Empanelment of the Population to the Primary Medical Care Institution of Sri Lanka: A Mixed-Methods Study on Outcomes and Challenges.

The registration of individuals with designated primary medical care institutions (PMCIs) is a key step towards their empanelment with these PMCIs, supported by the Primary Health Care System Strengthening Project in Sri Lanka. We conducted an explanatory mixed-methods study to assess the extent of registration at nine selected PMCIs and understand the challenges therein. By June 2021, 36,999 (19.2%, 95% CI-19.0-19.4%) of the 192,358 catchment population allotted to these PMCIs were registered. At this rate, only 50% coverage would be achieved by the end of the project (December 2023). Proportions of those aged <35 years and males among those registered were lower compared to their general population distribution. Awareness activities regarding registration were conducted in most of the PMCIs, but awareness in the community was low. Poor registration coverage was due to a lack of dedicated staff for registration, misconceptions of health care workers about individuals needing to be registered, reliance on opportunistic or passive registration, and lack of monitoring mechanisms; these were further compounded by the COVID-19 pandemic. Moving forward, there is an urgent need to address these challenges to improve registration coverage and ensure that all individuals are empaneled before the close of the project for it to have a meaningful impact.

Outcomes and Challenges in Noncommunicable Disease Care Provision in Health Facilities Supported by Primary Health Care System Strengthening Project in Sri Lanka: A Mixed-Methods Study.

The Primary Healthcare System Strengthening Project in Sri Lanka focuses on improving noncommunicable disease (NCD) care provision at primary medical care institutions (PMCIs). We conducted an explanatory mixed-methods study to assess completeness of screening for NCD risk, linkage to care, and outcomes of diabetes/hypertension care at nine selected PMCIs, as well as to understand reasons for gaps. Against a screening coverage target of 50% among individuals aged ≥ 35 years, PMCIs achieved 23.3% (95% CI: 23.0-23.6%) because of a lack of perceived need for screening among the public and COVID-19-related service disruptions. Results of investigations and details of further referral were not documented in almost half of those screened. Post screening, 45% of those eligible for follow-up NCD care were registered at medical clinics. Lack of robust recording/tracking mechanisms and preference for private providers contributed to post-screening attrition. Follow-up biochemical investigations for monitoring complications were not conducted in more than 50% of diabetes/hypertension patients due to nonprescription of investigations by healthcare providers and poor uptake among patients because of nonavailability of investigations at PMCI, requiring them to avail services from the private sector, incurring out-of-pocket expenditure. Primary care strengthening needs to address these challenges to ensure successful integration of NCD care within PMCIs.

Epidemiology and Response to the COVID-19 Pandemic in Kerala, India, 2020-2021: A Cross-Sectional Study.

Kerala, a southern state in India, experienced a slightly different COVID-19 pandemic than the rest of India. Using data from daily COVID-19 bulletins and two other Kerala health information systems, this study reported on epidemiological characteristics and response measures of the COVID-19 pandemic between January 2020 and December 2021. After the first six months, Kerala experienced three distinct phases, with COVID-19 cases peaking in October 2020, May 2021, and August 2021. This contrasts with India, which experienced two main peaks in September 2020 and May 2021. The demographic profile of cases aligned with the national profile except for a slight increase of COVID-19 in persons aged ≥60 years. Monthly COVID-19 deaths increased dramatically from May 2021 onwards in line with case numbers but also reflecting changes in definitions of COVID-19 deaths. Case fatality for the two years was significantly higher in males than females, increased with increasing age groups, and varied between districts (p < 0.001). Trends in bed occupancy in field hospitals, hospitals for severe disease, intensive care units, and mechanical ventilation mirrored the different phases of the pandemic. The monitoring system in Kerala allowed certain aspects of the pandemic to be mapped, but it would benefit from further strengthening.

Compliance with Medication amongst Persons with Diabetes Mellitus during the COVID-19 Pandemic, Kerala, India: A Cross Sectional Study.

Compliance with medication in persons with diabetes mellitus (DM) has been a challenge during the COVID-19 pandemic, leading to poor glycemic control and higher risk of complications. In the state of Kerala, India, 20-25% of adults have DM. Our cross-sectional study aimed to assess medication compliance and factors associated with poor compliance in DM persons attending selected primary care government facilities in Kerala during the COVID-19 pandemic. Persons registered with DM for >6 months were consecutively interviewed between August and September 2021. Poor compliance was defined as answering "No" to one or more of three questions related to access and intake of medication two weeks prior to and the day before the interview. Factors independently associated with poor compliance were assessed using adjusted prevalence ratios (aPr) and 95% confidence intervals. Of the 560 DM persons included, 209 (37%) exhibited poor compliance. Factors associated with poor compliance were age 19-45 years (aPr 1.4, 1.1-1.9); inability to be blood glucose tested during the COVID-19 pandemic (aPr 3.6, 2.9-4.3); not having COVID-19 (aPr 1.4, 1.0-1.9); and being double vaccinated against COVID-19 (aPr 1.4, 1.1-2.0). Focused attention must be paid to these groups to improve medication compliance and prevent DM complications and severe COVID-19-related disease.

