Commonwealth Office Research Articles

“Securitized” UK aid projects in Africa: Evidence from Kenya, Nigeria and South Sudan

AbstractMotivationIn 2020, the UK Department for International Development (DFID) was merged with the Foreign and Commonwealth Office (FCO) as the Foreign, Commonwealth and Development Office (FCDO). This policy move strengthens the trend to “securitize” development, whereby the provision of aid is motivated by national security concerns.PurposeMany researchers have raised concerns about the securitization of aid and its consequences for development, but little research has examined its impact on aid‐recipient countries.Approach and MethodsThis study evaluates 144 securitized aid projects implemented by DFID between 2000 and 2018 in Kenya, Nigeria and South Sudan, using the Organisation for Economic Co‐operation and Development (OECD) evaluation criteria of relevance, effectiveness, impact, and sustainability.FindingsOur analysis finds that although most of the projects assessed were “relevant”, i.e. formally aligned with recipient and funders’ objectives, many struggled to achieve their intended outputs (“effectiveness”). Few of the projects had a positive “impact”. We conclude that the securitized projects reviewed did not significantly strengthen the recipient countries’ institutions, stability, or security but had some negative side effects.Policy ImplicationsIn view of the merger of DFID with the FCO and the decision to reduce aid from 0.7% to 0.5% of Gross National Income (GNI), the UK is likely to draw an even closer connection between domestic security priorities and its development aid. In view of our empirical findings, the UK government needs to be more aware of the limitations of development interventions undertaken in the name of security and consider other means of enabling development.

Getting the Better of the Bargain: Technical Intelligence, Arms Sales, and Anglo-Israeli Relations 1967–1974

ABSTRACT This analysis explores the nature of Anglo-Israeli intelligence relations between 1967 and 1974, focusing in particular on how the legacy of the British mandate in Palestine, the influence of senior British diplomats, as well as wider commercial interests shaped attempts by intelligence officials on both sides to move this relationship beyond the purely functional. Whilst Israel looked to barter access to recently captured Soviet equipment for greater collaboration with the British in weapons development and arms sales, London demurred. Despite the urging of some in Whitehall, the Foreign and Commonwealth Office limited any collaboration to functional exchanges and kept them firmly in the shadows. The aftermath of the October 1973 war revealed the price paid by Britain. With Israel now dependent on Washington for the bulk of its military equipment, London’s ability to exercise any influence over Tel Aviv in reaching an accommodation with its Arab neighbours diminished greatly.

British Academia's Response to the coup d'état in Chile: The Case of Academics for Chile

This article seeks to shed light on British academia's response to the coup d'état in Chile in 1973 from a global history approach, arguing that the concern expressed from the academic world transcended the bipolarity of the global context to appeal to a cross‐cutting defence of human rights and university autonomy. To this end, the Judith Hart and the Chilean Solidarity Campaign collections were reviewed in the Labour History Archive in Manchester, in addition to documents from the British Foreign and Commonwealth Office at the National Archives. The above bibliography was complemented by secondary source bibliography.

Bottom-up citizen engagement for health emergency and disaster risk management: directions since COVID-19

Bottom-up citizen engagement for health emergency and disaster risk management: directions since COVID-19

