Lessons learnt from the COVID-19 pandemic in selected countries to inform strengthening of public health systems: a qualitative study.

INTRODUCTION: The COVID-19 pandemic has prompted governments internationally to consider strengthening their public health systems. To support the work of Ireland's Public Health Reform Expert Advisory Group, the Health Information and Quality Authority, an independent governmental agency, was asked to describe the lessons learnt regarding the public health response to COVID-19 internationally and the applicability of this response for future pandemic preparedness. METHODS: Semi-structured interviews with key public health representatives from nine countries were conducted. Interviews were conducted in March and April 2022 remotely via Zoom and were recorded. Notes were taken by two researchers, and a thematic analysis undertaken. RESULTS: Lessons learnt from the COVID-19 pandemic related to three main themes: 1) setting policy; 2) delivering public health interventions; and 3) providing effective communication. Real-time surveillance, evidence synthesis, and cross-sectoral collaboration were reported as essential for policy setting; it was noted that having these functions established prior to the pandemic would lead to a more efficient implementation in a health emergency. Delivering public health interventions such as testing, contact tracing, and vaccination were key to limiting and or mitigating the spread of the SARS-CoV-2 virus. However, a number of challenges were highlighted such as staff capacity and burnout, delays in vaccination procurement, and reduced delivery of regular healthcare services. Clear, consistent, and regular communication of the scientific evidence was key to engaging citizens with mitigation strategies. However, these communication strategies had to compete with an infodemic of information being circulated, particularly through social media. CONCLUSIONS: Overall, functions relating to policy setting, public health interventions, and communication are key to pandemic response. Ideally, these should be established in the preparedness phase so that they can be rapidly scaled-up during a pandemic.

Dietary exposure to aflatoxin from maize and groundnut in young children from Benin and Togo, West Africa.

Aflatoxins are a family of fungal toxins that are carcinogenic to man and cause immunosuppression, cancer and growth reduction in animals. We conducted a cross-sectional study among 480 children (age 9 months to 5 years) across 4 agro-ecological zones (SS, NGS, SGS and CS) in Benin and Togo to identify the effect of aflatoxin exposure on child growth and assess the pattern of exposure. Prior reports on this study [Gong, Y.Y.,Cardwell, K., Hounsa, A., Egal, S., Turner, Hall, A.J., Wild, C.P., 2002. Dietary aflatoxin exposure and impaired growth in young children from Benin and Togo: cross sectional study. British Medical Journal 325, 20-21, Gong, Y.Y., Egal, S., Hounsa, A., Turner, P.C., Hall, A.J., Cardwell, K., Wild, C.P., 2003. Determinants of aflatoxin exposure in young children from Benin and Togo, West Africa: the critical role of weaning and weaning foods. International Journal of Epidemiology, 32, 556-562] showed that aflatoxin exposure among these children is widespread (99%) and that growth faltering is associated with high blood aflatoxin-albumin adducts (AF-alb adducts), a measure of recent past exposure. The present report demonstrates that consumption of maize is an important source of aflatoxin exposure for the survey population. Higher AF-alb adducts were correlated with higher A. flavus (CFU) infestation of maize (p=0.006), higher aflatoxin contamination (ppb) of maize (p<0.0001) and higher consumption frequencies of maize (p=0.053). The likelihood of aflatoxin exposure from maize was particularly high in agro-ecological zones where the frequency of maize consumption (SGS and CS), the presence of aflatoxin in maize (SGS) or the presence of A. flavus on maize (NGS and SGS) was relatively high. Socio-economic background did not affect the presence of A. flavus and aflatoxin in maize, but better maternal education was associated with lower frequencies of maize consumption among children from the northernmost agro-ecological zone (SS) (p=0.001). The impact of groundnut consumption on aflatoxin exposure was limited in this population. High AF-alb adduct levels were correlated with high prevalence of A. flavus and aflatoxin in groundnut, but significance was weak after adjustment for weaning status, agro-ecological zone and maternal socio-economic status (resp. p=0.091 and p=0.083). Ingestion of A. flavus and aflatoxin was high in certain agro-ecological zones (SS and SGS) and among the higher socio-economic strata due to higher frequencies of groundnut consumption. Contamination of groundnuts was similar across socio-economic and agro-ecological boundaries. In conclusion, dietary exposure to aflatoxin from groundnut was less than from maize in young children from Benin and Togo. Intervention strategies that aim to reduce dietary exposure in this population need to focus on maize consumption in particular, but they should not ignore consumption of groundnuts.

