Abstract
Health systems resilience (HSR) is defined as the ability of a health system to continue providing normal services in response to a crisis, making it a critical concept for analysis of ...health systems in fragile and conflict-affected settings (FCAS). However, no consensus for this definition exists and even less about how to measure HSR. We examine three current HSR definitions (maintaining function, improving function and achieving health system targets) using real-time data from South Sudan to develop a data-driven understanding of resilience. We used 14 maternal, newborn and child health (MNCH) coverage indicators from household surveys in South Sudan collected at independence (2011) and following 2 years of protracted conflict (2015), to construct a resilience index (RI) for 9 of the former 10 states and nationally. We also assessed health system stress using conflict-related indicators and developed a stress index. We cross tabulated the two indices to assess the relationship of resilience and stress. For maintaining function for 80% of MNCH indicators, seven state health systems were resilient, compared with improving function for 50% of the indicators (two states were resilient). Achieving the health system national target of 50% coverage in half of the MNCH indicators displayed no resilience. MNCH coverage levels were low, with state averages ranging between 15% and 44%. Central Equatoria State displayed high resilience and high system stress. Lakes and Northern Bahr el Ghazal displayed high resilience and low stress. Jonglei and Upper Nile States had low resilience and high stress. This study is the first to investigate HSR definitions using a resilience metric and to simultaneously measure health system stress in FCAS. Improving function is the HSR definition detecting the greatest variation in the RI. HSR and health system stress are not consistently negatively associated. HSR is highly complex warranting more in-depth analyses in FCAS.
•An epilepsy prevalence of 4.4% was observed in villages in Maridi.•Living close to the Maridi river is a major risk factor for epilepsy.•Persons with nodding seizures and with other forms of ...epilepsy live in the same areas.•Ivermectin coverage needs to increase to prevent onchocerciasis associated epilepsy.
To determine the prevalence and incidence of epilepsy in an onchocerciasis endemic region of South Sudan.
In May 2018, a door-to-door household survey was conducted in 8 study sites in an onchocerciasis endemic area in Maridi County.
A total of 2511 households agreed to participate in the study, corresponding to 17,652 individuals. An epilepsy screening questionnaire identified 799 persons suspected to have epilepsy (4.5%); in 736 of the 766 persons (96.1%) seen by a clinical officer the diagnosis of epilepsy was confirmed. Adding 38 persons who were not seen but with a positive answer to a combination of screening questions, 774 persons (4.4%) had epilepsy. Epilepsy prevalence was highest in the 11–20 age group (10.5%); 66 persons with epilepsy (PWE) developed their first seizures in the year preceding the survey (annual incidence = 373.9/100.000). Neurocysticercosis cannot explain the high epilepsy prevalence since no pigs are kept in the area. Independent risk factors for epilepsy included male gender, belonging to a “permanent household” and a farming family, and living in a village bordering the Maridi River. Only 7209 (40.8%) of the population took ivermectin in 2017.
A very high prevalence and incidence of epilepsy was observed in several villages in Maridi County located close to the Maridi River and the Maridi dam. Urgent action is needed to prevent children in Maridi County from developing OAE by strengthening the onchocerciasis elimination program.
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•Onchocerciasis is associated with a wide clinical spectrum of seizure types.•Onchocerciasis-associated epilepsy is highly prevalent in Maridi, South Sudan.•Nodding seizures are more ...associated with disabilities including blindness than other seizures.
To describe the clinical manifestations of persons with epilepsy (PWE) in onchocerciasis endemic villages in South Sudan.
During a survey in Maridi County in May 2018, PWE were interviewed and examined in their households by a clinical officer or medical doctor. Onchocerciasis-associated epilepsy (OAE) was defined as ≥2 seizures without any obvious cause, starting between the ages of 3–18 years in previously healthy persons who had resided for at least 3 years in the onchocerciasis endemic area.
Seven hundred and thirty-six PWE were included in the study; 315 (42.8%) were females; median age was 18 years. A variety of seizure types were reported: generalized tonic-clonic seizures in 511 PWE (69.4%), absences in 15 (2.0%), focal motor seizures with full awareness in 7 (1.0%), focal motor seizures with impaired awareness in 25 (3.4%), brief episodes of hallucinations in 316 (43.9%) and nodding seizures in 335 (45.5%). The median age of onset of all seizures was 10 years, and 8 years for nodding seizures. PWE with nodding seizures presented with more cognitive disabilities. The diagnostic criteria for OAE were met by 414 (85.2%) of the 486 PWE with complete information. Eighty (11.0%) PWE presented with Nakalanga features. Only 378 (51.4%) PWE were taking anti-epileptic treatment.