Meningococcal Serogroup ACWYX Conjugate Vaccine in Malian Toddlers

BackgroundNeisseria meningitidis serogroups A, B, C, W, X, and Y cause outbreaks of meningococcal disease. Quadrivalent conjugate vaccines targeting the A, C, W, and Y serogroups are available. A pentavalent vaccine that also includes serogroup X (NmCV-5) is under development.MethodsWe conducted a phase 2, observer-blinded, randomized, controlled trial involving Malian children 12 to 16 months of age. Participants were assigned in a 2:2:1 ratio to receive nonadjuvanted NmCV-5, alum-adjuvanted NmCV-5, or the quadrivalent vaccine MenACWY-D, administered intramuscularly in two doses 12 weeks apart. Participants were followed for safety for 169 days. Immunogenicity was assessed with an assay for serum bactericidal antibody (SBA) with rabbit complement on days 0, 28, 84, and 112.ResultsA total of 376 participants underwent randomization, with 150 assigned to each NmCV-5 group and 76 to the MenACWY-D group; 362 participants received both doses of vaccine. A total of 1% of the participants in the nonadjuvanted NmCV-5 group, 1% of those in the adjuvanted NmCV-5 group, and 4% of those in the MenACWY-D group reported local solicited adverse events; 6%, 5%, and 7% of the participants, respectively, reported systemic solicited adverse events. An SBA titer of at least 128 was seen in 91 to 100% (for all five serotypes) of the participants in the NmCV-5 groups and in 36 to 99% (excluding serogroup X) of those in the MenACWY-D group at day 84 (before the second dose); the same threshold was met in 99 to 100% (for all five serotypes) of the participants in the NmCV-5 groups and in 92 to 100% (excluding serogroup X) of those in the MenACWY-D group at day 112. Immune responses to the nonadjuvanted and adjuvanted NmCV-5 formulations were similar.ConclusionsNo safety concerns were identified with two doses of NmCV-5. A single dose of NmCV-5 elicited immune responses that were similar to those observed with two doses of MenACWY-D. Adjuvanted NmCV-5 provided no discernible benefit over nonadjuvanted NmCV-5. (Funded by the U.K. Foreign, Commonwealth, and Development Office; ClinicalTrials.gov number, NCT03295318.)

Geographical distribution of fertility rates in 70 low-income, lower-middle-income, and upper-middle-income countries, 2010–16: a subnational analysis of cross-sectional surveys

SummaryBackgroundUnderstanding subnational variation in age-specific fertility rates (ASFRs) and total fertility rates (TFRs), and geographical clustering of high fertility and its determinants in low-income and middle-income countries, is increasingly needed for geographical targeting and prioritising of policy. We aimed to identify variation in fertility rates, to describe patterns of key selected fertility determinants in areas of high fertility.MethodsWe did a subnational analysis of ASFRs and TFRs from the most recent publicly available and nationally representative cross-sectional Demographic and Health Surveys and Multiple Indicator Cluster Surveys collected between 2010 and 2016 for 70 low-income, lower-middle-income, and upper-middle-income countries, across 932 administrative units. We assessed the degree of global spatial autocorrelation by using Moran's I statistic and did a spatial cluster analysis using the Getis-Ord Gi* local statistic to examine the geographical clustering of fertility and key selected fertility determinants. Descriptive analysis was used to investigate the distribution of ASFRs and of selected determinants in each cluster.FindingsTFR varied from below replacement (2·1 children per women) in 36 of the 932 subnational regions (mainly located in India, Myanmar, Colombia, and Armenia), to rates of 8 and higher in 14 subnational regions, located in sub-Saharan Africa and Afghanistan. Areas with high-fertility clusters were mostly associated with areas of low prevalence of women with secondary or higher education, low use of contraception, and high unmet needs for family planning, although exceptions existed.InterpretationSubstantial within-country variation in the distribution of fertility rates highlights the need for tailored programmes and strategies in high-fertility cluster areas to increase the use of contraception and access to secondary education, and to reduce unmet need for family planning.FundingWellcome Trust, the UK Foreign, Commonwealth and Development Office, and the Bill & Melinda Gates Foundation.

Building supply chain capacity for neglected tropical diseases: experience from the Ascend West and Central Africa programme.

The Ascend West and Central Africa programme, funded by the UK Foreign, Commonwealth and Development Office (FCDO) is supporting integrated preventative chemotherapy for up to five neglected tropical diseases (NTDs), including intestinal worms, lymphatic filariasis, river blindness, trachoma and schistosomiasis. The programme is implemented across 13 countries by a consortium of four leading international development partners: Sightsavers, Liverpool School of Tropical Medicine, Schistosomiasis Control Initiative Foundation and Mott Macdonald. This paper presents messages learnt from country assessments that took place prior to the global outbreak of coronavirus disease 2019 (COVID-19). These messages remain relevant post-COVID-19, with greater priority being given to the challenges for national NTD programmes in continuing to deliver mass drug administration (MDA) during the pandemic. Stakeholder coordination from the earliest stages of the pandemic has occurred at two levels: in the first mile with global partners of the NTD Supply Chain Forum and in the last mile with implementing partners in each country. This has been instrumental to manage delayed MDA, including the impact delays have on the shipment of NTD donated drugs and the distribution of stock held in country. The Ascend West and Central Africa programme is supporting countries with the resumption of MDA through a risk assessment and mitigation action (RAMA) process.

