WHO South-East Asia Journal of Public Health
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   Table of Contents - Current issue
September 2020
Volume 9 | Issue 2
Page Nos. 93-146

Online since Tuesday, September 8, 2020

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Safeguarding essential health services during emergencies: lessons learnt from the COVID-19 pandemic p. 93
Poonam Khetrapal Singh, Manoj Jhalani
DOI:10.4103/2224-3151.293433  PMID:32978338
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Mitigating the impact of the COVID-19 pandemic on progress towards ending tuberculosis in the WHO South-East Asia Region p. 95
Vineet Bhatia, Partha Pratim Mandal, Srinath Satyanarayana, Tjandra Yoga Aditama, Mukta Sharma
DOI:10.4103/2224-3151.294300  PMID:32978339
Almost half of the deaths worldwide caused by tuberculosis in 2018 occurred in the World Health Organization (WHO) South-East Asia Region, home to around a quarter of the global population. Maintaining robust progress in this region is therefore essential if the global goal of ending the tuberculosis epidemic is to be realized. Substantial gains have been made in the region, but the threat to health worldwide posed by the coronavirus disease 2019 (COVID-19) pandemic includes not only the direct effects of the pandemic but also the potential eclipsing of the global tuberculosis emergency. The results of modelling studies present stark warnings of a reversal of years of progress and a significant resurgence in deaths from tuberculosis. The COVID-19 pandemic has had variable impacts in the WHO South-East Asia Region to date, but in the countries most affected there has been targeted diversion and repurposing of tuberculosis services, health-care workers and diagnostic equipment. The combined effects of COVID-19, containment measures and fragmentation of tuberculosis services have resulted in delays in diagnosis or non-diagnosis and disruption in treatment resulting in increased morbidity, mortality, transmission and drug resistance. Countries of the region have made attempts to ensure continuity of services and civil society and nongovernmental organizations have instituted a range of innovative mechanisms to support national programmes. However, a comprehensive approach – including scaling up successful initiatives, empowering community leadership, harnessing digital tools, and implementing easily accessible cash transfers and nutrition support – will be critical to success. As COVID-19 recedes, countries will need “catch-up plans” to deploy supplementary measures to address the increased tuberculosis burden. Urgent, targeted and agile responses have the potential to mitigate and reverse the impact of the COVID-19 pandemic on tuberculosis in South-East Asia.
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Protecting sex workers in Thailand during the COVID-19 pandemic: opportunities to build back better p. 100
Surang Janyam, Dusita Phuengsamran, Jamrong Pangnongyang, Wutikan Saripra, Ladda Jitwattanapataya, Chalidaporn Songsamphan, Patchara Benjarattanaporn, Deyer Gopinath
DOI:10.4103/2224-3151.294301  PMID:32978340
The Government of Thailand was prompt to launch social and economic measures to mitigate the effects on the general population following lockdown measures to counter coronavirus disease 2019 (COVID-19). However, sex workers were one of the vulnerable groups who were unable to access state support. A rapid survey of sex workers in Thailand showed that almost all had become unemployed and lost their income as a consequence of the lockdown, restrictions on international flights into the country and the closure of entertainment venues. Most were unable to cover the costs of food and shelter for themselves and their dependents. COVID-19 had also disrupted testing and treatment for sexually transmitted infections and HIV services for sex workers. As in other countries, community-based organizations were essential to providing an immediate, short-term COVID-19 response for sex workers. Also as in other countries, the pandemic has demonstrated that many people’s health and well-being depends on very fragile foundations. This presents a clear opportunity to build back better by committing to a longer-term vision for the overall societal inclusion of sex workers. Thailand should advocate for decriminalization of sex work and ensure sex workers are entitled to equal labour rights and inclusion in the government social protection programme. Progress in innovative government initiatives aimed at ending HIV stigma and discrimination show how structural change can come about through harnessing community-based organizations. In turn, HIV services for sex workers need to expand and incorporate targeted interventions to reduce sex workers’ occupational susceptibility to COVID-19.
