Comparison of standard and modified human landing catching techniques for blackfly collection

BACKGROUND

Human landing catches (HLCs) are required to collect blackflies for entomological evaluation to verify onchocerciasis elimination. However, there are ethical concerns regarding exposure of vector collectors to infectious blackflies and safer alternative methods are needed. This study evaluated a modified HLC technique where collectors wore coloured trousers (blue, black or blue-black), protecting them from bites during fly collection, and their performance was compared with the standard.

METHODS

The study was conducted in Makouopsap, Cameroon, in the Massangam health district for 4 months. Four collector pairs-one 'standard' (bare-legged) and three modified-were placed 50 m apart along known breeding sites on the Mbam and Nja Rivers. Collections were performed from 07:00 to 17:00 h, 4 d/month. Hourly rates of flies caught were analysed using a negative binomial generalised linear model to explore associations between flies caught and collection techniques and seasons.

RESULTS

Overall, 17 246 blackflies were caught. There was no significant statistical difference in the number of blackflies and parous flies caught between black trousers and the standard. Thus there is a strong indication that wearing black trousers is a viable non-inferior alternative to the standard HLC.

CONCLUSIONS

Further studies are needed to confirm generalisability in different ecozones and transmission environments and among different blackfly species.

Correction: Ivermectin and doxycycline treatments against Onchocerciasis: Adaptations and impact among semi-nomadic population in Massangam Health District, Cameroon

[This corrects the article DOI: 10.1371/journal.pntd.0011463.].

Cost of implementing a doxycycline test-and-treat strategy for onchocerciasis elimination among settled and semi-nomadic groups in Cameroon

BACKGROUND

Onchocerciasis is a neglected tropical disease with 217.5 million people globally at risk of having the infection. In both settled and semi-nomadic communities of Massangam Health District in Cameroon, Sightsavers has been carrying out test-and-treat with doxycycline and twice-yearly ivermectin distribution. This paper focuses on the cost of test-and-treat with doxycycline in the two community contexts of settled and semi-nomadic.

METHODS

For the valuation, a combination of gross or micro-costing was used to identify cost components, as well as bottom-up and top-down approaches. The opportunity costs of vehicle and equipment use were estimated and included. Not included, however, were the opportunity costs of building use and Ministry of Public Health staff salaries. We only captured the incremental costs of implementing test-and-treat activities as part of a functional annual community-directed treatment with the ivermectin programme.

RESULTS

We estimate the economic cost per person tested and cost per person treated in Massangam to be US$135 and US$667 respectively. Total implementation cost in the settled community was US$79,409, and in the semi-nomadic community US$69,957. Overall, the total economic cost of implementing the doxycycline test-and-treat strategy for onchocerciasis elimination in Massangam came to US$168,345. Financial costs represented 91% of total costs.

CONCLUSIONS

Unit costs of test-and-treat in both settled and semi-nomadic communities are higher than unit costs of community-directed treatment with ivermectin. However, it is critical to note that a two-year implementation shows a significantly larger reduction in infection prevalence than the preceding 20 years of annual community-directed treatment with ivermectin. Test-and-treat with doxycycline may be a cost-effective intervention in places where the prevalence of microfilaria is still high, or in hard-to-reach areas where community-directed treatment with ivermectin and MDA coverage are not high enough to stop transmission or where marginalised populations consistently miss treatment.

Ivermectin and doxycycline treatments against Onchocerciasis: Adaptations and impact among semi-nomadic population in Massangam Health District, Cameroon

We trialed strategies to reach semi-nomadic population with interventions targeting onchocerciasis including a combination of community knowledge and Geographical Information System (GIS) technology; nomad-specific sensitization; and mobile outreach. The interventions included ivermectin (ivm) mass drug administration (MDA) and treating infected individuals (found upon skin snip microscopy test) with doxycycline for 35 days. Microscopy-negative snips were further tested by Polymerase Chain Reaction (PCR). After 8 months, individuals immigrating or emigrating constituted 47% of the initial population; 59% of individuals not born in the area have immigrated during the last five years; 28% (age>9) reportedly never taken ivm; 72% (compared to 51% previously) of eligible population (age ≥ 5 years) took ivm; and 47% (age > 8, not pregnant, not breastfeeding, not severely ill,) participated in the test. A high prevalence of onchocerciasis,15.1%, was found upon microscopy & PCR test; 9/10 tested by skin snip microscopy and PCR at follow-up were all negative. Microfilaria prevalence and intensity upon skin snip microscopy reduced significantly from baseline following the intervention (8.9% to 4.1%, p = 0.032; 0.18 to 0.16, p = 0.013, respectively). The strategies considerably increased reach to nomadic camps. Treating with doxycycline in combination with ivm is feasible and has led to a significant reduction in infection level within one year among the semi-nomads. Being potentially curative in one intervention round, this combination should be considered for population group faced with challenges of achieving adequate coverage and adhesion to ivm MDA over prolonged period (>10 years).