Are older people with disabilities neglected in the COVID-19 pandemic?

Are older people with disabilities neglected in the COVID-19 pandemic?

A Very South African Plot? The 1987 London Kidnap Plan

This essay considers a South African plot to kidnap and torture senior members of the African National Congress working in London in 1987 to extract information from them, and explores the response of the British state to this conspiracy. Using previously unexamined documents from the files of Britain’s Foreign and Commonwealth Office revealed following a Freedom of Information request, supplemented by interviews in the United Kingdom, South Africa and Norway, we make the following arguments. First, that the extent of South African covert activity abroad during the apartheid period has been underestimated and remains insufficiently explored. Secondly, that the agents of the South African security services continued to pursue their activities after the end of apartheid. Thirdly, that considerable information about these activities has yet to be revealed as it is held in government files that remain closed.

Global, Regional, and National Levels and Trends in Stillbirths from 2000 to 2019: A Systematic Assessment

Background: Stillbirths are a major public health issue and a sensitive marker of the quality of care around pregnancy and birth. The UN Global Strategy for Women’s, Children’s and Adolescents’ Health and the Every Newborn Action Plan (ENAP) call for ending preventable stillbirths. A first step to prevent stillbirths is obtaining standardized measurement of stillbirth levels and trends across countries. We estimated levels and trends in stillbirth rates at 28 weeks or more of gestation from 2000 to 2019 and assessed progress over time. Methods: Our dataset contained 2,800 country-year datapoints from 171 countries relevant to stillbirth rates, including data from registration systems, household-based surveys and population-based studies. We estimated country-specific stillbirth rates for all countries from 2000 to 2019 using a Bayesian hierarchical temporal sparse regression model. Our model combined covariates with a temporal smoothing process such that estimates were informed by data in country-periods with high-quality data and covariate-based for country-periods with limited or no data on stillbirth rates. Bias and additional uncertainty associated with observations using alternative stillbirth definitions, source types and observations that were subject to non-sampling errors were included in the model. Results: In 2019, an estimated 2.0 [90 percent uncertainty interval: 1.9, 2.2] million babies were stillborn at 28 weeks or more of gestation, with a global stillbirth rate of 13.9 [13.5, 15.4] stillbirths per 1,000 total births. Stillbirth rates varied widely across the world from 22.8 [19.8, 27.7] per 1,000 total births in West and Central Africa to 2.9 [2.7, 3.0] per 1,000 total births in Western Europe, with West and Central Africa, Eastern and Southern Africa and South Asia having the highest stillbirth rates in 2019. The global annual rate of reduction in the stillbirth rate was estimated at 2.3 [1.7, 2.7] per cent from 2000 to 2019, lower than the 2.9 [2.5, 3.2] percent reduction in the neonatal mortality rate and the 4.3 [3.8, 4.7] percent reduction in the mortality rate among children aged 1–59 months over the same period. Based on point estimates, 14 countries halved their stillbirth rate since 2000, and 115 countries reduced the stillbirth rate by more than 25 per cent. The remaining 80 countries for which we made estimates reduced their stillbirth rate by less than 25 percent since 2000, with the majority located in Sub-Saharan Africa. Interpretation: in reducing the stillbirth rate has been slow compared with declines in the mortality rate among children under 5 years of age. Accelerated improvements are most needed in the regions and countries with high stillbirth rates, particularly in sub-Saharan Africa where the increases in number of births has outpaced modest progress and declines in stillbirth rates, leading to a stagnation in the number of stillbirths since 2000. Increased efforts are needed to raise public awareness of stillbirths, to improve data collection and to prevent stillbirths. It’s not possible to assess progress going forward or understand public health priorities locally unless there is investment in gathering information about stillbirths. Funding Statement: UNICEF’s stillbirth estimation work was supported by the Bill & Melinda Gates Foundation (OPP1180460 OP190601 and INV-001395). We also acknowledge the Foreign, Commonwealth & Development Office (United Kingdom) for helping to initiate this work. Declaration of Interests: We declare that we have no conflicts of interest.

