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Background This study examines how leadership is provided at the operational level of a health system in a protracted crisis context. Despite advances in medical science and technology, health systems in low- and middle-income countries struggle to deliver quality care to all their citizens. The role of leadership in fostering resilience and positive transformation of a health system is established. However, there is little literature on this issue in Democratic Republic of the Congo (DRC). This study describes leadership as experienced and perceived by health managers in crisis affected health districts in Eastern DRC. Methods A qualitative cross-sectional study was conducted in eight rural health districts (corresponding to health zones, in DRC’s health system organization), in 2021. Data were collected through in-depth interviews and non-participatory observations. Participants were key health actors in each district. The study deductively explored six themes related to leadership, using an adapted version of the Leadership Framework conceptual approach to leadership from the United Kingdom National Health Service’s Leadership Academy. From these themes, a secondary analysis extracted emerging subthemes. Results The study has revealed deficiencies regarding management and organization of the health zones, internal collaboration within their management teams as well as collaboration between these teams and the health zone’s external partners. Communication and clinical and managerial capacities were identified as key factors to be strengthened in improving leadership within the districts. The findings have also highlighted the detrimental influence of vertical interventions from external partners and hierarchical supervisors in health zones on planning, human resource management and decision-making autonomy of district leaders, weakening their leadership. Conclusions Despite their decentralized basic operating structure, which has withstood decades of crisis and insufficient government investment in healthcare, the districts still struggle to assert their leadership and autonomy. The authors suggest greater support for personal and professional development of the health workforce, coupled with increased government investment, to further strengthen health system capacities in these settings.

Malnutrition is a public health problem, but outside the theoretical framework, little is known about the concrete intergenerational effects of malnutrition. The objective of this study is to compare the nutritional status and health indicators of school children born to mothers who were treated for severe acute malnutrition (SAM). The study took place in Miti-Murhesa health zone in the Democratic Republic of Congo. This is a cohort study assessing the nutritional and health status of school children born to mothers who had been treated for SAM, based on WHZ or edema, in Lwiro hospital between 1988-2002 compared to children born to mothers who were not exposed to SAM. Stunting and thinness were evaluated by Height for Age Z-score (HAZ) and Body Mass Index by Age criteria (BMIAZ) respectively. On admission, blood samples were taken to assess anemia, HIV serology, hemogram and others biological indicators. Stool's examinations were conducted by using Olympus optical microscope. Parametric and non-parametric tests were applied to compare the different variables in two groups. We identified 106 children aged 5-16 years (103 exposed and 58 unexposed) and we received 83.5% and 91.4% children respectively for anthropometric parameters. The mean of age was 7.9 ± 2.4 year in exposed group and 7.4 ± 2.1 year in unexposed group (p = 0.26). The prevalence of stunting was 68.3% in the exposed group and 67.3% in the unexposed group (p = 0.90). The prevalence of thinness was 12.8% in the exposed group and 9.6% in the unexposed group (p = 0.57). The biological profile (glycemia, urea, creatinine and hemogram) and the prevalence of intestinal parasites were similar in the two groups. In this sample, in a malnutrition-endemic area, there was no statistically significant difference in nutrition and health indicators between school children born to mothers exposed to SAM and their community controls.

