Value of the proposed review

Adolescents and young people have Sexual and Reproductive Health and Rights (SRHR) needs that become neglected and more complex during the disasters and outbreaks.12 Besides this, we have to underscore that their life experience is limited, and their decision-making abilities are still evolving. Consequently, their coping mechanisms and judgement capabilities to navigate complex circumstances triggered by these extraordinary disease outbreaks are also limited. Despite this developmental challenge, these crises offer a belated opportunity for governments to fill the gaps in sex education and provide access to contraceptives, safer motherhood, safer abortion and empowerment programmes to address inequities in SRHR and protect vulnerable adolescents in time. If governments do not take such opportunities, future outbreaks can further compound the public health burden, including exacerbation of mental health issues, gender inequalities and social injustices in society. We know that these social determinants of adolescent health are tied together, and this review will help understand the existing evidence and gaps. We have prioritised studying four significant outbreaks since 2000: swine influenza virus (H1N1/09), Ebola virus, Zika virus and SARS-CoV-2 and their impacts on the SRHR of young and adolescents in low and middle-income countries (LMICs).

Influenza (H1N1/09)

On the first July 2009, the WHO acknowledged that the influenza outbreak had become pandemic and called it the Pandemic H1N1/09 virus, popularly known as “swine influenza”. Pregnant women were considered a high-risk group for H1/N1, as there was a higher rate of spontaneous abortion, preterm birth, low birth weight, fetal disease as well as increased hospitalisation and maternal death.13–15 In a study at the outset of the pandemic in Australia and New Zealand, 9% of patients admitted to the intensive care units were pregnant, a high proportion, given that 1% of the Australasian population were pregnant.16 A global pooled analysis revealed that pregnant women had a 3.5–25.3-fold higher risk of hospitalisation compared with non-pregnant women of childbearing age.17 Due to the high mortality and morbidity rate in for pregnant women, vaccination of pregnant women was prioritised. However, studies show that poor vaccine uptake in pregnant women possibly a result of concerns regarding adverse effects.18 19 Despite multiple studies showing that influenza vaccines are safe and have no significant threat to pregnancy, including spontaneous abortion, stillbirth and congenital malformations.20–22

Zika virus

In March 2015, a group of patients were admitted in Brazil with rash, fatigue and arthralgia, caused by the Zika Virus. In October, that year, a few reports showed that the mother–newborn transmission of the virus23 might lead to fetal loss, preterm delivery and microcephalic (small head) babies, cumulatively known as congenital Zika syndrome.24 Case reports showed high semen viral load, 10 000 times higher in semen than in blood in one case.25 26 The transmission of the virus in humans is via sexual contact, blood transfusion and organ transplantation.27–29 Combining the sexual transmission of the virus between partners and vertical transmission to the fetus, the WHO recommendations were adoption of safer sex practices, abstinence during pregnancy and emergency contraception.23 To date, a total of 86 countries have reported evidence of Zika infection.30

In mid-January 2016, the health ministers of multiple Latin American countries recommended postponing pregnancy for at least 6–24 months. This seemed too idealistic and unrealistic, as more than half of the region’s pregnancies have been unintended.31 In addition, inadequate sex education, difficulty accessing contraception, high rape prevalence and local cultural constraints resulted in many women not adopting proper advice.32 Latin American countries have a relatively wide range of restrictive laws in SRHR. In El-Salvador, a self-induced abortion may lead to a penalty as high as 40 years of incarceration.33 On the other hand, in response to the Zika virus, the Columbian Ministry of Health declared that women have the right to have self-induced miscarriages. Nevertheless, due to poor education and scarcity of information, women are not well informed about the risk and their abortion rights.32 This was reflected by the fact that the rate of contraception usage did not change in Columbia during the outbreak in 2015–2016.34

Ebola virus

Ebola haemorrhagic fever is one of the fatal outbreaks within history. By the end of 2016, an estimated 11 310 deaths resulted from 28 618 definite cases, a staggering 40% mortality.35 The transmission route is through contact with infected patient’s blood or secretions and direct contact (mucus membrane and injured cutaneous tissue). Even after recovery, the virus may exist in the semen of cases for up to 7 weeks later.36 Burial ceremonies that require direct contact with the dead bodies contribute to Ebola transmission.37 The latter endanger women as they have significant roles in the ceremony. Pregnant women can also transmit the virus to their babies either in-utero or through breastmilk.38–40

