A descriptive assessment of the National Institute of Public Health's contribution to the COVID-19 response in Cambodia, 2020-2021.

Objective: This paper examines the contributions made by the National Institute of Public Health to Cambodia's response to the coronavirus disease (COVID-19) pandemic during 2020-2021. Methods: The activities conducted by the Institute were compared with adaptations of the nine pillars of the World Health Organization's 2020 COVID-19 strategic preparedness and response plan. To gather relevant evidence, we reviewed national COVID-19 testing data, information about COVID-19-related events documented by Institute staff, and financial and technical reports of the Institute's activities. Results: The main contributions the Institute made were to the laboratory pillar and the incident management and planning pillar. The Institute tested more than 50% of the 2 575 391 samples for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing and provided technical advice about establishing 18 new laboratories for SARS-CoV-2 testing in the capital city of Phnom Penh and 11 provinces. The Institute had representatives on many national committees and coauthored national guidelines for implementing rapid COVID-19 testing, preventing transmission in health-care facilities and providing treatment. The Institute contributed to six other pillars, but had no active role in risk communication and community engagement. Discussion: The Institute's support was essential to the COVID-19 response in Cambodia, especially for laboratory services and incident management and planning. Based on the contributions made by the Institute during the COVID-19 pandemic, continued investment in it will be critical to allow it to support responses to future health emergencies in Cambodia.

Descriptive assessment of COVID-19 responses and lessons learnt in Cambodia, January 2020 to June 2022.

As a member state of the International Health Regulations 2005, Cambodia is continuously strengthening its capacity to respond to health emergencies and prevent the international spread of diseases. Despite this, Cambodia's capacity to prevent, detect and rapidly respond to public health threats remained limited at the onset of the pandemic, as was the case in most countries. This paper describes epidemiological phases, response phases, strategy and lessons learnt in Cambodia between 27 January 2020 and 30 June 2022. We classified epidemiological phases in Cambodia into three phases, in which Cambodia responded using eight measures: (1) detect, isolate/quarantine; (2) face coverings, hand hygiene and physical distancing measures; (3) risk communication and community engagement; (4) school closures; (5) border closures; (6) public event and gathering cancellation; (7) vaccination; and (8) lockdown. The measures corresponded to six strategies: (1) setting up and managing a new response system, (2) containing the spread with early response, (3) strengthening the identification of cases and contacts, (4) strengthening care for patients with COVID-19, (5) boosting vaccination coverage and (6) supporting disadvantaged groups. Thirteen lessons were learnt for future health emergency responses. Findings suggest that Cambodia successfully contained the spread of SARS-CoV-2 in the first year and quickly attained high vaccine coverage by the second year of the response. The core of this success was the strong political will and high level of cooperation from the public. However, Cambodia needs to further improve its infrastructure for quarantining and isolating cases and close contacts and laboratory capacity for future health emergencies.

Multilevel Governance and Control of the COVID-19 Pandemic in the Democratic Republic of Congo: Learning from the Four First Waves.

The COVID-19 pandemic continues to impose a heavy burden on people around the world. The Democratic Republic of the Congo (DRC) has also been affected. The objective of this study was to explore national policy responses to the COVID-19 pandemic in the DRC and drivers of the response, and to generate lessons for strengthening health systems' resilience and public health capacity to respond to health security threats. This was a case study with data collected through a literature review and in-depth interviews with key informants. Data analysis was carried out manually using thematic content analysis translated into a logical and descriptive summary of the results. The management of the response to the COVID-19 pandemic reflected multilevel governance. It implied a centralized command and a decentralized implementation. The centralized command at the national level mostly involved state actors organized into ad hoc structures. The decentralized implementation involved state actors at the provincial and peripheral level including two other ad hoc structures. Non-state actors were involved at both levels. These ad hoc structures had problems coordinating the transmission of information to the public as they were operating outside the normative framework of the health system. Conclusions: Lessons that can be learned from this study include the strategic organisation of the response inspired by previous experiences with epidemics; the need to decentralize decision-making power to anticipate or respond quickly and adequately to a threat such as the COVID-19 pandemic; and measures decided, taken, or adapted according to the epidemiological evolution (cases and deaths) of the epidemic and its effects on the socio-economic situation of the population. Other countries can benefit from the DRC experience by adapting it to their own context.

