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Baxter L, Slater R, Hermany L, Bhatti A, Eiden AL, Mitrovich R, Connolly MP, Vanderslott S, Nyaku M, Bhatt A. Identifying characteristics that enable resilient immunisation programmes: a scoping review. BMJ Open 2024; 14:e072794. [PMID: 38806437 PMCID: PMC11138283 DOI: 10.1136/bmjopen-2023-072794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 02/14/2024] [Indexed: 05/30/2024] Open
Abstract
OBJECTIVES The COVID-19 pandemic highlighted the fragility of immunisation programmes and resulted in a significant reduction in vaccination rates, with increasing vaccine-preventable disease outbreaks consequently reported. These vulnerabilities underscore the importance of resilient immunisation programmes to ensure optimal performance during crises. To date, a framework for assessing immunisation programme resilience does not exist. We conducted a scoping review of immunisation programmes during times of crisis to identify factors that characterise resilient immunisation programmes, which may inform an Immunisation Programme Resilience Tool. DESIGN Scoping review design followed the Arksey and O'Malley framework, and manuscript reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews guidelines. DATA SOURCES CINAHL, CENTRAL, Embase, Google Scholar, MEDLINE, PsycINFO and Web of Science and databases were searched between 1 January 2011 and 2 September 2023. Citation searching of identified studies was also performed. ELIGIBILITY CRITERIA We included primary empirical peer-reviewed studies that discussed the resilience of immunisation programme to crises, shocks or disruptions. DATA EXTRACTION AND SYNTHESIS Two independent reviewers screened records and performed data extraction. We extracted data on study location and design, crisis description, and resilience characteristics discussed, and identified evidence gaps in the literature. Findings were synthesised using tabulation and an evidence gap map. RESULTS Thirty-seven studies met the eligibility criteria. These studies captured research conducted across six continents, with most concentrated in Africa, Asia and Europe. One study had a randomised controlled trial design, while 36 studies had observational designs (15 analytical and 21 descriptive). We identified five characteristics of resilient immunisation programmes drawing on the Health System Resilience Index (Integration, Awareness, Resource Availability and Access, Adaptiveness and Self-regulation) and several evidence gaps in the literature. CONCLUSIONS To our knowledge, no immunisation programme resilience tool exists. We identified factors from the Health System Resilience Index coupled with factors identified through primary empirical evidence, which may inform development of an immunisation programme resilience tool.
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Affiliation(s)
- Luke Baxter
- Department of Paediatrics, University of Oxford, Oxford, UK
| | | | | | | | | | | | | | | | | | - Aomesh Bhatt
- Department of Paediatrics, University of Oxford, Oxford, UK
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Ghaznavi C, Eguchi A, Suu Lwin K, Yoneoka D, Tanoue Y, Kumar Rauniyar S, Horiuchi S, Hashizume M, Nomura S. Estimating global changes in routine childhood vaccination coverage during the COVID-19 pandemic, 2020-2021. Vaccine 2023; 41:4151-4157. [PMID: 37246068 PMCID: PMC10201316 DOI: 10.1016/j.vaccine.2023.05.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 05/13/2023] [Accepted: 05/13/2023] [Indexed: 05/30/2023]
Abstract
OBJECTIVES The COVID-19 pandemic has disrupted the distribution of routine immunizations globally. Multi-country studies assessing a wide spectrum of vaccines and their coverage rates are needed to determine global performance in achieving vaccination goals. METHODS Global vaccine coverage data for 16 antigens were obtained from WHO/UNICEF Estimates of National Immunization Coverage. Tobit regression was performed for all country-antigen pairs for which data were continuously available between 2015-2020 or 2015-2021 to predict vaccine coverage in 2020/2021. Vaccines for which multi-dose data were available were assessed to determine whether vaccine coverage for subsequent doses were lower than that of first doses. RESULTS Vaccine coverage was significantly lower-than-predicted for 13/16 antigens in 2020 and all assessed antigens in 2021. Lower-than-predicted vaccine coverage was typically observed in South America, Africa, Eastern Europe, and Southeast Asia. There was a statistically significant coverage drop for subsequent doses of the diphtheria-tetanus-pertussis, pneumococcus, and rotavirus vaccines compared to first doses in 2020 and 2021. CONCLUSION The COVID-19 pandemic exerted larger disruptions to routine vaccination services in 2021 than in 2020. Global efforts will be needed to recoup vaccine coverage losses sustained during the pandemic and broaden vaccine access in areas where coverage was previously inadequate.
