Bedaquiline Resistance after Effective Treatment of Multidrug-Resistant Tuberculosis, Namibia.

Bedaquiline is currently a key drug for treating multidrug-resistant or rifampin-resistant tuberculosis. We report and discuss the unusual development of resistance to bedaquiline in a teenager in Namibia, despite an optimal background regimen and adherence. The report highlights the risk for bedaquiline resistance development and the need for rapid drug-resistance testing.

Malaria elimination and the need for intensive inter-country cooperation. a critical evaluation of regional technical co-operation in Southern Africa.

BACKGROUND: Malaria elimination requires closely co-ordinated action between neighbouring countries. In Southern Africa several countries have reduced malaria to low levels, but the goal of elimination has eluded them thus far. The Southern Africa Development Community (SADC) Malaria Elimination Eight (E8) initiative was established in 2009 between Angola, Botswana, Eswatini, Mozambique, Namibia, South Africa, Zambia, and Zimbabwe to coordinate malaria interventions aiming to eliminate malaria by 2030. Cross-border coordination is important in malaria elimination settings as it strengthens surveillance, joint planning and implementation, knowledge exchange and optimal use of resources. This paper describes how this collaboration is realized in practice, its achievements and challenges, and its significance for malaria elimination prospects. METHODS: The ministers of health of the E8 countries oversee an intergovernmental technical committee supported by specialist working groups consisting of technical personnel from member countries and partner institutions. These technical working groups are responsible for malaria elimination initiatives in key focus areas such as surveillance, vector control, diagnosis, case management, behaviour change and applied research. The technical working groups have initiated and guided several collaborative projects which lay essential groundwork for malaria elimination. RESULTS: The E8 collaboration has yielded achievements in the following key areas. (1) Establishment and evaluation of malaria border health posts to improve malaria services in border areas and reduce malaria among resident and, mobile and migrant populations. (2) The development of a regional malaria microscopy slide bank providing materials for diagnostic training and proficiency testing. (3) A facility for regional external competency assessment and training of malaria microscopy trainers in collaboration with the World Health Organization. (4) Entomology fellowships that improved capacity in entomological surveillance; an indoor residual spraying (IRS) training of trainers' scheme to enhance the quality of this core intervention in the region. (5) Capacity development for regional malaria parasite genomic surveillance. (6) A mechanism for early detection of malaria outbreak through near real time reporting and a quarterly bulletins of malaria incidence in border districts. CONCLUSIONS: The E8 technical working groups system embodies inter-country collaboration of malaria control and elimination activities. It facilitates sustained interaction between countries through a regional approach. The groundwork for elimination has been laid, but the challenge will be to maintain funding for collaboration at this level whilst reducing reliance on international donors and to build capacities necessary to prepare for malaria elimination.

Molecular epidemiology and antimicrobial resistance of vaginal Candida glabrata isolates in Namibia.

Candida glabrata is the most common non-albicans Candida species that causes vulvovaginal candidiasis (VVC). Given the intrinsically low susceptibility of C. glabrata to azole drugs, investigations into C. glabrata prevalence, fungal susceptibility profile, and molecular epidemiology are necessary to optimise the treatment of VVC. This molecular epidemiological study was conducted to determine antifungal drug profile, single nucleotide polymorphisms (SNPs) associated with phenotypic antifungal resistance and epidemic diversity of C. glabrata isolates from women with VVC in Namibia. Candida glabrata isolates were identified using phenotypic and molecular methods. Antifungal susceptibility of strains was determined for fluconazole, itraconazole, amphotericin B, and anidulafungin. Whole genome sequencing was used to determine SNPs in antifungal resistance genes and sequence type (ST) allocation. Among C. glabrata isolates, all (20/20; 100%) exhibited phenotypic resistance to the azole class antifungal drug, (fluconazole), and phenotypic susceptibility to the polyene class (amphotericin B), and the echinocandins (anidulafungin). Non-synonymous SNPs were identified in antifungal resistance genes of all fluconazole-resistant C. glabrata isolates including ERG6 (15%), ERG7 (15%), CgCDR1 (25%), CgPDR1 (60%), SNQ2 (10%), FKS1 (5.0%), FKS2 (5.0%), CgFPS1 (5.0%), and MSH2 (15%). ST15 (n = 8/20, 40%) was predominant. This study provides important insight into phenotypic and genotypic antifungal resistance across C. glabrata isolates from women with VVC in Namibia. In this study, azole resistance is determined by an extensive range of SNPs, while the observed polyene and echinocandin resistance-associated SNPs despite phenotypic susceptibility require further investigation.

