Reasons for Being "Zero-Dose and Under-Vaccinated" among Children Aged 12-23 Months in the Democratic Republic of the Congo.

(1) Introduction: The Democratic Republic of the Congo (DRC) has one of the largest cohorts of un- and under-vaccinated children worldwide. This study aimed to identify and compare the main reasons for there being zero-dose (ZD) or under-vaccinated children in the DRC. (2) Methods: This is a secondary analysis derived from a province-level vaccination coverage survey conducted between November 2021 and February 2022; this survey included questions about the reasons for not receiving one or more vaccines. A zero-dose child (ZD) was a person aged 12-23 months not having received any pentavalent vaccine (diphtheria-tetanus-pertussis-Hemophilus influenzae type b (Hib)-Hepatitis B) as per card or caregiver recall and an under-vaccinated child was one who had not received the third dose of the pentavalent vaccine. The proportions of the reasons for non-vaccination were first presented using the WHO-endorsed behavioral and social drivers for vaccination (BeSD) conceptual framework and then compared across the groups of ZD and under-vaccinated children using the Rao-Scott chi-square test; analyses were conducted at province and national level, and accounting for the sample approach. (3) Results: Of the 51,054 children aged 12-23 m in the survey sample, 19,676 ZD and under-vaccinated children were included in the study. For the ZD children, reasons related to people's thinking and feelings were cited as 64.03% and those related to social reasons as 31.13%; both proportions were higher than for under-vaccinated children (44.7% and 26.2%, respectively, p < 0.001). Regarding intentions to vaccinate their children, 82.15% of the parents/guardians of the ZD children said they wanted their children to receive "none" of the recommended vaccines, which was significantly higher than for the under-vaccinated children. In contrast, "practical issues" were cited for 35.60% of the ZD children, compared to 55.60% for the under-vaccinated children (p < 0.001). The distribution of reasons varied between provinces, e.g., 12 of the 26 provinces had a proportion of reasons for the ZD children relating to practical issues that was higher than the national level. (4) Conclusions: reasons provided for non-vaccination among the ZD children in the DRC were largely related to lack of parental/guardian motivation to have their children vaccinated, while reasons among under-vaccinated children were mostly related to practical issues. These results can help inform decision-makers to direct vaccination interventions.

Delayed and Interrupted Ventilation with Excess Suctioning after Helping Babies Breathe with Congolese Birth Attendants.

There is a substantial gap in our understanding of resuscitation practices following Helping Babies Breathe (HBB) training. We sought to address this gap through an analysis of observed resuscitations following HBB 2nd edition training in the Democratic Republic of the Congo. This is a secondary analysis of a clinical trial evaluating the effect of resuscitation training and electronic heart rate monitoring on stillbirths. We included in-born, liveborn neonates ≥28 weeks gestation whose resuscitation care was directly observed and documented. For the 2592 births observed, providers dried/stimulated before suctioning in 97% of cases and suctioned before ventilating in 100%. Only 19.7% of newborns not breathing well by 60 s (s) after birth ever received ventilation. Providers initiated ventilation at a median 347 s (>five minutes) after birth; no cases were initiated within the Golden Minute. During 81 resuscitations involving ventilation, stimulation and suction both delayed and interrupted ventilation with a median 132 s spent drying/stimulating and 98 s suctioning. This study demonstrates that HBB-trained providers followed the correct order of resuscitation steps. Providers frequently failed to initiate ventilation. When ventilation was initiated, it was delayed and interrupted by stimulation and suctioning. Innovative strategies targeting early and continuous ventilation are needed to maximize the impact of HBB.

"Zero Dose" Children in the Democratic Republic of the Congo: How Many and Who Are They?

