Impact of COVID-19 on food security and diet quality in Chilanga District, Zambia.

INTRODUCTION: Food security and nutrition have been severely impacted during the COVID-19 pandemic, particularly in low- and middle-income countries (LMICs). We aimed to quantify the impacts of the pandemic on food security and diet diversity within Chilanga District in Zambia and identify target areas for high-impact social protection and safety net programs. METHODS: We conducted a cross-sectional study in Chilanga district immediately after the Omicron variant surge in February 2022. Diet quality and food security were assessed based on a household diet questionnaire and a Minimum Dietary Diversity-Women (MDD-W) score was calculated. A paired t-test was used to determine whether there was a statistically significant change in the MDD-W score and McNemar test was used to investigate the change in food security between the pre- and peri-COVID-19 period. RESULTS: Compared to the pre-COVID-19 period, there were increases in food prices across the board in the peri-COVID-19 period and decreased consumption of key food categories including legumes, dairy and vitamin A rich foods. Despite high rates of food insecurity, only 6.6% of surveyed households received any cash or in-kind assistance from a government agency, non-profit, or other organization in the post-COVID-19 period. CONCLUSION: The COVID-19 pandemic had significant impacts on food security and dietary diversity in Chilanga district. This is particularly relevant in the low-income communities that we surveyed, which had pre-existing challenges with food security. Additional resources must be invested in Chilanga District and similarly affected areas to address this gap in access to food and promote national equity. Trial Registration N/A.

Undernutrition in older children and adolescents in peri-urban Zambia.

Background: Adolescents make up roughly a quarter of the population in Zambia; however, most nutrition-related programming is targeted at the under-five population. Understanding the scale of undernutrition in older children and adolescents is fundamental to alleviating food insecurity and addressing undernutrition across all age groups. Methods: A cross-sectional survey was performed in four low-income, peri-urban compounds in Chilanga District which included anthropometric measurements of children between ages 6 months-19 years and a household-level diet diversity and food security questionnaire. Wasting was used for children under 5 and thinness for children 5-19 years. Descriptive analysis and multivariate logistic regression were conducted to quantify the prevalence and distribution of malnutrition and understand the impact of food security. Results: We surveyed 393 households and 1,004 children between the ages of 6 months and 19 years. Children aged 6-9 years had the highest prevalence of severe thinness (5.2%) and adolescents (10-19 years) had the highest rates of moderate thinness (6.5%). Across all age groups, more than 75% of children were in households that worried about running out of food in the previous month. 24.9% of adolescents and 28.4% of older children were in households were more likely to go a whole day without eating compared to 16.9% of children under 5. Conclusion: Our survey indicated that malnutrition in adolescents and older children living in Chilanga district was comparable to those under 5. Interventions to address undernutrition must be targeted at older children and adolescents in order to ameliorate this burden.

Primary series COVID-19 vaccine effectiveness among healthcare workers in Albania, February-December 2021.

Background: Healthcare workers have experienced high rates of morbidity and mortality from coronavirus disease 2019 (COVID-19). Methods: A prospective cohort study was conducted in three Albanian hospitals between 19 February and 14 December 2021. All participants underwent polymerase chain reaction (PCR) and serological testing at enrolment, regular serology throughout, and PCR testing when symptomatic.Vaccine effectiveness (VE) against COVID-19 and against all severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infections (symptomatic or asymptomatic) was estimated. VE was estimated using a Cox regression model, with vaccination status as a time-varying variable. Findings: In total, 1504 HCWs were enrolled in this study; 70% had evidence of prior SARS-CoV-2 infection. VE was 65.1% [95% confidence interval (CI) 37.7-80.5] against COVID-19, 58.2% (95% CI 15.7-79.3) among participants without prior SARS-CoV-2 infection, and 73.6% (95% CI 24.3-90.8) among participants with prior SARS-CoV-2 infection. For BNT162b2 alone, VE was 69.5% (95% CI 44.5-83.2). During the period when the Delta variant was predominant, VE was 67.1% (95% CI 38.3-82.5). VE against SARS-CoV-2 infection for the full study period was 36.9% (95% CI 15.8-52.7). Interpretation: This study found moderate primary series VE against COVID-19 among healthcare workers in Albania. These results support the continued promotion of COVID-19 vaccination in Albania, and highlight the benefits of vaccination in populations with high levels of prior infection.

Factors associated with receipt of COVID-19 vaccination and SARS-CoV-2 seropositivity among healthcare workers in Albania (February 2021-June 2022): secondary analysis of a prospective cohort study.

