Evaluation of the collaborative integrated surveillance system (ViCo) in Guatemala: a qualitative study on lessons learned and future perspectives.

BACKGROUND: The collaborative integrated surveillance system known as Vigilancia Integrada Comunitaria (ViCo) was implemented in 2007 to better understand and characterize the burden of diarrheal, respiratory and febrile illnesses in Guatemala. METHODS: To evaluate the usefulness of ViCo and inform a redesign of the system and new surveillance activities in the Central American region, personnel from the United States Centers for Disease Control and Prevention (CDC) conducted thirty-nine in-depth interviews from June-December 2018 with key stakeholders responsible for the design and implementation of ViCo in Guatemala. A semi-structured questionnaire adapted from the Updated CDC Guidelines for Evaluating Public Health Surveillance Systems was used for data collection. We used a grounded theory approach to explore stakeholder perceptions of ViCo and generate recommendations for improvement. Primary qualitative findings were organized based on thematic areas using ATLAS.ti version 8 software. RESULTS: Emergent themes relevant to the usefulness of ViCo were organized across strengths, weaknesses, and recommendations pertaining to the: (1) Size and Complexity of ViCo, (2) Stakeholder Expectations About the Objectives of ViCo, (3) Data Management and Structure of the Information System, (4) Local Control of Data, (5) Integration of ViCo within the Ministry of Health, and, (6) Improvement of the Operational and Design Aspects of ViCo across System, Process, and Output levels. CONCLUSIONS: Stakeholders perceived ViCo to be useful. They recommended measures to improve system performance and quality, including simplifying the surveillance system, routine data analysis and feedback, and channeling efforts towards integrating surveillance data into the national health information system. To create a well-performing surveillance system and achieve the intended objective of surveillance for public health action, ongoing evaluation and assessment of surveillance activities are necessary.

Development and Validation of a Sociodemographic and Behavioral Characteristics-Based Risk-Score Algorithm for Targeting HIV Testing Among Adults in Kenya.

To inform targeted HIV testing, we developed and externally validated a risk-score algorithm that incorporated behavioral characteristics. Outpatient data from five health facilities in western Kenya, comprising 19,458 adults ≥ 15 years tested for HIV from September 2017 to May 2018, were included in univariable and multivariable analyses used for algorithm development. Data for 11,330 adults attending one high-volume facility were used for validation. Using the final algorithm, patients were grouped into four risk-score categories: ≤ 9, 10-15, 16-29 and ≥ 30, with increasing HIV prevalence of 0.6% [95% confidence interval (CI) 0.46-0.75], 1.35% (95% CI 0.85-1.84), 2.65% (95% CI 1.8-3.51), and 15.15% (95% CI 9.03-21.27), respectively. The algorithm's discrimination performance was modest, with an area under the receiver-operating-curve of 0.69 (95% CI 0.53-0.84). In settings where universal testing is not feasible, a risk-score algorithm can identify sub-populations with higher HIV-risk to be prioritized for HIV testing.

Mapping geographic clusters of new HIV diagnoses to inform granular-level interventions for HIV epidemic control in western Kenya.

BACKGROUND: As countries make progress towards HIV epidemic control, there is increasing need to identify finer geographic areas to target HIV interventions. We mapped geographic clusters of new HIV diagnoses, and described factors associated with HIV-positive diagnosis, in order to inform targeting of HIV interventions to finer geographic areas and sub-populations. METHODS: We analyzed data for clients aged > 15 years who received home-based HIV testing as part of a routine public health program between May 2016 and July 2017 in Siaya County, western Kenya. Geospatial analysis using Kulldorff's spatial scan statistic was used to detect geographic clusters (radius < 5 kilometers) of new HIV diagnoses. Factors associated with new HIV diagnosis were assessed in a spatially-integrated Bayesian hierarchical model. RESULTS: Of 268,153 clients with HIV test results, 2906 (1.1%) were diagnosed HIV-positive. We found spatial variation in the distribution of new HIV diagnoses, and identified nine clusters in which the number of new HIV diagnoses was significantly (1.56 to 2.64 times) higher than expected. Sub-populations with significantly higher HIV-positive yield identified in the multivariable spatially-integrated Bayesian model included: clients aged 20-24 years [adjusted relative risk (aRR) 3.45, 95% Bayesian Credible Intervals (CI) 2.85-4.20], 25-35 years (aRR 4.76, 95% CI 3.92-5.81) and > 35 years (aRR 2.44, 95% CI 1.99-3.00); those in polygamous marriage (aRR 1.84, 95% CI 1.55-2.16), or separated/divorced (aRR 3.36, 95% CI 2.72-4.08); and clients who reported having never been tested for HIV (aRR 2.35, 95% CI 2.02-2.72), or having been tested > 12 months ago (aRR 1.53, 95% CI 1.41-1.66). CONCLUSION: Our study used routine public health program data to identify granular geographic clusters of higher new HIV diagnoses, and sub-populations with higher HIV-positive yield in the setting of a generalized HIV epidemic. In order to target HIV testing and prevention interventions to finer granular geographic areas for maximal epidemiologic impact, integrating geospatial analysis into routine public health programs can be useful.

