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Lv SR, Wang MK, Yu XL, Li XY, Yang JS. Impact of COVID-19 pandemic on routine childhood vaccinations. World J Virol 2024; 13:90271. [PMID: 38984085 PMCID: PMC11229842 DOI: 10.5501/wjv.v13.i2.90271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/25/2024] [Accepted: 03/01/2024] [Indexed: 06/24/2024] Open
Abstract
Routine pediatric vaccination is one of the most effective public health inter-ventions for the control of a number of fatal diseases. However, during the coronavirus disease 2019 pandemic, routine pediatric vaccination rates were severely affected by disruptions of health services and vaccine confidence issues. Governments and the United Nations have taken measures to re-establish routine pediatric vaccination, while additional efforts are needed to catch up and develop plans to ensure routine vaccination services for the future pandemics.
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Affiliation(s)
- Shi-Rong Lv
- Department of Disease Control and Prevention, Naval Medical Center of PLA, Naval Medical University, Shanghai 200052, China
| | - Ming-Ke Wang
- Department of Disease Control and Prevention, Naval Medical Center of PLA, Naval Medical University, Shanghai 200052, China
| | - Xue-Lu Yu
- Department of Disease Control and Prevention, Naval Medical Center of PLA, Naval Medical University, Shanghai 200052, China
| | - Xin-Yue Li
- Department of Disease Control and Prevention, Naval Medical Center of PLA, Naval Medical University, Shanghai 200052, China
| | - Ji-Shun Yang
- Medical Care Center, Naval Medical Center of PLA, Naval Medical University, Shanghai 200052, China
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Mirieri H, Nasimiyu C, Dawa J, Mburu C, Jalang'o R, Kamau P, Igboh L, Ebama M, Wainaina D, Gitonga J, Karanja J, Njenga E, Kariuki J, Machani J, Oginga P, Baraka I, Wamaru P, Muhula S, Ratemo P, Ayugi J, Kariuki Njenga M, Emukule GO, Osoro E, Otieno NA. Resilience of routine childhood immunization services in two counties in Kenya in the face of the COVID-19 pandemic. Vaccine 2023; 41:7695-7704. [PMID: 38008664 PMCID: PMC11284176 DOI: 10.1016/j.vaccine.2023.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 09/03/2023] [Accepted: 09/13/2023] [Indexed: 11/28/2023]
Abstract
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.
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Affiliation(s)
- Harriet Mirieri
- Washington State University (WSU) Global Health Kenya, Nairobi, Kenya.
| | - Carolyne Nasimiyu
- Washington State University (WSU) Global Health Kenya, Nairobi, Kenya
| | - Jeanette Dawa
- Washington State University (WSU) Global Health Kenya, Nairobi, Kenya
| | - Caroline Mburu
- Department of Social Anthropology, University of St Andrews, Fife, Scotland, UK
| | - Rose Jalang'o
- National Vaccines and Immunization Program, Ministry of Health, Kenya
| | - Peter Kamau
- National Vaccines and Immunization Program, Ministry of Health, Kenya
| | - Ledor Igboh
- Global Immunization Division, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | - Jorim Ayugi
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - M Kariuki Njenga
- Washington State University (WSU) Global Health Kenya, Nairobi, Kenya; Paul G. Allen School of Global Health, Washington State University (WSU), Pullman, USA
| | - Gideon O Emukule
- Influenza Division, US Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Eric Osoro
- Washington State University (WSU) Global Health Kenya, Nairobi, Kenya; Paul G. Allen School of Global Health, Washington State University (WSU), Pullman, USA
| | - Nancy A Otieno
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
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Elbert B, Zainumi CM, Pujiastuti RAD, Yaznil MR, Yanni GN, Alona I, Lubis IND. Mothers' knowledge, attitude, and behavior regarding child immunization, and the association with child immunization status in Medan City during the COVID-19 pandemic. IJID REGIONS 2023:S2772-7076(23)00040-1. [PMID: 37363195 PMCID: PMC10157388 DOI: 10.1016/j.ijregi.2023.03.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 03/20/2023] [Accepted: 03/21/2023] [Indexed: 06/28/2023]
Abstract
Background The COVID-19 pandemic has caused disruption to healthcare access worldwide and has impacted basic childhood immunization services. A decline in immunization coverage can cause immunity gaps and lead to outbreaks of vaccine-preventable diseases. Our study evaluated the association between mothers' knowledge, attitude, and behavior regarding immunization and child immunization status during the COVID-19 pandemic in Medan, Indonesia. Methods An analytical cross-sectional study was conducted from April to November 2021. Mothers with children aged 0-12 months were interviewed about their knowledge, attitude, and behavior regarding immunization, and their child's immunization status. Results Of 196 participants, 46.5% had low knowledge on immunization, 41.3% had a negative attitude, and 20.4% had negative behavior. Only 62.8% of participants had children with a complete vaccination status, and mothers with moderate knowledge (OR 2.65, 95% CI 1.08-6.61), negative attitude (OR 5.33, 95% CI 2.71-10.59), and negative behavior (OR 7.88, 95% CI 3.36-19.47) were more likely to not vaccinate their children. Conclusion Mothers' attitude, behavior, and educational background were associated with child immunization status. Recovery efforts to improve immunization coverage are urgently needed, and should include efforts to reduce mothers' hesitancy regarding child vaccination during the pandemic.
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Affiliation(s)
- Bryant Elbert
- Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
| | - Cut Meliza Zainumi
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
| | | | - Muhammad Rizki Yaznil
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
| | - Gema Nazri Yanni
- Department of Pediatrics, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
| | - Ivana Alona
- Department of Community Medicine, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
| | - Inke Nadia D Lubis
- Department of Pediatrics, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
- Menzies School of Health Research, Darwin, Australia
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de Araújo GR, de Castro PA, Ávila IR, Bezerra JMT, Barbosa DS. Effects of public health emergencies of international concern on disease control: a systematic review. Rev Panam Salud Publica 2023; 47:e74. [PMID: 37089787 PMCID: PMC10120386 DOI: 10.26633/rpsp.2023.74] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 10/17/2022] [Indexed: 04/25/2023] Open
Abstract
Objectives To assess the accumulated knowledge of the effects of public health emergencies of international concern on disease control and local health systems, and contribute to a better understanding of their effects on health programs and systems. Methods This was a systematic review of published and gray literature (in English, Portuguese, or Spanish). Electronic databases (BVS/LILACS, PubMed, and SciELO) and Google Scholar were searched. Search terms were: COVID-19 OR H1N1 OR Ebola OR Zika OR poliomyelitis AND (outbreaks OR epidemics) AND (public health systems OR public health surveillance). Results A total of 3 508 studies were retrieved, of which 31 met the inclusion criteria. The studies addressed the effects of the emergencies on: communicable diseases notification systems; malaria, HIV/AIDS, tuberculosis, poliomyelitis, and malaria surveillance, control, and treatment; microcephaly; dengue; and vaccinations. The populations affected by the emergencies experienced reduced health services, which included fewer health visits, failures in the diagnostic chain, decrease in vaccination, and increased incidence or underreporting of notifiable diseases. Conclusions Socioeconomic inequity is a determinant of the effects of public health emergencies of international concern within affected populations. The diversion of resources and attention from health authorities disproportionately affects vulnerable populations and can lead, over time, to a weakening of health systems. The analysis of the effects of public health emergencies is important for the development of new protocols that can better respond to future crises.
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Affiliation(s)
- Giovanna Rotondo de Araújo
- Universidade Federal de Minas GeraisBelo HorizonteMinas GeraisBrasilUniversidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brasil.
| | - Pedro A.S.V. de Castro
- Universidade Federal de Minas GeraisBelo HorizonteMinas GeraisBrasilUniversidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brasil.
| | - Isabela R. Ávila
- Universidade Federal de Minas GeraisBelo HorizonteMinas GeraisBrasilUniversidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brasil.
| | - Juliana Maria T. Bezerra
- Universidade Federal de Minas GeraisBelo HorizonteMinas GeraisBrasilUniversidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brasil.
| | - David S. Barbosa
- Universidade Federal de Minas GeraisBelo HorizonteMinas GeraisBrasilUniversidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brasil.
- David S. Barbosa,
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5
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Ota MOC, de Moraes JC, Vojtek I, Constenla D, Doherty TM, Cintra O, Kirigia JM. Unveiling the contributions of immunization for progressing towards Universal Health Coverage. Hum Vaccin Immunother 2022; 18:2036048. [PMID: 35239460 PMCID: PMC9009948 DOI: 10.1080/21645515.2022.2036048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The aim of the United Nations' Sustainable Development Goal (SDG)3 is to ensure healthy lives and promote well-being for all, at all ages; including reducing maternal and child mortality, combating communicable and non-communicable diseases, and achieving Universal Health Coverage (UHC). UHC aims to provide everyone with equal access to quality essential and comprehensive healthcare services including preventions, interventions, and treatments, without exposing them to financial hardship. Making progress toward UHC requires significant investment in technical and financial resources and countries are pursuing the implementation of cost-saving measures within health systems to help them achieve UHC. Whilst many countries are far from attaining UHC, all countries, particularly low- and middle-income countries, can take steps toward achieving UHC. This paper discusses key data showing how immunization is a fundamental, cost-effective tool for reducing morbidity and mortality associated with infectious disease in all populations, creating more productive communities, reducing treatment costs, and consequently, facilitating social and economic advancement. Immunization is key to advancing toward UHC by relieving the burden that diseases place on the healthcare services, freeing essential resources to use elsewhere within the healthcare system. Immunization is an essential, readily available strategy that countries can deploy to achieve UHC and the SDG3 agenda.
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Affiliation(s)
| | - Jose C de Moraes
- Department of Collective Health, Faculty of Medical Sciences of Santa Casa de Sao Paulo, Sao Paulo, Brazil
| | - Ivo Vojtek
- Medical Affairs, GSK, Medical Affairs, Wavre, Belgium
| | - Dagna Constenla
- Medical Affairs, GSK, US Research & Development, Saloui Center, Rockville, MD,USA
| | - T Mark Doherty
- Medical Affairs, GSK, Medical Affairs, Brondfby, Denmark
| | - Otavio Cintra
- Medical Affairs, GSK, Medical Affairs, Rio de Janeiro, Brazil
| | - Joses M Kirigia
- African Sustainable Development Research Consortium (ASDRC), Nairobi, Kenya
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Bell J, Lartey B, Spickernell G, Darrell N, Salt F, Gardner C, Richards E, Fasakin L, Egbeniyi S, Odongo E, Ssenkungu J, Kouadio RK, Cissé M, Rérambyah ABAI, Adou M, West R, Sharma S. Applying a social-ecological model to understand factors impacting demand for childhood vaccinations in Nigeria, Uganda, and Guinea. SSM. QUALITATIVE RESEARCH IN HEALTH 2022; 2:None. [PMID: 36531294 PMCID: PMC9748306 DOI: 10.1016/j.ssmqr.2022.100180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 10/08/2022] [Accepted: 10/11/2022] [Indexed: 06/17/2023]
Abstract
Vaccines have reduced child mortality across the world, but low levels of demand for vaccination threatens to undermine progress. Existing frameworks to understand demand tend to prioritise primary caregivers' decision-making processes. We aimed to build a wider understanding of vaccine demand by applying an adapted socio-ecological model to analyse 158 interviews with primary caregivers and fathers of young children, and community influencers in Nigeria, Uganda, and Guinea. We found that several factors come together to inform a primary caregiver's demand for vaccination, including their familial and social relationships, their interactions with government and healthcare institutions, and the wider social and cultural norms in their communities. The study suggests that interventions targeted at families and communities instead of individuals could be effective. The results could be used to ensure that vaccine demand frameworks used by researchers and intervention designers are comprehensive and consider a wider range of influences on the primary caregiver.
