Assessing capacities and resilience of health services during the COVID-19 pandemic: Lessons learned from use of rapid key informant surveys.

This article is part of the Research Topic: 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict.' Problem: Many countries lacked rapid and nimble data systems to track health service capacities to respond to COVID-19. They struggled to assess and monitor rapidly evolving service disruptions, health workforce capacities, health products availability, community needs and perspectives, and mitigation responses to maintain essential health services. Method: Building on established methodologies, the World Health Organization developed a suite of methods and tools to support countries to rapidly fill data gaps and guide decision-making during COVID-19. The tools included: (1) a national "pulse" survey on service disruptions and bottlenecks; (2) a phone-based facility survey on frontline service capacities; and (3) a phone-based community survey on demand-side challenges and health needs. Use: Three national pulse surveys revealed persisting service disruptions throughout 2020-2021 (97 countries responded to all three rounds). Results guided mitigation strategies and operational plans at country level, and informed investments and delivery of essential supplies at global level. Facility and community surveys in 22 countries found similar disruptions and limited frontline service capacities at a more granular level. Findings informed key actions to improve service delivery and responsiveness from local to national levels. Lessons learned: The rapid key informant surveys provided a low-resource way to collect action-oriented health services data to inform response and recovery from local to global levels. The approach fostered country ownership, stronger data capacities, and integration into operational planning. The surveys are being evaluated to inform integration into country data systems to bolster routine health services monitoring and serve as health services alert functions for the future.

Generating statistics from health facility data: the state of routine health information systems in Eastern and Southern Africa.

Health facility data are a critical source of local and continuous health statistics. Countries have introduced web-based information systems that facilitate data management, analysis, use and visualisation of health facility data. Working with teams of Ministry of Health and country public health institutions analysts from 14 countries in Eastern and Southern Africa, we explored data quality using national-level and subnational-level (mostly district) data for the period 2013-2017. The focus was on endline analysis where reported health facility and other data are compiled, assessed and adjusted for data quality, primarily to inform planning and assessments of progress and performance. The analyses showed that although completeness of reporting was generally high, there were persistent data quality issues that were common across the 14 countries, especially at the subnational level. These included the presence of extreme outliers, lack of consistency of the reported data over time and between indicators (such as vaccination and antenatal care), and challenges related to projected target populations, which are used as denominators in the computation of coverage statistics. Continuous efforts to improve recording and reporting of events by health facilities, systematic examination and reporting of data quality issues, feedback and communication mechanisms between programme managers, care providers and data officers, and transparent corrections and adjustments will be critical to improve the quality of health statistics generated from health facility data.

Mapping the landscape of global programmes to evaluate health interventions in pregnancy: the need for harmonised approaches, standards and tools.

Pregnant women and their babies are among the populations most vulnerable to untoward health outcomes. Yet current standards for evaluating health interventions cannot be met during pregnancy because of lack of adequate evidence. The situation is even more concerning in low-income and middle-income countries, where the need for effective interventions is the greatest. Meeting the Sustainable Development Goals for health will require strengthened attention to maternal and child health. In this paper we examine ongoing initiatives aimed at improving the assessment of maternal interventions. We review current methodologies to monitor outcomes of maternal interventions and identify where harmonisation is needed. Based on this analysis we identify settings where different minimal data sets should be considered taking into consideration the clinical realities. Stronger coordination mechanisms and a roadmap to support harmonised monitoring of maternal interventions across programmes and partners, working on improving pregnancy and early childhood health events, will greatly enhance ability to generate evidence-based policies.

Isolite vs cotton roll isolation in the placement of dental sealants.