Epidemiological profile of individuals diagnosed with HIV: results from the preliminary phase of case-based surveillance in Kenya.

Understanding the characteristics of individuals who are newly diagnosed with HIV is critical to controlling the HIV epidemic. Characterizing this population can improve strategies to identify undiagnosed positives and assist in targeting the provision of HIV services to improve health outcomes. We describe the characteristics of newly diagnosed HIV cases in western Kenya from 124 health facilities. The study cohort cases were matched to prevent duplication and patients newly diagnosed between January and June 2015 were identified and descriptive analysis performed. Among 8664 newly identified HIV cases, during the pilot timeframe, 3.1% (n=265) had retested for HIV after initial diagnosis. Linkage to care was recorded for approximately half (45.3%, n = 3930) and 28.0% (n = 2425) had a CD4 count available during the pilot timeframe. The median baseline CD4 count was 332 cells/mL (IQR: 156-544). Among the newly diagnosed age 15 years or older with a CD4 test, 53.0% (n = 1216) were diagnosed late, including 32.9% (n = 755) who had advanced HIV at diagnosis. Factors associated with late diagnosis included being male and in an age group older than 34 years. In western Kenya, continued efforts are needed in the area of testing to enhance early HIV diagnosis and epidemic control.

Mortality Surveillance Methods to Identify and Characterize Deaths in Child Health and Mortality Prevention Surveillance Network Sites.

Despite reductions over the past 2 decades, childhood mortality remains high in low- and middle-income countries in sub-Saharan Africa and South Asia. In these settings, children often die at home, without contact with the health system, and are neither accounted for, nor attributed with a cause of death. In addition, when cause of death determinations occur, they often use nonspecific methods. Consequently, findings from models currently utilized to build national and global estimates of causes of death are associated with substantial uncertainty. Higher-quality data would enable stakeholders to effectively target interventions for the leading causes of childhood mortality, a critical component to achieving the Sustainable Development Goals by eliminating preventable perinatal and childhood deaths. The Child Health and Mortality Prevention Surveillance (CHAMPS) Network tracks the causes of under-5 mortality and stillbirths at sites in sub-Saharan Africa and South Asia through comprehensive mortality surveillance, utilizing minimally invasive tissue sampling (MITS), postmortem laboratory and pathology testing, verbal autopsy, and clinical and demographic data. CHAMPS sites have established facility- and community-based mortality notification systems, which aim to report potentially eligible deaths, defined as under-5 deaths and stillbirths within a defined catchment area, within 24-36 hours so that MITS can be conducted quickly after death. Where MITS has been conducted, a final cause of death is determined by an expert review panel. Data on cause of death will be provided to local, national, and global stakeholders to inform strategies to reduce perinatal and childhood mortality in sub-Saharan Africa and South Asia.

Menstrual cups and cash transfer to reduce sexual and reproductive harm and school dropout in adolescent schoolgirls: study protocol of a cluster-randomised controlled trial in western Kenya.

