Vaccine Preventable Disease Seroprevalence in a Nationwide Assessment of Timor-Leste (VASINA-TL): study protocol for a population-representative cross-sectional serosurvey.

INTRODUCTION: Historic disruption in health infrastructure combined with data from a recent vaccine coverage survey suggests there are likely significant immunity gaps to vaccine preventable diseases and high risk of outbreaks in Timor-Leste. Community-based serological surveillance is an important tool to augment understanding of population-level immunity achieved through vaccine coverage and/or derived from prior infection. METHODS AND ANALYSIS: This national population-representative serosurvey will take a three-stage cluster sample and aims to include 5600 individuals above 1 year of age. Serum samples will be collected by phlebotomy and analysed for measles IgG, rubella IgG, SARS-CoV-2 antispike protein IgG, hepatitis B surface antibody and hepatitis B core antigen using commercially available chemiluminescent immunoassays or ELISA. In addition to crude prevalence estimates and to account for differences in Timor-Leste's age structure, stratified age-standardised prevalence estimates will be calculated, using Asia in 2013 as the standard population. Additionally, this survey will derive a national asset of serum and dried blood spot samples which can be used for further investigation of infectious disease seroepidemiology and/or validation of existing and novel serological assays for infectious diseases. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the Research Ethics and Technical Committee of the Instituto Nacional da Saúde, Timor-Leste and the Human Research Ethics Committee of the Northern Territory Department of Health and Menzies School of Health Research, Australia. Co-designing this study with Timor-Leste's Ministry-of-Health and other relevant partner organisations will allow immediate translation of findings into public health policy, which may include changes to routine immunisation service delivery and/or plans for supplementary immunisation activities.

Country learning on maintaining quality essential health services during COVID-19 in Timor-Leste: a qualitative analysis.

OBJECTIVE: This case study examines the enabling factors, strengths, challenges and lessons learnt from Timor-Leste (TLS) as it sought to maintain quality essential health services (EHS) during the COVID-19 pandemic. DESIGN: A qualitative case study triangulated information from 22 documents, 44 key informant interviews and 6 focus group discussions. The framework method was used to thematically examine the factors impacting quality EHS in TLS. SETTING: National, municipal, facility levels in Baucau, Dili and Ermera municipalities in TLS. RESULTS: Based on the TLS National Health Statistics Reports, a reduction in outpatient, emergency department and primary care service delivery visits was observed in 2020 when compared with 2019. However, in contrast, maternal child health services simultaneously improved in the areas of skilled birth attendants, prenatal coverage and vitamin A distribution, for example. From the thematic analysis, five themes emerged as contributing to or impeding the maintenance of quality EHS including (1) high-level strategy for maintaining quality EHS, (2) measurement for quality and factors affecting service utilisation, (3) challenges in implementation of quality activities across the three levels of the health system, (4) the impact of quality improvement leadership in health facilities during COVID-19 and (5) learning systems for maintaining quality EHS now and for the future. CONCLUSION: The maintenance of quality EHS is critical to mitigate adverse health effects from the COVID-19 pandemic. When quality health services are delivered prior to and maintained during public health emergencies, they build trust within the health system and promote healthcare-seeking behaviour. Planning for quality as part of emergency preparedness can facilitate a high standard of care by ensuring health services continue to provide a safe environment, reduce harm, improve clinical care and engage patients, facilities and communities.

The use of residual serum samples to perform serological surveillance of severe acute respiratory syndrome coronavirus 2 in Dili and regional areas of Timor-Leste.

BACKGROUND: Lack of access to diagnostic testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can limit disease surveillance in remote areas. Serological surveillance can indicate the true extent and distribution of infections in such settings. METHODS: This study monitored SARS-CoV-2 seroprevalence in residual serum samples salvaged from laboratories at five healthcare facilities across Timor-Leste from March to October 2021. RESULTS: Seroprevalence increased from 8.3% to 87.0% during the study period. Potential immunity gaps were identified among children aged 0-15 y (who had not been eligible for vaccination) and individuals aged >60 y. CONCLUSIONS: Efforts to vaccinate vulnerable individuals including older people should be maintained. Residual serum samples can be analysed to give local, contemporary information about the extent and distribution of antibodies to infections, especially SARS-CoV-2, in areas where epidemiological information is limited.

The epidemiology of the COVID-19 pandemic in the small, low-resource country of Timor-Leste, January 2020 - June 2022.

Abstract: Timor-Leste, a small, mountainous half-island nation which shares a land border with Indonesia and which is 550 km from Australia, has a population of 1.3 million and achieved independence for the second time in 2002. It is one of the poorest nations in Asia. In response to the global coronavirus disease 2019 (COVID-19) pandemic, the Timor-Leste Ministry of Health undertook surveillance and contact tracing activities on all notified COVID-19 cases. Between 1 January 2020 and 30 June 2022, there were 22,957 cases of COVID-19 notified which occurred in three waves, the first which was delayed until April 2021 (community transmission of B.1.466.2 variant following major flooding), followed by waves in August 2021 (B.1.617.2 Delta variant transmission) and February 2022 (B.1.1.529 Omicron variant transmission). There were 753 people hospitalised due to COVID-19 and 133 deaths. Of the 133 deaths, 122 (92%) were considered not fully vaccinated (< 2 COVID-19 vaccines) and none had received boosters. Timor-Leste implemented measures to control COVID-19, including: rapid closure of international borders; isolation of cases; quarantining of international arrivals and close contacts; restrictions on internal travel; social and physical distancing; and, finally, a country-wide vaccination program. The health system's capacity was never exceeded.