(1) Background: The Democratic Republic of the Congo (DRC) is one of the countries with the highest number of never vaccinated or "zero-dose" (ZD) children in the world. This study was conducted to examine the proportion of ZD children and associated factors in the DRC. (2) Methods: Child and household data from a provincial-level vaccination coverage survey conducted between November 2021-February 2021 and 2022 were used. ZD was defined as a child aged 12 to 23 months who had not received any dose of pentavalent (diphtheria-tetanus-pertussis-Haemophilus influenzae type b (Hib)-Hepatitis B) vaccine (by card or recall). The proportion of ZD children was calculated and associated factors were explored using logistic regression, taking into account the complex sampling approach. (3) Results: The study included 51,054 children. The proportion of ZD children was 19.1% (95%CI: 19.0-19.2%); ZD ranged from 62.4% in Tshopo to 2.4% in Haut Lomami. After adjustment, being ZD was associated with low level of maternal education and having a young mother/guardian (aged ≤ 19 years); religious affiliation (willful failure to disclose religious affiliation as the highest associated factor compared to being Catholic, followed by Muslims, revival/independent church, Kimbanguist, Protestant); proxies for wealth such as not having a telephone or a radio; having to pay for a vaccination card or for another immunization-related service; not being able to name any vaccine-preventable disease. A child's lack of civil registration was also associated with being ZD. (4) Conclusions: In 2021, one in five children aged 12-23 months in DRC had never been vaccinated. The factors associated with being a ZD child suggest inequalities in vaccination that must be further explored to better target appropriate interventions.

Knowledge of Obstetric Danger Signs among Pregnant Women in the Eastern Democratic Republic of the Congo.

A lack of awareness regarding obstetric danger signs (ODS) is one of the factors that delay a pregnant woman's decision to seek emergency obstetric care. In developing countries, this delay can lead to high morbidity and mortality among pregnant women. In eastern Democratic Republic of Congo (DRC), very few studies have been conducted to assess the level of knowledge of pregnant women about ODS. Therefore, this study aimed to assess the knowledge of pregnant women about ODS in health facilities in eastern DRC. This quantitative cross-sectional, descriptive, and analytical study was conducted in 19 health facilities in the Kasongo health zone in the south Maniema Province of eastern DRC. A total of 624 pregnant women aged 12-49 years were interviewed in this study. Of these, 60.6% were secondary school graduates, >99% were married, 85.5% were cultivators, and 67.9% were Muslims. The knowledge of ODS among pregnant women was low (21.9%). The most cited danger signs during pregnancy, labor/delivery, and postpartum included severe abdominal pain and severe vaginal bleeding. Additionally, pregnant women aged 30-39 years (p = 0.015) and those who had given birth once (p = 0.049), twice (p = 0.003), 3-5 times (p = 0.004), and >5 times (p = 0.009) were more likely to be aware of ODS than others. Our findings indicated that pregnant women have little knowledge of ODS, which makes it difficult for them to take prompt decisions to seek emergency obstetric care. Thus, strategies to increase the knowledge of pregnant women about obstetrical danger signs by healthcare providers during prenatal consultations (antenatal care) must be developed to improve their rapid decision-making skills during pregnancy, labor, and postpartum.

Perceptions and experiences of Congolese midwives implementing a low-cost battery-operated heart rate meter during newborn resuscitation.

Background: 900,000 newborns die from respiratory depression each year; nearly all of these deaths occur in low- and middle-income countries. Deaths from respiratory depression are reduced by evidence-based resuscitation. Electronic heart rate monitoring provides a sensitive indicator of the neonate's status to inform resuscitation care, but is infrequently used in low-resource settings. In a recent trial in the Democratic Republic of the Congo, midwives used a low-cost, battery-operated heart rate meter (NeoBeat) to continuously monitor heart rate during resuscitations. We explored midwives' perceptions of NeoBeat including its utility and barriers and facilitators to use. Methods: After a 20-month intervention in which midwives from three facilities used NeoBeat during resuscitations, we surveyed midwives and conducted focus group discussions (FGDs) regarding the incorporation of NeoBeat into clinical care. FGDs were conducted in Lingala, the native language, then transcribed and translated from Lingala to French to English. We analyzed data by: (1) coding of transcripts using Nvivo, (2) comparison of codes to identify patterns in the data, and (3) grouping of codes into categories by two independent reviewers, with final categories determined by consensus. Results: Each midwife from Facility A used NeoBeat on an estimated 373 newborns, while each midwife at facilities B and C used NeoBeat an average 24 and 47 times, respectively. From FGDs with 30 midwives, we identified five main categories of perceptions and experiences regarding the use of NeoBeat: (1) Providers' initial skepticism evolved into pride and a belief that NeoBeat was essential to resuscitation care, (2) Providers viewed NeoBeat as enabling their resuscitation and increasing their capacity, (3) NeoBeat helped providers identify flaccid newborns as liveborn, leading to hope and the perception of saving of lives, (4) Challenges of use of NeoBeat included cleaning, charging, and insufficient quantity of devices, and (5) Providers desired to continue using the device and to expand its use beyond resuscitation and their own facilities. Conclusion: Midwives perceived that NeoBeat enabled their resuscitation practices, including assisting them in identifying non-breathing newborns as liveborn. Increasing the quantity of devices per facility and developing systems to facilitate cleaning and charging may be critical for scale-up.

