Assessment of the yellow fever outbreak in Angola from December 2015 through December 2016: A retrospective study.

Background and Aims: The acute tropical infectious disease known as yellow fever (YF) is caused by an arbovirus and is characterized by fever, jaundice, hemorrhage, headache, muscle pain, nausea, vomiting, and fatigue. Angola experienced a yellow fever virus (YFV) outbreak that was documented in December 2015. However, little is known about the outcome of this outbreak. We aimed to demonstrate epidemic features and lessons learned during the YF epidemic in Angola. Methods: A total of 4618 blood samples from suspected YF cases were sent to the Instituto Nacional de Investigação em Saúde (INIS), a national referral and public health laboratory, between December 5, 2015, and December 23, 2016. Sample analyses were conducted using enzyme-linked immunosorbent assay (ELISA) and reverse transcription polymerase chain reaction (RT-PCR) assays. Blood samples were sent from 16 out of the 18 provinces of Angola. Results: We detected 884 (19.1%) cases that were positive for ELISA, which were confirmed by RT-PCR assay. Considering the positive cases, the incidence among male patients was around three times higher (n = 223; 10.9%) than in female patients (n = 59; 2.6%) in the 20-29 age group, followed by the age group 10-19 with n = 211 (6.8%) in males versus n = 108 (3.3%) in females; and the age group 30-39 had n = 68 (4.8%) in males versus n = 28 (1.8%) in females. The other groups had an incidence below 3.0%. The case fatality ratio for YF was in young adults in the age group 20-29 with n = 39 cases, followed by the age group 10-19 with n = 16 cases, and finally the age group 0-9 with n = 13 cases. The other age groups had several deaths by YF below 10 cases. Conclusions: This study demonstrates features of the YF epidemic that occurred in Angola. Also, it demonstrates that YF causes deaths in young people but is preventable by high vaccine coverage. Thus, public health laboratory surveillance must be strengthened to reduce the possibility of emerging and re-emerging human infections.

Insights into SARS-CoV-2 in Angola during the COVID-19 peak: Molecular epidemiology and genome surveillance.

Background: In Angola, COVID-19 cases have been reported in all provinces, resulting in >105,000 cases and >1900 deaths. However, no detailed genomic surveillance into the introduction and spread of the SARS-CoV-2 virus has been conducted in Angola. We aimed to investigate the emergence and epidemic progression during the peak of the COVID-19 pandemic in Angola. Methods: We generated 1210 whole-genome SARS-CoV-2 sequences, contributing West African data to the global context, that were phylogenetically compared against global strains. Virus movement events were inferred using ancestral state reconstruction. Results: The epidemic in Angola was marked by four distinct waves of infection, dominated by 12 virus lineages, including VOCs, VOIs, and the VUM C.16, which was unique to South-Western Africa and circulated for an extended period within the region. Virus exchanges occurred between Angola and its neighboring countries, and strong links with Brazil and Portugal reflected the historical and cultural ties shared between these countries. The first case likely originated from southern Africa. Conclusion: A lack of a robust genome surveillance network and strong dependence on out-of-country sequencing limit real-time data generation to achieve timely disease outbreak responses, which remains of the utmost importance to mitigate future disease outbreaks in Angola.

Epidemiology of measles in Angola: Results from routine surveillance from 2015 to 2021.

Background: Measles, an acute infectious disease of extremely contagious viral aetiology, has been eliminated in some parts of the world. To the best of the authors' knowledge, this is the first study on the epidemiological pattern of the measles virus in Angola, and it was carried out through a review of 7 years of observational retrospective data from the national measles laboratory surveillance programme. Methods: A retrospective study using national databases on the laboratory surveillance of measles was performed. Patients of all ages with suspected measles from all provinces of Angola were included. Serum samples were used to detect IgM-type measles-virus-specific antibodies by enzyme-linked immunosorbent assay. Findings: In total, 3690 suspected measles samples were sent to the Instituto Nacional de Investigação em Saúde. There were 962 (26.1%) laboratory-confirmed cases, and the most affected age group was children aged 1-4 years. The highest incidence rate per 100,000 population was found in Benguela (17.9%), followed by Huambo (16.7%) and Cuanza Sul (13.6%). Of the study years, the incidence rate per 1,000,000 population was highest in 2020 (11.9%). The most common complication was diarrhoea (n=406, 42.2%). Of the confirmed cases, 209 (21.7%) were vaccinated, 633 (65.8%) were unvaccinated, and 120 (12.5%) had unknown vaccination status. For all study years, vaccination coverage was <70%. Interpretation: Measles continues to be a serious problem in Angola, and more efforts are needed to increase measles surveillance and achieve a high percentage of vaccination coverage.