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Affiliation(s)
- James Bell
- Ipsos Healthcare, 3 Thomas More Square, London, E1W 1YW, UK
| | - Belinda Lartey
- Ipsos Healthcare, 3 Thomas More Square, London, E1W 1YW, UK
| | | | | | - Frances Salt
- Ipsos Healthcare, 3 Thomas More Square, London, E1W 1YW, UK
| | - Cassie Gardner
- Ipsos Healthcare, 3 Thomas More Square, London, E1W 1YW, UK
| | - Emily Richards
- Ipsos Healthcare, 3 Thomas More Square, London, E1W 1YW, UK
| | - Lanre Fasakin
- CMRG, 24A, Eric Moore Street, Wemabod Estate, Off Ajao Road, Ikeja, Lagos, Nigeria
| | - Shadrach Egbeniyi
- CMRG, 24A, Eric Moore Street, Wemabod Estate, Off Ajao Road, Ikeja, Lagos, Nigeria
| | - Emmanuel Odongo
- Ipsos Uganda, 3rd Floor Padre Pio House, Plot 32, Lumumba Avenue P.O. Box 21571, Kampala, Uganda
| | - James Ssenkungu
- Ipsos Uganda, 3rd Floor Padre Pio House, Plot 32, Lumumba Avenue P.O. Box 21571, Kampala, Uganda
| | | | - Mamadi Cissé
- Ciblage, En Face de l’Ecole les Ecureuils, Lambanyi, Ratoma, Conakry, Guinea
| | | | - Maikol Adou
- Ciblage, Face SODECI, Imm. Hué, Porte B10, Riviera Attoban, Cocody, 09 BP 799, Abidjan 09, Cote d’Ivoire
| | - Rebecca West
- Ipsos Healthcare, 3 Thomas More Square, London, E1W 1YW, UK
- Boston University School of Public Health, 715 Albany St, Boston, MA, 02118, United States
| | - Sunny Sharma
- Ipsos Healthcare, 3 Thomas More Square, London, E1W 1YW, UK
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Kiarie H, Temmerman M, Nyamai M, Liku N, Thuo W, Oramisi V, Nyaga L, Karimi J, Wamalwa P, Gatheca G, Mwenda V, Ombajo LA, Thumbi SM. The COVID-19 pandemic and disruptions to essential health services in Kenya: a retrospective time-series analysis. Lancet Glob Health 2022; 10:e1257-e1267. [PMID: 35961349 PMCID: PMC9363041 DOI: 10.1016/s2214-109x(22)00285-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 06/16/2022] [Accepted: 06/22/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Public health emergencies can disrupt the provision of and access to essential health-care services, exacerbating health crises. We aimed to assess the effect of the COVID-19 pandemic on essential health-care services in Kenya. METHODS Using county-level data routinely collected from the health information system from health facilities across the country, we used a robust mixed-effect model to examine changes in 17 indicators of essential health services across four periods: the pre-pandemic period (from January, 2018 to February, 2020), two pandemic periods (from March to November 2020, and February to October, 2021), and the period during the COVID-19-associated health-care workers' strike (from December, 2020 to January, 2021). FINDINGS In the pre-pandemic period, we observed a positive trend for multiple indicators. The onset of the pandemic was associated with statistically significant decreases in multiple indicators, including outpatient visits (28·7%; 95% CI 16·0-43·5%), cervical cancer screening (49·8%; 20·6-57·9%), number of HIV tests conducted (45·3%; 23·9-63·0%), patients tested for malaria (31·9%; 16·7-46·7%), number of notified tuberculosis cases (26·6%; 14·7-45·1%), hypertension cases (10·4%; 6·0-39·4%), vitamin A supplements (8·7%; 7·9-10·5%), and three doses of the diphtheria, tetanus toxoid, and pertussis vaccine administered (0·9%; 0·5-1·3%). Pneumonia cases reduced by 50·6% (31·3-67·3%), diarrhoea by 39·7% (24·8-62·7%), and children attending welfare clinics by 39·6% (23·5-47·1%). Cases of sexual violence increased by 8·0% (4·3-25·0%). Skilled deliveries, antenatal care, people with HIV infection newly started on antiretroviral therapy, confirmed cases of malaria, and diabetes cases detected were not significantly affected negatively. Although most of the health indicators began to recover during the pandemic, the health-care workers' strike resulted in nearly all indicators falling to numbers lower than those observed at the onset or during the pre-strike pandemic period. INTERPRETATION The COVID-19 pandemic and the associated health-care workers' strike in Kenya have been associated with a substantial disruption of essential health services, with the use of outpatient visits, screening and diagnostic services, and child immunisation adversely affected. Efforts to maintain the provision of these essential health services during a health-care crisis should target the susceptible services to prevent the exacerbation of associated disease burdens during such health crises. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- Helen Kiarie
- Division of Monitoring and Evaluation, Ministry of Health, Nairobi, Kenya
| | - Marleen Temmerman
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi, Kenya
| | - Mutono Nyamai
- Centre for Epidemiological Modelling and Analysis, University of Nairobi, Nairobi, Kenya; Paul G Allen School for Global Health, Washington State University, Pullman, WA, USA
| | - Nzisa Liku
- Division of Monitoring and Evaluation, Ministry of Health, Nairobi, Kenya; Paul G Allen School for Global Health, Washington State University, Pullman, WA, USA
| | - Wangari Thuo
- Centre for Epidemiological Modelling and Analysis, University of Nairobi, Nairobi, Kenya
| | - Violet Oramisi
- National AIDS and STIs Control Programme, Ministry of Health, Nairobi, Kenya
| | - Lilly Nyaga
- Division of Monitoring and Evaluation, Ministry of Health, Nairobi, Kenya
| | - Janette Karimi
- Division of Monitoring and Evaluation, Ministry of Health, Nairobi, Kenya
| | | | - Gladwell Gatheca
- Division of Monitoring and Evaluation, Ministry of Health, Nairobi, Kenya
| | - Valerian Mwenda
- Division of Monitoring and Evaluation, Ministry of Health, Nairobi, Kenya
| | - Loice Achieng Ombajo
- Centre for Epidemiological Modelling and Analysis, University of Nairobi, Nairobi, Kenya; Department of Clinical Medicine and Therapeutics, College of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - S M Thumbi
- Centre for Epidemiological Modelling and Analysis, University of Nairobi, Nairobi, Kenya; Institute of Tropical and Infectious Diseases, University of Nairobi, Nairobi, Kenya; Paul G Allen School for Global Health, Washington State University, Pullman, WA, USA; Institute of Immunology and Infection Research, School of Biological Sciences, University of Edinburgh, Edinburgh, UK.
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Sexual and reproductive health services during outbreaks, epidemics, and pandemics in sub-Saharan Africa: a literature scoping review. Syst Rev 2022; 11:161. [PMID: 35945580 PMCID: PMC9361234 DOI: 10.1186/s13643-022-02035-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 07/26/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic could worsen adolescent sexual and reproductive health (ASRH). We sought evidence on the indirect impacts of previous infectious disease epidemics and the current COVID-19 pandemic on the uptake of ASRH in sub-Saharan Africa (SSA) to design relevant digital solutions. METHODS We undertook a literature scoping review to synthesize evidence on the indirect impacts of COVID-19 on ASRH in SSA per the Arksey and O'Malley framework and PRISMA reporting guidelines. We conducted the search on PubMed, Embase, Google Scholar, and ResearchGate in June and November 2020. We included all peer-reviewed, English-language primary studies on the indirect impacts of infectious disease epidemics on the uptake of sexual and reproductive health (SRH) in SSA. RESULTS We included 21 of 42 identified studies. Sixteen studies (76.2%) quantitatively assessed utilization and access to SRH during epidemics. Five studies (2 [9.6%] qualitative and 3 [14.3%] mixed methods) explored factors affecting SRH services. All studies focused on adult populations, most often on labor and delivery (n = 13 [61.9%]) and family planning (n = 8 [38.1%]) outcomes. Although we sought out to assess all outbreaks, epidemics, and pandemics, the only relevant studies took place during the West African Ebola pandemic (n = 17 [80.9%]) and COVID-19 pandemic (n = 4 [19.0%]). One study (4.8%) highlighted adolescent-specific outcomes and condom use. Most studies found declined access to and utilization of facility delivery, antenatal care, family planning, and HIV care. One study noted an increase in adolescent pregnancies. However, other studies noted similar, or even increasing trends in access to and utilization of other SRH services (family planning visits; HIV diagnosis; ART initiation) during epidemics. Barriers to SRH uptake included factors such as a reduced ability to pay for care due to lost income, travel restrictions, and fear of infection. Supply-side barriers included lack of open facilities, workers, commodities, and services. Community-based peer delivery systems, telemedicine, and transport services improved SRH uptake. CONCLUSION Access to SRH services during epidemics among adolescents and young people in SSA is understudied. We found that no studies focused on SRH outcomes of abortion, emergency contraception, sexually transmitted infections, or cervical cancer. To improve access to and utilization of SRH during pandemics, we recommend the following; in terms of research, key standardized SRH indicators should be included in routine data collection, routine data should be disaggregated by age, gender, and geography to understand gaps in ASRH service delivery, and additional rigorous epidemiological and social-behavioral studies should be conducted. On implementation, community-based peer delivery systems and telemedicine, internet-based, and other technological solutions may better reach adolescent and young people in SSA.
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Vaccine pragmatism in the 21st century. THE LANCET INFECTIOUS DISEASES 2022; 22:1097-1098. [PMID: 35588756 PMCID: PMC9110012 DOI: 10.1016/s1473-3099(22)00181-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 03/07/2022] [Indexed: 11/23/2022]
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10
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Giles ML, O'Bryan J, Angliss M, Lee S, Krishnaswamy S. How COVID-19 has impacted immunisation service delivery in Australia: a national study. Aust N Z J Public Health 2022; 46:495-501. [PMID: 35616400 PMCID: PMC9348466 DOI: 10.1111/1753-6405.13260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/01/2021] [Accepted: 04/01/2022] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE The objective of this study was to determine the impact the COVID-19 pandemic had on the delivery of adult, maternal and childhood immunisation services in Australia in 2020 prior to the rollout of COVID-19 vaccines, and to understand the adaptations made at a service delivery level that may have contributed to the successful delivery of immunisation services during the first year of the pandemic. METHODS An electronic survey was sent to immunisation providers and pharmacists in all states and territories in Australia between November 2020 and December 2020. It explored interruption to the delivery of immunisation services, strategies implemented to maintain services, prioritisation of populations, and self-reported challenges and solutions initiated by providers. RESULTS A total of 850 people responded to the survey. Of these, the most common professional groups identified were pharmacists followed by nurse immunisers, nurses/midwives and general practitioners. Several changes were implemented including relocation of vaccination clinics, change to bookings rather than walk-in appointments, infection prevention measures, clients waiting in cars pre- and post-vaccination and reduced observation period post-vaccination. CONCLUSION The pandemic has provided opportunities for services to trial new and innovative strategies such as electronic pre-assessment, electronic consent and drive-through vaccination services. IMPLICATIONS FOR PUBLIC HEALTH Immunisation providers mostly viewed these changes positively and intend to continue many post-pandemic. The experience gained from the trialling of these strategies may be adapted for vaccine delivery and National Immunisation Program vaccines beyond the pandemic.
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Affiliation(s)
- Michelle L. Giles
- Department of Obstetrics and Gynaecology, Monash University, Victoria,Correspondence to: Professor Michelle Giles, Department of Obstetrics and Gynaecology, Monash University, 246 Clayton Road, Clayton VIC 3168
| | | | | | - Sue Lee
- Central Clinical School, Monash University, Victoria
| | - Sushena Krishnaswamy
- Department of Obstetrics and Gynaecology, Monash University, Victoria,Department of Infectious Diseases, Monash Health, Victoria
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Early Impact of SARS-CoV-2 Pandemic on Immunization Services in Nigeria. Vaccines (Basel) 2022; 10:vaccines10071107. [PMID: 35891271 PMCID: PMC9315672 DOI: 10.3390/vaccines10071107] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 06/30/2022] [Accepted: 07/06/2022] [Indexed: 12/23/2022] Open
Abstract
Background: By 11 March 2022, there were 450,229,635 coronavirus disease (COVID-19) cases and 6,019,085 deaths globally, with Nigeria reporting 254,637 cases and 3142 deaths. One of the essential healthcare services that have been impacted by the pandemic is routine childhood immunization. According to the 2018 National Demographic and Health Survey, only 31% of children aged 12–23 months were fully vaccinated in Nigeria, and 19% of eligible children in the country had not received any vaccination. A further decline in coverage due to the pandemic can significantly increase the risk of vaccine-preventable-disease outbreaks among children in Nigeria. To mitigate such an occurrence, it is imperative to urgently identify how the pandemic and the response strategies have affected vaccination services, hence, the goal of the study. Methods: The research method was qualitative, including in-depth interviews of healthcare workers and focus group discussions (FGDs) with caregivers of children aged 0–23 months. We selected one state from each of the three zones of Nigeria: northern, central, and southern. Within each state, 10 local government areas and 20 healthcare facilities were purposively selected. In each facility, 10 healthcare workers were invited for interviews. Overall, 517 healthcare workers were interviewed. For the focus group discussion, 30 communities were selected. Within each selected community, six consenting caregivers were included. Overall, 180 caregivers participated. The data were analyzed using thematic inductive content analysis. Results: Three significant impacts that were observed are: difficulties in accessibility to immunization services, declining immunization demand and uptake among caregivers due to varying factors, and erosion of vaccine confidence among both caregivers and healthcare workers. Movement restriction and lockdown had numerous major impacts, such as decreased general healthcare service delivery, increased transportation costs, fewer engagements that promote vaccine uptake, and cessation of mobile vaccination campaigns that target hard-to-reach communities. Moreover, misinformation, conspiracy beliefs about the pandemic and COVID-19 vaccines, and risk perception negatively influenced general vaccine confidence. Conclusion: The results of this early impact study show that immunization was directly affected by the pandemic and provide insights into areas where interventions are needed for recovery.