Severe Acute Respiratory Syndrome Coronavirus 2 Infection and Pregnancy in Sub-Saharan Africa: A 6-Country Retrospective Cohort Analysis.

BACKGROUND: Few data are available on COVID-19 outcomes among pregnant women in sub-Saharan Africa (SSA), where high-risk comorbidities are prevalent. We investigated the impact of pregnancy on SARS-CoV-2 infection and of SARS-CoV-2 infection on pregnancy to generate evidence for health policy and clinical practice. METHODS: We conducted a 6-country retrospective cohort study among hospitalized women of childbearing age between 1 March 2020 and 31 March 2021. Exposures were (1) pregnancy and (2) a positive SARS-CoV-2 RT-PCR test. The primary outcome for both analyses was intensive care unit (ICU) admission. Secondary outcomes included supplemental oxygen requirement, mechanical ventilation, adverse birth outcomes, and in-hospital mortality. We used log-binomial regression to estimate the effect between pregnancy and SARS-CoV-2 infection. Factors associated with mortality were evaluated using competing-risk proportional subdistribution hazards models. RESULTS: Our analyses included 1315 hospitalized women: 510 pregnant women with SARS-CoV-2, 403 nonpregnant women with SARS-CoV-2, and 402 pregnant women without SARS-CoV-2 infection. Among women with SARS-CoV-2 infection, pregnancy was associated with increased risk for ICU admission (adjusted risk ratio [aRR]: 2.38; 95% CI: 1.42-4.01), oxygen supplementation (aRR: 1.86; 95% CI: 1.44-2.42), and hazard of in-hospital death (adjusted sub-hazard ratio [aSHR]: 2.00; 95% CI: 1.08-3.70). Among pregnant women, SARS-CoV-2 infection increased the risk of ICU admission (aRR: 2.0; 95% CI: 1.20-3.35), oxygen supplementation (aRR: 1.57; 95% CI: 1.17-2.11), and hazard of in-hospital death (aSHR: 5.03; 95% CI: 1.79-14.13). CONCLUSIONS: Among hospitalized women in SSA, both SARS-CoV-2 infection and pregnancy independently increased risks of ICU admission, oxygen supplementation, and death. These data support international recommendations to prioritize COVID-19 vaccination among pregnant women.

Maternal mortality study in the Eastern Democratic Republic of the Congo.

BACKGROUND: The reduction of maternal mortality in developing countries such as the Democratic Republic of Congo (DRC) still raises many questions. Indeed, this large country in the heart of Africa ranks 4th among the eight countries that alone account for more than 50% of maternal deaths in the world, behind India, Nigeria and Pakistan. However, there is no up-to-date data on maternal mortality in eastern DRC. This study measures the mortality rate rate in health facilities in eastern DRC and identifies the associated risk factors. METHODS: This analytical epidemiological study was based on retrospective data materna deaths recorded in 59 health facilities, in three health zones in the southern part of Maniema province in east DRC. The study was conducted from July 1, 2015 to June 30, 2020. Descriptive, bi and multivariate analyses were used. RESULTS: The maternal mortality rate was estimated at 620 deaths per 100,000 live births, of which 46% of maternal deaths were related to a parturients' delayed decision in seeking healthcare in time (first delay). Maternal deaths were significantly associated with extreme ages (≤ 19 years and ≥ 40 years: p = < 0.001), patient parity (in primigravidas and in large multiparas: p = 0.001), complications such as hemorrhagic, (p = < 0.001), uterine ruptures:(p = < 0.001), infections, (p = < 0.001), and dystocia (p = < 0.001). CONCLUSION: Despite the efforts made by the DRC and its partners in the fight against maternal mortality, women continue to lose their lives when they decide to give birth. The results imply that it is imperative to strengthen both women and health professionals' knowledge about pregnancy and maternal health and their power to reduce instances of first delay by supporting women in formulating their birth plans.

