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BACKGROUND: Afghanistan introduced monovalent rotavirus vaccine (Rotarix) into its national immunisation schedule in January, 2018. While post-licensure studies have shown substantial declines in rotavirus gastroenteritis cases and deaths globally, there is little evidence of rotavirus vaccine effectiveness and impact from low-income countries in Asia. We aimed to evaluate the effectiveness of the Rotarix vaccine and the impact of Rotarix vaccine on rotavirus gastroenteritis hospitalisations (ie, hospital admissions) among children younger than 5 years in Afghanistan. METHODS: We used a test-negative case-control design embedded in an active sentinel surveillance platform to evaluate vaccine effectiveness. Children born on or after Jan 1, 2018, who had documentation of their rotavirus vaccination status and who were admitted for acute gastroenteritis at one of four sentinel hospitals from May, 2018 to December, 2021 were eligible to be included. We used an unconditional logistic regression model to estimate vaccine effectiveness and 95% CIs for a complete series of doses compared with no rotavirus vaccine doses among patients admitted with acute gastroenteritis. Vaccine effectiveness against hospitalisation was calculated as (1â-â[odds of being vaccinated in cases]â/â[odds of being vaccinated in controls])â×â100%. We compared pre-vaccine (2013-15) and post-vaccine (2019-21) surveillance data from two sites to calculate vaccine impact. FINDINGS: The vaccine effectiveness analysis included 1172 cases and 2173 controls. Approximately 2108 (63·0%) of 3345 cases and controls were male, 1237 (37·0%) were female, and 2171 (65·0%) were aged 6-11 months. Two doses of Rotarix were 45% (95% CI 22-62) effective against rotavirus hospitalisation in children aged 6-59 months, adjusting for age, severity, admission year, and rotavirus season. Rotavirus positivity decreased from 51% pre-vaccine to 39% post-vaccine, resulting in a 39% adjusted reduction in rotavirus positivity among children younger than 5 years admitted with acute gastroenteritis. INTERPRETATION: Rotarix showed moderate effectiveness in preventing rotavirus gastroenteritis hospitalisations, consistent with findings in other low-income countries. These findings support the continued administration of the rotavirus vaccine in Afghanistan. FUNDING: Gavi, the Vaccine Alliance. TRANSLATION: For the Dari translation of the abstract see Supplementary Materials section.
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Gastroenteritis , Infecciones por Rotavirus , Vacunas contra Rotavirus , Eficacia de las Vacunas , Humanos , Vacunas contra Rotavirus/administración & dosificación , Infecciones por Rotavirus/prevención & control , Infecciones por Rotavirus/epidemiología , Afganistán/epidemiología , Estudios de Casos y Controles , Lactante , Masculino , Femenino , Preescolar , Gastroenteritis/prevención & control , Gastroenteritis/virología , Gastroenteritis/epidemiología , Eficacia de las Vacunas/estadística & datos numéricos , Vacunas Atenuadas/administración & dosificación , Hospitalización/estadística & datos numéricos , Vigilancia de Guardia , Vacunación/estadística & datos numéricosRESUMEN
Background: Noncommunicable diseases (NCDs) are the main reasons of mortality worldwide. One of every two person is dying due to NCDs in Afghanistan. International policy actors, mainly the World Health Organization (WHO), published several reports and declarations on controlling and preventing NCDs. This study aimed to provide a situation for governance of NCDs in Afghanistan and proper solutions for identified challenges. Methods: We conducted qualitative research utilizing interpretive phenomenology. A self-developed questionnaire was developed to conduct the semi-structured interviews with 39 experts from Afghanistan. The results were analyzed using a deductive framework analysis. Six building block framework of health system developed by the WHO was used as predefined framework for this study. Results: The governance building block of health system consists of five subthemes including policy making, planning, organizing, stewardship, and control. We identified main strengths, weaknesses, opportunities, and challenges for these subthemes. The experts also provided key recommendations to address the challenges. Conclusions: Management of NCDs is a neglected part of the health system in Afghanistan. Strengthening evidence-based policy making with technical and indigenous planning, establishing responsive units with adequate financial and human resources within different ministries to address "health in all policies" concept, passing and implementing national laws and regulations to support national strategies for prevention and control of NCDs, and establishing decentralized monitoring systems to control the implementation of these strategies are the main recommendations of this study. Local government and international policy actors should invest and support the development of a multisectoral coordination system at national level for Afghanistan.