Little is known about the outcomes of subjects with a history of severe acute malnutrition (SAM). We therefore sought to explore the long-term effects of SAM during childhood on human capital in adulthood in terms of education, cognition, self-esteem and health-related disabilities in daily living. We traced 524 adults (median age of 22) in the eastern Democratic Republic of the Congo, who were treated for SAM during childhood at Lwiro hospital between 1988 and 2007 (median age 41 months). We compared them with 407 community controls of comparable age and sex. Our outcomes of interest were education, cognitive function [assessed using the Mini Mental State Examination (MMSE) for literate participants, or its modified version created by Ertan et al. (MMSE-I) for uneducated participants], self-esteem (measured using the Rosenberg Self-Esteem Scale) and health-related social and functional disabilities measured using the World Health Organization Disability Assessment Schedule (WHODAS). For comparison, we used the Chi-squared test along with the Student's t-test for the proportions and means respectively. Compared with the community controls, malnutrition survivors had a lower probability of attaining a high level of education (p < 0.001), of reporting a high academic performance (p = 0.014) or of having high self-esteem (p = 0.003). In addition, malnutrition survivors had an overall mean score in the cognitive test that was lower compared with the community controls [25.6 compared with 27.8, p = 0.001 (MMSE) and 22.8 compared with 26.3, p < 0.001(MMSE-I)] and a lower proportion of subjects with a normal result in this test (78.0% compared with 90.1%, p < 0.001). Lastly, in terms of health-related disabilities, unlike the community controls, malnutrition survivors had less social disability (p = 0.034), but no difference was observed as regards activities of daily living (p = 0.322). SAM during childhood exposes survivors to low human capital as regards education, cognition and behaviour in adulthood. Policy-deciders seeking to promote economic growth and to address various psychological and medico-social disorders must take into consideration the fact that appropriate investment in child health as regards SAM is an essential means to achieve this.

Background and Aim The coronavirus disease 2019 (COVID‐19) pandemic was a priority public health problem because of its high mortality rate. This study mainly aimed to determine factors associated with a poor outcome in COVID‐19 hospitalized patients in South‐Kivu, an eastern province of the Democratic Republic of the Congo (DRC). Methods This observational study retrospectively evaluated medical records of patients consecutively admitted for probable or confirmed COVID‐19 between May 01 and July 31, 2020 at the Hôpital Provincial Général de Référence de Bukavu (HPGRB), a tertiary hospital located in South‐Kivu. A binary logistic regression model was performed to determine the predictors of mortality. Results A total of 157 hospitalized COVID‐19 patients aged 57.7 (13.2) years were included in this study. Male gender (69.4%), older age (52.9%), medical history of diabetes (38.2%), and arterial hypertension (35.1%) were the most frequent risk factors. Most patients presented with fever (73.3%), cough (72.6%), and dyspnea (66.2%). Overall, 45.1% of patients died. Intrahospital mortality was significantly associated with advanced age [odds ratio, OR (95% confidence interval, CI) = 2.34 (1.06–5.38)], hypoxemia [OR (95% CI) = 4.67 (2.02–10.77)], hyperglycemia [OR (95% CI) = 2.14 (1.06–4.31)], kidney failure [OR (95% CI) = 2.82 (1.4–5.68)], hyperleukocytosis [OR (95% CI) = 3.33 (1.67–6.66)], and higher C‐reactive protein (CRP) levels [OR (95% CI) = 3.93 (1.93–8.01)]. After adjustment for various covariates, only higher CRP levels [OR (95% CI) = 3.23 (1.23–8.5)] and hyperglycemia [OR (95% CI) = 2.5 (1.02–6.11)] at admission were independently associated with mortality. Conclusion Hyperglycemia and marked inflammatory syndrome were the major predictors of poor outcomes in patients hospitalized for COVID‐19 in South‐Kivu. These two factors should be quantified at hospital admission to establish the patient's prognosis.