PURPOSE: The purpose of this split-mouth, randomized, controlled trial was to evaluate the retention rates of sealants placed under Isolite vs cotton roll isolation. METHODS: A convenience sample of 29 patients, with a mean age of 9.8 years and a total of 96 teeth, was included in this study. Matched contralateral pairs of first and second molars were randomized to receive sealants with Isolite or cotton roll isolation. All sealants were performed by one standardized operator. Sealants were placed on first and second permanent molars that had a matched contralateral molar requiring a sealant as well. Photographs were taken of the sealants on the day of placement, and at 6-month and 12-month recalls. Photographs were viewed, and retention of the sealants was evaluated and scored by three calibrated pediatric dentists. The scores were analyzed via Mann-Whitney U and chi-square tests. RESULTS: There were no significant differences in the retention rates between sealants placed using Isolite isolation compared with cotton roll isolation. CONCLUSION: Isolite and cotton roll isolation both appear to be equally effective in creating a favorable environment for sealant placement by a single operator.

Can community health workers increase coverage of reproductive health services?

BACKGROUND: Health services were severely affected during the many years of instability and conflict in Afghanistan. In recent years, substantial increases in the coverage of reproductive health services have been achieved, yet absolute levels of coverage remain very low, especially in rural areas. One strategy for increasing use of reproductive health services is deploying community health workers (CHWs) to promote the use of services within the community and at health facilities. METHODS: Using a multilevel model employing data from a cross-sectional survey of 8320 households in 29 provinces of Afghanistan conducted in 2006, this study determines whether presence of a CHW in the community leads to an increase in use of modern contraceptives, skilled antenatal care and skilled birth attendance. This study further examines whether the effect varies by the sex of the CHW. RESULTS: Results show that presence of a female CHW in the community is associated with higher use of modern contraception, antenatal care services and skilled birth attendants but presence of a male CHW is not. Community-level random effects were also significant. CONCLUSIONS: This study provides evidence that indicates that CHWs can contribute to increased use of reproductive health services and that context and CHW sex are important factors that need to be addressed in programme design.

Infant and under-five mortality in Afghanistan: current estimates and limitations.

OBJECTIVE: To examine historical estimates of infant and under-five mortality in Afghanistan, provide estimates for rural areas from current population-based data, and discuss the methodological challenges that undermine data quality and hinder retrospective estimations of mortality. METHODS: Indirect methods of estimation were used to calculate infant and under-five mortality from a household survey conducted in 2006. Sex-specific differences in underreporting of births and deaths were examined and sensitivity analyses were conducted to assess the effect of underreporting on infant and under-five mortality. FINDINGS: For 2004, rural unadjusted infant and under-five mortality rates were estimated to be 129 and 191 deaths per 1000 live births, respectively, with some evidence indicating underreporting of female deaths. If adjustment for underreporting is made (i.e. by assuming 50% of the unreported girls are dead), mortality estimates go up to 140 and 209, respectively. CONCLUSION: Commonly used estimates of infant and under-five mortality in Afghanistan are outdated; they do not reflect changes that have occurred in the past 15 years or recent intensive investments in health services development, such as the implementation of the Basic Package of Health Services. The sociocultural aspects of mortality and their effect on the reporting of births and deaths in Afghanistan need to be investigated further.

Monitoring pediatric blood pressure at dental appointments.

Numerous studies have tracked blood pressure from adolescence into adulthood. It is increasingly apparent that the recent increase in obesity and resultant end-organ effects of hypertension originates in childhood. Pediatric hypertension is a significant health concern that, if left untreated, can affect a child's cardiovascular, endocrine, renal, and neurologic systems. In 2004, the National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents recommended that bloodpressure should be monitored in pediatric patients who are at least 3-years-old and that this procedure should be a part of the health care visit in all health facilities, rather than just within the medical office. The purpose of this article was to emphasize the need for following these recommendations at oral care visits and suggest a simplified pediatric blood pressure table that dental clinicians can use to identify children who need referrals to medical facilities for evaluation of blood pressure.

Infant oral exam and first dental home.

The purpose of this article is to familiarize general practitioners with the components of a dental home including an infant oral exam, and to the First Dental Home initiative, which is unique to the State of Texas. This article encourages the general practitioners to actively participate in providing care for young children under the age of 3. Components of an infant oral examination are described here with emphasis on knee-to-knee or lap exam, caries risk assessment, preventive treatment, age-appropriate anticipatory guidance, and parent education. The First Dental Home is uniquely designed to help pediatric clients 6 months through 35 months of age to establish a dental home. The objectives, goal and components of FDH are discussed in detail.

