Reflections from an old Queenslander: can rear and release strategies be the next great era of vector control?

In this perspective, I discuss the great eras of vector control, centring on Aedes aegypti, the primary vector of dengue, Zika and several other viruses. Since the discovery and acceptance of the role of mosquitoes as vectors of disease agents, several significant strategies have been developed and deployed to control them and the diseases they transmit. Environmental management, insecticides and, to a lesser extent, biological control have emerged as great eras of vector control. In the past decade, the release of massive numbers of specifically modified mosquitoes that mate with wild populations has emerged as a significant new strategy to fight vector-borne diseases. These reared and released mosquitoes have been modified by the addition of a symbiont (e.g. Wolbachia bacteria), radiation or introduction of a genetic construct to either sterilize the wild mosquitoes they mate with, crashing the population, or to reduce the wild population's capacity to vector pathogens. Will these new rear and release strategies become the next great era of vector control? From my vantage point as a dengue control manager and researcher involved in two Wolbachia programmes, I will discuss the hurdles that rear and release programmes face to gain widespread acceptance and success.

Prevalence of Burnout among Primary Health Care Staff and Its Predictors: A Study in Iran

Burnout, which is an emerging challenge in health systems, is very common among primary health care (PHC) workers. The aim of this study was to investigate the level of burnout among PHC workers, and its predictive factors, in a region in the west of Iran. In this cross-sectional study, all the health network staff (n = 539) were enrolled. The data collection instrument was the Maslach Burnout Inventory (MBI), which consists of 22 items and the three subscales of emotional exhaustion (EE), depersonalization (DP), and personal achievement (PA). High scores in EE and DP and low scores in PA are indicative of high burnout. Logistic regression was used to determine the predictors of high burnout. The data were analyzed using SPSS version 16. The findings showed that 90.5% of the staff had high DP, 55.3% had high EE, and 98.9% had low PA scores. Also, 52.9% (277 people) of the staff suffered from high burnout. Single people (OR = 3.33), less experienced employees (OR = 9.09), people aged over 35 years (OR = 2.35), physicians (OR = 1.72), and staff with permanent employment (OR = 5.0) were more likely to suffer high levels of burnout. We conclude that burnout is a common problem in PHC workers. Less experienced, younger, single employees and physicians were more at risk of suffering from high burnout. Preventive measures, such as strengthening social skills, communication competencies, and coping strategies, and reduction of risk factors such as job stress, are suggested for reducing employees’ risk of burnout.

Increasing Number and Volume of Cavitary Lesions on Chest Computed Tomography Are Associated With Prolonged Time to Culture Conversion in Pulmonary Tuberculosis

Background

Cavitary lesions (CLs) primarily identified by chest x-ray (CXR) have been associated with worse clinical outcomes among patients with pulmonary tuberculosis (PTB). Chest computed tomography (CT), which has better resolution and increased sensitivity to detect lung abnormalities, has been understudied in PTB patients. We compared detection of CLs by CT and CXR and assessed their association with time to sputum culture conversion (tSCC).

Methods

This was a retrospective cohort study of 141 PTB patients who underwent CT. We used multivariate Cox proportional hazards models to evaluate the association between CLs on CXR and the number and single largest volume of CLs on CT with tSCC.

Results

Thirty (21%) and 75 (53%) patients had CLs on CXR and CT, respectively. CT detected cavities in an additional 44 patients (31%) compared with CXR. After multivariable adjustment, we observed a negative association between CLs and tSCC, with an adjusted hazard ratio (aHR) of 0.56 (95% confidence interval [CI], 0.32 to 0.97) for single CLs and 0.31 (95% CI, 0.16 to 0.60) for multiple CLs present on CT. Patients with a CL volume ≥25 mL had a prolonged tSCC (aHR, 0.39; 95% CI, 0.21 to 0.72). CLs on CXR were not associated with increased tSCC after multivariable adjustment.

Conclusions

CT detected a larger number of cavities in patients with PTB relative to CXR. We observed an association between increasing number and volume of CLs on CT and delayed tSCC independent of sputum microscopy result. Our findings highlight a potential role for CT in the clinical and research setting as a tool to risk-stratify patients with PTB.

LLIN Evaluation in Uganda Project (LLINEUP): factors associated with childhood parasitaemia and anaemia 3 years after a national long-lasting insecticidal net distribution campaign: a cross-sectional survey

Background

Recent reductions in malaria burden have been attributed largely to long-lasting insecticidal nets (LLINs). In March–June 2017, approximately 3 years after a national LLIN distribution campaign, a cross-sectional community survey was conducted to investigate factors associated with malaria parasitaemia and anaemia, in advance of Uganda’s 2017–2018 LLIN campaign.

Methods

Households from 104 clusters in 48 districts were randomly selected using two-staged cluster sampling; 50 households were enrolled per cluster. Eligible children aged 2–10 years had blood obtained for a thick blood smear and those aged 2–4 years had haemoglobin measured. Associations between outcomes and variables of interest were assessed using log-binomial regression with generalized estimating equations to adjust for household clustering.

Results

In total, 5196 households, 8834 children with blood smear results, and 3753 with haemoglobin results were included. Only 16% of children lived in households with adequate LLIN coverage. Overall, parasite prevalence was 26.0%, ranging from 8.0% in the South West to 53.1% in East Central. Limiting data to children 2–4 years of age, parasite prevalence was 21.4%, up from 16.9% in 2014–2015 following the national LLIN campaign. In a multivariate analysis, factors associated with parasitaemia included region (East-Central vs South-Western; adjusted prevalence ratio [aPR] 6.45, 95% CI 5.55–7.50; p < 0.001), older age (8–10 vs 2–3 years; aPR 1.57, 95% CI 1.43–1.72; p < 0.001), living in a poorer household (poorest vs least poor tercile; aPR 2.32, 95% CI 2.05–2.63; p < 0.001), one constructed of traditional materials (aPR 1.13, 95% CI 1.03–1.24; p = 0.008), or without adequate LLIN coverage (aPR 1.30, 95% CI 1.14–1.48; p < 0.001). Overall, the prevalence of anaemia (haemoglobin < 10 g/dL) was 15.1% and varied geographically. In a multivariate analysis, factors associated with anaemia included region, younger age, living in a traditional house, and parasitaemia, which was the strongest predictor (aPR 2.50, 95% CI 2.12–2.95; p < 0.001).

Conclusions

Three years after a national LLIN campaign, LLIN coverage was low and parasite prevalence had increased. Parasite prevalence varied widely across Uganda; older children, those living in poorer households, and those with inadequate LLIN coverage, were at highest risk of parasitaemia. LLINs may need to be distributed more frequently through mass campaigns or continuously through sustainable mechanisms. Targeting interventions to geographic areas and populations at highest risk should also be considered.

Unmet care needs of community-dwelling stroke survivors: a protocol for systematic review and theme analysis of quantitative and qualitative studies

INTRODUCTION

Stroke is a leading cause of disability worldwide. The average hospital length of stay ranges from 3 to 28 days, and after discharge home the stroke survivors will live with physical, cognitive, even psychological disorders for the rest of their lives. It is essential to review the unmet needs of stroke survivors.

METHODS AND ANALYSIS

A systematic review of previous quantitative and qualitative studies reporting the unmet needs of stroke survivors in their homes will be conducted. The following six databases will be searched from inception to December 2018 for relevant articles: PubMed, EMBASE, CINAHL, PsycINFO, SCOPUS and China Biology Medicine. We will include studies limited to human and published in English or Chinese, and the patients with stroke should discharge home rather than any other professional organisations including nursing homes or community rehabilitation units and so on. Data of quantitative research will be standardised for comparison, thematic analysis will be used for qualitative data and a narrative synthesis and pooled analysis of the main outcomes will be reported.

ETHICS AND DISSEMINATION

This review will be submitted to an international professional journal, and the detailed search strategies and analysis flowchart will be openly included as supplements. This study does not require ethical approval as no patient's identifiable data will be used. Our findings will give a new look at the aspect of stroke survivors' unmet needs in their long-term recovery stage, especially the trajectories of unmet needs at different timepoints. What is more, this review will demonstrate the long-term unmet needs of stroke survivors from different countries, will compare any variations between high-income and low-income regions, and the geographical differences of needs will be mapped if necessary. We will endeavour to provide as much information as possible to healthcare professionals and public health policy makers in order to promote further medical reform.

TRIAL REGISTRATION NUMBER

CRD42018112181.

Essential guidelines for computational method benchmarking

In computational biology and other sciences, researchers are frequently faced with a choice between several computational methods for performing data analyses. Benchmarking studies aim to rigorously compare the performance of different methods using well-characterized benchmark datasets, to determine the strengths of each method or to provide recommendations regarding suitable choices of methods for an analysis. However, benchmarking studies must be carefully designed and implemented to provide accurate, unbiased, and informative results. Here, we summarize key practical guidelines and recommendations for performing high-quality benchmarking analyses, based on our experiences in computational biology.

