How can health systems be strengthened to control and prevent an Ebola outbreak? A narrative review

P, Talisuna A, Houndjo B, Kieta M, Baller A. Evaluation of a health systems strengthening intervention to improve Ebola Virus Disease infection prevention and control in the Democratic Republic of the Congo

Background

The Democratic Republic of Congo declared their tenth outbreak of Ebola in North Kivu in 2018, which was the second-largest in the world and took place in an active conflict zone. Transmission of Ebola occurs by direct contact with infected bodily fluids and can occur within facilities when infection prevention and control (IPC) precautions are not strictly practised.

Methods

To develop infection prevention and control (IPC) standards in health facilities, 45 medical students were trained and placed in 101 health facilities to mentor healthcare workers and support IPC practices between February and October 2019. A mixed-methods retrospective evaluation of quality improvement in North Kivu was conducted in October and November 2019 to capture key lessons from such a pilot IPC project. Five focus groups (N=49) and 42 key-informant interviews were conducted in addition to a secondary analysis of surveillance and programmatic data collected during the intervention.

Results

The intervention contributed 1.83 times (95% confidence interval, CI=1.10-3.06) to increased the likelihood of health facilities achieving an IPC score of 80% or above compared with facilities that did not receive the intervention. Overall, we found the odds of Ebola cases declining three times more likely in Butembo and Katwa (odds ratio, OR=3.00, 95% CI=1.87-5.62) relative to ten health zones in the region that were not reached by the intervention.

Conclusions

The results are difficult to attribute to any one type of intervention, given the number of other interventions implemented concurrently during the outbreak response. Further evaluations should be conducted to assess the cost-effectiveness of using medical students in conflict resolution and IPC, and to assess the suitability of scaling these approaches to other settings and diseases.

Factors Associated with the Implementation of Non-Pharmaceutical Interventions for Reducing Coronavirus Disease 2019 (COVID-19): A Systematic Review

There has been much discussion recently about the importance of implementing non-pharmaceutical interventions (NPIs) to protect the public from coronavirus disease 2019 (COVID-19) infection. Different governments across the world have adopted NPIs (e.g., social distancing, quarantine, isolation, lockdowns, curfews, travel restrictions, closures of schools and colleges). Two fundamental strategies, namely a strict containment strategy-also called suppression strategy-and a mitigation strategy have been adopted in different countries, mainly to reduce the reproduction number (R0) to below one and hence to reduce case numbers to low levels or eliminate human-to-human transmission, as well as to use NPIs to interrupt transmission completely and to reduce the health impact of epidemics, respectively. However, the adoption of these NPI strategies is varied and the factors impacting NPI are inconsistent and unclear. This study, therefore, aimed to review the factors associated with the implementation of NPIs (social distancing, social isolation and quarantine) for reducing COVID-19. Following PRISMA guidelines, we searched for published and unpublished studies, undertaking a systematic search of: MEDLINE, EMBASE, Allied and Complementary Medicine, COVID-19 Research, WHO database on COVID-19, and Google Scholar. Thirty-three studies were included in the study. Seven descriptive themes emerged on enablers and barriers to NPIs: the positive impact of NPIs, effective public health interventions, positive change in people's behaviour and concerns about COVID-19, the role of mass media, physical and psychological impacts, and ethnicity/age associated with COVID-19. This study has highlighted that the effectiveness of NPIs in isolation is likely to be limited, therefore, a combination of multiple measures e.g., SD, isolation and quarantine, and workplace distancing appeared more effective in reducing COVID-19. Studies suggest that targeted approaches alongside social distancing might be the way forward, and more acceptable. Further research to promote country- and context-specific adoption of NPIs to deliver public health measures is needed. Studies comparing the effectiveness of interventions and strategies will help provide more evidence for future pandemics.

