Gendered gaps to tuberculosis prevention and care in Kenya: a political economy analysis study.

BACKGROUND: Tuberculosis (TB) remains a public health concern in Kenya despite the massive global efforts towards ending TB. The impediments to TB prevention and care efforts include poor health systems, resource limitations and other sociopolitical contexts that inform policy and implementation. Notably, TB cases are much higher in men than women. Therefore, the political economy analysis (PEA) study provides in-depth contexts and understanding of the gender gaps to access and successful treatment for TB infection. DESIGN: PEA adopts a qualitative, in-depth approach through key informant interviews (KII) and documentary analysis. SETTING AND PARTICIPANTS: The KIIs were distributed among government entities, academia, non-state actors and community TB groups from Kenya. RESULTS: The themes identified were mapped onto the applied PEA analysis framework domains. The contextual and institutional issues included gender concerns related to the disconnect between TB policies and gender inclusion aspects, such as low prioritisation for TB programmes, limited use of evidence to inform decisions and poor health system structures. The broad barriers influencing the social contexts for TB programmes were social stigma and cultural norms such as traditional interventions that negatively impact health-seeking behaviours. The themes around the economic situation were poverty and unemployment, food insecurity and malnutrition. The political context centred around the systemic and governance gaps in the health system from the national and devolved health functions. CONCLUSION: Broad contextual factors identified from the PEA widen the disparity in targeted gender efforts toward men. Following the development of effective TB policies and strategies, it is essential to have well-planned gendered responsive interventions with a clear implementation plan and monitoring system to enhance access to TB prevention and care.

Mortality and Heart Transplantation After Hybrid Palliation of Hypoplastic Left Heart Syndrome: A Systematic Review and Meta-Analysis.

BACKGROUND: Newborns with hypoplastic left heart syndrome (HLHS) who are considered at increased risk for death following Norwood/Sano surgery often undergo hybrid palliation (HP) as initial surgery. We aimed to compile the HP experience in HLHS and its variants and assess the rates of, and risk factors for, death and heart transplantation. METHODS: CINAHL, CINAHL PLUS, PubMed/MEDLINE, and SCOPUS were systematically searched for HP outcome studies of death or heart transplantation in HLHS between 1998 and 2022. Pooled incidence was estimated, and potential risk factors were identified using random-effects meta-analysis and reconstructed time-to-event data from Kaplan-Meier curves. RESULTS: Thirty-three publications were included in our review. Overall, of 1,162 patients 417 died and 57 underwent heart transplantation, resulting in a combined outcome of 40.7%, (474/1,162). There was a trend toward decreasing mortality risk across the stages of palliation. Pooled mortality between HP and comprehensive stage 2 palliation was 25%, after stage 2 up to Fontan palliation was 16%, and 6% post-Fontan. The incidence of death or heart transplantation was higher in high-risk patients-43% died and 10% received heart transplantation. CONCLUSION: Our systematic review and meta-analysis found high rates of death or heart transplantation in HP of HLHS patients between HP and Fontan surgeries. All patients should be closely followed during the initial interstage period, which is associated with the highest hazard. Prospective studies on appropriate patient selection, indications, and / or alternatives, as well as refining HP strategies for managing newborns with HLHS are needed to improve outcomes.

Confronting the human papillomavirus-HIV intersection: Cervical cytology implications for Kenyan women living with HIV.

Background: High-risk human papillomavirus (HR-HPV) is the primary cause of cervical cancer, leading to over 311 000 global deaths, mainly in low- and middle-income countries. Kenyan women living with HIV (WLHIV) face a disproportionate burden of HR-HPV. Objectives: We determined the prevalence of HR-HPV infections and their association with cervical cytology findings among Kenyan WLHIV. Method: We conducted a cross-sectional study among WLHIV attending the HIV care and treatment clinic at the Kenyatta National Hospital (KNH), Kenya's national referral hospital. Study nurses collected a cervical sample with a cytobrush for HR-HPV genotyping using Gene Xpert® assays and HPV Genotypes 14 Real-TM Quant V67-100FRT. Bivariate analysis explored the associations. Results: We enrolled 647 WLHIV (mean age of 42.8 years), with 97.2% on antiretroviral therapy (ART) and 79% with a suppressed viral load (< 50 copies/mL plasma). The prevalence of any and vaccine-preventable HR-HPV was 34.6% and 29.4%, respectively, with HPV 52 being the most common genotype (13.4%). Among WLHIV with HR-HPV infections, 21.4% had abnormal cervical cytology. Women with multiple HR-HPV infections were more likely to have abnormal cytology compared to those with single HR-HPV infections (34.9 vs 9.3%, adjusted odds ratio [aOR] = 6.2, 95% confidence interval [CI]: 2.7-14.1, P = 0.001). Women with HR-HPV infection (single or multiple) were more likely to be on the second-line ART regimen compared to those without HR-HPV infections (53.1% vs 46.7%, aOR = 2.3, 95% CI: 1.3-4.1, P = 0.005). Conclusion: Among WLHIV at KNH, abnormal cytology was common and more frequent among women with multiple HR-HPV infections.