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Community action for people with HIV and sex workers during the COVID-19 pandemic in India p. 104
Sushena Reza-Paul, Lisa Lazarus, Partha Haldar, Manisha Reza Paul, Bhagya Lakshmi, Manjula Ramaiah, Akram Pasha, Syed Hafeez Ur Rahman, KT Venukumar, MS Venugopa, Bharat Bhushan Rewari, Robert Lorway
DOI:10.4103/2224-3151.294302  PMID:32978341
Sex workers have been one of the marginalized groups that have been particularly affected by India’s stringent lockdown in response to the coronavirus disease 2019 (COVID-19) pandemic. The sudden loss of livelihood and lack of access to health care and social protection intensified the vulnerabilities of sex workers, especially those living with HIV. In response, Ashodaya Samithi, an organization of more than 6000 sex workers, launched an innovative programme of assistance in four districts in Karnataka. Since access to antiretroviral therapy (ART) was immediately disrupted, Ashodaya adapted its HIV outreach programme to form an alternative, community-led system of distributing ART at discreet, private sites. WhatsApp messaging was used to distribute information on accessing government social benefits made available in response to the COVID-19 pandemic. Other assistance included advisory messages posted in WhatsApp groups to raise awareness, dispel myths and mitigate violence, and regular, discreet phone check-ins to follow up on the well-being of members. The lessons learnt from these activities represent an important opportunity to consider more sustainable approaches to the health of marginalized populations that can enable community organizations to be better prepared to respond to other public health crises as they emerge.
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Migration health research and policy in south and south-east Asia: mapping the gaps and advancing a collaborative agenda p. 107
Anuj Kapilashrami, Kolitha Wickramage, Nima Asgari-Jirhandeh, Anns Issac, Anjali Borharde, Ganesh Gurung, Jeevan R Sharma
DOI:10.4103/2224-3151.294303  PMID:32978342
Migrant health has been the subject of various international agreements in recent years. In parallel, there has been a growth in academic research in this area. However, this increase in focus at international level has not necessarily strengthened the capacity to drive evidence-informed national policy and action in many low- and middle-income countries. The Migration Health South Asia (MiHSA) network aims to challenge some of the barriers to progress in the region. Examples include the bias towards institutions in high-income countries for research funding and agenda-setting and the overall lack of policy-focused research in the region. MiHSA will engage researchers, funders and policy-makers in collectively identifying the most pressing, yet feasible, research questions that could help strengthen migrant and refugee health relevant to the region’s national contexts. In addition, policies and provisions for different migrant populations in the region will be reviewed from the health and rights perspectives, to identify opportunities to strategically align research agendas with the questions being asked by policy-makers. The convergence of migration policy with other areas such as health and labour at global level has created a growing imperative for policy-makers in the region to engage in cross-sector dialogue to align priorities and coordinate responses. Such responses must go beyond narrow public health interventions and embrace rights-based approaches to address the complex patterns of migration in the region, as well as migrants’ precarity, vulnerabilities and agency.
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Evaluation of the Indonesian Early Warning Alert and Response System (EWARS) in West Papua, Indonesia p. 111
Mersi K Manurung, Sarce EN Reo, Jerico F Pardosi, David J Muscatello
DOI:10.4103/2224-3151.294304  PMID:32978343
Background: The Early Warning and Response System (EWARS) is Indonesia’s national syndromic and early warning surveillance system for the rapid detection of infectious diseases and outbreaks. We evaluated EWARS in the remote West Papua province of Indonesia. Methods: Structured telephone interviews were conducted with 11 key informants from West Papuan health services. EWARS data were analysed for usefulness of reporting. Results: Most respondents reported that EWARS is important and useful in improving early detection of outbreaks. The system has led to increased disease control coordination among health jurisdictional levels in the province. However, respondents noted that the limited number of districts involved in the system affected representativeness, and some stated that only about 30–35% of districts in each regency were involved and trained in EWARS reporting, partly owing to lack of a mobile telephone network. Barriers to complete reporting and response to alerts included limited human and funding resources for surveillance, lack of epidemiological training, and technical limitations imposed by limited internet and mobile communication infrastructure in this remote region. Conclusion: Great progress has been made in integrating West Papua into a nationally consistent disease and outbreak detection system. Strategies for addressing barriers resulting from remoteness, constrained human, funding and laboratory resources, lack of training, and limited internet and communications infrastructure are needed if EWARS in West Papua is to advance.