Candida glabrata is inherently resistant to azole drugs. In this study, we identified a clone that was predominant in women with vulvovaginal candidiasis in Namibia, and that harboured various mutations in resistance-associated genes. This study provides important insight into antifungal resistance across C. glabrata isolates in a sub-Sahara African setting.

In sickness and health? Examining the co-occurrence and concordance of healthy lifestyle behaviours among spouses in Namibia.

OBJECTIVES: This study examines the extent to which healthy lifestyle behaviours co-occur in individuals. We also explore within-couples concordance in healthy lifestyle behaviours in Namibia. STUDY DESIGN: Cross-sectional study. METHODS: We used data from 910 couples (1820 individuals) who were interviewed in the Namibia Demographic and Health Survey conducted in 2013. We assessed five different healthy lifestyle behaviours (alcohol non-consumption, non-cigarette smoking, healthy diet, physical exercise, and normal body mass index). An individual healthy lifestyle index (HLI) was derived by summing values across the five behaviours, with a binary indicator categorising each individual's lifestyle behaviour as 'healthy' (HLI ≥ 3) or 'unhealthy' (HLI < 3). Multivariate logistic regression models were fitted to explore the association between binary indicators of men's and their female partner's healthy lifestyles. RESULTS: About 48% of men and 57% of women had at least three co-occurring healthy lifestyle behaviours. A third of couples were concordant in reporting a healthy lifestyle (HLI ≥ 3), while 27% were concordant in reporting an unhealthy lifestyle (HLI < 3). In multivariate analysis, Namibian men were almost twice (aOR, 1.90; 95%CI, 1.43-2.52) as likely to have a healthy lifestyle if their female partner also had a healthy lifestyle, compared with those who had a female partner who had an unhealthy lifestyle, after adjusting for relevant individual, partner and household characteristics. CONCLUSION: The observed co-occurrence of healthy lifestyle behaviours and spousal concordance suggests it may be beneficial to consider couples a target for intervention when aiming to promote healthy behaviours and reduce cardiovascular diseases in Namibia.

Policy framework that addresses malnutrition in Namibia: A retrospective qualitative review.

BACKGROUND: Although Namibia has made strides in improving the policy enabling environment, eradication of malnutrition is still elusive. OBJECTIVE: This review was aimed at determining the extent to which food and nutrition-related policies in Namibia address malnutrition. METHODS: This study used a qualitative approach by retrospectively analysing policy frameworks that address malnutrition in Namibia from 1991 to 2022. The analysis employed the policy triangle framework to elucidate the contextual factors, content, actors and process involved in the policy development. Moreover, a comparative analysis of Namibian policies and those of other southern African countries was undertaken. RESULTS: The review showed that there is a considerable degree of coherence in policy goals and strategies to address malnutrition despite parallel coordination structures. Policy process involved limited consultations with local communities which might have jeopardised the formulation of community problem-tailored interventions, ownership and participation in policy implementation. There is a strong political commitment to the eradication of malnutrition in Namibia. The Office of the Prime Minister played a leading role in policy development. Influential actors such as the UN agencies elevated the nutrition agenda. Further, the Namibian policy framework was generally similar to those of other southern African countries. CONCLUSIONS: The review showed that Namibia has relevant and comprehensive policies to address malnutrition, however, contextual factors indicated high levels of malnutrition still exist in the communities. Further research is needed to understand the barriers and enablers to optimal nutrition for children under five years in Namibia.

Factors affecting the adoption of circular economy in mining companies of developing economies - A Namibian stakeholder perspective.