Learning from the COVID-19 pandemic for future epidemics and pandemics preparedness and response in Guinea: Findings from a scoping review

The outbreak of the novel coronavirus (SARS-CoV-2) in December 2019 prompted a response from health systems of countries across the globe. The first case of COVID-19 in Guinea was notified on 12 March 2020;however, from January 2020 preparations at policy and implementation preparedness levels had already begun. This study aimed to assess the response triggered in Guinea between 27th January 2020 and 1st November 2021 and lessons for future pandemic preparedness and response. We conducted a scoping review using three main data sources: policy documents, research papers and media content. For each of these data sources, a specific search strategy was applied, respectively national websites, PubMed and the Factiva media database. A content analysis was conducted to assess the information found. We found that between January 2020 and November 2021, the response to the COVID-19 pandemic can be divided into five phases: (1) anticipation of the response, (2) a sudden boost of political actions with the implementation of strict restrictive measures, (3) alleviation of restrictive measures, (4) multiple epidemics period and (5) the COVID-19 variants phase, including the strengthening of vaccination activities. This study provides several learning points for countries with similar contexts including: (1) the necessity of setting up, in the pre-epidemic period, an epidemic governance framework that is articulated with the country's health system and epidemiological contexts;(2) the importance of mobilizing, during pre-epidemic period, emergency funds for a rapid health system response whenever epidemics hit;(3) each epidemic is a new experience as previous exposure to similar ones does not necessarily guarantee population and health system resilience;(4) epidemics generate social distress because of the restrictive measures they require for their control, but their excessive securitization is counterproductive. Finally, from a political point of view, decision-making for epidemic control is not always disinterested;it is sometimes rooted in political computations, and health system actors should learn to cope with it while, at the same time, safeguarding trusted and efficient health system responses. We conclude that health system actors anticipated the response to the COVID-19 pandemic and (re-) adapted response strategies as the pandemic evolved in the country. There is a need to rethink epidemics governance and funding mechanisms in Guinea to improve the health system response to epidemics.

A rapid assessment of health system preparedness and response to the COVID-19 pandemic in Guinea.

Epidemic-prone diseases have high adverse impacts and pose important threats to global health security. This study aimed to assess levels of health facility preparedness and response to the COVID-19 pandemic in Guinea. This was a cross-sectional study in public and private health facilities/services across 13 Guinean health districts. Managers and healthcare workers (HCWs) from departments in each facility/service were interviewed. Descriptive statistics and comparisons were presented using Pearson's Chi-Squared Test or Fischer exact test. Totally, 197 managers and 1020 HCWs participated in the study. Guidance documents and dedicated spaces for management/isolation of suspected COVID-19 cases were available only in 29% and 26% of facilities, respectively. Capacities to collect (9%) and safely transport (14%) samples were low. Intensive care units (5%), dedicated patient beds (3%), oxygenators (2%), and respirators (0.6%) were almost lacking. While 36% of facilities/services had received infection prevention and control supplies, only 20% had supplies sufficient for 30 days. Moreover, only 9% of HCWs had received formal training on COVID-19. The main sources of information for HCWs were the media (90%) and the internet (58%). Only 30% of HCWs had received personal protective equipment, more in the public sector (p<0.001) and in Conakry (p=0.022). This study showed low levels of preparedness of health facilities/services in Guinea and highlighted a lack of confidence among HCWs who felt unsafe at their workplace. Better governance to improve and maintain the capacity of the Guinean health system to respond to current and future epidemics is needed.

Attributes of national governance for an effective response to public health emergencies: Lessons from the response to the COVID-19 pandemic.