Interventions to enhance healthcare utilisation among pregnant women to reduce maternal mortality in low- and middle-income countries: a review of systematic reviews.

BACKGROUND: Maternal mortality in low- and middle-income countries (LMIC) has reduced considerably over the past three decades, but it remains high. Effective interventions are available, but their uptake and coverage remain low. We reviewed and synthesised evidence from systematic reviews on interventions to increase healthcare services utilisation to reduce maternal mortality in LMICs. METHODS: We searched Medline PubMed and Cochrane Library databases for systematic reviews published between January 2014 and December 2021, investigating interventions to increase healthcare services uptake among pregnant women in LMICs. We used the AMSTAR tool (A Measurement Tool to Assess Systematic Reviews) to assess the methodological quality of the included reviews. We extracted data on the interventions and their effects and grouped them into broad groups based on the outcomes reported in each systematic review. RESULTS: We retrieved 4,022 articles. After removing duplicates and screening, we included 14 systematic reviews. Male-partner interventions were effective in increasing skilled birth attendance (SBA) postnatal visits and maternal antiretroviral (ART) uptake for HIV-positive pregnant women. However, there was no evidence of their effectiveness on increased early ANC initiation or adequate ANC visits. Mobile health interventions were effective in increasing adequate ANC visits, SBA, facility-based service utilisation, early ANC initiation, and adherence to nutritional supplements. Incentive-based interventions, particularly financial incentives, were effective in increasing the number of ANC visits but not postnatal visits. Facility-based interventions were effective in increasing postnatal visits, maternal ART initiation and uptake, immunisation uptake and follow-up ANC visits. None of the reviews assessed their impact on SBA or adequate ANC visits. Community-based interventions were effective in increasing SBA, ANC service utilisation, ART initiation and uptake, and nutritional supplements and immunisation uptake. CONCLUSION: Our findings show that the different interventions effectively improved different outcomes on the maternal healthcare continuum. Implementing these interventions in combination has the potential to enhance healthcare service uptake further.

Functionality of technical working groups in enabling evidence-informed decision-making within Malawi's Ministry of Health: a cross-sectional qualitative study.

BACKGROUND: The roles and functionality of technical working groups (TWGs) in the health sectors vary across countries, still they aim to support government and ministries in formulating evidence-informed recommendations for policies and facilitate dialogue and alignment of activities among stakeholders within the health sector. Thus, TWGs have a role in enhancing the functionality and effectiveness of the health system structure. However, in Malawi, the functionality of TWGs and how they utilize research evidence to contribute to decision-making is not monitored. This study sought to understand the TWGs' performance and functionality in enabling evidence-informed decision-making (EIDM) in Malawi's health sector. METHODS: A cross-sectional descriptive qualitative study. Data were collected through interviews, documents review and observation of three TWG meetings. Qualitative data were analysed using a thematic approach. The WHO-UNICEF Joint Reporting Form (JRF) was used to guide the assessment of TWG functionality. RESULTS: TWG functionality varied in the Ministry of Health (MoH) in Malawi. The reasons for those perceived to be functioning well included meeting frequently, diverse representation of members, and that their recommendations to MoH were usually considered when decisions were made. For the TWGs that were perceived as not functioning well, the main reasons included lack of funding, periodic meetings and discussions that needed to provide clear decisions on the actions to be taken. In addition, evidence was recognized as important in decision-making, and research was valued by decision-makers within the MoH. However, some of the TWGs lacked reliable mechanisms for generating, accessing and synthesizing research. They also needed more capacity to review and use the research to inform their decisions. CONCLUSIONS: TWGs are highly valued and play a critical role in strengthening EIDM within the MoH. Our paper highlights the complexity and barriers of TWG functionality in supporting pathways for health policy-making in Malawi. These results have implications for EIDM in the health sector. This suggests that the MoH should actively develop reliable interventions and evidence tools, strengthen capacity-building and increase funding for EIDM.

Communication strategies to improve human papillomavirus (HPV) immunisation uptake among adolescents in sub-Saharan Africa: a systematic review and meta-analysis.

OBJECTIVES: Developing countries face the greatest cervical cancer disease burden and mortality with suboptimal immunisation uptake. This review explores the communication strategies adopted, successes, challenges and lessons learnt in sub-Saharan countries to enhance human papillomavirus (HPV) immunisation. DESIGN: Systematic review and meta-analysis. DATA SOURCES: PubMed, Hinari, Cochrane Library, Trip database, CINAHL, Web of Science, Scopus and seven grey resources were searched through May 2022. ELIGIBILITY CRITERIA: We included observational studies addressing communication strategies for HPV immunisation uptake. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers used standardised methods to search, screen and code included studies. Data extraction and assessment of risk of bias were done in duplicate to enhance validity of the results. Meta-analysis was conducted using the random-effects model. Findings were summarised and synthesised qualitatively. RESULTS: Communication intervention to facilitate decision-making achieved uptake rate of 100% (95% CI 0.99% to 1.00%), followed by intervention to enable communication, which achieved 92% (95% CI 0.92% to 0.92%). Communication intervention to inform and educate achieved 90% (95% CI 0.90% to 0.90%).Targeting both healthcare workers and community leaders with the communication intervention achieved 95% (95% CI 0.91% to 0.98%), while teachers and school boards achieved 92% (95% CI 0.84% to 1.01%). Targeting policymakers achieved 86% (95% CI 0.78% to 0.93%).Based on the method of communication intervention delivery, use of training achieved an uptake rate of 85% (95% CI 0.84% to 0.87%); similarly, drama and dance achieved 85% (95% CI 0.84% to 0.86%). However, use of information, education and communication materials achieved 82% (95% CI 0.78% to 0.87%). CONCLUSION: HPV vaccine communication is critical in ensuring that the community understands the importance of vaccination. The most effective communication strategies included those which educate the population about the HPV vaccine, facilitate decision-making on vaccine uptake and community ownership of the vaccination process immunisation. PROSPERO REGISTRATION NUMBER: CRD42021243683.