Background Malnutrition is a public health problem, as wasting affects 7.5% of children worldwide. The harmful effects of severe acute malnutrition (SAM) can last a lifetime, but how SAM in childhood affects later breastfeeding ability is not clear. In the present study, we assessed the human milk output and body composition among mothers with a history of childhood SAM. Methods This retrospective cohort study was carried out in Miti-Murhesa Health Zone (Democratic Republic of Congo) from January 15 to March 17, 2020. We selected lactating mothers with breastfed infants aged 2–12 months. Two categories of mothers were included: those who had been treated for SAM during their childhood (years 1988–2003; n  = 39) and a community control with no history of SAM ( n  = 40). The weight, height, and mid-upper arm circumference were measured and body mass index (BMI) calculated as weight/height 2 . Body composition and human milk output were assessed using standard deuterium dilution methods. Student t and chi 2 tests ware applied to compare two groups. Results The mean age ± standard deviation of the mothers was 24.4 ± 5.1 and 26.0 ± 6.1 years for the SAM and control groups, respectively ( p  = 0.186). The age of their infants was 5.4 ± 2.3 months in both groups ( p  = 0.962). In the SAM and control groups, the mean maternal BMI was 23.8 ± 2.3 and 23.6 ± 3.7 kg/m 2 ( p  = 0.849), mean Fat Mass 27.1% ± 5.0 and 27.1% ± 5.8% ( p  = 0.708), and the mean Fat Free mass 72.9% ± 5.0 and 72.9% ± 5.8% ( p  = 0.998), respectively. Human milk output was 833.7 ± 152.1 g/d in SAM group and 827.4 ± 171.4 g/d in the control group ( p  = 0.864). Conclusions We found no significant difference in human milk output and body composition in mothers treated for SAM during childhood compared to community controls.

It is well documented that treatment for severe acute malnutrition (SAM) is effective. However, little is known about the long-term outcomes for children treated for SAM. We sought to trace former SAM patients 11 to 30 years after their discharge from hospital, and to describe their longer-term survival and their growth to adulthood. A total of 1,981 records of subjects admitted for SAM between 1988 and 2007 were taken from the archives of Lwiro hospital, in South Kivu, DRC. The median age on admission was 41 months. Between December 2017 and June 2018, we set about identifying these subjects (cases) in the health zones of Miti-Murhesa and Katana. For deceased subjects, the cause and year of death were collected. A Cox proportional hazards multivariate regression analysis was used to identify the death-related factors. For the cases seen, age- and gender-matched community controls were selected for a comparison of anthropometric indicators. A total of 600 subjects were traced, and 201 subjects were deceased. Of the deceased subjects, 65·6% were under 10 years old at the time of their death. Of the deaths, 59·2% occurred within 5 years of discharge from hospital. The main causes of death were malaria (14·9%), kwashiorkor (13·9%), respiratory infections (10·4%), and diarrhoeal diseases (8·9%). The risk of death was higher in subjects with SAM, MAM combined with CM, and in male subjects, with HRs* of 1·83 (p = 0·043), 2.35 (p = 0·030) and 1.44 (p = 0·013) respectively. Compared with their controls, the cases had a low weight (-1·7 kg, p = 0·001), short height [sitting (-1·3 cm, p = 0·006) and standing (-1·7 cm, p = 0·003)], short legs (-1·6 cm, p = 0·002), and a small mid-upper arm circumference (-3·2mm, p = 0·051). There was no difference in terms of BMI, thoracic length, or head and thoracic circumference between the two groups. SAM during childhood has lasting negative effects on growth to adulthood. In addition, these adults have characteristics that may place them at risk of chronic non-communicable diseases later in life.

Background: Long-term impact of different forms of severe acute malnutrition (SAM) in childhood on the emergence of noncommunicable diseases (NCDs) is poorly known. Aim: To explore the association between subtypes of SAM during childhood, NCDs, and cardiovascular risk factors (CVRFs) in young adults 11 to 30 years after post-SAM nutritional rehabilitation. Methods: In this follow-up study, we investigated 524 adults (mean age 22 years) treated for SAM during childhood in eastern Democratic Republic of the Congo (DRC) between 1988 and 2007. Among them, 142 had a history of marasmus, 175 of kwashiorkor, and 207 had mixed-form SAM. These participants were compared to 407 aged- and sex-matched control adults living in the same community without a history of SAM. Our outcomes of interest were cardiometabolic risk markers for NCDs. Logistic and linear regressions models were sued to estimate the association between subtype of SAM in childhood and risk of NCDs. Results: Compared to unexposed, former mixed-type SAM participants had a higher adjusted ORs of metabolic syndrome [2.68 (1.18; 8.07)], central obesity [1.89 (1.11; 3.21)] and low HDL-C (High-density lipoprotein cholesterol) [1.52 (1.08; 2.62)]. However, there was no difference between groups in terms of diabetes, high blood pressure, elevated LDL-C (low-density lipoprotein cholesterol) and hyper TG (hypertriglyceridemia) and overweightness. Former mixed-type SAM participants had higher mean fasting glucose [3.38 mg/dL (0.92; 7.7)], reduced muscle strength [−3.47 kg (−5.82; −1.11)] and smaller hip circumference [−2.27 cm (−4.24; −0.31)] compared to non-exposed. Regardless of subtypes, SAM-exposed participants had higher HbA1c than unexposed (p < 0.001). Those with a history of kwashiorkor had cardiometabolic and nutritional parameters almost superimposable to those of unexposed. Conclusion: The association between childhood SAM, prevalence of NCDs and their CVRFs in adulthood varies according to SAM subtypes, those with mixed form being most at risk. Multicenter studies on larger cohorts of older participants are needed to elucidate the impact of SAM subtypes on NCDs risk.