Background: The Coronavirus Disease 2019 (COVID-19) pandemic takes variable shapes and forms in different regions and countries. This variability is explained by several factors, including the governance of the epidemic. We aimed to identify the key attributes of governance in response to the COVID-19 pandemic and gain lessons for an effective response to public health emergencies. Methods: We employed a mixed-methods design. We mapped the attributes of governance from well-established governance frameworks. A negative binomial regression was conducted to identify the effect of the established governance measures on the epidemiology of the COVID-19 pandemic. We used publicly available data on COVID-19 cases and deaths in countries around the world. Document review was conducted to identify the key approaches and attributes of governance during the pre-vaccine era of the response to the COVID-19 pandemic. We conducted a thematic analysis to identify key attributes for effective governance. Results: The established governance measures, including generation of intelligence, strategic direction, regulation, partnership, accountability, transparency, rule of law, control of corruption, responsiveness, effectiveness, efficiency, equity, ethics, and inclusiveness, are necessary but not sufficient to effectively respond to and contain the COVID-19 pandemic. Additional attributes of national governance were identified: 1) agile, adaptive, and transformative governance; 2) collective (collaborative, inclusive, cooperative, accountable, and transparent) governance; 3) multi-level governance; 4) smart and ethical governance: sensible, pragmatic, evidence-based, political, learner, and ethical. Conclusions: The current governance frameworks and their attributes are not adequate to contain the COVID-19 pandemic. We argue that countries need agile, adaptable, and transformational, collaborative, multi-level, smart and ethical governance to effectively respond to emerging and re-emerging public health threats. In addition, an effective response to public health emergencies depends not only on national governance but also on global governance. Hence, global health governance should be urgently renewed through a paradigm shift towards universal health coverage and health security to all populations and in all countries. This requires enhanced and consistent global health diplomacy based on knowledge, solidarity, and negotiation.

Analysis of the COVID-19 pandemic: lessons towards a more effective response to public health emergencies.

BACKGROUND: The pandemic of Coronavirus Disease 2019 (COVID-19) is a timely reminder of the nature and impact of Public Health Emergencies of International Concern. As of 12 January 2022, there were over 314 million cases and over 5.5 million deaths notified since the start of the pandemic. The COVID-19 pandemic takes variable shapes and forms, in terms of cases and deaths, in different regions and countries of the world. The objective of this study is to analyse the variable expression of COVID-19 pandemic so that lessons can be learned towards an effective public health emergency response. METHODS: We conducted a mixed-methods study to understand the heterogeneity of cases and deaths due to the COVID-19 pandemic. Correlation analysis and scatter plot were employed for the quantitative data. We used Spearman's correlation analysis to determine relationship strength between cases and deaths and socio-economic and health systems. We organized qualitative information from the literature and conducted a thematic analysis to recognize patterns of cases and deaths and explain the findings from the quantitative data. RESULTS: We have found that regions and countries with high human development index have higher cases and deaths per million population due to COVID-19. This is due to international connectedness and mobility of their population related to trade and tourism, and their vulnerability related to older populations and higher rates of non-communicable diseases. We have also identified that the burden of the pandemic is also variable among high- and middle-income countries due to differences in the governance of the pandemic, fragmentation of health systems, and socio-economic inequities. CONCLUSION: The COVID-19 pandemic demonstrates that every country remains vulnerable to public health emergencies. The aspiration towards a healthier and safer society requires that countries develop and implement a coherent and context-specific national strategy, improve governance of public health emergencies, build the capacity of their (public) health systems, minimize fragmentation, and tackle upstream structural issues, including socio-economic inequities. This is possible through a primary health care approach, which ensures provision of universal and equitable promotive, preventive and curative services, through whole-of-government and whole-of-society approaches.

The danger of the single storyline obfuscating the complexities of managing SARS-CoV-2/COVID-19.