EIDM training as a key intervention among researchers to enhance research uptake and policy engagement: an evaluation study.

The Evidence Informed Decision Making (EIDM) field has evolved faster in the past decade. This progress shows a need for capacity enhancement amongst evidence producers and evidence users in EIDM training. Through the Enhance DELTAS programme, led by the African Institute for Development Policy (AFIDEP), the project provided research uptake and policy engagement training, mentorship and webinars to awardees of the Developing Excellence in Leadership, Training and Science (DELTAS) Africa initiative, led by the African Academy of Sciences (AAS). Two workshops were offered to individual early career DELTAS researchers in policy engagement and evidence uptake, referred to as ENHD101, and among research leaders to enhance institutional capacity on policy engagement and evidence uptake, (ENHD102). Overall, the programme attracted 31 early career researchers and 20 research leaders over the eight months of training, mentorship and webinars. Following the programme, the early career researchers understood the importance of EIDM for better health policies and programmes. In addition, the team appreciated the complexities of the policymaking processes as they developed the policy engagement strategy for their research. The implementation of the EIDM knowledge was reflected during the mentorship of research fellows with policy briefs as the end product. Notably, research leaders, appreciated their role in strengthening the capacity for EIDM in decision-making spaces. Although none of the research leaders participated in strengthening the capacity for EIDM during the programme, the team anticipated improving in the long run. In addition, the research leaders developed and implemented institutional strategies for policy engagement and research uptake through the use of social media to influence policymakers. In conclusion, the project supported the capacity building of African researchers in EIDM. It was evident that enhancing knowledge and skills on EIDM through an integrated approach to include training, mentorship, and webinars demonstrated enhanced capacity for policy engagement and evidence uptake.

International air travel-related control measures to contain the Covid-19 pandemic: A companion review to a Cochrane rapid review.

Background: COVID-19 has proven to be challenging to manage for many reasons, including its high infection rate. One of the potential ways to limit its spread is by limiting international travel. The objective of this systematic review was to identify, critically appraise and summarise evidence on international air travel-related control measures for COVID-19. Methods: This review is based on the Cochrane review: International travel-related control measures to contain the COVID-19 pandemic and followed the same methods. In brief, we searched for clinical and modelling studies in general health and COVID-19-specific bibliographic databases. The primary outcome categories were (i) cases avoided, (ii) a shift in epidemic development and, (iii) cases detected. Results: From 6,202 citations identified by the search strategy, we included 22 new studies (modelling = 9, observational = 13) in addition to the 62 studies identified in the Cochrane review. Studies suggest that quarantine or microbial detection or a combination may avoid further cases. Similarly, these interventions may produce a positive shift in epidemic development and case detection may improve. Most studies were evaluated as having a moderate to critical risk of bias. The studies did not change the main conclusions of the Cochrane review nor the quality of the evidence (very low certainty); however, they added to the evidence base for most outcomes. Conclusions: Weak evidence supports the use of international air travel-related control measures to limit the spread of COVID-19 via air travel. More real-world studies are required to support these conclusions.

Understanding the local and international stakeholders in rheumatic heart disease field in Tanzania and Uganda: A systematic stakeholder mapping.

BACKGROUND: Our study aimed to systematically identify RHD stakeholders and categories of stakeholders to consider when developing a scorecard that reflects a broad stakeholder input. METHOD: We used the Schiller et al.(2013) framework to identify RHD stakeholders and stakeholder categories in Tanzania and Uganda. The process involved identifying stakeholders by searching literature related to incidence, prevalence, morbidity, mortality, health services, or health outcomes of Group A streptococcus, acute rheumatic fever, or rheumatic heart disease in these countries. The strategy was completed for two electronic databases in 2016 and in 2020 to update the results. We also engaged known stakeholders to obtain practice-based insight. We then categorised and visually represented the identified stakeholders. RESULTS: We identified 139 stakeholders in Uganda, with 68% being from 15 different countries across 31 locations. In comparison, local Ugandan stakeholders were dispersed in six locations across the country. In Tanzania, we identified 128 stakeholders, with 66% being locally based and dispersed in seven locations across the country and stakeholders from different countries were situated in 18 countries across 28 locations. We categorised all identified stakeholders into one or more of five categories 1) Civil Society and General Public, 2) Education Sector, 3) Research, Training and Capacity Building, 4) Healthcare service delivery, and 5) Health Policy and Administration. CONCLUSION: The stakeholder categories identified include multiple sectors and stakeholders from multiple countries, this reflects the complexities of RHD. This also highlights the need for collaboration and partnership as a critical action for preventing and controlling RHD.

