Vaccination Utilization and Subnational Inequities during the COVID-19 Pandemic: An Interrupted Time-Series Analysis of Administrative Data across 12 Low- and Middle-Income Countries.

BACKGROUND: During and after the SARS-CoV-2 (COVID-19) pandemic, many countries experienced declines in immunization that have not fully recovered to pre-pandemic levels. This study uses routine health facility immunization data to estimate variability between and within countries in post-pandemic immunization service recovery for BCG, DPT1, and DPT3. METHODS: After adjusting for data reporting completeness and outliers, interrupted time series regression was used to estimate the expected immunization service volume for each subnational unit, using an interruption point of March 2020. We assessed and compared the percent deviation of observed immunizations from the expected service volume for March 2020 between and within countries. RESULTS: Six countries experienced significant service volume declines for at least one vaccine as of October 2022. The shortfall in BCG service volume was ~6% (95% CI -1.2%, -9.8%) in Guinea and ~19% (95% CI -16%, 22%) in Liberia. Significant cumulative shortfalls in DPT1 service volume are observed in Afghanistan (-4%, 95% CI -1%, -7%), Ghana (-3%, 95% CI -1%, -5%), Haiti (-7%, 95% CI -1%, -12%), and Kenya (-3%, 95% CI -1%, -4%). Afghanistan has the highest percentage of subnational units reporting a shortfall of 5% or higher in DPT1 service volume (85% in 2021 Q1 and 79% in 2020 Q4), followed by Bangladesh (2020 Q1, 83%), Haiti (80% in 2020 Q2), and Ghana (2022 Q2, 75%). All subnational units in Bangladesh experienced a 5% or higher shortfall in DPT3 service volume in the second quarter of 2020. In Haiti, 80% of the subnational units experienced a 5% or higher reduction in DPT3 service volume in the second quarter of 2020 and the third quarter of 2022. CONCLUSIONS: At least one region in every country has a significantly lower-than-expected post-pandemic cumulative volume for at least one of the three vaccines. Subnational monitoring of immunization service volumes using disaggregated routine health facility information data should be conducted routinely to target the limited vaccination resources to subnational units with the highest inequities.

Association between urban-rural location and prevalence of type 2 diabetes and impaired fasting glucose in West Africa: a cross-sectional population-based epidemiological study.

OBJECTIVES: We investigated the association between urban/rural location and both type 2 diabetes mellitus (T2DM) and pre-diabetes among populations of five West African countries. DESIGN: Cross-sectional studies, using the WHO Stepwise (STEPs) survey data. SETTING: National representative data of both urban and rural areas from Benin, Burkina Faso, Ghana, Liberia and Mali. PARTICIPANTS: Adults comprising 15 468 participants (6774 men and 8746 women; 7663 urban and 7805 rural residents) aged between 25 and 64 years. RESULTS: The age and sex-adjusted prevalence of T2DM was 6.2% for urban areas and 2.5% for rural areas. The prevalence of impaired fasting glucose (IFG) was 6.6% for urban areas, and 3.0% for rural areas. No differences by sex were observed. The crude relative risk (RR) and 95% CI of T2DM and IFG in urban compared with rural areas were 2.69 (1.85 to 3.91) and 2.37 (1.53 to 3.66), respectively. This reduced to RR: 2.03, 95% CI (1.34 to 3.08) and RR: 2.04, 95% CI (1.27 to 3.28), respectively, after adjusting for covariables. CONCLUSION: The prevalence of both T2DM and IFG was more than two times as high in urban areas compared with rural areas in West Africa. Behavioural risk factors are common among urban populations, with ongoing urbanisation expected to drive increases in the prevalence of T2DM. These results could guide planning for T2DM screening, preventive strategies and resource allocation in West Africa.

Vaccine hesitancy among healthcare workers in low- and middle-income countries during the COVID-19 pandemic: Results from facility surveys across six countries.