Viral Pandemics of the Last Four Decades: Pathophysiology, Health Impacts and Perspectives

The twenty-first century has witnessed some of the deadliest viral pandemics with far-reaching consequences. These include the Human Immunodeficiency Virus (HIV) (1981), Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV) (2002), Influenza A virus subtype H1N1 (A/H1N1) (2009), Middle East Respiratory Syndrome Coronavirus (MERS-CoV) (2012) and Ebola virus (2013) and the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) (2019-present). Age- and gender-based characterizations suggest that SARS-CoV-2 resembles SARS-CoV and MERS-CoV with regard tohigher fatality rates in males, and in the older population with comorbidities. The invasion-mechanism of SARS-CoV-2 and SARS-CoV, involves binding of its spike protein with angiotensin-converting enzyme 2 (ACE2) receptors; MERS-CoV utilizes dipeptidyl peptidase 4 (DPP4), whereas H1N1 influenza is equipped with hemagglutinin protein. The viral infections-mediated immunomodulation, and progressive inflammatory state may affect the functions of several other organs. Although no effective commercial vaccine is available for any of the viruses, those against SARS-CoV-2 are being developed at an unprecedented speed. Until now, only Pfizer/BioNTech's vaccine has received temporary authorization from the UK Medicines and Healthcare products Regulatory Agency. Given the frequent emergence of viral pandemics in the 21st century, proper understanding of their characteristics and modes of action are essential to address the immediate and long-term health consequences.

Impact of non-pharmaceutical interventions for reducing transmission of COVID-19: a systematic review and meta-analysis protocol

INTRODUCTION

Implementing non-pharmaceutical interventions (NPIs) protect the public from COVID-19. However, the impact of NPIs has been inconsistent and remains unclear. This study, therefore, aims to measure the impact of major NPIs (social distancing, social isolation and quarantine) on reducing COVID-19 transmission.

METHODS AND ANALYSIS

We will conduct a systematic review and meta-analysis research of both randomised and non-randomised controlled trials. We will undertake a systematic search of: MEDLINE, Embase, Allied & Complementary Medicine, COVID-19 Research, WHO database on COVID-19, ClinicalTrails.Gov for clinical trials on COVID-19, Cochrane Resources on Coronavirus (COVID-19), Oxford COVID-19 Evidence Service and Google Scholar for published and unpublished literatures on COVID-19 including preprint engines such as medRxiv, bioRxiv, Litcovid and SSRN for unpublished studies on COVID-19 and will be reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Outcomes of interest for impact analysis will include the reduction of COVID-19 transmission, avoiding crowds and restricting movement, isolating ill and psychological impacts. The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols checklist has been used for this protocol. For quality of included studies, we will use the Cochrane Collaboration's tool for assessing risk of bias for randomised controlled trials and the Newcastle-Ottawa Scale for observational studies. The Grading of Recommendations Assessment, Development and Evaluation approach will grade the certainty of the evidence for all outcome measures across studies. Random-effects model for meta-analysis will measure the effect size of NPIs or the strengths of relationships. For quantitative data, risk ratio or OR, absolute risk difference (for dichotomous outcome data), or mean difference or standardised mean difference (for continuous data) and their 95% CIs will be calculated. Where statistical pooling is not possible, a narrative synthesis will be conducted for the included studies. To assess the heterogeneity of effects, I2 together with the observed effects will be evaluated to provide the true effects in the analysis.

ETHICS AND DISSEMINATION

Formal ethical approval from an institutional review board or research ethics committee is not required as primary data will not be collected. The final results of this study will be published in an open-access peer-reviewed journal, and abstract will be presented at suitable national/international conferences or workshops. We will also share important information with public health authorities as well as with the WHO. In addition, we may post the submitted manuscript under review to medRxiv, or other relevant preprint servers.

TRIAL REGISTRATION NUMBER

CRD42020207338.

Infection prevention and control compliance in Tanzanian outpatient facilities: a cross-sectional study with implications for the control of COVID-19

BACKGROUND

As coronavirus disease 2019 (COVID-19) spreads, weak health systems must not become a vehicle for transmission through poor infection prevention and control practices. We assessed the compliance of health workers with infection prevention and control practices relevant to COVID-19 in outpatient settings in Tanzania, before the pandemic.

METHODS

This study was based on a secondary analysis of cross-sectional data collected as part of a randomised controlled trial in private for-profit dispensaries and health centres and in faith-based dispensaries, health centres, and hospitals, in 18 regions. We observed provider-patient interactions in outpatient consultation rooms, laboratories, and dressing rooms, and categorised infection prevention and control practices into four domains: hand hygiene, glove use, disinfection of reusable equipment, and waste management. We calculated compliance as the proportion of indications (infection risks) in which a health worker performed a correct action, and examined associations between compliance and health worker and facility characteristics using multilevel mixed-effects logistic regression models.