The factors influencing the adoption and implementation of CE in developing countries are not yet fully examined. By focusing on the Namibian mining sector, this study highlights the perspectives of local stakeholders on CE adoption in a developing country. The mine managers recognized that waste is problematic and that CE practices are beneficial for mining companies and Namibia at large. Our findings also indicated that stronger academic institutions providing CE training and helping develop CE solutions, public awareness campaigns, financial support for CE practices, cooperation among industry stakeholders, and clear CE policy would all help drive the implementation of CE.

Ecotoxicological evaluation of surface waters in Northern Namibia.

The increasing pressure on freshwater systems due to intensive anthropogenic use is a big challenge in central-northern Namibia and its catchment areas, the Kunene and the Kavango Rivers, and the Cuvelai-Etosha Basin, that provide water for more than 1 million people. So far, there is no comprehensive knowledge about the ecological status and only few knowledge about the water quality. Therefore, it is crucial to learn about the state of the ecosystem and the ecological effects of pollutants to ensure the safe use of these resources. The surface waters of the three systems were sampled, and three bioassays were applied on three trophic levels: algae, daphnia, and zebrafish embryos. Additionally, in vitro assays were performed to analyze mutagenicity (Ames fluctuation), dioxin-like potential (micro-EROD), and estrogenicity (YES) by mechanism-specific effects. The results show that acute toxicity to fish embryos and daphnia has mainly been detected at all sites in the three catchment areas. The systems differ significantly from each other, with the sites in the Iishana system showing the highest acute toxicity. At the cellular level, only weak effects were identified, although these were stronger in the Iishana system than in the two perennial systems. Algae growth was not inhibited, and no cytotoxic effects could be detected in any of the samples. Mutagenic effects and an estrogenic potential were detected at three sites in the Iishana system. These findings are critical in water resource management as the effects can adversely impact the health of aquatic ecosystems and the organisms within them.

Risk Factors for Recent HIV Infections among Adults in 14 Countries in Africa Identified by Population-Based HIV Impact Assessment Surveys, 2015-2019.

Identifying persons who have newly acquired HIV infections is critical for characterizing the HIV epidemic direction. We analyzed pooled data from nationally representative Population-Based HIV Impact Assessment surveys conducted across 14 countries in Africa for recent infection risk factors. We included adults 15-49 years of age who had sex during the previous year and used a recent infection testing algorithm to distinguish recent from long-term infections. We collected risk factor information via participant interviews and assessed correlates of recent infection using multinomial logistic regression, incorporating each survey's complex sampling design. Compared with HIV-negative persons, persons with higher odds of recent HIV infection were women, were divorced/separated/widowed, had multiple recent sex partners, had a recent HIV-positive sex partner or one with unknown status, and lived in communities with higher HIV viremia prevalence. Prevention programs focusing on persons at higher risk for HIV and their sexual partners will contribute to reducing HIV incidence.

Factors associated with the unsuccessful TB treatment outcomes in the northern regions of Namibia: a mixed methods study.

BACKGROUND: Tuberculosis (TB) is among the leading causes of death globally. The disease has a huge burden in Namibia, with a case notification rate of at least 442 per 100,000. To date, Namibia is among the countries with the highest global TB burden, despite all efforts to reduce it. This study aimed to determine the factors associated with the unsuccessful treatment outcomes of the Directly Observed Therapy Short course (DOTS) programme in the Kunene and Oshana regions. METHODS: The study utilised a mixed-methods explanatory-sequential design to collect data from all TB patient records and healthcare workers who work directly with the DOTS strategy for TB patients. The relationship between independent and dependent variables was analysed using multiple logistic regression analysis, while interviews were analysed using inductive thematic analysis. RESULTS: The overall treatment success rates of the Kunene and Oshana regions throughout the review period were 50.6% and 49.4%, respectively. The logistic regression analyses showed that in the Kunene region, the type of DOT used (Community-based DOTS) (aOR = 0.356, 95% CI: 0.835-2.768, p = 0.006) was statistically significant with the unsuccessful treatment outcomes. While in the Oshana region, age groups 21-30 years old (aOR = 1.643, 95% CI = 1.005-2.686, p = 0.048), 31-40 years old (aOR = 1.725, 95% CI = 11.026-2.9, p = 0.040), 41-50 years old (aOR = 2.003, 95% CI = 1.155-3.476, p = 0.013) and 51-60 years old (aOR = 2.106, 95% CI = 1.228-3.612, p = 0.007) had statistically significant associations with the poor TB-TO. Inductive thematic analysis revealed that patients in the Kunene region were challenging to reach owing to their nomadic lifestyle and the vastness of the area, adversely affecting their ability to observe TB therapy directly. In the Oshana region, it was found that stigma and poor TB awareness among adult patients, as well as mixing anti-TB medication with alcohol and tobacco products among adult patients, was a prevalent issue affecting TB therapy. CONCLUSION: The study recommends that regional health directorates embark on rigorous community health education about TB treatment and risk factors and establish a robust patient observation and monitoring system to enhance inclusive access to all health services and ensure treatment adherence.

