The research questions/topics were ranked on five-point Likert scale (1 = very low to 5 = very high) based on seven agreed-on criteria. Research priority score was calculated for each question as the mean of the criteria scores.

RESULTS

A total of 123 research questions comprising, 29 on Epidemiology, 22 on Clinical, 23 on program Implementation, and 49 on cross-cutting issues were ranked. The top ten research priorities were: knowledge and skills of healthcare workers in detecting and responding effectively to disease outbreaks; quality of data (accuracy, timeliness, completeness) for epidemic prone diseases; determinants of vaccine hesitancy; determinants of infection transmission among health care workers during PHE; effective measures for protecting health workers from highly infectious pathogens in PHE; strategies to improve the effectiveness of contact tracing for epidemic prone diseases; effectiveness of current case definitions as screening tools for epidemic and pandemic prone diseases; measures to strengthen national and sub-national laboratory capacity for timely disease confirmation within the Integrated Diseases Surveillance and Response framework; factors affecting prompt data sharing on epidemic-prone diseases; and effective strategies for appropriate community participation in EPR.

CONCLUSIONS

The collaborative multi-stakeholder workshop produced a starting list of priority research questions and topics for strengthening EPR capacities in Africa. Action needs to be taken to continuously update the research agenda and support member States to contextualize the research priorities and commission research for timely generation and uptake of evidence.

Implementing Joint External Evaluations of the International Health Regulations (2005) capacities in all countries in the WHO African region: process challenges, lessons learnt and perspectives for the future

Following the West Africa Ebola virus disease outbreak (2013-2016), the Joint External Evaluation (JEE) is one of the three voluntary components recommended by the WHO for evaluating the International Health Regulations (2005) capacities in countries. Here, we share experience implementing JEEs in all 47 countries in the WHO African region. In February 2016, the United Republic of Tanzania (Mainland) was the first country globally to conduct a JEE. By April 2022, JEEs had been conducted in all 47 countries plus in the island of Zanzibar. A total of 360 subject matter experts (SMEs) from 88 organisations were deployed 607 times. Despite availability of guidelines, the process had to be contextualised while avoiding jeopardising the quality and integrity of the findings. Key challenges were: inadequate understanding of the process by in-country counterparts; competing country priorities; limited time for validating subnational capacities; insufficient availability of SMEs for biosafety and biosecurity, antimicrobial resistance, points of entry, chemical events and radio-nuclear emergencies; and inadequate financing to fill gaps identified. Key points learnt were: importance of country leadership and ownership; conducting orientation workshops before the self-assessment; availability of an external JEE expert to support the self-assessment; the skills, attitudes and leadership competencies of the team lead; identifying national experts as SMEs for future JEEs to promote capacity building and experience sharing; the centrality of involving One Health stakeholders from the beginning to the end of the process; and the need for dedicated staff for planning, coordination, implementation and timely report writing. Moving forward, it is essential to draw from this learning to plan future JEEs. Finally, predictable financing is needed immediately to fill gaps identified.

Short communication-Lessons learnt during the implementation of Unity-aligned SARS-CoV-2 seroprevalence studies in Africa

The WHO Unity Studies initiative engaged low- and middle-income countries in the implementation of standardised SARS-CoV-2 sero-epidemiological investigation protocols and timely sharing of comparable results for evidence-based action. To gain a deeper understanding of the methodological challenges faced when conducting seroprevalence studies in the African region, we conducted unstructured interviews with key study teams in five countries. We discuss the challenges identified: participant recruitment and retention, sampling, sample and data management, data analysis and presentation. Potential solutions to aid future implementation include preparedness actions such as the development of new tools, robust planning and practice.