FINDINGS

Between Feb 7 and April 5, 2018, we visited 228 health facilities, and observed at least one infection prevention and control indication in 220 facilities (118 [54%] dispensaries, 66 [30%] health centres, and 36 [16%] hospitals). 18 710 indications were observed across 734 health workers (49 [7%] medical doctors, 214 [29%] assistant medical officers or clinical officers, 106 [14%] nurses or midwives, 126 [17%] clinical assistants, and 238 [32%] laboratory technicians or assistants). Compliance was 6·9% for hand hygiene (n=8655 indications), 74·8% for glove use (n=4915), 4·8% for disinfection of reusable equipment (n=841), and 43·3% for waste management (n=4299). Facility location was not associated with compliance in any of the infection prevention and control domains. Facility level and ownership were also not significantly associated with compliance, except for waste management. For hand hygiene, nurses and midwives (odds ratio 5·80 [95% CI 3·91-8·61]) and nursing and medical assistants (2·65 [1·67-4·20]) significantly outperformed the reference category of assistant medical officers or clinical officers. For glove use, nurses and midwives (10·06 [6·68-15·13]) and nursing and medical assistants (5·93 [4·05-8·71]) also significantly outperformed the reference category. Laboratory technicians performed significantly better in glove use (11·95 [8·98-15·89]), but significantly worse in hand hygiene (0·27 [0·17-0·43]) and waste management (0·25 [0·14-0·44] than the reference category. Health worker age was negatively associated with correct glove use and female health workers were more likely to comply with hand hygiene.

INTERPRETATION

Health worker infection prevention and control compliance, particularly for hand hygiene and disinfection, was inadequate in these outpatient settings. Improvements in provision of supplies and health worker behaviours are urgently needed in the face of the current pandemic.

FUNDING

UK Medical Research Council, Economic and Social Research Council, Department for International Development, Global Challenges Research Fund, Wellcome Trust.

What makes health systems resilient against infectious disease outbreaks and natural hazards? Results from a scoping review

Background

The 2014–2016 Ebola outbreak was a wake-up call regarding the critical importance of resilient health systems. Fragile health systems can become overwhelmed during public health crises, further exacerbating the human, economic, and political toll. Important work has been done to describe the general attributes of a health system resilient to these crises, and the next step will be to identify the specific capacities that health systems need to develop and maintain to achieve resiliency.

Methods

We conducted a scoping review of the literature to identify recurring themes and capacities needed for health system resiliency to infectious disease outbreaks and natural hazards and any existing implementation frameworks that highlight these capacities. We also sought to identify the overlap of the identified themes and capacities with those highlighted in the World Health Organization’s Joint External Evaluation. Sources of evidence included PubMed, Web of Science, OAIster, and the websites of relevant major public health organizations.

Results

We identified 16 themes of health system resilience, including: the need to develop plans for altered standards of care during emergencies, the need to develop plans for post-event recovery, and a commitment to quality improvement. Most of the literature described the general attributes of a resilient health system; no implementation frameworks were identified that could translate these elements into specific capacities that health system actors can employ to improve resilience to outbreaks and natural hazards in a variety of settings.

Conclusions

An implementation-oriented health system resilience framework could help translate the important components of a health system identified in this review into specific capacities that actors in the health system could work to develop to improve resilience to public health crises. However, there remains a need to further refine the concept of resilience so that health systems can simultaneously achieve sustainable transformations in healthcare practice and health service delivery as well as improve their preparedness for emergencies.

Health system preparedness for emerging infectious diseases: A synthesis of the literature

This review reflects on what the literature to date has taught us about how health systems of low- and middle-income countries (LMICs) respond to emerging infectious disease (EID) outbreaks. These findings are then applied to propose a conceptual framework characterising an EID prepared health system. A narrative synthesis approach was adopted to explore the key elements of LMIC health systems during an EID outbreak. Overarching themes ('core health system constructs') and sub-themes ('elements') relevant to EID preparedness were extracted from 49 peer-reviewed articles. The resulting conceptual framework recognised six core constructs: four focused on material resources and structures (i.e. system 'hardware'), including (i) Surveillance, (ii) Infrastructure and medical supplies, (iii) Workforce, and (iv) Communication mechanisms; and two focused on human and institutional relationships, values and norms (i.e. system 'software'), including (i) Governance, and (ii) Trust. The article reinforces the interconnectedness of the traditional health system building blocks to EID detection, prevention and response, and highlights the critical role of system 'software' (i.e. governance and trust) in enabling LMIC health systems to achieve and maintain EID preparedness. The review provides recommendations for refining a set of indicators for an 'optimised' health system EID preparedness tool to aid health system strengthening efforts.