COVID-19 Amongst Travelers at Points of Entry in Nepal: Screening, Testing, Diagnosis and Isolation Practices.

WHO recommends surveillance for COVID-19 among travelers at Points of Entry (POE) to countries. At 13 selected POE at the Nepal-India border, between March 2021 and July 2021, we describe the screening, testing, diagnosis and isolation practices of COVID-19 amongst travelers. Those who stayed in India or elsewhere for > one day and those who did not have a negative RT-PCR result within the last 72 h of travel were tested for COVID-19 with rapid antigen diagnostic tests. Daily surveillance reports maintained at POE were used for analysis. Of 337,338 travelers screened, 69,886 (21%) were tested and 3907 (6%) were diagnosed with COVID-19. The proportions tested averaged 15% during April-May when screened numbers were high and increased to 35% in July when screened numbers had decreased. The proportions diagnosed positive peaked at 10% in April-May, but decreased to below 1% in June and July. Testing coverage varied from 0-99% in the different POE. Most COVID-19 cases were Nepalese, male, <60 years of age, migrant workers and presented with fever. Of COVID-19 cases, 32% had home-based isolation, 64% underwent community-based isolation and the remainder either went to hospital or returned to India. In conclusion, about one fifth of travelers overall were tested, with coverage varying considerably over time and among different POE. Strengthening surveillance processes at POE is needed.

Culture Requests and Multi-Drug Resistance among Suspected Urinary Tract Infections in Two Tertiary Hospitals in Freetown, Sierra Leone (2017-21): A Cross-Sectional Study.

In sub-Saharan Africa, there is limited information about the use of microbiology laboratory services in patients with suspected urinary tract infections (UTIs). This cross-sectional study assessed the requests for urine culture in patients with suspected UTI in two tertiary (maternal and paediatric) hospitals-Freetown and Sierra Leone, during May 2017-May 2021-and determined antimicrobial resistance (AMR) patterns among bacterial isolates. One laboratory served the two hospitals, with its electronic database used to extract information. Overall, there were 980 patients, of whom 168 (17%) had cultures requested and performed. Of these, 75 (45%) were culture positive. During 2017-2019, there were 930 patients, of whom 156 (17%) had cultures performed. During 2020-2021, when services were disrupted by the COVID-19 pandemic, there were 50 patients, of whom 12 (24%) had cultures performed. The four commonest isolates were Escherichia coli (36), Klebsiella pneumoniae (10), Staphylococcus aureus (9), and Pseudomonas spp. (6). There were high levels of AMR, especially for trimethoprim-sulfamethoxazole (47%), nalidixic acid (44%), nitrofurantoin (32%) and cefotaxime (36%). Overall, 41 (55%) bacterial isolates showed multidrug resistance, especially E. coli (58%), Pseudomonas spp. (50%), and S. aureus (44%). These findings support the need for better utilization of clinical microbiology services to guide antibiotic stewardship and monitoring of trends in resistance patterns.

The Structured Operational Research and Training Initiative for Strengthening Health Systems to Tackle Antimicrobial Resistance and Improve Public Health in Low-and-Middle Income Countries.

If research is to have an impact and change health outcomes for the better, the findings of the research should be translated into recommendations and actions that can influence policy and/or practice [...].

Going virtual for research training during the COVID-19 pandemic and beyond: e-SORT IT.

The Structured Operational Research and Training Initiative (SORT IT) model has contributed to building research capacity and has produced evidence for improving public health program performance in countries with limited research capacity. The model involves hands-on mentorship and consists of three modules/weeks. It is recognized to be an innovative research capacity building model. In a world changed by COVID-19, where bringing people together is not viable, an innovative, interactive, web-based, knowledge-transfer platform (e-SORT IT) for virtual implementation of SORT IT modules was created. The platform design imitated the residential course as closely as possible with the same lectures, plenary sessions, and breakout rooms. Despite the challenges, the platform performed well and even though participants and mentors were located in eight different time zones, the course was successful; 90% of participants achieved their milestones and 10 manuscripts were successfully completed. Participant evaluation revealed a satisfaction level that was nearly equivalent to the residential module. However, mentor evaluation indicated a number of shortcomings including capacity building, professional networking, communication, engagement, and contribution by participants, as well as overall module success. In conclusion, COVID-19 stimulated the creation of the e-SORT IT platform that provided a functional alternative to the residential version. Despite the limitations of reduced capacity building and networking, the e-SORT IT platform should be considered a success - it delivered the goods. This is an example of innovation and flexibility, two attributes that are sorely needed to maintain activities during the pandemic and beyond.

