Antimicrobial stewardship in the era of the COVID-19 pandemic : A systematic review protocol on the opportunities and challenges for Sub-Saharan Africa

Background: Antimicrobial resistance (AMR) remains one of the leading threats to global public health and this may increase following COVID-19 pandemic. This is particularly the case in Africa where regulations on antimicrobial usage are weak. This protocol outlines the steps to undertake a systematic review to synthesize evidence on drivers of AMR and evaluate existing approaches to strengthening antimicrobial stewardship (AMS) programs in Sub-Saharan Africa (SSA). On the basis of the evidence generated from the evidence synthesis, the overarching goal of this work is to provide recommendations to support best practices in AMS implementation in SSA. Methods: A systematic search will be conducted using the following databases: Global Health Library, PubMed, Cumulative Index to Nursing and Allied Health Literature, Scopus, Google Scholar, Global Health, Embase, African Journals Online Library, Web of Science, antimicrobial databases (WHO COVID-19, TrACSS, NDARO, and JPIAMR), and the Cochrane databases for systematic reviews. Studies will be included if they assess AMR and AMS in SSA from January 2000 to January 31, 2023. Results: The primary outcomes will include the drivers of AMR and approaches to AMS implementation in SSA. The Preferred Reporting Items for Systematic Reviews and Meta-analyses will guide the reporting of this systematic review. Conclusions: The findings are expected to provide evidence on best practices and resource sharing for policy consideration to healthcare providers and other stakeholders both at the local and international levels. Additionally, the study seeks to establish drivers specific to AMR during the COVID-19 era in the SSA, for example, with the observed increasing trend of antimicrobial misuse during the first or second year of the pandemic may provide valuable insights for policy recommendation in preparedness and response measures to future pandemics. PROSPERO registration number: CRD42022368853.publishedVersionPeer reviewe

Prevalence of Nasopharyngeal Pneumococcal Carriage and Otitis Media Among Cameroonian Children Under-five Years Old in The Era of 13-valent Pneumococcal Conjugate Vaccine : Baseline all-cause under-five mortality data and vaccine impact on otitis media