A Systematic Review of Interventions to Improve HPV Vaccination Coverage.

Human papillomavirus (HPV) infection is the most common sexually transmitted infection worldwide. Although most HPV infections are transient and asymptomatic, persistent infection with high-risk HPV types may results in diseases. Although there are currently three effective and safe prophylactic HPV vaccines that are used across the world, HPV vaccination coverage remains low. This review evaluates the effects of the interventions to improve HPV vaccination coverage. We searched the Cochrane Central Register of Controlled Trials, PubMed, Web of Science, Scopus, and the World Health Organization International Clinical Trials Registry Platform and checked the reference lists of relevant articles for eligible studies. Thirty-five studies met inclusion criteria. Our review found that various evaluated interventions have improved HPV vaccination coverage, including narrative education, outreach plus reminders, reminders, financial incentives plus reminders, brief motivational behavioral interventions, provider prompts, training, training plus assessment and feedback, consultation, funding, and multicomponent interventions. However, the evaluation of these intervention was conducted in high-income countries, mainly the United States of America. There is, therefore, a need for studies to evaluate the effect of these interventions in low-and middle-income countries, where there is a high burden of HPV and limited HPV vaccination programs.

Best practices and opportunities for integrating nutrition specific into nutrition sensitive interventions in fragile contexts: a systematic review.

BACKGROUND: Annually, undernutrition contributes globally to 45% (3.1 million) of preventable deaths in children under 5. Effect following undernutrition i.e. physical growth & cognitive development etc. can be prevented during the first 1000 days also called window of opportunity. There is substantial evidence of positive nutrition outcomes resulting from integrating nutrition-specific interventions into nutrition specific program. However, there is paucity of knowledge on establishing and sustaining effective integration of nutrition intervention in fragile context. The objective of this review is to map and review the integration of nutrition-specific intervention to nutrition sensitive program and its impacts on nutrition outcomes. METHODS: In the study, we systematically searched the literature on integrated nutrition intervention into multi-sectoral programme in PUBMED, Google's Scholar, the Cochrane Library, World Health Organisation (WHO), United Nations Children's Fund (UNICEF), World Bank and trial registers from their inception until Oct 30, 2020 for up-to-date published and grey resources. We screened records, extracted data, and assessed risk of bias in duplicates. This study is registered with PROSPERO (CRD42020209730). RESULT: Forty-four studies were included in this review, outlining the integration of nutrition-specific interventions among children 0-59 months with various existing programme. Most common integration platform in the study included integrated community case management and Integrated Management of Childhood Illness, Child Health Days, immunization, early child development, and cash transfers. Limited quantitative data were suggestive of some positive impact on nutrition and non-nutrition outcomes with a number of model of integration which varies according to the context and demands of the particular setting in which integration occurs. CONCLUSION: Overall, existing evidence for nutrition sensitive and specific interventions is not robust and remains limited. It's worthwhile to note, for future studies/interventions should be based on the context key criteria like relevance, political support, effectiveness, feasibility, expected contribution to health system strengthening, local capacities, ease of integration and targeting for sustainability, cost effectiveness and financial availability.

The RHD Action Small Grants Programme: Small Investment, Big Return!

Rheumatic Heart Disease (RHD) remains endemic in low- and middle-income countries (LMICs) despite its virtual elimination in high-income countries. RHD Action was launched to amplify global efforts to control RHD in 2015 by World Heart Federation and Reach, with demonstration projects in Uganda and Tanzania, and support from Medtronic Foundation. The Small Grants Programme focuses on three domains: People and Communities, Medicines and Technologies, and Systems and Services. It is designed to support patient and community groups in promoting awareness, advocacy, and to build health workers' capacity to prevent and treat RHD in LMICs. Our study evaluates the impact and effectiveness of the RHD Action Small Grants Programme. Methods: We conducted a mixed method study that involved both quantitative and qualitative surveys, through phone interviews and online surveys amongst the grant beneficiaries, to assess the impact and effectiveness of the small grant programme. An invitation to complete an online survey, using a Google Forms format, was issued to Small Grant Project Directors and Co-Directors that received funding for projects between 2017 and 2019. The online survey requested basic project information using tick boxes, Likert scales, and short answer open-ended questions about successes and challenges faced by recipients. The questionnaire also addressed recipients' experience with the RHD Action Small Grants process - applying for the grant, nature and quality of support received to carry out project, the reporting process, and any media coverage provided. For the phone interviews, responses to the short-answer questions were used as the basis for follow up phone interviews. The discussions were recorded, transcribed and thematically analysed for new and recurring themes emerging from the in-depth discussions. Initiated in 2017, RHD Action has funded 21 proposals from a pool of 60 submissions. Recipient countries include Zambia, Uganda (2), Namibia, Kenya, Malawi (2), Egypt, Ethiopia, Nigeria (3), Rwanda (2), Mozambique, and Cameroon (2) as well as Fiji (2), the Philippines and Nepal. Five recipients were funded in 2017, eight in 2018 and eight in 2019. Project directors are primarily junior doctors and project managers supervised by senior mentors. In most cases, this is their first funding award. These projects have demonstrated tangible impact and have provided content for first manuscript and abstract submissions and presentations at professional conferences. Grant reports are presented as website stories showcasing the achievements of small local efforts with meaningful impact. For RHD Action, there is large return on a modest monetary investment resulting in a very visible, viable global RHD networking platform for enthusiastic community and provider activists.