BACKGROUND: Adolescent girls in sub-Saharan Africa are disproportionally vulnerable to sexual and reproductive health (SRH) harms. In western Kenya, where unprotected transactional sex is common, young females face higher rates of school dropout, often due to pregnancy, and sexually transmitted infections (STIs), including HIV. Staying in school has shown to protect girls against early marriage, teen pregnancy, and HIV infection. This study evaluates the impact of menstrual cups and cash transfer interventions on a composite of deleterious outcomes (HIV, HSV-2, and school dropout) when given to secondary schoolgirls in western Kenya, with the aim to inform evidence-based policy to improve girls' health, school equity, and life-chances. METHODS: Single site, 4-arm, cluster randomised controlled superiority trial. Secondary schools are the unit of randomisation, with schoolgirls as the unit of measurement. Schools will be randomised into one of four intervention arms using a 1:1:1:1 ratio and block randomisation: (1) menstrual cup arm; (2) cash transfer arm, (3) cups and cash combined intervention arm, or (4) control arm. National and county agreement, and school level consent will be obtained prior to recruitment of schools, with parent consent and girls' assent obtained for participant enrolment. Participants will be trained on safe use of interventions, with all arms receiving puberty and hygiene education. Annually, the state of latrines, water availability, water treatment, handwashing units and soap in schools will be measured. The primary endpoint is a composite of incident HIV, HSV-2, and all-cause school dropout, after 3 years follow-up. School dropout will be monitored each term via school registers and confirmed through home visits. HIV and HSV-2 incident infections and risk factors will be measured at baseline, mid-line and end-line. Intention to treat analysis will be conducted among all enrolled participants. Focus group discussions will provide contextual information on uptake of interventions. Monitoring for safety will occur throughout. DISCUSSION: If proved safe and effective, the interventions offer a potential contribution toward girls' schooling, health, and equity in low- and middle-income countries. TRIAL REGISTRATION: ClinicalTrials.gov NCT03051789 , 15th February 2017.

Willingness to Know the Cause of Death and Hypothetical Acceptability of the Minimally Invasive Autopsy in Six Diverse African and Asian Settings: A Mixed Methods Socio-Behavioural Study.

BACKGROUND: The minimally invasive autopsy (MIA) is being investigated as an alternative to complete diagnostic autopsies for cause of death (CoD) investigation. Before potential implementation of the MIA in settings where post-mortem procedures are unusual, a thorough assessment of its feasibility and acceptability is essential. METHODS AND FINDINGS: We conducted a socio-behavioural study at the community level to understand local attitudes and perceptions related to death and the hypothetical feasibility and acceptability of conducting MIAs in six distinct settings in Gabon, Kenya, Mali, Mozambique, and Pakistan. A total of 504 interviews (135 key informants, 175 health providers [including formal health professionals and traditional or informal health providers], and 194 relatives of deceased people) were conducted. The constructs "willingness to know the CoD" and "hypothetical acceptability of MIAs" were quantified and analysed using the framework analysis approach to compare the occurrence of themes related to acceptability across participants. Overall, 75% (379/504) of the participants would be willing to know the CoD of a relative. The overall hypothetical acceptability of MIA on a relative was 73% (366/504). The idea of the MIA was acceptable because of its perceived simplicity and rapidity and particularly for not "mutilating" the body. Further, MIAs were believed to help prevent infectious diseases, address hereditary diseases, clarify the CoD, and avoid witchcraft accusations and conflicts within families. The main concerns regarding the procedure included the potential breach of confidentiality on the CoD, the misperception of organ removal, and the incompatibility with some religious beliefs. Formal health professionals were concerned about possible contradictions between the MIA findings and the clinical pre-mortem diagnoses. Acceptability of the MIA was equally high among Christian and Islamic communities. However, in the two predominantly Muslim countries, MIA acceptability was higher in Mali than in Pakistan. While the results of the study are encouraging for the potential use of the MIA for CoD investigation in low-income settings, they remain hypothetical, with a need for confirmation with real-life MIA implementation and in populations beyond Health and Demographic Surveillance System areas. CONCLUSIONS: This study showed a high level of interest in knowing the CoD of a relative and a high hypothetical acceptability of MIAs as a tool for CoD investigation across six distinct settings. These findings anticipate potential barriers and facilitators, both at the health facility and community level, essential for local tailoring of recommendations for future MIA implementation.

The relationship between adherence to clinic appointments and year-one mortality for newly enrolled HIV infected patients at a regional referral hospital in Western Kenya, January 2011-December 2012.