Acceptability of test and treat with doxycycline against Onchocerciasis in an area of persistent transmission in Massangam Health District, Cameroon

The main onchocerciasis elimination strategy is annual Community-Directed Treatment with ivermectin (CDTi). However, as a response to persistent high infection prevalence in Massangam Health District in Cameroon, two rounds of alternative treatments including biannual CDTi, ground larviciding and test and treat with doxycycline (TTd) were implemented. This led to a significant prevalence reduction from 35.7% to 12.3% (p<0.001) as reported by Atekem and colleagues. Here we report on the acceptability of TTd component based on qualitative and quantitative data. The TTd involved microscopic examination for microfilaria in skin biopsy and those infected were offered doxycycline 100 mg daily for 35 days by community-directed distributors (CDDs). Participation level was significantly high with 54% of eligible population (age > 8, not pregnant, not breastfeeding, not severely ill,) participating in the test in each round, increasing to 83% over the two rounds. Factors associated with non-participation included mistrust, being female; being younger than 26 years; short stay in the community; and belonging to semi-nomadic sub population due to their remote and disperse settlement, discrimination, their non selection as CDD, and language and cultural barriers. Treatment coverage was high -71% in round 1 and 83% in round 2. People moving away between testing and treatment impacted treatment coverage. Some participants noted mismatch between symptoms and test result; and that ivermectin is better than doxycycline, while others favoured doxycycline. CDD worried about work burden with unmatching compensation. Overall, TTd participation was satisfactory. But can be improved through reinforcing sensitisation, reducing time between test and treatment; combining TTd and CDTi in one outing; augmenting CDDs compensation and/or weekly visit; exploring for frequently excluded populations and adapting strategies to reach them; and use of a sensitive less invasive test.

Job satisfaction among community drug distributors in the Mass Drug Administration programme in Nigeria: a cross-sectional study

BACKGROUND

Despite having one of the largest human resources for health in Africa, the delivery of neglected tropical disease (NTD) health interventions in Nigeria has been hampered by health worker shortages. This study assessed factors associated with job satisfaction among community drug distributors (CDDs) supporting the Nigerian NTD programme, with the goal of identifying opportunities to improve job satisfaction in support of NTD control and elimination efforts in Nigeria.

METHODS

A health facility-based cross-sectional survey was conducted in 2019 among CDDs in two states with sharply contrasting NTD programme support, Kaduna and Ogun. A multivariate logistic regression model was used to determine the association between respondent characteristics, programme delivery modalities and job satisfaction.

RESULTS

Overall, 75.3% and 74.0% of CDDs were categorised as being satisfied with their job in Kaduna and Ogun states, respectively. The component with the highest reported satisfaction was motivation, where 98.9% and 98.6% of CDDs were satisfied, in Kaduna and Ogun, respectively. Participants were least satisfied with remuneration, communication, supplies and materials, as well as workload. Location (rural/urban) and state, years of experience, who delivers training and reimbursement of transport fare during medicine distribution were significantly associated with job satisfaction.

CONCLUSIONS

Including multiple health staff and NTD programme cadres in CDD training and providing remuneration to cover transport fares spent during MDA delivery may improve CDDs' job satisfaction both in Ogun and Kaduna states. Given these two states are at opposite ends of the programme support spectrum, such adaptative measures might help improve CDD job satisfaction in the wider Nigerian NTD programme context.

A multimodality intervention to improve musculoskeletal health, function, metabolism, and well-being in spinal cord injury: study protocol for the FIT-SCI randomized controlled trial

BACKGROUND

A spinal cord injury (SCI) is a devastating, life-changing event that has profoundly deleterious effects on an individual's health and well-being. Dysregulation of neuromuscular, cardiometabolic, and endocrine organ systems following an SCI contribute to excess morbidity, mortality and a poor quality of life. As no effective treatments currently exist for SCI, the development of novel strategies to improve the functional and health status of individuals living with SCI are much needed. To address this knowledge gap, the current study will determine whether a Home-Based Multimodality Functional Recovery and Metabolic Health Enhancement Program that consists of functional electrical stimulation of the lower extremity during leg cycling (FES-LC) plus arm ergometry (AE) administered using behavioral motivational strategies, and testosterone therapy, is more efficacious than FES-LC plus AE and placebo in improving aerobic capacity, musculoskeletal health, function, metabolism, and wellbeing in SCI.

METHODS

This single-site, randomized, placebo-controlled, parallel group trial will enroll 88 community-dwelling men and women, 19 to 70 years of age, with cervical and thoracic level of SCI, ASIA Impairment Scale grade: A, B, C, or D, 6 months or later after an SCI. Participants randomized to the multimodality intervention will undergo 16 weeks of home-based FES-LC and AE training plus testosterone undecanoate. Testosterone undecanoate injections will be administered by study staff in clinic or by a visiting nurse in the participant's home. The control group will receive 16 weeks of home-based FES-LC and AE exercise plus placebo injections. The primary outcome of this trial is peak aerobic capacity, measured during an incremental exercise testing protocol. Secondary outcomes include whole body and regional lean and adipose tissue mass; muscle strength and power; insulin sensitivity, lipids, and inflammatory markers; SCI functional index and wellbeing (mood, anxiety, pain, life satisfaction and depressive symptoms); and safety.

DISCUSSION

We anticipate that a multimodality intervention that simultaneously addresses multiple physiological impairments in SCI will result in increased aerobic capacity and greater improvements in other musculoskeletal, metabolic, functional and patient-reported outcomes compared to the control intervention. The findings of this study will have important implications for improving the care of people living with an SCI.

TRIAL REGISTRATION

ClinicalTrials.gov :  ( NCT03576001 ). Prospectively registered: July 3, 2018.