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BACKGROUND: In January 2018, Afghanistan introduced the monovalent oral rotavirus vaccine (Rotarix) nationwide, administered as a 2-dose series at six and ten weeks of age. We describe characteristics of intussusception cases and assess potential intussusception risk associated with Rotarix vaccination in Afghan infants. METHODS: Multi-center prospective active hospital-based surveillance for intussusception was conducted from May 2018 to March 2022 in four sentinel sites in Afghanistan. We applied the Brighton Level 1 criteria for intussusception and verified vaccination status by reviewing vaccine cards. We used the self-controlled case series (SCCS) methodology to compare intussusception incidence in the 1 to 21 days after each dose of Rotarix vaccination against non-risk periods. RESULTS: A total of 468 intussusception cases were identified in infants under 12 months, with 264 cases aged between 28 and 245 days having confirmed vaccination status contributing to the SCCS analysis. Most case-patients (98 %) required surgery for treatment, and over half (59 %) of those who underwent surgery required intestinal resection. Nineteen (7 %) case-patients died. Eighty-six percent of case-patients received the first dose of Rotarix, and 69 % received the second dose before intussusception symptom onset. There was no increased risk of intussusception in the 1-7 days (relative incidence: 0.9, 95 % CI: 0.1, 7.5), 8-21 days (1.3, 95 % CI: 0.4, 4.2), or 1-21 days (1.1, 95 % CI: 0.4, 3.4) following receipt of the first dose or in the 1-7 days (0.2, 95 % CI: 0.3, 1.8), 8-21 days (0.7, 95 % CI: 0.3, 1.5), or 1-21 days (0.6, 95 % CI: 0.3, 1.2) following the second dose. CONCLUSION: Rotarix vaccination was not associated with an increased intussusception risk, supporting its continued use in Afghanistan's immunization program. However, there was a high level of death and resection due to intussusception among Afghan infants.
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Intususcepción , Infecciones por Rotavirus , Vacunas contra Rotavirus , Lactante , Humanos , Vacunas contra Rotavirus/efectos adversos , Intususcepción/inducido químicamente , Intususcepción/epidemiología , Afganistán/epidemiología , Estudios Prospectivos , Vacunas Atenuadas/efectos adversos , Vacunación/efectos adversos , Vigilancia de Productos Comercializados , Infecciones por Rotavirus/epidemiología , Infecciones por Rotavirus/prevención & control , Infecciones por Rotavirus/complicacionesRESUMEN
Rotavirus vaccines have substantially decreased rotavirus hospitalizations in countries where they have been implemented. In some high- and middle-income countries, a low-level of increased risk of intussusception, a type of acute bowel obstruction, has been detected following rotavirus vaccination. However, no increased risk of intussusception was found in India, South Africa, or a network of 7 other African countries. We assessed the association between a 2-dose monovalent rotavirus vaccine (Rotarix) and intussusception in 3 early-adopter low-income Asian countries -- Afghanistan, Myanmar, and Pakistan. Children <12 months of age admitted to a sentinel surveillance hospital with Brighton level 1 intussusception were eligible for enrollment. We collected information about each child's vaccination status and used the self-controlled case series method to calculate the relative incidence of intussusception 1-7 days, 8-21 days, and 1-21 days following each dose of vaccine and derived confidence intervals with bootstrapping. Of the 585 children meeting the analytic criteria, the median age at intussusception symptom onset was 24 weeks (IQR: 19-29). Overall, 494 (84 %) children received the first Rotarix dose and 398 (68 %) received the second dose. There was no increased intussusception risk during any of the risk periods following the first (1-7 days: 1.01 (95 %CI: 0.39, 2.60); 8-21 days: 1.37 (95 %CI: 0.81, 2.32); 1-21 days: 1.28 (95 %CI: 0.78, 2.11)) or second (1-7 days: 0.81 (95 %CI: 0.42, 1.54); 8-21 days: 0.77 (95 %CI: 0.53, 1.16); 1-21 days: 0.78 (95 %CI: 0.53, 1.16)) rotavirus vaccine dose. Our findings are consistent with other data showing no increased intussusception risk with rotavirus vaccination in low-income countries and add to the growing body of evidence demonstrating safety of rotavirus vaccines.