The effects of HIV self-testing on the uptake of HIV testing, linkage to antiretroviral treatment and social harms among adults in Africa: A systematic review and meta-analysis.

INTRODUCTION: HIV infection is still a global public health problem. More than 75% of HIV-infected people are in Africa, and up to 54% are unaware of their HIV status, limiting access to antiretroviral treatment. CONTEXT AND PURPOSE OF THE STUDY: This review aimed to determine whether HIV self-testing (HIVST) increases the uptake of testing, the yield of new HIV-positive diagnoses, and the linkage to antiretroviral treatment, and social harms among adults in Africa. METHODS: PubMed, The Cochrane Central Register of Controlled Trials (CENTRAL), Pan African Clinical Trials Registry, The Cochrane Database of Systematic Reviews (CDSR), Databases of Abstracts of Reviews of Effectiveness (DARE), Social Sciences Citation Index, Web of Science and African Index Medicus databases were searched from 1998 to 2019 (updated in December 2019). Eligible trials employed randomized controlled trials (RCTs), before/after studies, and interrupted time series design comparing HIVST to standard HIV testing services or comparing different approaches to HIVST among adults living in Africa were systematically sought. RESULTS: After searching 2,617 citations eleven trials were identified including 59,119 participants from four (4) African countries. Meta-analysis of seven trials showed a significant increase in the uptake of HIVST compared to standard HIV testing services: Both fixed-effects (Rate Ratio (RR) = 2.64, 95% CI: 2.51 to 2.79), and random-effects (RR) = 3.10, 95% CI: 1.80 to 5.37, and a significant increase in the uptake of couples' HIVST (RR = 2.50, 95% CI: 2.29 to 2.73 in fixed-effects models; and RR = 2.64, 95% CI: 2.01 to 3.49 in random-effects model). A decrease in linkage to care and ART was observed in HIVST compared to standard HIV testing services (RR = 0.88, 95% CI: 0.88 to 0.95 in fixed-effects models; and RR = 0.78, 95% CI: 0. 56 to 1.08 in random-effects models). Six RCTs measured social harms, with a total of ten reported cases related to HIVST. One RCT comparing two approaches to HIVST showed that offering home-based HIVST with optional home-initiation of antiretroviral treatment increased the reporting of a positive HIV test result (RR: 1.86; 95% CI: 1.16 to 2.98), and linkage to antiretroviral treatment (RR: 2.94; 95% CI: 2.10 to 4.12), compared with facility-based linkage to antiretroviral treatment. CONCLUSIONS: HIVST has the potential to increase the uptake of HIV testing compared to standard HIV testing services. Offering HIVST with optional home initiation of HIV care compared to HIVST with facility-based HIV care increases HIV positivity and linkage to antiretroviral treatment. Reported incidences of intimate partner violence related to HIVST were rare. Future research should focus on the potential of HIVST to reach first-time testers, the effect of using different approaches to HIVST, and strategies for linkage to HIV services. SYSTEMATIC REVIEW REGISTRATION: This systematic review was prospectively registered on the Prospero International Prospective Register of Systematic Review (CRD42015023935).

Community interventions in Low-And Middle-Income Countries to inform COVID-19 control implementation decisions in Kenya: A rapid systematic review.