Background Monkeypox (mpox) remains a major global public health problem due to its rapid transmission, clinical severity and high case-fatality rate, especially for the clade I virus. Since August 2024, the disease was declared an public health emergency of international concern, with the resurgence of the disease cases and morbidity and mortality. Few studies exist in low-income countries. The Kamituga health zone (HZ) in South Kivu is the epicenter of the epidemic in the Democratic Republic of Congo (DRC). The aim of this study is to describe the transmission dynamics, epidemiological and clinical characteristics of mpox in this region. Methods This was a prospective cross-sectional study conducted over 9 months (October 2023 to June 2024) in the Kamituga HZ involving 160 confirmed patients. Data included seroprevalence, sociodemographic, epidemiological, clinical and behavioral characteristics. Variables were described by means, medians or proportions as appropriate; to compare proportions, Pearson’s chi-square, Z and Fisher’s exact tests were used. A margin of error of 5% was taken as threshold of statistical significance. Results Seroprevalence of mpox in Kamituga was 0.3%, well above the provincial average of 0,01% ( p  < 0,001). Over 80% of villages reported at least one case. The average age of patients was 23.5 years, with 58.7% women. Female sex workers accounted for 36.2% of cases. Around 26.3% had been in contact with an animal, mainly primate. mpox affected 52.2% of women with an sexual infected partner and 25.7% of men ( p  = 0.001). Overall, 70% of patients had more than one sexual partner in the last six months with more men (81.8%) than women (61.7%) ( p  = 0.003). Clinically, 86.3% presented with fever, and 91.9% with extensive pustular eruptions, predominantly genital (90%). Lymphadenopathy affected 98.7% of cases. Only 5.6% of patients had recovered fully. Conclusion mpox in Kamituga is alarmingly prevalent, affecting young adults and female sex workers with severe symptoms such as rashes and lymphandenopathy. Risky sexual behavior and late recourse to healthcare contribute to the spread of the disease. Urgent measures such as raising awareness, vaccine research and strengthening health infrastructures are essential. Collaboration between authorities, researchers and communities is important.