A step towards reinvigorating the COVID-19 response: an intra-action review of the WHO Regional Office for Africa Incident Management Support Team

The WHO Regional Office for Africa (AFRO) COVID-19 Incident Management Support Team (IMST) was first established on 21 January 2020 to coordinate the response to the pandemic in line with the Emergency Response Framework and has undergone three modifications based on intra-action reviews (IAR). An IAR of the WHO AFRO COVID-19 IMST was conducted to document best practices, challenges, lessons learnt and areas for improvement from the start of 2021 to the end of the third wave in November 2021. In addition, it was designed to contribute to improving the response to COVID-19 in the Region. An IAR design as proposed by WHO, encompassing qualitative approaches to collecting critical data and information, was used. It employed mixed methods of data collection: document reviews, online surveys, focus group discussions and key informant interviews. A thematic analysis of the data focused on four thematic areas, namely operations of IMST, data and information management, human resource management and institutional framework/governance. Areas of good practice identified, included the provision of guidelines, protocols and technical expertise, resource mobilisation, logistics management, provision of regular updates, timely situation reporting, timely deployment and good coordination. Some challenges identified included a communication gap; inadequate emergency personnel; lack of scientific updates; and inadequate coordination with partners. The identified strong points/components are the pivot for informed decisions and actions for reinvigorating the future response coordination mechanism.

Survivors and the Response to the Ebola Virus Disease in the Provinces of North Kivu and Ituri in the Democratic Republic of Congo

We explored issues around the integration of survivors in communities and the implications for the Ebola Virus Disease (EVD) response in the Democratic Republic of Congo (DRC). We conducted a survey with 800 randomly selected respondents using a structured questionnaire. Respondents were persons aged 18 years and above. Focus group discussions (FGDs) and in-depth interviews (IDIs) were employed to obtain contextual data on the issues. Community leaders, health workers, and response pillar leads engaged in IDIs, while community members were involved in FGDs. The results revealed that the survivors suffered stigmatization and, upon return to the communities, were avoided by the community members due to fear of contamination. Some thought that the survivors should be supported in adjusting to the community, while some recommended engaging the survivors in EVD response activities.

Response of Healthcare Service Providers, to the Ebola Virus Disease Epidemic in the Democratic Republic of Congo's North Kivu and Ituri Provinces

Healthcare service providers are crucial for effective responses to disease outbreaks. However, their performance is dependent on the level of system inputs, people's perception of the system, and their willingness to use health services. This study investigated the functionality of health services and healthcare providers in the Democratic Republic of Congo during the tenth Ebola virus disease outbreak. It employed qualitative methods, including 24 in-depth interviews of healthcare providers and community leaders, and 12 focus-group discussions with community members. The responses showed that the staff did not desert the health centers and remained at their jobs. Throughout this research, only one case of abandonment of duty by a nurse was reported. The healthcare system thus played a major role in responding to the COVID-19 pandemic. However, the healthcare service providers faced several challenges. Suggestions are made to enhance the contributions of healthcare service and its providers to health emergencies in the future.

The Impact of the Ebola Virus Disease Epidemic among Women in the Provinces of North Kivu and Ituri in the Democratic Republic of the Congo

Although an outbreak of the Ebola virus disease affects an entire population, women are more susceptible to the virus than men. Throughout the outbreaks of the Ebola virus disease in Central and West Africa, women have been impacted more significantly. Generally, over half of those who become ill are women. The situation is the same in terms of mortality. Further, the outcomes of the epidemic negatively affect women socially, as many become the heads of households following the loss of their spouses, which burdens them with new responsibilities. Women's access to health services is also lowered, as the epidemic usually leads to fewer healthcare workers, impacting gynecological assistance. Consequently, women are more exposed to health problems, particularly during pregnancy. Several factors contribute to the greater exposure of women to the Ebola virus disease during an epidemic. First, female healthcare workers are at the frontline of the fight against the virus. Second, women's duties in the domestic context increase their exposure to contamination, as they look after children and care for sick household members. Finally, women are responsible for several community duties such as public tasks and rituals. In the case of rituals, women undertake tasks such as undressing, washing, and dressing the deceased. Likewise, they engage in agricultural work and grocery shopping locally, as well as at cross-border markets. They also manage domestic chores such as fetching water in public places. Additionally, women have less access to information on the disease and its prevention and are thus more vulnerable. However, women's vulnerability is less visible, since information on the epidemic and response is not gender specific. This is true for the number of suspected cases, confirmed cases, vaccinated people, alerts, contacts, contacts followed up, and screened travelers. It is therefore crucial to highlight the importance of gender in the response to the Ebola virus disease epidemic, as women are the primary victims.