Client perceptions of the quality of primary care services in Afghanistan.

OBJECTIVE: To identify factors associated with client perceptions of the quality of primary care services in Afghanistan. DESIGN: Cross-sectional survey of outpatient health facilities, health workers, patients and caretakers. SETTING: Primary health care facilities in every province of Afghanistan. Main outcome measure Numerical scale of client perceptions of service quality. RESULTS: Clients report relatively high levels of perceived quality in Afghanistan. Most of the variation that is explained relates specifically to the patient's interaction with the health worker and not to other health facility characteristics, such as cleanliness, infrastructure, service capacity and the presence of equipment or drugs. The strongest determinants of client-perceived quality identified are health worker thoroughness in taking patient histories, conducting physical examinations and communicating with patients. Being seen by a doctor and being from a household in the poorest quintile are also associated with higher perceived quality. For female patients, being seen by a female provider is associated with higher perceived quality, while for male patients time and money spent for travel to the health facility are negatively associated with perceived quality. CONCLUSIONS: Clinical quality and client perceived quality appear to be mutually reinforcing, and efforts to improve health worker performance in taking histories, conducting exams and communicating with patients are likely to increase client perceived quality in this setting. Client perceptions of service quality assume additional importance in Afghanistan, where the perceived legitimacy of the government may depend partially on its ability to convince the population that it can deliver essential health services.

Laser treatment for retinopathy of prematurity through the incubator wall.

In this era of early treatment for retinopathy of prematurity, sick infants who develop aggressive diseases or remain oxygen and temperature dependent may be treated while they are inside the incubator itself, thus avoiding unnecessary delays. This article describes the treatment of eight infants with retinopathy of prematurity who were dependent on an incubator by using a laser indirect ophthalmoscope delivery system through the slanting transparent wall of the incubator. In this series, which is the largest to date, the relative advantages and disadvantages of the procedure are discussed.

Stress as an endogenous adjuvant: augmentation of the immunization phase of cell-mediated immunity.

Stress is thought to be immunosuppressive but paradoxically exacerbates inflammatory and autoimmune diseases. We initially showed that acute stress enhances skin immunity. Such immunoenhancement could promote immunoprotection in case of wounding, infection or vaccination but could also exacerbate immunopathological diseases. Here we identify the molecular and cellular mediators of the immunoenhancing effects of acute stress. Compared with non-stressed mice, acutely stressed animals showed significantly greater pinna swelling and leukocyte infiltration, and up-regulated macrophage chemoattractant protein-1, macrophage inflammatory protein-3alpha, IL-1alpha, IL-1beta, IL-6, tumor necrosis factor-alpha and IFN-gamma, but not IL-4 gene expression at the site of primary antigen exposure. Stressed animals also showed enhanced maturation and trafficking of dendritic cells (DCs) from skin to lymph nodes (LNs), higher numbers of activated macrophages in skin and LNs, increased T cell activation in LNs, and enhanced recruitment of surveillance T cells to skin. These findings show that important interactive components of innate (DCs and macrophages) and adaptive (surveillance T cells) immunity are mediators of the stress-induced enhancement of a primary immune response. Such enhancement during primary immunization may induce a long-term increase in immunologic memory resulting in subsequent augmentation of the immune response during secondary antigen exposure. Thus, the evolutionarily adaptive fight-or-flight stress response may protectively prepare the immune system for impending danger (e.g. infection and wounding by a predator), but may also contribute to stress-induced exacerbation of inflammatory and autoimmune diseases.

Short-term stress experienced at time of immunization induces a long-lasting increase in immunologic memory.