Effectiveness of the maternal and child health handbook for improving continuum of care and other maternal and child health indicators: A cluster randomized controlled trial in Angola.

Background: The maternal and child health (MCH) handbook is promoted as a tool for strengthening continuum of care. We assessed the effect of a MCH handbook intervention package on continuum of maternal and child health care and health outcomes for mother and child. Methods: We conducted an open-label, parallel two-arm cluster randomized controlled trial in Angola. We randomly assigned municipalities in Benguela province through block randomization to a group using a package of enhanced maternity care service (which included the MCH handbook distribution and its supplementary intervention) and another using usual care (two stand-alone home-based records). We included women who were pregnant at the beginning of the trial period and attended a public health care facility for maternity care services. Neither health care providers, study participants nor data assessors were masked, but the statistician was. The primary outcome was a measure of service utilization assessed via achievement of maternal behavior-based continuum of care at three months postpartum. We conducted an intention-to-treat analysis in women with available data. Results: We randomized 10 municipalities to either the intervention (five clusters) or control (five clusters) group. Of the 11 530 women approached between June 8, 2019, and September 30, 2020, 11 006 were recruited and 9039 included in the final analysis (82%; 3774 in the intervention group and 5265 in the control group). The odds for achievement of maternal behavior-based continuum of care in the intervention group was not significantly different from that in the control group (adjusted odds ratio (aOR) = 1.18, 95% confidence interval (CI) = 0.46-2.93) at three months postpartum. However, the odds of initiating antenatal care clinic use were significantly higher in the intervention group (odds ratio (OR) = 5.16, 95% CI = 2.50-10.67). No harms associated with the intervention were reported. Conclusions: Distribution of the MCH handbook and its supplementary interventions promoted initiation of antenatal care service use, but did not increase service utilization sufficiently enough for attainment of study defined maternal behavior-based continuum of care. Registration: ISRCTN20510127.

Development and implementation of the maternal and child health Handbook in Angola.

Although the maternal and child health (MCH) Handbook is widely used in many countries, its development and implementation process has not been sufficiently documented in scientific publications. This is a report of how the Angola MCH Handbook was developed, what challenges we encountered during its implementation and how they were solved. Leading the process was the MCH Handbook Committee set up to develop the MCH Handbook and implement the programme in liaison with various stakeholders. We developed the MCH Handbook through participatory workshops with the objective of producing user-responsive content and designs, foster healthy interaction and build common understanding among stakeholders. After pilot use in select health facilities, the MCH Handbook programme, which included training, monitoring and supervision, mothers' class and community awareness raising activities, was gradually implemented in three model provinces. Core members of the committee closely observed each step of the programme to identify challenges in each field, and revised the tool and programme throughout the process. As nationwide implementation of the MCH Handbook Programme progresses, it is important to continually identify challenges specific to different localities while taking measures to address them. In our experience, stakeholder involvement from the early planning and preparation stages was critical to ensure their continued commitment at later stages and for programme continuity. Our approach of tool development involving various stakeholders and flexible implementation strategies were key elements for user acceptance and programme sustainability that may be applicable for introduction of similar interventions in other settings.

The RE-AIM framework-based evaluation of the implementation of the Maternal and Child Health Handbook program in Angola: a mixed methods study.