Two Obstacles in Response Efforts to the Ebola Epidemic in the Provinces of North Kivu and Ituri in the Democratic Republic of the Congo: Denial of and Rumors about the Disease

Denial and rumors are two major obstacles impairing the implementation of activities in response to the Ebola virus disease (EVD) epidemic. This study investigated the roles of denial and rumors, among other challenges, in complicating the response to the EVD outbreak in the North Kivu and Ituri provinces of the Democratic Republic of the Congo. A total of 800 randomly selected respondents were surveyed using a structured questionnaire. In-depth interviews were conducted with 17 community religious and opinion leaders, as well as Ebola survivors. Furthermore, 20 focus group discussions were conducted with adult and youth male and female participants, and health care workers. The results revealed that the existence of the disease is widely denied by many, including political leaders, village chiefs, neighborhood chiefs, street chiefs, avenue chiefs, and members of the general population. These individuals generally consider the EVD to be the result of a misbehavior or a curse; consequently, the general population, including community members, teachers, and even health care professionals, refuse to comply with the authorities' strategies to fight the epidemic. Rumors are another obstacle in response efforts. Rumors pertaining to the denial of the existence of the EVD, as well as the epidemic, Ebola treatment centers, hospitals, vaccines, and safe and dignified burials have been identified. Rumors about the EVD and the response, spread by clerics, traditional therapists, men, and women, including healthcare professionals in focus group discussions, portrayed the EVD as an invention, as if the virus had been created. The response to the EVD has been marked by these two constraints, which have often hindered the involvement of community members in the fight against the disease.

Impact of multimodal strategies including a pay for performance strategy in the improvement of infection prevention and control practices in healthcare facilities during an Ebola virus disease outbreak

BACKGROUND

Strategy to mitigate various Ebola virus disease (EVD) outbreaks are focusing on Infection Prevention and Control (IPC) capacity building, supportive supervision and IPC supply donation. This study was conducted to assess the impact of a Pay for Performance Strategy (PPS) in improving IPC performance in healthcare facilities (HF) in context of the 2018-2019 Nord Kivu/ Democratic Republic of the Congo EVD outbreak.

METHODS

A quasi-experimental study was conducted analysing the impact of a PPS on the IPC performance. HF were selected following the inclusion criteria upon informed consent from the facility manager and the National Department of Health. Initial and process assessment of IPC performance was conducted by integrating response teams using a validated IPC assessment tool for HF. A bundle of interventions was then implemented in the different HF including training of health workers, donation of IPC kits, supportive supervision during the implementation of IPC activities, and monetary reward. IPC practices in HF were assessment every two weeks during the intervention period to measure the impact. The IPC assessment tool had 34 questions aggregated in 8 different thematic areas: triage and isolation capacity, IPC committee in HF, hand hygiene, PPE, decontamination and sterilization, linen management, hospital environment and Waste management. Data were analysed using descriptive statistics and analytical approaches according to assumptions. R software (version 4.0.3) was used for all the analyses and a p-value of 0.05 was considered as the threshold for statistically significant results.

RESULTS

Among 69 HF involved in this study, 48 were private facilities and 21 state facilities. The median baseline IPC score was 44% (IQR: 21-65%); this IPC median score reached respectively after 2, 4, 6 and 8 weeks 68% (IQR: 59-76%), 79% (71-84%), 76% (68-85%) and 79% (74-85%). The improvement of IPC score was statistically significative. Spearman's rank-order correlation revealed the associated between proportion of trained HW and IPC score performance after 8 weeks of interventions (rs = .280, p-value = 0.02).

CONCLUSION

Pay for Performance Strategy was proved effective in improving healthcare facilities capacity in infection prevention and control practice in context of 2018 EVD outbreak in Nord Kivu. However, the strategy for long-term sustainability of IPC needs further provision. More studies are warranted on the HW and patients' perceptions toward IPC program implementation in context of Nord Kivu Province.