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Ho LL, Gurung S, Mirza I, Nicolas HD, Steulet C, Burman AL, Danovaro-Holliday MC, Sodha SV, Kretsinger K. Impact of the SARS-CoV-2 pandemic on vaccine-preventable disease campaigns. Int J Infect Dis 2022; 119:201-209. [PMID: 35398300 PMCID: PMC8985404 DOI: 10.1016/j.ijid.2022.04.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 03/31/2022] [Accepted: 04/04/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic has contributed to the widespread disruption of immunization services, including the postponement of mass vaccination campaigns. METHODS In May 2020, the World Health Organization (WHO) and partners started monitoring COVID-19-related disruptions to mass vaccination campaigns against cholera, measles, meningitis A, polio, tetanus-diphtheria, typhoid and yellow fever through the Immunization Repository Campaign Delay Tracker. The authors reviewed the number and target population of reported preventive and outbreak response vaccination campaigns scheduled, postponed, canceled and reinstated, at four time-points: May 2020, December 2020, May 2021 and December 2021. FINDINGS Mass vaccination campaigns across all vaccines were disrupted heavily by COVID-19. In May 2020, 105 of 183 (57%) campaigns were postponed or canceled in 57 countries due to COVID-19, with an estimated 796 million postponed or missed vaccine doses. Campaign resumption was observed beginning in July 2020. In December 2021, 77 of 472 (16%) campaigns in 54 countries, mainly in the African Region, were still postponed or canceled due to COVID-19, with about 382 million postponed or missed vaccine doses. INTERPRETATION There is likely high risk of vaccine-preventable disease outbreaks due to an increased number of susceptible persons resulting from the large-scale mass vaccination campaign postponement caused by COVID-19 across all regions.
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Affiliation(s)
- Lee Lee Ho
- World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland.
| | - Santosh Gurung
- World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland
| | - Imran Mirza
- United Nations Children's Fund, 125 Maiden Lane, New York, NY 10038, USA
| | | | - Claudia Steulet
- World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland
| | - Ashley L Burman
- World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland
| | | | - Samir V Sodha
- World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland
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13
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Estimating Risk of Introduction of Ebola Virus Disease from the Democratic Republic of Congo to Tanzania: A Qualitative Assessment. EPIDEMIOLGIA (BASEL, SWITZERLAND) 2022; 3:68-80. [PMID: 36417268 PMCID: PMC9620938 DOI: 10.3390/epidemiologia3010007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 12/11/2021] [Accepted: 12/17/2021] [Indexed: 12/14/2022]
Abstract
Between April 2018 and November 2020, the Democratic Republic of Congo (DRC) experienced its 11th Ebola virus disease (EVD) outbreak. Tanzania's cross-border interactions with DRC through regular visitors, traders, and refugees are of concern, given the potential for further spread to neighboring countries. This study aimed to estimate the risk of introducing EVD to Tanzania from DRC. National data for flights, boats, and car transport schedules from DRC to Tanzania covering the period of May 2018 to June 2019 were analyzed to describe population movement via land, port, and air travel and coupled with available surveillance data to model the risk of EVD entry. The land border crossing was considered the most frequently used means of travel and the most likely pathway of introducing EVD from DRC to Tanzania. High probabilities of introducing EVD from DRC to Tanzania through the assessed pathways were associated with the viability of the pathogen and low detection capacity at the ports of entry. This study provides important information regarding the elements contributing to the risk associated with the introduction of EBV in Tanzania. It also indicates that infected humans arriving via land are the most likely pathway of EBV entry, and therefore, mitigation strategies including land border surveillance should be strengthened.
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14
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Lee DID, Vanderhout S, Aglipay M, Birken CS, Morris SK, Piché-Renaud PP, Keown-Stoneman CDG, Maguire JL. Delay in childhood vaccinations during the COVID-19 pandemic. CANADIAN JOURNAL OF PUBLIC HEALTH = REVUE CANADIENNE DE SANTE PUBLIQUE 2022; 113:126-134. [PMID: 35060107 PMCID: PMC8773389 DOI: 10.17269/s41997-021-00601-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 12/07/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES In many jurisdictions, routine medical care was reduced in response to the COVID-19 pandemic. The objective of this study was to determine whether the frequency of on-time routine childhood vaccinations among children age 0-2 years was lower following the COVID-19 declaration of emergency in Ontario, Canada, on March 17, 2020, compared to prior to the pandemic. METHODS We conducted a longitudinal cohort study of healthy children aged 0-2 years participating in the TARGet Kids! primary care research network in Toronto, Canada. A logistic mixed effects regression model was used to determine odds ratios (ORs) for delayed vaccination (> 30 days vs. ≤ 30 days from the recommended date) before and after the COVID-19 declaration of emergency, adjusted for confounding variables. A Cox proportional hazards model was used to explore the relationship between the declaration of emergency and time to vaccination. RESULTS Among 1277 children, the proportion of on-time vaccinations was 81.8% prior to the COVID-19 declaration of emergency and 62.1% after (p < 0.001). The odds of delayed vaccination increased (odds ratio = 3.77, 95% CI: 2.86-4.96), and the hazard of administration of recommended vaccinations decreased after the declaration of emergency (hazard ratio = 0.75, 95% CI: 0.60-0.92). The median vaccination delay time was 5 days (95% CI: 4-5 days) prior to the declaration of emergency and 17 days (95% CI: 12-22 days) after. CONCLUSION The frequency of on-time routine childhood vaccinations was lower during the first wave of the COVID-19 pandemic. Sustained delays in routine vaccinations may lead to an increase in rates of vaccine-preventable diseases.
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Affiliation(s)
- Da In Diane Lee
- Department of Paediatrics, St. Michael's Hospital, 61 Queen Street East, 2nd Floor, Toronto, ON, M5C 2T2, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Shelley Vanderhout
- Department of Paediatrics, St. Michael's Hospital, 61 Queen Street East, 2nd Floor, Toronto, ON, M5C 2T2, Canada.,Department of Nutritional Sciences, Medical Sciences Building, University of Toronto, 1 King's College Circle, Room 5253, Toronto, ON, M5S 1A8, Canada
| | - Mary Aglipay
- Department of Paediatrics, St. Michael's Hospital, 61 Queen Street East, 2nd Floor, Toronto, ON, M5C 2T2, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Catherine S Birken
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Department of Nutritional Sciences, Medical Sciences Building, University of Toronto, 1 King's College Circle, Room 5253, Toronto, ON, M5S 1A8, Canada.,Division of Paediatric Medicine, Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, Temerty Faculty of Medicine, University of Toronto, ON, Toronto, Canada
| | - Shaun K Morris
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Department of Pediatrics, Temerty Faculty of Medicine, University of Toronto, ON, Toronto, Canada.,Division of Infectious Diseases, Hospital for Sick Children, Toronto, ON, Canada
| | - Pierre-Philippe Piché-Renaud
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Department of Pediatrics, Temerty Faculty of Medicine, University of Toronto, ON, Toronto, Canada.,Division of Infectious Diseases, Hospital for Sick Children, Toronto, ON, Canada
| | - Charles D G Keown-Stoneman
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Applied Health Research Centre, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada
| | - Jonathon L Maguire
- Department of Paediatrics, St. Michael's Hospital, 61 Queen Street East, 2nd Floor, Toronto, ON, M5C 2T2, Canada. .,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada. .,Department of Nutritional Sciences, Medical Sciences Building, University of Toronto, 1 King's College Circle, Room 5253, Toronto, ON, M5S 1A8, Canada. .,Department of Pediatrics, Temerty Faculty of Medicine, University of Toronto, ON, Toronto, Canada. .,Applied Health Research Centre, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada.
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15
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Shimizu K, Checchi F, Warsame A. Disparities in Health Financing Allocation among Infectious Diseases in Ebola Virus Disease (EVD)-Affected Countries, 2005–2017. Healthcare (Basel) 2022; 10:healthcare10020179. [PMID: 35206794 PMCID: PMC8872520 DOI: 10.3390/healthcare10020179] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/09/2022] [Accepted: 01/11/2022] [Indexed: 02/04/2023] Open
Abstract
The Ebola virus disease (EVD) outbreaks impacted the population health due to overstretched health systems and disrupted essential health services. Despite a call to achieve equal financial allocation depending on public health needs, there has been scant examination of the fairness of investment among infectious diseases. This study analyzes the extent to which equitable development assistance for health (DAH) has been provided in accordance with disease burden in EVD-affected countries. Estimates of disability-adjusted life years (DALYs) in the Global Burden of Disease (GBD) Study 2017 and DAH Database 1990–2019 in 2005–2017 were analyzed by disease category: vaccine-preventable diseases (VPDs), HIV/AIDS, malaria, tuberculosis, and EVD. HIV/AIDS generally recorded higher ratios of DAH per DALYs (DAH/DALYs). Malaria and tuberculosis showed different trends by country, and VPDs generally presented lower ratios. In West Africa in 2013–2016, DAH/DALYs surged in EVD and fluctuated in HIV/AIDS and malaria. Tuberculosis and VPDs consistently recorded lower ratios. To achieve the risk reduction during and after health emergencies, optimal funding allocation between diseases based on the disease burden is warranted in the pre-emergency period, along with measurement of immediate health needs of populations in real-time during an emergency.
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Affiliation(s)
- Kazuki Shimizu
- Department of Health Policy, London School of Economics and Political Science, Cowdray House, Houghton Street, London WC2A 2AE, UK
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
- Health in Humanitarian Crises Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; (F.C.); (A.W.)
- Tokyo Foundation for Policy Research, Roppongi Grand Tower 34F, 3-2-1 Roppongi, Minato-ku, Tokyo 106-6234, Japan
- Correspondence:
| | - Francesco Checchi
- Health in Humanitarian Crises Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; (F.C.); (A.W.)
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Abdihamid Warsame
- Health in Humanitarian Crises Centre, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; (F.C.); (A.W.)
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
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16
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Rabbani U, Saigul AA, Sulaiman A, Ibrahim TH. Impact of COVID-19 on Antenatal Care Utilization Among Pregnant Women in Qassim, Saudi Arabia. Cureus 2021; 13:e19554. [PMID: 34956742 PMCID: PMC8675600 DOI: 10.7759/cureus.19554] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2021] [Indexed: 11/05/2022] Open
Abstract
Background and objectives Coronavirus disease 2019 (COVID-19) pandemic has affected routine service delivery which might affect antenatal care (ANC) utilization among pregnant women. This study aimed to assess the proportion of missed appointments among pregnant women in the Qassim region of Saudi Arabia during the COVID-19 pandemic. Methods A facility-based cross-sectional survey was conducted among pregnant women admitted for delivery in Maternity and Children Hospital (MCH), Buraidah. Data were collected on socio-demographics, obstetric history, missed appointments and reasons for missing the appointment. Analysis was carried out in Statistical Package for the Social Sciences (SPSS), version 21.0 (IBM Corp., Armonk, NY). Medians with interquartile range (IQR) were presented for continuous variables and frequency and proportions for categorical variables. Logistic regression was used to assess the factors associated with the missed appointment. Results A total of 400 women were included in the study. About one-third (30%) of the women had missed at least one ANC appointment in their current pregnancy. The most common reasons for missing the appointments in primary care and hospitals, respectively, were: fear of infection 52% and 47%, facility not working usual 25% and 7.5%, fear of infection to child 19% and 17%. Family size and gravidity were the significant factors associated with missed appointments in our study. Conclusions Nearly one-third of women missed their ANC appointments during the COVID-19 pandemic. Major reasons were related to COVID-19 fear and its effect on services. This calls for proper health communication in the general population and delivering routine care with evidence-based guidelines to maintain continuity of care.