Trends in knowledge of HIV status and efficiency of HIV testing services in sub-Saharan Africa, 2000–20: a modelling study using survey and HIV testing programme data

SummaryBackgroundMonitoring knowledge of HIV status among people living with HIV is essential for an effective national HIV response. This study estimates progress and gaps in reaching the UNAIDS 2020 target of 90% knowledge of status, and the efficiency of HIV testing services in sub-Saharan Africa, where two thirds of all people living with HIV reside.MethodsFor this modelling study, we used data from 183 population-based surveys (including more than 2·7 million participants) and national HIV testing programme reports (315 country-years) from 40 countries in sub-Saharan Africa as inputs into a mathematical model to examine trends in knowledge of status among people living with HIV, median time from HIV infection to diagnosis, HIV testing positivity, and proportion of new diagnoses among all positive tests, adjusting for retesting. We included data from 2000 to 2019, and projected results to 2020.FindingsAcross sub-Saharan Africa, knowledge of status steadily increased from 5·7% (95% credible interval [CrI] 4·6–7·0) in 2000 to 84% (82–86) in 2020. 12 countries and one region, southern Africa, reached the 90% target. In 2020, knowledge of status was lower among men (79%, 95% CrI 76–81) than women (87%, 85–89) across sub-Saharan Africa. People living with HIV aged 15–24 years were the least likely to know their status (65%, 62–69), but the largest gap in terms of absolute numbers was among men aged 35–49 years, with 701 000 (95% CrI 611 000–788 000) remaining undiagnosed. As knowledge of status increased from 2000 to 2020, the median time to diagnosis decreased from 9·6 years (9·1–10) to 2·6 years (1·8–3·5), HIV testing positivity declined from 9·0% (7·7–10) to 2·8% (2·1–3·9), and the proportion of first-time diagnoses among all positive tests dropped from 89% (77–96) to 42% (30–55).InterpretationOn the path towards the next UNAIDS target of 95% diagnostic coverage by 2025, and in a context of declining positivity and yield of first-time diagnoses, disparities in knowledge of status must be addressed. Increasing knowledge of status and treatment coverage among older men could be crucial to reducing HIV incidence among women in sub-Saharan Africa, and by extension, reducing mother-to-child transmission.FundingSteinberg Fund for Interdisciplinary Global Health Research (McGill University); Canadian Institutes of Health Research; Bill & Melinda Gates Foundation; Fonds the recherche du Québec—Santé; UNAIDS; UK Medical Research Council; MRC Centre for Global Infectious Disease Analysis; UK Foreign, Commonwealth & Development Office.

Safety, adherence, and HIV-1 seroconversion among women using the dapivirine vaginal ring (DREAM): an open-label, extension study