Investing in preparedness for rapid detection and control of epidemics: analysis of health system reforms and their effect on 2021 Ebola virus disease epidemic response in Guinea

The 2014-2016 West Africa Ebola Virus Disease (EVD) Epidemic devastated Guinea's health system and constituted a public health emergency of international concern. Following the crisis, Guinea invested in the establishment of basic health system reforms and crucial legal instruments for strengthening national health security in line with the WHO's recommendations for ensuring better preparedness for (and, therefore, a response to) health emergencies. The investments included the scaling up of Integrated Disease Surveillance and Response; Joint External Evaluation of International Health Regulation capacities; National Action Plan for Health Security; Simulation Exercises; One Health platforms; creation of decentralised structures such as regional and prefectural Emergency Operation Centres; Risk assessment and hazard identification; Expanding human resources capacity; Early Warning Alert System and community preparedness. These investments were tested in the subsequent 2021 EVD outbreak and other epidemics. In this case, there was a timely declaration and response to the 2021 EVD epidemic, a lower-case burden and mortality rate, a shorter duration of the epidemic and a significant reduction in the cost of the response. Similarly, there was timely detection, response and containment of other epidemics including Lassa fever and Marburg virus disease. Findings suggest the utility of the preparedness activities for the early detection and efficient containment of outbreaks, which, therefore, underlines the need for all countries at risk of infectious disease epidemics to invest in similar reforms. Doing so promises to be not only cost-effective but also lifesaving.

Transitioning the COVID-19 response in the WHO African region: a proposed framework for rethinking and rebuilding health systems

The onset of the pandemic revealed the health system inequities and inadequate preparedness, especially in the African continent. Over the past months, African countries have ensured optimum pandemic response. However, there is still a need to build further resilient health systems that enhance response and transition from the acute phase of the pandemic to the recovery interpandemic/preparedness phase. Guided by the lessons learnt in the response and plausible pandemic scenarios, the WHO Regional Office for Africa has envisioned a transition framework that will optimise the response and enhance preparedness for future public health emergencies. The framework encompasses maintaining and consolidating the current response capacity but with a view to learning and reshaping them by harnessing the power of science, data and digital technologies, and research innovations. In addition, the framework reorients the health system towards primary healthcare and integrates response into routine care based on best practices/health system interventions. These elements are significant in building a resilient health system capable of addressing more effectively and more effectively future public health crises, all while maintaining an optimal level of essential public health functions. The key elements of the framework are possible with countries following three principles: equity (the protection of all vulnerable populations with no one left behind), inclusiveness (full engagement, equal participation, leadership, decision-making and ownership of all stakeholders using a multisectoral and transdisciplinary, One Health approach), and coherence (to reduce the fragmentation, competition and duplication and promote logical, consistent programmes aligned with international instruments).

Sexual Violence-Related Pregnancy Among Internally Displaced Women in an Internally Displaced Persons Camp in Northeast Nigeria

Sexual violence is quite common in conflict situations and puts women at risk of unintended pregnancies. In the northeast region of Nigeria with the ongoing insurgency, a substantial number of women are kidnapped and subjected to forced marriages and repeated sexual assaults. This study set out to report on the disclosure and outcomes of sexual violence-related pregnancies (SVRPs) among women liberated from insurgents and relocated to one of largest Internally Displaced Persons (IDP) camps located in Borno State, northeast Nigeria. The clinic records of women with SVRP were reviewed. Forty-seven women with SVRP were identified by the health care providers using a snowball technique to reach as many of the women with SVRP as possible. The mean age of the participants was 15.3 years (SD = 3.4 years), and all the participants had spent 2 years or more in captivity. Most of the women first disclosed the pregnancy to their peers before disclosure to health care providers or family members. All the women initially requested to have the pregnancy terminated; however, abortion services are not offered in the clinic in line with the country's restrictive abortion laws. Following counseling and psychosocial support offered in the clinic, 19 (40%) of the women continued with the pregnancy and were delivered in the camp clinic while the remaining 26 women left the camp shortly after disclosure and pregnancy outcomes are not known. SVRP is not uncommon in humanitarian settings with its associated stigma and unwillingness among the survivors to keep the pregnancy. There is a need for further studies to provide more insight into the extent of this problem and help-seeking for SVRPs especially for women in such difficult circumstances to provide needed empirical information to drive advocacy efforts for more comprehensive services.