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Affiliation(s)
- Unaib Rabbani
- Family Medicine Academy, Qassim Health Cluster, Buraidah, SAU
| | | | - Amel Sulaiman
- Family Medicine Academy, Qassim Health Cluster, Buraidah, SAU
| | - Tayseer H Ibrahim
- Academic Affairs and Training Center, Maternity and Children Hospital, Buraidah, SAU
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17
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Mokaya EN, Isaac Z, Anyuon NA. Measles outbreak investigation in Aweil East county, South Sudan. Pan Afr Med J 2021; 40:87. [PMID: 34909076 PMCID: PMC8607948 DOI: 10.11604/pamj.2021.40.87.28370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 08/14/2021] [Indexed: 11/11/2022] Open
Abstract
During January 2018-June 2020, Aweil East confirmed five measles outbreaks. In March 2020, Aweil East reported twenty measles IgM+ cases. Before this outbreak, Aweil East had confirmed an outbreak in late November 2019. Even after conducting outbreak reactive vaccinations (ORV) in December 2019 and February 2020, measles spread was not interrupted. The nationally supported measles follow-up campaign (MFUC) conducted in late February 2020 was deferred in Aweil East because of the February ORV. We reviewed the measles data collected through passive and active surveillance. A matched case-control study was conducted to evaluate potential exposures. Face-to-face interviews with cases and controls using a semi-structured questionnaire were used to collect demographics, disease, and exposures related data. A total of 687 cases with eight deaths; attack and case fatality rate of 123/100,000 population and 1.16%, respectively. Among the cases, 51.8% were male, the median age was four years, and 59% of cases ≥9 months were unvaccinated. Eighty point six percent (80.6%) of cases reported after the February ORV were unvaccinated. The outbreak peaked in late March 2020. Unvaccinated persons had higher odds of getting measles (adjusted odds ratio (AOR)=8.569; 95% CI [1.41- 53.4], p=0.02). Non exposed persons had a lower odd of getting measles (AOR=0.114; 95% CI [0.02-0.61], p=0.011). During 2018-2019, the accumulated number of unvaccinated children (18,587) is more than a birth cohort of the county. Persistent low routine vaccination is the most critical driver of the measles outbreaks. Low-quality ORV and the intermediate population density are secondary drivers of the outbreaks.
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18
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Santos VS, Vieira SCF, Barreto IDDC, de Gois-Santos VT, Celestino AO, Domingues C, Cuevas LE, Gurgel RQ. Effects of the COVID-19 pandemic on routine pediatric vaccination in Brazil. Expert Rev Vaccines 2021; 20:1661-1666. [PMID: 34612135 DOI: 10.1080/14760584.2021.1990045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND COVID-19 pandemic has disrupted health services, including vaccination demand. We describe the impact of the COVID-19 pandemic on routine pediatric vaccination in Brazil. METHODS We conducted a retrospective analysis of all vaccine doses provided to children aged 0-6 years from January 2019 to December 2020. We obtained data stratified by age group (0 to 2 years and >2 to 6 years) and Brazilian region. Difference-in-difference (DiD) analyses were performed to compare vaccine uptake in the pre-pandemic (January-February), stay-at-home (March-June), and reopening (July-December) periods. RESULTS The number of vaccine doses administered declined in the stay-at-home period. For children aged 0 to 2 years, the highest reductions were recorded in the North (-25.3%), Northeast (-16.8%) and Central-West (-10.2%) regions. For children aged >2 to 6 years, the highest decline was observed in the North (DiD = -27.2%) and South (DiD = -14.0%) regions. The number of vaccine doses administered in the reopening period has slightly increased in all regions. CONCLUSIONS Vaccination decreased during the COVID-19 pandemic. Although the number of doses recovered in part during the reopening phase, additional strategies, such as increased public awareness and vaccination booster campaigns are required.
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Affiliation(s)
- Victor Santana Santos
- Centre for Epidemiology and Public Health, Federal University of Alagoas, Arapiraca, Brazil.,Graduate Program in Health Sciences, Federal University of Sergipe, Aracaju, Brazil.,Graduate Program in Health Sciences, Federal University of Alagoas, Maceió, Brazil
| | - Sarah Cristina Fontes Vieira
- Graduate Program in Health Sciences, Federal University of Sergipe, Aracaju, Brazil.,Pediatrics Subdivision, Department of Medicine, Federal University of Sergipe, Aracaju, Brazil
| | | | | | | | - Carla Domingues
- Epidemiologist, PhD in Tropical Medicine. Independent Researcher, Brasília, Brazil
| | - Luis Eduardo Cuevas
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Ricardo Queiroz Gurgel
- Graduate Program in Health Sciences, Federal University of Sergipe, Aracaju, Brazil.,Pediatrics Subdivision, Department of Medicine, Federal University of Sergipe, Aracaju, Brazil
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19
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Sell H, Assi A, Driedger SM, Dubé È, Gagneur A, Meyer SB, Robinson J, Sadarangani M, Tunis M, MacDonald SE. Continuity of routine immunization programs in Canada during the COVID-19 pandemic. Vaccine 2021; 39:5532-5537. [PMID: 34426028 PMCID: PMC8439618 DOI: 10.1016/j.vaccine.2021.08.044] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 07/21/2021] [Accepted: 08/12/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION In Canada, the COVID-19 pandemic has interrupted many routine health services, placed additional strain on the health care system, and resulted in many Canadians being either unable or unwilling to attend routine immunization appointments. We sought to capture and synthesize information about changes to routine immunization programs in response to the pandemic and plans to catch-up any missed immunizations. METHODS Provincial/territorial (P/T) public health leaders were interviewed via teleconference between August-October 2020 to collect information on the following topics: how routine immunization delivery was affected during and after initial lockdown periods, plans to catch-up missed doses, and major challenges and achievements in continuing routine immunization programs. Data were coded and categorized according to common responses and descriptive analysis was performed. RESULTS Interviews occurred with participants from 11 of 13 P/Ts. School immunization programs were reported to be most negatively affected by the pandemic (n = 9). In the early pandemic period, infant, preschool, and maternal/prenatal programs were prioritized, with most P/Ts continuing these services with adaptations for COVID-19. After the initial lockdown period, all routine programs were continuing with adaptations in most P/Ts. Infant, preschool, and school programs were most often targeted for catch-up through measures such as appointment rebooking and making additional clinics and/or providers available. Major challenges included resource limitations (e.g., staff shortages, PPE shortages, limited infrastructure) (n = 11), public health restrictions (n = 8), and public hesitancy to attend appointments (n = 5). CONCLUSIONS Canadian routine immunization programs faced some disruptions due to the COVID-19 pandemic, particularly the school, adult, and older adult programs. Further research is needed to determine the measurable impact of the pandemic on routine vaccine coverage levels.
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Affiliation(s)
- Hannah Sell
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada; Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Ali Assi
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - S Michelle Driedger
- Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ève Dubé
- Faculty of Social Sciences, Université Laval, Quebec City, Quebec, Canada
| | - Arnaud Gagneur
- Département de pédiatrie, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, Quebec, Canada
| | - Samantha B Meyer
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Joan Robinson
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | | | - Matthew Tunis
- Centre for Immunization and Respiratory Infectious Diseases, Public Health Agency of Canada, Ottawa, Ontario, Canada
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The first eight months of COVID-19 pandemic in three West African countries: leveraging lessons learned from responses to the 2014-2016 Ebola virus disease outbreak. Epidemiol Infect 2021; 149:e258. [PMID: 34493348 PMCID: PMC8712942 DOI: 10.1017/s0950268821002053] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Experience gained from responding to major outbreaks may have influenced the early coronavirus disease-2019 (COVID-19) pandemic response in several countries across Africa. We retrospectively assessed whether Guinea, Liberia and Sierra Leone, the three West African countries at the epicentre of the 2014–2016 Ebola virus disease outbreak, leveraged the lessons learned in responding to COVID-19 following the World Health Organization's (WHO) declaration of a public health emergency of international concern (PHEIC). We found relatively lower incidence rates across the three countries compared to many parts of the globe. Time to case reporting and laboratory confirmation also varied, with Guinea and Liberia reporting significant delays compared to Sierra Leone. Most of the selected readiness measures were instituted before confirmation of the first case and response measures were initiated rapidly after the outbreak confirmation. We conclude that the rapid readiness and response measures instituted by the three countries can be attributed to their lessons learned from the devastating Ebola outbreak, although persistent health systems weaknesses and the unique nature of COVID-19 continue to challenge control efforts.
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21
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Causey K, Fullman N, Sorensen RJD, Galles NC, Zheng P, Aravkin A, Danovaro-Holliday MC, Martinez-Piedra R, Sodha SV, Velandia-González MP, Gacic-Dobo M, Castro E, He J, Schipp M, Deen A, Hay SI, Lim SS, Mosser JF. Estimating global and regional disruptions to routine childhood vaccine coverage during the COVID-19 pandemic in 2020: a modelling study. Lancet 2021; 398:522-534. [PMID: 34273292 PMCID: PMC8285122 DOI: 10.1016/s0140-6736(21)01337-4] [Citation(s) in RCA: 186] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 05/17/2021] [Accepted: 06/08/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND The COVID-19 pandemic and efforts to reduce SARS-CoV-2 transmission substantially affected health services worldwide. To better understand the impact of the pandemic on childhood routine immunisation, we estimated disruptions in vaccine coverage associated with the pandemic in 2020, globally and by Global Burden of Disease (GBD) super-region. METHODS For this analysis we used a two-step hierarchical random spline modelling approach to estimate global and regional disruptions to routine immunisation using administrative data and reports from electronic immunisation systems, with mobility data as a model input. Paired with estimates of vaccine coverage expected in the absence of COVID-19, which were derived from vaccine coverage models from GBD 2020, Release 1 (GBD 2020 R1), we estimated the number of children who missed routinely delivered doses of the third-dose diphtheria-tetanus-pertussis (DTP3) vaccine and first-dose measles-containing vaccine (MCV1) in 2020. FINDINGS Globally, in 2020, estimated vaccine coverage was 76·7% (95% uncertainty interval 74·3-78·6) for DTP3 and 78·9% (74·8-81·9) for MCV1, representing relative reductions of 7·7% (6·0-10·1) for DTP3 and 7·9% (5·2-11·7) for MCV1, compared to expected doses delivered in the absence of the COVID-19 pandemic. From January to December, 2020, we estimated that 30·0 million (27·6-33·1) children missed doses of DTP3 and 27·2 million (23·4-32·5) children missed MCV1 doses. Compared to expected gaps in coverage for eligible children in 2020, these estimates represented an additional 8·5 million (6·5-11·6) children not routinely vaccinated with DTP3 and an additional 8·9 million (5·7-13·7) children not routinely vaccinated with MCV1 attributable to the COVID-19 pandemic. Globally, monthly disruptions were highest in April, 2020, across all GBD super-regions, with 4·6 million (4·0-5·4) children missing doses of DTP3 and 4·4 million (3·7-5·2) children missing doses of MCV1. Every GBD super-region saw reductions in vaccine coverage in March and April, with the most severe annual impacts in north Africa and the Middle East, south Asia, and Latin America and the Caribbean. We estimated the lowest annual reductions in vaccine delivery in sub-Saharan Africa, where disruptions remained minimal throughout the year. For some super-regions, including southeast Asia, east Asia, and Oceania for both DTP3 and MCV1, the high-income super-region for DTP3, and south Asia for MCV1, estimates suggest that monthly doses were delivered at or above expected levels during the second half of 2020. INTERPRETATION Routine immunisation services faced stark challenges in 2020, with the COVID-19 pandemic causing the most widespread and largest global disruption in recent history. Although the latest coverage trajectories point towards recovery in some regions, a combination of lagging catch-up immunisation services, continued SARS-CoV-2 transmission, and persistent gaps in vaccine coverage before the pandemic still left millions of children under-vaccinated or unvaccinated against preventable diseases at the end of 2020, and these gaps are likely to extend throughout 2021. Strengthening routine immunisation data systems and efforts to target resources and outreach will be essential to minimise the risk of vaccine-preventable disease outbreaks, reach children who missed routine vaccine doses during the pandemic, and accelerate progress towards higher and more equitable vaccination coverage over the next decade. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- Kate Causey
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Nancy Fullman
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Reed J D Sorensen
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Natalie C Galles
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Peng Zheng
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Aleksandr Aravkin
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA; Department of Applied Mathematics, University of Washington, Seattle, WA, USA
| | | | - Ramon Martinez-Piedra
- Pan American Health Organization, Comprehensive Family Immunization Unit, Washington, DC, USA
| | - Samir V Sodha
- Department of Immunization, Vaccines and Biologicals, Word Health Organization, Geneva, Switzerland
| | | | - Marta Gacic-Dobo
- Department of Immunization, Vaccines and Biologicals, Word Health Organization, Geneva, Switzerland
| | - Emma Castro
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Jiawei He
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Megan Schipp
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Amanda Deen
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Simon I Hay
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Stephen S Lim
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Jonathan F Mosser
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA; Pediatric Infectious Diseases, Seattle Children's Hospital, Seattle, WA, USA.
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22
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Jain R, Chopra A, Falézan C, Patel M, Dupas P. COVID-19 related immunization disruptions in Rajasthan, India: A retrospective observational study. Vaccine 2021; 39:4343-4350. [PMID: 34154863 PMCID: PMC8196298 DOI: 10.1016/j.vaccine.2021.06.022] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 06/07/2021] [Accepted: 06/09/2021] [Indexed: 02/07/2023]
Abstract
Disruptions during the COVID-19 lockdown caused children to miss immunizations. Government catch-up efforts substantially reversed these effects. Yet, children that were due vaccinations during the lockdown remained 10–15% less likely to be immunized 4–5 months later. Catch-up was more likely to be incomplete among children of low socioeconomic status. Ensuring all children are fully immunized requires careful tracking and disaggregated data.