Pneumokokin nenänielukantajuuden ja välikorvatulehduksen esiintyvyys alle viisivuotiailla kamerunilaislapsilla 13-valenttisen pneumokokki konjugaatti-rokotteen aikakaudella: tutkimus alle viisivuotiaiden kuolleisuudesta ennen rokotteen käyttöönottoa ja rokotteen vaikutuksesta välikorvatulehdukseen. Streptococcus pneumoniaella on yli yhdeksänkymmentä serotyyppiä ja ne ovat edelleen maailmanlaajuisesti merkittävä lapsuuden infektioiden ja kuolemantapausten aiheuttaja. Tartunnan saaneiden lasten hoitaminen ja tartunnan leviämisen estäminen on kansanterveyden kannalta ensisijaisen tärkeää. 13-valenttinen pneumokokki-konjugaattirokote (PCV13) sisällytettiin Kamerunin laajennettuun rokotusohjelmaan heinäkuussa 2011, GAVI allianssin (The Global vaccine alliance initiative) rahoituksella. PCV13-rokote annetaan imeväisille nopeutettuna perusannossarjana: kolme annosta, kuuden, kymmenen ja neljäntoista viikon iässä. PCV13 rokotusohjelmalla pyritään ehkäisemään vakavia pneumokokkitauteja ja välikorvantulehduksia. Ilman GAVIn rahoitusta PCV13:sta ei olisi mahdollista pitää Kamerunin, tai muidenkaan alhaisen tulotason valtioiden, rokoteohjelmassa. Jotta rahoitusta olisi mahdollista saada täytyy poliitikoille todistaa pneumokokkirokotteen vähentävän infektioita ja vähentävän myös alle viisivuotiainen kokonaissairastavuutta ja -kuolleisuutta. Edellisestä huolimatta, tutkimuksia, joissa arvioidaan PCV13 tehoa pinnallisiin infektioihin ja vakaviin tauteihin ja nenänielukantajuuteen, ei ole tehty. Tämän väitöskirjan tarkoituksena oli arvioida pneumokokkiin liittyvien kuolemantapausten määrää ennen rokoteohjelmaa, ja vertailla välikorvatulehduksen ja Streptococcus pneumoniae -bakteerin nenänielukantajuuden esiintyvyyttä alle viisivuotiailla rokotetuilla ja rokottamattomilla lapsilla PCV13 rokotusohjelman aikana. Tämä väitöskirja koostuu neljästä alkuperäistutkimuksesta. Tutkimuksessa I käytimme retrospektiivistä tutkimusasetelmaa tarkastellaksemme tietoja alle viisivuotiaiden kuolleisuuden tärkeimmistä syistä, jotka kirjattiin tartuntatautien seurantapaikoissa (sairaaloissa) Yaoundéssa tammikuun 2006 ja joulukuun 2012 välisenä aikana (Tutkimus I). Välikorvatulehdusten ja nenänielukantajuuden esiintyvyyttä PCV13 aikakaudella tutkittiin kahdella poikkileikkaustutkimuskierroksella, joilla kerättiin tympanometriatietoja ja nenänielunäytteitä satunnaisesti valituilta 24-36 kuukauden ikäisiltä Yaondéssa asuvilta lapsilta vuosina 2013 ja 2015. Tutkimuksen kohteena olivat kesäkuussa 2010 – kesäkuussa 2011 syntyneet (rokottamattomat) ja kesäkuussa 2012 – kesäkuussa 2013 syntyneet (vertailutiedot). Tutkimus I:n (N=817) tulokset antoivat maakohtaista näyttöä siitä, että noin 29% alle viisivuotiaiden kuolemista johtui pneumokokki-infektioista (mm. keuhkokuume, aivokalvontulehdus ja sepsis) tammikuun 2006 ja joulukuun 2012 välisenä aikana. Lisäksi yli 70 prosenttia lapsista tässä tutkimusasetelmassa menehtyi ennen toista syntymäpäiväänsä. Tutkimuksen II (N=877) mukaan pneumokokin kokonaiskantajuus oli 62% ja rokoteserotyyppien kantajuus 18%. Lisäksi kierrossa oli edelleen yksitoista rokotteen kolmestatoista serotyypistä. Rokoteserotyyppien kantajuus (18%) oli hyvin samanlainen kuin Gambiassa raportoitu (13%), tosin Gambiassa havaittiin vain kolmea rokoteserotyyppiä neljä vuotta imeväisikäisten rokotusten alkamisen jälkeen. Välikorvatulehdustutkimusten tulokset olivat yllättäviä. Kaksi vuotta PCV13 käyttöönoton jälkeen, vuonna 2013, (Tutkimus III, N=433) rokottamattomista lapsista 9,7 % sairasti korvatulehdusta. Neljä vuotta PCV-rokotusten aloittamisesta (Tutkimus IV, N=413) 16,7 % rokotetuista sairasti korvatulehduksen. Näin ollen korvatulehduksen esiintyvyys oli korkeampi rokotetuilla kuin rokottamattomilla. Lisäksi PCV13 arvioitu tehokkuus korvatulehdusta vastaan oli -72 % neljä vuotta PCV13 rokotusohjelman aloituksen jälkeen. Monimuuttuja-analyysi ei kuitenkaan osoittanut, että PCV13 rokotetuilla olisi vuonna 2015 ollut suurempi riski saada korvatulehdus kuin rokottamattomilla lapsilla vuonna 2013. Tulostemme mukaan PCV13 rokotteen teho korvatulehduksia vastaan olisi voinut olla 42 %, joten 58% korvatulehduksista ei olisi voitu estää. Kuitenkin tutkimuksen osanottajat oli valittu samasta väestöstä eri aikapisteissä ja tuloksiin on voinut vaikuttaa useat tekijät: muiden patogeenien/ei-rokoteserotyyppien aiheuttamat infektiot tai rokotetehon heikkeneminen ajan myötä tai jäännössekoittuneisuus. Lisäksi luonnollinen immuniteetti on voinut vaikuttaa tuloksiin. Yhteenvetona voidaan todeta, että jatkuva seuranta on tarpeen, jotta voidaan arvioida PCV13:n pitkän aikavälin vaikutuksia nenänielukantajuuteen, pneumokokkitauteihin ja pneumokokkiin liittyvään alle viisivuotiaiden kuolleisuuteen. Mielestäni näiden löydösten ja tässä väitöstyössä esiin nostettujen PCV13 ohjelman kansanterveydellisten tutkimustulosten tulisi ohjata Kamerunin hallinon politiikkaa priorisoimaan PCV13 ohjelman jatkamista GAVI rahoituksen loppuessa.Streptococcus pneumoniae has more than ninety serotypes and continue to be a major cause of childhood illnesses