Ébola, abordaje clínico integral

Introducción. El virus del Ébola, antes llamado fiebre hemorrágica del Ébola, es una enfermedad altamente contagiosa con mortalidad entre 50% y 90%, para la cual existen prometedoras opciones de tratamiento que se encuentran en fase de evaluación y uso compasional.Objetivos. Revisar la mejor evidencia médica publicada y analizar el comportamiento de las epidemias por virus del Ébola, sus manifestaciones clínicas, sus complicaciones, los elementos más significativos para su diagnóstico y las nuevas opciones terapéuticas disponibles, para así aprender y aplicar estas experiencias en nuevos brotes.Materiales y métodos. Se realizó una búsqueda sistemática en las bases de datos PubMed, ProQuest, Embase, Redalyc, Ovid, Medline, DynaMed y ClinicalKey durante el periodo 2009-2017 en el contexto internacional, regional y local.Resultados. La revisión sistemática de artículos aportó un total de 51 430 registros, de los cuales 772 eran elegibles; de estos, 722 no eran relevantes, por lo que quedaron incluidos 50. A punto de partida se pudieron precisar los aspectos objeto de esta revisión.Conclusión. La enfermedad causada por el virus del Ébola, a pesar de su alta mortalidad, puede ser prevenida, diagnosticada oportunamente y tratada con efectividad, lo cual permite evaluar su impacto epidemiológico en las áreas endémicas y a nivel mundial. Existe un potencial arsenal terapéutico en fase de experimentación con resultados prometedores.

The implementation of the free maternal health policy in rural Northern Ghana: synthesised results and lessons learnt

Objective

A free maternal health policy was implemented under Ghana’s National Health Insurance Scheme to promote the use of maternal health services. Under the policy, women are entitled to free services throughout pregnancy and at childbirth. A mixed methods study involving women, providers and insurance managers was carried out in the Kassena-Nankana municipality of Ghana. It explored the affordability, availability, acceptability and quality of services. In this manuscript, we present synthesised results categorised as facilitators and barriers to access as well as lessons learnt (implications).

Results

Reasonable waiting times, cleanliness of facilities as well as good interpersonal relationships with providers were the facilitators to access. Barriers included out of pocket payments, lack of, or inadequate supply of drugs and commodities, equipment, water, electricity and emergency transport. Four lessons (implications) were identified. Firstly, out of pocket payments persisted. Secondly, the health system was not strengthened before implementing the free maternal health policy. Thirdly, lower level facilities were poorly resourced. Finally, the lack of essential inputs and infrastructure affected quality of care and therefore, access to care. It is suggested that the Government of Ghana, the Health Insurance Scheme and other stakeholders improve the provision of resources to facilities.

What should the African health workforce know about disasters? Proposed competencies for strengthening public health disaster risk management education in Africa

BACKGROUND

As part of efforts to implement the human resources capacity building component of the African Regional Strategy on Disaster Risk Management (DRM) for the health sector, the African Regional Office of the World Health Organization, in collaboration with selected African public health training institutions, followed a multistage process to develop core competencies and curricula for training the African health workforce in public health DRM. In this article, we describe the methods used to develop the competencies, present the identified competencies and training curricula, and propose recommendations for their integration into the public health education curricula of African member states.

METHODS

We conducted a pilot research using mixed methods approaches to develop and test the applicability and feasibility of a public health disaster risk management curriculum for training the African health workforce.

RESULTS

We identified 14 core competencies and 45 sub-competencies/training units grouped into six thematic areas: 1) introduction to DRM; 2) operational effectiveness; 3) effective leadership; 4) preparedness and risk reduction; 5) emergency response and 6) post-disaster health system recovery. These were defined as the skills and knowledge that African health care workers should possess to effectively participate in health DRM activities. To suit the needs of various categories of African health care workers, three levels of training courses are proposed: basic, intermediate, and advanced. The pilot test of the basic course among a cohort of public health practitioners in South Africa demonstrated their relevance.

CONCLUSIONS

These competencies compare favourably to the findings of other studies that have assessed public health DRM competencies. They could provide a framework for scaling up the capacity development of African healthcare workers in the area of public health DRM; however further validation of the competencies is required through additional pilot courses and follow up of the trainees to demonstrate outcome and impact of the competencies and curriculum.