Home-based records' quality and validity of caregivers' recall of children's vaccination in Lebanon

INTRODUCTION

Home-based records (HBRs) (also known as vaccination cards) and caregivers' recall are the main means to ascertain vaccination status; however, data on the quality of HBRs and the validity of recall vaccination data compared to HBRs is scarce. This manuscript presents results from two analyses related to HBRs, one on HBR pictures taken during a vaccination coverage survey, including an assessment of the HBR quality and legibility, and an evaluation of the agreement between caregivers' recall and the vaccination information in the HBRs.

METHODS

Using pictures from 500 randomly selected HBRs collected during the 2016 district-based immunization coverage evaluation survey in Lebanon, two independent researchers assessed the quality of the picture and then of the HBR itself against a pre-defined set of criteria. HBRs were classified into three types: private, public and all others. In addition, caregivers' recall was compared to data found in vaccination HBRs to assess measures of vaccination status agreement for 5713 children for whom both sources of data were available.

RESULTS

Over 90% of the 500 HBR pictures reviewed were considered adequate to assess the HBR quality. In the sample, most cards were type 1 (41%), followed by type 2 (34%). Most HBRs met the set criteria for quality in terms of physical condition and legibility, while, among the 28 different types of cards, vaccination cards' content and design met a moderate level of quality. Concordance, sensitivity, specificity, positive and negative predictive values, and the Kappa statistic showed diverse levels of agreement for vaccination status per vaccine dose between caregivers' recall and vaccination HBRs.

CONCLUSION

This study illustrates that taking pictures of HBRs in a coverage survey is feasible and useful to conduct secondary analyses related to HBRs, such as assessing their quality and comparing recall with HBRs when both sources of data are available.

Psychometric properties of the St. Elizabeth Youngstown hospital wellbeing inventory and non-burnout inventory for physicians and nurses

BACKGROUND

Physicians and nurses have substantial problems with wellbeing and burnout. We examined the reliability and construct validity of a wellbeing inventory (WBI) administered to some physicians and nurses working in St. Elizabeth Youngstown Hospital (SEYH).

METHODS

The SEYH-WBI, consisting of 4 positive affect (PA) items and 7 negative affect (NA) items developed from 5 validated surveys, was administered (n = 419). A non-burnout inventory (SEYH-NBI) consisting of 2 PA items and 3 NA items was derived from the SEYH-WBI. The Positive and Negative Affect Schedule (PANAS), a validated survey consisting of 10 PA items and 10 NA items, was conducted (n = 191). The Maslach Burnout Inventory (MBI), a validated survey consisting of 3 domains (3 items each), was completed (n = 150).

RESULTS

For the SEYH-WBI, Cronbach coefficients were 0.76 for PA items and 0.83 for NA items. The NA item loading on factor 1 was 0.55-0.84 and the PA item loading on factor 2 was 0.47-0.89. Confirmatory indices were as follows: root mean square residual, 0.07 and Bentler Comparative Fit Index, 0.92. For the SEYH-NBI, Cronbach coefficients were 0.76 for PA items and 0.79 for NA items. The NA item loading on factor 1 was 0.80-0.87 and the PA item loading on factor 2 was 0.89-0.90. Confirmatory indices were as follows: root mean square residual, 0.02; and Bentler Comparative Fit Index, 0.99. PANAS correlations were as follows: SEYH-WBI PA and PANAS PA scores, r = 0.9; p <  0.0001; SEYH-WBI NA and PANAS NA scores, r = 0.9; p <  0.0001; SEYH-NBI PA and PANAS PA scores, r = 0.8; p <  0.0001; and SEYH-NBI NA and PANAS NA scores, r = 0.7; p <  0.0001. Correlations for SEYH-NBI and MBI were as follows: total NBI and total MBI, r = - 0.6, p <  0.0001; NA and emotional exhaustion, r = 0.6, p <  0.0001; PA and personal accomplishment, r = 0.3, p = 0.0003; and NA and depersonalization, r = 0.3, p = 0.0008.

CONCLUSIONS

Validation assessments indicate that the SEYH-WBI and SEYH-NBI have acceptable psychometric performance. Similar findings in a larger cohort would be more compelling.

Detection of Mycobacterium tuberculosis RNA in bioaerosols from pulmonary tuberculosis patients

BACKGROUND

Bioaerosols from pulmonary tuberculosis (PTB) patients are a quantitative predictor of transmission. Current methods involve sophisticated instruments and time-consuming techniques to assess viable TB bacteria in bioaerosols. We tested the feasibility of detecting Mycobacterium tuberculosis (Mtb) specific RNA from bioaerosols retained on TB patients' masks.

METHODS

Adult PTB patients (n=33) were recruited at diagnosis before GeneXpert confirmation between April-2017 to February-2019 from private TB clinics in Mumbai. Face mask worn for 1 or 3h or N95 mask containing a cellulose acetate membrane worn for 5min by the patients were tested for the presence of Mtb RNA by quantitative PCR and bacterial load was estimated.

RESULTS

Quantitative PCR targeting rpoB, sigA,16S and fgd1 and sequencing of rpoB confirmed the presence of Mtb specific RNA in mask samples including masks of two patients with unproductive sputum. Membrane samples had seven-fold higher RNA and bacterial load that correlated to bacterial load estimated by sputum GeneXpert.

CONCLUSION

The study demonstrates that patient masks can be used to sample bioaerosols for detection of viable Mtb. The findings have translational value in the diagnosis of TB and monitoring Mtb variations between and within patients useful for assessing infectiousness and treatment response.

Using ‘Theories of Change’ and responsive feedback to design a digital service business for patent and proprietary medicine vendors in Nigeria

In a paper titled “Responsive feedback: Towards a new paradigm to enhance intervention effectiveness”, Viswanath et al. argue that dominant models of intervention design do not account for the complexity and unpredictability of implementation challenges.  Particularly in the behavioural sciences, intervention designs need to consider many factors that will be uncertain, or unknown, at the beginning of a new project. 

 This letter describes how we were able to respond to feedback during the design phase of a proof-of-concept project to create a digital service business for Nigerian patent and proprietary medicine vendors (PPMVs).  Our approach was to create an initial ‘Theory of Change’ (ToC) based on a similar project with Kenyan shopkeepers.  This ToC was revised following user feedback and a landscape analysis with key stakeholders.  The new ToC required us to access additional funding to create a ‘digital ordering’ facility for the PPMVs.  Digital ordering provides a mechanism whereby we can reduce the prevalence of counterfeit medicines, offer the PPMVs credit and group-buying facilities, and reduce supply chain costs through co-distribution with fast-moving consumer goods.

 An important learning point was that while our focus was on designing a platform to meet users’ needs, changes in regulation meant that we spent considerably more time than anticipated meeting the needs of multiple stakeholders. However, the importance of ensuring stakeholders’ continued buy-in cannot be underestimated and has likely increased the sustainability of the project in the longer term.

 As Viswanath et al. suggest, for responsive approaches to be widely adopted needs more flexibility than exists in current funding models and project plans.  Both funding bodies and grantees will need to be more responsive to feedback coming from the field.

A genomic approach to inferring kinship reveals limited intergenerational dispersal in the yellow fever mosquito

Understanding past dispersal and breeding events can provide insight into ecology and evolution and can help inform strategies for conservation and the control of pest species. However, parent-offspring dispersal can be difficult to investigate in rare species and in small pest species such as mosquitoes. Here, we develop a methodology for estimating parent-offspring dispersal from the spatial distribution of close kin, using pairwise kinship estimates derived from genome-wide single nucleotide polymorphisms (SNPs). SNPs were scored in 162 Aedes aegypti (yellow fever mosquito) collected from eight close-set, high-rise apartment buildings in an area of Malaysia with high dengue incidence. We used the SNPs to reconstruct kinship groups across three orders of kinship. We transformed the geographical distances between all kin pairs within each kinship category into axial standard deviations of these distances, then decomposed these into components representing past dispersal events. From these components, we isolated the axial standard deviation of parent-offspring dispersal and estimated neighbourhood area (129 m), median parent-offspring dispersal distance (75 m) and oviposition dispersal radius within a gonotrophic cycle (36 m). We also analysed genetic structure using distance-based redundancy analysis and linear regression, finding isolation by distance both within and between buildings and estimating neighbourhood size at 268 individuals. These findings indicate the scale required to suppress local outbreaks of arboviral disease and to target releases of modified mosquitoes for mosquito and disease control. Our methodology is readily implementable for studies of other species, including pests and species of conservation significance.