and deaths worldwide. Treating affected children and preventing the spread of infection is a critical public health priority especially in developing countries including Cameroon. The 13-valent pneumococcal conjugate vaccine (PCV13) was introduced to Cameroon's Expanded Programme on Immunization (EPI) in July 2011, through funding from the Global vaccine alliance initiative (GAVI, the Vaccine Alliance). PCV13 is administered to infants using the accelerated primary dose series of three doses at six, ten and fourteen weeks of age. PCV13 vaccination programme targets the prevention of paediatric invasive pneumococcal diseases and infections of the middle ear resulting from the pneumococcus. In the absence of GAVI funding, sustaining PCV13 immunization in Cameroon, as in most low-income economies, would be practically impossible. It will rely heavily on convincing policymakers of the PCV’s effectiveness in reducing the burden of disease associated with pneumococcal infections as well as overall under-five morbidity and mortality. However, studies evaluating the effectiveness of the PCV-13 against both mucosal and invasive pneumococcal diseases as well as nasopharyngeal carriage in the country are lacking. The purpose of this research project was to estimate the baseline proportion of pneumococcal associated deaths, prevalence of otitis media, and nasopharyngeal carriage of Streptococcus pneumoniae among children under the age of five who were vaccinated with PCV13 versus those who were not vaccinated during the PCV13 era. This dissertation consists of four original studies. A retrospective cohort study design was used to examine existing hospital data on the major causes of under-five mortality recorded at the infectious disease surveillance sites (hospitals) in Yaoundé, between January 2006 and December 2012 (Study I). In order to examine the prevalence of otitis media and nasopharyngeal carriage in the era of PCV13, two rounds of surveillance studies were conducted in which tympanometry data and nasopharyngeal swabs were collected from randomly selected 24 to 36 months old children living in and around Yaoundé, in 2013 and 2015, respectively. Children born between June 2010 and June 2011 (baseline data) and between June 2012 and June 2013 (comparison data), were targeted (Studies II, III and IV). The findings from Study I (N=817) provided country-specific evidence that approximately 29% of under-five deaths between January 2006 – December 2012 were due to pneumococcal infections (including pneumonia, meningitis and sepsis). Additionally, more than 70% of children in this setting die before their second birthdays. In Study II (N=877), overall carriage and residual vaccine-type pneumococci prevalence were 62% and 18%, respectively. Furthermore, eleven of the thirteen vaccine-serotypes were still in circulation. However, the 18% residual vaccine-type pneumococci obtained in Cameroon four years after PCV13 introduction were not very different from those reported in The Gambia (13%), except that, only three vaccine-type pneumococci were identified four years after infant vaccination programme. The results of the otitis media studies were surprising. Two years after PCV13 introduction in 2013 (Study III, N=433), 9.7% of PCV13-unvaccinated children had otitis media (OM). Four years after PCV13 implementation (Study IV, N=413), 16.7% of PCV13-vaccinated children had OM. This shows an unexpectedly higher OM prevalence among the PCV13-vaccinated group compared to the PCV13-unvaccinated. Additionally, PCV13 effectiveness estimate against OM prevalence was negative 72%, four years after PCV13 infant vaccination. However, multivariate analyses did not show any statistically significant evidence that PCV13-vaccinated children in 2015 were associated with higher odds of OM compared to PCV13-unvaccinated children in 2013. Furthermore, the attributable proportion estimates which depicts the public health impact of PCV13 against OM infection was 42%; suggesting that the remainder (58%) of OM infections in the PCV13-vaccinated cohort would have still occurred even without PCV13 vaccination. However, study participants were drawn from same population overtime, and the results may be attributed to several factors including: the predominance of other pathogens and/or non-PCV13-type pneumococci as disease causing microbes or early vaccine waning effects or residual confounding. Furthermore, immunity due to natural exposure could as well be a contributing factor. In conclusion, these findings support the need for continuous surveillance to determine the possible long-term effects of the PCV13 implementation programme in Cameroon on nasopharyngeal carriage, pneumococcal disease and pneumococcal-associated under-five mortality. I am of the opinion that in addition to these findings, the evidence and gaps on the broader public health impact of the PCV13 implementation discussed in this thesis will support Cameroon government’s policies to prioritize the continuation of PCV13 programme in the absence of GAVI funding