Determinants of aflatoxin exposure in young children from Benin and Togo, West Africa: the critical role of weaning.

BACKGROUND: Dietary exposure to high levels of the fungal toxin, aflatoxin, occurs in West Africa, where long-term crop storage facilitates fungal growth. METHODS: We conducted a cross-sectional study in Benin and Togo to investigate aflatoxin exposure in children around the time of weaning and correlated these data with food consumption, socioeconomic status, agro-ecological zone of residence, and anthropometric measures. Blood samples from 479 children (age 9 months to 5 years) from 16 villages in four agro-ecological zones were assayed for aflatoxin-albumin adducts (AF-alb) as a measure of recent past (2-3 months) exposure. RESULTS: Aflatoxin-albumin adducts were detected in 475/479 (99%) children (geometric mean 32.8 pg/mg, 95% CI: 25.3-42.5). Adduct levels varied markedly across agro-ecological zones with mean levels being approximately four times higher in the central than in the northern region. The AF-alb level increased with age up to 3 years, and within the 1-3 year age group was significantly (P = 0.0001) related to weaning status; weaned children had approximately twofold higher mean AF-alb adduct levels (38 pg AF-lysine equivalents per mg of albumin [pg/mg]) than those receiving a mixture of breast milk and solid foods after adjustment for age, sex, agro-ecological zone, and socioeconomic status. A higher frequency of maize consumption, but not groundnut consumption, by the child in the preceding week was correlated with higher AF-alb adduct level. We previously reported that the prevalence of stunted growth (height for age Z-score HAZ) and being underweight (weight for age Z-score WAZ) were 33% and 29% respectively by World Health Organziation criteria. Children in these two categories had 30-40% higher mean AF-alb levels than the remainder of the children and strong dose- response relationships were observed between AF-alb levels and the extent of stunting and being underweight. CONCLUSIONS: Exposure to this common toxic contaminant of West African food increases markedly following weaning and exposure early in life is associated with reduced growth. These observations reinforce the need for aflatoxin exposure intervention strategies within high-risk countries, possibly targeted specifically at foods used in the post-weaning period.

The Effect of Endophytic Fusarium verticillioides on Infestation of Two Maize Varieties by Lepidopterous Stemborers and Coleopteran Grain Feeders.

ABSTRACT A series of experiments were conducted to test the effect of the presence of Fusarium verticillioides in the maize plant on subsequent infestation by coleopteran and lepidopteran pests. The effect of percent internodes 1 to 5 infected with F. verticillioides, time after planting, and maize variety on attacks of stem and ears by lepidopterous and coleopteran pests was assessed in field experiments in early and late season 1998 and early season 1999 in Benin Republic. Artificial inoculation of the first internode with fungal-treated toothpicks was compared with a hot-water-fungicide seed treatment and a control. In 1998, two varieties that differed in husk tightness, the improved DMRLSR-W and the local Gbogbe, were used. Percentage of node 1 to 5 and plants infected was highest with the inoculation treatment but tended to be similar in the seed treatment and the control. The infection rate tended to increase with time and, within sampling date, decreased with node level. Ear infection was strongly correlated with percent infected nodes, indicating that F. verticillioides in the stem predisposed kernel infection. F. verticillioides incidence was higher in Gbogbe than in DMRLSR-W. Stem and ear infestations by the pyralid Eldana saccharina, the major pest in the area, tended to be highest in inoculation and lowest in the protection treatment. The same trends were found for the pyralid Chilo spp., the tortricid Cryptophlebia leucotreta, and beetles pooled across species. Significant positive correlations were found between ear/stem F. verticillioides infection and E. saccharina, Cryptophlebia leucotreta, Mussidia nigrivenella, and the noctuid Sesamia calamistis, but the latter three pest species were only significantly correlated with fungal infection of the upper nodes of the plant. Similar to disease incidence, E. saccharina numbers in stem and ear were higher in Gbogbe than DMRLSR-W in late 1998, whereas for the pyralid ear feeder M. nigrivenella, it was reversed. It was suggested that some lepidopterous and coleopteran pests are attracted by and survive longer (or have lower mortality) on plants infected with F. verticillioides.