Background Maternal mortality (MM) remains a real scourge that hits hardest in the poorest regions of the world, particularly those affected by conflict. However, despite this worrying reality, few studies have been conducted about MM ratio in the Democratic Republic of Congo (DRC). The study aimed to describe the trends as well as the epidemiological profile and causes of reported institutional maternal deaths between 2013 and 2022 in Eastern DRC. Methods A retrospective descriptive study was conducted between March 2023 and August 2023 in eight Health Zones (HZ), five in South Kivu Province (Mwana, Minova, Miti-Murhesa, Kamituga and Idjwi) and three in North Kivu Province (Kirotshe, Karisimbi and Kayna) in the eastern region of the DRC. Our study covers 242 health facilities: 168 health centers (HC), 16 referral health centers (RHCs),50 referral hospitals (RH) and 8 general referral hospitals (GRHs). Data from registers and medical records of maternal deaths recorded in these zones from 2013–2022 were extracted along with information on the number of deliveries and live births. Sociodemographic, clinical parameters, blood and ultrasound tests and suspected causes of death between provinces were assessed. Results In total, we obtained 177 files on deceased women. Of these, 143 (80.8%) were retained for the present study, including 75 in the 3 HZs of North Kivu and 68 in the 5 HZs of South Kivu. From 2013 to 2022, study sites experienced two significant drops in maternal mortality ratio (MMR) (in 2015 and 2018), and a spike in 2016–2017. Nonetheless, the combined MMR (across study sites) started and ended the 10-year study period at approximately the same level (53 and 57 deaths per 100,000 live births in 2013 and 2022 respectively). Overall, 62,6% of the deaths were reported from secondary hospital. Most deaths were of married women in their thirties (93.5%). Almost half (47.8%) had not completed four antenatal consultations. The main direct causes of death were, in decreasing order of frequency: post-partum haemorrhage (55.2%), uterine rupture (14.0), hypertensive disorders (8.4%), abortion (7.7%) puerperal infections (2.8%) and placental abruption (0.7%). When comparing among provinces, reported abortion-related maternal mortality (14.1% vs 0%) was more frequent in North Kivu than in South Kivu. Conclusion This study imperatively highlights the need for targeted interventions to reduce maternal mortality. By emphasizing the crucial importance of antenatal consultations, intrapartum/immediate post-partum care and quality of care, significant progress can be made in guaranteeing maternal health and reducing many avoidable deaths.

Background The studies on the use and performance of the Mid-Upper Arm Circumference for age (MUACZ) for the diagnosis of severe acute malnutrition (SAM) are still rare. Our study aimed to analyze the performance of MUACZ for diagnosis of SAM in South Kivu, eastern DR Congo. Methods We analyzed a database of children admitted from 1987 to 2008 for management of SAM in the east of the DRC. Anthropometric indicators (z-score) were calculated and classified according to the standards of the World Health Organization (WHO). To evaluate the performance of MUACZ using the combination of weight-for-height (WHZ) and Mid-Upper Arm Circumference (MUAC) as the reference, we calculated sensitivity, specificity, positive and negative predictive values (PPV and NPV) overall. Subsequently, we stratified the results by age category, presence or absence of stunting, and presence or absence of edema. Results Of the 9969 children aged 6 to 59 months selected, 30.2% had nutritional edema, 70.1% had stunting. Of all cases of SAM (identified by at least one of the WHZ, MUAC, or MUACZ indicators), MUACZ alone identified 85% of them, surpassing other criteria such as MUAC (58%) and WHZ (45%). The MUACZ-WHZ combination identified 97%, surpassing the MUAC-WHZ combination (76%). In the presence of edema, MUACZ-WHZ identified 99%, while MUAC-WHZ identified only 72%. The proportions of SAM cases diagnosed by MUACZ increased according to age groups, with rates of 73% (6–11 months), 85% (12–23 months) and 91% (24–59 months). In the presence of stunting, the detection rates were 58% for MUAC alone, 44% for WHZ alone, 89% for MUACZ alone, 67% for the MUAC-WHZ combination, and 98% for the MUACZ-WHZ combination. MUACZ had a sensitivity of 80.7% (79.9–81.5), a specificity of 92.3% (91.8–92.8), a PPV of 71.5% (70.7–72.4) with a prior prevalence was 19,3% defined by the reference, and an NPV of 95.2% (94.8–95.7). Sensitivity increased in the presence of edema [90.1% (88.9–91.1)], stunting [84.7% (83.8–85.5)] and in children over 12 months [83.6% (82.2–84.9)]. Conclusion The MUACZ was performing well in our region. In a context of high prevalence of stunting and kwashiorkor, MUACZ appears to be a more reliable indicator than MUAC alone. Moreover, the MUACZ-WHZ combination also seems to outperform the MUAC-WHZ combination. These results highlight the MUACZ potential, as well as its combination with WHZ, in enhancing screening of SAM in similar contexts.