Health-related quality of life and healthcare consultations among adult patients before and after diagnosis with rheumatic heart disease in Namibia.

BACKGROUND: Rheumatic Heart Disease (RHD) causes high morbidity and mortality rates among children and young adults, impacting negatively on their health-related quality of life (HRQoL). This study aimed to evaluate the HRQoL and healthcare consultations of adult patients with RHD in Namibia. METHODS: From June 2019 to March 2020, a questionnaire was administered to 83 RHD patients during routine follow-ups. The EQ-5D-5L instrument was used to assess the health-related quality of life before diagnosis and at the time of the survey. The Ethiopian value set for EQ-5D-5L was used to calculate Quality-Adjusted Life Years (QALY). RESULTS: Most respondents were women (77%), young adults below the age of 30 years (42%), and individuals who grew up in rural areas (87%). The mean QALY statistically significantly improved from 0.773 pre-diagnosis to 0.942 in the last 12 months (p < 0.001). Sixty-six patients who had surgery reported a better QALY. Healthcare visits statistically significantly increased from on average 1.6 pre-diagnosis to 2.7 days in the last 12 months (p < 0.001). The mean distance to the nearest facility was 55 km, mean cost of transport was N$65, and mean time spent at the clinic was 3.6 h. The median time from diagnosis to the survey was 7 years (quartiles 4 and 14 years). CONCLUSION: Treatment and surgery can improve HRQoL substantially among RHD patients. Being diagnosed with RHD affects patients living in socioeconomically disadvantaged rural areas through cost and time for healthcare visits. It would be valuable with further research to understand differences between disease severities.

Adolescent suicidal behaviour in Namibia: a cross-sectional study of prevalence and correlates among 3,152 school learners aged 12-17 years.

BACKGROUND: While adolescent suicidal behaviour (ideation, planning, and attempt) remains a global public health concern, available county-specific evidence on the phenomenon from African countries is relatively less than enough. The present study was conducted to estimate the 12-month prevalence and describe some of the associated factors of suicide behaviour among school-going adolescents aged 12-17 years old in Namibia. METHODS: Participants (n = 4531) answered a self-administered anonymous questionnaire developed and validated for the nationally representative Namibia World Health Organization Global School-based Student Health Survey conducted in 2013. We applied univariate, bivariable, and multivariable statistical approaches to the data. RESULTS: Of the 3,152 analytical sample, 20.2% (95% confidence interval [CI]: 18.3-22.2%) reported suicidal ideation, 25.2% (95% CI: 22.3-28.4%) engaged in suicide planning, and 24.5% (95% CI: 20.9-28.6%) attempted suicide during the previous 12 months. Of those who attempted suicide, 14.6% (95% CI: 12.5-16.9%) reported one-time suicide attempt, and 9.9% (95% CI: 8.1-12.1%) attempted suicide at least twice in the previous 12 months. The final adjusted multivariable models showed physical attack victimisation, bullying victimisation, loneliness, and parental intrusion of privacy as key factors associated with increased likelihood of suicidal ideation, planning, one-time suicide attempt, and repeated attempted suicide. Cannabis use showed the strongest association with increased relative risk of repeated attempted suicide. CONCLUSION: The evidence highlights the importance of paying more attention to addressing the mental health needs (including those related to psychological and social wellness) of school-going adolescents in Namibia. While the current study suggests that further research is warranted to explicate the pathways to adolescent suicide in Namibia, identifying and understanding the correlates (at the individual-level, family-level, interpersonal-level, school context and the broader community context) of adolescent suicidal ideations and non-fatal suicidal behaviours are useful for intervention and prevention programmes.