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Affiliation(s)
- Cyrus Ghaznavi
- Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan; Medical Education Program, Washington University School of Medicine in St Louis, Saint Louis, USA.
| | - Akifumi Eguchi
- Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan; Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Center for Preventive Medical Sciences, Chiba University, Chiba, Japan
| | - Kaung Suu Lwin
- Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Daisuke Yoneoka
- Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan; Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Tokyo Foundation for Policy Research, Tokyo, Japan; Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Tokyo, Japan
| | - Yuta Tanoue
- Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan; Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Institute for Business and Finance, Waseda University, Tokyo, Japan
| | - Santosh Kumar Rauniyar
- Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Sayaka Horiuchi
- Center for Birth Cohort Studies, University of Yamanashi, Yamanashi, Japan
| | - Masahiro Hashizume
- Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shuhei Nomura
- Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan; Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Tokyo Foundation for Policy Research, Tokyo, Japan
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Jeong Y, Min J. Impact of COVID-19 Pandemic on Tuberculosis Preventive Services and Their Post-Pandemic Recovery Strategies: A Rapid Review of Literature. J Korean Med Sci 2023; 38:e43. [PMID: 36747365 PMCID: PMC9902666 DOI: 10.3346/jkms.2023.38.e43] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 11/14/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) pandemic has disrupted tuberculosis (TB) care and prevention around the world. The aim of this study is to review literature on the impact of COVID-19 on TB preventive services and discuss their policy options during and after the pandemic. METHODS We conducted a rapid review of scientific literature on the impact of COVID-19 on TB preventive services and their recovery strategies. After conducting a line-by-line open coding, their codes were applied in the descriptive theme building process, which was guided by the End TB strategy. TB preventive measures were selected and classified into five analytical categories: 1) vaccination against TB, 2) detection and treatment of latent TB infection (LTBI), 3) screening and diagnostics, 4) active case finding and contact tracing, and 5) surveillance. RESULTS We identified 93 articles, of which 65 were research articles. During the pandemic, we observed decrease in Bacillus Calmette-Guérin (BCG) coverage, TB diagnostic services, case finding activities, and LTBI management. TB case detection was declined, which was not resumed to the pre-pandemic level after loosening the lock-down. Several recommendations were highlighted: 1) secure BCG stocks and its supply chains, 2) consider catch-up activities of routine immunization and LTBI screening, 3) maintain minimal TB health services, infection prevention and control, and surveillance, 4) leverage laboratory capacity and contact tracing mechanisms, 5) consider simultaneous testing for TB and COVID-19, and 6) Incorporate digital health technologies. CONCLUSIONS Our findings and lessons learnt from the pandemic can aid in the development of future national TB control program.
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Affiliation(s)
| | - Jinsoo Min
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
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Delamou A, Tripathi V, Camara BS, Sidibe S, Grovogui FM, Kolie D, Bouedouno P, Kourouma K, Banze DF, Mafu MM. Capacity building in operational research on obstetric fistula: Experience in the Democratic Republic of Congo, 2017-2021. Int J Gynaecol Obstet 2023; 160:459-467. [PMID: 35900176 PMCID: PMC10087752 DOI: 10.1002/ijgo.14377] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/14/2022] [Accepted: 07/25/2022] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To implement a Flexible Operational Research Training (FORT) course within the Fistula Care Plus Project, Democratic Republic of Congo, from 2017 to 2021. METHODS A descriptive study using design and implementation (process and outcome) data. Two to four members of medical teams from three supported sites were selected for the training based on their research interests and level of involvement in the program. RESULTS Two courses (13-14 months each) involving nine facilitators and 17 participants overall were conducted between 2017 and 2021. Most participants in both courses were medical doctors (67% and 71%, respectively) from the supported hospitals (83% and 77%, respectively). About half were women. In addition to classic face-to-face didactic modules, the courses integrated online platforms to cope with the changing contexts (Ebola virus and COVID-19). Most participants reported having gained new skills in developing research protocols, collecting, managing, and analyzing data, and developing research manuscripts. The two courses resulted in six scientific manuscripts and three presentations at international conferences. Participants subsequently published five papers from their research after the first course. The total direct costs for both courses were representing a cost of $3669 per participant trained. CONCLUSION The FORT model proved feasible, efficient, and successful. However, scaling up will require more adaptation efforts from programs and participating sites.