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Intususcepción , Infecciones por Rotavirus , Vacunas contra Rotavirus , Rotavirus , Humanos , Lactante , Intususcepción/inducido químicamente , Intususcepción/epidemiología , Pakistán/epidemiología , Infecciones por Rotavirus/epidemiología , Infecciones por Rotavirus/prevención & control , Infecciones por Rotavirus/complicaciones , Vacunas contra Rotavirus/efectos adversos , Sudáfrica , Vacunación/efectos adversosRESUMEN
Background: Afghanistan is suffering from 40-year chronic conflicts, displacement, and demolition of its infrastructure. Afghanistan mortality survey 2010 shows nearly 46% of all deaths in the country were attributed to noncommunicable diseases (NCDs). In this study, we aimed to understand the differences in mortality and premature death due to NCDs by sex and the trend for the next 8 years. Methods: We applied trend analysis using the secondary data from the Institute for Health Metrics and Evaluation, Global Burden of Diseases 2019. The information on NCD mortality, NCD deaths attributed to its risk factors, NCD percent of total years lived with disability (YLDs) attribution to each risk factor extracted from this database from 2008 to 2019. We investigated the trend from 2008 to 2019 for the mentioned factors and then forecast their trends until 2030. Results: Our study shows that Afghanistan has had an increasing death number due to NCDs from 2008 to 2019 (50% for both sexes) and this will reach nearly 54% by 2030. Currently, half of NCDs deaths are premature in Afghanistan. The mortality rate and prevalence of risk factors are higher among women. More than 70% of YLDs will be due to NCDs in Afghanistan till 2030. Five risk factors including high systolic blood pressure (28.3%), high body mass index (23.4%), high blood glucose (20.6%), high low-density lipoprotein cholesterol (16.3%), and smoking (12.3%) will have the highest contribution to NCDs death in 2030, respectively. Conclusions: In general, our study indicates that without any specific intervention to address NCDs in Afghanistan, not only the Sustainable Development Goal target for NCDs will not be met, but an increase in almost all risk factors prevalence, as well as NCD mortality, will be seen in Afghanistan.
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In 2017, in the middle of the armed conflict with the Taliban, the Ministry of Public Health decided that the Afghan health system needed a well-defined priority package of health services taking into account the increasing burden of non-communicable diseases and injuries and benefiting from the latest evidence published by DCP3. This leads to a 2-year process involving data analysis, modelling and national consultations, which produce this Integrated Package of Essential health Services (IPEHS). The IPEHS was finalised just before the takeover by the Taliban and could not be implemented. The Afghanistan experience has highlighted the need to address not only the content of a more comprehensive benefit package, but also its implementation and financing. The IPEHS could be used as a basis to help professionals and the new authorities to define their priorities.
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Servicios de Salud , Salud Pública , Humanos , AfganistánRESUMEN
Non-communicable diseases (NCDs) and their risk factors are the leading cause of death worldwide and contribute to 74.3% of deaths globally in 2019. The burden of NCDs is escalating in Afghanistan. Currently, every seconds, people in Afghanistan are dying of NCDs. Addressing this challenge in Afghanistan needs effective and practical interventions. This study aimed to identify the strategies developed and implemented in countries with low non-communicable premature death. To conduct a scoping review, we followed the six-step Arksey and O'Malley protocol and searched for eligible articles on eight international databases and the gray literature. The study followed the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) guidelines. The inclusion criteria were English documents and evidence produced up to 30 November 2021 for the control of NCDs. We excluded incomplete texts, duplicates, and dissertations due to lack of access. We used EndNote X9 and MaxQDA software for data management and analysis. We conducted content analysis for this study. A total of 122 documents developed between 1984 and 2021 met the inclusion criteria. We identified 35 strategies from which the most used strategies were related to unhealthy diets and smoking cessation programs. Canada (26.4%), Korea (19.8%), and the United Kingdom (19%) have the most publications on the control and prevention of NCDs among the countries included in the study. Most strategies were implemented over 2 years (41%). This study recommends specific interventions to control and prevent NCDs for the main risk factors of tobacco use, unhealthy diet, physical inactivity, and the main non-communicable diseases such as heart diseases, cancers, diabetes, and chronic obstructive pulmonary diseases. Afghanistan Ministry of Public Health, the WHO country office, and other involved stakeholders can use the findings of this review to design and implement strategies for controlling and preventing NCDs in Afghanistan. International organizations such as the World Health Organization, United Nations Agencies, the World Bank, and other involving communities should invest in strengthening good health governance in Afghanistan. The Afghan Government should focus on promoting and funding health literacy among the public and self-care to control and prevent NCDs.
