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Background This cohort study assessed seroprevalence trends of SARS-CoV-2 antibodies in the general Belgian population between March 2021 and April 2022, and explored factors associated with seropositivity among the vaccinated and unvaccinated population. Seroreversion and its potential determinants were also examined. Methods A random sample of the adult population in Belgium was invited to provide a saliva sample and to complete a survey questionnaire. Participants were followed up twice for a new saliva sample and updated information. Antibodies were assessed with a semi-quantitative measure of anti-RBD (Receptor Binding Domain) IgG ELISA. Seven time periods were defined for estimating SARS-CoV-2 antibody prevalence using post stratification weights to match the population distribution. Seroreversion was defined as passing from a positive to a negative antibody test from one data collection point to the next. Potential determinants of seropositivity were assessed through hierarchical multiple logistic regressions. Results In total 6,178 valid observations were obtained from 2,768 individuals. SARS-CoV-2 antibody prevalence increased from 25.1% in the beginning of the study period to 92.3% in the end. Among the vaccinated population, factors significantly associated with a higher seropositivity were being younger, having a bachelor diploma, living with others, having had a vaccine in the last 3 months and having received a nucleic-acid vaccine or a combination. Lower seropositivity rates were observed among vaccinated people with a neurological disease and transplant patients. Factors significantly associated with a higher seropositivity rate among the unvaccinated population were having non-O blood type and being non-smoker. Among fully vaccinated people the seroreversion rate was much lower (0.3%) among those who had received their latest vaccine in the last 3 months compared to those who had received their latest vaccine more than 3 months ago (2.7%). Conclusions The rapid increase in antibody seropositivity in the general adult population in Belgium during the study period was driven by the vaccination campaign which ran at full speed during this period. Factors associated with higher and lower seropositivity were identified among the vaccinated and unvaccinated people.

ObjectivesTo estimate the prevalence, incidence and longevity of antibodies against SARS-CoV-2 among primary healthcare providers (PHCPs).DesignProspective cohort study with 12 months of follow-up.SettingPrimary care in Belgium.ParticipantsAny general practitioner (GP) working in primary care in Belgium and any other PHCP from the same GP practice who physically manages (examines, tests, treats) patients were eligible. A convenience sample of 3648 eligible PHCPs from 2001 GP practices registered for this study (3044 and 604 to start in December 2020 and January 2021, respectively). 3390 PHCPs (92,9%) participated in their first testing time point (2820 and 565, respectively) and 2557 PHCPs (70,1%) in the last testing time point (December 2021).InterventionsParticipants were asked to perform a rapid serological test targeting IgM and IgG against the receptor binding domain of SARS-CoV-2 and to complete an online questionnaire at each of maximum eight testing time points.Primary and secondary outcome measuresThe prevalence, incidence and longevity of antibodies against SARS-CoV-2 both after natural infection and after vaccination.ResultsAmong all participants, 67% were women and 77% GPs. Median age was 43 years. The seroprevalence in December 2020 (before vaccination availability) was 15.1% (95% CI 13.5% to 16.6%), increased to 84.2% (95% CI 82.9% to 85.5%) in March 2021 (after vaccination availability) and reached 93.9% (95% CI 92.9% to 94.9%) in December 2021 (during booster vaccination availability and fourth (delta variant dominant) COVID-19 wave). Among not (yet) vaccinated participants the first monthly incidence of antibodies against SARS-CoV-2 was estimated to be 2.91% (95% CI 1.80% to 4.01%). The longevity of antibodies is higher in PHCPs with self-reported COVID-19 infection.ConclusionsThis study confirms that occupational health measures provided sufficient protection when managing patients. High uptake of vaccination resulted in high seroprevalence of SARS-CoV-2 antibodies in PHCPs in Belgium. Longevity of antibodies was supported by booster vaccination and virus circulation.Trial registration numberNCT04779424.

Representative school data on SARS-CoV-2 past-infection are scarce, and differences between pupils and staff remain ambiguous. We performed a nation-wide prospective seroprevalence study among pupils and staff over time and in relation to determinants of infection using Poisson regression and generalised estimating equations. A cluster random sample was selected with allocation by region and sociodemographic (SES) background. Surveys and saliva samples were collected in December 2020, March, and June 2021, and also in October and December 2021 for primary pupils. We recruited 885 primary and 569 secondary pupils and 799 staff in 84 schools. Cumulative seroprevalence (95% CI) among primary pupils increased from 11.0% (7.6; 15.9) at baseline to 60.4% (53.4; 68.3) in December 2021. Group estimates were similar at baseline; however, in June they were significantly higher among primary staff (38.9% (32.5; 46.4)) compared to pupils and secondary staff (24.2% (20.3; 28.8)). Infections were asymptomatic in 48–56% of pupils and 28% of staff. Seropositivity was associated with individual SES in pupils, and with school level, school SES and language network in staff in June. Associations with behavioural characteristics were inconsistent. Seroconversion rates increased two- to four-fold after self-reported high-risk contacts, especially with adults. Seroprevalence studies using non-invasive sampling can inform public health management.