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Affiliation(s)
- Alexandre Delamou
- Africa Center of Excellence (CEA-PCMT), Faculty of Health Sciences and Techniques, University Gamal Abdel Nasser, Conakry, Guinea.,Centre National de Formation et de Recherche en Santé Rurale (CNFRSR) de Maferinyah, Forecariah, Guinea
| | | | - Bienvenu Salim Camara
- Africa Center of Excellence (CEA-PCMT), Faculty of Health Sciences and Techniques, University Gamal Abdel Nasser, Conakry, Guinea.,Centre National de Formation et de Recherche en Santé Rurale (CNFRSR) de Maferinyah, Forecariah, Guinea
| | - Sidikiba Sidibe
- Africa Center of Excellence (CEA-PCMT), Faculty of Health Sciences and Techniques, University Gamal Abdel Nasser, Conakry, Guinea.,Centre National de Formation et de Recherche en Santé Rurale (CNFRSR) de Maferinyah, Forecariah, Guinea
| | - Fassou Mathias Grovogui
- Africa Center of Excellence (CEA-PCMT), Faculty of Health Sciences and Techniques, University Gamal Abdel Nasser, Conakry, Guinea
| | - Delphin Kolie
- Africa Center of Excellence (CEA-PCMT), Faculty of Health Sciences and Techniques, University Gamal Abdel Nasser, Conakry, Guinea.,Centre National de Formation et de Recherche en Santé Rurale (CNFRSR) de Maferinyah, Forecariah, Guinea
| | - Patrice Bouedouno
- Centre National de Formation et de Recherche en Santé Rurale (CNFRSR) de Maferinyah, Forecariah, Guinea
| | - Karifa Kourouma
- Centre National de Formation et de Recherche en Santé Rurale (CNFRSR) de Maferinyah, Forecariah, Guinea
| | | | - Michel M Mafu
- Engenderhealth, Kinshasa, Democratic Republic of Congo
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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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Lunghi I, Babington-Ashaye A, Vassalli JD, Heller Y, Michaud PA, Wernli D, Heller O, Flahault A, Dagron S. The impact of the Ebola epidemics on children's rights: a scoping review. Glob Health Action 2022; 15:2061240. [PMID: 35506948 PMCID: PMC9090402 DOI: 10.1080/16549716.2022.2061240] [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: 01/12/2023] Open
Abstract
BACKGROUND The Ebola virus is known as one of the deadliest pathogens to infect humans. Children represent a minority of Ebola Virus Disease cases globally. Yet, the different Ebola outbreaks in Africa had a wide impact on children's lives and children' rights. OBJECTIVE Review the published literature to date on Children's rights during Ebola outbreaks. Outcomes shall contribute to get a better understanding of the main limitations or violations of children's rights, identify potential gaps in the literature and support the promotion and protection of children's rights for current and future health crisis. METHODS A scoping review from PubMed, Medline, Cochrane Library and Web of Science was performed using PRISMA-ScR guidelines. Articles, reports and editorial, published on Ebola Outbreaks between 1976 and 2020 were retrieved. The UNCRC clusters of rights and treaty specific guidelines were used as a framework. Documents were found through a targeted search of websites from international or regional organisations involved in Ebola crises and children's protection. RESULTS 48 articles and reports were reviewed. Few documents focused solely on children's rights. Several articles covered the topic of children and Ebola outbreaks. Most of the data are linked to basic health, education, discrimination of orphans and survivors. 31% of the reviewed articles underline the violence against the children (rape, abuse, Female genital mutilations), while 21% focus on the right to education. 23% cover the topic of orphans. Impact on mental health and SRH were amongst the other covered topics. CONCLUSION A lack of data on children's rights and their violations during epidemics is observed. Regional and international collaboration is needed to document the situation of children in health emergencies. Health measures and strategies based on children's opinions and raising awareness of their crucial role in society is key. Child-centred guidelines should be developed based on these elements.
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Affiliation(s)
- Irene Lunghi
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Awa Babington-Ashaye
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Jean-Dominique Vassalli
- International Institute for the rights of the child (Institut International des Droits de l’Enfant, IDE), Sion, Switzerland
| | - Yvon Heller
- International Institute for the rights of the child (Institut International des Droits de l’Enfant, IDE), Sion, Switzerland
| | | | - Didier Wernli
- Global Studies Institute, University of Geneva, Geneva, Switzerland
| | - Olivia Heller
- Department of Primary Care, Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Antoine Flahault
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Stéphanie Dagron
- Faculties of Law and Medicine, Global Studies Institute, University of Geneva, Geneva, Switzerland,CONTACT Stéphanie Dagron University of Geneva Global Studies Institute Sciences II- 30, Quai Ernest-Ansermet Case Postale CH-1211 Genève 4, Geneva, Switzerland
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Apolonio JS, da Silva Júnior RT, Cuzzuol BR, Araújo GRL, Marques HS, Barcelos IDS, Santos LKDS, Malheiro LH, Lima de Souza Gonçalves V, Freire de Melo F. Syndemic aspects between COVID-19 pandemic and social inequalities. World J Methodol 2022; 12:350-364. [PMID: 36186746 PMCID: PMC9516541 DOI: 10.5662/wjm.v12.i5.350] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 06/22/2022] [Accepted: 07/25/2022] [Indexed: 02/08/2023] Open
Abstract
Although the coronavirus disease 2019 (COVID-19) pandemic has reached all over the world population, it has demonstrated a heterogeneous impact on different populations. The most vulnerable communities which coexist daily with the social inequalities like low access to hygiene and personal protection products, crowded residences, and higher levels of chronic diseases have a higher risk of contact and the spread of infection, beyond unfavorable clinical outcomes. The elevation of the risk of infection exposure can be related to gender due to the presence of a larger contingent of women in essential services, as well as frontline and cleaning professionals who regardless of gender have the greatest exposure to the virus. Such exposures can contribute to the development of fear of contaminating themselves or their family members associated also with the work stress, both of which are related to the emergence of mental disturbances in these populations. Furthermore, conditions of unsanitary living and low socioeconomic status, populations at war, pre-existing social barriers, and ethnicity have contributed to more impact of the pandemic both in the exposure to the virus and access to health services, COVID-19 management, and management of other pathologies. At the same time, factors such as the closing of non-essential services, the loss of jobs, and the increase in household spending aggravated the social vulnerabilities and impacted the family economy. Lastly, the COVID-19 pandemic contributed still more to the impact on women's health since it propitiated a favorable environment for increasing domestic violence rates, through the segregation of women from social life, and increasing the time of the victims with their aggressors.