Introduction Governments around the world suspended immunization outreach to control COVID-19 spread. Many have since resumed services with an emphasis on catch-up vaccinations. This paper evaluated immunization disruptions during India’s March-May 2020 lockdown and the extent to which subsequent catch-up efforts reversed them in Rajasthan, India. Methods In this retrospective observational study, we conducted phone surveys to collect immunization details for 2,144 children that turned one year old between January and October 2020. We used logistic regressions to compare differences in immunization timeliness and completed first-year immunization status among children that were due immunizations just before (unexposed), during (heavily exposed), and after (post-exposure) the lockdown. Results Relative to unexposed children, heavily exposed children were significantly less likely to be immunized at or before 9 months (OR 0.550; 95% CI 0.367–0.824; p = 0.004), but more likely to be immunized at 10–12 months (OR 1.761; 95% CI 1.196–2.591; p = 0.004). They were also less likely to have completed their key first-year immunizations (OR 0.624; 95% CI 0.478–0.816; p = 0.001) by the time of survey. In contrast, post-exposure children showed no difference in timeliness or completed first-year immunizations relative to unexposed children, despite their younger age. First-year immunization coverage among heavily exposed children decreased by 6.9 pp to 10.4 pp (9.7% to 14.0%). Declines in immunization coverage were larger among children in households that were poorer, less educated, lower caste, and residing in COVID red zones, although subgroup comparisons were not statistically significant. Conclusion Disruptions to immunization services resulted in children missing immunization during the lockdown, but catch-up efforts after it was eased ensured many children were reached at later ages. Nevertheless, catch-up was incomplete and children due their immunizations during the lockdown remained less likely to be fully immunized 4–5 months after it lifted, even as younger cohorts due immunizations in June or later returned to pre-lockdown schedules.
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Affiliation(s)
- Radhika Jain
- Stanford University, Stanford, CA 94305-6055, United States.
| | - Ambika Chopra
- The Abdul Latif Jameel Poverty Action Lab (J-PAL) South Asia, Institute for Financial Management and Research, New Delhi, Delhi, India
| | | | - Mustufa Patel
- The Abdul Latif Jameel Poverty Action Lab (J-PAL) South Asia, Institute for Financial Management and Research, New Delhi, Delhi, India
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23
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Lutz CS, Biggerstaff M, Rolfes MA, Lafond KE, Azziz-Baumgartner E, Porter RM, Reed C, Bresee JS. Estimating the number of averted illnesses and deaths as a result of vaccination against an influenza pandemic in nine low- and middle-income countries. Vaccine 2021; 39:4219-4230. [PMID: 34119348 DOI: 10.1016/j.vaccine.2021.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 04/29/2021] [Accepted: 05/03/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND During the 2009 influenza A(H1N1)pdm09 pandemic, 77 countries received donated monovalent A(H1N1)pdm09 vaccine through the WHO Pandemic Influenza A(H1N1) Vaccine Deployment Initiative. However, 47% did not receive their first shipment until after the first wave of virus circulation, and 8% did not receive their first shipment until after the WHO declared the end of the pandemic. Arguably, these shipments were too late into the pandemic to have a substantial effect on virus transmission or disease burden during the first waves of the pandemic. OBJECTIVES In order to evaluate the potential benefits of earlier vaccine availability, we estimated the number of illnesses and deaths that could be averted during a 2009-like influenza pandemic under five different vaccine-availability timing scenarios. METHODS We adapted a model originally developed to estimate annual influenza morbidity and mortality burden averted through US seasonal vaccination and ran it for five vaccine availability timing scenarios in nine low- and middle-income countries that received donated vaccine. RESULTS Among nine study countries, we estimated that the number of averted cases was 61-216,197 for actual vaccine receipt, increasing to 2,914-283,916 had vaccine been available simultaneously with the United States. CONCLUSIONS Earlier delivery of vaccines can reduce influenza case counts during a simulated 2009-like pandemic in some low- and middle-income countries. For others, increasing the number of cases and deaths prevented through vaccination may be dependent on factors other than timely initiation of vaccine administration, such as distribution and administration capacity.
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Affiliation(s)
- Chelsea S Lutz
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Atlanta, GA 30329, United States; Oak Ridge Institute for Science and Education, United States Department of Energy, 100 ORAU Way, Oak Ridge, TN 37830, United States; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, United States.
| | - Matthew Biggerstaff
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Atlanta, GA 30329, United States
| | - Melissa A Rolfes
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Atlanta, GA 30329, United States
| | - Kathryn E Lafond
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Atlanta, GA 30329, United States
| | - Eduardo Azziz-Baumgartner
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Atlanta, GA 30329, United States
| | - Rachael M Porter
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Atlanta, GA 30329, United States
| | - Carrie Reed
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Atlanta, GA 30329, United States
| | - Joseph S Bresee
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Atlanta, GA 30329, United States
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24
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Piché-Renaud PP, Ji C, Farrar DS, Friedman JN, Science M, Kitai I, Burey S, Feldman M, Morris SK. Impact of the COVID-19 pandemic on the provision of routine childhood immunizations in Ontario, Canada. Vaccine 2021; 39:4373-4382. [PMID: 34108076 DOI: 10.1016/j.vaccine.2021.05.094] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 05/26/2021] [Accepted: 05/28/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND The COVID-19 pandemic has a worldwide impact on all health services, including childhood immunizations. In Canada, there is limited data to quantify and characterize this issue. METHODS We conducted a descriptive, cross-sectional study by distributing online surveys to physicians across Ontario. The survey included three sections: provider characteristics, impact of COVID-19 on professional practice, and impact of COVID-19 on routine childhood immunization services. Multivariable logistic regression identified factors associated with modification of immunization services. RESULTS A total of 475 respondents answered the survey from May 27th to July 3rd 2020, including 189 family physicians and 286 pediatricians. The median proportion of in-person visits reported by physicians before the pandemic was 99% and dropped to 18% during the first wave of the pandemic in Ontario. In total, 175 (44.6%) of the 392 respondents who usually provide vaccination to children acknowledged a negative impact caused by the pandemic on their immunization services, ranging from temporary closure of their practice (n = 18; 4.6%) to postponement of vaccines in certain age groups (n = 103; 26.3%). Pediatricians were more likely to experience a negative impact on their immunization services compared to family physicians (adjusted odds ratio [aOR] = 2.64, 95% CI: 1.48-4.68), as well as early career physicians compared to their more senior colleagues (aOR = 2.69, 95% CI: 1.30-5.56), whereas physicians from suburban settings were less impacted than physicians from urban settings (aOR = 0.62, 95% CI: 0.39-0.99). Some of the proposed solutions to decreased immunization services included assistance in accessing personal protective equipment, dedicated centers or practices for vaccination, universal centralized electronic immunization records and education campaigns for parents. CONCLUSIONS COVID-19 has caused substantial modifications to pediatric immunization services across Ontario. Strategies to mitigate barriers to immunizations during the pandemic need to be implemented in order to avoid immunity gaps that could lead to an eventual increase in vaccine preventable diseases.
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Affiliation(s)
| | - Catherine Ji
- Toronto Western Family Health Team, University Health Network, Canada; Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Canada
| | - Daniel S Farrar
- Centre for Global Child Health, The Hospital for Sick Children, Canada
| | - Jeremy N Friedman
- Division of Pediatric Medicine, The Hospital for Sick Children, Canada; Department of Pediatrics, Faculty of Medicine, University of Toronto, Canada
| | - Michelle Science
- Division of Infectious Diseases, The Hospital for Sick Children, Canada; Department of Pediatrics, Faculty of Medicine, University of Toronto, Canada
| | - Ian Kitai
- Division of Infectious Diseases, The Hospital for Sick Children, Canada; Department of Pediatrics, Faculty of Medicine, University of Toronto, Canada
| | - Sharon Burey
- Pediatricians Alliance of Ontario, Canada; Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, Canada
| | - Mark Feldman
- Division of Pediatric Medicine, The Hospital for Sick Children, Canada; Department of Pediatrics, Faculty of Medicine, University of Toronto, Canada
| | - Shaun K Morris
- Division of Infectious Diseases, The Hospital for Sick Children, Canada; Centre for Global Child Health, The Hospital for Sick Children, Canada; Department of Pediatrics, Faculty of Medicine, University of Toronto, Canada; Division of Clinical Public Health and Centre for Vaccine Preventable Diseases, Dalla Lana School of Public Health, Canada.
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25
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Nuzhath T, Ajayi KV, Fan Q, Hotez P, Colwell B, Callaghan T, Regan AK. Childhood immunization during the COVID-19 pandemic in Texas. Vaccine 2021; 39:3333-3337. [PMID: 34020814 PMCID: PMC8078904 DOI: 10.1016/j.vaccine.2021.04.050] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 04/09/2021] [Accepted: 04/23/2021] [Indexed: 12/02/2022]
Abstract
In 2020, the state of Texas implemented coronavirus disease 2019 (COVID-19) social distancing guidelines in order to prevent surges at Texas hospital emergency rooms and in intensive care units. As noted in other states, an unintended consequence of these activities was significant declines in childhood immunizations. After analyzing state-wide immunization register data for Texas, we observed a 47% relative decline in immunization rates between 2019 and 2020 among 5-month-olds and a 58% decline among 16-month-olds. We observed a small decline (5%) among 24-month-olds, and no decline in vaccines received at birth (Hepatitis B). Declines were larger in rural counties compared to urban. These declines are superimposed on increases in state vaccine exemptions over the last five years due to an aggressive anti-vaccine movement in Texas. There are concerns that continued declines in childhood immunization coverage due to COVID-19 could lead to co-endemics of measles and other vaccine preventable diseases.
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Affiliation(s)
- Tasmiah Nuzhath
- Texas A&M School of Public Health, College Station, TX, USA; Hagler Institute for Advanced Study at Texas A&M University, College Station, TX, USA
| | - Kobi V Ajayi
- Department of Health and Kinesiology, Texas A&M University, College Station, TX, USA; Laboratory for Community Health Evaluation and Systems Science (CHESS), Texas A&M University, College Station, TX, USA
| | - Qiping Fan
- Texas A&M School of Public Health, College Station, TX, USA
| | - Peter Hotez
- Hagler Institute for Advanced Study at Texas A&M University, College Station, TX, USA; Texas Children's Hospital Center for Vaccine Development and Center for Medical Ethics and Health Policy, Departments of Pediatrics and Molecular Virology & Microbiology, National School of Tropical Medicine, Baylor College of Medicine, Houston, TX, USA; Scowcroft Institute of International Affairs, Bush School of Policy and Government, Texas A&M University, College Station, TX, USA; Department of Biology, Baylor University, Waco, TX, USA; James A Baker III Institute of Public Policy, Rice University Houston, TX, USA
| | - Brian Colwell
- Texas A&M School of Public Health, College Station, TX, USA
| | | | - Annette K Regan
- Texas A&M School of Public Health, College Station, TX, USA; School of Nursing and Health Professions, University of San Francisco, San Francisco, CA, USA; UCLA Fielding School of Public Health, Los Angeles, CA, USA.
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26
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Mansour Z, Arab J, Said R, Rady A, Hamadeh R, Gerbaka B, Bizri AR. Impact of COVID-19 pandemic on the utilization of routine immunization services in Lebanon. PLoS One 2021; 16:e0246951. [PMID: 33596271 PMCID: PMC7888608 DOI: 10.1371/journal.pone.0246951] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 01/28/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction The global abrupt progression of the COVID-19 pandemic may disrupt critical life-saving services such as routine immunization (RI), thus increasing the susceptibility of countries to outbreaks of vaccine-preventable diseases (VPDs). Being endemic to several infectious diseases, Lebanon might be at increased risk of outbreaks as the utilization of RI services might have deteriorated due to the pandemic and the country’s political unrest following the October 2019 uprising. The aim of this study was to assess the changes in the utilization of RI services in both the public and private sectors following the COVID-19 pandemic. Methods A self-administered cross-sectional survey was completed electronically, in April 2020, by 345 private pediatricians who are registered in professional associations of physicians in Lebanon and provide immunization services at their clinics. Means of the reported percentages of decrease in the utilization of vaccination services by pediatricians were calculated. As for the public sector, an examination of the monthly differences in the number of administered vaccine doses in addition to their respective percentages of change was performed. Adjustment for the distribution of RI services between the sectors was performed to calculate the national decrease rate. Results The utilization of vaccination services at the national level decreased by 31%. In the private sector, immunization services provision diminished by 46.9% mainly between February and April 2020. The highest decrease rates were observed for oral poliovirus vaccine (OPV) and hepatitis A, followed by measles and pneumococcal conjugate vaccines. The number of vaccine doses administered in the public sector decreased by 20%. The most prominent reductions were detected for the OPV and measles vaccines, and during October 2019 and March 2020. Conclusion The substantial decrease in the utilization of RI as a result of the COVID-19 pandemic requires public health interventions to prevent future outbreaks of VPDs.