BACKGROUND: Vaccine hesitancy remains a critical barrier in mitigating the effects of the ongoing COVID-19 pandemic. The willingness of health care workers (HCWs) to be vaccinated, and, in turn, recommend the COVID-19 vaccine for their patient population is an important strategy. This study aims to understand the uptake of COVID-19 vaccines and the reasoning for vaccine hesitancy among facility-based health care workers (HCWs) in LMICs. METHODS: We conducted nationally representative phone-based rapid-cycle surveys across facilities in six LMICs to better understand COVID-19 vaccine hesitancy. We gathered data on vaccine uptake among facility managers, their perceptions of vaccine uptake and hesitancy among the HCWs operating in their facilities, and their perception of vaccine hesitancy among the patient population served by the facility. RESULTS: 1,148 unique public health facilities participated in the study, with vaccines being almost universally offered to facility-based respondents across five out of six countries. Among facility respondents who have been offered the vaccine, more than 9 in 10 survey respondents had already been vaccinated at the time of data collection. Vaccine uptake among other HCWs at the facility was similarly high. Over 90% of facilities in Bangladesh, Liberia, Malawi, and Nigeria reported that all or most staff had already received the COVID-19 vaccine when the survey was conducted. Concerns about side effects predominantly drive vaccine hesitancy in both HCWs and the patient population. CONCLUSION: Our findings indicate that the opportunity to get vaccinated in participating public facilities is almost universal. We find vaccine hesitancy among facility-based HCWs, as reported by respondents, to be very low. This suggests that a potentially effective effort to increase vaccine uptake equitably would be to channel promotional activities through health facilities and HCWs.However, reasons for hesitancy, even if limited, are far from uniform across countries, highlighting the need for audience-specific messaging.

Availability and use of personal protective equipment in low- and middle-income countries during the COVID-19 pandemic.

BACKGROUND: Availability and appropriate use of personal protective equipment (PPE) is of particular importance in Low and Middle-Income countries (LMICs) where disease outbreaks other than COVID-19 are frequent and health workers are scarce. This study assesses the availability of necessary PPE items during the COVID-19 pandemic at health facilities in seven LMICs. METHODS: Data were collected using a rapid-cycle survey among 1554 health facilities in seven LMICs via phone-based surveys between August 2020 and December 2021. We gathered data on the availability of World Health Organization (WHO)-recommended PPE items and the use of items when examining patients suspected to be infected with COVID-19. We further investigated the implementation of service adaptation measures in a severe shortage of PPE. RESULTS: There were major deficiencies in PPE availability at health facilities. Almost 3 out of 10 health facilities reported a stock-out of medical masks on the survey day. Forty-six percent of facilities did not have respirator masks, and 16% did not have any gloves. We show that only 43% of health facilities had sufficient PPE to comply with WHO guidelines. Even when all items were available, healthcare workers treating COVID-19 suspected patients were reported to wear all the recommended equipment in only 61% of health facilities. We did not find a statistically significant difference in implementing service adaptation measures between facilities experiencing a severe shortage or not. CONCLUSION: After more than a year into the COVID-19 pandemic, the overall availability of PPE remained low in our sample of low and middle-income countries. Although essential, the availability of PPE did not guarantee the proper use of the equipment. The lack of PPE availability and improper use of available PPE enable preventable COVID-19 transmission in health facilities, leading to greater morbidity and mortality and risking the continuity of service delivery by healthcare workers.

Readiness of health facilities to provide safe childbirth in Liberia: a cross-sectional analysis of population surveys, facility censuses and facility birth records.

BACKGROUND: The provision of quality obstetric care in health facilities is central to reducing maternal mortality, but simply increasing childbirth in facilities not enough, with evidence that many facilities in sub-Saharan Africa do not fulfil even basic requirements for safe childbirth care. There is ongoing debate on whether to recommend a policy of birth in hospitals, where staffing and capacity may be better, over lower level facilities, which are closer to women's homes and more accessible. Little is known about the quality of childbirth care in Liberia, where facility births have increased in recent decades, but maternal mortality remains among the highest in the world. We will analyse quality in terms of readiness for emergency care and referral, staffing, and volume of births. METHODS: We assessed the readiness of the Liberian health system to provide safe care during childbirth use using three data sources: Demographic and Health Surveys (DHS), Service Availability and Readiness Assessments (SARA), and the Health Management Information System (HMIS). We estimated trends in the percentage of births by location and population caesarean-section coverage from 3 DHS surveys (2007, 2013 and 2019-20). We examined readiness for safe childbirth care among all Liberian health facilities by analysing reported emergency obstetric and neonatal care signal functions (EmONC) and staffing from SARA 2018, and linking with volume of births reported in HMIS 2019. RESULTS: The percentage of births in facilities increased from 37 to 80% between 2004 and 2017, while the caesarean section rate increased from 3.3 to 5.0%. 18% of facilities could carry out basic EmONC signal functions, and 8% could provide blood transfusion and caesarean section. Overall, 63% of facility births were in places without full basic emergency readiness. 60% of facilities could not make emergency referrals, and 54% had fewer than one birth every two days. CONCLUSIONS: The increase in proportions of facility births over time occurred because women gave birth in lower-level facilities. However, most facilities are very low volume, and cannot provide safe EmONC, even at the basic level. This presents the health system with a serious challenge for assuring safe, good-quality childbirth services.