Intervening along the spectrum of tuberculosis: meeting report from the World TB Day nanosymposium in the Institute of Infectious Disease and Molecular Medicine at the University of Cape Town

Tuberculosis, caused by the highly infectious Mycobacterium tuberculosis, remains a leading cause of death worldwide, with an estimated 1.6 million associated deaths reported in 2017. In South Africa, an estimated 322,000 people were infected with TB in 2017, and a quarter of them lost their lives due to the disease. Bacille Calmette-Guérin remains the only effective vaccine against disseminated TB, but its inability to confer complete protection against pulmonary TB in adolescents and adults calls for an urgent need to develop new and better vaccines. There is also a need to identify markers of disease protection and develop novel drugs. On March 25th 2019, the Institute of Infectious Disease and Molecular Medicine at the University of Cape Town hosted the second annual World TB Day nanosymposium. The theme of the nanosymposium was “Intervening across the spectrum of TB II” and the goal was to commemorate World TB Day by showcasing research insights shared by early-career scientists and researchers in the field. The speakers spoke on four broad topics: identification of novel drug targets, development of host-directed drug therapies, transmission of tuberculosis and immunology of TB/HIV co-infections. Assistant Professor Bryan Bryson gave a highly interesting keynote address that showcased the application of engineering tools to answer fundamental biological questions, particularly in the context of tuberculosis.

Is Anopheles gambiae a Natural Host of Wolbachia?

Wolbachia (Alphaproteobacteria, Rickettsiales) is an intraovarially transmitted symbiont of insects able to exert striking phenotypes, including reproductive manipulations and pathogen blocking. These phenotypes make Wolbachia a promising tool to combat mosquito-borne diseases. Although Wolbachia is present in the majority of terrestrial arthropods, including many disease vectors, it was considered absent from Anopheles gambiae mosquitos, the main vectors of malaria in sub-Saharan Africa. In 2014, Wolbachia sequences were detected in A. gambiae samples collected in Burkina Faso. Subsequently, similar evidence came from collections all over Africa, revealing a high Wolbachia 16S rRNA sequence diversity, low abundance, and a lack of congruence between host and symbiont phylogenies. Here, we reanalyze and discuss recent evidence on the presence of Wolbachia sequences in A. gambiae. We find that although detected at increasing frequencies, the unusual properties of these Wolbachia sequences render them insufficient to diagnose natural infections in A. gambiae Future studies should focus on uncovering the origin of Wolbachia sequence variants in Anopheles and seeking sequence-independent evidence for this new symbiosis. Understanding the ecology of Anopheles mosquitos and their interactions with Wolbachia will be key in designing successful, integrative approaches to limit malaria spread. Although the prospect of using Wolbachia to fight malaria is intriguing, the newly discovered strains do not bring it closer to realization.IMPORTANCEAnopheles gambiae mosquitos are the main vectors of malaria, threatening around half of the world's population. The bacterial symbiont Wolbachia can interfere with disease transmission by other important insect vectors, but until recently, it was thought to be absent from natural A. gambiae populations. Here, we critically analyze the genomic, metagenomic, PCR, imaging, and phenotypic data presented in support of the presence of natural Wolbachia infections in A. gambiae We find that they are insufficient to diagnose Wolbachia infections and argue for the need of obtaining robust data confirming basic Wolbachia characteristics in this system. Determining the Wolbachia infection status of Anopheles is critical due to its potential to influence Anopheles population structure and Plasmodium transmission.

Providers and women's perspectives on person-centered maternity care: a mixed methods study in Kenya

Background

Globally, there has been increasing attention to women’s experiences of care and calls for a person-centered care approach. At the heart of this approach is the patient-provider relationship. It is necessary to examine the extent to which providers and women agree on the care that is provided and received. Studies have found that incongruence between women’s and providers’ perceptions may negatively impact women’s compliance, satisfaction, and future use of health facilities. However, there are no studies that examine patient and provider perspectives on person-centered care.

Methods

To fill this gap in the literature, we use cross-sectional data of 531 women and 33 providers in seven government health facilities in Kenya to assess concordance and discordance in person-centered care measures. Additionally, we analyze 41 in-depth interviews with providers from three of these facilities to examine why differences in reporting may occur. Descriptive statistical methods were used to measure the magnitude of differences between reports of women and reports of providers. Thematic analyses were conducted for provider surveys.

Results

Our findings suggest high discordance between women and providers’ perspectives in regard to person-centered care experiences. On average, women reported lower levels of person-centered care compared to providers, including low respectful and dignified care, communication and autonomy, and supportive care. Providers were more likely to report higher rates of poor health facility environment such as having sufficient staff. We summarize the overarching reasons for the divergence in women and provider reports as: 1) different understanding or interpretation of person-centered care behaviors, and 2) different expectations, norms or values of provider behaviors. Providers rationalized abuse towards women, did not allow a companion of choice, and blamed women for poor patient-provider communication. Women lacked assurance in privacy and confidentiality, and faced challenges related to the health facility environment. Providers attributed poor person-centered care to both individual and facility/systemic factors.

Conclusions

Implications of this study suggests that providers should be trained on person-centered care approaches and women should be counseled on understanding patient rights and how to communicate with health professionals.

Sustained Wolbachia-mediated blocking of dengue virus isolates following serial passage in Aedes aegypti cell culture

Wolbachia is an intracellular endosymbiont of insects that inhibits the replication of a range of pathogens in its arthropod hosts. The release of Wolbachia into wild populations of mosquitoes is an innovative biocontrol effort to suppress the transmission of arthropod-borne viruses (arboviruses) to humans, most notably dengue virus. The success of the Wolbachia-based approach hinges upon the stable persistence of the ‘pathogen blocking’ effect, whose mechanistic basis is poorly understood. Evidence suggests that Wolbachia may affect viral replication via a combination of competition for host resources and activation of host immunity. The evolution of resistance against Wolbachia and pathogen blocking in the mosquito or the virus could reduce the public health impact of the symbiont releases. Here, we investigate if dengue 3 virus (DENV-3) is capable of accumulating adaptive mutations that improve its replicative capacity during serial passage in Wolbachia wMel-infected cells. During the passaging regime, viral isolates in Wolbachia-infected cells exhibited greater variation in viral loads compared to controls. The viral loads of these isolates declined rapidly during passaging due to the blocking effects of Wolbachia carriage, with several being lost all together and the remainder recovering to low but stable levels. We attempted to sequence the genomes of the surviving passaged isolates but, given their low abundance, were unable to obtain sufficient depth of coverage for evolutionary analysis. In contrast, viral loads in Wolbachia-free control cells were consistently high during passaging. The surviving isolates passaged in the presence of Wolbachia exhibited a reduced ability to replicate even in Wolbachia-free cells. These experiments demonstrate the challenge for dengue in evolving resistance to Wolbachia-mediated blocking.

Xpert MTB/RIF and Xpert MTB/RIF Ultra for pulmonary tuberculosis and rifampicin resistance in adults

BACKGROUND

Xpert MTB/RIF (Xpert MTB/RIF) and Xpert MTB/RIF Ultra (Xpert Ultra), the newest version, are the only World Health Organization (WHO)-recommended rapid tests that simultaneously detect tuberculosis and rifampicin resistance in persons with signs and symptoms of tuberculosis, at lower health system levels. A previous Cochrane Review found Xpert MTB/RIF sensitive and specific for tuberculosis (Steingart 2014). Since the previous review, new studies have been published. We performed a review update for an upcoming WHO policy review.

OBJECTIVES

To determine diagnostic accuracy of Xpert MTB/RIF and Xpert Ultra for tuberculosis in adults with presumptive pulmonary tuberculosis (PTB) and for rifampicin resistance in adults with presumptive rifampicin-resistant tuberculosis.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register, MEDLINE, Embase, Science Citation Index, Web of Science, Latin American Caribbean Health Sciences Literature, Scopus, the WHO International Clinical Trials Registry Platform, the International Standard Randomized Controlled Trial Number Registry, and ProQuest, to 11 October 2018, without language restriction.

SELECTION CRITERIA

Randomized trials, cross-sectional, and cohort studies using respiratory specimens that evaluated Xpert MTB/RIF, Xpert Ultra, or both against the reference standard, culture for tuberculosis and culture-based drug susceptibility testing or MTBDRplus for rifampicin resistance.

DATA COLLECTION AND ANALYSIS

Four review authors independently extracted data using a standardized form. When possible, we also extracted data by smear and HIV status. We assessed study quality using QUADAS-2 and performed meta-analyses to estimate pooled sensitivity and specificity separately for tuberculosis and rifampicin resistance. We investigated potential sources of heterogeneity. Most analyses used a bivariate random-effects model. For tuberculosis detection, we first estimated accuracy using all included studies and then only the subset of studies where participants were unselected, i.e. not selected based on prior microscopy testing.