Interactions Between Fusarium verticillioides, Aspergillus flavus, and Insect Infestation in Four Maize Genotypes in Lowland Africa.

ABSTRACT An experiment was designed to compare cycles of selection of four maize genotypes for ear- and grain-quality characteristics, interactions with Aspergillus flavus and Fusarium verticillioides infection, and insect ear infestation in two seasons. Mean infection levels by A. flavus and F. verticillioides were significantly higher in inoculated rows than in the controls. The F. verticillioides-inoculated rows had significantly more coleopteran beetles and lepidopteran borers per ear than the controls and A. flavus-inoculated rows. Genotypes and cycles of selection within genotype were not different with respect to number of insects or percent fungal incidence in the ear, but they were different for husk extension, field weight, 100-grain weight, and grain density. Inoculation with either fungus resulted in significantly higher percentage of floaters (i.e., loss of grain density) and lower grain weight than the controls. Aflatoxin (B1 and B2) in A. flavus-inoculated rows averaged 327 ppb in the first season and 589 ppb in the second (dryer) season. Fumonisin levels in F. verticillioides-inoculated rows did not differ between seasons, with an average of 6.2 ppm across seasons. In the noninoculated control rows, fumonisin was significantly higher in the first (5.3 ppm) than in the second (3.1 ppm) season. For all genotypes, husk extension and yield parameters decreased in the fungal-inoculated treatments. General ear-rot scoring was significantly correlated with incidence of F. verticillioides in kernels and grain-weight loss but not with A. flavus in the grain.

Resistance to aflatoxin accumulation in kernels of maize inbreds selected for ear rot resistance in West and Central Africa.

Thirty-six inbred lines selected in West and Central Africa for moderate to high resistance to maize ear rot under conditions of severe natural infection were screened for resistance to aflatoxin contamination using the previously established kernel screening assay. Results showed that more than half the inbreds accumulated aflatoxins at levels as low as or lower than the resistant U.S. lines GT-MAS:gk or MI82. In 10 selected aflatoxin-resistant or aflatoxin-susceptible inbreds, Aspergillus flavus growth, which was quantified using an A. flavus transformant containing a GUS-beta-tubulin reporter gene construct, was, in general, positively related to aflatoxin accumulation. However, one aflatoxin-resistant inbred supported a relatively high level of fungal infection, whereas two susceptibles supported relatively low fungal infection. When kernels of the 10 tested lines were profiled for proteins using sodium dodecyl sulfate-polyacrylamide gel electrophoresis, significant variations from protein profiles of U.S. lines were observed. Confirmation of resistance in promising African lines in field trials may significantly broaden the resistant germplasm base available for managing aflatoxin contamination through breeding approaches. Biochemical resistance markers different from those being identified and characterized in U.S. genotypes, such as ones inhibitory to aflatoxin biosynthesis rather than to fungal infection, may also be identified in African lines. These discoveries could significantly enhance the host resistance strategy of pyramiding different traits into agronomically useful maize germplasm to control aflatoxin contamination.

Marasmiellus Leaf Disease on Maize in West Africa.