ObjectivesTo validate a rapid serological test (RST) for SARS-CoV-2 antibodies used in seroprevalence studies in healthcare providers, including primary healthcare providers (PHCPs) in Belgium.DesignA phase III validation study of the RST (OrientGene) within a prospective cohort study.SettingPrimary care in Belgium.ParticipantsAny general practitioner (GP) working in primary care in Belgium and any other PHCP from the same GP practice who physically manages patients were eligible in the seroprevalence study. For the validation study, all participants who tested positive (376) on the RST at the first testing timepoint (T1) and a random sample of those who tested negative (790) and unclear (24) were included.InterventionAt T2, 4 weeks later, PHCPs performed the RST with fingerprick blood (index test) immediately after providing a serum sample to be analysed for the presence of SARS-CoV-2 immunoglobulin G antibodies using a two-out-of-three assay (reference test).Primary and secondary outcome measuresThe RST accuracy was estimated using inverse probability weighting to correct for missing reference test data, and considering unclear RST results as negative for the sensitivity and positive for the specificity. Using these conservative estimates, the true seroprevalence was estimated both for T2 and RST-based prevalence values found in a cohort study with PHCPs in Belgium.Results1073 paired tests (403 positive on the reference test) were included. A sensitivity of 73% (a specificity of 92%) was found considering unclear RST results as negative (positive). For an RST-based prevalence at T1 (13.9), T2 (24.9) and T7 (70.21), the true prevalence was estimated to be 9.1%, 25.9% and 95.7%, respectively.ConclusionThe RST sensitivity (73%) and specificity (92%) make an RST-based seroprevalence below (above) 23% overestimate (underestimate) the true seroprevalence.Trial registration numberNCT04779424.

ObjectivesTo estimate the prevalence, incidence, and longevity of antibodies against SARS-CoV-2 among primary healthcare providers (PHCPs).DesignProspective cohort study with 12 months of follow-up.SettingPrimary care in BelgiumParticipantsAny general practitioner (GP) working in primary care in Belgium and any other PHCP from the same GP practice who physically manages (examines, tests, treats) patients were eligible. A convenience sample of 3,648 eligible PHCPs from 2,001 GP practices registered for this study (3,044 and 604 to start in December 2020 and January 2021, respectively). 3,390 PHCPs (92,9%) participated in their first testing timepoint (2,820 and 565, respectively) and 2,557 PHCPs (70,1%) in the last testing timepoint (December 2021).InterventionsParticipants were asked to perform a rapid serological test (RST) targeting IgM and IgG against the receptor binding domain (RBD) of SARS-CoV-2 and to complete an online questionnaire at each of maximum 8 testing timepoints.Primary and secondary outcome measuresThe prevalence, incidence, and longevity of antibodies against SARS-CoV-2 both after natural infection and after vaccination.ResultsAmong all participants, 67% were women and 77% GPs. Median age was 43 years. The seroprevalence in December 2020 (before vaccination availability) was 15.1% (95% CI: 13.5% to 16.6%), increased to 84.2% (95% CI: 82.9% to 85.5%) in March 2021 (after vaccination availability) and reached 93.9% (95% CI: 92.9% to 94.9%) in December 2021 (during booster vaccination availability and fourth (delta variant dominant) covid wave). Among not (yet) vaccinated participants the first monthly incidence of antibodies against SARS-CoV-2 was estimated to be 2.91% (95% CI: 1.80% to 4.01%). The longevity of antibodies is higher in PHCPs with self-reported COVID-19 infection.ConclusionsThis study confirms that occupational health measures provided sufficient protection when managing patients. High uptake of vaccination resulted in high seroprevalence of SARS-CoV-2 antibodies in PHCPs in Belgium. Longevity of antibodies was supported by booster vaccination and virus circulation.RegistrationTrial registration number: NCT04779424Strengths and limitations of this studyThis large cohort study with 12 months follow-up could provide precise estimates of the prevalence and incidence of antibodies against SARS-CoV-2 among primary health care providers (PHCPs) at national and regional level in Belgium.The rapid serological test (RST) used targets IgM and IgG against the receptor binding domain of SARS-CoV-2 and could therefore also assess the antibody response after vaccination, and longevity of antibodies against SARS-CoV-2 both after natural infection and after vaccination, but cannot distinguish between both.The results in PHCPs could be compared to that of the general population and other population groups, e.g. health care workers in hospitals and nursing homes.The use of a convenience sample, missing data points and reduced RST accuracy when performed and interpreted by many different participants could limit the validity of the study results.

IntroductionAs the role of school-aged children was unclear at the onset of the COVID-19 pandemic, public health authorities recommended to implement infection prevention and control (IPC) measures in school settings. Few studies evaluated the implementation of these measures and their effect on SARS-CoV-2 infection rates among pupils and staff.AimTo describe the implementation of IPC measures in Belgian primary and secondary schools and assess its relation to the prevalence of anti-SARS-CoV-2 antibodies among pupils and staff.MethodsWe conducted a prospective cohort study in a representative sample of primary and secondary schools in Belgium. Implementation of IPC measures in schools was assessed using an online questionnaire. Saliva samples were collected from pupils and staff to determine the SARS-CoV-2 seroprevalence.ResultsA variety of IPC measures (ventilation, hygiene and physical distancing) was implemented by more than 60% of primary and secondary schools with most attention for hygiene measures. Almost no differences in implementation coverage were observed between primary and secondary schools or the Dutch and French language network. Poor implementation of IPC measures was associated with an increased anti-SARS-CoV-2 antibody prevalence among pupils from 8.6% (95% CI: 4.5 - 16.6) to 16.7% (95% CI: 10.2 - 27.4) and staff from 11.5% (95% CI: 8.1 - 16.4) to 17.6% (95% CI: 11.5 - 27.0). This association was statistically significant for all IPC measures and pupils and staff combined.ConclusionBelgian schools were relatively compliant with recommended IPC measures at the school level. Poor implementation of IPC measures was associated with higher SARS-CoV-2 seroprevalence among pupils and staff.Trial registration numberTrial registration number: NCT04613817