MAIN RESULTS

We identified in total 95 studies (77 new studies since the previous review): 86 studies (42,091 participants) evaluated Xpert MTB/RIF for tuberculosis and 57 studies (8287 participants) for rifampicin resistance. One study compared Xpert MTB/RIF and Xpert Ultra on the same participant specimen.Tuberculosis detectionOf the total 86 studies, 45 took place in high tuberculosis burden and 50 in high TB/HIV burden countries. Most studies had low risk of bias.Xpert MTB/RIF pooled sensitivity and specificity (95% credible Interval (CrI)) were 85% (82% to 88%) and 98% (97% to 98%), (70 studies, 37,237 unselected participants; high-certainty evidence). We found similar accuracy when we included all studies.For a population of 1000 people where 100 have tuberculosis on culture, 103 would be Xpert MTB/RIF-positive and 18 (17%) would not have tuberculosis (false-positives); 897 would be Xpert MTB/RIF-negative and 15 (2%) would have tuberculosis (false-negatives).Xpert Ultra sensitivity (95% confidence interval (CI)) was 88% (85% to 91%) versus Xpert MTB/RIF 83% (79% to 86%); Xpert Ultra specificity was 96% (94% to 97%) versus Xpert MTB/RIF 98% (97% to 99%), (1 study, 1439 participants; moderate-certainty evidence).Xpert MTB/RIF pooled sensitivity was 98% (97% to 98%) in smear-positive and 67% (62% to 72%) in smear-negative, culture-positive participants, (45 studies). Xpert MTB/RIF pooled sensitivity was 88% (83% to 92%) in HIV-negative and 81% (75% to 86%) in HIV-positive participants; specificities were similar 98% (97% to 99%), (14 studies).Rifampicin resistance detectionXpert MTB/RIF pooled sensitivity and specificity (95% Crl) were 96% (94% to 97%) and 98% (98% to 99%), (48 studies, 8020 participants; high-certainty evidence).For a population of 1000 people where 100 have rifampicin-resistant tuberculosis, 114 would be positive for rifampicin-resistant tuberculosis and 18 (16%) would not have rifampicin resistance (false-positives); 886 would be would be negative for rifampicin-resistant tuberculosis and four (0.4%) would have rifampicin resistance (false-negatives).Xpert Ultra sensitivity (95% CI) was 95% (90% to 98%) versus Xpert MTB/RIF 95% (91% to 98%); Xpert Ultra specificity was 98% (97% to 99%) versus Xpert MTB/RIF 98% (96% to 99%), (1 study, 551 participants; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

We found Xpert MTB/RIF to be sensitive and specific for diagnosing PTB and rifampicin resistance, consistent with findings reported previously. Xpert MTB/RIF was more sensitive for tuberculosis in smear-positive than smear-negative participants and HIV-negative than HIV-positive participants. Compared with Xpert MTB/RIF, Xpert Ultra had higher sensitivity and lower specificity for tuberculosis and similar sensitivity and specificity for rifampicin resistance (1 study). Xpert MTB/RIF and Xpert Ultra provide accurate results and can allow rapid initiation of treatment for multidrug-resistant tuberculosis.

Personalized Text Messages and Automated Calls for Improving Vaccine Coverage Among Children in Pakistan: Protocol for a Community-Based Cluster Randomized Clinical Trial

BACKGROUND

A major reason for poor childhood vaccine coverage in developing countries is the lack of awareness among parents and caregivers regarding the need for immunization and the importance of completing the entire series of vaccines. Short message service (SMS)-based interventions have been quite effective in different programs such as smoking cessation, treatment adherence, health care scheduled appointment attendance, antenatal care attendance, and compliance to immunization. However, there are limited data from low- and middle-income countries on the role of SMS and automated call-based messages and interventions to improve routine immunization (RI) coverage.

OBJECTIVE

The primary objective of this study is to evaluate whether automated mobile phone-based personalized messages (SMS or automated call) can improve RI uptake at 6, 10, and 14 weeks of age per the expanded program immunization schedule, compared with a usual care control group. Secondary objectives include assessing the effects of different types of automated SMS text or calls on RI coverage at 20 weeks of age.

METHODS

This is a mixed methods study using a clustered randomized controlled trial with 4 intervention arms and 1 control arm, augmented by qualitative interviews for personalizing the message. The study is being conducted in Pakistan (an urban site in Karachi and a rural site Matiari). In Karachi, 250 administrative structures are taken as 1 cluster, whereas in Matiari, a catchment area of 4 Lady Health Workers is considered as 1 cluster. The intervention targets families to receive weekly 1-way or 2-way (interactive) personalized automated SMS or automated phone call messages regarding vaccination. Possible barriers to vaccination are assessed in each family at the time of inclusion to determine the type of personalized messages that should be sent to the family to increase the chance of a positive response. Finally, in-depth interviews using purposive sampling are conducted before and after the trial to determine the family's vaccination experience and related factors.

RESULTS

All study participants for the cluster randomized trial were enrolled by January 14, 2019. Study exit interviews at 20-weeks follow-up visits will be completed by June 2019.

CONCLUSIONS

The results of this study will be useful to understand the respective effects of SMS text messages versus automated phone-based communication to improve RI coverage and timelines. Moreover, information regarding families' perceptions of vaccination and the daily life challenges for timely visits to the vaccine clinic will be used for developing more complex interventions that use mobile phone messages and possibly other approaches to overcome barriers in the uptake of correct and timely immunization practices.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03341195; https://clinicaltrials.gov/ct2/show/NCT03341195 (Archived by WebCite at http://www.webcitation.org/78EWA56Uo).

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/12851.

Trends in global health financing

Low income countries are still unable to fund a basic package of health services

Knowledge, perception and experience of sexual entrapment among undergraduate students of the University of Ibadan, Nigeria

Background: Deceit into sexual activities without the victim being aware of the intended action is common in tertiary institutions as the environment promote activities that make students vulnerable, especially females, young and new students. The resulting physical, psychological and social consequences, including harassment, sexual assault, non-consensual sex, injury, psychological trauma and suicide attempts, have affected many young people. This study was aimed at exploring the knowledge, perception, experience of sexual entrapment among undergraduate students of the University of Ibadan, Ibadan, Nigeria. Methods: This multi-stage cross-sectional survey involved 422 participants using semi-structured questionnaire and an in-depth interview guide. Quantitative data were analyzed statistically, while Qualitative data was analyzed thematically. Results: Mean age of respondents was 20.5±3.0 years, 52.6% were males, 58.8% and 81% had a good knowledge and perception of sexual entrapment, respectively. Prevalence of sexual entrapment was 18%, affecting more males (55.3%) and first year students (39.5%), 59.2% of the perpetrators are friends of the victim. Students were entrapped on campus through; emotional support (42.1%), money (34.2%), accommodation assistance (7.9%), material things/gifts (21.1%), assignment assistance (10.5%), help with registration (4.0%), religious activities (6.6%), debt repayment (11.8%) and counseling (9.2%). It resulted to; unwanted sex (34%), rape (4%), pregnancy (1.3%), STDs (4%), Injury (13%), psychological trauma (27.6%), loss of trust (52.6%) and attempted suicide (23.7%) among victims. Effective coping mechanisms were adopted by 55.3% of respondents. There was a significant association between knowledge and perception; knowledge and experience; perception and experience (p<0.05). Findings from the in-depth interview revealed care, tutoring, political positions, and pretense to need help as other tactics. Conclusions: Sexual entrapment is common on campus, affecting males and females, knowledge and perception influence experience of sexual entrapment, requiring the need for a holistic approach to reduce its prevalence.

Perceptions and experiences of skilled birth attendants on using a newly developed strap-on electronic fetal heart rate monitor in Tanzania

BACKGROUND

Regular fetal heart rate monitoring during labor can drastically reduce fresh stillbirths and neonatal mortality through early detection and management of fetal distress. Fetal monitoring in low-resource settings is often inadequate. An electronic strap-on fetal heart rate monitor called Moyo was introduced in Tanzania to improve intrapartum fetal heart rate monitoring. There is limited knowledge about how skilled birth attendants in low-resource settings perceive using new technology in routine labor care. This study aimed to explore the attitude and perceptions of skilled birth attendants using Moyo in Dar es Salaam, Tanzania.

METHODS

A qualitative design was used to collect data. Five focus group discussions and 10 semi-structured in-depth interviews were carried out. In total, 28 medical doctors and nurse/midwives participated in the study. The data was analyzed using qualitative content analysis.