Integrating immunisation services into nutrition sites to improve immunisation status of internally displaced persons' children living in Bentiu protection of civilian site, South Sudan

Introduction

The protracted war in South Sudan has led to severe humanitarian crisis with high level of malnutrition and disruption of the health systems with continuous displacement of the population and low immunization coverage predisposing the population to vaccine preventable diseases. The study aimed at evaluating the effect of integrating immunization services with already established nutrition services on immunization coverage in resource-constrained humanitarian response.

Methods

A community and health facility based interventional study involving integration of immunization into nutrition services in two Outpatient Therapeutic Program(OTP)centers in Bentiu PoC between January-December 2017. The main hypothesis was that inclusion of immunization services during nutrition services both at the OTP and community outreaches be an effective strategy for reducing missed opportunity for immunizing all eligible children accessing nutrition services. Data analyzed using STATA version 15 and bivariate analysis using logistic regression was conducted to identify predictor of missed vaccinations.

Results

Integration of immunization into the nutrition services through the OTP centres increased the number of children immunized with various antigens and the dropout rate was much lower and statistically significant among children who received immunization at the OTP centers than those in the Primary Health Care Centers (PHC Centers) in the study sites. Children who were vaccinated at the OTP centre in sector 2 were 45% less likely to miss vaccination than those vaccinated at the PHCC (OR: 0.45; 95%CI:0.36- 0.55), p<0.05 while those vaccinated at the OTP sector in sector 5 were 27% less likely to miss vaccination than those vaccinated at the PHCC (OR: 0.27; 95%CI: 0.20 -0.35) p<0.05).

Conclusion

This study indicated that immunization coverage improved effectively with integration with nutrition services as a model of an integrated immunization programme for child health in line with the Integrated Management of Childhood Illnesses (IMCI) and the Global Immunization Vision and Strategy (GIV).

Caregiver satisfaction with paediatric HIV treatment and care in Nigeria and equity implications for children living with HIV

Caregiver satisfaction has the potential to promote equity for children living with HIV, by influencing health-seeking behaviour. We measured dimensions of caregiver satisfaction with paediatric HIV treatment in Nigeria, and discuss its implications for equity by conducting facility-based exit interviews for caregivers of children receiving antiretroviral therapy in 20 purposively selected facilities within 5 geopolitical zones. Descriptive analysis and factor analysis were performed. Due to the hierarchical nature of the data, multilevel regression modelling was performed to investigate relationships between satisfaction factors and socio-demographic variables. Of 1550 caregivers interviewed, 63% (95% CI: 60.6–65.4) reported being very satisfied overall; however, satisfaction varied in some dimensions: only 55.6% (53.1–58.1) of caregivers could talk privately with health workers, 56.9% (54.4–59.3) reported that queues to see health workers were too long, and 89.9% (88.4–91.4) said that some health workers did not treat patients living with HIV with sufficient respect. Based on factor analysis, two underlying factors, labelled Availability and Attitude, were identified. In multilevel regression, the satisfaction with availability of services correlated with formal employment status (p < .01), whereas caregivers receiving care in private facilities were less likely satisfied with both availability (p < .01) and attitude of health workers (p < .05). State and facility levels influenced attitudes of the health workers (p < .01), but not availability of services. We conclude that high levels of overall satisfaction among caregivers masked dissatisfaction with some aspects of services. The two underlying satisfaction factors are part of access typology critical for closing equity gaps in access to HIV treatment between adults and children, and across socio-economic groups.

Understanding the Influence of Socioeconomic Environment on Paediatric Antiretroviral Treatment Coverage: Towards Closing Treatment Gaps in Sub-Saharan Africa

OBJECTIVE

Many sub-Saharan African countries have massively scaled-up their antiretroviral treatment (ART) programmes, but many national programmes still show large gaps in paediatric ART coverage making it challenging to reduce AIDS-related deaths among HIV-infected children. We sought to identify enablers of paediatric ART coverage in Africa by examining the relationship between paediatric ART coverage and socioeconomic parameters measured at the population level so as to accelerate reaching the 90-90-90 targets.

METHODS

Ecological analyses of paediatric ART coverage and socioeconomic indicators were performed. The data were obtained from the United Nations agencies and Forum for a new World Governance reports for the 21 Global Plan priority countries in Africa with highest burden of mother-to-child HIV transmission. Spearman's correlation and median regression were utilized to explore possible enablers of paediatric ART coverage.