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Affiliation(s)
- Jonathan Santos Apolonio
- Universidade Federal da Bahia, Instituto Multidisciplinar em Saúde, Vitória da Conquista 45029-094, Bahia, Brazil
| | | | - Beatriz Rocha Cuzzuol
- Universidade Federal da Bahia, Instituto Multidisciplinar em Saúde, Vitória da Conquista 45029-094, Bahia, Brazil
| | - Glauber Rocha Lima Araújo
- Universidade Federal da Bahia, Instituto Multidisciplinar em Saúde, Vitória da Conquista 45029-094, Bahia, Brazil
| | - Hanna Santos Marques
- Universidade Estadual do Sudoeste da Bahia, Campus Vitória da Conquista, Vitória da Conquista 45083-900, Bahia, Brazil
| | - Isadora de Souza Barcelos
- Universidade Federal da Bahia, Instituto Multidisciplinar em Saúde, Vitória da Conquista 45029-094, Bahia, Brazil
| | - Luana Kauany de Sá Santos
- Universidade Federal da Bahia, Instituto Multidisciplinar em Saúde, Vitória da Conquista 45029-094, Bahia, Brazil
| | - Luciano Hasimoto Malheiro
- Universidade Federal da Bahia, Instituto Multidisciplinar em Saúde, Vitória da Conquista 45029-094, Bahia, Brazil
| | | | - Fabrício Freire de Melo
- Universidade Federal da Bahia, Instituto Multidisciplinar em Saúde, Vitória da Conquista 45029-094, Bahia, Brazil
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King J, Sadique Z, Amara M, Borghi J. Has Ebola delayed progress on access to routine care and financial protection in Sierra Leone? Evidence from a difference-in-differences analysis with propensity score weighting. Soc Sci Med 2022; 303:114995. [PMID: 35576766 PMCID: PMC9055447 DOI: 10.1016/j.socscimed.2022.114995] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 04/25/2022] [Accepted: 04/27/2022] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Covid-19 has highlighted the need to understand the long-term impact of epidemics on health systems. There is extensive evidence that the Ebola epidemic of 2014-16 dramatically reduced coverage of key reproductive, maternal, newborn, child and adolescent health (RMNCAH) indicators during the period of acute crisis in Sierra Leone. However, less is known about the longer lasting effects, and whether patients continue to be deterred from seeking care either through fear or cost some years after the end of the epidemic METHODS: We analysed nationally representative household surveys from before (2011) and after (2018) the Ebola epidemic to estimate the coverage of 11 indicators of access to RMNCAH, and affordability of care. We used a differences-in-differences analysis, exploiting the variation in epidemic intensity across chiefdoms, to identify the effect of epidemic intensity on access and affordability outcomes, with propensity score weighting to adjust for differences in underlying characteristics between chiefdoms. RESULTS 13537 households were included across both datasets. Epidemic intensity was associated with a significant stalling in progress (-12.2 percentage points, 95% CI: 23.2 to -1.3, p = 0.029) in the proportion of births attended by a skilled provider. Epidemic intensity did not have a significant impact on any other indicator. CONCLUSION While there is evidence that chiefdoms which experienced worse Ebola outbreaks had poorer coverage of attendance of skilled providers at birth than would have otherwise been expected, more broadly the intensity of the epidemic did not impact on most indicators. This suggests the measures to restore both staffing and trust were effective in supporting the health system to recover from Ebola.
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Affiliation(s)
- Jessica King
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, London, United Kingdom.