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Affiliation(s)
- Ziad Mansour
- Connecting Research to Development, Beirut, Lebanon
| | - Jinan Arab
- Connecting Research to Development, Beirut, Lebanon
- * E-mail:
| | - Racha Said
- Connecting Research to Development, Beirut, Lebanon
| | - Alissar Rady
- World Health Organization Lebanon Country Office, Beirut, Lebanon
| | | | - Bernard Gerbaka
- Division of Pediatric Intensive Care Unit and Pediatric Emergencies, Department of Pediatrics, Hôtel-Dieu de France, Beirut, Lebanon
| | - Abdul Rahman Bizri
- Division of Infectious Diseases, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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27
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Al-Kuwari MG, Abdulmalik MA, Al-Mudahka HR, Bakri AH, Al-Baker WA, Abushaikha SS, Kandy MC, Gibb J. The impact of COVID-19 pandemic on the preventive services in Qatar. J Public Health Res 2021; 10:1910. [PMID: 33575226 PMCID: PMC7868775 DOI: 10.4081/jphr.2021.1910] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 12/20/2020] [Indexed: 02/08/2023] Open
Abstract
Background: In March 2020, Qatar started reporting increased numbers of COVID-19 cases. At that stage, containment measures were put in place. The health authority in Qatar developed an emergency action plan to respond to the outbreak with the Primary Health Care as the main component of that response and suspended all non-urgent services including preventive health services. The aim of the retrospective analysis to measure the Impact of COVID-19 on the preventive services provided in Qatar. Methods: A retrospective data analysis was conducted for all the preventive services utilization volume across the 27 PHCC health centres from the 1st of January 2017 to the 31st of July 2020. Results: With 17,012 no-show appointments, well-baby and Immunization services utilization demonstrated a reduction of 40% in May and started to come back to volumes higher than expected in June. The breast cancer and colorectal cancer screening programmes expected volumes demand has dropped by 100% in comparison to 2017 demand due to their respective appointments’ cancelation. Wellness services only met 20% of its projected utilization in April, however, the services picked up in June. Conclusion: These findings will guide the public health policymakers to understand the effects COVID-19 on preventive services and the risk of having an increased number of outbreaks for childhood communicable disease, cancer cases with delayed diagnosis due to the screening services suspension. In addition, the plan will address the increased number of sedately behaviour due to the service’s reduced utilization of wellness services. Significance for public health The impact of the utilization of the preventive health services such as immunization, screening, and lifestyle modification was heavy due to the containment measures. The high number of immunization defaulters and individuals missed the screening needs the attention of the public health specialist to put urgent recovery plan.
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Affiliation(s)
| | | | | | - Ahmad Haj Bakri
- Health intelligence, Primary Health Care Corporation, Doha, Qatar
| | | | | | | | - John Gibb
- Health intelligence, Primary Health Care Corporation, Doha, Qatar
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28
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Immunization During the COVID-19 Pandemic: Recommendations From Indian Academy of Pediatrics Advisory Committee on Vaccines and Immunization Practices. Indian Pediatr 2021. [PMID: 33318323 PMCID: PMC7781827 DOI: 10.1007/s13312-020-2071-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
During the severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) pandemic, immunization practices of all age groups, especially routine childhood vaccines, have been interrupted. Immunization is considered an essential health activity, which needs to be resumed as early as possible. This pandemic has created several unique issues related to routine immunization of individual children at clinics, which needs to be addressed. In this communication, the Advisory Committee on Vaccines and Immunization Practices (ACVIP) of Indian Academy of Pediatrics addresses the common questions and issues related to SARS-CoV-2 and routine immunization services. This also includes the recommendations for routine immunization of SARS-CoV-2 suspect and positive children, and for the logistics to be followed for immunization services.
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29
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Kasi SG, Dhir SK, Verma S, Pemde HK, Balasubramanian S, Agarwalla S, Shah AK, Shivananda S, Marathe S, Chatarjee K, Srirampur S, Kalyani S, Parekh BJ, Basavaraja GV, Gupta P. Immunization During the COVID-19 Pandemic: Recommendations From Indian Academy of Pediatrics Advisory Committee on Vaccines and Immunization Practices. Indian Pediatr 2020; 57:1147-1152. [PMID: 33318323 PMCID: PMC7781827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
During the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, immunization practices of all age groups, especially routine childhood vaccines, have been interrupted. Immunization is considered an essential health activity, which needs to be resumed as early as possible. This pandemic has created several unique issues related to routine immunization of individual children at clinics, which needs to be addressed. In this communication, the Advisory Committee on Vaccines and Immunization Practices (ACVIP) of Indian Academy of Pediatrics addresses the common questions and issues related to SARS-CoV-2 and routine immunization services. This also includes the recommendations for routine immunization of SARS-CoV-2 suspect and positive children, and for the logistics to be followed for immunization services.
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Affiliation(s)
- Srinivas G Kasi
- Kasi Clinic, Bengaluru, Karnataka, India. Correspondence to: Dr Srinivas G Kasi, Convener, ACVIP of IAP, Kasi Clinic, 2nd Cross, 3rd Block, Jayanagar, Bengaluru, Karnataka, India.
| | - Shashi Kant Dhir
- Department of Pediatrics, Guru Gobind Singh Medical College, Faridkot, Punjab, India
| | - Sanjay Verma
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - S Balasubramanian
- Department of Pediatrics, Kanchi Kamakoti Childs Trust Hospital, Chennai, Tamil Nadu, India
| | | | - Abhay K Shah
- Dr Abhay K Shah Children Hospital, Ahmedabad, Gujarat, India
| | | | | | | | | | | | | | | | - Piyush Gupta
- University College of Medical Sciences, New Delhi, India
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30
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Ogundele OA, Omotoso AA, Fagbemi AT. COVID-19 outbreak: a potential threat to routine vaccination programme activities in Nigeria. Hum Vaccin Immunother 2020; 17:661-663. [PMID: 32991237 DOI: 10.1080/21645515.2020.1815490] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
COVID-19 is an infectious disease caused by the most recently discovered coronavirus (SARS-CoV-2). The virus and disease were unknown before the outbreak began in the city of Wuhan, China, in December 2019. Nigeria and other sub-Sahara Africa countries like the rest of the world introduced several lockdown measures as part of their public health response to mitigate the spread of the virus. This, however, was not without the likelihood of consequences considering the weak health systems. The access and supply side of vaccination was more likely to have been affected by the lockdown measures. When vaccination services are disrupted even for brief periods during emergencies, the risk of outbreak-prone vaccine-preventable diseases increases, leading to excess morbidity and mortality. This highlights the importance of maintaining essential services such as vaccination in times of emergency. There is therefore an urgent need to ensure that children are protected against those diseases for which vaccines already exist. The COVID-19 outbreak has posed a new hindrance to vaccination activities in Nigeria and across Sub-Saharan Africa with associated threat to surveillance of vaccine-preventable diseases. Achieving and sustaining high levels of vaccination coverage during this period must, therefore, be a priority for all health systems.
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31
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Saso A, Skirrow H, Kampmann B. Impact of COVID-19 on Immunization Services for Maternal and Infant Vaccines: Results of a Survey Conducted by Imprint-The Immunising Pregnant Women and Infants Network. Vaccines (Basel) 2020; 8:E556. [PMID: 32972015 PMCID: PMC7563512 DOI: 10.3390/vaccines8030556] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/06/2020] [Accepted: 09/15/2020] [Indexed: 12/14/2022] Open
Abstract
The COVID-19 pandemic response has caused disruption to healthcare services globally, including to routine immunizations. To understand immunization service interruptions specifically for maternal, neonatal and infant vaccines, we captured the local experiences of members of the Immunising Pregnant Women and Infants Network (IMPRINT) by conducting an online survey over 2-weeks in April 2020. IMPRINT is a global network of clinicians and scientists working in maternal and neonatal vaccinology. The survey included discrete questions to quantify the extent of disruption as well as free-text options to explore the reasons behind reported disruptions. Of the 48 responses received, the majority (75%) were from low-and-middle-income countries (LMICs). Of all respondents, 50% or more reported issues with vaccine delivery within their country. Thematic analysis identified three key themes behind immunization disruption: "access" issues, e.g., logistical barriers, "provider" issues, e.g., staff shortages and user "concern" about attending immunization appointments due to COVID-19 fear. Access and provider issues were more commonly reported by LMIC respondents. Overall, respondents reported uncertainty among parents and healthcare providers regarding routine immunization. We conclude that further quantification of routine vaccination disruption is needed, alongside health service prioritization, logistical support and targeted communication strategies to reinforce routine immunizations during the COVID-19 response.
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Affiliation(s)
- Anja Saso
- The Vaccine Centre, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London WC1 7HT, UK;
- Vaccines and Immunity Theme, MRC Unit the Gambia at LSHTM, Banjul P.O. Box 273, Gambia
| | - Helen Skirrow
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London W6 8RP, UK;
| | - Beate Kampmann
- The Vaccine Centre, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London WC1 7HT, UK;
- Vaccines and Immunity Theme, MRC Unit the Gambia at LSHTM, Banjul P.O. Box 273, Gambia
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32
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Adamu AA, Jalo RI, Habonimana D, Wiysonge CS. COVID-19 and routine childhood immunization in Africa: Leveraging systems thinking and implementation science to improve immunization system performance. Int J Infect Dis 2020; 98:161-165. [PMID: 32592908 PMCID: PMC7313512 DOI: 10.1016/j.ijid.2020.06.072] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/18/2020] [Accepted: 06/20/2020] [Indexed: 12/11/2022] Open
Abstract
One of the routine health services that is being disrupted by coronavirus disease 2019 (COVID-19) in Africa is childhood immunization. This is because the immunization system relies on functioning health facilities and stable communities to be effective. Its disruption increases the risk of epidemics of vaccine-preventable diseases, which could increase child mortality. Therefore, policymakers must quickly identify robust and context-specific strategies to rapidly scale-up routine immunization in order to mitigate the impact of COVID-19 on their national immunization performance. To achieve this, we propose a paradigm shift towards systems thinking and use of implementation science in immunization decision-making. Systems thinking can inform a more nuanced and holistic understanding of the interrelationship between COVID-19, its control strategies, and childhood immunization. Tools like causal loop diagrams can be used to explicitly illustrate the systems structure by identifying feedback loops. Once mapped and leverage points for interventions have been identified, implementation science can be used to guide the rapid uptake and utilization of multifaceted evidence-based innovations in complex practice settings. As Africa re-strategizes for the post-2020 era, these emerging fields could contribute significantly in accelerating progress towards universal access to vaccines for all children on the continent despite COVID-19.
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Affiliation(s)
- Abdu A Adamu
- Cochrane South Africa, South African Medical Research Council, Francie Van Zijl Drive, Parrowvallei, Tygerberg, 7505, Cape Town, South Africa; Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie Van Zijl Drive, Parrowvallei, Tygerberg, 7505, Cape Town, South Africa.