This retrospective cohort analysis was conducted to describe the association between adherence to clinic appointments and mortality, one year after enrollment into HIV care. We examined appointment-adherence for newly enrolled patients between January 2011 and December 2012 at a regional referral hospital in western Kenya. The outcomes of interest were patient default, risk factors for repeat default, and year-one risk of death. Of 582 enrolled patients, 258 (44%) were defaulters. GEE revealed that once having been defaulters, patients were significantly more likely to repeatedly default (OR 1.4; 95% CI 1.12-1.77), especially the unemployed (OR 1.43; 95% CI 1.07-1.91), smokers (OR 2.22; 95% CI 1.31-3.76), and those with no known disclosure (OR 2.17; 95% CI 1.42-3.3). Nineteen patients (3%) died during the follow-up period. Cox proportional hazards revealed that the risk of death was significantly higher among defaulters (HR 3.12; 95% CI 1.2-8.0) and increased proportionally to the rate of patient default; HR was 4.05 (95% CI1.38-11.81) and 4.98 (95% CI 1.45-17.09) for a cumulative of 4-60 and ≥60 days elapsed between all scheduled and actual clinic appointment dates, respectively. Risk factors for repeat default suggest a need to deliver targeted adherence programs.

Evidence for declining numbers of Ebola cases--Montserrado County, Liberia, June-October 2014.

The epidemic of Ebola virus disease (Ebola) in West Africa that began in March 2014 has caused approximately 13,200 suspected, probable, and confirmed cases, including approximately 6,500 in Liberia. About 50% of Liberia's reported cases have been in Montserrado County (population 1.5 million), the most populous county, which contains the capital city, Monrovia. To examine the course of the Ebola epidemic in Montserrado County, data on Ebola treatment unit (ETU) admissions, laboratory testing of patient blood samples, and collection of dead bodies were analyzed. Each of the three data sources indicated consistent declines of 53%-73% following a peak incidence in mid-September. The declines in ETU admissions, percentage of patients with reverse transcription-polymerase chain reaction (RT-PCR) test results positive for Ebola, and dead bodies are the first evidence of reduction in disease after implementation of multiple prevention and response measures. The possible contributions of these interventions to the decline is not yet fully understood or corroborated. A reduction in cases suggests some progress; however, eliminating Ebola transmission is the critical goal and will require greatly intensified efforts for complete, high-quality surveillance to direct and drive the rapid intervention, tracking, and response efforts that remain essential.

Biological control of mosquitoes in scrap tires in Brownsville, Texas, USA and Matamoros, Tamaulipas, Mexico.

Dengue periodically circulates in southern Texas and neighboring Tamaulipas, Mexico; thus, a closer examination of human and vector ecology at the northern limits of North American transmission may improve prevention activities. Scrap tires produce large mosquito populations and increase the risk of dengue transmission. Some households choose not to pay tire disposal fees, and many tires are illegally dumped in residential areas. Biological control may provide low-cost and environmentally friendly mosquito control. This pilot study evaluated the ability of Mesocyclops longisetus to reduce mosquito populations in existing residential scrap tire piles. Mosquito populations were measured by the number of all mosquito pupae within tires or adult Aedes aegypti and Ae. albopictus near piles. Mesocyclops longisetus treated piles did not significantly reduce total mosquito pupae (P = 0.07) in Matamoros, Mexico. The study also evaluated the efficacy of native Toxorhynchites moctezuma which preferentially colonized tire piles under vegetation cover in Brownsville, TX. Toxorhynchites moctezuma larvae significantly reduced total mosquito pupae, but the strength of control diminished over time.

Novel species of Triatoma (Hemiptera: Reduviidae) identified in a case of vectorial transmission of Chagas disease in northern Belize.

Chagas disease is a leading cause of non-ischemic cardiomyopathy in endemic regions of Central and South America. In Belize, Triatoma dimidiata sensu lato has been identified as the predominate taxon but vectorial transmission of Chagas disease is considered to be rare in the country. We recently identified an acute case of vector-borne Chagas disease in the northern region of Belize. Here we present a subsequent investigation of triatomines collected around the case-patient's home. We identified yet undescribed species, closely related to Triatoma huehuetenanguensis vector by molecular systematics methods occurring in the peridomestic environment. The identification of a T. cruzi-positive, novel species of Triatoma in Belize indicates an increased risk of transmission to humans in the region and warrants expanded surveillance and further investigation.