Reach and Utility of COVID-19 Information and Preventive Measures for Nomadic Populations in Massangam, West Region of Cameroon

The separation of nomadic pastoralist settlements from settled communities is a well-known challenge to the health system. Difficulties reaching these groups contribute to inequities in their health and impact the spread or control of several diseases. COVID-19 has led to the suspension of many public health interventions in Cameroon, while preventive measures including behavior change communication have been ongoing since the onset of the pandemic. The reach and utility of these campaigns in semi-nomadic population remain unclear. This exploratory qualitative study was conducted in September to October 2020 using semi-structured interviews and focus group discussions with nomadic camp heads, and their wives to explore their interactions with communication campaigns, awareness, understanding, and acceptance of behavior change messages. The study revealed a general awareness of COVID-19 and its preventive measures and a prevailing belief that they were less at risk because their camps are isolated from the main communities, and the fact that they had never met a COVID-19 case. They perceived that the women were at lower risk because of their limited interaction outside the camps. There was a common concern regarding the transmission of COVID-19 to their cattle. Routes of communication were markets and mosques frequented by men, making access to information limited to or dependent on men. Financial constraints and lack of water were the main barriers affecting the access to and use of COVID-19 prevention measures. There is need for adaptive communication strategies especially tailored to the culture of nomadic pastoralists addressing gender dynamics of this subgroup.

Evaluation of facial cleanliness and environmental improvement activities: Lessons learned from Malawi, Tanzania, and Uganda

The World Health Organization promotes the SAFE (Surgery, Antibiotics, Facial cleanliness, and Environmental improvements) strategy for trachoma control and prevention. The F&E components of the strategy focus on promotion of healthy hygiene and sanitation behaviors. In order to monitor F&E activities implemented across villages and schools in Malawi, Tanzania, and Uganda, an F&E Monitoring and Evaluation (FEME) framework was developed to track quarterly program outputs and to provide the basis for a pre and post evaluation of the activities. Results showed an increase in knowledge at the school and household levels, and in some cases, an increase in presence of hand/face washing stations. However, this did not always result in a change in trachoma prevention behaviors such as facial cleanliness or keeping compounds free of human feces. The results highlight that the F&E programs were effective in increasing awareness of trachoma prevention but not able to translate that knowledge into changes in behavior during the time between pre and post-surveys. This study also indicates the potential to improve the data collection and survey design and notes that the period of intervention was not long enough to measure significant changes.

Trachoma control programs promote facial cleanliness, use of latrines, and emphasizes the importance of access to water as means to reduce trachoma transmission. To address these areas, various country ministries and supporting non-governmental organizations (NGOs) support the implementation of tailored behavior change programs. The process and results of evaluating these types of programs in Malawi, Tanzania, and Uganda are described here. The goal of this manuscript is to provide trachoma program managers and supporting NGOs with insights, recommendations, and data collection tools that could be used to support their efforts to conduct monitoring and evaluation of their current or future trachoma prevention activities.

Parallel Sequencing Reveals Campylobacter spp. in Commercial Meat Chickens Less than 8 Days Old

Campylobacter from contaminated poultry meat is a major source of human gastroenteritis worldwide. To date, attempts to control this zoonotic infection with on-farm biosecurity measures have been inconsistent in outcome. A cornerstone of these efforts has been the detection of chicken infection with microbiological culture, where Campylobacter is generally not detectable until birds are at least 21 days old. Using parallel sequence-based bacterial 16S profiling analysis and targeted sequencing of the porA gene, Campylobacter was identified at very low levels in all commercial flocks at less than 8 days old that were tested from the United Kingdom, Switzerland, and France. These young chicks exhibited a much greater diversity of porA types than older birds testing positive for Campylobacter by culture or quantitative PCR (qPCR). This suggests that as the bacteria multiply sufficiently to be detected by culture methods, one or two variants, as indicated by porA type, dominate the infection. The findings that (i) most young chicks carry some Campylobacter and (ii) not all flocks become Campylobacter positive by culture suggest that efforts to control infection, and therefore avoid contamination of poultry meat, should concentrate on how to limit Campylobacter to low levels by the prevention of the overgrowth of single strains. IMPORTANCE Our results demonstrate the presence of Campylobacter DNA among fecal samples from a range of commercially reared meat chicks that are less than 8 days of age, consistent across 3 European countries. The recently developed, sensitive detection method indicates that infection occurs on commercial farms much earlier and more widely than previously thought, which opens up new opportunities to control Campylobacter contamination at the start of the food chain and reduce the unacceptably high levels of human disease.

Guiding principles for quality, ethical standards and ongoing learning in implementation research: multicountry learnings from participatory action research to strengthen health systems

Global health gains can be achieved through strengthening health systems to identify and address implementation challenges in low- and middle-income countries. Participatory research, that promotes joint problem and solution finding between communities and different health systems actors, supports policy implementation analysis at all levels. Within the neglected tropical disease programmes in Liberia and Nigeria, we applied participatory action research (PAR) to address programmatic and health system bottlenecks with health systems strengthening embedded. This paper shares learning from 20 interviews with co-researchers, from national and sub-national levels and academic researchers who worked collaboratively to understand challenges, co-create solutions and advocate for policy change. Through analysis and reflections of existing PAR principles, we inductively identified five additional guiding principles for quality, ethical standards and ongoing learning within PAR projects that aim to strengthen health systems. (1) Recognize communities as units of identity and define stakeholder participation to ensure equitable engagement of all actors; (2) enable flexible action planning that builds on existing structures whilst providing opportunities for embedding change; (3) address health systems and research power differentials that can impede co-production of knowledge and solution development; (4) embed relational practices that lead to new political forms of participation and inquiry within health systems and (5) develop structures for ongoing learning at multiple levels of the health system. PAR can strengthen health systems by connecting and co-creating potentially sustainable solutions to implementation challenges. Additional research to explore how these five additional principles can support the attainment of quality and ethical standards within implementation research using a PAR framework for health systems strengthening is needed.