| | - Rabiu I Jalo
- Department of Community Medicine, Bayero University/Aminu Kano Teaching Hospital, Zaria Road, Kano State, Nigeria
| | - Desire Habonimana
- Research and Innovation Unit, Department of Community Medicine, Faculty of Medicine, University of Burundi, Bujumbura, Burundi
| | - Charles S Wiysonge
- Cochrane South Africa, South African Medical Research Council, Francie Van Zijl Drive, Parrowvallei, Tygerberg, 7505, Cape Town, South Africa; Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie Van Zijl Drive, Parrowvallei, Tygerberg, 7505, Cape Town, South Africa; School of Public Health and Family Medicine, University of Cape Town, Observatory, 7925, Cape Town, South Africa
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33
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Affiliation(s)
- Sonia Saxena
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Helen Skirrow
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Helen Bedford
- UCL Great Ormond Street Institute of Child Health, London, UK
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Duonamou L, Konate A, Djègo Djossou S, Mensah GA, Xu J, Humle T. Consumer perceptions and reported wild and domestic meat and fish consumption behavior during the Ebola epidemic in Guinea, West Africa. PeerJ 2020; 8:e9229. [PMID: 32566394 PMCID: PMC7293194 DOI: 10.7717/peerj.9229] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 04/30/2020] [Indexed: 11/20/2022] Open
Abstract
The handling, capturing, butchering, and transportation of wildmeat can increase the risk of zoonoses, including the Ebola virus disease (EVD). Guinea, West Africa, experienced a catastrophic outbreak of EVD between 2013 and 2016. This study aimed to understand local people's sources of information concerning EVD, their perceptions of potential wildlife carriers of EVD and their meat and fish consumption behavior during this period. A semi-structured questionnaire was administered to 332 participants in two urban centers (N = 209) and three villages (N = 123) between January 3 and March 30, 2015 in the prefecture of Lola in southeastern Guinea. Chi-square analyses revealed that, in rural areas, awareness missions represented the main source of information about EVD (94.3%), whereas in urban settings such missions (36.1%), as well as newspapers (31.6%) and radio (32.3%) were equally mentioned. Bats (30.1% and 79.4%), chimpanzees (16.3% and 48.8%) and monkeys (13.0% and 53.1%) were the most commonly cited potential agents of EVD in both rural and urban areas respectively, while the warthog (2.3% rural and 6.5% urban), crested porcupine (1.7% rural and 10.7% urban), duiker (1.19% rural and 2.6% urban) and the greater cane rat (1.1% rural and 9.5% urban) were also cited but to a lesser extent. However, 66.7% of rural respondents compared to only 17.2% in the urban area did not consider any of these species as potential carriers of the Ebola virus. Nonetheless, a fifth of our respondents reported not consuming any of these species altogether during the EVD outbreak. Among all seven faunal groups mentioned, a significant reduction in reported consumption during the Ebola outbreak was only noted for bats (before: 78.3% and during: 31.9%) and chimpanzees (before: 31.6% and during: 13.5%). Automatic Chi-Square Interaction Detection (CHAID) analysis revealed that the belief that bats or chimpanzees were associated with EVD or not had a significant effect respectively on their non-consumption or continued consumption. However, only 3.9% of respondents reported shifting to alternative protein sources such as domestic meat or fish specifically to avoid EVD. Only 10.8% reported consuming more domestic meat during the EVD outbreak compared with before; affordability and availability were the main reported reasons for why people did not consume more domestic meat and why two thirds reported consuming more fish. While increased domestic meat consumption was linked to the belief that duikers, the most commonly consumed wildmeat before the epidemic, were associated with EVD, increased fish consumption was not predicted by any EVD related factors. Our study revealed deep-rooted false beliefs among rural respondents and constraints when it comes to access to alternative protein sources such as domestic meat. Our findings emphasize the urgent need for greater consideration of the relationship between socio-economic context, food security, and public health.
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Affiliation(s)
- Lucie Duonamou
- School of Ecology and Nature Conservation, Beijing Forestry University, Beijing, China
- Applied Ecology Laboratory, Faculty of Agronomic Sciences, University of Abomey-Calavi, Benin
| | - Alexandre Konate
- Department of Agroforestry, Institute Superior of Agronomy and Veterinary of Faranah (ISAV/F), Faranah, Guinea
| | - Sylvie Djègo Djossou
- Applied Ecology Laboratory, Faculty of Agronomic Sciences, University of Abomey-Calavi, Benin
- Department of Zoology/Primates Conservation Biology, Faculty of Science and Technology, University of Abomey-Calavi, Abomey-Calavi, Benin
| | - Guy Apollinaire Mensah
- Agricultural Research Center of Agonkanmey, National Institute of Agronomic Research (INRAB), Abomey-Calavi, Benin
| | - Jiliang Xu
- School of Ecology and Nature Conservation, Beijing Forestry University, Beijing, China
| | - Tatyana Humle
- Durrell Institute of Conservation and Ecology, School of Anthropology and Conservation, University of Kent, Canterbury, United Kingdom
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35
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Linton NM, Keita M, Moitinho de Almeida M, Gil Cuesta J, Guha-Sapir D, Nishiura H, van Loenhout JAF. Impact of mass vaccination campaigns on measles transmission during an outbreak in Guinea, 2017. J Infect 2020; 80:326-332. [PMID: 31958541 DOI: 10.1016/j.jinf.2019.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 11/20/2019] [Accepted: 11/21/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To estimate the time-dependent measles effective reproduction number (Rt) as an indicator of the impact of three outbreak response vaccination (ORV) campaigns on measles transmission during a nationwide outbreak in Guinea. METHODS Rt represents the average number of secondary cases generated by a single primary case in a partially immune population during a given time period. Measles Rt was estimated using daily incidence data for 3952 outbreak-associated measles cases in Guinea in 2017 for the time periods prior to, between, and following each of three ORV campaigns using a simple and extensible mathematical model. RESULTS Rt was estimated to be above the threshold value of 1 during the initial growth period of the outbreak until the first ORV campaign began on March 13 (Rt = 1.60, 95% CI: 1.55-1.67). It subsequently dropped below 1 and remained <1 through the end of the year (range: 0.71-0.91), although low levels of transmission persisted. CONCLUSIONS Reduction in Rt coincided with implementation of the ORV campaigns, indicating success of the campaigns at maintaining measles transmission intensity below epidemic growth levels. However, persistent measles transmission remains an issue in Guinea due to insufficient levels of herd immunity. Estimation of Rt should be further leveraged to help decision makers and field staff understand outbreak progress and the timing and type of vaccination efforts needed to halt transmission.
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Affiliation(s)
- Natalie Marie Linton
- Centre for Research on the Epidemiology of Disasters, Institute of Health and Society, Catholic University of Louvain, Brussels, Belgium; Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Mory Keita
- World Health Organization Country Office, Conakry, Guinea
| | - Maria Moitinho de Almeida
- Centre for Research on the Epidemiology of Disasters, Institute of Health and Society, Catholic University of Louvain, Brussels, Belgium
| | - Julita Gil Cuesta
- Luxembourg Operational Research Unit, Operational Centre Brussels, Médecins Sans Frontières, Brussels, Belgium
| | - Debarati Guha-Sapir
- Centre for Research on the Epidemiology of Disasters, Institute of Health and Society, Catholic University of Louvain, Brussels, Belgium
| | - Hiroshi Nishiura
- Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Joris Adriaan Frank van Loenhout
- Centre for Research on the Epidemiology of Disasters, Institute of Health and Society, Catholic University of Louvain, Brussels, Belgium.
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36
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Masresha BG, Luce R, Weldegebriel G, Katsande R, Gasasira A, Mihigo R. The impact of a prolonged ebola outbreak on measles elimination activities in Guinea, Liberia and Sierra Leone, 2014-2015. Pan Afr Med J 2020; 35:8. [PMID: 32373259 PMCID: PMC7196330 DOI: 10.11604/pamj.supp.2020.35.1.19059] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 01/05/2020] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Guinea, Sierra Leone and Liberia have attained significant reduction in measles incidence between 2004 and 2013. The Ebola outbreak in 2014-2015 in West Africa caused significant disruption of the health service delivery in the three worst affected countries. The magnitude of the impact on the immunization program has not been well documented. METHODS We reviewed national routine immunization administrative coverage data as well as measles surveillance performance and measles epidemiology in the years before, during and after the EVD outbreak in Guinea, Liberia, Sierra Leone. RESULTS Both Liberia and Guinea experienced a sharp decline of more than 25% in the monthly number of children vaccinated against measles in 2014 and 2015 as compared to the previous years, while there was no reported decline in Sierra Leone. Guinea and Liberia experienced a decline in measles surveillance activity and performance indicators in 2014 and 2015. During this period, there was an increase in measles incidence and a decline in the mean age of measles cases reported in Liberia and Sierra Leone. Guinea started reporting high measles incidence in 2016. All three countries organized measles supplemental immunization activities by June 2015. Liberia achieved 99% administrative coverage, while Guinea and Sierra Leone attained 90.6% and 97.2% coverage respectively. There were no severe adverse events reported during these mass vaccination activities. The disruptive effect of the Ebola outbreak on immunization services was especially evident in Guinea and Liberia. Our review of the reported administrative vaccination coverage at national level does not show significant decline in measles first dose vaccination coverage in Sierra Leone as compared to other reports. This may be due to inaccuracies in coverage monitoring and data quality problems. The increases in measles transmission and incidence in these three countries can be explained by the rapid accumulation of susceptible children. Despite the organization of mass vaccination activities, measles incidence through 2017 has remained higher than the pre-Ebola period in all three countries. CONCLUSION The Ebola outbreak in West Africa significantly affected measles vaccination coverage rates in two of the three worst affected countries, and led to persistent gaps in coverage, along with high measles incidence that was documented until two years after the end of the Ebola outbreak. Liberia and Sierra Leone have demonstrated coverage improvements after the end of the Ebola outbreak.
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Affiliation(s)
| | - Richard Luce
- WHO, Inter-country team for Western Africa, Ouagadougou, Burkina Faso
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37
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Wilhelm JA, Helleringer S. Utilization of non-Ebola health care services during Ebola outbreaks: a systematic review and meta-analysis. J Glob Health 2019; 9:010406. [PMID: 30701070 PMCID: PMC6344071 DOI: 10.7189/jogh.09.010406] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background Beyond their direct effects on mortality, outbreaks of Ebola Virus Disease (EVD) might disrupt the provision of health care services in affected countries, possibly resulting in an increase in the number of deaths from non-EVD causes. We conducted a systematic review and meta-analysis of studies documenting the impact of EVD outbreaks on health care utilization. Methods We searched PubMed, Embase, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Global Health, Pascal and grey literature to identify observational studies that compared indicators of health care utilization before and during the outbreak. We identified 14 752 unique citations, 22 of which met inclusion criteria. All were related to the 2013-2016 West African EVD outbreak. From the 22 studies, we extracted 235 estimates of the relative change in health care utilization during the EVD outbreak. We used multivariate regression to estimate the average effect of the outbreak on health care utilization, and to assess heterogeneity across study characteristics. Findings On average, health care utilization declined by 18.0% during the outbreak (95% Confidence Interval: -26.5%, -9.5%). The observed declines in health care utilization were largest in settings affected by higher levels of EVD incidence (>2.5 cases per 100 000 per week) whereas utilization did not change in settings with EVD incidence less than 0.5 cases per 100 000 per week. Declines in utilization were greater for inpatient care and for deliveries than for outpatient care. They were also larger in studies based on small samples of health facilities, suggestive of publication bias. However, several studies based on larger samples of facilities also observed declines in health care utilization. Conclusions During the West African EVD outbreak, the utilization of health services declined significantly. During outbreaks of EVD, attention needs to be paid to the disruption of the health services, which can have large indirect health impacts.
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Affiliation(s)
- Jess Alan Wilhelm
- Johns Hopkins University, Bloomberg School of Public Health, Department of International Health, Baltimore, Maryland, USA
| | - Stéphane Helleringer
- Johns Hopkins University, Bloomberg School of Public Health, Deptartment of Population, Family, and Reproductive Health, Baltimore, Maryland, USA
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38
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Hennessee I, Guilavogui T, Camara A, Halsey ES, Marston B, McFarland D, Freeman M, Plucinski MM. Adherence to Ebola-specific malaria case management guidelines at health facilities in Guinea during the West African Ebola epidemic. Malar J 2018; 17:230. [PMID: 29898719 PMCID: PMC6000938 DOI: 10.1186/s12936-018-2377-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 06/05/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malaria case management in the context of the 2014-2016 West African Ebola virus disease (EVD) epidemic was complicated by a similar initial clinical presentation of the two diseases. In September 2014, the World Health Organization (WHO) released recommendations titled, "Guidance on temporary malaria control measures in Ebola-affected countries", which aimed at reducing the risk of EVD transmission and improving malaria outcomes. This guidance recommended malaria diagnostic testing of fever cases only if adequate personal protective equipment (PPE) was available, defined as examination gloves, face shield, disposable gown, boots, and head cover; otherwise presumptive anti-malarial treatment was recommended. The extent to which health workers adhered to these guidelines in affected countries has not been assessed. METHODS A cross-sectional survey was conducted in 118 health units in Guinea in November 2014 to produce a representative and probabilistic sample of health facilities and patients. Adherence to the EVD-specific malaria case management guidelines during the height of the EVD epidemic was assessed. Associations between case management practices and possible determinants were calculated using multivariate logistic regression, controlling for expected confounders and the complex sample design. RESULTS Most (78%) facilities reported availability of examination gloves, but adequate PPE was available at only 27% of facilities. Only 28% of febrile patients received correct malaria case management per the WHO temporary malaria case management guidelines. The most common error was diagnostic testing in the absence of adequate PPE (45% of febrile patients), followed by no presumptive treatment in the absence of adequate PPE (14%). Having had a report of an EVD case at a health facility and health worker-reported participation in EVD-specific malaria trainings were associated with lower odds of diagnostic testing and higher odds of presumptive treatment. CONCLUSIONS Adherence to guidance on malaria case management in EVD-affected countries was low at the height of the EVD epidemic in Guinea, and there was substantial malaria diagnostic testing in the absence of adequate PPE, which could have contributed to increased EVD transmission in the healthcare setting. Conversely, low presumptive treatment when diagnostic tests were not performed may have led to additional morbidity and mortality among malaria positive patients. National malaria control programs may consider preparing contingency plans for future implementation of temporary changes to malaria case management guidelines to facilitate uptake by health workers. Additional training on standard and transmission-based precautions should help health workers understand how to protect themselves in the face of emerging and unknown pathogens.