Chimamanda Ngozi Adichie showed how a single story is limited and thereby distorts the true nature of an issue. During this COVID-19 pandemic there have been, at least, three consecutive single stories-the 'lethal threat' story, followed by the 'economic threat' story, and finally the 'vaccine miracle' story. None of these single stories can convincingly and permanently capture the dynamics of the pandemic. This is because countries experienced different morbidity and mortality patterns, different socioeconomic disadvantage, age and vulnerability of population, timing and level of lockdown with economic variability, and, despite heavy promotion, vaccines were beset with a significant and variable degree of hesitancy. Lack of transparency, coherence and consistency of pandemic management-arising from holding on to single storylines-showed the global deficiency of public health policy and planning, an underfunding of (public) health and social services, and a growing distrust in governments' ability to manage crises effectively. Indeed, the global management has increased already large inequities, and little has been learnt to address the growing crises of more infectious and potentially more lethal virus mutations. Holding onto single stories prevents the necessary learnings to understand and manage the complexities of 'wicked' problems, whereas listening to the many stories provides insights and pathways to do so effectively as well as efficiently.

COVID-19 vaccine equity: a health systems and policy perspective.

INTRODUCTION: The global COVID-19 vaccine rollout has highlighted inequities in the accessibility of countries to COVID-19 vaccines. Populations in low- and middle-income countries have found it difficult to have access to COVID-19 vaccines. AREAS COVERED: This perspective provides analyses on historical and contemporary policy trends of vaccine development and immunization programs, including the current COVID-19 vaccination drive, and governance challenges. Moreover, we also provide a comparative health system analysis of the COVID-19 vaccine deployment in some countries from different continents. It recommends that the international Access to COVID-19 Tools Accelerator (ACT-A) partnership requires a strong governance mechanism and urgent financial investment. EXPERT OPINION: All WHO member states should agree on technology transfer and voluntary license-sharing via a commonly governed technology access pool and supported by a just Intellectual Property regime. Contextualized, dynamic understandings and country-specific versions of health systems strengthening are needed to improve vaccine equity in a sustainable matter.

What Could Explain the Lower COVID-19 Burden in Africa despite Considerable Circulation of the SARS-CoV-2 Virus?

The differential spread and impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causing Coronavirus Disease 2019 (COVID-19), across regions is a major focus for researchers and policy makers. Africa has attracted tremendous attention, due to predictions of catastrophic impacts that have not yet materialized. Early in the pandemic, the seemingly low African case count was largely attributed to low testing and case reporting. However, there is reason to consider that many African countries attenuated the spread and impacts early on. Factors explaining low spread include early government community-wide actions, population distribution, social contacts, and ecology of human habitation. While recent data from seroprevalence studies posit more extensive circulation of the virus, continuing low COVID-19 burden may be explained by the demographic pyramid, prevalence of pre-existing conditions, trained immunity, genetics, and broader sociocultural dynamics. Though all these prongs contribute to the observed profile of COVID-19 in Africa, some provide stronger evidence than others. This review is important to expand what is known about the differential impacts of pandemics, enhancing scientific understanding and gearing appropriate public health responses. Furthermore, it highlights potential lessons to draw from Africa for global health on assumptions regarding deadly viral pandemics, given its long experience with infectious diseases.

Intimate Partners Violence against Women during a COVID-19 Lockdown Period: Results of an Online Survey in 7 Provinces of the Democratic Republic of Congo.