A leaf disease of maize previously described as borde blanco (1) or horizontal banded blight (2) was recently observed for the first time in three West African countries. The symptom was white, dry lesions that grew phasically on the edge of the leaf, resulting in horizontal bands delineated by purple to brown margins. Minute basidiocarps (1 mm high) were seen in the white zone of the banded lesions, often arranged linearly. The appearance of the fungus was consistent with a report from Sierra Leone and Guinea Conakry of a basidiomycete on maize of the order Agaricales, Marasmiellus paspalli (Petch) Singer (2). Lamellae were lacking, replaced on mature basidiomes by up to four ridges, which concurred with the description of an unnamed West African variety (1). The pileus and stipe of the mushroom were consistently white when fresh, and light beige when mature. The fungus grew readily on potato dextrose agar, forming a cottony white colony with occasional dark stromatic tissue, and hyphae with abundant clamp connections. Out of over 100 fields visited in 1993 and 1994, the disease was seen in one site only in southern Cameroon in 1994. In 1997, it was found in all maize fields in four separate areas in the southern humid forest zone of that country. In Ghana in November 1996, it was prevalent in a survey of 60 fields, with leaf area losses from 30 to 40%. In August of 1997, the disease appeared in low incidence on maize in Nigeria. The appearance of the Marasmiellus disease in Cameroon, Nigeria, and Ghana in the last 3 years represents a geographic shift from where the pathogen has been previously reported (1,2). It is not known at this time if significant yield loss is being incurred. References: (1) F. M. Latterell and A. E. Rossi. Plant Dis. 68:728, 1984. (2) M. M. Payak and R. C. Sharma. Curr. Sci. 55:1135, 1986.

Distribution of Aspergillus Section Flavi among Field Soils from the Four Agroecological Zones of the Republic of Bénin, West Africa.

Certain members of Aspergillus section Flavi produce carcinogenic and immunotoxic metabo-lites called aflatoxins. These fungi perennate in soils and infect maize grain in the field and in storage. The distribution of Aspergillus section Flavi across the four different agroecologies of Bénin Republic was determined. The four agroecological zones range from humid equatorial tropics in the south to the dry savanna near the Sahara desert in the north. Soil samples collected in 1994 to 1996 from 44 different maize fields in Bénin were assayed over 3 years (88 samples total) for fungi in Aspergillus section Flavi. All soils tested contained A. flavus. Isolates (1,454 total) were collected by dilution plate from the soils and existed in populations ranging from <10 to >200 CFU/g of soil. CFU counts did not differ from year to year or change significantly with cropping systems within a zone, but differed significantly among zones. Incidence of A. flavus strain isolations varied from south to north, with greater number of CFU of L strain isolates in southern latitudes and higher numbers of CFU of S strain isolates found in the north. The L strain isolates occurred in 81 of 88 samples, whereas S strain isolates were in only 41 of 88 soil samples. Of 96 L strain isolates tested, 44% produced aflatoxins. Only B toxins were produced, and toxigenic isolates averaged over 100 µg of aflatoxin B1 per 70 ml of fermentation medium (~1.4 ppm). All S strain isolates produced both B and G aflatoxins, averaging over 557 µg of aflatoxin B1 per 70 ml (8 ppm) and 197 µg of aflatoxin G1 per 70 ml of fermentation me- dium (2.8 ppm). A. parasiticus and A. tamarii were present in less than 10% of the fields and were not associated with any particular agroecological zone.

Aspergillus flavus Infection and Aflatoxin Contamination of Preharvest Maize in Benin.

Eighty and sixty maize fields were sampled in 1994 and 1995, respectively, to monitor Aspergillus infection and aflatoxin contamination of preharvest maize in Benin. Three Aspergillus species were isolated from different agroecological zones, with A. flavus being the most prevalent. The countrywide mean percentage of kernel infection was about 20% in both years. Aflatoxin was extracted from maize in at least 30% of the fields sampled. Toxin concentrations exhibited a distinct zonal variation, with relatively high levels in the Guinea Savanna. There was a trend toward higher rate of aflatoxin accumulation per percentage A. flavus infection from the south to the north. Damage by the ear borer, Mussidia nigrivenella, increased aflatoxin accumulation in maize. Hence, the geographic pattern observed in the occurrence of A. flavus and aflatoxin may be related to the incidence of M. nigrivenella.

First Report of Aflatoxin in Dried Yam Chips in Benin.