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Knowledge, attitudes and preparedness to respond to COVID-19 among the border population of northern Thailand in the early period of the pandemic: a cross-sectional study p. 118
Peeradone Srichan, Tawatchai Apidechkul, Ratipark Tamornpark, Fartima Yeemard, Siriyaporn Khunthason, Siwarak Kitchanapaiboon, Pilasinee Wongnuch, Asamaphon Wongphaet, Panupong Upala
DOI:10.4103/2224-3151.294305  PMID:32978344
Background: Chiang Rai province in northern Thailand is a site of many people travelling among nearby countries and areas, including Yunnan province, China. In February 2020, there was concern about the population’s vulnerability to coronavirus disease 2019 (COVID-19). Methods: A cross-sectional study was conducted in 15 villages less than 10 km from a border. A questionnaire was developed and tested for reliability and validity; 48 questions covered participant characteristics, plus knowledge about, attitudes to and preparedness for COVID-19. Chi-squared tests were used to detect any significant association between variables. Unadjusted and adjusted odds ratios with 95% confidence intervals (CIs) were calculated to assess the possible association of various factors with participants’ level of reported knowledge, attitudes and preparedness. Results: A total of 520 participants were recruited of whom 320 (61.5%) were women. The age range was 18–90 years; the average age was 45.2 years. Variables with an association with good to moderate preparedness for COVID-19 prevention and control that remained after adjustment were: women were better prepared than men (adjusted odds ratio (ORadj) = 2.52; 95% CI = 1.36–4.68); those aged 18–30 years (ORadj = 4.26; 95% CI = 1.18–15.30), 31–45 years (ORadj = 4.60; 95% CI = 1.59–13.32) or 46–60 years (ORadj = 2.69; 95% CI = 1.16–6.26) were better prepared than those aged 60–90 years; and, compared with those with no formal education, those educated to primary school level (ORadj = 2.43; 95% CI = 1.09–5.43) or to university level (ORadj = 3.18; 95% CI = 1.06–9.51) were better prepared. Conclusion: Effective communication of essential, accurate and up-to-date information regarding COVID-19 prevention and control is essential in this population – especially for men, older age groups and those lacking formal education.
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Impact of COVID-19 on the global supply chain of antiretroviral drugs: a rapid survey of Indian manufacturers p. 126
Bharat Bhushan Rewari, Nabeel Mangadan-Konath, Mukta Sharma
DOI:10.4103/2224-3151.294306  PMID:32978345
Most people living with HIV in low- and middle-income countries are treated with generic antiretroviral (ARV) drugs produced by manufacturers in India – the “pharmacy of the developing world”. India’s nationwide lockdown in March 2020 in response to the coronavirus disease 2019 (COVID-19) pandemic therefore prompted concerns about disruption to this essential supply. A preliminary assessment of ARV drug manufacturers in India in March 2020 indicated a range of concerns. This prompted a rapid questionnaire-based survey in May 2020 of eight manufacturers that account for most of India’s ARV drug exports. The greatest challenges reported were in international shipping, including delays, increased lead times and rising costs. Contrary to expectations, lack of access to the active pharmaceutical ingredients (APIs) required for ARV drug manufacture was not a major hindrance, as manufacturers reported that their reliance on China for API supplies had reduced in recent years. However, their reliance on overseas markets for the raw materials required for local API synthesis was a major challenge. The findings from this survey have implications for addressing some of the immediate and medium-term concerns about the production and supply of generic ARV drugs. Long-term orders to support multi-month dispensing and buffer stocks need to be in place, together with computerized inventory management systems with real-time information from the lowest-level dispensation unit. Manufacturers and industry associations should have regular, formal interaction with the key ministries of the Government of India regarding these issues. Measures to improve the resilience of the generic ARV drug supply system are essential to minimize ongoing supply shocks resulting from the COVID-19 pandemic and to prepare for future emergencies.