PWE presented with a wide spectrum of seizures. The high percentage of PWE who met the diagnostic criteria for OAE suggests that better onchocerciasis control could prevent new cases. Urgent action is needed to close the anti-epileptic treatment gap.
Weight-for-age z-score (WAZ) is not currently an admission criterion to therapeutic feeding programs, and children with low WAZ at high risk of mortality may not be admitted. We conducted a secondary ...analysis of RCT data to assess response to treatment according to WAZ and mid-upper arm circumference (MUAC) and type of feeding protocol given: a simplified, combined protocol for severe and moderate acute malnutrition (SAM and MAM) vs. standard care that treats SAM and MAM, separately. Children with a moderately low MUAC (11.5-12.5 cm) and a severely low WAZ (<-3) respond similarly to treatment in terms of both weight and MUAC gain on either 2092 kJ (500 kcal)/day of therapeutic or supplementary food. Children with a severely low MUAC (<11.5 cm), with/without a severely low WAZ (<-3), have similar recovery with the combined protocol or standard treatment, though WAZ gain may be slower in the combined protocol. A limitation is this analysis was not powered for these sub-groups specifically. Adding WAZ < -3 as an admission criterion for therapeutic feeding programs admitting children with MUAC and/or oedema may help programs target high-risk children who can benefit from treatment. Future work should evaluate the optimal treatment protocol for children with a MUAC < 11.5 and/or WAZ < -3.0.
ObjectiveInvestigating attitudes accepting two categories of violence against women and girls (VAWG) (intimate partner violence—IPV—and other expressions of VAWG) and their association with seven ...demographic/social determinants and health-seeking behaviours in South Sudan.DesignCross-sectional study using data from the South Sudan National Household Survey 2020.SettingSouth Sudan.Participants and methods1741 South Sudanese women and 1739 men aged 15–49 years; data captured between November 2020 and February 2021 and analysed using binary logistic regression.ResultsPeople with secondary or higher education displayed attitudes rejecting acceptance of IPV (OR 0.631, 95% CI 0.508 to 0.783). Women and men living in states with more numerous internally displaced people (IDP) or political/military violence had attitudes accepting IPV more than residents of less violence-affected regions (OR 1.853, 95% CI 1.587 to 2.164). Women had a higher odd of having attitudes accepting IPV than men (OR 1.195, 95% CI 1.014 to 1.409). People knowing where to receive gender-based violence healthcare and psychological support (OR 0.703, 95% CI 0.596 to 0.830) and with primary (OR 0.613, 95% CI 0.515 to 0.729), secondary or higher education (OR 0.596, 95% CI 0.481 to 0.740) displayed attitudes rejecting acceptance of other expressions of VAWG. People residing in states with proportionately more IDP and who accepted IPV were more likely to have attitudes accepting other expressions of VAWG (OR 1.699, 95% CI 1.459 to 1.978; OR 3.195, 95% CI 2.703 to 3.775, respectively).ConclusionAttitudes towards accepting VAWG in South Sudan are associated with women’s and men’s education, gender, residence and knowledge about health-seeking behaviour. Prioritising women’s empowerment and gender transformative programming in the most conflict-affected areas where rates of VAWG are higher should be prioritised along with increasing girls’ access to education. A less feasible strategy to decrease gender inequalities is reducing insecurity, military conflict, and displacement, and increasing economic stability.
Several factors determine uptake of HIV testing services (HTS) by female sex workers (FSW), including their knowledge of HIV and their awareness of services supporting people who are HIV-positive. ...HTS provided entry into the UNAIDS 90-90-90 cascade of care. We conducted a cross-sectional biobehavioural survey (BBS) to determine HIV prevalence and progress towards UNAIDS 90-90-90 cascade targets among this population in South Sudan.
Respondent-driven sampling (RDS) was used to recruit women and sexually exploited girls aged 13-18 years who exchanged sex for goods or money in the past 6 months and resided in the town for at least 1 month. Consenting participants were interviewed and tested for HIV and, if positive, they were also tested for their viral load (VL). Data were weighted in RDS Analyst and analyzed with Stata 13.
A total of 1,284 participants were recruited. The overall HIV cascade coverages were 64.8% aware of their HIV-positive status; 91.0% of those aware of their positive status were on ART; and VL suppression among those on ART was 93.0%.
Being unaware of their HIV-positive status limits, the uptake of HIV treatment among FSW in South Sudan. This underscores the importance of optimized case-finding approaches to increase HTS among FSW and sexually exploited minors.