IntroductionNational severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seroprevalence data provides essential information about population exposure to the virus and helps predict the future course of the epidemic. Early cohort studies have suggested declines in levels of antibodies in individuals, associated with, for example, illness severity, age and co-morbidities. This protocol focuses on the seroprevalence among primary health care providers (PHCPs) in Belgium. They manage the vast majority of COVID-19 patients in addition to other patients and therefore play an essential role in the efficient organisation of health care. Currently, evidence is lacking on 1. how many PHCPs get infected with SARS-CoV-2 in Belgium, 2. the rate at which this happens, 3. their clinical spectrum, 4. their risk factors, 5. the effectiveness of the measures to prevent infection and 6. the accuracy of the serology-based point-of-care test in a primary care setting.Methods and analysisThis study will be set up as a prospective cohort study. General practitioners (GPs) and other PHCPs (working in a GP practice) will be recruited via professional networks and professional media outlets to register online to participate. Registered GPs and other PHCPs will be asked at each testing point (n=9) to perform a capillary blood sample antibody point-of-care test (OrientGene®) and complete an online questionnaire. The primary outcomes are the prevalence and incidence of antibodies against SARS-CoV-2 in PHCPs during a 12-month follow-up period. Secondary outcomes include the longevity of antibodies against SARS-CoV-2.Ethics and disseminationEthical approval has been granted by the Ethics Committee of the University Hospital Antwerp/University of Antwerp (Belgian registration number: 3002020000237). Alongside journal publications, dissemination activities include the publication of monthly reports to be shared with the participants and the general population through the publicly available website of the Belgian health authorities (Sciensano).RegistrationTrial registration number:NCT04779424Article summaryStrengths and limitations of this studyThis large cohort study will provide regular, timely and precise data at national level on prevalence and incidence of antibodies against SARS-CoV-2 among primary health care providers (PHCPs) managing the vast majority of COVID-19 and other patients and therefore essential to organise health care efficiently.This study will familiarise PHCPs with the use of serology-based point-of-care tests (POCTs) and validate the POCT in a primary care setting.Missing data points and the use of a convenience sample could limit the validity of the study results.

It is not yet clear to what extent SARS-CoV-2 infection rates in children reflect community transmission, nor whether infection rates differ between primary schoolchildren and young teenagers. A cross-sectional serosurvey compared the SARS-CoV2 attack-rate in a sample of 362 children recruited from September 21 to October 6, 2020, in primary (ages 6-12) or lower secondary school (ages 12-15) in a municipality with low community transmission (Pelt) to a municipality with high community transmission (Alken) in Belgium. Children were equally distributed over grades and regions. Blood samples were tested for the presence of antibodies to SARS-CoV-2 with an enzyme-linked immunosorbent assay. We found anti-SARS-CoV-2 antibodies in 4.4% of children in the low transmission region and in 14.4% of children in the high transmission region. None of the primary schoolchildren were seropositive in the low transmission region, whereas the seroprevalence among primary and secondary schoolchildren did not differ significantly in the high transmission region. None of the seropositive children suffered from severe disease. Children who were in contact with a confirmed case (RR 2.9; 95%CI 1.6-4.5), who participated in extracurricular activities (RR 5.6; 95%CI 1.2-25.3), or whose caregiver is a healthcare worker who had contact with COVID-19 patients (RR 2.2; 95%CI 1.0-4.6) were at higher risk of seropositivity. If SARS-CoV2 circulation in the community is high, this will be reflected in the pediatric population with similar infection rates in children aged 6-12 years and 12-15 years. What is Known: Children are generally less affected by COVID-19 than adults but SARS-CoV2 infection rates among children are not well known. There were large regional differences in infection rates during the first wave of the SARS-CoV2 pandemic. What is New: None of the primary schoolchildren (6-12 years) were seropositive for SARS-CoV2 in an area with a low community transmission, but infection rates were higher in adolescents (12-15 years). In an area with high community transmission, seroprevalence rates in younger children were more comparable to those in adolescents. Sciensano

Introduction The number of patients and clinical conditions treated in home healthcare (HHC) is increasing. Care in home settings presents many challenges, including healthcare-associated infections (HAI). Currently, in Belgium, data and guidelines on the topic are lacking. Aim To develop a definition of HAI in HHC and investigate associated risk factors and recommendations for infection prevention and control (IPC). Methods The study included three components: a scoping literature review, in-depth interviews with individuals involved in HHC and a two-round Delphi survey to reach consensus among key informants on the previous steps’ results. Results The literature review included 47 publications. We conducted 21 in-depth interviews. The Delphi survey’s two rounds had 21 and 23 participants, respectively. No standard definition was broadly accepted or known. Evidence on associated risk factors was impacted by methodological limitations and recommendations were inconsistent. Agreement was reached on defining HAI in HHC as any infection specifically linked with providing care that develops in a patient receiving HHC from a professional healthcare worker and occurs ≥ 48 hours after starting HHC. Risk factors were hand hygiene, untrained patients and caregivers, patients’ hygiene and presence and management of invasive devices. Agreed recommendations were to adapt and standardise existing IPC guidelines to HHC and to perform a national point prevalence study to measure the burden of HAI in HHC. Conclusions This study offers an overview of available evidence and field knowledge of HAI in HHC. It provides a framework for a prevalence study, future monitoring policies and guidelines on IPC in Belgium.