BACKGROUND: The World Health Organization recommends the Maternal and Child Health Handbook (MCH-HB) to promote health service utilization from pregnancy to early childhood. Although many countries have adopted it as a national health policy, there is a paucity of research in MCH-HB's implementation. Thus, this study aimed to evaluate the MCH-HB's implementation status based on the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, Maintenance), and identify facilitators of, and barriers to its implementation in Angola to understand effective implementation strategies. METHODS: A cross-sectional survey was conducted targeting all health facilities which implemented MCH-HB, subsamples of health workers, and officers responsible for the MCH-HB at the municipality health office. Using the 14 indicators based on the RE-AIM framework, health facilities' overall implementation statuses were assessed. This categorized health facilities into optimal-implementation and suboptimal-implementation groups. To identify barriers to and facilitators of MCH-HB implementation, semi-structured interviews were conducted among health workers and municipality health officers responsible for MCH-HB. The data were analyzed via content analysis. RESULTS: A total of 88 health facilities and 216 health workers were surveyed to evaluate the implementation status, and 155 interviews were conducted among health workers to assess the barriers to and facilitators of the implementation. The overall implementation target was achieved in 50 health facilities (56.8%). The target was achieved by more health facilities in urban than rural areas (urban 68.4%, rural 53.6%) and by more health facilities of higher facility types (hospital 83.3%, health center 59.3%, health post 52.7%). Through the interview data's analysis, facilitators of and barriers to MCH-HB were comprehensively demonstrated. MCH-HB's content advantage was the most widely recognized facilitator and inadequate training for health workers was the most widely recognized barrier. CONCLUSIONS: Strengthening education for health workers, supervision by municipality health officers, and community sensitization were potential implementation strategies. These strategies must be intensified in rural and lower-level health facilities.

The Maternal and Child Health Handbook for Improving the Continuum of Care and Other Maternal and Child Health Indicators in Angola: An Implementation Study Protocol.

Background: Reducing maternal, neonatal, and infant mortality tops the health targets of sustainable development goals. Many lifesaving interventions are being introduced in antenatal, delivery, and postnatal care. However, many low- and middle-income countries (LMICs) have not reached maternal and child health targets. The Maternal and Child Health Handbook (MCH-HB) is recommended as a home-based record to promote a continuum of care from pregnancy to early childhood, and is gaining increasing attention among LMICs. Several countries have adopted it as national health policy. To effectively utilize the MCH-HB in LMICs, implementation needs to be considered. Angola is an LIMC in Sub-Saharan Africa, where maternal and child health indicators are among the poorest. The Angolan Ministry of Health adopted the MCH-HB program in its national health policy and is currently conducting a cluster randomized controlled trial (MCH-HB RCT) to evaluate its impact on the continuum of care. This study aimed to evaluate implementation status, and barriers and facilitators of MCH-HB program implementation in Angola. Methods: To evaluate implementation status comprehensively, the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework will be used. Four components other than effectiveness will be investigated. A cross-sectional survey will be conducted targeting all health facilities and officers in charge of the MCH-HB at the municipality health office in the intervention group after the MCH-HB RCT. Data from the cross-sectional survey, secondary MCH-HB RCT data, and operational MCH-HB RCT records will be analyzed. Health facilities will be classified into good-implementation and poor-implementation groups using RE-AIM indicators. To identify barriers to and facilitators of MCH-HB implementation, semi-structured interviews/focus group discussions will be conducted among health workers at a sub-sample of health facilities and all municipality health officers in charge of MCH-HB in the intervention group. The Consolidated Framework for Implementation Research will be adopted to develop interview items. Thematic analysis will be performed. By comparing good-implementation and poor-implementation health facilities, factors that differ between groups that contribute to successful implementation can be identified. Discussion: This study's findings are expected to inform MCH-HB implementation policy and guidelines in Angola and in other countries that plan to adopt the MCH-HB program.

Medical faculty profile is an important determinant of student profile and future practice expectations of medical students in Angola.

BACKGROUND: Angola is among one of the most deprived countries in the world in terms of medical professionals. In the past decade, the Angolan Government has invested in the expansion of faculties of medicine in the country.  We analysed the profiles of medical students in Angola according to four clusters of medical schools: older faculty in the country, private faculties, Cuban sponsored faculties and military faculty; under the assumption that the organizational culture of the different faculties might influence the expectations and decisions towards future professional life of medical students regarding where they want to work (community versus hospital) and in which sector (exclusively public versus not exclusively public). METHODS: Observational cross-sectional study. Piloted, standardized questionnaire to final year medical students or higher year of training in the first four-month of 2014 (N = 402). Data were entered into a SPSS v.20 database and descriptive statistics computed. Statistical significance for categorical variables was tested by Pearson chi-square, Fisher exact or likelihood ratio tests as appropriate. Comparison of means was tested with Anova. Backward elimination binary logistic regression was used to test the hypothesis that type of faculty of medicine is an important determinant of future professional practice, i.e., level (hospital vs. community) or sector of practice (exclusive public sector vs. private or private and public), while controlling for confounders. RESULTS: After controlling for age, sex, marital status, place of birth and place of primary and secondary education, type of family and family influence, students were more likely to choose community over hospital practice and to prefer exclusive public practice if attending a Cuba supported faculty of medicine. CONCLUSIONS: Medical education cannot be isolated from planning of the medical workforce. Some important and impactful careers choices, like choosing rural over urban practice, public over private sector practice, have deep influences in the medical professionals' labour market. Some of these decisions are shaped even before the end of the medical training. As such, the monitoring of future professional intentions in medical schools should be done regularly to accommodate both the health system needs and the hopes and dreams of medical trainees.