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Diabetes Mellitus , Enfermedades no Transmisibles , Humanos , Afganistán , Atención a la Salud , Factores de RiesgoRESUMEN
Background: The Afghanistan Reconstruction Trust Fund, managed by the World Bank through a contracted-out instrument called Sehatmandi, financed health service delivery in Afghanistan, with substantial achievements in infant, child and maternal health. After the collapse of the Afghan Government on 15 August 2021, the health system has been on the brink of collapse. Aims: We assessed the use of basic health services and estimated excess mortality resulting from the interruption to healthcare funding. Methods: We conducted a cross-sectional study that compared health services utilization from June to September for 3 consecutive years, 2019, 2020 and 2021, using 11 output indicators reported by the health management and information system. We used the Lives Saved Tool, a linear mathematical model with input data from the Afghanistan Demographic Health Survey 2015, to calculate the additional maternal, neonatal and child mortality at 25%, 50%, 75% and 95% reduction in health coverage. Results: During August and September 2021, after the announced ban on financing, health service utilization decreased to a range of 7-59%. Family planning, major surgeries and postnatal care showed the greatest decreases. Uptake of child immunization showed one-third decrease. Sehatmandi provides around 75% of primary and secondary health services: pausing funds to this programme will result in additional 2862 maternal deaths, 15 741 neonatal deaths, 30 519 child deaths, and 4057 stillbirths. Conclusion: Sustaining the current level of health services delivery is crucial to avoid excess, preventable morbidity and mortality in Afghanistan.
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Mortalidad del Niño , Atención a la Salud , Programas de Gobierno , Financiación de la Atención de la Salud , Niño , Humanos , Lactante , Recién Nacido , Afganistán/epidemiología , Estudios Transversales , Familia , Atención a la Salud/economíaRESUMEN
Background: Despite large-scale investment in health service delivery outsourcing, few studies have examined human resources for health (HRH) in Afghanistan. Aims: To review the HRH situation of outsourced healthcare services in Afghanistan and evaluate nongovernment organization (NGO) investments in the health workforce. Methods: Two questionnaires were used for data collection. One gathered information about the characteristics of HRH in 2020 and the other collected budgetary data for 2017-2020 to analyse budget allocation and expenditure by NGOs on the health workforce. Results: A total of 25 262 (65% male, 35% female) individuals were employed by NGOs in 31 provinces of Afghanistan. There was a critical shortage of personnel and a prevalence of gender imbalance across all provinces. Healthcare workers were mostly aged 26 to 30 years. Services were mostly provided by local NGOs and their scopes were not limited to outsourced projects. More than 75% of the budget of NGOs was allocated to the health workforce in 2017-2020, and more than 70% of allocations was spent on staff salaries, followed by other health workforce expenditure. Less than 5% was spent on capacity building. Conclusion: There is a gross shortage and large gender imbalance in the Afghanistan health workforce. It is essential to maintain and increase current financial and technical investments to ensure sustainability and enhance the fragile health system in Afghanistan.
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Servicios de Salud , Fuerza Laboral en Salud , Masculino , Humanos , Femenino , Afganistán , Recursos Humanos , Personal de SaludRESUMEN
This paper reviews the experience of six low-income and lower middle-income countries in setting their own essential packages of health services (EPHS), with the purpose of identifying the key requirements for the successful design and transition to implementation of the packages in the context of accelerating progress towards universal health coverage (UHC). The analysis is based on input from three meetings of a knowledge network established by the Disease Control Priorities 3 Country Translation Project and working groups, supplemented by a survey of participating countries.All countries endorsed the Sustainable Development Goals target 3.8 on UHC for achievement by 2030. The assessment of country experiences found that health system strengthening and mobilising and sustaining health financing are major challenges. EPHS implementation is more likely when health system gaps are addressed and when there are realistic and sustainable financing prospects. However, health system assessments were inadequate and the government planning and finance sectors were not consistently engaged in setting the EPHS in most of the countries studied. There was also a need for greater engagement with community and civil society representatives, academia and the private sector in package design. Leadership and reinforcement of technical and managerial capacity are critical in the transition from EPHS design to sustained implementation, as are strong human resources and country ownership of the process. Political commitment beyond the health sector is key, particularly commitment from parliamentarians and policymakers in the planning and finance sectors. National ownership, institutionalisation of technical and managerial capacity and reinforcing human resources are critical for success.The review concludes that four prerequisites are crucial for a successful EPHS: (1) sustained high-level commitment, (2) sustainable financing, (3) health system readiness, and (4) institutionalisation.