Simplified antibiotic regimens for young infants with possible serious bacterial infection when the referral is not feasible in the Democratic Republic of the Congo.

INTRODUCTION: Neonates with serious bacterial infections should be treated with injectable antibiotics after hospitalization, which may not be feasible in many low resource settings. In 2015, the World Health Organization (WHO) launched a guideline for the management of young infants (0-59 days old) with possible serious bacterial infection (PSBI) when referral for hospital treatment is not feasible. We evaluated the feasibility of the WHO guideline implementation in the Democratic Republic of the Congo (DRC) to achieve high coverage of PSBI treatment. METHODS: From April 2016 to March 2017, in a longitudinal, descriptive, mixed methods implementation research study, we implemented WHO PSBI guideline for sick young infants (0-59 dyas of age) in the public health programme setting in five health areas of North and South Ubangi Provinces with an overall population of about 60,000. We conducted policy dialogue with national and sub-national level government planners, decision-makers, academics and other stakeholders. We established a Technical Support Unit to provide implementation support. We built the capacity of health workers and managers and ensured the availability of necessary medicines and commodities. We followed infants with PSBI signs up to 14 days. The research team systematically collected data on adherence to treatment and outcomes. RESULTS: We identified 3050 live births and 285 (9.3%) young infants with signs of PSBI in the study area, of whom 256 were treated. Published data have reported 10% PSBI incidence rate in young infants. Therefore, the estimated coverage of treatment was 83.9% (256/305). Another 426 from outside the study catchment area were also identified with PSBI signs by the nurses of a health centre within the study area. Thus, a total of 711 young infants with PSBI were identified, 285 (40%) 7-59 days old infants had fast breathing (pneumonia), 141 (20%) 0-6 days old had fast breathing (severe pneumonia), 233 (33%) had signs of clinical severe infection (CSI), and 52 (7%) had signs of critical illness. Referral to a hospital was advised to 426 (60%) infants with CSI, critical illness or severe pneumonia. The referral was refused by 282 families who accepted simplified antibiotic treatment on an outpatient basis at the health centres. Treatment failure among those who received outpatient treatment occurred in 10/128 (8%) with severe pneumonia, 25/147 (17%) with CSI, including one death, and 2/7 (29%) young infants with a critical illness. Among 285 infants with pneumonia, 257 (90%) received oral amoxicillin treatment, and 8 (3%) failed treatment. Adherence to outpatient treatment was 98% to 100% for various PSBI sub-categories. Among 144 infants treated in a hospital, 8% (1/13) with severe pneumonia, 23% (20/86) with CSI and 40% (18/45) with critical illness died. CONCLUSION: Implementation of the WHO PSBI guideline when a referral was not possible was feasible in our context with high coverage. Without financial and technical input to strengthen the health system at all levels, including the community and the referral level, it may not be possible to achieve and sustain the same high treatment coverage.

Assessment of Clinical Outcomes Among Children and Adolescents Hospitalized With COVID-19 in 6 Sub-Saharan African Countries.