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Assessing the COVID-19 diagnostic laboratory capacity in Indonesia in the early phase of the pandemic p. 134
Harimat Hendarwan, Syachroni Syachroni, Ni Ketut Aryastami, Amir Su'udi, Made Dewi Susilawati, Mieska Despitasari, Ully Adhie Mulyani, Mimi Sumiarsih, Nelly Puspandari, Agnes Rengga Indrati, Dewi Amila Solikha, Dyah Armi Riana, Indira Rezky Wahyuni
DOI:10.4103/2224-3151.294307  PMID:32978346
The coronavirus disease 2019 (COVID-19) pandemic has put a great burden on countries as a result of the demand for laboratory diagnostic testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This paper reports our experiences in rapidly assessing Indonesia’s COVID-19 laboratory testing capacity in the early phase of the pandemic response. Through a questionnaire-based survey carried out between 23 March and 2 April, we estimated the daily tests that could be done by the 44 facilities, excluding the national referral laboratory, first assigned to be COVID-19 diagnostic laboratories. The capacity constraints were lack of reagents and equipment, and limited human resources; because of these constraints, most of the laboratories were not yet operational. A major hindrance was reliance on imported supplies and the associated procurement time. Expanding real-time polymerase chain reaction testing capacity, through increased numbers of laboratories and optimization of existing facilities, was clearly the main priority. We also assessed the potential yield from using rapid molecular testing machines in the country’s referral hospitals. Even assuming this potential could be tapped, several provinces would still be poorly served by diagnostic services in the event of a surge in cases. Since this rapid assessment, the number of designated COVID-19 laboratories has increased and, by 1 July 2020, was 163. On 29 July 2020, for the first time, the number of specimens examined in a day reached more than 30 000, achieving the WHO testing capacity target of 1 in 1000 inhabitants per week.
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Monitoring COVID-19 where capacity for testing is limited: use of a three-step analysis based on test positivity ratio p. 141
Sirenda Vong, Manish Kakkar
DOI:10.4103/2224-3151.294308  PMID:32978347
In an effort to monitor coronavirus disease 2019 (COVID-19), many countries have been calculating the ratio of cases confirmed to tests performed (test positivity ratio – TPR). While inferior to sentinel surveillance, TPR has the benefit of being easily calculated using readily available data; however, interpreting TPR and its trends can be complex because both the numerator and the denominator are constantly changing. We describe a three-step process where the ratio of relative increase in cases to relative increase in tests is accounted for in an adjusted TPR. This adjusted value more appropriately reflects the case number and factors out the effect of changes in the number of tests done. Unadjusted and adjusted TPRs are then assessed step-wise with reference to the epidemic curve and the cumulative numbers of cases and tests. Use of this three-step analysis and its potential use in guiding public health interventions are demonstrated for selected countries and subnational areas of the World Health Organization South-East Asia Region, together with the Republic of Korea as a reference. To date, application of the three-step analysis to data from countries of the region has signalled potential inadequacies of testing strategies. Further work is needed on approaches to support countries where testing capacity is likely to remain constrained. One example would be enumeration of the average number of tests needed to detect one COVID-19 case, which could be stratified by factors such as location and population. Such data would allow evidence-informed strategies that best balance the highest detection rate with the prevailing testing capacity.
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