THE INTRODUCTION OF THE PNEUMOCOCCAL CONJUGATE VACCINE INTO CAMEROON'S EXPANDED PROGRAMME ON IMMUNISATION: Would every child be reached?

Pneumonia like many other communicable infections is vaccine-preventable, but the increasing death toll resulting from the disease globally is a call for concern; partly attributed to the incomplete vaccine coverage in children. There are several factors why vaccines have failed to reach every child. Most of these include the perceptions, knowledge, attitudes and practices of parents/guardians and healthcare providers. Previous studies on the introduction of new and under-utilized vaccines as is the case with the Pneumococcal Conjugate Vaccine (PCV) have focused on experimental trials, coverage figures and vaccine efficacy in developed countries. Little attention has been given to the factors which may hinder the implementation process despite the great challenges this may encounter in developing countries. The present study explored the essential issues in the introduction of the PCV in two health districts in Yaounde, Cameroon to ensure that every child is reached. The objectives of the study were to describe the knowledge, attitude and practices of parents/guardians on pneumonia and immunisations/EPI vaccines. It also aimed to identify the parental socio-economic/demographic characteristics that are predictive of good knowledge on pneumonia infections and EPI vaccines. Finally, the study described health center personnel perceptions about immunisations prior to the PCV introduction into the EPI. A cross sectional study design was adopted and targeted parents/guardians (n=205) of children aged 0-59 months and health centre personnel (n=13) directly involved with vaccination activities in two health districts in Cameroon. The WHO’s immunisation coverage cluster survey design was used to select the subjects with a response rate of 79.3%. The study was conducted between July-September 2010. Descriptive statistics and multivariate logistic models were used to analyse the parental/guardian data while the health personnel data was only analysed descriptively. SPSS version 17.0 was used as the analytical tool. The knowledge, attitudes and practices of the respondents were found to be generally good and positive about pneumonia disease burden and immunisations/EPI vaccines. However, only 19% of the parents/guardians were aware of the availability of the PCV. Most parents/guardians were of the opinion that increased sensitisation/mass vaccination campaigns would remain essential for the PCV to reach every child. Logistic modelling identified associations between; - educational level and parental knowledge on the consequences/seriousness of pneumonia infections, income and parental knowledge on pneumonia causes/risk factors, occupational level and parental knowledge on pneumonia prevention beside that of region of origin and parental knowledge on the availability of the PCV. Also, a friendly attitude from health personnel was thought to motivate parents/guardians to respect vaccination schedules. According to parents/guardians, the strongest factors promoting wide access to the PCV are public sensitisation/mass vaccination campaigns and use of social network avenues. Hence, a short and clear message on the dangers of pneumonia and the need for prevention provided to parents/guardians by health personnel during sensitisation/out-reach campaigns would be primordial, if the PCV is to reach every child.  Asiasanat:knowledge, attitudes, practices; parents/guardians; health personnel; PCV; EPI; new vaccine introduction; pneumonia; Cameroon; vaccinations/immunisation, Sub-Saharan Afric

THE INTRODUCTION OF THE PNEUMOCOCCAL CONJUGATE VACCINE INTO CAMEROON'S EXPANDED PROGRAMME ON IMMUNISATION: Would every child be reached?