In the past century, multiple outbreaks of the Ebola virus occurred; the first one was in Zaire (currently known as the Democratic Republic of the Congo) and Sudan in 1976. The second outbreak occurred in Sudan around 1979. The third epidemic was in Gabon,1996. In this century, Northern Uganda faced the fourth epidemic in the fall of 2000. The 2014–2016 Ebola virus epidemic was the largest outbreak of the Ebola, considered a pandemic41 42. The outset was from Guinea and then moved to other countries such as Liberia and Sierra Leone. The current outbreak (2018- now) in the eastern Democratic Republic of Congo is the last reported outbreak.43

WHO Advisory Group on the Ebola Virus Disease Response recommended that the male who survived the Ebola virus disease practice hygiene and safer sex until 1 year from symptom beginning or after two negative semen specimens for the Ebola virus. In some patients after recovery, Ebola virus can persist in several tissues, such as testicles, the eye and the central nervous system.44 In women who have contracted the disease during pregnancy, the virus remains in the placenta, amniotic fluid and fetus. In those women who have been infected during breastfeeding, the virus could persist in breast milk.38 45–50

Ebola revealed many problems in adolescence SRHR in Africa.51 It is well established that in humanitarian crises and disasters, women and girls are more vulnerable to gender-based violence (GBV).52 53 Multiple studies showed that in Sierra Leone, during the Ebola outbreak, the rate of adolescent pregnancy, rape, sexual and gender-based violation increased.51 54 55 United Nations Department of Political Affairs estimates that the teenage pregnancy rate increased by 65% during the outbreak.56 More girls were forced into prostitution/transactional sex due to family members’ loss and financial insecurity.57 This makes the girls two times victims, as pregnant girls are forbidden to attend school in Libera and Sierra Leone.58 In Sierra Leone, Ebola increased the fear of clinic attendance and impacted newborn and maternal care by disrupting the health services. This led to 549 maternal deaths, 2161 neonatal deaths and 883 still births in the year 2014–2015.59 The studies showed that even after pandemics in Liberia and Sierra Leone, the level of contraceptive care and family planning had returned or exceeded the baseline level after 6 months60 to 24 months.61 After 6 months of the outbreak in Guinea, the number of family planning sessions and prenatal care visits did not reverse to the prior level, harshly influencing the already insufficient care level.60

SARS-CoV-2

In late 2019, multiple patients were diagnosed with a pneumonia-causing virus. Numerous subsequent studies showed a beta-coronidae family virus named ‘SARS-CoV-2’ by WHO to be the causative agent. In March 2020, the WHO declared SARS-CoV-2 a pandemic and called the disease ‘coronavirus disease of 2019’, or simply ‘COVID-19’. Currently, there is no substantial evidence that the virus is transmitted sexually or through breast feeding. The possibility of vertical transmission is controversial. However, a recently published systematic review and meta-analysis suggest that a minority of pregnant women can transmit the virus to newborns.62

As the COVID-19 escalated, many countries adopted lockdown measures to mitigate the virus spread. The pandemic disrupted the supply chain of key contraceptive commodities.63 In practice, most governments categorised sexual and reproductive health (SRH) services as non-essential and forced them to close. In late April 2020, United Nations Population Fund predicted an estimated 7 million unintended pregnancies would occur,64 as a result of lack of access to SRH services like contraception and safe abortion care and time-sensitive potentially lifesaving services.65

COVID-19 has forced nearly 1.4 billion children and youths out of school/university, including 743 million girls globally.66 This has raised concerns around long-term impact on their lives. As in addition to increasing poverty levels, they might also experience increased sexual and GBV, furthering the need not only for remediation and support services but also access to emergency contraception and other reproductive health services.67 COVID-19 has impacted health systems and services severely globally. It has also led to closure of educational institutions’, public places for recreation and leisure, and has impacted movement.68 The protracted closures across the world have increased concerns around mental well-being and the availability/accessibility of critical SRH services for adolescents in LMICs.69