Highlights • We evaluated a bead-based Luminex assay for the detection of SARS-CoV-2 antibodies. • A combination of the nucleocapsid protein and the receptor-binding domain results in a highly sensitive (96 %) and specific (99 %) assay that can detect positive cases at least five months after infection. • Because we find that IgG and neutralizing antibody levels can differ significantly between severe/mild and recent/old cases, we argue that serological tests should be validated on samples from all groups before use in serosurveillance studies., Large-scale serosurveillance of severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) will only be possible if serological tests are sufficiently reliable, rapid and affordable. Many assays are either labour-intensive and require specialised facilities (e.g. virus neutralization assays), or are expensive with suboptimal specificity (e.g. commercial ELISAs and RDTs). Bead-based assays offer a cost-effective alternative and allow for multiplexing to test for antibodies against multiple antigens and against other pathogens. Here, we compare the performance of spike (S) and nucleocapsid (NP) antigens for the detection of SARS-CoV-2 specific IgG, IgM and IgA antibodies in a panel of sera that includes recent (up to six weeks after symptom onset, severe n = 44; and mild cases n = 52) and old infections (five months after symptom onset, mild n = 104), using a Luminex-bead based assay and comparison to a virus neutralization test. While we show that neutralizing antibody levels are significantly lower in mild than in severe cases, we demonstrate that a combination of the recombinant nucleocapsid protein (NP) and receptor-binding domain (RBD) results in highly specific (99 %) IgG antibody detection five months after infection in 96 % of cases. Although most severe Covid-19 cases developed a clear IgM and IgA response, titers fell below the detection threshold in more than 20 % of mild cases in our bead-based assay. In conclusion, our data supports the use of RBD and NP for the development of SARS-CoV-2 serological IgG bead-based assays.

BackgroundGiven the current SARS-CoV-2 pandemic and the occurrence of a second wave, assessing the burden of disease among health care workers (HCWs) is crucial. We aim to document the prevalence of SARS-CoV-2 and the seroprevalence of anti-SARS-CoV-2 IgG among HCWs in Belgian hospitals, and to study potential risk factors for the infection in order to guide infection prevention and control (IPC) measures in healthcare institutions.MethodsWe performed a cross-sectional analysis of the baseline results (April 22 - April 26) of an ongoing cohort study. All staff who were present in the hospital during the sampling period and whose profession involved contact with patients were eligible. Fourteen hospitals across Belgium and 50 HCW per hospital were randomly selected. RT-qPCR was performed to detect SARS-CoV-2 RNA on nasopharyngeal swabs, and a semi-quantitative IgG ELISA was used to detect anti-SARS-CoV-2 antibodies in sera. Individual characteristics likely to be associated with seropositivity were collected using an online questionnaire.Findings698 participants completed the questionnaire; 80.8% were women, median age was 39.5, and 58.5% were nurses. Samples were collected on all 699 participants. The weighted anti-SARS-CoV-2 IgG seroprevalence was 7.7% (95%CI, 4.7%-12.2%), while 1.1% (95%CI, 0.4%-3.0%) of PCR results were positive. Unprotected contact with a confirmed case was the only factor associated with seropositivity (PR 2.16, 95% CI, 1.4-3.2).InterpretationMost Belgian HCW did not show evidence of SARS-CoV-2 infection by late April 2020, and unprotected contact was the most important risk factor. This confirms the importance of widespread availability of protective equipment and use of adequate IPC measures in hospital settings.

IntroductionNational SARS-CoV-2 seroprevalence data provide essential information about population exposure to the virus and help predict the future course of the epidemic. Early cohort studies have suggested declines in levels of antibodies in individuals associated with, for example, illness severity, age and comorbidities. This protocol focuses on the seroprevalence among primary healthcare providers (PHCPs) in Belgium. PHCPs manage the vast majority of (COVID-19) patients and therefore play an essential role in the efficient organisation of healthcare. Currently, evidence is lacking on (1) how many PHCPs get infected with SARS-CoV-2 in Belgium, (2) the rate at which this happens, (3) their clinical spectrum, (4) their risk factors, (5) the effectiveness of the measures to prevent infection and (6) the accuracy of the serology-based point-of-care test (POCT) in a primary care setting.Methods and analysisThis study will be set up as a prospective cohort study. General practitioners (GPs) and other PHCPs (working in a GP practice) will be recruited via professional networks and professional media outlets to register online to participate. Registered GPs and other PHCPs will be asked at each testing point (n=9) to perform a capillary blood sample antibody POCT targeting IgM and IgG against the receptor-binding domain of SARS-CoV-2 and complete an online questionnaire. The primary outcomes are the prevalence and incidence of antibodies against SARS-CoV-2 in PHCPs during a 12-month follow-up period. Secondary outcomes include the longevity of antibodies against SARS-CoV-2.Ethics and disseminationEthical approval has been granted by the ethics committee of the University Hospital of Antwerp/University of Antwerp (Belgian registration number: 3002020000237). Alongside journal publications, dissemination activities include the publication of monthly reports to be shared with the participants and the general population through the publicly available website of the Belgian health authorities (Sciensano).Trial registration numberNCT04779424.