Intimate Partners' Violence (IPV) is a public health problem with long-lasting mental and physical health consequences for victims and their families. As evidence has been increasing that COVID-19 lockdown measures may exacerbate IPV, our study sought to describe the magnitude of IPV in women and identify associated determinants. An online survey was conducted in the Democratic Republic of Congo (DRC) from 24 August to 8 September 2020. Of the 4160 respondents, 2002 eligible women were included in the data analysis. Their mean age was 36.3 (SD: 8.2). Most women (65.8%) were younger than 40 years old. Prevalence of any form of IPV was 11.7%. Being in the 30-39 and >50 years' age groups (OR = 0.66, CI: 0.46-0.95; p = 0.026 and OR = 0.23, CI: 0.11-048; p < 0.001, respectively), living in urban setting (OR = 0.63, CI: 0.41-0.99; p = 0.047), and belonging to the middle socioeconomic class (OR = 0.48, CI: 0.29-0.79; p = 0.003) significantly decreased the odds for experiencing IPV. Lower socioeconomic status (OR = 1.84, CI: 1.04-3.24; p = 0.035) and being pregnant (OR = 1.63, CI: 1.16-2.29; p = 0.005) or uncertain of pregnancy status (OR = 2.01, CI: 1.17-3.44; p = 0.011) significantly increased the odds for reporting IPV. Additional qualitative research is needed to identify the underlying reasons and mechanisms of IPV in order to develop and implement prevention interventions.

Adherence to COVID-19 Prevention Measures in the Democratic Republic of the Congo, Results of Two Consecutive Online Surveys.

Adherence to preventive measures is essential to reduce the risk of COVID-19 transmission. Two online surveys were conducted in the Democratic Republic of the Congo (DRC) from 23 April to 8 June 2020, and from August 24th to September 8th, respectively. A total of 3268 (round 1) and 4160 (round 2) participants were included. In both surveys, there was a moderate level of adherence to regular handwashing (85% and 77%, respectively), wearing of facemasks (41.4% and 69%, respectively), and respecting physical distancing (58% and 43.4%, respectively). The second survey found that, working in private (OR = 2.31, CI: 1.66-3.22; p < 0.001) and public organizations (OR = 1.61, CI: 1.04-2.49; p = 0.032) and being a healthcare worker (OR = 2.19, CI: 1.57-3.05; p < 0.001) significantly increased the odds for better adherence. However, a unit increase in age (OR = 0.99, CI: 0.98-0.99; p < 0.026), having attained lower education levels (OR = 0.60, CI: 0.46-0.78; p < 0.001), living in a room (OR = 0.36, CI: 0.15-0.89; p = 0.027), living in a studio (OR = 0.26, CI: 0.11-0.61; p = 0.002) and apartment (OR = 0.29, CI: 0.10-0.82; p = 0.019) significantly decreased the odds for better adherence. We recommend a multi-sectorial approach to monitor and respond to the pandemic threat. While physical distancing may be difficult in Africa, it should be possible to increase the use of facemasks.

Factors associated with adherence to COVID-19 prevention measures in the Democratic Republic of the Congo (DRC): results of an online survey.

OBJECTIVES: We aimed to assess the level of adherence to COVID-19 preventive measures in the Democratic Republic of the Congo (DRC) and to identify factors associated with non-adherence. DESIGN: A cross-sectional population-based online survey. SETTINGS: The study was conducted in 22 provinces of the DRC. Five provinces with a satisfactory number of respondents were included in the analysis: Haut Katanga, Kasaï-Central, Kasaï-Oriental, Kinshasa and North Kivu. PARTICIPANTS: The participants were people aged ≥18 years, living in the DRC. A total of 3268 participants were included in the study analysis. INTERVENTIONS: Both convenience sampling (surveyors themselves contacted potential participants in different districts) and snowball sampling (the participants were requested to share the link of the questionnaire with their contacts) methods were used. PRIMARY AND SECONDARY OUTCOME MEASURES: We computed adherence scores using responses to 10 questions concerning COVID-19 preventive measures recommended by the WHO and the DRC Ministry of Health. We used logistic regression analysis with generalised estimating equations to identify factors of poor adherence. We also asked about the presence or absence of flu-like symptoms during the preceding 14 days, whether a COVID-19 test was done and the test result. RESULTS: Data from 3268 participants were analysed. Face masks were not used by 1789 (54.7%) participants. Non-adherence to physical distancing was reported by 1364 (41.7%) participants. 501 (15.3%) participants did not observe regular handwashing. Five variables were associated with poor adherence: lower education level, living with other people at home, being jobless/students, living with a partner and not being a healthcare worker. CONCLUSION: Despite compulsory restrictions imposed by the government, only about half of the respondents adhered to COVID-19 preventive measures in the DRC. Disparities across the provinces are remarkable. There is an urgent need to further explore the reasons for these disparities and factors associated with non-adherence.