Implementing quality management strategies improves clinical quality as a voluntary medical male circumcision program in Namibia matures: a process analysis.

BACKGROUND: Surgical voluntary medical male circumcision (VMMC) is a safe procedure; however, maintaining quality standards at scale, particularly during scale-up, is a challenge making ongoing quality management (QM) efforts essential. This study describes program quality measured by rates of adverse events (AEs) over four years of VMMC implementation in Namibia, compares AE rates over time, and discusses QM processes that contextualize AE trends and illustrate improvements in quality as the program matured. The International Training and Education Center for Health (I-TECH) assisted the Namibian Ministry of Health and Social Services (MoHSS) in expanding VMMC in three regions among boys and men over 10 years of age between January 2015 and September 2019. METHODS: A comprehensive package of QM strategies was implemented by multi-disciplinary onsite teams with support from national and international technical advisors. Retrospective routine MoHSS data from the VMMC register, client forms, and monthly AE reports were collected during implementation in the three regions to assess the impact of QM interventions on AEs and to calculate the proportion of clients who experienced AEs over time. The proportion of clients who experienced an AE over time was compared using a Cochran-Armitage test for trend. RESULTS: Between January 2015 and September 2019, 40,336 clients underwent VMMC and 593 (1.5%) clients experienced a post-operative AE in the three supported regions. The AE rate was highest in the first quarter of clinical service delivery in each region (January-March 2015 in Oshana and Zambezi, October-December 2017 in //Kharas) but declined over the implementation period as the program matured. This observed trend between program maturity and declining AE rates over time was significant (p < 0.001) when compared using a Cochran-Armitage test for trend. CONCLUSIONS: As the I-TECH-supported VMMC program matured, QM measures were introduced and routinized, and clinical quality improved over time with the rate of AEs decreasing significantly over the implementation period. Applying systematic and continuous QM processes and approaches across the continuum of VMMC services and considering local context can contribute to increased clinical safety. QM measures that are established in more mature program sites can be quickly adopted to respond to quality issues in program expansion sites.

Confidential Enquiry into Maternal Deaths in Namibia, 2018-2019: A Local Approach to Strengthen the Review Process and a Description of Review Findings and Recommendations.

OBJECTIVES: First objective was to strengthen the national maternal death review, by addressing local challenges with each step of the review cycle. Second objective was to describe review findings and compare these with available findings of previous reviews. METHODS: Confidential Enquiry into Maternal Deaths methodology was used to review maternal deaths. To improve reporting, the national committee focussed on addressing fear of blame among healthcare providers. Second focus was on dissemination of findings and acting on recommendations forthcoming the review. Reviewed were reported maternal deaths, that occurred between 1 April 2018 and 31 March 2019. RESULTS: Seventy maternal deaths were reported; for 69 (98.6%) medical records were available, compared to 80/119 (67.2%) in 2012-2015. Reported maternal mortality ratio increased with 48% (92/100,000 live births compared to 62/100,000 in 2012-2015). Obstetric haemorrhage was leading cause of death in the past three reviews. The "no name, no blame" policy, aiming to identify health system failures, rather than mistakes of individuals, was repeatedly explained to healthcare providers during facility visits. Recommendations based on findings of the review, such as retaining experienced staff, continuous in-service training and guidance, were shared with decision makers at regional and national levels. Healthcare providers received training based on review findings, which resulted in improved management of similar cases. CONCLUSIONS FOR PRACTICE: Enhanced implementation of Confidential Enquiry into Maternal Deaths was possible after addressing local challenges. Focussing on obtaining trust of healthcare providers and feeding back findings, resulted in better reporting and prevention of potential maternal deaths.

Water and sediment pollution of intensively used surface waters during a drought period - a case study in Central Northern Namibia.