Introduction In Africa, a majority of women bring their infant to health services for immunization, but few are checked in the postpartum (PP) period. The Missed opportunities for maternal and infant health (MOMI) EU-funded project has implemented a package of interventions at community and facility levels to uptake maternal and infant postpartum care (PPC). One of these interventions is the integration of maternal PPC in child clinics and infant immunization services, which proved to be successful for improving maternal and infant PPC. Aim Taking stock of the progress achieved in terms of PPC with the implementation of the interventions, this paper assesses the economic cost of maternal PPC services, for health services and households, before and after the project start in Kaya health district (Burkina Faso). Methods PPC costs to health services are estimated using secondary data on personnel and infrastructure and primary data on time allocation. Data from two household surveys collected before and after one year intervention among mothers within one year PP are used to estimate the household cost of maternal PPC visits. We also compare PPC costs for households and health services with or without integration. We focus on the costs of the PPC intervention at days 6–10 that was most successful. Results The average unit cost of health services for days 6–10 maternal PPC decreased from 4.6 USD before the intervention in 2013 (Jan-June) to 3.5 USD after the intervention implementation in 2014. Maternal PPC utilization increased with the implementation of the interventions but so did days 6–10 household mean costs. Similarly, the household costs increased with the integration of maternal PPC to BCG immunization. Conclusion In the context of growing reproductive health expenditures from many funding sources in Burkina Faso, the uptake of maternal PPC led to a cost reduction, as shown for days 6–10, at health services level. Further research should determine whether the increase in costs for households would be deterrent to the use of integrated maternal and infant PPC.

Introduction In 2007, a new federal legislation in Belgium prohibited non-biosafety level 3 laboratories to process culture tubes suspected of containing mycobacteria. Aim To present mycobacterial surveillance/diagnosis data from the Belgian National Reference Centre for mycobacteria (NRC) from 2007 to 2016. Methods This retrospective observational study investigated the numbers of analyses at the NRC and false positive cultures (interpreted as containing mycobacteria at referring clinical laboratories, but with no mycobacterial DNA detected by PCR in the NRC). We reviewed mycobacterial species identified and assessed trends over time of proportions of nontuberculous mycobacteria (NTM) vs Mycobacterium tuberculosis complex (MTBc), and false positive cultures vs NTM. Results From 2007 to 2016, analyses requests to the NRC doubled from 12.6 to 25.3 per 100,000 inhabitants. A small but significant increase occurred in NTM vs MTBc proportions, from 57.9% (587/1,014) to 60.3% (867/1,437) (p M. avium predominated (ca 20% of NTM cultures), but M. intracellulare culture numbers rose significantly, from 13.0% (74/587) of NTM cultures in 2007 to 21.0% (178/867) in 2016 (RR: 1.05; 95% CI: 1.03–1.07). The number of false positive cultures also increased, reaching 43.3% (1,097/2,534) of all samples in 2016. Conclusion We recommend inclusion of NTM in sentinel programmes. The large increase of false positive cultures is hypothesised to result from processing issues prior to arrival at the NRC, highlighting the importance of sample decontamination/transport and equipment calibration in peripheral laboratories.

Objective To propose a rationale to improve maternal postpartum care in reproductive, maternal, newborn, and child health (RMNCH) services. Methods We conducted a cross-sectional mixed study in the Kaya health district in Burkina Faso based on two data collection exercises conducted between December 2012 and May 2013. A household survey of 757 mothers in their first year after delivery was processed. It was complemented with a qualitative analysis using in-depth interviews with key informants, focus group discussions with mothers, and participant observation. Results Postpartum services showed serious weaknesses. Overall, 52% (n=384) of mothers did not receive any maternal postpartum care; however among them, 47% (n= 349) received infant postpartum care. Conclusion We suggest the integration of maternal postpartum care in RMNCH services as a key step to improving postpartum care. The intervention would require the overcoming of challenges related to the quality and cost of services, and to reaching the poor populations with low education and a high parity.

Highlights • Hydroxychloroquine (HCQ) 2400 mg over 5 days was used in Belgium for COVID-19. • Impact of HCQ on mortality among 8075 patients with COVID-19 was assessed. • Lower mortality in HCQ-treated patients as compared to supportive care. • Lower mortality was irrespective of symptom duration., Hydroxychloroquine (HCQ) has been largely used and investigated as therapy for COVID-19 across various settings at a total dose usually ranging from 2400 mg to 9600 mg. In Belgium, off-label use of low-dose HCQ (total 2400 mg over 5 days) was recommended for hospitalised patients with COVID-19. We conducted a retrospective analysis of in-hospital mortality in the Belgian national COVID-19 hospital surveillance data. Patients treated either with HCQ monotherapy and supportive care (HCQ group) were compared with patients treated with supportive care only (no-HCQ group) using a competing risks proportional hazards regression with discharge alive as competing risk, adjusted for demographic and clinical features with robust standard errors. Of 8075 patients with complete discharge data on 24 May 2020 and diagnosed before 1 May 2020, 4542 received HCQ in monotherapy and 3533 were in the no-HCQ group. Death was reported in 804/4542 (17.7%) and 957/3533 (27.1%), respectively. In the multivariable analysis, mortality was lower in the HCQ group compared with the no-HCQ group [adjusted hazard ratio (aHR) = 0.684, 95% confidence interval (CI) 0.617–0.758]. Compared with the no-HCQ group, mortality in the HCQ group was reduced both in patients diagnosed ≤5 days (n = 3975) and >5 days (n = 3487) after symptom onset [aHR = 0.701 (95% CI 0.617–0.796) and aHR = 0.647 (95% CI 0.525–0.797), respectively]. Compared with supportive care only, low-dose HCQ monotherapy was independently associated with lower mortality in hospitalised patients with COVID-19 diagnosed and treated early or later after symptom onset.