| | - Zia Sadique
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Michael Amara
- Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Josephine Borghi
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Gurman T, Harris D, Sidibé S. Findings and Implications From an Evaluation of the Gold Star Campaign in Post-Ebola Guinea: The Role of Gender and Education. GLOBAL HEALTH: SCIENCE AND PRACTICE 2022; 10:GHSP-D-21-00427. [PMID: 35294383 PMCID: PMC8885355 DOI: 10.9745/ghsp-d-21-00427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 01/17/2022] [Indexed: 11/25/2022]
Abstract
During public health crises, such as an Ebola epidemic, people may lose trust in local health facilities. Short-duration mass media campaigns can improve attitudes about the quality of health facilities for men and women and can play an important role in encouraging future health service utilization. In post-Ebola Guinea, the Health Communication Capacity Collaborative (HC3) project worked to rebuild trust in the health system and increase the utilization of reproductive, maternal, neonatal, and child health services. Core to HC3 Guinea was the promotion of quality local health centers through the Gold Star campaign (2016–2017). The current study aimed to determine the relationship between campaign exposure and attitudes/intentions regarding local health centers, to inform communication efforts in future epidemics. Between June–July 2017, HC3 Guinea conducted a telephone survey with men (n=1,000) and women (n=2,000) aged 18–49 years. Multivariate regression analyses estimated the association between campaign exposure and attitudinal/intention outcomes for the overall sample as well as for gender- and education-stratified samples. Survey results indicated that more than 30% of the sample recalled either the campaign (32.5%) or logo (37.6%). Statistically significant associations existed between exposure and various attitudinal outcomes. For example, regardless of gender/level of education, campaign recall was strongly associated with agreeing that the local health center improved in the last 6 months. Given that the campaign itself was short in duration, it is encouraging that attitudes changed with campaign exposure. Although a greater percentage of women than men held positive attitudes about health facilities, men seemed more influenced by campaign exposure. The current study provides evidence that mass media campaigns can help rebuild trust in health care facilities after an epidemic. Study findings also stress the value of conducting stratified analyses by important demographic characteristics (e.g., gender, education). Stratified analyses can help identify meaningful differences and better tailor health promotion activities and achieve greater success. The recent recurrence of Ebola in Guinea has resulted in renewed discussions about ways to incorporate these evaluation findings into current programming, including exploring ways to address gender considerations in message design and overall program strategy.
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Affiliation(s)
- Tilly Gurman
- Johns Hopkins Bloomberg School of Public Health, Center for Communication Programs Baltimore, MD, USA.
| | - Darriel Harris
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sidikiba Sidibé
- Johns Hopkins Center for Communication Programs-Guinea, Conakry, Guinea
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Decline in Uptake of Childhood Vaccinations in a Tertiary Hospital in Northern Ghana during the COVID-19 Pandemic. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6995096. [PMID: 34926689 PMCID: PMC8672106 DOI: 10.1155/2021/6995096] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 11/11/2021] [Accepted: 11/20/2021] [Indexed: 02/08/2023]
Abstract
At the beginning of the COVID-19 pandemic, early modelling studies estimated a reduction in childhood vaccinations in low- and middle-income countries. Regular provision of both curative and preventive services such as antenatal care and childhood immunizations has been negatively affected since the onset of the pandemic. Our study was aimed at examining the impact that the pandemic had on childhood vaccination services at the Tamale Teaching Hospital (TTH). A mixed methods study design was employed for the study, which was conducted at the Child Welfare Clinic (CWC) of the TTH. With quantitative approach, we retrospectively looked at the uptake of the various vaccines during the pandemic era, defined as the period between 1st March 2020 and 28th February, 2021, and the prepandemic era defined as the period 1st March 2019 to 29th February, 2020. The qualitative approach was used to understand the perspective of five healthcare providers at the CWC and the four caregivers of children who have missed a vaccine or delayed in coming, on the factors accounting for any observed change. Data analysis was done using Microsoft Excel 2016 and thematic content analysis. Quantitative data were presented in frequencies, percentages, and line graphs. With the exception of the Measles Rubella (MR) 2 vaccine, we observed a decline ranging from 47% (2298) to 10.5% (116), with the greatest decline seen in the BCG and the least decline seen in the MR1 vaccine. The month of May 2020 saw the greatest decline, that is, 70.6% (813). A decline of 38.3% (4473) was noted when comparison was made between the designated prepandemic and pandemic eras, for all the vaccines in our study. Fear of COVID-19 infection and misinformation were commonly given as reasons for the decline. Catch-up immunization schedule should be instituted to curtail possible future outbreaks of vaccine-preventable diseases.
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Kapiriri L, Essue B, Bwire G, Nouvet E, Kiwanuka S, Sengooba F, Reeleder D. A framework to support the integration of priority setting in the preparedness, alert, control and evaluation stages of a disease pandemic. Glob Public Health 2021; 17:1479-1491. [PMID: 34293263 DOI: 10.1080/17441692.2021.1931402] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The COVID-19 pandemic, where the need-resource gap has necessitated decision makers in some contexts to ration access to life-saving interventions, has demonstrated the critical need for systematic and fair priority setting and resource allocation mechanisms. Disease outbreaks are becoming increasingly common and priority setting lessons from previous disease outbreaks could be better harnessed to inform decision making and planning for future disease outbreaks. The purpose of this paper is to discuss how priority setting and resource allocation could, ideally, be integrated into the WHO pandemic planning and preparedness framework and used to inform the COVID-19 pandemic recovery plans and plans for future outbreaks. Priority setting and resource allocation during disease outbreaks tend to evoke a process similar to the 'rule of rescue'. This results in inefficient and unfair resource allocation, negative effects on health and non-health programs and increased health inequities. Integrating priority setting and resource allocation activities throughout the four phases of the WHO emergency preparedness framework could ensure that priority setting during health emergencies is systematic, evidence informed and fair.