Pneumonia like many other communicable infections is vaccine-preventable, but the increasing death toll resulting from the disease globally is a call for concern; partly attributed to the incomplete vaccine coverage in children. There are several factors why vaccines have failed to reach every child. Most of these include the perceptions, knowledge, attitudes and practices of parents/guardians and healthcare providers. Previous studies on the introduction of new and under-utilized vaccines as is the case with the Pneumococcal Conjugate Vaccine (PCV) have focused on experimental trials, coverage figures and vaccine efficacy in developed countries. Little attention has been given to the factors which may hinder the implementation process despite the great challenges this may encounter in developing countries. The present study explored the essential issues in the introduction of the PCV in two health districts in Yaounde, Cameroon to ensure that every child is reached. The objectives of the study were to describe the knowledge, attitude and practices of parents/guardians on pneumonia and immunisations/EPI vaccines. It also aimed to identify the parental socio-economic/demographic characteristics that are predictive of good knowledge on pneumonia infections and EPI vaccines. Finally, the study described health center personnel perceptions about immunisations prior to the PCV introduction into the EPI. A cross sectional study design was adopted and targeted parents/guardians (n=205) of children aged 0-59 months and health centre personnel (n=13) directly involved with vaccination activities in two health districts in Cameroon. The WHO’s immunisation coverage cluster survey design was used to select the subjects with a response rate of 79.3%. The study was conducted between July-September 2010. Descriptive statistics and multivariate logistic models were used to analyse the parental/guardian data while the health personnel data was only analysed descriptively. SPSS version 17.0 was used as the analytical tool. The knowledge, attitudes and practices of the respondents were found to be generally good and positive about pneumonia disease burden and immunisations/EPI vaccines. However, only 19% of the parents/guardians were aware of the availability of the PCV. Most parents/guardians were of the opinion that increased sensitisation/mass vaccination campaigns would remain essential for the PCV to reach every child. Logistic modelling identified associations between; - educational level and parental knowledge on the consequences/seriousness of pneumonia infections, income and parental knowledge on pneumonia causes/risk factors, occupational level and parental knowledge on pneumonia prevention beside that of region of origin and parental knowledge on the availability of the PCV. Also, a friendly attitude from health personnel was thought to motivate parents/guardians to respect vaccination schedules. According to parents/guardians, the strongest factors promoting wide access to the PCV are public sensitisation/mass vaccination campaigns and use of social network avenues. Hence, a short and clear message on the dangers of pneumonia and the need for prevention provided to parents/guardians by health personnel during sensitisation/out-reach campaigns would be primordial, if the PCV is to reach every child.  Asiasanat:knowledge, attitudes, practices; parents/guardians; health personnel; PCV; EPI; new vaccine introduction; pneumonia; Cameroon; vaccinations/immunisation, Sub-Saharan Afric

Data_PCV13_OM Impact analysis_12 Dec 2021.csv

This dataset consist of socia-demographic information and tympanograms obtained from 2-3 year-old Cameroonian children during two rounds of retrospective cohort studies conducted following the introduction of the 13-valent pneumococcal conjugate vaccine (PCV13) in Cameroon since July 2011.</p

Assessing the causes of under-five mortality and proportion associated with pneumococcal diseases in Cameroon. A case-finding retrospective observational study: 2006-2012

<div><p>Background</p><p>Vital registration data outlining causes of deaths (CoD) are important for a sustainable health system, targeted interventions and other relevant policies. There is data paucity on vital registration systems in developing countries. We assessed the leading causes and proportions of under-five deaths, and particularly those related to pneumococcal infections in Yaoundé, Cameroon, using hospital registration data.</p><p>Methods</p><p>A retrospective case-finding observational study design was used to access and identify data on 817 death cases in children under-five years of age recorded in health facilities in Yaoundé, within the period January 1, 2006 and December 31, 2012. Patients’ files were randomly selected and needed information including demographic data, date of admission, clinical and laboratory diagnosis, principal and/or underlying causes of death were abstracted into structured case report forms. The International Classification of Diseases and Clinical Modifications 10^th revision (ICD-10-CM) codes (ICD10Data.com 2017 edition) were used to classify the different CoD, retrospectively. Ascertainment of CoD was based on medical report and estimates were done using the Kaplan-Meier procedure and descriptive statistics.</p><p>Results</p><p>Of the 817 death records assessed, malaria was the leading CoD and was responsible for 17.5% of cases. Meningitis was the second largest CoD with 11.0%; followed by sepsis (10.0%), <i>Streptococcus pneumoniae</i> infections (8.3%), malnutrition (8.3%), gastro-enteritis / diarrhoea (6.2%), anaemia (6.1%) and HIV (3.5%), respectively.</p><p>Conclusion</p><p>The main CoD in this population are either treatable or vaccine-preventable; a trend consistent with previous reports across developing countries. Besides, the health effects from non-communicable infections should not be neglected. Therefore, scaling-up measures to reduce causes of under-five deaths will demand sustainable efforts to enhance both treatment and disease prevention strategies, to avoid a decline in the progress towards reducing under-five deaths by 2/3 from the 1990 baseline.</p></div