RESULTS

The participants in the study perceived that the device was a useful tool that made it possible to monitor several laboring women at the same time and to react faster to fetal distress alerts. It was also perceived to improve the care provided to the laboring women. Prior to the introduction of Moyo, the participants described feeling overwhelmed by the high workload, an inability to adequately monitor each laboring woman, and a fear of being blamed for negative fetal outcomes. Challenges related to use of the device included a lack of adherence to routines for use, a lack of clarity about which laboring women should be monitored continuously with the device, and misidentification of maternal heart rate as fetal heart rate.

CONCLUSION

The electronic strap-on fetal heart rate monitor, Moyo, was considered to make labor monitoring easier and to reduce stress. The study findings highlight the importance of ensuring that the device's functions, its limitations and its procedures for use are well understood by users.

Taking stock of the present and looking ahead: envisioning challenges in the design of future HIV prevention efficacy trials

Despite the recent success of antiretrovirals for HIV prevention, additional, more effective, or more acceptable biomedical interventions will ultimately be needed to end the HIV epidemic. Designing clinical trials to evaluate the efficacy of new products that reduce HIV infection risk is challenging because of the existence of highly effective interventions to prevent HIV. However, the implementation of these interventions is uneven, and the fact that multiple HIV prevention efficacy trials are currently evaluating new products means the field confronts uncertainty in the emerging standard of prevention. In this Viewpoint, we take stock of the current state of HIV prevention, and subsequently discuss the key challenges in designing future trials to evaluate the next generation of HIV prevention products. We also highlight gaps in the knowledge base that need to be addressed to advance the design of research. Future trials are tenable, even in the context of existing and effective interventions, and should involve careful statistical approaches and multidisciplinary collaborative design.

The Incremental Cost of Delivering PrEP as a Bridge to ART for HIV Serodiscordant Couples in Public HIV Care Clinics in Kenya

Background

In 2016, the Kenyan Ministry of Health (MOH) released guidelines that recommend preexposure prophylaxis (PrEP) for persons with substantial ongoing HIV risk, including those in HIV serodiscordant partnerships. Estimates of the costs of delivering PrEP within Kenyan public health facilities are needed for planning for PrEP scale up.

Methods

We estimated the incremental annual costs of providing PrEP to HIV uninfected partners as a time-limited “bridge” until the infected partner is virally suppressed on ART within HIV serodiscordant couples as part of routine clinic care in Thika, Kenya. Costs were collected from the Partners Demonstration Project, a prospective evaluation of integrated delivery of preexposure prophylaxis (PrEP) and antiretroviral therapy (ART) to high-risk HIV serodiscordant couples. We conducted time and motion studies to distinguish between activities related to research, routine clinical care, and PrEP delivery. Costs (2015 US dollars) were collected from the MOH perspective and divided into staff, transportation, equipment, supplies, buildings and overhead, and start-up.

Results

PrEP related activities conducted during the screening, enrollment, and follow-up visits took an average of 13 minutes, 51 minutes, and 12 minutes, respectively. Assuming a staff structure of 3 counselors, 1 nurse, and 2 clinicians, we estimate that 3,178 couples can be screened, 1,444 couples offered PrEP and ART, and 6,138 couples followed up annually in an average HIV care clinic. Using costs incurred by the MOH for personnel, drug, and laboratory tests, we estimate that the incremental cost of offering PrEP to HIV uninfected partners within existing ART programs is $86.79 per couple per year. Personnel and PrEP medication made up the largest portion of the costs. We estimate that the total cost to Ministry of Health of delivering integrated PrEP and ART program in public health facilities is $250.19 per HIV serodiscordant couple per year.

Conclusions

Time-limited provision of PrEP to the HIV uninfected partner within HIV serodiscordant couples can be an affordable delivery model implemented in HIV care programs in Kenya and similar settings. These costs can be used for budgetary planning and cost effectiveness analyses.

Adherence to the iDSI reference case among published cost-per-DALY averted studies

BACKGROUND

The iDSI reference case, originally published in 2014, aims to improve the quality and comparability of cost-effectiveness analyses (CEA). This study assesses whether the development of the guideline is associated with an improvement in methodological and reporting practices for CEAs using disability-adjusted life-years (DALYs).

METHODS

We analyzed the Tufts Medical Center Global Health CEA Registry to identify cost-per-DALY averted studies published from 2011 to 2017. Among each of 11 principles in the iDSI reference case, we translated all methodological specifications and reporting standards into a series of binary questions (satisfied or not satisfied) and awarded articles one point for each item satisfied. We then calculated methodological and reporting adherence scores separately as a percentage of total possible points, measured as normalized adherence score (0% = no adherence; 100% = full adherence). Using the year 2014 as the dissemination period, we conducted a pre-post analysis. We also conducted sensitivity analyses using: 1) optional criteria in scoring, 2) alternate dissemination period (2014-2015), and 3) alternative comparator classification.

RESULTS

Articles averaged 60% adherence to methodological specifications and 74% adherence to reporting standards. While methodological adherence scores did not significantly improve (59% pre-2014 vs. 60% post-2014, p = 0.53), reporting adherence scores increased slightly over time (72% pre-2014 vs. 75% post-2014, p<0.01). Overall, reporting adherence scores exceeded methodological adherence scores (74% vs. 60%, p<0.001). Articles seldom addressed budget impact (9% reporting, 10% methodological) or equity (7% reporting, 7% methodological).

CONCLUSIONS

The iDSI reference case has substantial potential to serve as a useful resource for researchers and policy-makers in global health settings, but greater effort to promote adherence and awareness is needed to achieve its potential.

Short Message Service (SMS) Surveys Assessing Pre-exposure Prophylaxis (PrEP) Adherence and Sexual Behavior are Highly Acceptable Among HIV-Uninfected Members of Serodiscordant Couples in East Africa: A Mixed Methods Study

Short message service (SMS) surveys are a promising data collection method and were used to measure sexual behavior and adherence to HIV pre-exposure prophylaxis (PrEP) among HIV-uninfected partners of serodiscordant couples enrolled in a sub-study of the Partners Demonstration Project (an open-label study of integrated antiretroviral therapy and PrEP for HIV prevention in Kenya and Uganda). Questionnaires were completed by 142 participants after study exit. Median age was 29 years; 69% were male. Ninety-five percent (95%) felt SMS surveys were "easy" or "very easy", 74% reported no challenges, and 72% preferred SMS surveys over in-person study visits. Qualitative interviews involving 32 participants confirmed the ease of responding to SMS surveys. Participants also indicated that surveys acted as reminders for adherence to PrEP and condom use and were experienced as support from the study. SMS surveys were generally found to be acceptable in this population and provided real-time context of PrEP use.

Functional Connectivity in Term Neonates With Hypoxic-Ischemic Encephalopathy Undergoing Therapeutic Hypothermia

BACKGROUND

We investigated whether therapeutic hypothermia and rewarming impact functional connectivity using electroencephalography (EEG) as a measure in neonates with hypoxic-ischemic encephalopathy. We hypothesized that EEG coherence and voltage correlations would be lower and phase lag greater in infants with hypoxic-ischemic encephalopathy than control subjects and that functional connectivity would evolve during therapeutic hypothermia with the greatest improvement occurring during rewarming.

METHODS

This study was a retrospective study of 14 term neonates (greater than 37 weeks) with moderate hypoxic-ischemic encephalopathy who underwent therapeutic hypothermia and rewarming. Continuous EEG and video monitoring was conducted for 96 hours during therapeutic hypothermia and rewarming. The primary quantitative EEG measures of functional connectivity were coherence, phase lag, and voltage correlations. These EEG parameters were compared with a cohort of normal age-matched neonates.

RESULTS

Neonates with hypoxic-ischemic encephalopathy had marked decreases in power, coherences, and voltage correlation and increases in phase lag when compared with control neonates. However, there were no significant changes in these measures between therapeutic hypothermia and rewarming.

CONCLUSIONS

Neonates with hypoxic-ischemic encephalopathy demonstrate significant abnormalities in functional connectivity compared with control subjects. These abnormalities persist through therapeutic hypothermia and rewarming and are not altered after rewarming. Although hypoxic-ischemic encephalopathy is associated with impaired functional brain connectivity, there is no evidence, using quantitative EEG measures, that therapeutic hypothermia or rewarming either improves or exacerbates these abnormalities in connectivity.

Datastorr: a workflow and package for delivering successive versions of 'evolving data' directly into R

The sharing and re-use of data has become a cornerstone of modern science. Multiple platforms now allow easy publication of datasets. So far, however, platforms for data sharing offer limited functions for distributing and interacting with evolving datasets- those that continue to grow with time as more records are added, errors fixed, and new data structures are created. In this article, we describe a workflow for maintaining and distributing successive versions of an evolving dataset, allowing users to retrieve and load different versions directly into the R platform. Our workflow utilizes tools and platforms used for development and distribution of successive versions of an open source software program, including version control, GitHub, and semantic versioning, and applies these to the analogous process of developing successive versions of an open source dataset. Moreover, we argue that this model allows for individual research groups to achieve a dynamic and versioned model of data delivery at no cost.