Background: The Missed Opportunities for Maternal and Infant Health (MOMI) project, which aimed at upgrading maternal and infant postpartum care (PPC), implemented a package of interventions including the integration of maternal PPC in infant immunization services in 12 health facilities in Kaya Health district in Burkina Faso from 2013 to 2015. This paper assesses the coverage and the quality of combined mother-infant PPC in reproductive, maternal, newborn and child health services (RMNCH). Methods: We conducted a mixed methods study with cross-sectional surveys before and after the intervention in the Kaya health and demographic surveillance system. On the quantitative side, two household surveys were performed in 2012 ( N = 757) and in 2014 ( N = 754) among mothers within one year postpartum. The analysis examines the result of the intervention by the date of delivery at three key time points in the PPC schedule: the first 48 h, days 6 - 10 and during weeks 6 - 8 and beyond. On the qualitative side, in depth interviews, focus group discussions and observations were conducted in four health facilities in 2012 and 2015. They involved mothers in the postpartum period, facility and community health workers, and other stakeholders. We performed a descriptive analysis and a two-sample test of proportions of the quantitative data. The qualitative data were recorded, transcribed and analysed along the themes relevant for the intervention. Results: The findings show that the WHO guidelines, in terms of content and improvement of maternal PPC, were followed for physical examinations and consultations. They also show a significant increase in the coverage of maternal PPC services from 50% (372/752) before the intervention to 81% (544/672) one year after the start of the intervention. However, more women were assessed at days 6 - 10 than at later visits. Integration of maternal PPC was low, with little improvements in history taking and physical examination of mothers in immunization services. While health workers are polyvalent, difficulties in restructuring and organizing services hindered the integration. Conclusion: Unless a comprehensive strategy of integration within RMNCH services is implemented to address the primary health care challenges within the health system, integration will not yield the desired results.

Objective To assess the impact of an intervention consisting of a computer-assisted clinical decision support system and performance-based incentives aiming at improving quality of antenatal and childbirth care. Methods Intervention study in rural primary healthcare (PHC) facilities in Burkina Faso Ghana and Tanzania. In each country six intervention and six non-intervention PHC facilities located in one intervention and one non-intervention rural districts were selected. Quality was assessed in each facility by health facility surveys direct observation of antenatal and childbirth care exit interviews and reviews of patient records and maternal and child health registers. Findings of pre- and post-intervention and of intervention and non-intervention health facility quality assessments were analyzed and assessed for significant (P < 0.05) quality of care differences. Results Post-intervention quality scores do not show a clear difference to pre-intervention scores and scores at non-intervention facilities. Only a few variables had a statistically significant better post-intervention quality score and when this is the case this is mostly observed in only one study-arm being pre-/post-intervention or intervention/non-intervention. Post-intervention care shows similar deficiencies in quality of antenatal and childbirth care and in detection prevention and management of obstetric complications as at baseline and non-intervention study facilities. Conclusion Our intervention study did not show a significant improvement in quality of care during the study period. However the use of new technology seems acceptable and feasible in rural PHC facilities in resource-constrained settings creating the opportunity to use this technology to improve quality of care.

Background The Missed Opportunities in Maternal and Infant Health (MOMI) project aimed at reducing maternal and newborn mortality and morbidity within the year after childbirth in four sub-Saharan African countries. MOMI interventions including the integration of maternal and infant services in the postpartum (PP) period at day 6–10, week 6–8, and month 9 were implemented from September 2013 to December 2015. We hereby assess the effect of integrating maternal postpartum care (PPC) in infant immunization services in Kaya health district in Burkina Faso. Methods We apply a longitudinal mixed method on monthly monitoring data collected from 12 months before the project start to the end. Outcome indicators were: attendance of PPC at day 6–10 and week 6–8, provision of PP family planning counselling, and management of PP morbidity in mother and infant. We tested the significance level of changes in the different indicators by performing an interrupted time series analysis with Newey–West standard errors and one lag. Additional data were extracted at the individual level which allowed to link infant immunization with maternal PPC from September 2013 to August 2014 in the health facilities’ (HF) PP and immunization registers. We also conducted a review of documents that allowed for a qualitative evaluation of the effects. Results Show an increasing trend of all monitored indicators during the interventions, particularly at day 6–10 when PPC increased from 61% in 2013 to 81% in 2015 and especially in rural areas (p