The Ring Study, a phase 3 trial in 1959 sexually active women (randomised 2:1), showed a favourable safety profile and a 31% HIV-1 infection risk reduction for a vaginal ring containing 25 mg of dapivirine, compared with a placebo ring. We report here the DREAM study, which aimed to evaluate safety, adherence, and HIV-1 incidence in those using the dapivirine vaginal ring (DVR) in open-label use. The DREAM study is an open-label extension of The Ring Study, done at five research centres in South Africa and one research centre in Uganda. Former participants from The Ring Study, who remained HIV-negative and who did not discontinue the study due to an adverse event or safety concern that was considered to be related to the investigational product, were eligible. Women who were pregnant, planning to become pregnant, or breastfeeding at screening for DREAM were excluded. All participants received the DVR for insertion at the enrolment visit. Participants attended a 1-month follow-up visit and could either proceed with visits once every 3 months or attend monthly visits up to month 3 and then continue with visits once every 3 months. At each visit, HIV testing and safety evaluations were done, and residual dapivirine measured in used rings (approximately 4 mg is released from the DVR over 28 days of consistent use). HIV-1 incidence was compared descriptively with the simulated incidence rate obtained from bootstrap sampling of participants in the placebo group of The Ring Study, matched for research centre, age, and presence of sexually transmitted infections at enrolment. This study is registered with ClinicalTrials.gov, NCT02862171. Between July 12, 2016, and Jan 11, 2019, 1034 former participants from The Ring Study were screened, 941 were enrolled and 848 completed the trial. 616 (65·5%) of 941 participants reported treatment-emergent adverse events. Of these, six (0·6%) had events considered to be treatment-related. No treatment-related serious adverse events were reported. Measurements of monthly ring residual amounts in participants enrolled in both trials showed consistently lower mean values in DREAM than in The Ring Study. Arithmetic mean ring residual amounts of participants in The Ring Study DVR group who enrolled in DREAM were 0·25 mg lower (95% CI 0·03-0·47; p=0·027) than the mean ring residual amounts of these participants in The Ring Study. 18 (1·9%) HIV-1 infections were confirmed during DVR use, resulting in an incidence of 1·8 (95% CI 1·1-2·6) per 100 person-years, 62% lower than the simulated placebo rate. Although efficacy estimation is limited by the absence of a placebo group, the observed low HIV-1 incidence and improved adherence observed in DREAM support the hypothesis that increased efficacy due to improved adherence occurs when women know the demonstrated safety and efficacy of the DVR. The feasibility of a visit schedule of once every 3 months was shown, indicating that the DVR can be used in a real-world situation in usual clinical practice. The Ministry of Foreign Affairs (MFA) Denmark, Flanders MFA, Irish Aid, Dutch MFA, UK Aid from the UK Government's Foreign, Commonwealth and Development Office, and the US President's Emergency Plan for AIDS Relief through the US Agency for International Development.

Tomanovic and Others v. Foreign and Commonwealth Office

483State responsibility — International organizations — Attribution — Kosovo — European Rule of Law Mission in Kosovo — Special Prosecutions Office of the Republic of Kosovo — Prosecutor seconded to Special Prosecutions Office — United Kingdom — Foreign and Commonwealth Office — Ethnic tensions — Killings — Abductions — Failure of Special Prosecutions Office to investigate crimes — Whether conduct of Special Prosecutions Office attributable to United Kingdom Foreign and Commonwealth OfficeJurisdiction — Territorial — European Convention on Human Rights, 1950 — Article 1 — Exceptions to jurisdiction — State agent authority — European Rule of Law Mission in Kosovo — Special Prosecutions Office of the Republic of Kosovo — United Kingdom prosecutor seconded to Special Prosecutions Office — Police investigations — Whether United Kingdom exercising extra-territorial jurisdiction in Kosovo by reason of State agent authorityHuman rights — Right to life — Prohibition of torture — European Convention on Human Rights, 1950 — Article 2 — Article 3 –– Positive obligation — Human Rights Act 1998 — Whether United Kingdom having investigative duty — Whether investigative duty arising in respect of events before Human Rights Act 1998 entering into force — Whether investigative duty arising where no breach of substantive rightInternational organizations — Immunity — United Nations Interim Administration Mission in Kosovo Regulation 2000/47 — European Rule of Law Mission in Kosovo — Special Prosecutions Office of the Republic of Kosovo — Special Representative of the Secretary-General for Kosovo — Executive Decision No 2008/36 — Prosecutor seconded from Foreign and Commonwealth Office to Special Prosecutions Office of the Republic of Kosovo — Whether immunity protecting Foreign and Commonwealth Office — The law of England

Regina (Charles and Dunn) v. Secretary of State for Foreign and Commonwealth Affairs