IMPORTANCE: Little is known about COVID-19 outcomes among children and adolescents in sub-Saharan Africa, where preexisting comorbidities are prevalent. OBJECTIVE: To assess the clinical outcomes and factors associated with outcomes among children and adolescents hospitalized with COVID-19 in 6 countries in sub-Saharan Africa. DESIGN, SETTING, AND PARTICIPANTS: This cohort study was a retrospective record review of data from 25 hospitals in the Democratic Republic of the Congo, Ghana, Kenya, Nigeria, South Africa, and Uganda from March 1 to December 31, 2020, and included 469 hospitalized patients aged 0 to 19 years with SARS-CoV-2 infection. EXPOSURES: Age, sex, preexisting comorbidities, and region of residence. MAIN OUTCOMES AND MEASURES: An ordinal primary outcome scale was used comprising 5 categories: (1) hospitalization without oxygen supplementation, (2) hospitalization with oxygen supplementation, (3) ICU admission, (4) invasive mechanical ventilation, and (5) death. The secondary outcome was length of hospital stay. RESULTS: Among 469 hospitalized children and adolescents, the median age was 5.9 years (IQR, 1.6-11.1 years); 245 patients (52.4%) were male, and 115 (24.5%) had comorbidities. A total of 39 patients (8.3%) were from central Africa, 172 (36.7%) from eastern Africa, 208 (44.3%) from southern Africa, and 50 (10.7%) from western Africa. Eighteen patients had suspected (n = 6) or confirmed (n = 12) multisystem inflammatory syndrome in children. Thirty-nine patients (8.3%) died, including 22 of 69 patients (31.9%) who required intensive care unit admission and 4 of 18 patients (22.2%) with suspected or confirmed multisystem inflammatory syndrome in children. Among 468 patients, 418 (89.3%) were discharged, and 16 (3.4%) remained hospitalized. The likelihood of outcomes with higher vs lower severity among children younger than 1 year expressed as adjusted odds ratio (aOR) was 4.89 (95% CI, 1.44-16.61) times higher than that of adolescents aged 15 to 19 years. The presence of hypertension (aOR, 5.91; 95% CI, 1.89-18.50), chronic lung disease (aOR, 2.97; 95% CI, 1.65-5.37), or a hematological disorder (aOR, 3.10; 95% CI, 1.04-9.24) was associated with severe outcomes. Age younger than 1 year (adjusted subdistribution hazard ratio [asHR], 0.48; 95% CI, 0.27-0.87), the presence of 1 comorbidity (asHR, 0.54; 95% CI, 0.40-0.72), and the presence of 2 or more comorbidities (asHR, 0.26; 95% CI, 0.18-0.38) were associated with reduced rates of hospital discharge. CONCLUSIONS AND RELEVANCE: In this cohort study of children and adolescents hospitalized with COVID-19 in sub-Saharan Africa, high rates of morbidity and mortality were observed among infants and patients with noncommunicable disease comorbidities, suggesting that COVID-19 vaccination and therapeutic interventions are needed for young populations in this region.

Effect of resuscitation training and implementation of continuous electronic heart rate monitoring on identification of stillbirth.

AIM: To evaluate the effect of resuscitation training and continuous electronic heart rate (HR) monitoring of non-breathing newborns on identification of stillbirth. METHODS: We conducted a pre-post interventional trial in three health facilities in the Democratic Republic of the Congo. We collected data on a retrospective control group of newborns that reflected usual resuscitation practice (Epoch 1). In the prospective, interventional group, skilled birth attendants received resuscitation training in Helping Babies Breathe and implemented continuous electronic HR monitoring of non-breathing newborns (Epoch 2). Our primary outcome was the incidence of stillbirth with secondary outcomes of fresh or macerated stillbirth, neonatal death before discharge and perinatal death. Among a subset, we conducted expert review of electronic HR data to estimate misclassification of stillbirth in Epoch 2. We used a generalized estimating equation, adjusted for variation within-facility, to compare risks between EPOCHs. RESULTS: There was no change in total stillbirths following resuscitation training and continuous electronic HR monitoring of non-breathing newborns (aRR 1.15 [0.95, 1.39]). We observed an increased rate of macerated stillbirth (aRR 1.58 [1.24, 2.02]), death before discharge (aRR 3.31 [2.41, 4.54]), and perinatal death (aRR 1.61 [1.38, 1.89]) during the intervention period. In expert review, 20% of newborns with electronic HR data that were classified by SBAs as stillborn were liveborn. CONCLUSION: Resuscitation training and use of continuous electronic HR monitoring did not reduce stillbirths nor eliminate misclassification.

Improving Newborn Resuscitation by Making Every Birth a Learning Event.