Prevalence and seroprevalence of Plasmodium infection in Myanmar reveals highly heterogeneous transmission and a large hidden reservoir of infection

Malaria incidence in Myanmar has significantly reduced over recent years, however, completeness and timeliness of incidence data remain a challenge. The first ever nationwide malaria infection and seroprevalence survey was conducted in Myanmar in 2015 to better understand malaria epidemiology and highlight gaps in Annual Parasite Index (API) data. The survey was a cross-sectional two-stage stratified cluster-randomised household survey conducted from July-October 2015. Blood samples were collected from household members for ultra-sensitive PCR and serology testing for P. falciparum and P. vivax. Data was gathered on demography and a priori risk factors of participants. Data was analysed nationally and within each of four domains defined by API data. Prevalence and seroprevalence of malaria were 0.74% and 16.01% nationwide, respectively. Prevalent infection was primarily asymptomatic P. vivax, while P. falciparum was predominant in serology. There was large heterogeneity between villages and by domain. At the township level, API showed moderate correlation with P. falciparum seroprevalence. Risk factors for infection included socioeconomic status, domain, and household ownership of nets. Three K13 P. falciparum mutants were found in highly prevalent villages. There results highlight high heterogeneity of both P. falciparum and P. vivax transmission between villages, accentuated by a large hidden reservoir of asymptomatic P. vivax infection not captured by incidence data, and representing challenges for malaria elimination. Village-level surveillance and stratification to guide interventions to suit local context and targeting of transmission foci with evidence of drug resistance would aid elimination efforts.

Mass administration of medicines in changing contexts: Acceptability, adaptability and community directed approaches in Kaduna and Ogun States, Nigeria

Nigeria has the highest burden of NTDs in sub-Saharan Africa. Commitments to reach the control and elimination of many Neglected Tropical Diseases (NTDs), particularly those amenable to preventive chemotherapy (onchocerciasis, schistosomiasis, soil transmitted helminths, lymphatic filariasis and trachoma) by 2020 are detailed in the London declaration. Strategies to reach targets build on existing approaches, one of which is the use of community directed intervention (CDI) methods to deliver the mass administration of medicines (MAM). However, treatment using this approach has been inconsistent and there are questions about the acceptability and adaptability of these interventions during periods of programmatic, social, and political change. This paper explores the current strengths and weaknesses of CDI approaches in MAM delivery. We consider the acceptability and adaptability of existing MAM approaches to ensure equity in access to essential treatments. Using qualitative methods, we explore implementer perspectives of MAM delivery. We purposively selected programme implementers to ensure good programmatic knowledge and representation from the different levels of health governance in Nigeria. Data collection took place across two States (Kaduna and Ogun). Our results indicate that CDI approaches have underpinned many historic successes in NTD programme acceptance in Nigeria, specifically in Kaduna and Ogun State. However, our results also show that in some contexts, factors that underpin the success of CDI have become disrupted presenting new challenges for programme implementers. Capturing the tacit knowledge of health implementers at varying levels of the health system, we present the current and changing context of MAM delivery in Kaduna and Ogun States and consolidate a platform of evidence to guide future programme delivery and research studies. We situate our findings within the broader NTD literature, specifically, in identifying how our findings align to existing reviews focused on factors that shape individual acceptance of MAM.

Nigeria has the highest number of people affected by neglected tropical diseases in sub-Saharan Africa. Many of these diseases (onchocerciasis, lymphatic filariasis, schistosomiasis and soil transmitted helminths) can be prevented and treated using mass administration of medicines (MAM), which involves giving everyone in communities medicines based on their height. MAM has been going on for a long time in Nigeria and has achieved many successes, however, the programmatic, social, political and economic context in Nigeria is rapidly changing and there is limited evidence about the ability of current MAM approaches to ensure everyone who needs these medicines is able to access them during this time of change. We asked MAM programme implementers at different levels of the health system in Nigeria to tell us what they thought the key strengths and weaknesses of the current programme were and what they would do to make it better to ensure that everyone who needs the medicines would still be able to access them. They told us that the commitment of health workers and community leaders to telling communities about the medicines and encouraging them to accept them as well as the knowledge of the disability these diseases can cause had supported programme success. However, they also told us that in some areas, such as those with security concerns or where communities feel fatigued by the programme, the way communities respond is changing. To address the change in community responses our study participants felt that we need to support programme implementers with the time, tools and resources to build stronger more trusting relationships with communities to ensure everyone can access medicines.