The Guttmacher institute predicted that with a hypothetical 1 year 10% decline in the use of short and long-acting contraceptives in LMICs during the COVID-19 pandemic, 49 million women would lose their access to contraception of their choice. They estimated that around 15 million unintended pregnancies might occur, leading to an additional 1.7 million deliveries, 2.6 million newborns with significant complications, 168 000 newborn deaths and 28 000 maternal deaths. The second hypothesis was that with a yearly 10% shift of safe abortion to unsafe abortion, an additional 3.3 unsafe abortions might occur in LMICs, and 1000 maternal deaths are expected.63 We know that the impact is possibly more than a 10% decline in such services, as frontline partners have predicted a slip could be up to 80%.70 In India, by March 2020, compared with December 2019, a 36% decrease in injectable contraceptives use and a 21% reduction in Intrauterine devise (IUD) insertion were reported. Simultaneously, the distribution of the condoms and oral contraceptive pills dipped 23% and 15%, respectively. The COVID-19 has interrupted the prevention programmes and impacted the household economic status and is expected to result to 13 million child marriages and two million female genital mutilations in the next decade.54 The health record analysis showed a 68% reduction in HPV vaccination from February to early April 2020.71

We aim to conduct a scoping review to map the range, extent and nature of effects of H1N1, Ebola virus, Zika virus and SARS-CoV-2 on SRHR among adolescents and youth in LMICs. Our goal is to identify current evidence in the literature, identify research gaps and suggest future research. The details pertaining to population, exposure and outcomes are provided in table 1. Our data charting table is also available in (online supplemental table A-1).

Timing

The first significant outbreak of the third millennium was the H1N1/09 (swine influenza) in 2009; hence, all the papers published from 2009 until 2021 will be included.

Setting

Our study will focus on LMICs. LMICs were defined according to the 2020–2021 World Bank classification.75

Language

Our review compiles articles with no language restriction. We will use Google Translate for the primary translation of abstracts of non-English articles. In case the abstract of the article fits the scope of this review, we will request the experts in SRHR familiar with that specific language, to evaluate the paper based on the inclusion/exclusion criteria and extract the data. Alternatively, we will request official language translation centres to make the English version of the article for our evaluation.

Search

Online supplemental table A-2 shows our proposed search strategy in Pubmed. Online supplemental tables A-3 to A-5 is our search strategy for each of the other target databases (Cochrane Library, Embase, PsycINFO).

Selection of sources of evidence

A four-step search strategy is being followed in this study. First, the authors have done a preliminary (and limited) search in several databases (Pubmed and Google Scholar) on this topic. We assessed the keywords, abstract and several full texts to reach our study’s final keywords. We discussed our search strategy multiple times until all authors reached a consensus reflected in online supplemental table 3-8. Following the duplication removal, title/abstract and full-text screening of studies using RAYYAN,76 we will choose our relevant evidence considering the inclusion/exclusion criteria.

In the third step, we will check the articles’ reference lists to find more relevant studies. Finally, we will look for studies that have cited or included studies and check them for their eligibility. Any discrepancy would be addressed via discussion until consensus is reached in each stage. Two authors worked separately in all searching and extraction stages, and discrepancies would be resolved through discussion.

Data charting process

After choosing the eligible papers, two authors will separately extract the required items based on the extraction excel sheet form designed and approved by researchers for the process.

Data items

Following the selected papers’ primary selection and inclusion and extracting the results, the tabulation phase begins. We will categorise the extracted data based on the items mentioned before. We will extract the following data: authors, year, country and continent (region of the study), study design, participants (differentiated by age and gender), purpose and main findings. Any disagreements in the process of data extraction will be resolved through discussion until consensus. We will also indicate the country’s income level where studies are being done (low, lower-middle and higher-middle income).

Critical appraisal of individual sources of evidence and synthesis of result

Based on the nature of scoping review, we will neither synthesise the findings/results, nor critically appraise the papers, which is more applicable by performing a systematic review.77 However, publications and the mentioned data would be summarised and categorised.

Ethics and dissemination

As the nature of the work is a scoping review of the currently published papers in peer review journals, ethical approval is not required for this study. The results of the study will be presented in a peer-reviewed publication.