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Affiliation(s)
- Lydia Kapiriri
- Department of Health, Aging and Society, McMaster University, Hamilton, Canada
| | | | - Godfrey Bwire
- Department of Integrated Epidemiology Surveillance and Public Health Emergencies, Ministry of Health, Kampala, Uganda
| | | | - Suzanne Kiwanuka
- Department of Health Policy Planning and Management, Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda
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12
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Hendrickson ZM, Tibbels N, Sidikiba S, Mills H, Vondrasek C, Gurman T. 'I can't leave everything in the hands of my husband': Economic constraints and gender roles in care-seeking in post-Ebola Guinea. Glob Public Health 2021; 17:1578-1593. [PMID: 34242118 DOI: 10.1080/17441692.2021.1953107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The 2014-2016 Ebola epidemic in West Africa had enduring effects on health systems and healthcare utilisation. This study explores the intersection of economic constraints and gender roles in Guinea to understand delays in care-seeking post-Ebola. In-depth interviews (n = 45) and focus group discussions (n = 24) were conducted with mothers, male heads of household, grandmothers, and health workers in rural and urban areas in Basse-Guinée and Guinée Forestière. A thematic analysis identified salient themes related to gender and economic constraints on health care-seeking. Participants, particularly men, emphasised the high cost of seeking care, which led to delays as women secured funds. Men's engagement in care-seeking included providing funds and permission, picking up medication, and giving appointment reminders. As principal actors when 'navigating' the healthcare system, women were intimately involved in economic decisions and responsible for securing funds for services - even when lacking direct financial control. Essentialist descriptions of men as 'providers' and women as 'navigators', therefore, masked nuances in care-seeking and economic responsibilities. Programmes must acknowledge men's engagement in care-seeking and address both the economic barriers women face when seeking care and their economic roles. Greater attention to the complex intersection of economic constraints and gender roles could address care-seeking delays.
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Affiliation(s)
- Zoé Mistrale Hendrickson
- Johns Hopkins Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Natalie Tibbels
- Johns Hopkins Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sidibé Sidikiba
- Public Health Department, Africa Center of Excellence for Prevention and Control of Communicable Diseases (CEA-PCMT), Université Gamal Abdel Nasser de Conakry , Conakry, Guinea
| | - Hannah Mills
- Johns Hopkins Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Claudia Vondrasek
- Johns Hopkins Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Tilly Gurman
- Johns Hopkins Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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13
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Camara BS, Okumura J, Delamou A. Do memories of the Ebola virus disease outbreak influence post-Ebola health seeking behaviour in Guéckédou district (epicentre) in Guinea? A cross-sectional study of children with febrile illness. BMC Public Health 2020; 20:1298. [PMID: 32854668 PMCID: PMC7450797 DOI: 10.1186/s12889-020-09359-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 08/06/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The 2013-2015 Ebola Virus Disease (EVD) outbreak in Guinea resulted in community mistrust that influenced health care service utilization. This study aimed to assess whether EVD-related memories affect post-outbreak health-seeking behaviours for children under 5 years of age with febrile illnesses in Guéckédou district, Guinea. METHODS This cross-sectional study was conducted by surveying caregivers of children under 5 years of age in the sub-district most affected by the EVD outbreak (Guèndembou) and the least affected sub-district (Bolodou) in Guéckédou district. Memories of the outbreak were referred to as EVD-related fears in the post-EVD period, which was based on a series of questions regarding current feelings. RESULTS While the majority of caregivers sought care for their children with febrile illness in both districts, a statistically significantly higher proportion of caregivers in Guèndembou sought care, compared to caregivers in Bolodou.. More caregivers in Guèndembou (19.9%; n = 39) reported the death of family members or friends due to EVD compared to Bolodou (6.9%; n = 14; P < 0.001). The mean EVD fear score of caregivers was significantly higher in Guèndembou (3.0; SD: 3.0) than in Bolodou (2.0; SD: 1.1) (p < 0.001). Caregivers with a fear score above the median were 1.68 times more likely to seek care than those whose fear score was equal to or below the median; however, this difference was not statistically significant. Caregivers who reported family members' or friends' death due to EVD were also more likely to seek care (AOR = 2.12; 95%CI: 0.91-4.91), however, with no statistical significance. Only residing in the EVD-most affected sub-district of Guèndembou (AOR = 1.74; 95%CI: 1·09-2.79) was positively associated with seeking care. CONCLUSIONS This study reveals that community members in the rural district of Guéckédou still live with fear related to EVD nearly 2 years after the outbreak. It calls for more efforts in the health domain to preserve communities' key values and address the psychosocial effect of EVD in rural Guinea.