RESULTS

Factors associated with paediatric ART coverage included adult literacy (r=0.6, p=0.004), effective governance (r=0.6, p=0.003), virology testing by 2 months of age (r=0.9, p=0.001), density of healthcare workers per 10,000 population (r=0.6, p=0.007), and government expenditure on health (r=0.5, p=0.046). The paediatric ART coverage had a significant inverse relationship with the national mother-to-child transmission (MTCT) rate (r=-0.9, p<0.001) and gender inequality index (r=-0.6, p=0.006). Paediatric ART coverage had no relationship with poverty and HIV stigma indices.

CONCLUSIONS

Low paediatric ART coverage continues to hamper progress towards eliminating AIDS-related deaths in HIV-infected children. Achieving this requires full commitment to a broad range of socioeconomic development goals.

Integration of HIV Testing into Maternal, Newborn, and Child Health Weeks for Improved Case Finding and Linkage to Prevention of Mother-to-Child Transmission Services in Benue State, Nigeria

Background

In Nigeria, maternal, newborn, and child health (MNCH) weeks are campaign-like events designed to accelerate progress toward Millennium Development Goals. The authors examined whether integrating HIV testing into MNCH weeks was feasible and could lead to increased case finding and linkage to prevention of mother-to-child transmission (PMTCT) services.

Methods

Pregnant women attending MNCH week during the first week of December 2014 in 13 local government areas in Benue State were provided with HIV tests and referrals to PMTCT services. Demographic, past antenatal care (ANC), and HIV testing information were collected using a structured questionnaire. We used routine ANC/PMTCT data from national electronic system (DHIS-2) to compare with the results obtained from MNCH week.

Results

A total of 50,271 pregnant women with a median age of 25 years (IQR: 21–29) were offered HIV testing. About 50,253 (99.96%) agreed to get HIV testing, with 1,063 (2.1%) testing positive. Six hundred forty-four (60.6%) of those with positive results were linked to PMTCT. In multivariate analysis, marital status, gestation age, and those with no ANC visit during this pregnancy were associated with a positive HIV test. Approximately 30% (50,253 versus 39,080) more pregnant women received HIV testing in MNCH week compared to those who received HIV testing in routine ANC services in 2013. Of the 50,253 who accepted testing, 15,611 (31.1%) did not attend ANC during this pregnancy, of which 9,615 (61.6%) had not had any previous HIV tests. Four hundred forty-two (4.6%) of these 9,615 tested HIV-positive.

Conclusion

Integration of HIV testing into MNCH weeks is feasible and improved uptake of HIV testing and linkage to care. However, the rate of HIV positivity was lower than that reported by previous studies. The findings indicate that MNCH weeks provides opportunity to reach those who do not attend ANC services for HIV care.

Integration of HIV infant testing into immunization programmes: a systematic review

BACKGROUND

Integration of HIV infant testing into immunization sessions is one of the strategies designed to increase coverage of early infant diagnosis.

OBJECTIVE

To determine the evidence on the outcomes of such integration.

METHODS

A systematic review of peer-reviewed and grey literature was undertaken from electronic sources such as MEDLINE, Google Scholar, websites of international agencies, past conferences and ministries of health reports published between year 2002 and 2013. Randomized controlled trials, observational and qualitative studies were searched and those meeting selection criteria were selected and relevant information extracted using structured tool. Statistical pooling was not possible owing to the heterogeneity of the study designs and outcome measures.

RESULTS

Of the nine articles which met the selection criteria, none used a randomized controlled design. Of these, five articles measured mother's acceptability of their infants being tested for HIV during its first pentavalent or DPT vaccination visit, and 89·5-100% accepted. Four articles reported the proportion of mothers who returned for HIV test results, ranging from 56·8% to 86·0%. Increased uptake of HIV testing following integration was confirmed by two articles. Only one study in Tanzania determined the uptake of vaccinations following integration, with urban facilities showing stable or slight increase of monthly vaccine uptake while decreases were observed across the rural sites. In two articles, stigma was perceived by service-providers and mothers as the potential risk following integration, particularly in rural settings.