One third of all neonatal deaths are caused by intrapartum-related events, resulting in neonatal respiratory depression (i.e., failure to breathe at birth). Evidence-based resuscitation with stimulation, airway clearance, and positive pressure ventilation reduces mortality from respiratory depression. Improving adherence to evidence-based resuscitation is vital to preventing neonatal deaths caused by respiratory depression. Standard resuscitation training programs, combined with frequent simulation practice, have not reached their life-saving potential due to ongoing gaps in bedside performance. Complex neonatal resuscitations, such as those involving positive pressure ventilation, are relatively uncommon for any given resuscitation provider, making consistent clinical practice an unrealistic solution for improving performance. This review discusses strategies to allow every birth to act as a learning event within the context of both high- and low-resource settings. We review strategies that involve clinical-decision support during newborn resuscitation, including the visual display of a resuscitation algorithm, peer-to-peer support, expert coaching, and automated guidance. We also review strategies that involve post-event reflection after newborn resuscitation, including delivery room checklists, audits, and debriefing. Strategies that make every birth a learning event have the potential to close performance gaps in newborn resuscitation that remain after training and frequent simulation practice, and they should be prioritized for further development and evaluation.

Knowledge of Antimalarials and Health Seeking Behaviour of Households in Case of Suspected Malaria in Democratic Republic of the Congo.

(1) Background: The Democratic Republic of the Congo (DRC) is heavily affected by malaria despite availability of effective treatments. Ignorance and unrecommended behaviour toward a suspected malaria case in households may contribute to this problem. (2) Method: In communities of one rural and one urban Health Centres in each of the 11 previous provinces of DRC, all households with a case of malaria in the 15 days prior to the survey were selected. The patient or caregiver (responder) were interviewed. Logistic regression was used to assess predictors of knowledge of recommended antimalarials and adequate behaviour in case of suspected malaria. (3) Results: 1732 households participated; about 62% (1060/1721) of the responders were informed about antimalarials, 70.1% (742/1059) knew the recommended antimalarials and 58.6% (995/1699) resorted to self-medication. Predictors of knowledge of antimalarials were education to secondary school or university, information from media and smaller households. Predictors of good behaviour were Catholic religion and smaller households. Receiving information from Community Health Workers (CHWs) failed to be determinants of knowledge or adequate behaviour. (4) Conclusion: malaria control in DRC is hampered by ignorance and non-adherence to national recommendations. These aspects are influenced by unsuccessful communication, size of households and level of education.

Optimizing initial neonatal resuscitation to reduce neonatal encephalopathy around the world.

One million two hundred thousand neonatal lives are lost each year due to intrapartum-related events; 99% of these deaths occur in low- and lower middle-income countries. Neonates exposed to intrapartum-related events present with failure to breathe at birth. Quick and effective delivery room management of these neonates is critical in the prevention of brain injury. Given the prominent role of lung aeration in the cardiopulmonary transition at birth, the mainstay of neonatal resuscitation is effective ventilation. Basic neonatal resuscitation focuses on simple stimulation, airway positioning and clearing, and bag-mask ventilation. Although principles for basic neonatal resuscitation remain the same for high- and low-resource settings, guidelines may differ based on available human and material resources. Formal training in basic resuscitation reduces intrapartum-related neonatal mortality in low-resource settings. However, there remain opportunities to improve provider performance for increased impact with other strategies such as regular practice and continuous quality improvement.

Effects of implementing a postabortion care strategy in Kinshasa referral hospitals, Democratic Republic of the Congo.

OBJECTIVES: To evaluate the effects of the implementation of a postabortion care (PAC) strategy in Kinshasa referral hospitals, this study analyzed the quality of postabortion care services, including postabortion contraception, and the duration of hospitalization. METHODOLOGY: We estimated the effects of the PAC strategy using a quasi-experimental study by evaluating the outcomes of 334 patients with the diagnosis of a complication of induced abortion admitted to 10 hospitals in which the PAC strategy was implemented compared to the same outcomes in 314 patients with the same diagnosis admitted to 10 control facilities from 01/01/2016 to 12/31/2018. In response to government policy, the PAC strategy included the treatment of abortion complications with recommended uterine evacuation technology, the family planning counseling and service provision, linkages with other reproductive health services, including STI evaluation and HIV counseling and/or referral for testing, and partnerships between providers and communities. The information was collected using a questionnaire and stored using open data kit software. We supplemented this information with data abstracted from patient records, facility registries of gynecological obstetrical emergencies, and family planning registries. We analyzed data and developed regression models using STATA15. Thus, we compared changes in use of specific treatments and duration of hospitalization using a "difference-in-differences" analysis. RESULTS: The implementation of PAC strategy in Kinshasa referral hospitals has resulted in the utilization of WHO recommended uterine evacuation method MVA (29.3% more in the experimental structures, p = 0.025), a significant decline in sharp-curettage (19.3% less, p = 0.132), and a decline in the duration of hospitalization of patients admitted for PAC (1 day less, p = 0.020). We did not observe any change in the use of PAC services, mortality, and the provision of post abortion contraception. CONCLUSION: Despite significant improvement in the management of PAC, the uptake in WHO approved technology-namely MVA, and the duration of hospitalization, these outcomes while a significant improvement for DRC, indicate that additional quality improvement strategies for management of PAC and risk-mitigating strategies to reduce barriers to care are required.