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Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
HIV prevalence is estimated to be 2.7% in South Sudan; however, little is known about the young country's epidemic. We conducted a respondent-driven sampling biobehavioral survey in Juba of female ...sex workers (FSW) aged greater than or equal to15 years who sold or exchanged sex in the last 6 months to learn more about this population. We enrolled 838 FSW from November 2015 to March 2016 and estimated HIV prevalence to be 37.8%. Prevalence of active syphilis was 7.3%. FSW were from South Sudan and most neighboring countries. Comprehensive knowledge of HIV was 11.1% and 64.2% of FSW had never spoken with an outreach worker. In multivariable analysis, HIV was associated with being from Uganda (aOR: 3.3, 95% CI: 1.7-6.1) or Kenya (aOR: 4.3, 95% CI: 1.5-13.0) versus from South Sudan. Our survey suggests that FSW may play a critical role in South Sudan's HIV epidemic and highlights the importance of tailoring services to the unique needs of FSW of all nationalities in Juba.
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Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Little is known about HIV in South Sudan and even less about HIV among female sex workers (FSW). We characterized progress towards UNAIDS 90-90-90 targets among female sex workers (FSW) and sexually ...exploited female adolescents in Juba and Nimule, South Sudan.
We conducted a biobehavioral survey of FSW and sexually exploited female adolescents using respondent-driven sampling (RDS) in Juba (November 2015-March 2016) and in Nimule (January-March 2017) to estimate achievements toward the UNAIDS 90-90-90 targets (90% of HIV-positive individuals know their status; of these, 90% are receiving antiretroviral therapy ART; and of these, 90% are virally suppressed). Eligibility criteria were girls and women who were aged ≥15 years; spoke English, Juba Arabic, or Kiswahili; received money, goods, or services in exchange for sex in the past 6 months; and resided, worked, or socialized in the survey city for ≥1 month. Data were weighted for RDS methods.
We sampled 838 FSW and sexually exploited female adolescents in Juba (HIV-positive, 333) and 409 in Nimule (HIV-positive, 108). Among HIV-positive FSW and sexually exploited female adolescents living in Juba, 74.8% self-reported being aware of their HIV status; of these, 73.3% self-reported being on ART; and of these, 62.2% were virally suppressed. In Nimule, 79.5% of FSW and sexually exploited female adolescents living with HIV self-reported being aware of their HIV status; of these, 62.9% self-reported being on ART; and of these, 75.7% were virally suppressed.
Although awareness of HIV status is the lowest of the 90-90-90 indicators in many countries, treatment uptake and viral suppression were lowest among FSW and sexually exploited female adolescents in South Sudan. Differentiated service delivery facilitate linkage to and retention on treatment in support of attainment of viral suppression.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Objectives
We adapted a rapid quality of care monitoring method to a fragile state with two aims: to assess the delivery of child health services in South Sudan at the time of independence and to ...strengthen local capacity to perform regular rapid health facility assessments.
Methods
Using a two‐stage lot quality assurance sampling (LQAS) design, we conducted a national cross‐sectional survey among 156 randomly selected health facilities in 10 states. In each of these facilities, we obtained information on a range of access, input, process and performance indicators during structured interviews and observations.
Results
Quality of care was poor with all states failing to achieve the 80% target for 14 of 19 indicators. For example, only 12% of facilities were classified as acceptable for their adequate utilisation by the population for sick‐child consultations, 16% for staffing, 3% for having infection control supplies available and 0% for having all child care guidelines. Health worker performance was categorised as acceptable in only 6% of cases related to sick‐child assessments, 38% related to medical treatment for the given diagnosis and 33% related to patient counselling on how to administer the prescribed drugs. Best performance was recorded for availability of in‐service training and supervision, for seven and ten states, respectively.
Conclusions
Despite ongoing instability, the Ministry of Health developed capacity to use LQAS for measuring quality of care nationally and state‐by‐state, which will support efficient and equitable resource allocation. Overall, our data revealed a desperate need for improving the quality of care in all states.
Objectifs
Nous avons adapté une méthode rapide de surveillance de la qualité des soins dans un Etat fragile avec deux buts: évaluer la prestation des services de santé de l'enfant dans le Sud‐Soudan à l’époque de l'indépendance et renforcer les capacités locales à effectuer des évaluations rapides et régulières des établissements de santé.
Méthodes
En utilisant le concept d’échantillonnage par Assurance de la Qualité du Lot (LQAS) à deux étapes de la conception, nous avons mené une enquête transversale nationale dans 156 établissements de santé choisis aléatoirement dans 10 Etats. Dans chacun de ces établissements, nous avons obtenu des informations sur une gamme d'accès, d'intrants, de processus et d'indicateurs de performance au cours d'entretiens et d'observations structurés.