Real-Time Operational Research: Case Studies from the Field of Tuberculosis and Lessons Learnt.

Real-time operational research can be defined as research on strategies or interventions to assess if they are feasible, working as planned, scalable and effective. The research involves primary data collection, periodic analysis during the conduct of the study and dissemination of the findings to policy makers for timely action. This paper aims to illustrate the use of real-time operational research and discuss how to make it happen. Four case studies are presented from the field of tuberculosis. These include (i) mis-registration of recurrent tuberculosis in Malawi; (ii) HIV testing and adjunctive cotrimoxazole to reduce mortality in TB patients in Malawi; (iii) screening TB patients for diabetes mellitus in India; and (iv) mitigating the impact of COVID-19 on TB case detection in capital cities in Kenya, Malawi and Zimbabwe. The important ingredients of real-time operational research are sound ethics; relevant research; adherence to international standards of conducting and reporting on research; consideration of comparison groups; timely data collection; dissemination to key stakeholders; capacity building; and funding. Operational research can improve the delivery of established health interventions and ensure the deployment of new interventions as they become available, irrespective of diseases. This is particularly important when public health emergencies, including pandemics, threaten health services.

Operational Research to Assess the Real-Time Impact of COVID-19 on TB and HIV Services: The Experience and Response from Health Facilities in Harare, Zimbabwe.

When COVID-19 was declared a pandemic, there was concern that TB and HIV services in Zimbabwe would be severely affected. We set up real-time monthly surveillance of TB and HIV activities in 10 health facilities in Harare to capture trends in TB case detection, TB treatment outcomes and HIV testing and use these data to facilitate corrective action. Aggregate data were collected monthly during the COVID-19 period (March 2020-February 2021) using EpiCollect5 and compared with monthly data extracted for the pre-COVID-19 period (March 2019-February 2020). Monthly reports were sent to program directors. During the COVID-19 period, there was a decrease in persons with presumptive pulmonary TB (40.6%), in patients registered for TB treatment (33.7%) and in individuals tested for HIV (62.8%). The HIV testing decline improved in the second 6 months of the COVID-19 period. However, TB case finding deteriorated further, associated with expiry of diagnostic reagents. During the COVID-19 period, TB treatment success decreased from 80.9 to 69.3%, and referral of HIV-positive persons to antiretroviral therapy decreased from 95.7 to 91.7%. Declining trends in TB and HIV case detection and TB treatment outcomes were not fully redressed despite real-time monthly surveillance. More support is needed to transform this useful information into action.

TB and COVID-19: paying attention to diabetes mellitus.

In 2019, global diabetes prevalence was 463 million. Diabetes increases the risk of TB and adverse treatment outcomes including death and relapse. Diabetes also increases the risk of severe disease, multi-organ failure, coagulopathy and death in COVID-19. TB and COVID-19 share many features, suggesting opportunities to integrate prevention, diagnosis and care. Three areas for further work are highlighted: better infection control in diabetes clinics, easier and quicker diagnosis using similar technology platforms and optimal blood glucose control. The funding and resources for COVID-19 should be harnessed to improve TB and diabetes care and achieve their respective sustainable development goal targets.

Assessing the Impact of COVID-19 on TB and HIV Programme Services in Selected Health Facilities in Lilongwe, Malawi: Operational Research in Real Time.

When the COVID-19 pandemic was announced in March 2020, there was concern that TB and HIV programme services in Malawi would be severely affected. We set up real-time monthly surveillance of TB and HIV activities in eight health facilities in Lilongwe to see if it was possible to counteract the anticipated negative impact on TB case detection and treatment and HIV testing. Aggregate data were collected monthly during the COVID-19 period (March 2020-February 2021) using an EpiCollect5 application and compared with monthly data collected during the pre-COVID-19 period (March 2019-February 2020); these reports were sent monthly to programme directors. During COVID-19, there was an overall decrease in persons presenting with presumptive pulmonary TB (45.6%), in patients registered for TB treatment (19.1%), and in individuals tested for HIV (39.0%). For presumptive TB, children and females were more affected, but for HIV testing, adults and males were more affected. During COVID-19, the TB treatment success rate (96.1% in pre-COVID-19 and 96.0% during COVID-19 period) and referral of HIV-positive persons to antiretroviral therapy (100% in pre-COVID-19 and 98.6% during COVID-19 period) remained high and largely unchanged. Declining trends in TB and HIV case detection were not redressed despite real-time monthly surveillance.