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Affiliation(s)
- Bienvenu Salim Camara
- Centre National de Formation et de Recherche en Santé Rurale de Maferinyah, Forécariah, Guinea. .,School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan.
| | - Junko Okumura
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan. .,Institute of Tropical Medicine, Nagasaki University, Nagasaki, Japan.
| | - Alexandre Delamou
- Centre National de Formation et de Recherche en Santé Rurale de Maferinyah, Forécariah, Guinea.,Department of Public Health, Gamal Abdel Nasser University, Conakry, Guinea
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14
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Iwu CJ, Ngcobo N, Jaca A, Wiyeh A, Pienaar E, Chikte U, Wiysonge CS. A systematic review of vaccine availability at the national, district, and health facility level in the WHO African Region. Expert Rev Vaccines 2020; 19:639-651. [PMID: 32605395 DOI: 10.1080/14760584.2020.1791088] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION To describe vaccine stock-outs at national, district, and health facility levels in the WHO African region. AREAS COVERED We conducted a systematic review to identify studies reporting on vaccine stock-outs at national, district, and health facility levels in 47 African countries. We searched both published and unpublished literature, including the WHO/UNICEF Joint Reporting Form (JRF), for eligible studies. EXPERT OPINION Countries within the WHO African region continue to face the challenge of vaccine stock-outs at national, district, and health facility levels and this impacts on the delivery of immunization services. The frequency and the proportion of stock-outs vary between countries and between regions within a country. Countries need to put more efforts toward finding lasting solutions to vaccine shortages. We look forward to having more countries reporting vaccine stock-outs especially at the health facility level. Furthermore, countries are currently exploring different approaches for improving vaccine stock management. It is expected that in half a decade from now, more well-designed studies will be available that will inform decision-making.
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Affiliation(s)
- Chinwe Juliana Iwu
- Division of Health Systems and Public Health, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University , Cape Town, South Africa
| | - Ntombehle Ngcobo
- Cochrane South Africa, South African Medical Research Council , Cape Town, South Africa.,Independent Consultant , Pretoria, South Africa
| | - Anelisa Jaca
- Cochrane South Africa, South African Medical Research Council , Cape Town, South Africa
| | - Alison Wiyeh
- Cochrane South Africa, South African Medical Research Council , Cape Town, South Africa
| | - Elizabeth Pienaar
- Cochrane South Africa, South African Medical Research Council , Cape Town, South Africa
| | - Usuf Chikte
- Division of Health Systems and Public Health, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University , Cape Town, South Africa
| | - Charles S Wiysonge
- Cochrane South Africa, South African Medical Research Council , Cape Town, South Africa.,Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town , Cape Town, South Africa
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Iwu CJ, Ngcobo N, McCaul M, Mangqalaza H, Magwaca A, Chikte U, Wiysonge CS. Vaccine stock management in primary health care facilities in OR Tambo District, Eastern Cape, South Africa. Vaccine 2020; 38:4111-4118. [PMID: 32362525 DOI: 10.1016/j.vaccine.2020.04.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 03/23/2020] [Accepted: 04/07/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Poor stock management has been identified as one of the causes of vaccine stock-outs in health facilities. This study assessed the occurrence of vaccine stock-outs and vaccine stock management practices in primary health care facilities in OR Tambo district of the Eastern Cape province, South Africa. METHODS Descriptive cross-sectional study design was used in this study to assess both the stock management practices and the availability of vaccines in the facilities. The study was conducted in 64 primary health care facilities across all sub-districts in OR Tambo. Data were collected using a questionnaire administered by the researcher, record checks and through observation. The occurrence of stock-outs of six tracer vaccines on the day of the visit and in the preceding 24 months were assessed. The data were captured into REDCap tool and analysed using STATA version 14. RESULTS Most standard stock management procedures were not adhered to, as these procedures were mostly handled by health care workers who either required formal training or refresher training on vaccine management. Cold chain capacity was not adequate and some vaccines were exposed to freezing. Both stock cards and the stock visibility solution (SVS) device were used in all the facilities for vaccine stock management. Less than half of the facilities visited 27 (44%) filled their stock cards regularly. Delays in receiving supplies from the pharmaceutical depot were commonly reported by facilities, which contributed to stock-outs. A total of 49 (77%) health facilities had at least one stockout for at least one vaccine on the day of the visit. Furthermore, BCG and OPV were the most affected vaccines in 37 (58%) and 28 (44%) of facilities, respectively. CONCLUSION Interventions for improving vaccine availability should be considered, especially those targeting human resources and the entire stock management system.