The Critical Need for Pooled Data on Coronavirus Disease 2019 in African Children: An AFREhealth Call for Action Through Multicountry Research Collaboration.

Globally, there are prevailing knowledge gaps in the epidemiology, clinical manifestations, and outcomes of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among children and adolescents; and these gaps are especially wide in African countries. The availability of robust age-disaggregated data is a critical first step in improving knowledge on disease burden and manifestations of coronavirus disease 2019 (COVID-19) among children. Furthermore, it is essential to improve understanding of SARS-CoV-2 interactions with comorbidities and coinfections such as human immunodeficiency virus (HIV), tuberculosis, malaria, sickle cell disease, and malnutrition, which are highly prevalent among children in sub-Saharan Africa. The African Forum for Research and Education in Health (AFREhealth) COVID-19 Research Collaboration on Children and Adolescents is conducting studies across Western, Central, Eastern, and Southern Africa to address existing knowledge gaps. This consortium is expected to generate key evidence to inform clinical practice and public health policy-making for COVID-19 while concurrently addressing other major diseases affecting children in African countries.

Effect of SARS-CoV-2 Infection in Pregnancy on Maternal and Neonatal Outcomes in Africa: An AFREhealth Call for Evidence through Multicountry Research Collaboration.

In the African context, there is a paucity of data on SARS-CoV-2 infection and associated COVID-19 in pregnancy. Given the endemicity of infections such as malaria, HIV, and tuberculosis (TB) in sub-Saharan Africa (SSA), it is important to evaluate coinfections with SARS-CoV-2 and their impact on maternal/infant outcomes. Robust research is critically needed to evaluate the effects of the added burden of COVID-19 in pregnancy, to help develop evidence-based policies toward improving maternal and infant outcomes. In this perspective, we briefly review current knowledge on the clinical features of COVID-19 in pregnancy; the risks of preterm birth and cesarean delivery secondary to comorbid severity; the effects of maternal SARS-CoV-2 infection on the fetus/neonate; and in utero mother-to-child SARS-CoV-2 transmission. We further highlight the need to conduct multicountry surveillance as well as retrospective and prospective cohort studies across SSA. This will enable assessments of SARS-CoV-2 burden among pregnant African women and improve the understanding of the spectrum of COVID-19 manifestations in this population, which may be living with or without HIV, TB, and/or other coinfections/comorbidities. In addition, multicountry studies will allow a better understanding of risk factors and outcomes to be compared across countries and subregions. Such an approach will encourage and strengthen much-needed intra-African, south-to-south multidisciplinary and interprofessional research collaborations. The African Forum for Research and Education in Health's COVID-19 Research Working Group has embarked upon such a collaboration across Western, Central, Eastern and Southern Africa.

Innovations in Cardiorespiratory Monitoring to Improve Resuscitation With Helping Babies Breathe.

Ninety percent of intrapartum-related neonatal deaths are attributable to respiratory depression, with the vast majority of these deaths occurring in low- and lower-middle-income countries. Neonatal resuscitation training with Helping Babies Breathe (HBB) decreases mortality from respiratory depression. Cardiorespiratory monitoring in conjunction with HBB can provide valuable resuscitation feedback for both training and bedside purposes. In this article, we discuss 3 innovations that couple cardiorespiratory monitoring with HBB: NeoNatalie Live, the Augmented Infant Resuscitator, and NeoBeat. NeoNatalie Live is a high-fidelity manikin that facilitates bag mask ventilation training through case scenarios of varying difficulty. The Augmented Infant Resuscitator is added in-line between a face mask and ventilation bag during bag mask ventilation training to provide users with real-time feedback on ventilation quality. NeoBeat is a battery-operated heart rate meter that digitally displays the newborn heart rate during bedside resuscitations. For each innovation, we review details of the device, implementation in the field, and areas for further research. Using early experience implementing these devices, we suggest building blocks for effective translation of training into improved care. We also highlight general challenges in implementation of devices in facilities in low- and lower-middle-income countries including considerations for training, adaptations to existing workflow, and integration into the ecosystem. Although the devices highlighted in this article hold promise, more data are needed to understand their impact on newborn outcomes.