Background: Healthcare workers (HCWs) have been disproportionally affected by COVID-19. We investigated factors associated with two- and three-dose COVID-19 vaccine uptake and SARS-CoV-2 seropositivity among 1504 HCWs enrolled (19 February-7 May 2021) in a prospective COVID-19 vaccine effectiveness cohort in Albania through a secondary analysis. Methods: We collected sociodemographic, occupational, health, prior SARS-CoV-2 infection, and COVID-19 vaccination data from all HCWs at enrollment. Vaccination status was assessed weekly through June 2022. A serum sample was collected from all participants at enrollment and tested for anti-spike SARS-CoV-2 antibodies. We analyzed HCWs characteristics and outcomes using multivariable logistic regression. Findings: By 11 June 2022, 1337 (88.9%) HCWs had received two COVID-19 vaccine doses, of whom 255 (19.1%) received a booster. Factors significantly associated with receiving three doses (adjusted odds ratio (aOR), 95% CIs) were being ≥35 years (35-44 years: 1.76 (1.05-2.97); 45-54 years: 3.11 (1.92-5.05); ≥55 years: 3.38 (2.04-5.59)) and vaccinated against influenza (1.78; 1.20-2.64). Booster dose receipt was lower among females (0.58; 0.41-0.81), previously infected (0.67; 0.48-0.93), nurses and midwives (0.31; 0.22-0.45), and support staff (0.19; 0.11-0.32). Overall 1076 (72%) were SARS-CoV-2 seropositive at enrollment. Nurses and midwifes (1.45; 1.05-2.02), support staff (1.57; 1.03-2.41), and HCWs performing aerosol-generating procedures (AGPs) (1.40; 1.01-1.94) had higher odds of being seropositive, while smokers had reduced odds (0.55; 0.40-0.75). Interpretation: In a large cohort of Albanian HCWs, COVID-19 vaccine booster dose uptake was very low, particularly among younger, female, and non-physician HCWs, despite evidence demonstrating the added benefit of boosters in preventing infection and severe disease. Reasons behind these disparities should be explored to develop targeted strategies in order to promote uptake in this critical population. SARS-CoV-2 seroprevalence was higher among non-physicians and HCWs performing APGs. A better understanding of the factors contributing to these differences is needed to inform interventions that could reduce infections in the future. Funding: This study was funded by the Task Force for Global Health (US Centers for Disease Control (CDC) cooperative agreement # NU51IP000873) and the World Health Organization, Regional Office for Europe.

Learning to walk the walk: Incorporating praxis for decolonization in global health education.

Colonial history has deeply influenced the structures that govern global health. Though many curricula promote equity, few focus on developing competency in understanding and dismantling colonialism, and the structural barriers to global health equity. To dismantle colonial structures and create equitable collaborations, learners must be able to recognise how colonialism permeates global health practice. We propose a praxis cycle in education that asks learners to actively engage with these concepts. The praxis cycle includes: Theory: Learners explore the principles of decoloniality to understand how attitudes and practices are shaped by biased social structures influenced by colonialism. Reflection: Learners reflect on their work in LMIC settings through a lens of decoloniality and positionality. Action: Learners work in LMIC settings where they apply and actively engage with these concepts and insights. During implementation of this curriculum, we encountered several challenges including the cognitive dissonance of the learner to changing mental models of global health practice, existing systemic barriers to changing one's practice and the development of accountability mechanisms for learners in this type of curriculum. Intentionally incorporating a praxis cycle helps learners recognise their role in disrupting the structural forces that promote inequities, and actively dismantle the forces upholding systemic oppression.

Learner Milestones to Guide Decolonial Global Health Education.

The current movement to 'decolonize' global health aims to both dismantle colonial frameworks that perpetuate inequity and racism, as well as to rebuild and uplift structures and systems that celebrate indigeneity. However, it is critical to recognize that teaching decoloniality within global health education is more than just the acknowledgement that there are key paradigms missing from current global health education. It is imperative to have a methodology to hold ourselves and our learners accountable to progress in practices and ideals that promote equity-based praxis. In this paper, we propose the creation of a tool to assess learner levels and their progression over time in both recognizing the impacts of colonialism and acting to transform their own global health praxis towards equity and decoloniality. We developed a model to illustrate an increasing scope and impact of decolonial and global health equity praxis. We hypothesize through this model that the way in which learners engage with power dynamics and structural advocacy at each level is essential to describing learner stages. Based on extensive literature review, existing curricular frameworks, global partner discussion(s), feedback on our pilot curriculum, and adaptation of philosophical theory, these learner milestones were conceptualized. We discuss the inherent challenges in assessment of the complex mix of knowledge, attitude and skills described in these milestones with the understanding that any such assessment would always be formative, as we all continue learning how to do better. We hope these milestones can be utilized to promote critical transformational change in the field of global health. This requires deep self-reflection and examination of existing structures of oppression followed by intentional reparative actions to embody decoloniality in our praxis and advocacy and reimagine global health based on equity and local leadership.

COVID-19 vaccine effectiveness among healthcare workers in Albania (COVE-AL): protocol for a prospective cohort study and cohort baseline data.