Assessing the Real-Time Impact of COVID-19 on TB and HIV Services: The Experience and Response from Selected Health Facilities in Nairobi, Kenya.

There was concern that the COVID-19 pandemic would adversely affect TB and HIV programme services in Kenya. We set up real-time monthly surveillance of TB and HIV activities in 18 health facilities in Nairobi so that interventions could be implemented to counteract anticipated declining trends. Aggregate data were collected and reported monthly to programme heads during the COVID-19 period (March 2020-February 2021) using EpiCollect5 and compared with monthly data collected during the pre-COVID period (March 2019-February 2020). During the COVID-19 period, there was an overall decrease in people with presumptive pulmonary TB (31.2%), diagnosed and registered with TB (28.0%) and in those tested for HIV (50.5%). Interventions to improve TB case detection and HIV testing were implemented from August 2020 and were associated with improvements in all parameters during the second six months of the COVID-19 period. During the COVID-19 period, there were small increases in TB treatment success (65.0% to 67.0%) and referral of HIV-positive persons to antiretroviral therapy (91.2% to 92.9%): this was more apparent in the second six months after interventions were implemented. Programmatic interventions were associated with improved case detection and treatment outcomes during the COVID-19 period, suggesting that monthly real-time surveillance is useful during unprecedented events.

Building better tuberculosis control systems in a post-COVID world: learning from Pakistan during the COVID-19 pandemic.

OBJECTIVES: All countries impacted by COVID-19 have had to change routine health service delivery. Although this has reversed some of the progress made in reducing the global burden of tuberculosis (TB) disease, there is an opportunity to incorporate lessons learned to improve TB programmes going forward. APPROACH: We use Pakistan as a case study to discuss three important adaptations in light of COVID-19: bringing care closer to patients; strengthening primary health care systems; and proactively addressing stigma and fear. FINDINGS: COVID-19 control in Pakistan has restricted people's ability to travel and this has forced the TB programme to reduce the need for in-person health facility visits and bring care closer to patients' homes. Strategies that may be useful for providing more convenient care to patients in the future include: : remote treatment support using telemedicine; collaborating with private healthcare providers; and establishing community medicine collection points. As part of the response to COVID-19 in Pakistan, the out-patient departments of major tertiary and secondary care hospitals were closed, and this highlighted the importance of strengthening primary healthcare for both better pandemic and TB control. Finally, stigma associated with COVID-19 and TB can be addressed using trusted community-based health workers, such as Lady Health Workers in Pakistan.

What is operational research and how can national tuberculosis programmes in low- and middle-income countries use it to end TB?

Despite considerable progress over the years, tuberculosis (TB) still remains the top cause of death among the infectious diseases and has devastating socio-economic consequences for people in low- and middle-income countries. To add to this, the emergence of the COVID-19 pandemic has worsened delivery of TB care across the globe. As a global community, we have committed to end the TB epidemic by 2030. The World Health Organization has framed a strategy to achieve this goal which consists of three pillars namely i) integrated patient-centred care and prevention, ii) bold policies and systems and iii) intensified research and innovation. An analysis of the performance of national tuberculosis programmes (NTPs) across the globe against the ten priority indicators recommended for monitoring the end TB strategy show that there are huge gaps at every step in the cascade of care of TB patients. In our view, these gaps reflect suboptimal implementation of existing strategies known to be efficacious and operational research (OR) is one of the best available tools to plug the gaps. In this paper, we define what operational research is and how it differs from other kinds of research. We also share our views and experiences about how operational research can be used by NTPs to identify implementation gaps and their reasons, and develop and test possible solutions - which are then integrated to make changes to policy and practice and eventually improve programme outcomes. OR can be defined as research into interventions, strategies and tools which produces practical useable knowledge that can be used to enhance the quality, coverage, effectiveness and efficiency of disease control programmes, health services or health systems in which the research is conducted. The key steps in integrating operational research in the NTPs include: i) securing political commitment reflected by inclusion of OR in the national strategic plans of NTPs and earmarked funding, ii) having a critical mass of dedicated and trained human resources in OR within the NTP, iii) setting research priorities and steering the direction of research in the country, iv) using output-oriented models of capacity building such as the Structured Operational Research Training Initiative (SORT IT) model and building communities of practice, v) harnessing existing capacity in the country by forging partnerships with academia, vi) NTP-led nationwide, multicentre OR studies, vii) providing access to anonymized patient and programme surveillance data, vii) creating a forum for evidence dissemination and fostering policy change and ix) monitoring and accountability. In conclusion, ending the TB epidemic will not be possible without new tools (diagnostics, drugs, vaccines) and a multi-sectoral response involving stakeholders beyond the health ministry, including private providers, patients and communities. However, timely conduct of operational research to fine-tune programme implementation and ensuring proper deployment of new tools will be equally crucial to maximize the effectiveness and efficiency of interventions and ultimately contribute towards ending TB.