Globally, public health measures like face masks, hand hygiene and maintaining social distancing have been implemented to delay and reduce local transmission of COVID-19. To date there is emerging evidence to provide effectiveness and compliance to intervention measures on COVID-19 due to rapid spread of the disease. We synthesized evidence of community interventions and innovative practices to mitigate COVID-19 as well as previous respiratory outbreak infections which may share some aspects of transmission dynamics with COVID-19. In the study, we systematically searched the literature on community interventions to mitigate COVID-19, SARS (severe acute respiratory syndrome), H1N1 Influenza and MERS (middle east respiratory syndrome) epidemics in PubMed, Google Scholar, World Health Organization (WHO), MEDRXIV and Google from their inception until May 30, 2020 for up-to-date published and grey resources. We screened records, extracted data, and assessed risk of bias in duplicates. We rated the certainty of evidence according to Cochrane methods and the GRADE approach. This study is registered with PROSPERO (CRD42020183064). Of 41,138 papers found, 17 studies met the inclusion criteria in various settings in Low- and Middle-Income Countries (LMICs). One of the papers from LMICs originated from Africa (Madagascar) with the rest from Asia 9 (China 5, Bangladesh 2, Thailand 2); South America 5 (Mexico 3, Peru 2) and Europe 2 (Serbia and Romania). Following five studies on the use of face masks, the risk of contracting SARS and Influenza was reduced OR 0.78 and 95% CI = 0.36-1.67. Equally, six studies on hand hygiene practices reported a reduced risk of contracting SARS and Influenza OR 0.95 and 95% CI = 0.83-1.08. Further two studies that looked at combined use of face masks and hand hygiene interventions showed the effectiveness in controlling the transmission of influenza OR 0.94 and 95% CI = 0.58-1.54. Nine studies on social distancing intervention demonstrated the importance of physical distance through closure of learning institutions on the transmission dynamics of disease. The evidence confirms the use of face masks, good hand hygiene and social distancing as community interventions are effective to control the spread of SARS and influenza in LMICs. However, the effectiveness of community interventions in LMICs should be informed by adherence of the mitigation measures and contextual factors taking into account the best practices. The study has shown gaps in adherence/compliance of the interventions, hence a need for robust intervention studies to better inform the evidence on compliance of the interventions. Nevertheless, this rapid review of currently best available evidence might inform interim guidance on similar respiratory infectious diseases like Covid-19 in Kenya and similar LMIC context.

Integrating the Prevention and Control of Rheumatic Heart Disease into Country Health Systems: A Systematic Review and Meta-Analysis.

Background: National and international political commitments have been made recently on rheumatic heart disease (RHD), a preventable heart condition that is endemic in low-resource countries. To inform best practice and identify evidence gaps, we assessed the effectiveness of RHD prevention and control programmes and the extent and nature of their integration into local health systems. Methods: We conducted a systematic review and meta-analysis using a previously published protocol that included electronic and manual searches for studies published between January 1990 and July 2019 reporting on prevention and control programmes for populations at risk for streptococcal pharyngitis, rheumatic fever, and/or RHD. We analysed programme integration according to a previously published framework and programme effectiveness using a results-chain framework. We meta-analysed secondary prophylaxis adherence using random-effects models. Study quality was assessed using peer-reviewed checklists (CASP and PRISM). PROSPERO registration: CRD42017076307. Findings: Five observational studies met with the inclusion criteria. Studies were similar in extent and nature of integration into health systems; no programme was completely integrated or non-integrated. A single study reported on programme impact. Secondary prophylaxis adherence improved among partially integrated RHD programmes (RR, 1.18 [95% CI, 1.03 to 1.36], 3 studies, n = 618). Risk of bias was low in two studies, and indeterminable in the remaining three studies. Interpretation: There is evidence that partially integrated RHD programmes are beneficial for a range of intermediate health outcomes. This review provides a starting point for the design and implementation of future RHD programmes by outlining current best practice for integration and identifying key gaps in knowledge. Funding: National Research Foundation of South Africa.

Standard echocardiography versus handheld echocardiography for the detection of subclinical rheumatic heart disease: a systematic review and meta-analysis of diagnostic accuracy.

OBJECTIVE: To summarise the accuracy of handheld echocardiography (HAND) which, if shown to be sufficiently similar to that of standard echocardiography (STAND), could usher in a new age of rheumatic heart disease (RHD) screening in endemic areas. DESIGN: Systematic review and meta-analysis. DATA SOURCES: PubMed, Scopus, EBSCOHost and ISI Web of Science were initially searched on 27 September 2017 and again on 3 March 2020 for studies published from 2012 onwards. ELIGIBILITY CRITERIA: Studies assessing the accuracy of HAND compared with STAND when performed by an experienced cardiologist in conjunction with the 2012 World Heart Federation criteria among populations of children and adolescents living in endemic areas were included. DATA EXTRACTION AND SYNTHESIS: Two reviewers independently extracted data and assessed the methodological quality of included studies against review-specific Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 criteria. A meta-analysis using the hierarchical summary receiver operating characteristic model was conducted to produce summary results of sensitivity and specificity. Forest plots and scatter plots in receiver operating characteristic space in combination with subgroup analyses were used to investigate heterogeneity. Publication bias was not investigated. RESULTS: Six studies (N=4208) were included in the analysis. For any RHD detection, the pooled results from six studies were as follows: sensitivity: 81.56% (95% CI 76.52% to 86.61%) and specificity: 89.75% (84.48% to 95.01%). Meta-analytical results from five of the six included studies were as follows: sensitivity: 91.06% (80.46% to 100%) and specificity: 91.96% (85.57% to 98.36%) for the detection of definite RHD only and sensitivity: 62.01% (31.80% to 92.22%) and specificity: 82.33% (65.15% to 99.52%) for the detection of borderline RHD only. CONCLUSIONS: HAND displayed good accuracy for detecting definite RHD only and modest accuracy for detecting any RHD but demonstrated poor accuracy for the detection of borderline RHD alone. Findings from this review provide some evidence for the potential of HAND to increase access to echocardiographic screening for RHD in resource-limited and remote settings; however, further research into feasibility and cost-effectiveness of wide-scale screening is still needed. PROSPERO REGISTRATION NUMBER: CRD42016051261.