Background: QUALMAT project aimed at improving quality of maternal and newborn care in selected health care facilities in three African countries. An electronic clinical decision support system was implemented to support providers comply with established standards in antenatal and childbirth care. Given that health care resources are limited and interventions differ in their potential impact on health and costs (efficiency), this study aimed at assessing cost-effectiveness of the system in Tanzania.Methods: This was a quantitative pre- and post- intervention study involving 6 health centres in rural Tanzania. Cost information was collected from health provider's perspective. Outcome information was collected through observation of the process of maternal care. Incremental cost-effectiveness ratios for antenatal and childbirth care were calculated with testing of four models where the system was compared to the conventional paper-based approach to care. One-way sensitivity analysis was conducted to determine whether changes in process quality score and cost would impact on cost-effectiveness ratios.Results: Economic cost of implementation was 167,318 USD, equivalent to 27,886 USD per health center and 43 USD per contact. The system improved antenatal process quality by 4.5% and childbirth care process quality by 23.3% however these improvements were not statistically significant. Base-case incremental cost-effectiveness ratios of the system were 2469 USD and 338 USD per 1% change in process quality for antenatal and childbirth care respectively. Cost-effectiveness of the system was sensitive to assumptions made on costs and outcomes.Conclusions: Although the system managed to marginally improve individual process quality variables, it did not have significant improvement effect on the overall process quality of care in the short-term. A longer duration of usage of the electronic clinical decision support system and retention of staff are critical to the efficiency of the system and can reduce the invested resources. Realization of gains from the system requires effective implementation and an enabling healthcare system.Trial registration: Registered clinical trial at www.clinicaltrials.gov ( NCT01409824). Registered May 2009.

Objective The aims of this study were to (i) assess healthcare workers' counselling practices concerning danger signs during antenatal consultations in rural primary healthcare (PHC) facilities in Burkina Faso, Ghana and Tanzania; to (ii) assess pregnant women's awareness of these danger signs; and (iii) to identify factors affecting counselling practices and women's awareness. Methods Cross-sectional study in rural PHC facilities in Burkina Faso, Ghana and Tanzania. In each country, 12 facilities were randomly selected. WHO guidelines were used as standard for good counselling. We assessed providers' counselling practice on seven danger signs through direct observation study (35 observations/facility). Exit interviews (63 interviews/facility) were used to assess women's awareness of the same seven danger signs. We used negative binomial regression to assess associations with health services' and socio-demographic characteristics and to estimate per study site the average number of danger signs on which counselling was provided and the average number of danger signs mentioned by women. Results About one in three women was not informed of any danger sign. For most danger signs, fewer than half of the women were counselled. Vaginal bleeding and severe abdominal pain were the signs most counselled on (between 52% and 66%). At study facilities in Burkina Faso, 58% of the pregnant women were not able to mention a danger sign, in Ghana this was 22% and in Tanzania 30%. Fever, vaginal bleeding and severe abdominal pain were the danger signs most frequently mentioned. The type of health worker (depending on the training they received) was significantly associated with counselling practices. Depending on the study site, characteristics significantly associated with awareness of signs were women's age, gestational age, gravidity and educational level. Conclusion Counselling practice is poor and not very efficient. A new approach of informing pregnant women on danger signs is needed. However, as effects of antenatal care education remain largely unknown, it is very well possible that improved counselling will not affect maternal and newborn mortality and morbidity.

OBJECTIVES: To measure pre-intervention quality of routine antenatal and childbirth care in rural districts of Burkina Faso Ghana and Tanzania and to identify shortcomings. METHODS: In each country we selected two adjoining rural districts. Within each district we randomly sampled 6 primary healthcare facilities. Quality of care was assessed through health facility surveys direct observation of antenatal and childbirth care exit interviews and review of patient records. RESULTS: By and large quality of antenatal and childbirth care in the six districts was satisfactory but we did identify some critical gaps common to the study sites in all three countries. Counselling and health education practices are poor; laboratory investigations are often not performed; examination and monitoring of mother and newborn during childbirth are inadequate; partographs are not used. Equipment required to provide assisted vaginal deliveries (vacuum extractor or forceps) was absent in all surveyed facilities. CONCLUSION: Quality of care in the three study sites can be improved with the available human resources and without major investments. This improvement could reduce maternal and neonatal mortality and morbidity. (c) 2013 Blackwell Publishing Ltd.

Background The need to translate research into policy, i.e. making research findings a driving force in agenda-setting and policy change, is increasingly acknowledged. However, little is known about translation mechanisms in the field of sexual and reproductive health (SRH) outside North American or European contexts. This paper seeks to give an overview of the existing knowledge on this topic as well as to document practical challenges and remedies from the perspectives of researchers involved in four SRH research consortium projects in Latin America, sub-Saharan Africa, China and India. Methods A literature review and relevant project documents were used to develop an interview guide through which researchers could reflect on their experiences in engaging with policy-makers, and particularly on the obstacles met and the strategies deployed by the four project consortia to circumvent them. Results Our findings confirm current recommendations on an early and steady involvement of policy-makers, however they also suggest that local barriers between researchers and policy-making spheres and individuals can represent major hindrances to the realization of translation objectives. Although many of the challenges might be common to different contexts, creating locally-adapted responses is deemed key to overcome them. Researchers’ experiences also indicate that - although inevitable - recognizing and addressing these challenges is a difficult, time- and energy-consuming process for all partners involved. Despite a lack of existing knowledge on translation efforts in SRH research outside North American or European contexts, and more particularly in low and middle-income countries, it is clear that existing pressure on health and policy systems in these settings further complicates them. Conclusions This article brings together literature findings and researchers’ own experiences in translating research results into policy and highlights the major challenges research conducted on sexual and reproductive health outside North American or European contexts can meet. Future SRH projects should be particularly attentive to these potential obstacles in order to tailor appropriate and consistent strategies within their existing resources. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1889-1) contains supplementary material, which is available to authorized users.