Clinical Characteristics and Outcomes of Patients Hospitalized for COVID-19 in Africa: Early Insights from the Democratic Republic of the Congo.

Little is known about the clinical features and outcomes of SARS-CoV-2 infection in Africa. We conducted a retrospective cohort study of patients hospitalized for COVID-19 between March 10, 2020 and July 31, 2020 at seven hospitals in Kinshasa, Democratic Republic of the Congo (DRC). Outcomes included clinical improvement within 30 days (primary) and in-hospital mortality (secondary). Of 766 confirmed COVID-19 cases, 500 (65.6%) were male, with a median (interquartile range [IQR]) age of 46 (34-58) years. One hundred ninety-one (25%) patients had severe/critical disease requiring admission in the intensive care unit (ICU). Six hundred twenty patients (80.9%) improved and were discharged within 30 days of admission. Overall in-hospital mortality was 13.2% (95% CI: 10.9-15.8), and almost 50% among those in the ICU. Independent risk factors for death were age < 20 years (adjusted hazard ratio [aHR] = 6.62, 95% CI: 1.85-23.64), 40-59 years (aHR = 4.45, 95% CI: 1.83-10.79), and ≥ 60 years (aHR = 13.63, 95% CI: 5.70-32.60) compared with those aged 20-39 years, with obesity (aHR = 2.30, 95% CI: 1.24-4.27), and with chronic kidney disease (aHR = 5.33, 95% CI: 1.85-15.35). In marginal structural model analysis, there was no statistically significant difference in odds of clinical improvement (adjusted odds ratio [aOR] = 1.53, 95% CI: 0.88-2.67, P = 0.132) nor risk of death (aOR = 0.65, 95% CI: 0.35-1.20) when comparing the use of chloroquine/azithromycin versus other treatments. In this DRC study, the high mortality among patients aged < 20 years and with severe/critical disease is of great concern, and requires further research for confirmation and targeted interventions.

Polyhydramnios among women in a cluster-randomized trial of ultrasound during prenatal care within five low and low-middle income countries: a secondary analysis of the first look study.

BACKGROUND: In many low and low-middle income countries, the incidence of polyhydramnios is unknown, in part because ultrasound technology is not routinely used. Our objective was to report the incidence of polyhydramnios in five low and low-middle income countries, to determine maternal characteristics associated with polyhydramnios, and report pregnancy and neonatal outcomes. METHODS: We performed a secondary analysis of the First Look Study, a multi-national, cluster-randomized trial of ultrasound during prenatal care. We evaluated all women enrolled from Guatemala, Pakistan, Zambia, Kenya and the Democratic Republic of Congo (DRC) who received an examination by prenatal ultrasound. We used pairwise site comparisons with Tukey-Kramer adjustment and multivariable logistic models with general estimating equations to control for cluster-level effects. The diagnosis of polyhydramnios was confrimed by an U.S. based radiologist in a majority of cases (62%). RESULTS: We identified 305/18,640 (1.6%) cases of polyhydramnios. 229 (75%) cases were from the DRC, with an incidence of 10%. A higher percentage of women with polyhydramnios experienced obstructed labor (7% vs 4%) and fetal malposition (4% vs 2%). Neonatal death was more common when polyhydramnios was present (OR 2.43; CI 1.15, 5.13). CONCLUSIONS: Polyhydramnios occured in these low and low-middle income countries at a rate similar to high-income contries except in the DRC where the incidence was 10%. Polyhydramnios was associated with obstructed labor, fetal malposition, and neonatal death. TRIAL REGISTRATION: NCT01990625 , November 21, 2013.