Résultats
La qualité des soins était faible avec tous les Etats n'atteignant pas l'objectif de 80% pour 14 sur 19 indicateurs. Par exemple, seuls 12% des établissements ont été classés comme acceptables pour leur utilisation adéquate par la population pour les consultations des enfants malades, 16% pour le personnel, 3% pour la disponibilité de fournitures de lutte contre les infections et 0% pour la disponibilité de toutes les directives pour les soins de l'enfant. La performance des agents de santé a été classée comme acceptable dans seulement 6% des cas liés aux évaluations des enfants malades, 38% des cas liés à un traitement médical pour le diagnostic posé et 33% des cas liés à des conseils aux patients sur la façon d'administrer les médicaments prescrits. La meilleure performance a été enregistrée pour la disponibilité de la formation et la supervision au sein du service pour 7 et 10 Etats, respectivement.
Conclusions
Malgré l'instabilité actuelle, le Ministère de la Santé a développé la capacité à utiliser la méthode LQAS pour mesurer la qualité des soins à l’échelle nationale et par Etat, ce qui soutiendra une répartition efficace et équitable des ressources. Dans l'ensemble, nos données ont révélé un besoin désespéré de l'amélioration de la qualité des soins dans tous les Etats.
Objetivos
Hemos adaptado un método rápido para la monitorización de la calidad de cuidados sanitarios a un estado frágil con dos objetivos: evaluar la entrega de servicios sanitarios infantiles en el Sur de Sudán en el momento de la independencia, y fortalecer la capacidad local de desempeñar evaluaciones regulares rápidas a los centros sanitarios.
Métodos
Utilizando un diseño de muestreo de aceptación de lotes (LQAS), hemos realizado un estudio croseccional a nivel nacional en 156 centros sanitarios de 10 estados seleccionados al azar. En cada una de estas instalaciones hemos obtenido información sobre un rango de indicadores de acceso, ingresos, procesos, y desempeño durante entrevistas estructuradas y observaciones.
Resultados
La calidad de los cuidados era mala y en ninguno de los estados se alcanzaba el objetivo del 80% en 14 de 19 indicadores. Por ejemplo, solo un 12% de las instalaciones estaban clasificadas como aceptables para un uso adecuado de la población en lo que respectaba a consultas de niños enfermos, 16% por personal, 3% por disponibilidad de insumos para el control de infecciones, y 0% por tener todas las guías para el cuidado y la atención infantil. El desempeño de los trabajadores sanitarios estaba catalogado como aceptable en solo un 6% de los casos relacionados con la evaluación de niños enfermos, 38% relacionados con el tratamiento médico para un diagnóstico específico, y 33% relacionado con el aconsejamiento del paciente acerca de la administración de la medicación prescrita. El mejor desempeño se registró para la disponibilidad de formación y supervisión dentro del servicio, en siete de los diez estados, respectivamente.
Conclusiones
A pesar de la inestabilidad existente, el Ministerio de Salud ha desarrollado la capacidad de utilizar LQAS para medir la calidad de los cuidados a nivel nacional y en cada estado, lo cual facilitará una distribución eficiente y equitativa de los recursos. En general, nuestros datos revelan una gran necesidad de mejora en la calidad de la atención en todos los estados.
Nodding syndrome (NS) is a devastating and enigmatic childhood epilepsy. NS is accompanied by multiple neurological impairments and neuroinflammation, and associated with the parasite Onchocerca ...volvulus (Ov) and other environmental factors. Moreover, NS seems to be an 'Autoimmune Epilepsy' since: 1. ~50% of NS patients have neurotoxic cross-reactive Ov/Leimodin-I autoimmune antibodies. 2. Our recently published findings: Most (~86%) of NS patients have glutamate-receptor AMPA-GluR3B peptide autoimmune antibodies that bind, induce Reactive Oxygen Species, and kill both neural cells and T cells. Furthermore, NS patient's IgG induce seizures, brain multiple damage alike occurring in brains of NS patients, and elevation of T cells and activated microglia and astrocytes, in brains of normal mice. Human Leukocyte antigen (HLA) class I and II molecules are critical for initiating effective beneficial immunity against foreign microorganisms and contributing to proper brain function, but also predispose to detrimental autoimmunity against self-peptides. We analyzed seven HLA loci, either by next-generation-sequencing or Sequence-Specific-Oligonucleotide-Probe, in 48 NS patients and 51 healthy controls from South Sudan. We discovered that NS associates significantly with both protective HLA haplotype: HLA-B*42:01, C*17:01, DRB1*03:02, DQB1*04:02 and DQA1*04:01, and susceptible motif: Ala24, Glu63 and Phe67, in the HLA-B peptide-binding groove. These amino acids create a hydrophobic and sterically closed peptide-binding HLA pocket, favoring proline residue. Our findings suggest that immunogenetic fingerprints in HLA peptide-binding grooves tentatively associate with protection or susceptibility to NS. Accordingly, different HLA molecules may explain why under similar environmental factors, only some children, within the same families, tribes and districts, develop NS, while others do not.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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