People are neglected, not diseases: the relationship between disability and neglected tropical diseases

People with disabilities and the neglected tropical diseases (NTDs) are separately receiving increased focus. In light of this positive development, and the similarities and intersections between the negative impacts experienced by both people with disabilities and people with NTDs, we believe now is the right time to focus attention on the overlap between the two. Both people with NTDs and people with disabilities experience a myriad of overlapping negative health, financial and socio-cultural consequences. Despite this, we believe that disability is not yet properly prioritised on the development agenda, and that there are multiple opportunities to make NTD programming more inclusive, to the benefit of those at this neglected intersection and beyond. There are both opportunities and need to scale up, integrate, and invest in inclusive, health system-focused NTD programming. Realisation of the Sustainable Development Goals, Universal Health Coverage, and the control and elimination of NTDs all rely on ensuring people with disabilities are not left behind.

"It Runs in Your Blood": Reflections from Treatment Seeking Gamblers on Their Family History of Gambling

There are considerable gaps in our understanding of the familial transmission of gambling problems. This convergent mixed-methods study aimed to explore the: (1) sources of heterogeneity in the familial (paternal, maternal, and sibling) transmission of gambling problems; (2) degree to which family-of-origin characteristics are associated with family-of-origin problem gambling; and (3) beliefs of gamblers about the nature of the familial transmission of problem gambling. The sample consisted of 97 treatment-seeking gamblers in Australia. One-quarter (25.5%) of participants reported that at least one family member (16.5% father, 7.5% mother, 7.6% siblings) living with them when they were growing up had a gambling problem. Most participants reported that family members with a positive history of problem gambling were biological relatives, lived with them full-time, and experienced long-term difficulties with gambling. Participants with a family history of problem gambling were young (less than 12 years of age) at the onset of parental, but not sibling, problem gambling, were women, and reported difficulties with the same gambling activity as their family member. Participants raised in families with problem gambling were more likely to report parental separation (risk ratio [RR] = 2.32) and divorce (RR = 2.83), and extreme family financial hardship (RR = 1.80), as well as low levels of paternal authoritative parenting than participants raised in non-problem gambling families. Qualitatively, both social learning and genetics were perceived to play a central role in the familial transmission of gambling problems. These findings inform theories of the familial transmission of gambling problems and the design of targeted prevention and intervention strategies.

Testing a method of sampling for entomological determination of transmission of Wuchereria bancrofti to inform lymphatic filariasis treatment strategy in urban settings

BACKGROUND

There is on-going debate about scale-up of lymphatic filariasis treatment to include urban areas. Determining Wuchereria bancrofti transmission is more complex in these settings and entomological methodologies suggested as a solution as yet have no clear guidance.

METHODS

The study was conducted in six communities in Minna and Kaduna cities in Nigeria selected based on pre-disposing risk factors for mosquitoes and Transmission Assessment Survey (TAS) results in 2016 indicating need for treatment (> 1% prevalence). In each community, 4 gravid traps (GT), 15 exit traps (ET) and 21 pyrethrum spray catches (PSC) were used for 5 months targeting a sample size of 10,000 mosquitoes inclusive of at least 1500 Anopheles. Community researchers were selected and trained to facilitate community acceptability and carry out collection. We have evaluated the mosquito sampling and trapping methodology in terms of success at reaching targeted sample size, cost effectiveness, and applicability.

RESULTS

Community researchers were influential in enabling high acceptability of the methods of collection and were able to conduct collections independently. Overall, 12.1% of trapping events (one trapping event corresponds to one visit to one trap to collect mosquitoes) were affected by householder actions, weather conditions or trap malfunction leading to lower than optimal catches. Exit traps were the most cost-effective way to catch Anopheles (6.4 USD per trapping event and 12.8 USD per Anopheles caught). Sample size of 10,000 mosquitoes overall in each city was met though Anopheles catch was insufficient in one city. However, sample size was met only in one implementation unit out of the four.

CONCLUSIONS

Methods need adapting to maximise Anopheles catch: we propose planning 250 gravid trap and 3724 exit trap trapping events in similar settings in West African urban areas where Culex is dominant, not using pyrethrum spray catches, and weighting trapping events later in the rainy season. Planning should increase involvement of community researchers, incorporate null catches and participants' actions to predict catches. Importantly, evaluation units should be analogous with implementation units, the units at which treatment decisions will be made in the urban context.

Neglected Tropical Diseases as a 'litmus test' for Universal Health Coverage? Understanding who is left behind and why in Mass Drug Administration: Lessons from four country contexts

Introduction

Individuals and communities affected by NTDs are often the poorest and most marginalised; ensuring a gender and equity lens is centre stage will be critical for the NTD community to reach elimination goals and inform Universal Health Coverage (UHC). NTDs amenable to preventive chemotherapy have been described as a ‘litmus test’ for UHC due to the high mass drug administration (MDA) coverage rates needed to be effective and their model of community engagement. However, until now highly aggregated coverage data may have masked inequities in availability, accessibility and acceptability of medicines, slowing down the equitable achievement of elimination goals.

Methods

We conducted qualitative programmatic analysis across different country contexts through the novel application of the Tanahashi Coverage Framework enhanced by gendered intersectional theory to interrogate different components of programme coverage: availability, accessibility, acceptability, contact and effective. Drawing on communities and health implementers perspectives (using focus groups, interviews, and participatory methods) from varying levels of the health system, across four African country contexts (Cameroon, Ghana, Liberia and Nigeria), we show who is left behind and provide recommendations for programmes to respond.