Healthcare utilization and maternal and child mortality during the COVID-19 pandemic in 18 low- and middle-income countries: An interrupted time-series analysis with mathematical modeling of administrative data.

BACKGROUND: The Coronavirus Disease 2019 (COVID-19) pandemic has had wide-reaching direct and indirect impacts on population health. In low- and middle-income countries, these impacts can halt progress toward reducing maternal and child mortality. This study estimates changes in health services utilization during the pandemic and the associated consequences for maternal, neonatal, and child mortality. METHODS AND FINDINGS: Data on service utilization from January 2018 to June 2021 were extracted from health management information systems of 18 low- and lower-middle-income countries (Afghanistan, Bangladesh, Cameroon, Democratic Republic of the Congo (DRC), Ethiopia, Ghana, Guinea, Haiti, Kenya, Liberia, Madagascar, Malawi, Mali, Nigeria, Senegal, Sierra Leone, Somalia, and Uganda). An interrupted time-series design was used to estimate the percent change in the volumes of outpatient consultations and maternal and child health services delivered during the pandemic compared to projected volumes based on prepandemic trends. The Lives Saved Tool mathematical model was used to project the impact of the service utilization disruptions on child and maternal mortality. In addition, the estimated monthly disruptions were also correlated to the monthly number of COVID-19 deaths officially reported, time since the start of the pandemic, and relative severity of mobility restrictions. Across the 18 countries, we estimate an average decline in OPD volume of 13.1% and average declines of 2.6% to 4.6% for maternal and child services. We projected that decreases in essential health service utilization between March 2020 and June 2021 were associated with 113,962 excess deaths (110,686 children under 5, and 3,276 mothers), representing 3.6% and 1.5% increases in child and maternal mortality, respectively. This excess mortality is associated with the decline in utilization of the essential health services included in the analysis, but the utilization shortfalls vary substantially between countries, health services, and over time. The largest disruptions, associated with 27.5% of the excess deaths, occurred during the second quarter of 2020, regardless of whether countries reported the highest rate of COVID-19-related mortality during the same months. There is a significant relationship between the magnitude of service disruptions and the stringency of mobility restrictions. The study is limited by the extent to which administrative data, which varies in quality across countries, can accurately capture the changes in service coverage in the population. CONCLUSIONS: Declines in healthcare utilization during the COVID-19 pandemic amplified the pandemic's harmful impacts on health outcomes and threaten to reverse gains in reducing maternal and child mortality. As efforts and resource allocation toward prevention and treatment of COVID-19 continue, essential health services must be maintained, particularly in low- and middle-income countries.

Disruptions in maternal and child health service utilization during COVID-19: analysis from eight sub-Saharan African countries.

The coronavirus-19 pandemic and its secondary effects threaten the continuity of essential health services delivery, which may lead to worsened population health and a protracted public health crisis. We quantify such disruptions, focusing on maternal and child health, in eight sub-Saharan countries. Service volumes are extracted from administrative systems for 63 954 facilities in eight countries: Cameroon, Democratic Republic of Congo, Liberia, Malawi, Mali, Nigeria, Sierra Leone and Somalia. Using an interrupted time series design and an ordinary least squares regression model with facility-level fixed effects, we analyze data from January 2018 to February 2020 to predict what service utilization levels would have been in March-July 2020 in the absence of the pandemic, accounting for both secular trends and seasonality. Estimates of disruption are derived by comparing the predicted and observed service utilization levels during the pandemic period. All countries experienced service disruptions for at least 1 month, but the magnitude and duration of the disruptions vary. Outpatient consultations and child vaccinations were the most commonly affected services and fell by the largest margins. We estimate a cumulative shortfall of 5 149 491 outpatient consultations and 328 961 third-dose pentavalent vaccinations during the 5 months in these eight countries. Decreases in maternal health service utilization are less generalized, although significant declines in institutional deliveries, antenatal care and postnatal care were detected in some countries. There is a need to better understand the factors determining the magnitude and duration of such disruptions in order to design interventions that would respond to the shortfall in care. Service delivery modifications need to be both highly contextualized and integrated as a core component of future epidemic response and planning.

Strengthening the community health program in Liberia: Lessons learned from a health system approach to inform program design and better prepare for future shocks.