Semiarid regions are often affected by water scarcity and poor water quality. Seasonal changes in precipitation and drought events increase the pressure of use on water bodies and their pollution. In Central Northern Namibia, a high seasonal intra- and inter-annual variability of precipitation caused a 5-year lasting drought period. In the semiarid region, ephemeral channels and water pans represent the main water source, besides the institutionalized water supply. No systematic analysis of its quality has been conducted so far. The states of the surface waters at the end of the dry season in 2017 and the end of the rainy seasons in 2018 and 2019 were characterized by the analysis of physical-chemical parameters, focusing on usability. The first results show coarse contamination of the waters, which results in high turbidity values. Salt concentrations, such as Ca2+ and Na+, greatly increased due to evaporation. Al is present in high concentrations in solid and liquid phases, which indicates direct anthropogenic pollution. Spatial differences are evident in the study area and based on the precipitation gradient, land use, and population density. The waters cannot be used as drinking water without prior treatment.

When wildlife comes to town: interaction of sylvatic and domestic host animals in transmission of Echinococcus spp. in Namibia.

The present study was conducted in the isolated desert town of Oranjemund in the far south of Namibia. It is an extremely arid region where no livestock husbandry is practiced and only animals adapted to the desert can be found. However, in and around the city, artificial irrigation maintains lush green patches of grass that attract wild animals, in particular oryx antelopes (Oryx gazella). In 2015 four oryx antelopes were euthanised due to poor conditions and a post-mortem examination was conducted. Two were found positive for cystic echinococcosis and 16 cysts were collected for molecular analyses. In addition, faecal samples from black-backed jackals (n=5) and domestic dogs (n=9), which were regularly observed to feed on oryx carcasses, were collected and taeniid eggs isolated. Parasite species identification of the cysts and eggs was done by amplifying and sequencing the mitochondrial nad1 gene. Both oryx antelopes were found infected with E. ortleppi and one co-infected with E. canadensis G6/7. Both Echinococcus species were able to develop fertile cysts in oryx, making oryx antelopes competent hosts for these parasites. Therefore, the analysis of faecal samples was of high interest and although the numbers were quite small, taeniid eggs were found in three out of five faecal samples of jackals and in all nine dog samples. However, species determination was only successful with two jackal and one dog sample. All three were positive for E. canadensis G6/7. The absence of E. ortleppi may be due to the low number of faecal samples examined. In our small study, we discovered a rather unique lifecycle of Echinococcus spp. between jackals and domestic dogs as definitive hosts and oryx antelopes as intermediate hosts. Here, the presence of E. canadensis G6/7 is of particular concern, as it is the second most important causative agent of CE in humans.

"Youth speaking truth to power": intersectional decolonial activism in Namibia.

This article portrays a recent movement towards intersectional activism in urban Namibia. Since 2020, young Namibian activists have come together in campaigns to decolonize public space through removing colonial monuments and renaming streets. These have been linked to enduring structural violence and issues of gender and sexuality, especially queer and women's reproductive rights politics, which have been expressly framed as perpetuated by coloniality. I argue that the Namibian protests amount to new political forms of intersectional decoloniality that challenge the notion of decolonial activism as identity politics. The Namibian case demonstrates that decolonial movements may not only emphatically not be steeped in essentialist politics but also that activists may oppose an identity-based politics which postcolonial ruling elites have promoted. I show that, for the Namibian movements' ideology and practice, a fully intersectional approach has become central. They consciously juxtapose colonial memory with a living vision for the future to confront and situate colonial and apartheid history. Young Namibian activists challenge the intersectional inequalities and injustices, which, they argue, postcolonial Namibia inherited from its colonial-apartheid past: class inequality, racism, sexism, homophobia, and gender-based violence.

Prevalence of depression, anxiety and burnout in medical students at the University of Namibia.