Highlights from the 4th PALOP-AORTIC Conference on Cancer, 29-31 July 2020, Luanda, Angola.

The 4th Países Africanos de Língua Oficial Portuguesa (PALOP)-African Organisation for Research and Training in Cancer (AORTIC) Conference on Cancer was held in July 2020 in Luanda, Angola, under the theme: 'Training to better care'. It was hosted by the Ministry of Health of Angola and AORTIC. It was held virtually using an online platform. The PALOP organisation comprises Lusophone African countries. The conference brought together 360 delegates from 12 countries. Key themes covered during the conference included: Instruments for Proficient Cancer Control in PALOP, oncology education and training in PALOP, CanScreen5-International Agency for Research on Cancer platform to improve quality in tracking cancer, International Gynecologic Cancer Society-Global Curriculum and Mentorship Programme, Oncology Training/Intervention-Support Programmes, Telepathology and Cancer: Challenges and Opportunities, Cancer Burden in PALOP region and Sub-Saharan Africa, Breast Cancer-The current situation in PALOP and The African Breast Cancer Coalition-Disparities in outcomes study in PALOP Countries (ABC-DO-PALOP) study: a proposal. It has been demonstrated that the collaboration and exchange of experiences between African countries and amongst PALOP, in particular, are crucial, whether in the organisation of population-based cancer registries, in the realization of national oncology plans, in the creation of therapeutic recommendations and in strengthening capacities in radiotherapy, amongst other important topics in oncology. The PALOP oncology school will be a fundamental training tool to be administered for better care for cancer patients.

Stage at presentation of breast cancer in Luanda, Angola - a retrospective study.

BACKGROUND: It is expected that, by 2020, 15 million new cases of cancer will occur every year in the world, one million of them in Africa. Knowledge of cancer trends in African countries is far from adequate, and improvements in cancer prevention efforts are urgently needed. The aim of this study was to characterize breast cancer clinically and pathologically at presentation in Luanda, Angola; we additionally provide quality information that will be useful for breast cancer care planning in the country. METHODS: Data on breast cancer cases were retrieved from the Angolan Institute of Cancer Control, from 2006 to 2014. For women diagnosed in 2009 (5-years of follow-up), demographic, clinical and pathological information, at presentation, was collected, namely age at diagnosis, parity, methods used for pathological diagnoses, tumor pathological characteristics, stage of disease and treatment. Descriptive statistics were performed. RESULTS: The median age of women diagnosed with breast cancer in 2009 was 47 years old (range 25-89). The most frequent clinical presentation was breast swelling with axillary lymph nodes metastasis (44.9 %), followed by a mass larger than 5 cm (14.2 %) and lump (12.9 %). Invasive ductal carcinoma was the main histologic type (81.8 %). Only 10.1 % of cancer cases had a well differentiated histological grade. Cancers were diagnosed mostly at advanced stages (66.7 % in stage III and 11.1 % in stage IV). DISCUSSION: In this study, breast cancer was diagnosed at a very advanced stage. Although it reports data from a single cancer center in Luanda, Angola it reinforces the need for early diagnosis and increasing awareness. According to the main challenges related to breast cancer diagnosis and treatment herein presented, we propose a realistic framework that would allow for the implementation of a breast cancer care program, built under a strong network based on cooperation, teaching, audit, good practices and the organization of health services. CONCLUSION: Angola needs urgently a program for early diagnosis of breast cancer.