Factors associated with tuberculosis diagnosis and treatment delays in Middle East and North Africa: a systematic review.

BACKGROUND: Political instability, economic sanctions and substandard quality of health care negatively affect tuberculosis (TB) control in the Middle East and North Africa (MENA) region. AIMS: We aimed to elucidate factors contributing to delays in TB diagnosis and treatment in MENA countries. METHODS: Two reviewers independently appraised eligible articles identified through comprehensive searching and extracted data which were subjected to meta-analysis. RESULTS: Delays in TB diagnosis were associated with older age and low income [(OR = 1.49; 95% CI: 1.31-1.70) and (OR = 1.26; 95% CI: 1.09-1.45)] respectively (n = 17 studies). Being female was associated with patient delay and health system delay [(OR = 1.24; 95% CI: 1.02-1.50) and (OR = 1.68; 95% CI: 1.18-2.38)] respectively. Knowledge and perception of TB, having employment and low levels of crowding were each protective against patient delay. The GRADE system rated the evidence as of low quality. CONCLUSION: This review provides evidence for facilitators and barriers to TB diagnosis and health system delays. For successful TB control in the MENA region, TB awareness and interventions targeting the elderly and those from lower-income settings, particularly directed at gender differences, are essential.

Improving vaccination uptake among adolescents.

BACKGROUND: Adolescent vaccination has received increased attention since the Global Vaccine Action Plan's call to extend the benefits of immunisation more equitably beyond childhood. In recent years, many programmes have been launched to increase the uptake of different vaccines in adolescent populations; however, vaccination coverage among adolescents remains suboptimal. Therefore, understanding and evaluating the various interventions that can be used to improve adolescent vaccination is crucial. OBJECTIVES: To evaluate the effects of interventions to improve vaccine uptake among adolescents. SEARCH METHODS: In October 2018, we searched the following databases: CENTRAL, MEDLINE Ovid, Embase Ovid, and eight other databases. In addition, we searched two clinical trials platforms, electronic databases of grey literature, and reference lists of relevant articles. For related systematic reviews, we searched four databases. Furthermore, in May 2019, we performed a citation search of five other websites. SELECTION CRITERIA: Randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series studies of adolescents (girls or boys aged 10 to 19 years) eligible for World Health Organization-recommended vaccines and their parents or healthcare providers. DATA COLLECTION AND ANALYSIS: Two review authors independently screened records, reviewed full-text articles to identify potentially eligible studies, extracted data, and assessed risk of bias, resolving discrepancies by consensus. For each included study, we calculated risk ratios (RR) or mean differences (MD) with 95% confidence intervals (CI) where appropriate. We pooled study results using random-effects meta-analyses and assessed the certainty of the evidence using GRADE. MAIN RESULTS: We included 16 studies (eight individually randomised trials, four cluster randomised trials, three non-randomised trials, and one controlled before-after study). Twelve studies were conducted in the USA, while there was one study each from: Australia, Sweden, Tanzania, and the UK. Ten studies had unclear or high risk of bias. We categorised interventions as recipient-oriented, provider-oriented, or health systems-oriented. The interventions targeted adolescent boys or girls or both (seven studies), parents (four studies), and providers (two studies). Five studies had mixed participants that included adolescents and parents, adolescents and healthcare providers, and parents and healthcare providers. The outcomes included uptake of human papillomavirus (HPV) (11 studies); hepatitis B (three studies); and tetanus-diphtheria-acellular-pertussis (Tdap), meningococcal, HPV, and influenza (three studies) vaccines among adolescents. Health education improves HPV vaccine uptake compared to usual practice (RR 1.43, 95% CI 1.16 to 1.76; I² = 0%; 3 studies, 1054 participants; high-certainty evidence). In addition, one large study provided evidence that a complex multi-component health education intervention probably results in little to no difference in hepatitis B vaccine uptake compared to simplified information leaflets on the vaccine (RR 0.98, 95% CI 0.97 to 0.99; 17,411 participants; moderate-certainty evidence). Financial incentives may improve HPV vaccine uptake compared to usual practice (RR 1.45, 95% CI 1.05 to 1.99; 1 study, 500 participants; low-certainty evidence). However, we are uncertain whether combining health education and financial incentives has an effect on hepatitis B vaccine uptake, compared to usual practice (RR 1.38, 95% CI 0.96 to 2.00; 1 study, 104 participants; very low certainty evidence). Mandatory vaccination probably leads to a large increase in hepatitis B vaccine uptake compared to usual practice (RR 3.92, 95% CI 3.65 to 4.20; 1 study, 6462 participants; moderate-certainty evidence). Provider prompts probably make little or no difference compared to usual practice, on completion of Tdap (OR 1.28, 95% CI 0.59 to 2.80; 2 studies, 3296 participants), meningococcal (OR 1.09, 95% CI 0.67 to 1.79; 2 studies, 3219 participants), HPV (OR 0.99, 95% CI 0.55 to 1.81; 2 studies, 859 participants), and influenza (OR 0.91, 95% CI 0.61 to 1.34; 2 studies, 1439 participants) vaccination schedules (moderate-certainty evidence). Provider education with performance feedback may increase the proportion of adolescents who are offered and accept HPV vaccination by clinicians, compared to usual practice. Compared to adolescents visiting non-participating clinicians (in the usual practice group), the adolescents visiting clinicians in the intervention group were more likely to receive the first dose of HPV during preventive visits (5.7 percentage points increase) and during acute visits (0.7 percentage points for the first and 5.6 percentage points for the second doses of HPV) (227 clinicians and more than 200,000 children; low-certainty evidence). A class-based school vaccination strategy probably leads to slightly higher HPV vaccine uptake than an age-based school vaccination strategy (RR 1.09, 95% CI 1.06 to 1.13; 1 study, 5537 participants; moderate-certainty evidence). A multi-component provider intervention (including an education session, repeated contacts, individualised feedback, and incentives) probably improves uptake of HPV vaccine compared to usual practice (moderate-certainty evidence). A multi-component intervention targeting providers and parents involving social marketing and health education may improve HPV vaccine uptake compared to usual practice (RR 1.41, 95% CI 1.25 to 1.59; 1 study, 25,869 participants; low-certainty evidence). AUTHORS' CONCLUSIONS: Various strategies have been evaluated to improve adolescent vaccination including health education, financial incentives, mandatory vaccination, and class-based school vaccine delivery. However, most of the evidence is of low to moderate certainty. This implies that while this research provides some indication of the likely effect of these interventions, the likelihood that the effects will be substantially different is high. Therefore, additional research is needed to further enhance adolescent immunisation strategies, especially in low- and middle-income countries where there are limited adolescent vaccination programmes. In addition, it is critical to understand the factors that influence hesitancy, acceptance, and demand for adolescent vaccination in different settings. This is the topic of an ongoing Cochrane qualitative evidence synthesis, which may help to explain why and how some interventions were more effective than others in increasing adolescent HPV vaccination coverage.