BACKGROUND: Arising from the Ebola virus disease (EVD) outbreak, the 2015-2021 Investment Plan aimed to improve the health status of the Liberian population through building a resilient health system that contributes to achieving equitable health outcomes. Recognizing the significance of community participation in overcoming the EVD outbreak, strengthening community systems emerged as one of the most important strategies for bridging the gap in accessing primary health care (PHC) services. This study reviewed the community health policy development process in order to draw lessons from the health system strengthening efforts in Liberia post-EVD crisis. METHODS: A government-led health system analysis approach was applied to assess, review and revise the community health program in Liberia. The mixed method approach combines the use of an adapted tool to assess bottlenecks and solutions during workshops, a qualitative survey (key informant interviews and focus group discussions) to assess perceptions of challenges and perspectives from different stakeholders, and an inter-agency framework - a benchmarks matrix - to jointly review program implementation gaps using the evidence compiled, and identify priorities to scale up of the community program. RESULTS: Stakeholders identified key health system challenges and proposed policy and programmatic shifts to institutionalize a standardized community health program with fit for purpose and incentivized community health assistants to provide PHC services to the targeted populations. The community health program in Liberia is currently at the phase of implementation and requires strengthened leadership, local capacities, and resources for sustainability. Lessons learned from this review included the importance of: establishing a coordination mechanism and leveraging partnership support; using a systems approach to better inform policy shifts; strengthening community engagement; and conducting evidence-based planning to inform policy-makers. CONCLUSIONS: This article contributes toward the existing body of knowledge about policy development processes and reforms on community health in Liberia, and most likely other African settings with weak health systems. Community-based systems will play an even bigger role as we move toward building resilience for future shocks and strengthening PHC, which will require that communities be viewed as actors in the health system rather than just clients of health services.

Contact tracing performance during the Ebola epidemic in Liberia, 2014-2015.

BACKGROUND: During the Ebola virus disease (EVD) epidemic in Liberia, contact tracing was implemented to rapidly detect new cases and prevent further transmission. We describe the scope and characteristics of contact tracing in Liberia and assess its performance during the 2014-2015 EVD epidemic. METHODOLOGY/PRINCIPAL FINDINGS: We performed a retrospective descriptive analysis of data collection forms for contact tracing conducted in six counties during June 2014-July 2015. EVD case counts from situation reports in the same counties were used to assess contact tracing coverage and sensitivity. Contacts who presented with symptoms and/or died, and monitoring was stopped, were classified as "potential cases". Positive predictive value (PPV) was defined as the proportion of traced contacts who were identified as potential cases. Bivariate and multivariate logistic regression models were used to identify characteristics among potential cases. We analyzed 25,830 contact tracing records for contacts who had monitoring initiated or were last exposed between June 4, 2014 and July 13, 2015. Contact tracing was initiated for 26.7% of total EVD cases and detected 3.6% of all new cases during this period. Eighty-eight percent of contacts completed monitoring, and 334 contacts were identified as potential cases (PPV = 1.4%). Potential cases were more likely to be detected early in the outbreak; hail from rural areas; report multiple exposures and symptoms; have household contact or direct bodily or fluid contact; and report nausea, fever, or weakness compared to contacts who completed monitoring. CONCLUSIONS/SIGNIFICANCE: Contact tracing was a critical intervention in Liberia and represented one of the largest contact tracing efforts during an epidemic in history. While there were notable improvements in implementation over time, these data suggest there were limitations to its performance-particularly in urban districts and during peak transmission. Recommendations for improving performance include integrated surveillance, decentralized management of multidisciplinary teams, comprehensive protocols, and community-led strategies.

Community health workers during the Ebola outbreak in Guinea, Liberia, and Sierra Leone.

BACKGROUND: The role of community health workers (CHWs) in the West Africa Ebola outbreak has been highlighted to advocate for increasing numbers of CHWs globally to build resilience, strengthen health systems, and provide emergency response capacity. However, the roles CHWs played, the challenges they faced, and their effectiveness during the outbreak are not well documented. This study assessed the impact of Ebola on community-based maternal, newborn, and child health (MNCH) services, documented the contribution of CHWs and other community-based actors to the Ebola response, and identified lessons learned to strengthen resilience in future emergencies. METHODS: This mixed methods study was conducted in Guinea, Liberia, and Sierra Leone, with data collected in four Ebola-affected districts of each country. Qualitative data were collected through in-depth interviews and focus group discussions with stakeholders at national, district, and community levels. Quantitative program data were used to assess trends in delivery of community-based MNCH services. RESULTS: There was a sharp decline in MNCH service provision due to weak service delivery, confusion over policy, and the overwhelming nature of the outbreak. However, many CHWs remained active in their communities and were willing to continue providing services. When CHWs received clear directives and were supported, service provision rebounded. Although CHWs faced mistrust and hostility from community members because of their linkages to health facilities, the relationship between CHWs and communities proved resilient over time, and CHWs were more effectively able to carry out Ebola-related activities than outsiders. Traditional birth attendants, community health committees, community leaders, and traditional healers also played important roles, despite a lack of formal engagement or support. Service delivery weaknesses, especially related to supply chain and supervision, limited the effectiveness of community health services before, during, and after the outbreak. CONCLUSIONS: CHWs and other community-level actors played important roles during the Ebola outbreak. However, maintenance of primary care services and the Ebola response were hampered because community actors were engaged late in the response and did not receive sufficient support. In the future, communities should be placed at the forefront of emergency preparedness and response plans and they must be adequately supported to strengthen service delivery.