Seroprevalence of Anti-SARS-CoV-2 IgG Antibodies in Healthcare Personnel in El Salvador Prior to Vaccination Campaigns.

COVID-19, caused by the SARS-CoV-2 virus, is a highly pathogenic emerging infectious disease. Healthcare personnel (HCP) are presumably at higher risk of acquiring emerging infections because of occupational exposure. The prevalence of COVID-19 in HCP is unknown, particularly in low- to middle-income countries like El Salvador. The goal of this study was to determine the seroprevalence of anti-SARS-CoV-2 antibodies among HCP in El Salvador just prior to vaccine rollout in March 2021. We evaluated 2176 participants from a nationally representative sample of national healthcare institutions. We found 40.4% (n = 880) of the study participants were seropositive for anti-spike protein antibodies. Significant factors associated with infection included younger age; living within the central, more populated zone of the country; living in a larger household (≥7 members); household members with COVID-19 or compatible symptoms; and those who worked in auxiliary services (i.e., housekeeping and food services). These findings provide insight into opportunities to mitigate SARS-CoV-2 risk and other emerging respiratory pathogens in HCP in El Salvador.

Trust and COVID-19 vaccine hesitancy in the Dominican Republic: a national cross-sectional household survey, June-October 2021.

OBJECTIVE: This study investigates the role of trust in shaping COVID-19 vaccine acceptance in the Dominican Republic (DR) during the COVID-19 pandemic. DESIGN: Cross-sectional household survey. SETTING: Randomly selected households across 134 clusters in the DR, from 30 June 2021 to 12 October 2021. PARTICIPANTS: 5999 participants ≥16 years of age were enrolled. OUTCOME MEASURES: COVID-19 vaccine hesitancy (CVH) data were collected from participants ≥16 years of age and analysed as both an ordinal and binary variable. RESULTS: Overall, CVH was low (5.2% (95% CI 4.6% to 5.8%)), but more common among younger individuals, women and individuals of Mestizo ethnicity. Higher trust in local government, national government, scientists and local doctors (considered official sources) was associated with lower odds of CVH (OR 0.89 (95% CI 0.72 to 0.88), 0.89 (95% CI 0.81 to 0.98), 0.87 (95% CI 0.80 to 0.94) and 0.70 (95% CI 0.62 to 0.80), respectively). Higher trust in religious leaders, social media and traditional media (considered unofficial sources) was associated with higher odds of CVH, with respective ORs of 1.32 (95% CI 1.18 to 1.47), 1.30 (95% CI 1.19 to 1.41) and 1.08 (95% CI 0.97 to 1.22). CONCLUSION: We report findings on CVH from a national household survey in the DR and identify overall low rates of CVH but marked heterogeneity by age, gender and ethnicity. Trust in unofficial versus official sources of information is associated with increased CVH. These findings highlight and quantify the importance of trust as a key parameter when considering public health communication strategies.

Sociodemographic Factors Associated with COVID-19 Vaccination among People in Guatemalan Municipalities.

The Republic of Guatemala's reported COVID-19 vaccination coverage is among the lowest in the Americas and there are limited studies describing the disparities in vaccine uptake within the country. We performed a cross-sectional ecological analysis using multi-level modeling to identify sociodemographic characteristics that were associated with low COVID-19 vaccination coverage among Guatemalan municipalities as of 30 November 2022. Municipalities with a higher proportion of people experiencing poverty (ß = -0.25, 95% CI: -0.43--0.07) had lower vaccination coverage. Municipalities with a higher proportion of people who had received at least a primary education (ß = 0.74, 95% CI: 0.38-1.08), children (ß = 1.07, 95% CI: 0.36-1.77), people aged 60 years and older (ß = 2.94, 95% CI: 1.70-4.12), and testing for SARS-CoV-2 infection (ß = 0.25, 95% CI: 0.14-0.36) had higher vaccination coverage. In the simplified multivariable model, these factors explained 59.4% of the variation in COVID-19 vaccination coverage. Poverty remained significantly associated with low COVID-19 vaccination coverage in two subanalyses restricting the data to the time period of the highest national COVID-19-related death rate and to COVID-19 vaccination coverage only among those aged 60 years or older. Poverty is a key factor associated with low COVID-19 vaccination and focusing public health interventions in municipalities most affected by poverty may help address COVID-19 vaccination and health disparities in Guatemala.