The global epidemiology of viral-induced acute liver failure: a systematic review protocol.

INTRODUCTION: The burden of viral-induced acute liver failure (ALF) around the world still remains unclear, with little to no data collected regarding the disease incidence in general and synthesised data on the relative contribution of different viruses to the aetiology of ALF is missing in the field. The aim of this review is to estimate the burden (prevalence, incidence, mortality, hospitalisation) of ALF following infection HAV, HBV, HCV, HDV, HEV, EBV), HSV1, HSV2, VZV, parvo-virus B19, HPIVs, YFV, HVV-6, CMV, CA16 and/or HAdVs. Establishing the common aetiologies of viral-induced ALF, which vary geographically, is important so that: (1) treatment can be initiated quickly, (2) contraindications to liver transplant can be identified, (3) prognoses can be deterined more accurately, and most importantly, (4) vaccination against viral ALF aetiologies can be prioritised especially in under-resourced regions with public health risks associated with the relevant attributable diseases. METHODS AND ANALYSIS: EBSCOhost, PubMed, ScienceDirect, Scopus and Web of Science databases will be searched for relevant literature published and grey literature from 2009 up to 2019. Published cross-sectional and cohort studies will be eligible for inclusion in this review. Qualifying studies will be formally assessed for quality and risk of bias using a standardised scoring tool. Following standardised data extraction, meta-analyses will be carried out using STATA. Depending on characteristics of included studies, subgroup analyses and meta-regression analyses will be performed. This review will be reported according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. ETHICS AND DISSEMINATION: No ethics approval is required as the systematic review will use only published data already in the public domain. Findings will be disseminated through publication in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER: CRD42018110309.

A systematic review of the epidemiology of hepatitis A in Africa.

BACKGROUND: Hepatitis A, caused by the hepatitis A virus (HAV), is a vaccine preventable disease. In Low and Middle-Income Countries (LMICs), poor hygiene and sanitation conditions are the main risk factors contributing to HAV infection. There have been, however, notable improvements in hygiene and sanitation conditions in many LMICs. As a result, there are studies showing a possible transition of some LMICs from high to intermediate HAV endemicity. The World Health Organization (WHO) recommends that countries should routinely collect, analyse and review local factors (including disease burden) to guide the development of hepatitis A vaccination programs. Up-to-date information on hepatitis A burden is, therefore, critical in aiding the development of country-specific recommendations on hepatitis A vaccination. METHODS: We conducted a systematic review to present an up-to-date, comprehensive synthesis of hepatitis A epidemiological data in Africa. RESULTS: The main results of this review include: 1) the reported HAV seroprevalence data suggests that Africa, as a whole, should not be considered as a high HAV endemic region; 2) the IgM anti-HAV seroprevalence data showed similar risk of acute hepatitis A infection among all age-groups; 3) South Africa could be experiencing a possible transition from high to intermediate HAV endemicity. The results of this review should be interpreted with caution as the reported data represents research work with significant sociocultural, economic and environmental diversity from 13 out of 54 African countries. CONCLUSIONS: Our findings show that priority should be given to collecting HAV seroprevalence data and re-assessing the current hepatitis A control strategies in Africa to prevent future disease outbreaks.