Determinants of Use of Intermittent Preventive Treatment of Malaria in Pregnancy: Jinja, Uganda

BACKGROUND: Maternal malaria is associated with serious adverse pregnancy outcomes. One recommended means of preventing malaria during pregnancy is intermittent preventive therapy (IPTp) with sulfadoxine/pyrimethamine (SP). We sought to identify determinants of preventive use of SP during pregnancy among recently pregnant women in Uganda. Additionally, we characterized the timing of and indications for the administration of SP at antenatal care (ANC) visits and missed opportunities for SP administration. METHODOLOGY/PRINCIPAL FINDINGS: Utilizing a population-based random sample, we interviewed 500 women living in Jinja, Uganda who had been pregnant in the past year. Thirty-eight percent (192/500) of women received SP for the treatment of malaria and were excluded from the analysis of IPTp-SP. Of the remaining women, 275 (89.3%) reported at least two ANC visits after the first trimester and had an opportunity to receive IPTp-SP according to the Ugandan guidelines, but only 86 (31.3%) of these women received a full two-dose course of IPTp. The remaining 189 (68.7%) women missed one or more doses of IPTp-SP. Among the 168 women that were offered IPTp, 164 (97.6%) of them took the dose of SP. CONCLUSIONS/SIGNIFICANCE: Use of IPTp in Uganda was found to be far below target levels. Our results suggest that women will take SP for IPTp if it is offered during an ANC visit. Missed opportunities to administer IPTp-SP during ANC were common in our study, suggesting provider-level improvements are needed

Psychosocial, Behavioural and Health System Barriers to Delivery and Uptake of Intermittent Preventive Treatment of Malaria in Pregnancy in Tanzania - Viewpoints of Service Providers in Mkuranga and Mufindi Districts.

Intermittent preventive treatment of malaria in pregnancy (IPTp) using sulphurdoxine-pyrimethamine (SP) is one of key malaria control strategies in Africa. Yet, IPTp coverage rates across Africa are still low due to several demand and supply constraints. Many countries implement the IPTp-SP strategy at antenatal care (ANC) clinics. This paper reports from a study on the knowledge and experience of health workers (HWs) at ANC clinics regarding psychosocial, behavioural and health system barriers to IPTp-SP delivery and uptake in Tanzania. Data were collected through questionnaire-based interviews with 78 HWs at 28 ANC clinics supplemented with informal discussions with current and recent ANC users in Mkuranga and Mufindi districts. Qualitative data were analysed using a qualitative content analysis approach. Quantitative data derived from interviews with HWs were analysed using non-parametric statistical analysis. The majority of interviewed HWs were aware of the IPTp-SP strategy's existence and of the recommended one month spacing of administration of SP doses. Some HWs were unsure of that it is not recommended to administer IPTp-SP and ferrous/folic acid concurrently. Others were administering three doses of SP per client following instruction from a non-governmental agency while believing that this was in conflict with national guidelines. About half of HWs did not find it appropriate for the government to recommend private ANC providers to provide IPTp-SP free of charge since doing so forces private providers to recover the costs elsewhere. HWs noted that pregnant women often register at clinics late and some do not comply with the regularity of appointments for revisits, hence miss IPTp and other ANC services. HWs also noted some amplified rumours among clients regarding health risks and treatment failures of SP used during pregnancy, and together with clients' disappointment with waiting times and the sharing of cups at ANC clinics for SP, limit the uptake of IPTp-doses. HWs still question SP's treatment advantages and are confused about policy ambiguity on the recommended number of IPTp-SP doses and other IPTp-SP related guidelines. IPTp-SP uptake is further constrained by pregnant women's perceived health risks of taking SP and of poor service quality

A Multifaceted Intervention to Improve the Quality of Care of Children in District Hospitals in Kenya: A Cost-Effectiveness Analysis

A cost-effective analysis conducted by Edwine Barasa and colleagues estimates that a complex intervention aimed at improving quality of pediatric care would be affordable and cost-effective in Kenya

Determinants of Use of Insecticide Treated Nets for the Prevention of Malaria in Pregnancy: Jinja, Uganda

One established means of preventing the adverse consequences of malaria during pregnancy is sleeping under an insecticide treated net (ITN) throughout pregnancy. Despite increased access to this intervention over time, consistent ITN use during pregnancy remains relatively uncommon in sub-Saharan Africa.We sought to identify determinants of ITN use during pregnancy. Utilizing a population-based random sample, we interviewed 500 women living in Jinja, Uganda, who had been pregnant in the past year. ITN ownership at the start of pregnancy was reported by 359 women (72%) and 28 women (20%) acquired an ITN after the first trimester of pregnancy. Among 387 ITN owners, 73% reported either always sleeping under the ITN during all trimesters of pregnancy, or after acquiring their net. Owning more than 1 net was slightly associated with always sleeping under an ITN during pregnancy (RR: 1.13; 95% CI: 1.00, 1.28). Women who always slept under an ITN during pregnancy were more likely to be influenced by an advertisement on the radio/poster than being given an ITN free of charge (RR: 1.48; 95% CI: 1.24, 1.76). No differences were found between other socio-demographic factors, pregnancy history, ANC use or socio-cultural factors.While self-reported ITN ownership and use was common throughout pregnancy, we were unable to pinpoint why a sizable fraction of Ugandan women did not always adhere to recommendations for use of an ITN during pregnancy. More data are needed on the capacity of individual households to support the installation of ITNs which may provide insight into interventions targeted at improving the convenience and adherence of daily ITN use