662Diplomatic relations — Diplomatic correspondence — Exchange of Notes between United States Embassy and United Kingdom’s Foreign and Commonwealth Office — Express waiver of United States Embassy Administrative and Technical staff’s diplomatic immunity from criminal jurisdiction of United Kingdom, in relation to acts performed outside course of duties — Whether express waiver of criminal immunity applying to family members of United States Embassy Administrative and Technical staff — Vienna Convention on Diplomatic Relations, 1961 — Whether entitling family members of diplomatic staff to derivative set of privileges and immunities or conferring separate entitlements to inviolability and immunity — The law of England

Immune Responses Following the First Dose of the Sputnik V (Gam-COVID-Vac)

Background: As the first dose of Sputnik V Gam-COVID-Vac, is currently used as a single dose vaccine in some countries, we investigated the immunogenicity of a single dose of this vaccine in Sri Lankan adults at 4 weeks and compared the immune responses with our previously published data following AZD1222.Methods: SARS-CoV-2 antibodies were assessed at 504 individuals at the time of recruitment and at 4 weeks since receiving the single dose in Sri Lankan adults. ACE2 receptor blocking antibodies, antibodies to the receptor binding domain (RBD) of variants of concern, ex vivo IFNγ ELISpot responses, intracellular cytokine assays and B cell ELISpot assays were carried out in a sub-cohort.Findings: Of the 327/504 individuals who were baseline seronegative, 88.7% seroconverted, with significantly lower seroconversion rates in those >60-years old (p-value = 0.004) and significantly lower than previously seen with AZD1222 (p=0.018). 82.6% developed ACE2 receptor blocking antibodies, although the levels were significantly lower than seen following natural infection (p=0.0009) and following a single dose of AZD1222 (pInterpretation: A single dose of Sputnik V Gam-COVID-Vac induced high seroconversion rates although lower responses in older age groups in Sri Lankan adults. The overall antibody responses, ACE2 receptor blocking antibody responses and ex vivo T cell responses appear to be significantly lower than previously seen with AZD1222, and so there is likely to be benefit from delivery of the second dose.Funding: We are grateful to the World Health Organization, UK Medical Research Council. theForeign and Commonwealth Office and NIH, USA (grant number 5U01AI151788-02) for support.T.K.T. is funded by the Townsend-Jeantet Charitable Trust (charity number 1011770) and the EPACephalosporin Early Career Researcher Fund.Declaration of Interest: None of the authors have any conflicts of interest.Ethical Approval: Ethics approval was obtained from the Ethics Review Committee of University of Sri Jayewardenepura (COVID 01/21).

Exploring Equity in Health and Poverty Impacts of Control Measures for SARS-CoV-2 in Six Countries

Background: Policy makers need to be rapidly informed about the potential equity consequences of different COVID-19 strategies, alongside their broader health and economic impacts. While there are complex models to inform both potential health and macro-economic impact, there are few tools available to rapidly assess potential equity impacts of interventions.Methods: We created an economic model to simulate the impact of lockdown measures in Pakistan, Georgia, Chile, United Kingdom, Philippines, and South Africa. We consider impact of lockdown in terms of inability to socially distance, and income loss during lockdown, and tested the impact of assumptions on social protection coverage in a scenario analysis.Findings: In all examined countries, lower socioeconomic quintiles were likely to experience disproportionately more income loss and greater inability to socially distance during lockdown. Improving social protection increased the percentage of the workforce able to socially distance from 40% (30% Chile - 55% UK) to 60% (57% Chile - 67% UK). We estimate the cost of this social protection would be equivalent to an average of 0.5% GDP.Interpretation: We illustrate the potential for using publicly available data to rapidly assess the equity implications of social protection and non-pharmaceutical intervention policy. We highlight potential for social protection to mitigate inequitable health and economic impacts of lockdown. Although social protection is usually targeted to the poorest, middle quintiles will likely also need support as they suffer the worst income losses and are disproportionately more exposed.Funding: This work was supported by the UK Foreign, Commonwealth and Development Office and Wellcome [grant number 221303/Z/20/Z].Declaration of Interests: We declare no competing interests.