Dried yam (Dioscorea spp.) chips are widely consumed in Bénin but are often attacked by molds. Invasion of food by Aspergillus flavus may lead to aflatoxin contamination. We report here the result of a survey on the sanitary quality of dried yam chips in Bénin. During July and August 2000, 50 dried yam chips samples were collected from different points in the marketing chain; 10 samples were collected from each of 5 stages: producers, wholesalers, retailers, dried yam-based food sellers and consumers. Aflatoxin content was assayed by the bio-luminescence method (1) after methanol/water extraction. Aflatoxins were detected in all dried yam chip samples, with levels ranging from 2.2 to 200 ppb and a mean value of 14 ppb. An aflatoxin concentration higher than the European Union's maximum residue limit (MRL) of 4 ppb was found in 98% of the samples (N = 50), while 6% had an aflatoxin concentration higher than the World Health Organization's MRL of 20 ppb. Molds were analyzed from two samples, each with aflatoxin levels around 5 ppb, on colony unit medium specific for A. flavus (2). Aspergillus spp. were detected in the inner part of dried yam chips of both samples, with a mean level of 9,000 CFU/g. Fusarium colonies were also present but were not identified to species. References: (1) D. Champiat and J. Larpent. Bio-chimie-luminescence: Principes et Applications. Masson, Paris, France. 1993. (2) P. J. Cotty. Mycopathologia 125:157, 1994.

Distribution, relative importance and effect of lepidopterous borers on maize yields in the forest zone and mid-altitude of Cameroon.

Geographic distribution, relative importance, and effect of lepidopterous stem and ear borers on maize, Zea mays L., were studied in the humid forest and the mid-altitude zones of Cameroon from 1994 to 1997. Six villages were chosen in the forest zone and grouped into three blocks representing gradients in human population density. A single block with three villages was chosen in the mid-altitude. Farmers' maize fields were surveyed during the vegetative growth phase for Busseola fusca (Fuller) egg batches, and at harvest for number of larvae and pupae by species, plant damage, and ear weight. There was no significant block effect for any of the variables measured, and most of the overall variance (72-99%) was attributed to within-field variability. In the forest zone, the noctuid B. fusca and the pyralid Eldana saccharina (Walker) accounted for >80% of all species in almost all locations, followed by the pyralid Mussidia nigrivenella (Ragonot) and the tortricid Cryptophlebia leucotreta (Meyrick). The noctuid Sesamia calamistis (Hampson) was found in almost all locations during the first season but disappeared in most locations in the second season. B. fusco egg infestation was significantly higher during the second compared with the first season, whereas larval and pupal densities were much higher during the first season. E. saccharina was the predominant species during the second season, when densities increased fourfold. In the mid-altitude, B. fusca was the predominant species. No significant differences in pest densities, plant damage, and ear weight were found between years. Results of stepwise regression of stem and ear damage on pest densities verified the relative importance of the individual species. In the forest zone, ear and stem damage significantly reduced ear weight, whereas in the mid-altitude only stem tunneling was significant.

Public information campaign on aflatoxin contamination of maize grains in market stores in Benin, Ghana and Togo.

Rotary International with the International Institute of Tropical Agriculture (IITA) conducted an information campaign from 2000 to 2004 to increase public awareness of aflatoxin in Benin, Ghana and Togo. Key informant interviews with 2416 respondents showed poor baseline knowledge of aflatoxin and its health risks. The campaign included monitoring of aflatoxin contamination in maize grains from market stores in 38 cities and towns. Aflatoxin concentration in contaminated samples ranged from 24 to 117.5 ng g(-1) in Benin, from 0.4 to 490.6 ng g(-1) in Ghana, and from 0.7 to 108.8 ng g(-1) in Togo. The campaign significantly increased public awareness that populations were exposed to high levels of aflatoxin. The number of maize traders who were informed about the toxin increased 10.3 and 3.2 times in Togo and Benin, respectively; at least 33% more traders believed the information in each of Benin and Togo; 11.4 and 28.4% more consumers sorted out and discarded bad grains in Benin and Ghana, respectively. This paper concludes that sustained public education can help reduce aflatoxin contamination.

Divergence of West African and North American communities of Aspergillus section Flavi.

West African Aspergillus flavus S isolates differed from North American isolates. Both produced aflatoxin B1. However, 40 and 100% of West African isolates also produced aflatoxin G1 in NH4 medium and urea medium, respectively. No North American S strain isolate produced aflatoxin G1. This geographical and physiological divergence may influence aflatoxin management.