Prospects, achievements, challenges and opportunities for scaling-up malaria chemoprevention in pregnancy in Tanzania: the perspective of national level officers

OBJECTIVES: To describe the prospects, achievements, challenges and opportunities for implementing intermittent preventive treatment for malaria in pregnancy (IPTp) in Tanzania in light of national antenatal care (ANC) guidelines and ability of service providers to comply with them. METHODS: In-depth interviews were made with national level malaria control officers in 2006 and 2007. Data was analysed manually using a qualitative content analysis approach. RESULTS: IPTp has been under implementation countrywide since 2001 and the 2005 evaluation report showed increased coverage of women taking two doses of IPTp from 29% to 65% between 2001 and 2007. This achievement was acknowledged, however, several challenges were noted including (i) the national antenatal care (ANC) guidelines emphasizing two IPTp doses during a woman's pregnancy, while other agencies operating at district level were recommending three doses, this confuses frontline health workers (HWs); (ii) focused ANC guidelines have been revised, but printing and distribution to districts has often been delayed; (iii) reports from district management teams demonstrate constraints related to women's late booking, understaffing, inadequate skills of most HWs and their poor motivation. Other problems were unreliable supply of free SP at private clinics, clean and safe water shortage at many government ANC clinics limiting direct observation treatment and occasionally pregnant women asked to pay for ANC services. Finally, supervision of peripheral health facilities has been inadequate and national guidelines on district budgeting for health services have been inflexible. IPTp coverage is generally low partly because IPTp is not systematically enforced like programmes on immunization, tuberculosis, leprosy and other infectious diseases. Necessary concerted efforts towards fostering uptake and coverage of two IPTp doses were emphasized by the national level officers, who called for further action including operational health systems research to understand challenges and suggest ways forward for effective implementation and high coverage of IPTp. CONCLUSION: The benefit of IPTp is appreciated by national level officers who are encouraged by trends in the coverage of IPTp doses. However, their appeal for concerted efforts towards IPTp scaling-up through rectifying the systemic constraints and operational research is important and supported by suggestions by other authors

The combined effect of determinants on coverage of intermittent preventive treatment of malaria during pregnancy in the Kilombero Valley, Tanzania

BACKGROUND\ud \ud Intermittent preventive treatment during pregnancy (IPTp) at routine antenatal care (ANC) clinics is an important and efficacious intervention to reduce adverse health outcomes of malaria infections during pregnancy. However, coverage for the recommended two IPTp doses is still far below the 80% target in Tanzania. This paper investigates the combined impact of pregnant women's timing of ANC attendance, health workers' IPTp delivery and different delivery schedules of national IPTp guidelines on IPTp coverage.\ud \ud METHODS\ud \ud Data on pregnant women's ANC attendance and health workers' IPTp delivery were collected from ANC card records during structured exit interviews with ANC attendees and through semi-structured interviews with health workers in south-eastern Tanzania. Women's timing of ANC visits and health worker's timing of IPTp delivery were analyzed in relation to the different national IPTp schedules and the outcome on IPTp coverage was modelled.\ud \ud RESULTS\ud \ud Among all women eligible for IPTp, 79% received a first dose of IPTp and 27% were given a second dose. Although pregnant women initiated ANC attendance late, their timing was in line with the national guidelines recommending IPTp delivery between 20-24 weeks and 28-32 weeks of gestation. Only 15% of the women delayed to the extent of being too late to be eligible for a first dose of IPTp. Less than 1% of women started ANC attendance after 32 weeks of gestation. During the second IPTp delivery period health workers delivered IPTp to significantly less women than during the first one (55% vs. 73%) contributing to low second dose coverage. Simplified IPTp guidelines for front-line health workers as recommended by WHO could lead to a 20 percentage point increase in IPTp coverage.\ud \ud CONCLUSIONS\ud \ud This study suggests that facility and policy factors are greater barriers to IPTp coverage than women's timing of ANC attendance. To maximize the benefit of the IPTp intervention, revision of existing guidelines is needed. Training on simplified IPTp messages should be consolidated as part of the extended antenatal care training to change health workers' delivery practices and increase IPTp coverage. Pregnant women's knowledge about IPTp and the risks of malaria during pregnancy should be enhanced as well as their ability and power to demand IPTp and other ANC services