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Servicios de Salud , Sector Privado , Humanos , Programas de Gobierno , Desarrollo Sostenible , PobrezaAsunto(s)
COVID-19/epidemiología , Control de Enfermedades Transmisibles/organización & administración , Atención a la Salud/organización & administración , Pandemias , Neumonía Viral/epidemiología , Afganistán/epidemiología , Programas de Gobierno , Política de Salud , Disparidades en Atención de Salud , Humanos , Neumonía Viral/virología , SARS-CoV-2RESUMEN
BACKGROUND: Plasmodium vivax resistance to chloroquine (CQ) has been reported from many endemic regions in the world. Plasmodium vivax is responsible for 95% of malaria cases in Afghanistan and CQ is the first-line treatment given for vivax malaria. The pvmdr-1 and pvcrt-o (K10 insertion) genes are possible markers for CQ-resistance in P. vivax isolates. There have been no studies done on the presence or absence of molecular markers for CQ-resistance P. vivax in Afghanistan. The present work aimed to evaluate the frequency of mutations in the pvmdr-1 and K10 insertion in the pvcrt-o genes of P. vivax. METHODS: Plasmodium vivax isolates were collected from Laghman, Baghlan and Khost provinces. For investigation of polymorphisms of desired regions in pvmdr-1 and pvcrt-o genes, sequencing was applied on the PCR products. A new asymmetric qPCR and melting analysis assay based on unlabelled probe developed for scanning of K10 insertion in pvcrt-o gene. RESULTS: The analysis of sequencing data of the pvmdr-1 gene showed wild type Y976 and K997 and mutant M958 and L1076 in 33 isolates from three provinces. Of the 36 samples evaluated for K10 insertion in pvcrt-o, 2/18(11%), 0/10(0%) and 0/8(0%) isolates from Laghman, Baghlan and Khost province, respectively, possessed K10 insertion, confirmed by either sequencing and unlabelled probes. CONCLUSION: Two samples with K10 insertion and 33 samples with pvmdr1 polymorphism, indicating on the possibility of CQ resistance in P. vivax populations in Afghanistan. Furthermore, unlabelled probes are simple and inexpensive alternative tools for screening of P. vivax mutations.
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Antimaláricos/farmacología , Cloroquina/farmacología , Resistencia a Medicamentos , Plasmodium vivax/genética , Reacción en Cadena de la Polimerasa/métodos , Afganistán , Marcadores Genéticos/genética , Malaria Vivax/parasitología , Reacción en Cadena en Tiempo Real de la Polimerasa/métodosRESUMEN
BACKGROUND: Despite the large investments in donor-related health activities in areas of the globe prone to tension and conflict, few studies have examined in detail the role of these donor investments in human resources for health (HRH). METHODS: We used a mixed-methods research methodology comprising both quantitative and qualitative analyses to analyze the Enhanced Financial Reporting System of the Global Fund to Fight AIDS, Tuberculosis and Malaria budget and expenditure data from 2003 to 2017 for 13 countries in the Eastern Mediterranean Region (EMR). We analyzed additional detailed budgetary data over the period 2015-2017 for a sub-set of these countries. Two country-case studies were conducted in Afghanistan and Sudan for a more in-depth understanding of the HRH-related activities that occurred as a result of Global Fund grants. RESULTS: The results show that US$2.2 billion Global Fund dollars had been budgeted and US$1.6 billion were expended over the period 2003-2017 in 13 Eastern Mediterranean countries. The average expenditures for human resources for health (training and human resources) as a percentage of total expenditure are 28%. Additional detailed budgetary data analysis shows a more conservative investment in HRH with 13% of total budgets allocated to "direct" HRH activities such as salaries, training costs, and technical assistance. HRH-related activities supported by the Global Fund in Afghanistan and Sudan were similar, including pre-service and in-services training, hiring of program coordinators and staff, and top-ups for clinical staff. CONCLUSIONS: HRH remains a key issue in strengthening the health systems of low- and middle-income countries. While this study suggests that Global Fund's HRH investments in the EMR are not lagging behind the global average, there appears to be a need to further scale up these investments considering this region's unique HRH challenges.