An open toolkit for tracking open science partnership implementation and impact

Serious concerns about the way research is organized collectively are increasingly being raised. They include the escalating costs of research and lower research productivity, low public trust in researchers to report the truth, lack of diversity, poor community engagement, ethical concerns over research practices, and irreproducibility. Open science (OS) collaborations comprise of a set of practices including open access publication, open data sharing and the absence of restrictive intellectual property rights with which institutions, firms, governments and communities are experimenting in order to overcome these concerns. We gathered two groups of international representatives from a large variety of stakeholders to construct a toolkit to guide and facilitate data collection about OS and non-OS collaborations. Ultimately, the toolkit will be used to assess and study the impact of OS collaborations on research and innovation. The toolkit contains the following four elements: 1) an annual report form of quantitative data to be completed by OS partnership administrators; 2) a series of semi-structured interview guides of stakeholders; 3) a survey form of participants in OS collaborations; and 4) a set of other quantitative measures best collected by other organizations, such as research foundations and governmental or intergovernmental agencies. We opened our toolkit to community comment and input. We present the resulting toolkit for use by government and philanthropic grantors, institutions, researchers and community organizations with the aim of measuring the implementation and impact of OS partnership across these organizations. We invite these and other stakeholders to not only measure, but to share the resulting data so that social scientists and policy makers can analyse the data across projects.

An open toolkit for tracking open science partnership implementation and impact

Serious concerns about the way research is organized collectively are increasingly being raised. They include the escalating costs of research and lower research productivity, low public trust in researchers to report the truth, lack of diversity, poor community engagement, ethical concerns over research practices, and irreproducibility. Open science (OS) collaborations comprise of a set of practices including open access publication, open data sharing and the absence of restrictive intellectual property rights with which institutions, firms, governments and communities are experimenting in order to overcome these concerns. We gathered two groups of international representatives from a large variety of stakeholders to construct a toolkit to guide and facilitate data collection about OS and non-OS collaborations. Ultimately, the toolkit will be used to assess and study the impact of OS collaborations on research and innovation. The toolkit contains the following four elements: 1) an annual report form of quantitative data to be completed by OS partnership administrators; 2) a series of semi-structured interview guides of stakeholders; 3) a survey form of participants in OS collaborations; and 4) a set of other quantitative measures best collected by other organizations, such as research foundations and governmental or intergovernmental agencies. We opened our toolkit to community comment and input. We present the resulting toolkit for use by government and philanthropic grantors, institutions, researchers and community organizations with the aim of measuring the implementation and impact of OS partnership across these organizations. We invite these and other stakeholders to not only measure, but to share the resulting data so that social scientists and policy makers can analyse the data across projects.

Loss of cytoplasmic incompatibility in Wolbachia-infected Aedes aegypti under field conditions

Wolbachia bacteria are now being introduced into Aedes aegypti mosquito populations for dengue control. When Wolbachia infections are at a high frequency, they influence the local transmission of dengue by direct virus blocking as well as deleterious effects on vector mosquito populations. However, the effectiveness of this strategy could be influenced by environmental temperatures that decrease Wolbachia density, thereby reducing the ability of Wolbachia to invade and persist in the population and block viruses. We reared wMel-infected Ae. aegypti larvae in the field during the wet season in Cairns, North Queensland. Containers placed in the shade produced mosquitoes with a high Wolbachia density and little impact on cytoplasmic incompatibility. However, in 50% shade where temperatures reached 39°C during the day, wMel-infected males partially lost their ability to induce cytoplasmic incompatibility and females had greatly reduced egg hatch when crossed to infected males. In a second experiment under somewhat hotter conditions (>40°C in 50% shade), field-reared wMel-infected females had their egg hatch reduced to 25% when crossed to field-reared wMel-infected males. Wolbachia density was reduced in 50% shade for both sexes in both experiments, with some mosquitoes cleared of their Wolbachia infections entirely. To investigate the critical temperature range for the loss of Wolbachia infections, we held Ae. aegypti eggs in thermocyclers for one week at a range of cyclical temperatures. Adult wMel density declined when eggs were held at 26–36°C or above with complete loss at 30–40°C, while the density of wAlbB remained high until temperatures were lethal. These findings suggest that high temperature effects on Wolbachia are potentially substantial when breeding containers are exposed to partial sunlight but not shade. Heat stress could reduce the ability of Wolbachia infections to invade mosquito populations in some locations and may compromise the ability of Wolbachia to block virus transmission in the field. Temperature effects may also have an ecological impact on mosquito populations given that a proportion of the population becomes self-incompatible.

Aedes aegypti mosquitoes infected with Wolbachia symbionts are being deployed in the tropics as a way of reducing disease transmission. Some Wolbachia strains are vulnerable to high temperatures but these effects have not been evaluated outside of a laboratory setting. We reared Ae. aegypti infected with the wMel strain of Wolbachia in the field during the wet season in Cairns, Australia, where the first releases of Wolbachia-infected Ae. aegypti took place. wMel-infected mosquitoes became partially self-incompatible, with reduced egg hatch, when larvae were reared in partial shade where maximum daily temperatures exceeded 39°C. Under these conditions the amount of Wolbachia in adult mosquitoes was reduced to less than 1% of laboratory-reared mosquitoes on average, while some mosquitoes were cleared of Wolbachia entirely. In contrast, wMel was stable when mosquitoes were reared under cooler conditions in full shade. Field trials with the wMel strain are now underway in over 10 countries, but high temperatures in some locales may constrain the ability of Wolbachia to invade natural mosquito populations and block disease transmission.

Flooding in Townsville, North Queensland, Australia, in February 2019 and Its Effects on Mosquito-Borne Diseases

In February 2019, a major flooding event occurred in Townsville, North Queensland, Australia. Here we present a prediction of the occurrence of mosquito-borne diseases (MBDs) after the flooding. We used a mathematical modelling approach based on mosquito population abundance, survival, and size as well as current infectiousness to predict the changes in the occurrences of MBDs due to flooding in the study area. Based on 2019 year-to-date number of notifiable MBDs, we predicted an increase in number of cases, with a peak at 104 by one-half month after the flood receded. The findings in this study indicate that Townsville may see an upsurge in the cases of MBDs in the coming days. However, the burden of diseases will go down again if the mosquito control program being implemented by the City Council continues. As our predictions focus on the near future, longer term effects of flooding on the occurrence of mosquito-borne diseases need to be studied further.

Pluripotency of Wolbachia against Arboviruses: the case of yellow fever

Background: Yellow fever outbreaks have re-emerged in Brazil during 2016-18, with mortality rates up to 30%. Although urban transmission has not been reported since 1942, the risk of re-urbanization of yellow fever is significant, as Aedes aegypti is present in most tropical and sub-tropical cities in the World and still remains the main vector of urban YFV. Although the YFV vaccine is safe and effective, it does not always reach populations at greatest risk of infection and there is an acknowledged global shortage of vaccine supply. The introgression of Wolbachia bacteria into Ae. aegypti mosquito populations is being trialed in several countries ( www.worldmosquito.org) as a biocontrol method against dengue, Zika and chikungunya. Here, we studied the ability of Wolbachia to reduce the transmission potential of Ae. aegypti mosquitoes for Yellow fever virus (YFV). Methods: Two recently isolated YFV (primate and human) were used to challenge field-derived wild-type and Wolbachia-infected ( wMel +) Ae. aegypti mosquitoes. The YFV infection status was followed for 7, 14 and 21 days post-oral feeding (dpf). The YFV transmission potential of mosquitoes was evaluated via nano-injection of saliva into uninfected mosquitoes or by inoculation in mice. Results: We found that Wolbachia was able to significantly reduce the prevalence of mosquitoes with YFV infected heads and thoraces for both viral isolates. Furthermore, analyses of mosquito saliva, through indirect injection into naïve mosquitoes or via interferon-deficient mouse model, indicated Wolbachia was associated with profound reduction in the YFV transmission potential of mosquitoes (14dpf). Conclusions: Our results suggest that Wolbachia introgression could be used as a complementary strategy for prevention of urban yellow fever transmission, along with the human vaccination program.

Chest radiograph reading panel performance in a Bangladesh pneumococcal vaccine effectiveness study

Introduction

To evaluate WHO chest radiograph interpretation processes during a pneumococcal vaccine effectiveness study of children aged 3–35 months with suspected pneumonia in Sylhet, Bangladesh.