SARS-CoV-2: how safe is it to fly and what can be done to enhance protection?

With lockdown restrictions over coronavirus disease 2019 being relaxed, airlines are returning to the skies. Published evidence of severe acute respiratory syndrome (SARS) coronavirus 2 transmission on aircraft is limited, but in-flight transmission of respiratory infections such as tuberculosis, influenza and SARS has been well described. Risk factors include proximity to index patients and sitting in aisle seats. Personal protection on aircraft could be enhanced by always wearing a well-fitting face mask and face shield or sunglasses, wiping surfaces and hands with alcohol-based sanitizers, not touching the face, not queuing for washrooms, changing seats if nearby passengers are coughing and choosing a window rather than an aisle seat.

Investing in Operational Research Capacity Building for Front-Line Health Workers Strengthens Countries' Resilience to Tackling the COVID-19 Pandemic.

(1) Introduction. The Structured Operational Research and Training IniTiative (SORT IT) supports countries to build operational research capacity for improving public health. We assessed whether health workers trained through SORT IT were (1) contributing to the COVID-19 pandemic response and if so, (2) map where and how they were applying their SORT IT skills. (2) Methods. An online questionnaire survey of SORT IT alumni trained between 2009 and 2019. (3) Results. Of 895 SORT IT alumni from 93 countries, 652 (73%) responded to the survey and 417 were contributing to the COVID-19 response in 72 countries. Of those contributing, 307 (74%) were applying their SORT IT skills to tackle the pandemic in 60 countries and six continents including Africa, Asia, Europe, South Pacific and North/South America. Skills were applied to all the pillars of the emergency response with the highest proportions of alumni applying their skills in data generation/analysis/reporting (56%), situation analysis (55%) and surveillance (41%). Skills were also being used to mitigate the health system effects of COVID-19 on other diseases (27%) and in conducting research (26%). (4) Conclusion. Investing in people and in research training ahead of public health emergencies generates downstream dividends by strengthening health system resilience for tackling pandemics. It also strengthens human resources for health and the integration of research within health systems.

Testing wastewater to detect severe acute respiratory syndrome coronavirus 2 in communities.

Research groups around the world are starting to analyse whether wastewater surveillance is a useful tool to monitor the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in communities. Reported studies from the Netherlands, USA, Australia and France have demonstrated that SARS-CoV-2 can be detected and quantified in wastewater, allowing the total number of community infections to be estimated as well as monitoring whether the virus has returned to a community after elimination. Further work is required to improve the quantification of virus, to better detect the virus at low levels and to ensure wastewater samples are representative of the community under surveillance.

Investing in Operational Research Capacity Building for Front-Line Health Workers Strengthens Countries’ Resilience to Tackling the COVID-19 Pandemic

(1) Introduction. The Structured Operational Research and Training IniTiative (SORT IT) supports countries to build operational research capacity for improving public health. We assessed whether health workers trained through SORT IT were (1) contributing to the COVID-19 pandemic response and if so, (2) map where and how they were applying their SORT IT skills. (2) Methods. An online questionnaire survey of SORT IT alumni trained between 2009 and 2019. (3) Results. Of 895 SORT IT alumni from 93 countries, 652 (73%) responded to the survey and 417 were contributing to the COVID-19 response in 72 countries. Of those contributing, 307 (74%) were applying their SORT IT skills to tackle the pandemic in 60 countries and six continents including Africa, Asia, Europe, South Pacific and North/South America. Skills were applied to all the pillars of the emergency response with the highest proportions of alumni applying their skills in data generation/analysis/reporting (56%), situation analysis (55%) and surveillance (41%). Skills were also being used to mitigate the health system effects of COVID-19 on other diseases (27%) and in conducting research (26%). (4) Conclusion. Investing in people and in research training ahead of public health emergencies generates downstream dividends by strengthening health system resilience for tackling pandemics. It also strengthens human resources for health and the integration of research within health systems.