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Presupuestos/estadística & datos numéricos , Organización de la Financiación/estadística & datos numéricos , Cooperación Internacional , Recursos Humanos/economía , Recursos Humanos/estadística & datos numéricos , África del Norte , Humanos , Medio OrienteRESUMEN
BACKGROUND: Malaria is threatening more than half of Afghanistan population. Asymptomatic malaria is notable problem against malaria controlling strategies. In this study we evaluated the asymptomatic malaria status in Nangarhar Province, Afghanistan in 2017. METHODS: Overall, 296 finger blood samples were taken on DNA Banking Cards and microscopic slides from asymptomatic individuals in Jalalabad city. We used a novel post real time PCR high resolution melting analysis beside microscopy and semi-nested multiplex PCR to evaluate status of asymptomatic malaria in this city. RESULTS: The prevalence of asymptomatic malaria in Jalalabad city was determined 1.7% (5/296), 7.43% (22/296) and 7.78% (26/296) by microscopy, Seminested multiplex PCR and qRT-PCR-HRM, respectively. Out of 26 positive cases were detected by qRT-PCR-HRM, 21, 1 and 4 cases were detected P. falciparum, P. vivax and mixed infection of P. falciparum and P. vivax, respectively. CONCLUSION: Our data indicating on existence of significant number of asymptomatic reservoirs that assists in prolonged endemicity of the disease. On the other hand, the molecular methods are better alternatives for microscopy especially for monitoring of asymptomatic cases of malaria.
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INTRODUCTION: Human papillomavirus (HPV) vaccination has not been introduced in many countries in South-Central Asia, including Afghanistan, despite the sub-region having the highest incidence rate of cervical cancer in Asia. This study estimates the potential health impact and cost-effectiveness of HPV vaccination in Afghanistan to inform national decision-making. METHOD: An Excel-based static cohort model was used to estimate the lifetime costs and health outcomes of vaccinating a single cohort of 9-year-old girls in the year 2018 with the bivalent HPV vaccine, compared to no vaccination. We also explored a scenario with a catch-up campaign for girls aged 10-14 years. Input parameters were based on local sources, published literature, or assumptions when no data was available. The primary outcome measure was the discounted cost per disability-adjusted life-year (DALY) averted, evaluated from both government and societal perspectives. RESULTS: Vaccinating a single cohort of 9-year-old girls against HPV in Afghanistan could avert 1718 cervical cancer cases, 125 hospitalizations, and 1612 deaths over the lifetime of the cohort. The incremental cost-effectiveness ratio was US$426 per DALY averted from the government perspective and US$400 per DALY averted from the societal perspective. The estimated annual cost of the HPV vaccination program (US$3,343,311) represents approximately 3.53% of the country's total immunization budget for 2018 or 0.13% of total health expenditures. CONCLUSION: In Afghanistan, HPV vaccine introduction targeting a single cohort is potentially cost-effective (0.7 times the GDP per capita of $586) from both the government and societal perspective with additional health benefits generated by a catch-up campaign, depending on the government's willingness to pay for the projected health outcomes.
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Análisis Costo-Beneficio , Infecciones por Papillomavirus , Vacunas contra Papillomavirus , Neoplasias del Cuello Uterino , Vacunación/economía , Adolescente , Adulto , Afganistán/epidemiología , Anciano , Anciano de 80 o más Años , Niño , Femenino , Humanos , Persona de Mediana Edad , Infecciones por Papillomavirus/epidemiología , Infecciones por Papillomavirus/prevención & control , Neoplasias del Cuello Uterino/epidemiología , Neoplasias del Cuello Uterino/prevención & control , Neoplasias del Cuello Uterino/virología , Adulto JovenRESUMEN
[This corrects the article DOI: 10.1371/journal.pone.0103732.].