It would be extremely beneficial if one could harness natural, endogenous, health-promoting defense mechanisms to fight disease and restore health. The psychophysiological stress response is the most underappreciated of nature's survival mechanisms. We show that acute stress experienced before primary immunization induces a long-lasting increase in immunity. Compared with controls, mice restrained for 2.5 h before primary immunization with keyhole limpet hemocyanin (KLH) show a significantly enhanced immune response when reexposed to KLH 9 mo later. This immunoenhancement is mediated by an increase in numbers of memory and effector helper T cells in sentinel lymph nodes at the time of primary immunization. Further analyses show that the early stress-induced increase in T cell memory may stimulate the robust increase in infiltrating lymphocyte and macrophage numbers observed months later at a novel site of antigen reexposure. Enhanced leukocyte infiltration may be driven by increased levels of the type 1 cytokines, IL-2 and IFN-gamma, and TNF-alpha, observed at the site of antigen reexposure in animals that had been stressed at the time of primary immunization. In contrast, no differences were observed in type 2 cytokines, IL-4 or IL-5. Given the importance of inducing long-lasting increases in immunologic memory during vaccination, we suggest that the neuroendocrine stress response is nature's adjuvant that could be psychologically and/or pharmacologically manipulated to safely increase vaccine efficacy. These studies introduce the novel concept that a psychophysiological stress response is nature's fundamental survival mechanism that could be therapeutically harnessed to augment immune function during vaccination, wound healing, or infection.

Stress-induced enhancement of leukocyte trafficking into sites of surgery or immune activation.

Effective immunoprotection requires rapid recruitment of leukocytes into sites of surgery, wounding, infection, or vaccination. In contrast to immunosuppressive chronic stressors, short-term acute stressors have immunoenhancing effects. Here, we quantify leukocyte infiltration within a surgical sponge to elucidate the kinetics, magnitude, subpopulation, and chemoattractant specificity of an acute stress-induced increase in leukocyte trafficking to a site of immune activation. Mice acutely stressed before sponge implantation showed 200-300% higher neutrophil, macrophage, natural killer cell, and T cell infiltration than did nonstressed animals. We also quantified the effects of acute stress on lymphotactin- (LTN; a predominantly lymphocyte-specific chemokine), and TNF-alpha- (a proinflammatory cytokine) stimulated leukocyte infiltration. An additional stress-induced increase in infiltration was observed for neutrophils, in response to TNF-alpha, macrophages, in response to TNF-alpha and LTN, and natural killer cells and T cells in response to LTN. These results show that acute stress initially increases trafficking of all major leukocyte subpopulations to a site of immune activation. Tissue damage-, antigen-, or pathogen-driven chemoattractants subsequently determine which subpopulations are recruited more vigorously. Such stress-induced increases in leukocyte trafficking may enhance immunoprotection during surgery, vaccination, or infection, but may also exacerbate immunopathology during inflammatory (cardiovascular disease or gingivitis) or autoimmune (psoriasis, arthritis, or multiple sclerosis) diseases.

Short day lengths augment stress-induced leukocyte trafficking and stress-induced enhancement of skin immune function.

Environmental conditions influence the onset and severity of infection and disease. Stressful conditions during winter may weaken immune function and further compromise survival by means of hypothermia, starvation, or shock. To test the hypothesis that animals may use photoperiod to anticipate the onset of seasonal stressors and adjust immune function, we evaluated glucocorticoids and the distribution of blood leukocytes in Siberian hamsters (Phodopus sungorus) exposed to long day lengths (i.e., summer) or short day (SD) lengths (i.e., winter) at baseline and during acute stress. We also investigated the influence of photoperiod and acute stress on a delayed-type hypersensitivity response in the skin. SDs increased glucocorticoid concentrations and the absolute number of circulating blood leukocytes, lymphocytes, T cells, and natural killer cells at baseline in hamsters. During stressful challenges, it appears beneficial for immune cells to exit the blood and move to primary immune defense areas such as the skin, in preparation for potential injury or infection. Acute (2 h) restraint stress induced trafficking of lymphocytes and monocytes out of the blood. This trafficking occurred more rapidly in SDs compared to long days. Baseline delayed-type hypersensitivity responses were enhanced during SDs; this effect was augmented by acute stress and likely reflected more rapid redistribution of leukocytes out of the blood and into the skin. These results suggest that photoperiod may provide a useful cue by which stressors in the environment may be anticipated to adjust the repertoire of available immune cells and increase survival likelihood.