Reducing maternal mortality continues to be a major challenge for African countries. We conducted a literature review to identify the factors associated with the utilization of maternal and child healthcare services during the postpartum period and the strategies for strengthening postpartum healthcare in Africa. We carried out an electronic search in several databases of texts published between 1995 and 2012 related to maternal and child health. Seventyfive publications fitted the eligibility criteria. Our analysis shows that to a large extent the socio-economic context was dominant among the factors associated with the quality and utilization of postpartum services. The best interventions were those on immediate postpartum maternal care combining several intervention packages such as community mobilization and provision of services, community outreach services and health training. The integration within health facilities of mother and child clinics was shown to contribute signifiHealthcantly to improving the frequency of mothers’ postpartum visits. Key words: postpartum care, postnatal care, maternal and child health, health interventions, health strategies, sub-Saharan Africa

Background: Postpartum maternal and infant mortality is high in sub-Saharan Africa and improving postpartum care as a strategy to enhance maternal and infant health has been neglected. We describe the design and selection of suitable, context-specific interventions that have the potential to improve postpartum care. Methods: The study is implemented in rural districts in Burkina Faso, Kenya, Malawi and Mozambique. We used the four steps 'systems thinking' approach to design and select interventions: 1) we conducted a stakeholder analysis to identify and convene stakeholders; 2) we organised stakeholders causal analysis workshops in which the local postpartum situation and challenges and possible interventions were discussed; 3) based on comprehensive needs assessment findings, inputs from the stakeholders and existing knowledge regarding good postpartum care, a list of potential interventions was designed, and; 4) the stakeholders selected and agreed upon final context-specific intervention packages to be implemented to improve postpartum care. Results: Needs assessment findings showed that in all study countries maternal, newborn and child health is a national priority but specific policies for postpartum care are weak and there is very little evidence of effective postpartum care implementation. In the study districts few women received postpartum care during the first week after childbirth (25 % in Burkina Faso, 33 % in Kenya, 41 % in Malawi, 40 % in Mozambique). Based on these findings the interventions selected by stakeholders mainly focused on increasing the availability and provision of postpartum services and improving the quality of postpartum care through strengthening postpartum services and care at facility and community level. This includes the introduction of postpartum home visits, strengthening postpartum outreach services, integration of postpartum services for the mother in child immunisation clinics, distribution of postpartum care guidelines among health workers and upgrading postpartum care knowledge and skills through training. Conclusion: There are extensive gaps in availability and provision of postpartum care for mothers and infants. Acknowledging these gaps and involving relevant stakeholders are important to design and select sustainable, context-specific packages of interventions to improve postpartum care.

Background : The European Union (EU) supports North–South Partnerships and collaborative research projects through its Framework Programmes and Horizon 2020. There is limited research on how such projects can be harnessed to provide a structured platform for doctoral level studies as a way of strengthening health system research capacity in sub-Saharan Africa (SSA). Objective : The aim of this study was to explore the challenges of, and facilitating factors for, ‘nesting’ doctoral students in North–South collaborative research projects. The term nesting refers to the embedding of the processes of recruiting, supervising, and coordinating doctoral students in the overall research plan and processes. Design : This cross-sectional qualitative study was undertaken by the EU-funded QUALMAT Project. A questionnaire was implemented with doctoral students, supervisors, and country principal investigators (PIs), and content analysis was undertaken. Results : Completed questionnaires were received from nine doctoral students, six supervisors, and three country PIs (86% responses rate). The doctoral students from SSA described high expectations about the input they would receive (administrative support, equipment, training, supervision). This contrasted with the expectations of the supervisors for proactivity and self-management on the part of the students. The rationale for candidate selection, and understandings of the purpose of the doctoral students in the project were areas of considerable divergence. There were some challenges associated with the use of the country PIs as co-supervisors. Doctoral student progress was at times impeded by delays in the release of funding instalments from the EU. The paper provides a checklist of essential requirements and a set of recommendations for effective nesting of doctoral students in joint North–South projects. Conclusion : There are considerable challenges to the effective nesting of doctoral students within major collaborative research projects. However, ways can be found to overcome them. The nesting process ultimately helped the institutions involved in this example to take better advantage of the opportunities that collaborative projects offer to foster North–South partnerships as a contribution to the strengthening of local research capacity. Keywords : collaborative project; doctoral students; health systems research capacity; North–South Partnership (Published: 15 July 2014) Citation : Glob Health Action 2014, 7 : 24070 - http://dx.doi.org/10.3402/gha.v7.24070

The QUALMAT research project aims to improve maternal and newborn health by improving the quality of antenatal and childbirth care provided in primary healthcare facilities. Within the frame of this project, a comprehensive quality assessment took place in selected health centres in northern Ghana. The results of this assessment showed that overall quality of routine antenatal and childbirth care was satisfactory, although some critical gaps were identified. Counselling and health education practices need to be improved; laboratory investigations are often not performed; examination and monitoring of mother and newborn during childbirth are inadequate; partographs are often not used and poorly completed; and equipment to provide assisted vaginal deliveries was absent.