Findings

We have unmasked inequities in programme delivery that repeatedly leave vulnerable populations underserved in relation to the prevention and treatment of PC NTDs across all components of coverage explored within the Tanahashi framework. Inequities are influenced by health systems challenges and limitations, due to lack of consideration of gender, power and equity issues. Effective treatment for individuals and communities is shaped by individual identities and the intersecting axes of inequity that converge to shape these positions including gender, age, disability, and geography. Health systems are inherently social and gendered thus they become mediators in managing the impact that social and structural processes have on individual health outcomes.

Significance

To our knowledge this is the only paper which has combined a comprehensive equity framework with intersectional feminist theory, to establish a fuller understanding of who is left behind and why in MDA across countries and contexts. Ensuring the most vulnerable have continued access to future treatment options will contribute to the progressive realisation of UHC, allowing the NTD community to continue to support their vision of being a true ‘litmus test’.

Individuals and communities affected by Neglected Tropical Diseases (NTDs) are often the poorest and most marginalised. Some NTDs (lymphatic filariasis, onchocerciasis, soil transmitted helminths, schistosomiasis and trachoma) have been given specific targets for control and elimination by the year 2020. Reaching these goals is important for the attainment of Universal Health Coverage (UHC) as well as the Sustainable Development Goals and has been described as a litmus test. However, few studies have considered how fair progress toward attainment of these goals has been to date. We used qualitative research methods to explore the equity of progress toward these targets across four countries (Ghana, Cameroon, Liberia and Ghana). We used a framework for assessing health services coverage (The Tanahashi Framework) and combined it with gendered intersectional theory (a theory that helps us think about how individuals position of power and privilege shape their experience) to understand who is left behind and why in NTD programme delivery. We found that health systems challenges and limitations due to lack of consideration of gender and equity issues have left vulnerable populations underserved in relation to the prevention and treatment of PC NTDs. Key steps need to be taken at different health system levels to ensure the most vulnerable have continued access to future treatment options. This will contribute to the attainment of UHC, allowing the NTD community to continue to support their vision of being a true ‘litmus test’.

Optimising the performance of frontline implementers engaged in the NTD programme in Nigeria: lessons for strengthening community health systems for universal health coverage

BACKGROUND

The control and elimination of Neglected Tropical Diseases (NTDs) is dependent on mass administration of medicines (MAM) in communities and schools by community drug distributers (CDDs) who are supported and supervised by health facility staff (FLHF) and teachers. Understanding how to motivate, retain and optimise their performance is essential to ensure communities accept medicines. This study aimed to capture and translate knowledge, problems and solutions, identified by implementers, to enhance NTD programme delivery at the community level in Nigeria.

METHODS

Qualitative data was collected through participatory stakeholder workshops organised around two themes: (i) identification of problems and (ii) finding solutions. Eighteen problem-focused workshops and 20 solution-focussed workshops were held with FLHF, CDDs and teachers in 12 purposively selected local government areas (LGA) across two states in Nigeria, Ogun and Kaduna States.

RESULT

The problems and solutions identified by frontline implementers were organised into three broad themes: technical support, social support and incentives. Areas identified for technical support included training, supervision, human resource management and workload, equipment and resources and timing of MAM implementation. Social support needs were for more equitable drug distributor selection processes, effective community sensitisation mechanisms and being associated with the health system. Incentives identified were both non-financial and financial including receiving positive community feedback and recognition and monetary remuneration. The results led to the development of the 'NTD frontline implementer's framework' which was adapted from the Community Health Worker (CHW) Generic Logic Model by Naimoli et al. (Hum Resour Health 12:56, 2014).

CONCLUSION

Maximising performance of frontline implementers is key to successful attainment of NTD goals and other health interventions. As NTDs are viewed as a 'litmus test' for universal health coverage, the lessons shared here could cut across programmes aiming to achieve equitable coverage. It is critical to strengthen the collaboration between health systems and communities so that together they can jointly provide the necessary support for frontline implementers to deliver health for all. This research presents additional evidence that involving frontline implementers in the planning and implementation of health interventions through regular feedback before, during and after implementation has the potential to strengthen health outcomes.

Treatment of primary Sjögren's syndrome with hydroxychloroquine: a retrospective, open-label study

Objectives

To determine whether patients with primary Sjögren's syndrome (SS), diagnosed according to San Diego criteria, had improvement in their laboratory or clinical features during treatment with hydroxychloroquine (6–7 mg/kg/day) for at least two years., Methods: The study population included 50 consecutive patients with primary SS who were diagnosed according to San Diego criteria, and in whom hydroxychloroquine was suggested as treatment. This group included 10 patients who were early dropouts (side effects or desire not to take antimalarial drugs) and 40 patients who received drugs for at least two years (range 24-48 months). In a subset of SS patients, values for ESR (westergren) and quantitative immunoglobulins were available for comparison. Improvement with therapy was defined as: (a) ≥20% improvement in variables of tear flow (Schirmer's test I) or corneal integrity (rose Bengal): (b) ≥20% salivary function (flow rate); and (c) improvement in at least two of the following measures: physicians assessment of global disease activity by ≥ 20%, patient assessment of improvement in pain or fatigue by ≥20%, and ESR improved by ≥20mm/ hr.