Methods

Eight physicians masked to all data were standardised to WHO methodology and interpreted chest radiographs between 2015 and 2017. Each radiograph was randomly assigned to two primary readers. If the primary readers were discordant for image interpretability or the presence or absence of primary endpoint pneumonia (PEP), then another randomly selected, masked reader adjudicated the image (arbitrator). If the arbitrator disagreed with both primary readers, or concluded no PEP, then a masked expert reader finalised the interpretation. The expert reader also conducted blinded quality control (QC) for 20% of randomly selected images. We evaluated agreement between primary readers and between the expert QC reading and the final panel interpretation using per cent agreement, unadjusted Cohen’s kappa, and a prevalence and bias-adjusted kappa.

Results

Among 9723 images, the panel classified 21.3% as PEP, 77.6% no PEP and 1.1% uninterpretable. Two primary readers agreed on interpretability for 98% of images (kappa, 0.25; prevalence and bias-adjusted kappa, 0.97). Among interpretable radiographs, primary readers agreed on the presence or absence of PEP in 79% of images (kappa, 0.35; adjusted kappa, 0.57). Expert QC readings agreed with final panel conclusions on the presence or absence of PEP for 92.9% of 1652 interpretable images (kappa, 0.75; adjusted kappa, 0.85).

Conclusion

Primary reader performance and QC results suggest the panel effectively applied the WHO chest radiograph criteria for pneumonia.

Host Determinants of Infectiousness in Smear-Positive Patients With Pulmonary Tuberculosis

Background

Epidemiologic data suggests that only a minority of tuberculosis (TB) patients are infectious. Cough aerosol sampling is a novel quantitative method to measure TB infectiousness.

Methods

We analyzed data from three studies conducted in Uganda and Brazil over a 13-year period. We included sputum acid fast bacilli (AFB) and culture positive pulmonary TB patients and used a cough aerosol sampling system (CASS) to measure the number of colony-forming units (CFU) of Mycobacterium tuberculosis in cough-generated aerosols as a measure for infectiousness. Aerosol data was categorized as: aerosol negative (CFU = 0) and aerosol positive (CFU > 0). Logistic regression models were built to identify factors associated with aerosol positivity.

Results

M. tuberculosis was isolated by culture from cough aerosols in 100/233 (43%) TB patients. In an unadjusted analysis, aerosol positivity was associated with fewer days of antituberculous therapy before CASS sampling (p = .0001), higher sputum AFB smear grade (p = .01), shorter days to positivity in liquid culture media (p = .02), and larger sputum volume (p = .03). In an adjusted analysis, only fewer days of TB treatment (OR 1.47 per 1 day of therapy, 95% CI 1.16-1.89; p = .001) was associated with aerosol positivity.

Conclusion

Cough generated aerosols containing viable M. tuberculosis, the infectious moiety in TB, are detected in a minority of TB patients and rapidly become non-culturable after initiation of antituberculous treatment. Mechanistic studies are needed to further elucidate these findings.

Aedes-Chikungunya Virus Interaction: Key Role of Vector Midguts Microbiota and Its Saliva in the Host Infection

Aedes mosquitoes are important vectors for emerging diseases caused by arboviruses, such as chikungunya (CHIKV). These viruses’ main transmitting species are Aedes aegypti and Ae. albopictus, which are present in tropical and temperate climatic areas all over the globe. Knowledge of vector characteristics is fundamentally important to the understanding of virus transmission. Only female mosquitoes are able to transmit CHIKV to the vertebrate host since they are hematophagous. In addition, mosquito microbiota is fundamentally important to virus infection in the mosquito. Microorganisms are able to modulate viral transmission in the mosquito, such as bacteria of the Wolbachia genus, which are capable of preventing viral infection, or protozoans of the Ascogregarina species, which are capable of facilitating virus transmission between mosquitoes and larvae. The competence of the mosquito is also important in the transmission of the virus to the vertebrate host, since their saliva has several substances with biological effects, such as immunomodulators and anticoagulants, which are able to modulate the host’s response to the virus, interfering in its pathogenicity and virulence. Understanding the Aedes vector-chikungunya interaction is fundamentally important since it can enable the search for new methods of combating the virus’ transmission.

Vector competence of Australian Aedes aegypti and Aedes albopictus for an epidemic strain of Zika virus

BACKGROUND

Recent epidemics of Zika virus (ZIKV) in the Pacific and the Americas have highlighted its potential as an emerging pathogen of global importance. Both Aedes (Ae.) aegypti and Ae. albopictus are known to transmit ZIKV but variable vector competence has been observed between mosquito populations from different geographical regions and different virus strains. Since Australia remains at risk of ZIKV introduction, we evaluated the vector competence of local Ae. aegypti and Ae. albopictus for a Brazilian epidemic ZIKV strain. In addition, we evaluated the impact of daily temperature fluctuations around a mean of 28°C on ZIKV transmission and extrinsic incubation period.

METHODOLOGY/PRINCIPAL FINDINGS

Mosquitoes were orally challenged with a Brazilian ZIKV strain (8.8 log CCID50/ml) and maintained at either 28°C constant or fluctuating temperature conditions. At 3, 7 and 14 days post-infection (dpi), ZIKV RNA copies were quantified in mosquito bodies, as well as wings and legs, using qRT-PCR, while virus antigen in saliva (a proxy for transmission) was detected using a cell culture ELISA. Despite high body and disseminated infection rates in both vectors, the transmission rates of ZIKV in saliva of Ae. aegypti (50-60%) were significantly higher than in Ae. albopictus (10%) at 14 dpi. Both species supported a high viral load in bodies, with no significant differences between constant and fluctuating temperature conditions. However, a significant difference in viral load in wings and legs between species was observed, with higher titres in Ae. aegypti maintained at constant temperature conditions. For ZIKV transmission to occur in Ae. aegypti, a disseminated virus load threshold of 7.59 log10 copies had to be reached.

CONCLUSIONS/SIGNIFICANCE

Australian Ae. aegypti are better able to transmit a Brazilian ZIKV strain than Ae. albopictus. The results are in agreement with the global consensus that Ae. aegypti is the major vector of ZIKV.

Adopting a logical framework model to help achieve a balanced and healthy vaccine R&D portfolio

Vaccines are currently the 5th biggest therapy area with global sales for prophylactic and therapeutic vaccines to be ~ $30B, which is expected to increase to $45B by 2024. Immunization is globally recognized as one of the best investments to improve health, with impact lasting beyond saving 2-3M lives every year with benefits accrued over a lifetime. Enterprise value of any R&D company is a cumulative sum of its projects and proprietary technologies. Hence organizations need to continuously evaluate their portfolios to review the health of projects as changes in external environment may impact project viability. Simultaneously, addition of any new project in a company’s portfolio is a significant investment and needs to be evaluated using an objective multi-parametric framework. In this pursuit, Hilleman Labs, an equal joint venture by MSD and Wellcome Trust, has created a logical framework to evaluate potential vaccine candidates before they are added to the portfolio.

The benefits of family planning (FP) use in Benin: an application of the Demographic Dividend Model (DemDiv)

Background: Despite the increasing interest in improving access to and utilization of family planning (FP) methods, contraceptives prevalence rates remain low in Benin, and its benefits are not well studied. This study projected FP's benefits for maternal health and child survival over the Sustainable Development Goals period. Methods: The Demographic Dividend Model created by the Health Policy Project using a large range of data was applied based exclusively on assumptions on FP policy options between 2015 and 2030. Results: It was found that, under the base scenario with no improvements in FP, education and economic variables, however unrealistic, the number of children per Beninese woman would be the same in 2030 as it was in 2015 - about 4.5 children per woman. Benin's age structure would remain very young and be dominated by dependents. But, FP-scenarios of improvements in contraceptive variables alone showed a negative and linear relationship between FP use and maternal and child deaths. Under the optimistic scenario, increasing access to and use of FP alone from 7.9% (2015) to 33.95% (2030) will save lives of about 200,000 under five year children and 10,000 mothers by 2030. In addition, the average number of children per woman will fall to 3.5 increasing female life expectancy by 5 years. Benin's age structure will be balanced with more working age people. The country will also record an increase in its human development indicator. Conclusion: To accelerate progresses towards improvement of maternal health and child survival, and get on track in meeting related health targets of SDGs, the present study revealed the importance of strengthening actions toward access to and use of FP in Benin Republic. There is also a need to strengthen education and economic policies to successfully harness the demographic dividend.