Background: There is an increased prevalence of depression, anxiety, and burnout among medical students worldwide with no information from Namibia. Aim: This study aimed to determine the prevalence and factors associated with depression, anxiety, and burnout among medical students at the University of Namibia (UNAM). Methods: A quantitative descriptive cross-sectional survey was conducted utilising a specially designed questionnaire for the study and standardised instruments to evaluate depression, anxiety, and burnout. Results: Of the 229 students in this study, 71.6% were female and 28.4% were male. The prevalence of depression, anxiety, and burnout was 43.6%, 30.6%, and 36.2%, respectively. The prevalence of emotional exhaustion (EX), cynicism (CY), and professional efficacy (EF) was 68.1% (n = 156), 77.3% (n = 177) and 53.3% (n = 122), respectively. In the final regression model, participants with a current psychiatric illness were more likely to screen positive for depression (adjusted odds ratio [aOR] 4.06, confidence interval [CI] 1.28-12.91; p = 0.02) and anxiety (aOR: 3.63, CI: 1.17-11.23; p = 0.03). Emotional exhaustion and cynicism were significantly associated with female gender (EX: aOR, 0.40, CI: 0.20-0.79; p = 0.01) (CY: aOR, 0.42, CI: 0.20-0.91; p = 0.03). Conclusion: More than one in three medical students at the UNAM were either depressed or burnt out. Contribution: This is the first study to highlight the mental health needs of medical students at the University of Namibia.

Viral Hepatitis E Outbreaks in Refugees and Internally Displaced Populations, sub-Saharan Africa, 2010-2020.

Hepatitis E virus is a common cause of acute viral hepatitis. We analyzed reports of hepatitis E outbreaks among forcibly displaced populations in sub-Saharan Africa during 2010-2020. Twelve independent outbreaks occurred, and >30,000 cases were reported. Transmission was attributed to poor sanitation and overcrowding.

Use of Project ECHO in Response to COVID-19 in Countries Supported by US President's Emergency Plan for AIDS Relief.

The US Centers for Disease Control and Prevention, with funding from the US President's Plan for Emergency Relief, implements a virtual model for clinical mentorship, Project Extension for Community Healthcare Outcomes (ECHO), worldwide to connect multidisciplinary teams of healthcare workers (HCWs) with specialists to build capacity to respond to the HIV epidemic. The emergence of and quick evolution of the COVID-19 pandemic created the need and opportunity for the use of the Project ECHO model to help address the knowledge requirements of HCW responding to COVID-19 while maintaining HCW safety through social distancing. We describe the implementation experiences of Project ECHO in 5 Centers for Disease Control and Prevention programs as part of their COVID-19 response, in which existing platforms were used to rapidly disseminate relevant, up-to-date COVID-19-related clinical information to a large, multidisciplinary audience of stakeholders within their healthcare systems.

Experiences of a dedicated Heart and Maternal Health Service providing multidisciplinary care to pregnant women with cardiac disease in a tertiary centre in Namibia.

OBJECTIVES: First, to describe the implementation process, benefits and challenges of a multidisciplinary service for pregnant women with cardiac disease in Namibia. Second, to assess pregnancy outcomes in this population. METHODS: In a tertiary hospital in Namibia, a multidisciplinary service was implemented by staff of obstetric and cardiology departments and included preconception counselling, provision of antenatal care and reliable contraception. Management guidelines developed for high-income settings were used, since no locally adapted guidelines were available. A cohort study was performed to assess cardiac, obstetric and fetal outcomes. Included were pregnant women with cardiac disease, referred to this service between 1 August 2016 and 31 July 2018. RESULTS: Important benefits of this service were the integrated approach, improved access to reliable contraception and insight into drivers of poor outcome. Several challenges with use of available guidelines were encountered, as contextual factors specific to lower-income settings were not taken into consideration, such as higher rates of infection or barriers to access care. The cohort consisted of 65 women. Cardiac disease was diagnosed for the first time in 16 (24.6%) women, of whom 11 had pre-existing cardiac disease. These women presented more often with heart failure than women with known heart disease (75.0% vs. 6.1%, RR 12.5, 95% CI 3.9-38.0). Five women died. Cardiac events occurred in twenty-two women of whom eight developed thromboembolic events and two endocarditis. The majority had no indication for prophylaxis, based on available guidelines. Fetal events occurred in 36 pregnancies. After pregnancy more than half of women (35/65, 53.8%) were using long-acting reversible contraception. CONCLUSIONS: Despite several barriers, it was possible to implement a multidisciplinary service in a high-burden setting. Cardiac and fetal event rates in this cohort were high. To improve outcomes the focus should be on availability of context-specific guidelines and better detection of cardiac disease.