Analyse van de oversterfte in de zomer van 2023

De zomerperiode van 2023 (week 20 tot week 40) vertoonde een ondersterfte van -2,5% met 1 043 sterfgevallen minder dan verwacht op basis van de cijfers van de voorgaande vijf jaar. De waarschuwingsfase van het Ozon- en hitteplan werd in deze periode twee keer geactiveerd, maar de meteorologische en omgevingsrisicofactoren bleven gematigd. In deze twee specifieke tijdspannen is een geringe oversterfte vastgesteld, maar voor de zomerperiode als geheel is er sprake van ondersterfte. De aanzienlijke oversterfte in de afgelopen jaren hield verband met de COVID-19-epidemie en heeft ongetwijfeld bijgedragen tot de ondersterfte in deze&nbsp;zomerperiode.&nbsp;</p

Epidemiology of COVID-19 mortality in Belgium from wave 1 to wave 7 (March 2020 – 11 September 2022)

Based on the epidemiological surveillance of COVID-19 mortality, the observations on the first seven waves combined of the epidemic in Belgium (01/03/2020 – 11/09/2022) are as&nbsp;follows: Waves 66.8% of the COVID-19 deaths occurred during the first two waves of the epidemic. In absolute numbers, most deaths took place in wave 2 due to its length, but the highest peak of weekly COVID-19 deaths was observed during wave 1 (1,985 deaths during week 15&nbsp;2020). Age and&nbsp;sex 91.8% of the COVID-19 deaths were 65 years and&nbsp;older. The median age of COVID-19 deaths was 84 years old and the average age was 81.6 years&nbsp;old. In all age groups up to 80-84 years old, males represented the highest fraction of COVID-19&nbsp;deaths. Places of&nbsp;death Most of the COVID-19 deaths took place in hospitals (67.7%), followed by nursing homes&nbsp;(31.9%). During wave 1, there was an even distribution (50.2% and 48.7%&nbsp;respectively). Case&nbsp;classification 87.7% of the COVID-19 deaths in Belgium were laboratory-confirmed cases. In 2021 and 2022 around 96% of the COVID-19 deaths were laboratory-confirmed cases. During wave 1, 4.0% of COVID-19 deaths were radiologically-confirmed cases and 26.8% were possible&nbsp;cases. Nursing home&nbsp;residents 44.7% of the COVID-19 deaths were nursing home (NH) residents and 71.3% of them died in NH. While in waves 1 and 2, a quarter of all the NH deaths took place in hospital, in the following waves, it shifted to a more equal distribution of deaths between NH and&nbsp;hospitals. COVID-19 mortality&nbsp;rate The overall crude mortality rate (CMR) due to COVID-19 in Belgium, reached 281 per 100,000 inhabitants. It was higher in Wallonia (331 per 100,000 inhabitants), followed by Brussels-Capital Region (297 per 100,000 inhabitants) and Flanders (252 per 100,000&nbsp;inhabitants). At provincial level (and Brussels-Capital Region), Hainaut had the highest overall COVID-19 CMR (385 per 100,000 persons), while Walloon Brabant had the lowest (213 per 100,000 inhabitants). When taking the age structure into account, Brussels-Capital Region had the highest and Flemish Brabant the lowest COVID-19 age standardized mortality&nbsp;rate. Among NH residents (all ages) the COVID-19 CMR in Belgium reached 7,500 per 100,000 inhabitants and 923 per 100,000 inhabitants among non-NH residents&nbsp;(65+). COVID-19 case fatality&nbsp;ratio The COVID-19 case-fatality ratio (CFR) in Belgium was estimated to be 0.65%, but it increased exponentially with age (4.92% for 75-84 years old and 9.87% above 85 years old for both sex). During wave 1, when testing capacity was limited and only severe and hospitalized patients were tested, it reached&nbsp;11.3%. The risk of dying from COVID-19 was larger and consistent for men, across all age&nbsp;groups. COVID-19 CFR decreased over&nbsp;time. All-cause and excess&nbsp;mortality The all-cause CMR for Belgium was the highest for wave 2 (522 per 100,000&nbsp;inhabitants). The number of deaths in excess for wave 1 was roughly comparable to those caused by COVID-19 obtained via the epidemiological&nbsp;surveillance. Excess mortality was also the highest during wave 1, with a 26.6% excess of death (8,410 deaths in excess). Brussels-Capital Region experienced the highest excess mortality among the three regions (1,379 deaths in excess,&nbsp;57.2%). The percentage of excess mortality was relatively high in all regions during the first two waves and then dropped drastically. There was an under mortality in Flanders in wave 3, suggesting a harvesting&nbsp;effect. </ul