Estimating the Cost of Achieving Universal Basic Wash Standards in Health Care Facilities in the 46 Least Developed Countries

Background: An alarming number of health care facilities in low- and middle-income countries lack basic water, sanitation, hygiene, and waste management (WASH services). This study estimates the costs of achieving universal coverage of basic WASH services in health facilities in the 46 least developed countries (LDCs). Methods: In-need facilities were quantified by combining published facility counts with estimated WASH service coverage. Country-specific per-facility capital and recurrent costs to deliver basic service standards were collected via survey. Baseline estimates were modelled alongside lower and upper estimates for which key assumptions were adjusted. Findings: An estimated US$6·5–9·6 billion over 10 years is needed to achieve universal coverage of basic WASH services in LDCs’ health facilities. Capital and recurrent costs are 44–50% and 50–56% of the total, respectively. On average, US$0·24–40 per capita in capital investment is needed each year, while annual maintenance and operation costs are expected to increase from US$0·10 in 2021 to US$0·39–0·60 in 2030. Waste management accounts for the greatest share of costs (43–49%), followed by sanitation (21–28%), water (20%), and hygiene (10–11%). Needs are greatest for non-hospital facilities (94%) and in rural areas (68%). Interpretation: Investment will need to be scaled up to reach universal coverage of basic WASH services in health facilities. Financial needs are modest compared to overall health and WASH spending and will yield numerous health benefits. To sustain services, countries will need to routinely budget for operations and maintenance. Funding Information: World Health Organization (including underlying grants from the governments of Japan, Netherlands, and UK), World Bank, and UNICEF. Declaration of Interests: MC reports personal fees from the World Health Organization during the conduct of the study and from Results for Development, ThinkWell, and the World Bank outside the submitted work. SM reports personal fees from the World Health Organization during the conduct of the study and from Vysnova Partners outside the submitted work. RJ reports grants from Agence francaise de developpement, Bill and Melinda Gates Foundation, Government of the Netherlands Ministry of Foreign Affairs, UN-Water Inter-Agency Trust Fund, United Kingdom Foreign, Commonwealth & Development Office, and Swiss Agency for Development and Cooperation, both during the conduct of the study and outside the submitted work. IA, JA-ST, SG, OH, TS, CC, GH, and MM have nothing to disclose.

Quantifying the Dynamics of COVID-19 Burden and Impact of Interventions in Java, Indonesia

Background: As in many countries, quantifying COVID-19 spread in Indonesia remains challenging due to testing limitations. In Java, non-pharmaceutical interventions (NPIs) were implemented throughout 2020. However, as a vaccination campaign launches, cases and deaths are rising across the island.Methods: We used modelling to explore the extent to which data on burials in Jakarta using strict COVID-19 protocols (C19P) provide additional insight into the transmissibility of the disease, epidemic trajectory, and the impact of NPIs. We assess how implementation of NPIs in early 2021 will shape the epidemic during the period of likely vaccine roll-out.Findings: C19P burial data in Jakarta suggest a death toll approximately 3·3 times higher than reported. Transmission estimates using these data suggest earlier, larger, and more sustained impact of NPIs. Measures to reduce sub-national spread, particularly during Ramadan, substantially mitigated spread to more vulnerable rural areas. Given current trajectory, daily cases and deaths are likely to increase in most regions as the vaccine is rolled-out. Transmission may peak in early 2021 in Jakarta if current levels of control are maintained. However, relaxation of control measures is likely to lead to a subsequent resurgence in the absence of an effective vaccination campaign.Interpretation: Syndromic measures of mortality provide a more complete picture of COVID-19 severity upon which to base decision-making. The high potential impact of the vaccine in Java is attributable to reductions in transmission to date and dependent on these being maintained. Increases in control in the relatively short-term will likely yield large, synergistic increases in vaccine impact.Funding: UK Foreign, Commonwealth and Development Office, Medical Research Council, and Wellcome Trust.Declaration of Interests: We declare no competing interests.