Acceptability of minimally invasive autopsy by community members and healthcare workers in Siaya and Kisumu counties, western Kenya, 2017-2018.

Worldwide, nearly six million children under the age of five (<5s) die annually, a substantial proportion of which are due to preventable and treatable diseases. Efforts to reduce child mortality indicators in the most affected regions are often undermined by a lack of accurate cause of death data. To generate timely and more accurate causes of death data for <5s, the Child Health and Mortality Prevention Surveillance (CHAMPS) Network established mortality surveillance in multiple countries using Minimally Invasive Tissue Sampling (MITS) in <5 deaths. Here we present acceptability of MITS by community members and healthcare workers in Siaya and Kisumu counties, western Kenya. From April 2017 to February 2018, we conducted 40 in-depth interviews and five focus group discussions with healthcare workers and community members, before and during CHAMPS implementation. Participants were purposively selected. Field observations to understand traditional death-related practices were also performed. Interviews were transcribed into Nvivo 11.0 for data organization and management. Analysis was guided by the grounded theory approach. Facilitators of acceptability were desire to understand why death occurred, timely performance of MITS procedures, potential for MITS results in improving clinical practice and specific assistance provided to families by the CHAMPS program. However, cultural and religious beliefs highlighted important challenges to acceptability, including CHAMPS teams recruiting after a child's death, rumours and myths, unmet expectations from families, and fear by healthcare workers that some families could use MITS results to sue for negligence. Increasing MITS uptake requires sustained strategies to strengthen the identified facilitators of acceptability and simultaneously address the barriers. MITS acceptance will contribute to better characterization of causes of death and support the development of improved interventions aimed at reducing <5 mortality.

Engagement with Traditional Healers for Early Detection of Plague in Uganda.

In rural Uganda, many people who are ill consult traditional healers prior to visiting the formal healthcare system. Traditional healers provide supportive care for common illnesses, but their care may delay diagnosis and management of illnesses that can increase morbidity and mortality, hinder early detection of epidemic-prone diseases, and increase occupational risk to traditional healers. We conducted open-ended, semi-structured interviews with a convenience sample of 11 traditional healers in the plague-endemic West Nile region of northwestern Uganda to assess their knowledge, practices, and attitudes regarding plague and the local healthcare system. Most were generally knowledgeable about plague transmission and its clinical presentation and expressed willingness to refer patients to the formal healthcare system. We initiated a public health outreach program to further improve engagement between traditional healers and local health centers to foster trust in the formal healthcare system and improve early identification and referral of patients with plaguelike symptoms, which can reflect numerous other infectious and noninfectious conditions. During 2010-2019, 65 traditional healers were involved in the outreach program; 52 traditional healers referred 788 patients to area health centers. The diagnosis was available for 775 patients; malaria (37%) and respiratory tract infections (23%) were the most common diagnoses. One patient had confirmed bubonic plague. Outreach to improve communication and trust between traditional healers and local healthcare settings may result in improved early case detection and intervention not only for plague but also for other serious conditions.

Prevalence and Missed Cases of Respiratory Distress Syndrome Disease Amongst Neonatal Deaths Enrolled in the Kenya Child Health and Mortality Prevention Surveillance Network (CHAMPS) Program Between 2017 and 2021.

Objectives. To describe RDS in neonatal deaths at the CHAMPS-Kenya site between 2017 and 2021. Methods. We included 165 neonatal deaths whose their Causes of death (COD) were determined by a panel of experts using data from post-mortem conducted through minimally invasive tissue specimen testing, clinical records, and verbal autopsy. Results. Twenty-six percent (43/165) of neonatal deaths were attributable to RDS. Most cases occurred in low birthweight and preterm neonates. From these cases, less than half of the hospitalizations were diagnosed with RDS before death, and essential diagnostic tests were not performed in most cases. Most cases received suboptimal levels of supplemental oxygen, and critical interventions like surfactant replacement therapy and mechanical ventilation were not adequately utilized when available. Conclusion. The study highlights the urgent need for improved diagnosis and management of RDS, emphasizing the importance of increasing clinical suspicion and enhancing training in its clinical management to reduce mortality rates.