DISCUSSION

Despite the limited number of articles, the findings in this systematic review suggest that HIV testing during immunization clinic visits is acceptable and feasible as a possible model for service delivery. However, the impact on vaccination uptake needs further study.

Morbidity and mortality in HIV-exposed uninfected children

Approximately 1.5 million HIV-positive women become pregnant annually. Antiretroviral therapy (ART) is central to prevention of mother-to-child transmission and maternal ART continued postpartum allows breastfeeding for at least 1 year of life, with important benefits for the child. In the pre-ART era, it was suggested that HIV-exposed uninfected (HEU) children may be at higher morbidity and mortality risk than children of HIV-negative mothers, associated with maternal illness and death and the lack, or limited duration, of breastfeeding as recommended for preventing mother-to-child transmission at that time. This review summarizes the evidence on morbidity and mortality risk in HEU children compared with HIV-unexposed children, and assesses the likely impact of roll-out of ART, which prolongs maternal survival and allows breastfeeding.

Lessons learnt from coordinating emergency health response during humanitarian crises: a case study of implementation of the health cluster in northern Uganda

Background

Between the late 1980s and 2000s, Northern Uganda experienced over twenty years of armed conflict between the Government of Uganda and Lord’s Resistance Army. The resulting humanitarian crisis led to displacement of a large percentage of the population and disruption of the health care system of the area. To better coordinate the emergency health response to the crisis, the humanitarian cluster approach was rolled out in Uganda in October 2005. The health, nutrition and HIV/AIDS cluster became fully operational at the national level and in all the conflict affected districts of Acholi and Lango in April 2006. It was phased out in 2011 following the return of the internally displaced persons to their original homelands.

Conclusions

The implementation of the health cluster approach in the northern Uganda and other humanitarian crises in Africa highlights a few issues which are important for strengthening health coordination in similar settings. While health clusters are often welcome during humanitarian crises because they have the possibility to improve health coordination, their potential to create an additional layer of bureaucracy into already complex and bureaucratic humanitarian response architecture is a real concern. Although anecdotal evidence has showed that implementation of the humanitarian reforms and the roll out of the cluster approach did improve humanitarian response in northern Uganda; it is critical to establish a mechanism for measuring the direct impact of health clusters on improving health outcomes, and in reducing morbidity and mortality during humanitarian crisis. Successful implementation of health clusters requires availability of other components of the humanitarian reforms such as predictable funding, strong humanitarian coordination system and strong partnerships. Importantly, successful health clusters require political commitment of national humanitarian and government stakeholders.

Recommendations

Although leaving health coordination entirely to governments (in crises where they exist) may result in political interference and ineffectiveness of the aid response efforts, the role of government in health coordination cannot be overemphasized. Health clusters must respond to the rapidly changing humanitarian environment and the changing needs of populations affected by humanitarian crises as they evolve from emergency towards transition, early recovery and development.

Integration of HIV infant testing into immunization programmes: a systematic review

Background: Integration of HIV infant testing into immunization sessions is one of the strategies designed to increase coverage of early infant diagnosis. Objective: To determine the evidence on the outcomes of such integration. Methods: A systematic review of peer-reviewed and grey literature was undertaken from electronic sources such as MEDLINE, Google Scholar, websites of international agencies, past conferences and ministries of health reports published between year 2002 and 2013. Randomized controlled trials, observational and qualitative studies were searched and those meeting selection criteria were selected and relevant information extracted using structured tool. Statistical pooling was not possible owing to the heterogeneity of the study designs and outcome measures. Results: Of the nine articles which met the selection criteria, none used a randomized controlled design. Of these, five articles measured mother's acceptability of their infants being tested for HIV during its first pentavalent or DPT vaccination visit, and 89·5-100% accepted. Four articles reported the proportion of mothers who returned for HIV test results, ranging from 56·8% to 86·0%. Increased uptake of HIV testing following integration was confirmed by two articles. Only one study in Tanzania determined the uptake of vaccinations following integration, with urban facilities showing stable or slight increase of monthly vaccine uptake while decreases were observed across the rural sites. In two articles, stigma was perceived by service-providers and mothers as the potential risk following integration, particularly in rural settings. Discussion: Despite the limited number of articles, the findings in this systematic review suggest that HIV testing during immunization clinic visits is acceptable and feasible as a possible model for service delivery. However, the impact on vaccination uptake needs further study.