Results

In a retrospective study of SS patients who completed the trial, a significant improvement was noted in ocular symptoms (pain and dryness) in patients (55 and 57%) and improved corneal integrity (rose Bengal straining) in 53% of patients. The Schirmer's test was improved by ≥ 2 mm/5 minutes in 50% in patients. Improvement was noted in oral symptoms (pain and dryness) in patients (57 and 60%) and salivary flow rate was increased in 82% of patients. In a subset of SS patients evaluated, the ESR improved by ≥20mm/hr in 17/32 patients (53%) and quantitative IgG level by ≥20% in 8/13 patients (61%). Physician global assessment of overall patient status and patient assessment of overall status indicated improvement in over 62% of patients.

Conclusion

In a retrospective study of patients fulfilling San Diego Criteria for SS, we found: (a) sustained improvement of local symptoms (painful eyes, painful mouth) and improvement of systemic manifestations (arthralgias and myalgias) after treatment with hydroxychloroquine 6-7 mg/kg/day over mean three-year follow-up; (b) laboratory analysis showed a significant improvement in their ESR and their quantitative IgG levels; (c) no significant late toxicity was observed in this study cohort. A prospective study of hydroxychloroquine in patients fulfilling San Diego criteria for SS is indicated.

On-going transmission of human onchocerciasis in the Massangam health district in the West Region of Cameroon: Better understanding transmission dynamics to inform changes in programmatic interventions

BACKGROUND

Massangam health district (HD), in the West Region of Cameroon, has received ivermectin mass drug administration (MDA) for 20 years, however there is evidence of continued high transmission of Onchocerca volvulus. In order to better understand the transmission dynamics in the HD and inform intervention strategies there is a need to delineate the boundaries of the suspected area of high transmission within the wider transmission zone.

METHODOLOGY/PRINCIPAL FINDINGS

Parasitological and entomological surveys were conducted to map out the breeding sites of Simulium damnosum and evaluate the prevalence of onchocerciasis in neighbouring communities, including Makouopsap sentinel community. Potential rapids were prospected for identification of S. damnosum larvae and black flies collected to determine infectivity rates. Adults were assessed for the presence of O. volvulus microfilariae through a skin snip biopsy and examined for the presence of nodules. Anti Ov-16 antibodies were tested for in children. Four perennial breeding sites were identified on the Rivers Mbam and Nja. Large number of flies were collected along the River Mbam, especially in the rainy season, with up to 955 flies per day, suggesting this river is a perennial source of black flies. A total of 0.8% of parous flies were infective across the study area. Parasitological studies provided evidence of high rates of infection in the sentinel community and three neighbouring communities, with 37.1% of adults microfilariae positive in Makouopsap. High Ov-16 seropositivity in children also provided evidence of recent on-going transmission. In comparison, communities sampled further away from the sentinel community and neighbouring breeding sites were much closer to reaching onchocerciasis elimination targets.

CONCLUSIONS/SIGNIFICANCE

This study provides evidence of a particular geographic area of high transmission in an approximate 12 km range around the sentinel community of Makouopsap and the neighbouring breeding sites on the River Nja. To eliminate onchocerciasis by 2025, there is a need to explore alternative intervention strategies in this area of high transmission.

Taking the heat or taking the temperature? A qualitative study of a large-scale exercise in seeking to measure for improvement, not blame

Measurement of quality and safety has an important role in improving healthcare, but is susceptible to unintended consequences. One frequently made argument is that optimising the benefits from measurement requires controlling the risks of blame, but whether it is possible to do this remains unclear. We examined responses to a programme known as the NHS Safety Thermometer (NHS-ST). Measuring four common patient harms in diverse care settings with the goal of supporting local improvement, the programme explicitly eschews a role for blame. The study design was ethnographic. We conducted 115 hours of observation across 19 care organisations and conducted 126 interviews with frontline staff, senior national leaders, experts in the four harms, and the NHS-ST programme leadership and development team. We also collected and analysed relevant documents. The programme theory of the NHS-ST was based in a logic of measurement for improvement: the designers of the programme sought to avoid the appropriation of the data for any purpose other than supporting improvement. However, organisational participants - both at frontline and senior levels - were concerned that the NHS-ST functioned latently as a blame allocation device. These perceptions were influenced, first, by field-level logics of accountability and managerialism and, second, by specific features of the programme, including public reporting, financial incentives, and ambiguities about definitions that amplified the concerns. In consequence, organisational participants, while they identified some merits of the programme, tended to identify and categorise it as another example of performance management, rich in potential for blame. These findings indicate that the search to optimise the benefits of measurement by controlling the risks of blame remains challenging. They further suggest that a well-intentioned programme theory, while necessary, may not be sufficient for achieving goals for improvement in healthcare systems dominated by institutional logics that run counter to the programme theory.

The epidemiology of soil-transmitted helminths in Bihar State, India

BACKGROUND

Soil-transmitted helminths (STHs) infect over a billion individuals worldwide. In India, 241 million children are estimated to need deworming to avert the negative consequences STH infections can have on child health and development. In February-April 2011, 17 million children in Bihar State were dewormed during a government-led school-based deworming campaign. Prior to programme implementation, a study was conducted to assess STH prevalence in the school-age population to direct the programme. The study also investigated risk factors for STH infections, including caste, literacy, and defecation and hygiene practices, in order to inform the development of complementary interventions.

METHODS

A cross-sectional survey was conducted among children in 20 schools in Bihar. In addition to providing stool samples for identification of STH infections, children completed a short questionnaire detailing their usual defecation and hand-hygiene practices. Risk factors for STH infections were explored.