Serological surveillance of healthcare workers to evaluate natural infection- and vaccine-derived immunity to SARS-CoV-2 during an outbreak in Dili, Timor-Leste.

Background Serosurveillance can be used to investigate the extent and distribution of immunity to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) within a population. Characterisation of humoral immune responses gives insight into whether immunity is infection- or vaccine-derived. Methods A longitudinal study of health care workers (HCWs) in Dili, Timor-Leste, was conducted during vaccine rollout (ChAdOx1) and a concurrent SARS-CoV-2 outbreak. Results A total of 324 HCWs were included at baseline (April-May 2021). Out of those, 32 (9.9%) were seropositive for anti-nucleocapsid protein (anti-N) IgG antibodies, indicating a significant sub-clinical infection among HCWs early in the local outbreak. Follow-up was conducted in 157 (48.5%) participants (July-September 2021), by which time there had been high uptake of vaccination (91.7%), and 86.0% were seropositive for anti-spike protein antibodies. Acquisition of anti-N antibodies was observed in partially vaccinated HCWs (30/76, 39.5%), indicating some post-dose-1 infections. Discussion Serosurveillance of HCWs may provide early warning of SARS-CoV-2 outbreaks and should be considered in non-endemic settings, particularly where there is limited availability/uptake of testing for acute infection. Characterisation of humoral immune responses may be used to assess vaccine impact and coverage. Such studies should be considered in national and international efforts to investigate and mitigate against future emerging pathogens.

Association between television viewing and overweight and obesity among women of reproductive age in Timor-Leste: evidence from the demographic health survey 2016.

OBJECTIVE: This study aimed to assess the possible relationship between television viewing and overweight and obesity among Timorese women of reproductive age. METHODS: This cross-sectional study analysed the Timor-Leste Demographic and Health Survey 2016 dataset. A weighted sample of 11 398 Timorese women aged 15-49 years was chosen using a two-stage stratified random sampling technique. Asian criteria-based body mass index (BMI) cut-offs were used to define overweight (BMI 23.0 to <27.5 kg/m2) and obesity (BMI ≥27.5 kg/m2). Frequency of TV viewing was categorised into three groups: (1) not at all, (2) less than once a week and (3) at least once a week. Multilevel ordered logistic regression was performed to identify the correlates of overweight and obesity. Both crude and adjusted odds ratios (AOR) along with a 95% CI were calculated to show the strength of association. RESULTS: Among 11 398 respondents, 19.4% were overweight or obese (overweight: 15.7% and obese: 3.8%). Although about half of the respondents reportedly did not watch TV at all, just over two-thirds watched TV at least once a week. Women who watched TV at least once a week were found to have 1.3 times the odds of being overweight or obese compared with those who never watched TV (AOR: 1.3, 95% CI: 1.1 to 1.5; p<0.001). However, when stratified by settlement type, the statistical significance stood for the rural women only (AOR: 1.5, 95% CI: 1.2 to 1.8; p<0.001), after adjusting for the covariates. CONCLUSION: Watching TV at least once a week was found to be a significant correlate of overweight and obesity in rural Timorese women of reproductive age. Further studies need to be undertaken to assess physical activity, sedentary and dietary patterns to clarify the possible mechanism through which TV viewing may influence BMI in those groups.

Association between the spread of COVID-19 and weather-climatic parameters.

OBJECTIVE: To explore whether the climate has played a role in the COVID-19 outbreak, we compared virus lethality in countries closer to the Equator with others. Lethality in European territories and in territories of some nations with a non-temperate climate was also compared. MATERIALS AND METHODS: Lethality was calculated as the rate of deaths in a determinate moment from the outbreak of the pandemic out of the total of identified positives for COVID-19 in a given area/nation, based on the COVID-John Hopkins University website. Lethality of countries located within the 5th parallels North/South on 6 April and 6 May 2020, was compared with that of all the other countries. Lethality in the European areas of The Netherlands, France and the United Kingdom was also compared to the territories of the same nations in areas with a non-temperate climate. RESULTS: A lower lethality rate of COVID-19 was found in Equatorial countries both on April 6 (OR=0.72 CI 95% 0.66-0.80) and on May 6 (OR=0.48, CI 95% 0.47-0.51), with a strengthening over time of the protective effect. A trend of higher risk in European vs. non-temperate areas was found on April 6, but a clear difference was evident one month later: France (OR=0.13, CI 95% 0.10-0.18), The Netherlands (OR=0.5, CI 95% 0.3-0.9) and the UK (OR=0.2, CI 95% 0.01-0.51). This result does not seem to be totally related to the differences in age distribution of different sites. CONCLUSIONS: The study does not seem to exclude that the lethality of COVID-19 may be climate sensitive. Future studies will have to confirm these clues, due to potential confounding factors, such as pollution, population age, and exposure to malaria.