The 2014-2015 Ebola virus disease outbreak and primary healthcare delivery in Liberia: Time-series analyses for 2010-2016.

BACKGROUND: The aim of this study is to estimate the immediate and lasting effects of the 2014-2015 Ebola virus disease (EVD) outbreak on public-sector primary healthcare delivery in Liberia using 7 years of comprehensive routine health information system data. METHODS AND FINDINGS: We analyzed 10 key primary healthcare indicators before, during, and after the EVD outbreak using 31,836 facility-month service outputs from 1 January 2010 to 31 December 2016 across a census of 379 public-sector health facilities in Liberia (excluding Montserrado County). All indicators had statistically significant decreases during the first 4 months of the EVD outbreak, with all indicators having their lowest raw mean outputs in August 2014. Decreases in outputs comparing the end of the initial EVD period (September 2014) to May 2014 (pre-EVD) ranged in magnitude from a 67.3% decrease in measles vaccinations (95% CI: -77.9%, -56.8%, p < 0.001) and a 61.4% decrease in artemisinin-based combination therapy (ACT) treatments for malaria (95% CI: -69.0%, -53.8%, p < 0.001) to a 35.2% decrease in first antenatal care (ANC) visits (95% CI: -45.8%, -24.7%, p < 0.001) and a 38.5% decrease in medroxyprogesterone acetate doses (95% CI: -47.6%, -29.5%, p < 0.001). Following the nadir of system outputs in August 2014, all indicators showed statistically significant increases from October 2014 to December 2014. All indicators had significant positive trends during the post-EVD period, with every system output exceeding pre-Ebola forecasted trends for 3 consecutive months by November 2016. Health system outputs lost during and after the EVD outbreak were large and sustained for most indicators. Prior to exceeding pre-EVD forecasted trends for 3 months, we estimate statistically significant cumulative losses of -776,110 clinic visits (95% CI: -1,480,896, -101,357, p = 0.030); -24,449 bacille Calmette-Guérin vaccinations (95% CI: -45,947, -2,020, p = 0.032); -9,129 measles vaccinations (95% CI: -12,312, -5,659, p < 0.001); -17,191 postnatal care (PNC) visits within 6 weeks of birth (95% CI: -28,344, -5,775, p = 0.002); and -101,857 ACT malaria treatments (95% CI: -205,839, -2,139, p = 0.044) due to the EVD outbreak. Other outputs showed statistically significant cumulative losses only through December 2014, including losses of -12,941 first pentavalent vaccinations (95% CI: -20,309, -5,527, p = 0.002); -5,122 institutional births (95% CI: -8,767, -1,234, p = 0.003); and -45,024 acute respiratory infections treated (95% CI: -66,185, -24,019, p < 0.001). Compared to pre-EVD forecasted trends, medroxyprogesterone acetate doses and first ANC visits did not show statistically significant net losses. ACT treatment for malaria was the only indicator with an estimated net increase in system outputs through December 2016, showing an excess of +78,583 outputs (95% CI: -309,417, +450,661, p = 0.634) compared to pre-EVD forecasted trends, although this increase was not statistically significant. However, comparing December 2013 to December 2017, ACT malaria cases have increased 49.2% (95% CI: 33.9%, 64.5%, p < 0.001). Compared to pre-EVD forecasted trends, there remains a statistically significant loss of -15,144 PNC visits within 6 weeks (95% CI: -29,453, -787, p = 0.040) through December 2016. CONCLUSIONS: The Liberian public-sector primary healthcare system has made strides towards recovery from the 2014-2015 EVD outbreak. All primary healthcare indicators tracked have recovered to pre-EVD levels as of November 2016. Yet, for most indicators, it took more than 1 year to recover to pre-EVD levels. During this time, large losses of essential primary healthcare services occurred compared to what would have been expected had the EVD outbreak not occurred. The disruption of malaria case management during the EVD outbreak may have resulted in increased malaria cases. Large and sustained investments in public-sector primary care health system strengthening are urgently needed for EVD-affected countries.