Has the quality of serosurveillance in low- and middle-income countries improved since the last HIV estimates round in 2007? Status and trends through 2009

BACKGROUND

HIV surveillance systems aim to monitor trends of HIV infection, the geographical distribution and its magnitude, and the impact of HIV. The quality of HIV surveillance is a key element in determining the uncertainty ranges around HIV estimates. This paper aims to assess the quality of HIV surveillance systems in low- and middle-income countries in 2009 compared with 2007.

METHODS

Four dimensions related to the quality of surveillance systems are assessed: frequency and timeliness of data; appropriateness of populations; consistency of locations and groups; and representativeness of the groups. An algorithm for scoring the quality of surveillance systems was used separately for low and concentrated epidemics and for generalised epidemics.

RESULTS

The number of countries categorised as fully functioning in 2009 was 35, down from 40 in 2007. 47 countries were identified as partially functioning, while 56 were categorised as poorly functioning. When compared with 2007, the quality of HIV surveillance remains similar. The number of ANC sites in sub-Saharan Africa has increased over time. The number of countries with low and concentrated epidemics that do not have functioning HIV surveillance systems has increased from 53 to 56 between 2007 and 2009.

CONCLUSION

Overall, the quality of surveillance in low- and middle-income countries has remained stable. Still too many countries have poorly functioning surveillance systems. Several countries with generalised epidemics have conducted more than one population-based survey which can be used to confirm trends. In countries with concentrated or low-level epidemics, the lack of data on high-risk populations remains a challenge.

Transition to injection and sharing of needles/syringes: potential for HIV transmission among heroin users in Chengdu, China

This cross-sectional survey interviewed heroin injectors admitted in three detoxification centres from August 2003 to June 2004 in Chengdu City, China. Logistic regression and survival analysis were performed to identify factors associated with sharing of needles/syringes and time from initiation of heroin to adoption of injection, respectively. Out of 266 subjects studied, 206 (77.44%) were males, 103 (38.72%) never shared injecting materials, 113 (42.48%) were non-Chengdu residents and 9 (3.38%) belonged to ethnic minorities. Those with short history of heroin injection (P<0.05) and those belonged to ethnic minorities (P<0.05) were more likely to share injecting materials. Only age, ethnicity and duration of heroin use were associated with time to first injection. Median time to injection was 6 months for those who used heroin for the duration up to 1 year and 21 months for those who used heroin for 2-5 years. The study suggests that there is early initiation of injection and sharing of injecting materials is high among heroin users, a major risk for HIV transmission. Ethnic minorities have been identified to be the most risky group, which needs further attention.

The assessment of patients' health-related quality of life during tuberculosis treatment in Wuhan, China

OBJECTIVES

To validate the SF-36 questionnaire in a Chinese population and to assess the patients' health-related quality of life (HQoL) during tuberculosis (TB) treatment.

DESIGN

The SF-36 (Chinese version) scores of 102 TB cases before treatment, after the initial phase and at the end of treatment were compared with those of 103 control subjects.

RESULTS

The SF-36 scores were valid (internal consistency > 0.4) and reliable (Cronchbach's micro > 0.7). Before treatment, all except the role-emotional, social function and mental health scales of the TB patients were lower than those of the controls (P < 0.01); the patients' scores increased significantly during treatment (P < 0.01). In a stepwise regression model, age (P < 0.01, OR 0.95), white blood cell count (P < 0.01, OR 0.92) and number of symptoms (P < 0.05, OR 0.99) were associated with the total SF-36 score. At completion of treatment, sex (P < 0.01, OR 0.25) and haemoglobin (P < 0.05, OR 0.88) remained at the end of the model.

CONCLUSION

The SF-36 scores of TB patients are low before treatment, indicating a decline in HQoL, with physical scales most affected. However, scores increase over the course of treatment. The Chinese version of SF-36 is a reliable tool for monitoring HQoL throughout TB treatment.