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Affiliation(s)
- Chinwe Juliana Iwu
- Department of Nursing and Midwifery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa.
| | - Ntombenhle Ngcobo
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa; Independent Consultant, Pretoria, South Africa
| | - Michael McCaul
- Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Hlokoma Mangqalaza
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa; School of Public Leadership, Stellenbosch University, Cape Town, South Africa
| | - Abongile Magwaca
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa; Ikhwezi Township, Mthatha, Eastern Cape Province, South Africa
| | - Usuf Chikte
- Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Charles S Wiysonge
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa; Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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16
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Kolie D, Camara BS, Delamou A, Béavogui AH, Hermans V, Edwards JK, Benedetti G, Muller CP, van Griensven J, Zachariah R. The Ebola-effect in Guinea 2014-15: Tangled trends of malaria care in children under-five. PLoS One 2018; 13:e0192798. [PMID: 29489836 PMCID: PMC5830300 DOI: 10.1371/journal.pone.0192798] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 01/30/2018] [Indexed: 01/28/2023] Open
Abstract
Introduction The 2014–15 Ebola outbreak in West Africa was disruptive for the general health services in the affected countries. This study assessed the impact of the outbreak on the reported number and management of malaria in children under-five in rural Guinea. Materials and methods A retrospective cross-sectional study was conducted in nineteen health centres in two rural, malaria-endemic health districts, one at the epicentre of the outbreak (Guéckédou) and one (Koubia) spared by Ebola. Routine surveillance data at health facility level were compared over similar periods of high malaria transmission in both districts before, during and after the outbreak. Results There were significant declines in the number of visits during the Ebola outbreak (3,700) in Guéckédou compared to before (4,616) and after it (4,195), while this trend remained more stable within the three periods for Koubia. Differences were nonetheless significant in both districts (p<0.001). In 2014, during the peak of the outbreak, the overall number of malaria cases treated exceeded the number of confirmed malaria cases in Guéckédou. There were decreases in antimalarial treatment provision in August and November 2014. In contrast, during 2015 and 2016, the proportion of malaria positive cases and those treated were closely aligned. During the peak of the Ebola outbreak, there was a significant decrease in oral antimalarial drug administration, which corresponded to an increase in injectable antimalarial treatments. Stock-outs in rapid diagnostic tests were evident and prolonged in Guéckédou during the outbreak, while more limited in Koubia. Conclusion The Ebola outbreak of 2014–15 in Guinea had a significant impact on the admission and management of malaria in children under-five. This study identifies potential challenges in the delivery of care for those at highest risk for malaria mortality during an Ebola outbreak and the need to improve preparedness strategies pre-Ebola and health systems recovery post-Ebola.
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Affiliation(s)
- Delphin Kolie
- Centre National de Formation et de Recherche en Santé Rurale de Maferinyah, Forécariah, Guinea
- * E-mail: ,
| | - Bienvenu S. Camara
- Centre National de Formation et de Recherche en Santé Rurale de Maferinyah, Forécariah, Guinea
| | - Alexandre Delamou
- Centre National de Formation et de Recherche en Santé Rurale de Maferinyah, Forécariah, Guinea
- Department of Public Health, Gamal University of Conakry, Conakry, Guinea
- Woman and Child Health Research Centre, Institute of Tropical Medicine, Antwerp, Belgium
| | - Abdoul H. Béavogui
- Centre National de Formation et de Recherche en Santé Rurale de Maferinyah, Forécariah, Guinea
- Department of Public Health, Gamal University of Conakry, Conakry, Guinea
| | - Veerle Hermans
- Médecins sans Frontières, Medical Department (Operational Research), Operational Centre Brussels, Luxembourg, Luxembourg
| | - Jeffrey K. Edwards
- Médecins sans Frontières, Medical Department (Operational Research), Operational Centre Brussels, Luxembourg, Luxembourg
- University of Washington, Department of Global Health, Seattle, Washington, United States of America
| | - Guido Benedetti
- Médecins sans Frontières, Medical Department (Operational Research), Operational Centre Brussels, Luxembourg, Luxembourg
| | - Claude P. Muller
- Department of Infection and Immunity, Luxembourg Institute of Health, Esch-sur-Alzette, Luxembourg
- Laboratoire National de Santé, Dudelange, Luxembourg
| | - Johan van Griensven
- Clinical Sciences Department, Institute of Tropical Medicine, Antwerp, Belgium
| | - Rony Zachariah
- Médecins sans Frontières, Medical Department (Operational Research), Operational Centre Brussels, Luxembourg, Luxembourg
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17
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Abstract
The West African outbreak of 2013 to 2016 was the largest Ebola epidemic in history. With tens of thousands of patients treated during this outbreak, much was learned about how to optimize clinical care for children with Ebola. In anticipation of inevitable future outbreaks, a firsthand summary of the major aspects of pediatric Ebola case management in austere settings is presented. Emphasis is on early and aggressive critical care, including fluid resuscitation, electrolyte repletion, antimicrobial therapy, and nutritional supplementation.
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Affiliation(s)
- Indi Trehan
- Lao Friends Hospital for Children, Luang Prabang, Lao PDR; Department of Pediatrics, One Children's Place, Campus Box 8116, St Louis, MO 63110, USA; Maforki Ebola Holding and Treatment Centre, Port Loko, Sierra Leone.
| | - Stephanie C De Silva
- Department of Pediatrics, One Children's Place, Campus Box 8116, St Louis, MO 63110, USA
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