Has Ebola delayed progress on access to routine care and financial protection in Sierra Leone? Evidence from a difference-in-differences analysis with propensity score weighting.

INTRODUCTION: Covid-19 has highlighted the need to understand the long-term impact of epidemics on health systems. There is extensive evidence that the Ebola epidemic of 2014-16 dramatically reduced coverage of key reproductive, maternal, newborn, child and adolescent health (RMNCAH) indicators during the period of acute crisis in Sierra Leone. However, less is known about the longer lasting effects, and whether patients continue to be deterred from seeking care either through fear or cost some years after the end of the epidemic METHODS: We analysed nationally representative household surveys from before (2011) and after (2018) the Ebola epidemic to estimate the coverage of 11 indicators of access to RMNCAH, and affordability of care. We used a differences-in-differences analysis, exploiting the variation in epidemic intensity across chiefdoms, to identify the effect of epidemic intensity on access and affordability outcomes, with propensity score weighting to adjust for differences in underlying characteristics between chiefdoms. RESULTS: 13537 households were included across both datasets. Epidemic intensity was associated with a significant stalling in progress (-12.2 percentage points, 95% CI: 23.2 to -1.3, p = 0.029) in the proportion of births attended by a skilled provider. Epidemic intensity did not have a significant impact on any other indicator. CONCLUSION: While there is evidence that chiefdoms which experienced worse Ebola outbreaks had poorer coverage of attendance of skilled providers at birth than would have otherwise been expected, more broadly the intensity of the epidemic did not impact on most indicators. This suggests the measures to restore both staffing and trust were effective in supporting the health system to recover from Ebola.

Individual variation in susceptibility or exposure to SARS-CoV-2 lowers the herd immunity threshold.

Individual variation in susceptibility and exposure is subject to selection by natural infection, accelerating the acquisition of immunity, and reducing herd immunity thresholds and epidemic final sizes. This is a manifestation of a wider population phenomenon known as "frailty variation". Despite theoretical understanding, public health policies continue to be guided by mathematical models that leave out considerable variation and as a result inflate projected disease burdens and overestimate the impact of interventions. Here we focus on trajectories of the coronavirus disease (COVID-19) pandemic in England and Scotland until November 2021. We fit models to series of daily deaths and infer relevant epidemiological parameters, including coefficients of variation and effects of non-pharmaceutical interventions which we find in agreement with independent empirical estimates based on contact surveys. Our estimates are robust to whether the analysed data series encompass one or two pandemic waves and enable projections compatible with subsequent dynamics. We conclude that vaccination programmes may have contributed modestly to the acquisition of herd immunity in populations with high levels of pre-existing naturally acquired immunity, while being crucial to protect vulnerable individuals from severe outcomes as the virus becomes endemic.

Infection prevention and control compliance in Tanzanian outpatient facilities: a cross-sectional study with implications for the control of COVID-19.

BACKGROUND: As coronavirus disease 2019 (COVID-19) spreads, weak health systems must not become a vehicle for transmission through poor infection prevention and control practices. We assessed the compliance of health workers with infection prevention and control practices relevant to COVID-19 in outpatient settings in Tanzania, before the pandemic. METHODS: This study was based on a secondary analysis of cross-sectional data collected as part of a randomised controlled trial in private for-profit dispensaries and health centres and in faith-based dispensaries, health centres, and hospitals, in 18 regions. We observed provider-patient interactions in outpatient consultation rooms, laboratories, and dressing rooms, and categorised infection prevention and control practices into four domains: hand hygiene, glove use, disinfection of reusable equipment, and waste management. We calculated compliance as the proportion of indications (infection risks) in which a health worker performed a correct action, and examined associations between compliance and health worker and facility characteristics using multilevel mixed-effects logistic regression models. FINDINGS: Between Feb 7 and April 5, 2018, we visited 228 health facilities, and observed at least one infection prevention and control indication in 220 facilities (118 [54%] dispensaries, 66 [30%] health centres, and 36 [16%] hospitals). 18 710 indications were observed across 734 health workers (49 [7%] medical doctors, 214 [29%] assistant medical officers or clinical officers, 106 [14%] nurses or midwives, 126 [17%] clinical assistants, and 238 [32%] laboratory technicians or assistants). Compliance was 6·9% for hand hygiene (n=8655 indications), 74·8% for glove use (n=4915), 4·8% for disinfection of reusable equipment (n=841), and 43·3% for waste management (n=4299). Facility location was not associated with compliance in any of the infection prevention and control domains. Facility level and ownership were also not significantly associated with compliance, except for waste management. For hand hygiene, nurses and midwives (odds ratio 5·80 [95% CI 3·91-8·61]) and nursing and medical assistants (2·65 [1·67-4·20]) significantly outperformed the reference category of assistant medical officers or clinical officers. For glove use, nurses and midwives (10·06 [6·68-15·13]) and nursing and medical assistants (5·93 [4·05-8·71]) also significantly outperformed the reference category. Laboratory technicians performed significantly better in glove use (11·95 [8·98-15·89]), but significantly worse in hand hygiene (0·27 [0·17-0·43]) and waste management (0·25 [0·14-0·44] than the reference category. Health worker age was negatively associated with correct glove use and female health workers were more likely to comply with hand hygiene. INTERPRETATION: Health worker infection prevention and control compliance, particularly for hand hygiene and disinfection, was inadequate in these outpatient settings. Improvements in provision of supplies and health worker behaviours are urgently needed in the face of the current pandemic. FUNDING: UK Medical Research Council, Economic and Social Research Council, Department for International Development, Global Challenges Research Fund, Wellcome Trust.