INTRODUCTION: Critical questions remain about COVID-19 vaccine effectiveness (VE) in real-world settings, particularly in middle-income countries. We describe a study protocol to evaluate COVID-19 VE in preventing laboratory-confirmed SARS-CoV-2 infection in health workers (HWs) in Albania, an upper-middle-income country. METHODS AND ANALYSIS: In this 12-month prospective cohort study, we enrolled HWs at three hospitals in Albania. HWs are vaccinated through the routine COVID-19 vaccine campaign. Participants completed a baseline survey about demographics, clinical comorbidities, and infection risk behaviours. Baseline serology samples were also collected and tested against the SARS-CoV-2 spike protein, and respiratory swabs were collected and tested for SARS-CoV-2 by RT-PCR. Participants complete weekly symptom questionnaires and symptomatic participants have a respiratory swab collected, which is tested for SARS-CoV-2. At 3, 6, 9 months and 12 months of the study, serology will be collected and tested for antibodies against the SARS-CoV-2 nucleocapsid protein and spike protein. VE will be estimated using a piecewise proportional hazards model (VE=1-HR). BASELINE DATA: From February to May 2021, 1504 HWs were enrolled. The median age was 44 (range: 22-71) and 78% were female. At enrolment, 72% of participants were seropositive for SARS-CoV-2. 56% of participants were vaccinated with one dose, of whom 98% received their first shot within 4 days of enrolment. All HWs received the Pfizer BNT162b2 mRNA COVID-19 vaccine. ETHICS AND DISSEMINATION: The study protocol and procedures were reviewed and approved by the WHO Ethical Review Board, reference number CERC.0097A, and the Albanian Institute of Public Health Ethical Review Board, reference number 156. All participants have provided written informed consent to participate in this study. The primary results of this study will be published in a peer-reviewed journal at the time of completion. TRIAL REGISTRATION NUMBER: NCT04811391.

Implementation of a Pediatric Early Warning Score to Improve Communication and Nursing Empowerment in a Rural District Hospital in Rwanda.

BACKGROUND: Pediatric early warning (PEW) scores represent a "track-and-trigger system" that identifies clinical deterioration in a patient's condition in the hours preceding a sentinel event. Before implementation, nurses reported feeling unprepared to identify and advocate for acutely ill patients owing to a lack of skills, vocabulary, and agency. We implemented a Pediatric Early Warning Score for Resource-Limited Settings (PEWS-RL) with nurses in a rural district hospital in Rwanda. Although PEW scores can improve clinical outcomes, empowering nurses in resource-limited settings to discuss patient acuity with physicians is a critical first step. Our primary aims were to train nurses to obtain more accurate vital signs and assess their importance as early warning signs of clinical deterioration and use PEW scores to improve communication between nurses and physicians. IMPLEMENTATION: The PEWS-RL tool implementation began with a training program that was created through discussions with nurses, physicians, and the medical director of the hospital. The program included lectures and application of learned skills through direct clinical mentorship of nurses, as well as training of physicians regarding PEWS-RL as a communication tool. EVALUATION: The PEWS-RL protocol was evaluated based on pre- and post-tests to assess improvement in nurses' knowledge and skill, as well as skills assessments of accurate recognition of clinical deterioration. All 6 nurses passed skill testing with >80% accuracy. Nurses' feelings of empowerment to advocate for patients and to escalate care were assessed through pre- and post-training interviews. Nurses described increased confidence in calling for physician support. DISCUSSION: Implementation of PEW scores increased nurses' technical skills and feelings of confidence and empowerment; however, the low-resource setting presented major challenges. Barriers to sustainable implementation include the rapid ward staff turnover as well as limited physician buy-in. Nevertheless, the PEWS-RL tool has the potential to empower nurses and improve patient outcomes if fully embraced by staff.

Multisectoral Integration of Nutrition, Health, and Agriculture: Implementation Lessons From Ethiopia.

BACKGROUND: The Government of Ethiopia and development partners have invested heavily in nutrition through multisectoral nutrition programs and the recently announced Food and Nutrition Policy. By making nutrition a political priority, the government has enabled multisectoral collaboration. OBJECTIVE: To trace the development of multisectoral nutrition policy in Ethiopia and identify lessons learned from implementation. METHODS: We utilize the literature and stakeholder interviews across government ministries, donors, and nongovernmental organizations (NGOs) to analyze Ethiopia's progress toward multisectoral nutrition governance through 5 lenses: coordination and structural accountability, political commitment, financing, human resources, and data monitoring and transparency. RESULTS: Despite significant progress, coordination and structural accountability for nutrition activities and outcomes across and within sectors remain challenges. While political will is strong, financing is often insufficient. Ethiopia has a shortage of nutrition policy makers and experts but is investing in education to close this gap. Finally, wider sharing of data across ministries and partners would enable enhanced feedback and improvement upon existing programs. Several lessons are notable for policy makers and partners: (1) making nutrition a national political priority is key to fostering multisectoral collaboration and improving nutrition outcomes; (2) nutrition champions are critical for political prioritization of nutrition; (3) multisectoral collaboration has helped reduce undernutrition in Ethiopia, due to expansion from nutrition-specific to nutrition-sensitive strategies; and (4) accountability structures are vital to effective coordination, monitoring, and evaluation in multisectoral nutrition governance. CONCLUSIONS: Ethiopia has made significant progress toward multisectoral integration for nutrition. Despite contextual differences, lessons learned from Ethiopia may guide other countries aiming to reduce malnutrition.