RESULTS

In January-February 2011, 1279 school children aged four to seventeen provided stool samples and 1157 children also completed the questionnaire. Overall, 68% of children (10-86% across schools) were infected with one or more soil-transmitted helminth species. The prevalence of ascariasis, hookworm and trichuriasis was 52%, 42% and 5% respectively. The majority of children (95%) practiced open defecation and reported most frequently cleansing hands with soil (61%). Increasing age, lack of maternal literacy and certain castes were independently associated with hookworm infection. Absence of a hand-washing station at the schools was also independently associated with A. lumbricoides infection.

CONCLUSIONS

STH prevalence in Bihar is high, and justifies mass deworming in school-aged children. Open defecation is common-place and hands are often cleansed using soil. The findings reported here can be used to help direct messaging appropriate to mothers with low levels of literacy and emphasise the importance of water and sanitation in the control of helminths and other diseases.

Norovirus-like virus outbreak at a correctional facility in Haliburton Kawartha Pine Ridge District Health Unit, March to April 2008

In March 2008, an enteric outbreak was reported from a correctional facility in Central East Ontario to the Haliburton, Kawartha, Pine Ridge District Health Unit. The clinical and epidemiological data were compatible with the presence of norovirus in this enteric outbreak. This report summarizes the outbreak investigation conducted and the various public health measures undertaken through a coordinated response by the facility health care and correctional staff and local and provincial health authorities to contain the infection within the facility. Correctional facilities present unique challenges to the implementation of infection control measures, and the investigators eventually recommended that the facility be closed to transfers and new admissions until the outbreak was brought under control.

P5-02-04: Disruption of Endothelial Cells Barrier Integrity by Invasive Breast Cancer Cells

Despite its critical role in cancer metastasis the molecular mechanisms regulating breast cancer cells transendothelial migration are poorly understood, but clearly depend on the invasive capacity of tumor cells and their ability to breach the endothelial cell barrier. Vascular endothelial-cadherin (VE-cadherin) is found specifically in the endothelial cell adherens junction and has been implicated in playing a fundamental role in controlling the transport across the endothelial barrier. Tyrosine phosphorylation of VE-cadherin has been implicated in the disruption of endothelial cells adherens junctions and diapedesis of metastatic cancer cells. We tested this hypothesis that interaction of breast cancer cells with endothelial cells initiates the signal transductions that disrupt the endothelium barrier integrity. Our studies demonstrated that the attachment of MDA-MB-231 human breast cancer cells to Human Umbilical Vein Endothelial Cells (HUVECs) leads to tyrosine phosphorylation of VE-cadherin and the formation of gaps between endothelial cells. These were accompanied by activation of two tyrosine kinases, Src and proline rich tyrosine kinase (Pyk-2). In addition, immunoprecipitation studies indicated that the endothelial cells adherens junction structure was disrupted through MDA-MB-231-induced dissociation of VE-cadherin and β-catenin complex. Activation of RhoA and HRas by over expression of constitutively active forms of the genes leads to tyrosine phosphorylation of VE-cadherin and Pyk-2 in HUVECs. Over expression of dominant negative forms of RhoA, HRas, Raf and ERK2 but not Rac1 and Cdc42 attenuated breast cancer cell-induced tyrosine phosphorylation of VE-cadherin and Pyk-2 in HUVECs. Indicating that breast cancer cell-induced VE-cadherin tyrosine phosphorylation and disruption of adherens junction in endothelial cells is mediated by RhoA and HRas\Raf\MEK\ERK signaling cascade. Understanding the precise molecular mechanisms that facilitate breast cancer cells transendothelial migration could develop novel therapeutic strategies targeting cancer cell metastasis by improving the protective role of endothelial cells.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-02-04.

SB-742457 and donepezil in Alzheimer disease: a randomized, placebo-controlled study

OBJECTIVE

To estimate the treatment effects of SB-742457 and donepezil in Alzheimer disease (AD) in a contemporary clinical trial.

METHOD

Randomized, controlled, parallel-group, exploratory study with a 4-week, single-blind, placebo run-in phase and 24-week, double-blind treatment phase. Primary endpoints were Clinician's Interview-Based Impression of Change with caregiver input (CIBIC+) and the Alzheimer's Disease Assessment Scale-cognitive subscale (ADAS-Cog).

RESULTS

One hundred ninety eight subjects with mild-to-moderate probable AD (MMSE scores 12-26) were randomized; 196 were included in the intent-to-treat population (placebo, n = 61; SB-742457 35 mg/day, n = 68; donepezil 10 mg/day, n = 67), and 161 completed. Drug-placebo treatment differences in CIBIC+ score at week 24 were -0.17 (90% confidence interval [CI]: -0.50, 0.16) for SB-742457 and -0.28 (90% CI: -0.61, 0.05) for donepezil. Drug-placebo treatment differences (90% CI) in change from baseline ADAS-Cog score at Week 24 were -0.4 (-2.2, 1.4) for SB-742457 and -1.2 (-3.0, 0.6) for donepezil. All treatments were generally safe and well tolerated.

CONCLUSIONS

In this exploratory study, SB-742457 and donepezil were associated with improvements in global function. Treatment effect on cognition for both SB-742457 and donepezil was smaller than those previously observed in previous clinical studies with donepezil.