Self-administration of injectable contraception: a systematic review and meta-analysis

Introduction

Depot medroxyprogesterone acetate subcutaneous injectable contraception (DMPA-SC) may facilitate self-administration and expand contraceptive access. To inform WHO guidelines on self-care interventions, we conducted a systematic review and meta-analysis comparing self-administration versus provider administration of injectable contraception on outcomes of pregnancy, side effects/adverse events, contraceptive uptake, contraceptive continuation, self-efficacy/empowerment and social harms.

Methods

We searched PubMed, Cumulative Index to Nursing and Allied Health Literature, LILACS and EMBASE in September 2018 for peer-reviewed studies comparing women who received injectable contraception with the option of self-administration with women who received provider-administered injectable contraception on at least one outcome of interest. Risk of bias was assessed using the Cochrane tool for randomised controlled trials (RCTs) and the Evidence Project tool for non-randomised studies. Meta-analysis was conducted using random-effects models to generate pooled estimates of relative risk (RR).

Results

Six studies with 3851 total participants met the inclusion criteria: three RCTs and three controlled cohort studies. All studies examined self-injection of DMPA-SC; comparison groups were either provider-administered DMPA-SC or provider-administered intramuscular DMPA. All studies followed women through 12 months of contraceptive coverage and measured (dis)continuation of injectable contraception. Meta-analysis found higher rates of continuation with self-administration compared with provider administration in three RCTs (RR: 1.27, 95% CI 1.16 to 1.39) and three controlled cohort studies (RR: 1.18, 95% CI 1.10 to 1.26). Four studies reported pregnancies; all showed no difference across study arms. Four studies reported side effects/adverse events; while two controlled cohort studies showed increased injection site reactions with self-administration, no other side effects increased with self-administration. One study found no difference in social harms. No studies reported measuring uptake or self-efficacy/empowerment.

Conclusion

A growing evidence base suggests that self-administration of DMPA-SC can equal or improve contraceptive continuation rates compared with provider administration. This benefit comes without notable increases in pregnancy or safety concerns. Self-injection of DMPA-SC is a promising approach to increasing contraceptive use.

Enrollment in HIV Care and Treatment Clinic and Associated Factors Among HIV Diagnosed Patients in Magu District, Tanzania

HIV care and treatment clinics (CTC) are important for management of HIV morbidity and mortality, and to reduce HIV transmission. Enrollment in HIV care and treatment clinics remains low in many developing countries. We followed up 632 newly diagnosed HIV patients aged 15 years and above from Magu District, Tanzania. Logistic regression was used to assess factors significantly associated with enrollment for CTC services. Kaplan-Meier plots and log-rank tests were used to evaluate differences in timing uptake of services. Among 632 participants, 214 (33.9%) were enrolled in CTC, and of those enrolled 120 (56.6%) took longer than 3 months to enroll. Those living in more rural villages were less likely to be enrolled than in the villages with semi-urban settings (OR 0.36; 95% CI 0.17-0.76). Moreover, those with age group 35-44 years and with age group 45 years and above were 2 times higher odds compared to those with age group 15-24 years, (OR 2.03; 95% CI 1.05-3.91) and (OR 2.69; 95% CI 1.40-5.18) respectively. Enrollment in the CTC in Tanzania is low. To increase uptake of antiretroviral therapy, it is critical to improve linkage between HIV testing and care services, and to rollout these services into the primary health facilities.

Implementation of a comprehensive safer conception intervention for HIV-serodiscordant couples in Kenya: uptake, use and effectiveness

INTRODUCTION

Safer conception strategies minimize HIV risk during condomless sex to become pregnant. Gaps remain in understanding the acceptability, feasibility and choices HIV-serodiscordant couples make when multiple safer conception options are available.

METHODS

We conducted a pilot study of a comprehensive safer conception package for HIV-serodiscordant couples with immediate fertility desires in Kenya from March 2016 to April 2018. The intervention package included antiretroviral therapy (ART) for HIV-positive partners, oral pre-exposure prophylaxis (PrEP) for HIV-negative partners, daily fertility and sexual behaviour tracking via short message service (SMS) surveys, counselling on self-insemination, and referrals for voluntary medical male circumcision and fertility care. Couples attended monthly visits until pregnancy with HIV testing for negative partners at each visit. We estimated the number of expected HIV seroconversions using a counterfactual cohort simulated from gender-matched couples in the placebo arm of a previous PrEP clinical trial. We used bootstrap methods to compare expected and observed seroconversions.

RESULTS

Of the 74 enrolled couples, 54% were HIV-negative female/HIV-positive male couples. The 6 and 12-month cumulative pregnancy rates were 45.3% and 61.9% respectively. In the month preceding pregnancy, 80.9% of HIV-positive partners were virally suppressed, 81.4% of HIV-negative partners were highly adherent to PrEP, and SMS surveys indicated potential timing of condomless sex to peak fertility (median of sex acts = 10, interquartile range (IQR) 7 to 12; median condomless sex acts = 3.5, IQR 1 to 7). Most (95.7%) pregnancies were protected by ≥2 strategies: 57.4% were protected by high PrEP and ART adherence, male circumcision with or without timed condomless sex; 10 (21.3%) were protected by viral suppression in the HIV-positive partner and male circumcision with or without timed condomless sex; 8 (17.0%) were protected by high PrEP adherence and male circumcision with or without timed condomless sex. We observed 0 HIV seroconversions (95% CI 0.0 to 6.0 per 100 person years), indicating a 100% reduction in HIV risk (p = 0.04).

CONCLUSIONS

The use of multiple safer conception strategies, primarily PrEP, ART, male circumcision and/or tracking fertility, was acceptable and feasible for African HIV-serodiscordant couples and significantly reduced HIV transmission risk. It is important to increase the availability of and counselling about safer conception services in regions with HIV epidemics involving heterosexual transmission and high fertility.

Cost per insertion and couple year of protection for postpartum intrauterine devices and implants provided during service scale-up in Kigali, Rwanda

Introduction: In two high-volume government hospitals, their two affiliated health facilities, and two additional health facilities, we developed and implemented postpartum intrauterine device (PPIUD) and postpartum (PP) implant promotional counseling and service delivery procedures between May-July 2017 in Kigali, Rwanda. Between August 2017 and July 2018, 9,073 pregnant women received PPIUD/PP implant promotions who later delivered in one of our selected facilities. Of those, 2,633 had PPIUDs inserted, and 955 had PP implants inserted. The goal of the present analysis is to detail implementation expenditures and estimate incremental costs per insertion and couple years of protection (CYP) for PPIUD and PP implant users. Methods: We detail the incremental costs during the implementation from the health system perspective (including both the implementation costs and the cost of contraceptive methods) and use of standard methods to estimate the cost per insertion and CYP for PPIUD and PP implant users. In addition to the incremental costs of labor and supplies, the costs of promotional activities are included. Research costs for formative work were excluded. Results: A total of $74,147 USD was spent on the implementation between August 2017 and July 2018. The largest expense (34% of total expenses) went toward personnel, including doctoral-level, administrative, data management and nurse counseling staff. Training for PPIUD and implant providers and promoters comprised 8% of total expenses. Recruitment and reimbursements comprised 6% of expenses. Costs of implants to the government comprised 12% of the expenses, much higher than the cost of IUDs (1%). Costs per insertion were $25/PPIUDs and $77/PP implant. Costs per CYP were $5/PPIUDs and $20/PP implant. Conclusion: Understanding the cost per PPIUD/PP implant inserted and CYP can help to inform the cost of scaling up PPIUD/PP implant service implementation activities and resource allocation decision-making by the Rwandan Ministry of Health.

Improving resource mobilisation for global health R&D: a role for coordination platforms?

Achieving many of the health targets in the Sustainable Development Goals will not be possible without increased financing for global health research and development (R&D). Yet financing for neglected disease product development fell from 2009-2015, with the exception of a one-time injection of Ebola funding. An important cause of the global health R&D funding gap is lack of coordination across R&D initiatives. In particular, existing initiatives lack robust priority-setting processes and transparency about investment decisions. Low-income countries (LICs) and middle-income countries (MICs) are also often excluded from global investment initiatives and priority-setting discussions, leading to limited investment by these countries. An overarching global health R&D coordination platform is one promising response to these challenges. This analysis examines the essential functions such a platform must play, how it should be structured to maximise effectiveness and investment strategies for diversifying potential investors, with an emphasis on building LIC and MIC engagement. Our analysis suggests that a coordination platform should have four key functions: building consensus on R&D priorities; facilitating information sharing about past and future investments; building in accountability mechanisms to track R&D spending against investment targets and curating a portfolio of prioritised projects alongside mechanisms to link funders to these projects. Several design features are likely to increase the platform’s success: public ownership and management; separation of coordination and financing functions; inclusion of multiple diseases; coordination across global and national efforts; development of an international R&D ‘roadmap’ and a strategy for the financial sustainability of the platform’s secretariat.