Seroprevalence of SARS-CoV-2 after the Second Wave in South Africa in HIV-Infected and Uninfected Persons: A Cross-Sectional Household Survey, November 2020 – April 2021

Background: Seroprevalence studies are important for quantifying the burden of SARS-CoV-2 infections in resource-constrained countries.Methods: We conducted a cross-sectional household survey spanning the second pandemic wave (November 2020 – April 2021) in three communities. Blood was collected for SARS-CoV-2 antibody (two ELISA assays targeting spike and nucleocapsid) and HIV testing. An individual was considered seropositive if testing positive on ≥1 assay. Factors associated with infection, and the age-standardised infection to case detection rate (ICR), infection hospitalisation rate (IHR) and infection fatality rate (IFR) were calculated.Findings: Overall 7959 participants were enrolled, with a median age of 34 years and HIV prevalence of 22.7%. SARS-CoV-2 seroprevalence was 45.2% (95% confidence interval 43.7% - 46.7%), and increased from 26.9% among individuals enrolled in December 2020 to 47.1% among individuals in April 2021. On multivariable analysis, seropositivity was associated with age, sex, race, being overweight/obese, having respiratory symptoms, and low socioeconomic status. Persons living with HIV (PLWH) with high viral load were less likely to be seropositive compared to HIV-uninfected individuals. The site-specific ICR, IHR and IFR ranged across sites from 4.4% to 8.2%, 1.2% to 2.5% and 0.3% to 0.6%, respectively.Interpretation: South Africa has experienced a large burden of SARS-CoV-2 infections, with Funding Information: This study was supported by the South African MRC, Wellcome Trust and UK Foreign, Commonwealth and Development Office, and US CDC.Declaration of Interests: C. Cohen has received grant support from Sanofi Pasteur, Advanced Vaccine Initiative, and payment of travel costs from Parexel. NW and AvG have received grant support from Sanofi Pasteur. All other authors declare no conflict of interest.Ethics Approval Statement: This study was approved by the University of the Witwatersrand (M200861) and by the respective community and provincial research committees.

The Contribution of Primary Care Expansion to Sustainable Development Goal Three for Health: A Microsimulation of the Fifteen Largest Cities in Brazil

Background: As middle-income countries strive to achieve the Sustainable Development Goals (SDGs), it remains unclear to what degree expanding primary care coverage can help achieve those goals and reduce within-country inequalities in mortality. We estimated the potential impact of primary care expansion on cause-specific mortality in the 15 largest Brazilian cities. Methods: We obtained hazard ratios of death by cause and by demographic group, from a national administrative database linked to the Estrategia de Saude da Familia (Family Health Strategy, FHS) electronic health and death records among 1.2 million residents of Rio de Janeiro (2010-2016). We incorporated these hazard ratios into a microsimulation to estimate the impact of changing primary care coverage. Findings: Increased FHS coverage would be expected to reduce inequalities in mortality among cities (from 2.8 to 2.4 deaths per 1,000 between the highest- and lowest-mortality city, given a 40 percentage point increase in coverage), between welfare recipients and non-recipients (from 1.3 to 1.0 deaths per 1,000), and among race/ethnic groups (between Black and White Brazilians from 1.0 to 0.8 deaths per 1,000). A 40 percentage point increase in coverage would be insufficient to reach SDG targets --reducing premature mortality from non-communicable diseases by 20% (versus the target of 33%), and communicable diseases by 15% (versus 100%). Interpretation: Primary care coverage may be critically beneficial to reducing within-country health inequalities, but reaching SDG targets will likely require coordination between primary care and other sectors. Funding Statement: This work was supported by a grant from the Health Systems Research Initiative with funding from the Foreign, Commonwealth and Development Office, the UK Medical Research Council and Wellcome Trust, in collaboration with the UK Economic and Social Research Council (grant no. MR/P014593/1).DR acknowledges support from the Spanish Ministry of Science and Innovation through the “Centro de Excelencia Severo Ochoa 2019-2023” Program (CEX2018- 000806-S), and support from the Generalitat de Catalunya through the CERCA Program. Declaration of Interests: None. Ethics Approval Statement: Approval for this study was obtained from the Brazilian National Commission for Ethics in Research (Comissao Nacional de Etica em Pesquisa [CONEP]; number 2.689.528) and Imperial College London’s Ethical Comittee.