Prevalence, risk factors and management of common mental health disorders in Cameroon: a systematic review protocol

Background Mental health disorders (MHDs) are considered a serious public health concern globally. The burden of mental health conditions is estimated to be higher in low-income and middle-income countries, including Cameroon, where reliable estimates are lacking. This review aims to synthesise evidence on the prevalence of MHDs, the effectiveness of mental health management interventions and identify risk factors for MHDs in Cameroon.Method This review will systematically search electronic databases for studies focusing on one or more MHDs of interest within the context of Cameroon. We will include cohort, case–control and cross-sectional studies which assessed the prevalence or risk factors for MHDs in Cameroon and intervention studies to provide evidence on the effectiveness of interventions for managing MHDs. Two reviewers will independently perform all screening stages, data extraction and synthesis. We will provide a narrative synthesis and, if we identify enough articles that are homogeneous, we will perform a meta-analysis using a random effect model. The strength of the evidence will be assessed using the Grading of Recommendation, Assessment, Development and Evaluation approach.Conclusion This review will contribute to the current body of knowledge by providing a synthesis of current evidence on the prevalence of common MHDs, risk factors for different MHDs and the effectiveness of interventions for managing different mental health conditions in Cameroon.Ethics and dissemination This study will involve synthesis of published literature and does not warrant ethical approval. The findings will be disseminated through internationally peer-reviewed journals related to mental health.PROSPERO registration number CRD42022348427

Prevalence of pneumococcal nasopharyngeal colonization and serotypes circulating in Cameroonian children after the 13-valent pneumococcal conjugate vaccine introduction

BACKGROUND: Streptococcus pneumoniae remains a major contributor to childhood infections and deaths globally. In Cameroon, the 13-valent pneumococcal conjugate vaccine (PCV13) was introduced in July 2011, using a 3-dose Expanded programme on immunization (EPI) schedule administered to infants at 6, 10 and 14 weeks of age. To evaluate PCV13 effects, we assessed pneumococcal nasopharyngeal colonization and serotype distribution among Cameroonian children after PCV13 introduction. METHODS: Nasopharyngeal (NP) swabs were collected from eligible children aged 24-36 months in two cross-sectional surveys conducted from March to July: in 2013 (PCV13-unvaccinated), and in 2015 (PCV13-vaccinated). Using a systematic World Health Organization (WHO) cluster coverage sampling technique in 40 communities, NP swabs collected were processed following WHO recommendations. Standard bacterial culture techniques were used for the isolation of S. pneumoniae from gentamicin-blood agar plates and identification using optochin susceptibility testing. Serotyping was performed using sequential multiplex polymerase chain reaction, supplemented with Quellung test. RESULTS: Among the PCV13-vaccinated children, overall pneumococcal carriage prevalence was 61.8% (426/689) and PCV13 vaccine-type carriage prevalence was 18.0% (123/689). Eleven out of the 13 vaccine serotypes were detected in the vaccinated children. The most common serotypes were 19F (4.5%, 31/689) and 15B/C (7.3%, 50/689). CONCLUSION: In Cameroon, four years after infant vaccination nearly all of the PCV13-serotypes continued to circulate in the population. This suggests that the direct and indirect effects of the vaccination programme have not resulted in expected low levels of vaccine-type transmission. Continuous monitoring is needed to assess the long term effects of the PCV13 on nasopharyngeal carriage and disease.publishedVersionPeer reviewe