Interim Results of a Phase 1-2a Trial of Ad26.COV2.S Covid-19 Vaccine.

BACKGROUND: Efficacious vaccines are urgently needed to contain the ongoing coronavirus disease 2019 (Covid-19) pandemic of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A candidate vaccine, Ad26.COV2.S, is a recombinant, replication-incompetent adenovirus serotype 26 (Ad26) vector encoding a full-length and stabilized SARS-CoV-2 spike protein. METHODS: In this multicenter, placebo-controlled, phase 1-2a trial, we randomly assigned healthy adults between the ages of 18 and 55 years (cohort 1) and those 65 years of age or older (cohort 3) to receive the Ad26.COV2.S vaccine at a dose of 5×1010 viral particles (low dose) or 1×1011 viral particles (high dose) per milliliter or placebo in a single-dose or two-dose schedule. Longer-term data comparing a single-dose regimen with a two-dose regimen are being collected in cohort 2; those results are not reported here. The primary end points were the safety and reactogenicity of each dose schedule. RESULTS: After the administration of the first vaccine dose in 805 participants in cohorts 1 and 3 and after the second dose in cohort 1, the most frequent solicited adverse events were fatigue, headache, myalgia, and injection-site pain. The most frequent systemic adverse event was fever. Systemic adverse events were less common in cohort 3 than in cohort 1 and in those who received the low vaccine dose than in those who received the high dose. Reactogenicity was lower after the second dose. Neutralizing-antibody titers against wild-type virus were detected in 90% or more of all participants on day 29 after the first vaccine dose (geometric mean titer [GMT], 212 to 354), regardless of vaccine dose or age group, and reached 96% by day 57 with a further increase in titers (GMT, 288 to 488) in cohort 1a. Titers remained stable until at least day 71. A second dose provided an increase in the titer by a factor of 2.6 to 2.9 (GMT, 827 to 1266). Spike-binding antibody responses were similar to neutralizing-antibody responses. On day 15, CD4+ T-cell responses were detected in 76 to 83% of the participants in cohort 1 and in 60 to 67% of those in cohort 3, with a clear skewing toward type 1 helper T cells. CD8+ T-cell responses were robust overall but lower in cohort 3. CONCLUSIONS: The safety and immunogenicity profiles of Ad26.COV2.S support further development of this vaccine candidate. (Funded by Johnson & Johnson and the Biomedical Advanced Research and Development Authority of the Department of Health and Human Services; COV1001 ClinicalTrials.gov number, NCT04436276.).

COVID-19: Does the infectious inoculum dose-response relationship contribute to understanding heterogeneity in disease severity and transmission dynamics?

The variation in the speed and intensity of SARS-CoV-2 transmission and severity of the resulting COVID-19 disease are still imperfectly understood. We postulate a dose-response relationship in COVID-19, and that "the dose of virus in the initial inoculum" is an important missing link in understanding several incompletely explained observations in COVID-19 as a factor in transmission dynamics and severity of disease. We hypothesize that: (1) Viral dose in inoculum is related to severity of disease, (2) Severity of disease is related to transmission potential, and (3) In certain contexts, chains of severe cases can build up to severe local outbreaks, and large-scale intensive epidemics. Considerable evidence from other infectious diseases substantiates this hypothesis and recent evidence from COVID-19 points in the same direction. We suggest research avenues to validate the hypothesis. If proven, our hypothesis could strengthen the scientific basis for deciding priority containment measures in various contexts in particular the importance of avoiding super-spreading events and the benefits of mass masking.