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Affiliation(s)
- Ian Hennessee
- Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, 1600 Clifton Rd, MS A-04, Atlanta, GA, 30306, USA.
- Rollins School of Public Health, Emory University, Atlanta, GA, USA.
| | | | | | - Eric S Halsey
- Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, 1600 Clifton Rd, MS A-04, Atlanta, GA, 30306, USA
- U.S. President's Malaria Initiative, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Barbara Marston
- Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, 1600 Clifton Rd, MS A-04, Atlanta, GA, 30306, USA
| | | | - Matthew Freeman
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Mateusz M Plucinski
- Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, 1600 Clifton Rd, MS A-04, Atlanta, GA, 30306, USA
- U.S. President's Malaria Initiative, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Graham M, Suk JE, Takahashi S, Metcalf CJ, Jimenez AP, Prikazsky V, Ferrari MJ, Lessler J. Challenges and Opportunities in Disease Forecasting in Outbreak Settings: A Case Study of Measles in Lola Prefecture, Guinea. Am J Trop Med Hyg 2018. [PMID: 29532773 PMCID: PMC5953353 DOI: 10.4269/ajtmh.17-0218] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
We report on and evaluate the process and findings of a real-time modeling exercise in response to an outbreak of measles in Lola prefecture, Guinea, in early 2015 in the wake of the Ebola crisis. Multiple statistical methods for the estimation of the size of the susceptible (i.e., unvaccinated) population were applied to weekly reported measles case data on seven subprefectures throughout Lola. Stochastic compartmental models were used to project future measles incidence in each subprefecture in both an initial and a follow-up iteration of forecasting. Measles susceptibility among 1- to 5-year-olds was estimated to be between 24% and 43% at the beginning of the outbreak. Based on this high baseline susceptibility, initial projections forecasted a large outbreak occurring over approximately 10 weeks and infecting 40 children per 1,000. Subsequent forecasts based on updated data mitigated this initial projection, but still predicted a significant outbreak. A catch-up vaccination campaign took place at the same time as this second forecast and measles cases quickly receded. Of note, case reports used to fit models changed significantly between forecast rounds. Model-based projections of both current population risk and future incidence can help in setting priorities and planning during an outbreak response. A swiftly changing situation on the ground, coupled with data uncertainties and the need to adjust standard analytical approaches to deal with sparse data, presents significant challenges. Appropriate presentation of results as planning scenarios, as well as presentations of uncertainty and two-way communication, is essential to the effective use of modeling studies in outbreak response.
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Affiliation(s)
- Matthew Graham
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jonathan E Suk
- World Health Organization, Geneva, Switzerland.,European Centre for Disease Prevention and Control, Solna, Sweden
| | - Saki Takahashi
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, New Jersey
| | - C Jessica Metcalf
- Woodrow Wilson School, Princeton University, Princeton, New Jersey.,Department of Ecology and Evolutionary Biology, Princeton University, Princeton, New Jersey
| | - A Paez Jimenez
- World Health Organization, Geneva, Switzerland.,European Centre for Disease Prevention and Control, Solna, Sweden
| | - Vladimir Prikazsky
- World Health Organization, Geneva, Switzerland.,European Centre for Disease Prevention and Control, Solna, Sweden
| | - Matthew J Ferrari
- Department of Statistics, Pennsylvania State University, University Park, Pennsylvania.,Department of Biology, Center for Infectious Disease Dynamics, Pennsylvania State University, University Park, Pennsylvania
| | - Justin Lessler
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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40
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Colavita F, Biava M, Castilletti C, Quartu S, Vairo F, Caglioti C, Agrati C, Lalle E, Bordi L, Lanini S, Guanti MD, Miccio R, Ippolito G, Capobianchi MR, Di Caro A. Measles Cases during Ebola Outbreak, West Africa, 2013-2106. Emerg Infect Dis 2018; 23:1035-1037. [PMID: 28518027 PMCID: PMC5443435 DOI: 10.3201/eid2306.161682] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The recent Ebola outbreak in West Africa caused breakdowns in public health systems, which might have caused outbreaks of vaccine-preventable diseases. We tested 80 patients admitted to an Ebola treatment center in Freetown, Sierra Leone, for measles. These patients were negative for Ebola virus. Measles virus IgM was detected in 13 (16%) of the patients.
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McQuilkin PA, Udhayashankar K, Niescierenko M, Maranda L. Health-Care Access during the Ebola Virus Epidemic in Liberia. Am J Trop Med Hyg 2017; 97:931-936. [PMID: 28722621 PMCID: PMC5590567 DOI: 10.4269/ajtmh.16-0702] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 05/01/2017] [Indexed: 11/07/2022] Open
Abstract
The Ebola virus disease (EVD) epidemic, which began in West Africa in December 2013, claimed more than 11,000 lives, with more than 4,800 of these deaths occurring in Liberia. The epidemic had an additional effect of paralyzing the health-care systems in affected countries, which led to even greater mortality and morbidity. Little is known about the impact that the epidemic had on the provision of basic health care. During the period from March to May 2015, we undertook a nationwide, community-based survey to learn more about health-care access during the EVD epidemic in Liberia. A cluster sampling strategy was used to administer a structured in-person survey to heads of households located within the catchment areas surrounding all 21 government hospitals in Liberia. A total of 543 heads of household from all 15 counties in Liberia participated in the study; more than half (67%) of urban respondents and 46% of rural respondents stated that it was very difficult or impossible to access health care during the epidemic. In urban areas, only 20-30% of patients seeking care during the epidemic received care, and in rural areas, only 70-80% of those seeking care were able to access it. Patients requiring prenatal and obstetric care and emergency services had the most difficulty accessing care. The results of this survey support the observation that basic health care was extremely difficult to access during the EVD epidemic in Liberia. Our results underscore the critical need to support essential health-care services during humanitarian crises to minimize preventable morbidity and mortality.
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Affiliation(s)
- Patricia A. McQuilkin
- Department of Pediatrics University of Massachusetts Medical School, Worcester, Massachusetts
| | | | | | - Louise Maranda
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
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42
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Camara BS, Delamou AM, Diro E, El Ayadi A, Béavogui AH, Sidibé S, Grovogui FM, Takarinda KC, Kolié D, Sandouno SD, Okumura J, Baldé MD, Van Griensven J, Zachariah R. Influence of the 2014-2015 Ebola outbreak on the vaccination of children in a rural district of Guinea. Public Health Action 2017; 7:161-167. [PMID: 28695091 DOI: 10.5588/pha.16.0120] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 03/24/2017] [Indexed: 12/24/2022] Open
Abstract
Setting: All health centres in Macenta District, rural Guinea. Objective: To compare stock-outs of vaccines, vaccine stock cards and the administration of various childhood vaccines across the pre-Ebola, Ebola and post-Ebola virus disease periods. Design: This was an ecological study. Results: Similar levels of stock-outs were observed for all vaccines (bacille Calmette-Guérin [BCG], pentavalent, polio, measles, yellow fever) in the pre-Ebola and Ebola periods (respectively 2760 and 2706 facility days of stock-outs), with some variation by vaccine. Post-Ebola, there was a 65-fold reduction in stock-outs compared to pre-Ebola. Overall, 24 facility-months of vaccine stock card stock-outs were observed during the pre-Ebola period, which increased to 65 facility-months of stock-outs during the Ebola outbreak period; no such stock-out occurred in the post-Ebola period. Apart from yellow fever and measles, vaccine administration declined universally during the peak outbreak period (August-November 2014). Complete cessation of vaccine administration for BCG and a prominent low for polio (86% decrease) were observed in April 2014, corresponding to vaccine stock-outs. Post-Ebola, overall vaccine administration did not recover to pre-Ebola levels, with the highest gaps seen in polio and pentavalent vaccines, which had shortages of respectively 40% and 38%. Conclusion: These findings highlight the need to sustain vaccination activities in Guinea so that they remain resilient and responsive, irrespective of disease outbreaks.
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Affiliation(s)
- B S Camara
- Department of Public Health, Gamal University of Conakry, Conakry, Guinea
| | - A M Delamou
- Department of Public Health, Gamal University of Conakry, Conakry, Guinea.,Woman and Child Health Research Centre, Institute of Tropical Medicine, Antwerp, Belgium
| | - E Diro
- University of Gondar, Gondar, Ethiopia
| | - A El Ayadi
- Bixby Center for Global Reproductive Health, University of California, San Francisco, California, USA
| | - A H Béavogui
- Centre National de Formation et de Recherche en Santé Rurale de Maferinyah, Forecariah, Guinea
| | - S Sidibé
- Department of Public Health, Gamal University of Conakry, Conakry, Guinea
| | - F M Grovogui
- Centre National de Formation et de Recherche en Santé Rurale de Maferinyah, Forecariah, Guinea
| | - K C Takarinda
- International Union Against Tuberculosis and Lung Disease, Paris, France
| | - D Kolié
- Centre National de Formation et de Recherche en Santé Rurale de Maferinyah, Forecariah, Guinea
| | - S D Sandouno
- Department of Public Health, Gamal University of Conakry, Conakry, Guinea
| | - J Okumura
- Institute of Tropical Medicine, Nagasaki University, Nagasaki, Japan
| | - M D Baldé
- Department of Gynecology-Obstetrics, Gamal University of Conakry, Conakry, Guinea
| | - J Van Griensven
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - R Zachariah
- Médecins Sans Frontières, Brussels Operational Centre (LuxOR), Luxembourg
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Kamara MH, Najjemba R, van Griensven J, Yorpoi D, Jimissa AS, Chan AK, Mishra S. Increase in acute malnutrition in children following the 2014-2015 Ebola outbreak in rural Sierra Leone. Public Health Action 2017; 7:S27-S33. [PMID: 28744436 PMCID: PMC5515560 DOI: 10.5588/pha.16.0084] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 12/05/2016] [Indexed: 02/02/2023] Open
Abstract
Setting: All health facility and community malnutrition screening programmes in Tonkolili, a rural Ebola-affected district in Sierra Leone. Objectives: Before the Ebola disease outbreak, Sierra Leone had set a goal to reduce the prevalence of severe acute malnutrition (SAM) in children aged <5 years to <0.2%. We compared the number of children screened, diagnosed and treated for malnutrition before, during and after the outbreak (2013-2016). Design: This was a retrospective cross-sectional study. Results: Health facility screening declined from 16 805 children per month pre-outbreak to 13 510 during the outbreak (P = 0.02), and returned to pre-outbreak levels after the outbreak. Community-based screening remained stable during the outbreak, and increased by 30% post-outbreak (P < 0.001). The proportion diagnosed with moderate acute malnutrition using mid-upper arm circumference increased from respectively 3.6% and 5.1% pre-outbreak in the community and health facilities to 8.2% and 7.9% post-outbreak (P < 0.001, P = 0.003). The proportion of children diagnosed with SAM using a weight-for-age ratio at health facilities increased from 1.5% pre-outbreak to 3.5% post-outbreak (P = 0.003). On average, for every four children diagnosed with SAM per month, one child completed SAM treatment. Conclusion: After a decline in screening during the Ebola outbreak, diagnoses of acute malnutrition increased post-outbreak. Nutrition programmes need to be strengthened to pre-empt such effects in the event of future Ebola outbreaks.
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Affiliation(s)
- M H Kamara
- Sierra Leone Ministry of Health and Sanitation, Magburaka, Sierra Leone
| | - R Najjemba
- School of Public Health, Makerere College of Health Sciences, Kampala, Uganda
| | | | - D Yorpoi
- Sierra Leone Ministry of Health and Sanitation, Magburaka, Sierra Leone
| | - A S Jimissa
- Sierra Leone Ministry of Health and Sanitation, Magburaka, Sierra Leone
| | - A K Chan
- Dignitas International, Zomba, Malawi
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - S Mishra
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Abstract
As of the end of March 2016, the West Africa epidemic of Ebola virus disease (Ebola) had resulted in a total of 28,646 cases, 11,323 of them fatal, reported to the World Health Organization. Guinea, Liberia, and Sierra Leone were most heavily affected, but Ebola cases were exported to several other African and European countries as well as the United States, with limited further transmission, including to healthcare workers. We review the descriptive epidemiology of the outbreak, novel aspects and insights concerning the unprecedented response, scientific observations, and public health implications. The large number of Ebola survivors has highlighted the frequency of persistent symptoms and the possibility of virus persistence in sanctuary sites, sometimes leading to delayed transmission. Although transmission appears to have ceased in 2016, the West Africa Ebola epidemic has profoundly influenced discussions and practice concerning global health security.
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Affiliation(s)
- Terrence Q Lo
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia 30333; , , ,
| | - Barbara J Marston
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia 30333; , , ,
| | - Benjamin A Dahl
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia 30333; , , ,
| | - Kevin M De Cock
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia 30333; , , ,
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