Lessons Learned from Public Health and State Prison Collaborations during COVID-19 Pandemic and Multifacility Tuberculosis Outbreak, Washington, USA.

The large COVID-19 outbreaks in prisons in the Washington (USA) State Department of Corrections (WADOC) system during 2020 highlighted the need for a new public health approach to prevent and control COVID-19 transmission in the system's 12 facilities. WADOC and the Washington State Department of Health (WADOH) responded by strengthening partnerships through dedicated corrections-focused public health staff, improving cross-agency outbreak response coordination, implementing and developing corrections-specific public health guidance, and establishing collaborative data systems. The preexisting partnerships and trust between WADOC and WADOH, strengthened during the COVID-19 response, laid the foundation for a collaborative response during late 2021 to the largest tuberculosis outbreak in Washington State in the past 20 years. We describe challenges of a multiagency collaboration during 2 outbreak responses, as well as approaches to address those challenges, and share lessons learned for future communicable disease outbreak responses in correctional settings.

Parsing a plethora of pollen: the role of pollen size and shape in the evolution of Boraginaceae.

Pollen, the microgametophyte of seed plants, has an important role in plant reproduction and, therefore, evolution. Pollen is variable in, for example, size, shape, aperture number; these features are particularly diverse in some plant taxa and can be diagnostic. In one family, Boraginaceae, the range of pollen diversity suggests the potential utility of this family as a model for integrative studies of pollen development, evolution and molecular biology. In the present study, a comprehensive survey of the diversity and evolution of pollen from 538 species belonging to 72 genera was made using data from the literature and additional scanning electron microscopy examination. Shifts in diversification rates and the evolution of various quantitative characters were detected, and the results revealed remarkable differences in size, shape and number of apertures. The pollen of one subfamily, Boraginoideae, is larger than that in Cynoglossoideae. The diversity of pollen shapes and aperture numbers in one tribe, Lithospermeae, is greater than that in the other tribes. Ancestral pollen for the family was resolved as small, prolate grains that bear three apertures and are iso-aperturate. Of all the tribes, the greatest number of changes in pollen size and aperture number were observed in Lithospermeae and Boragineae, and the number of apertures was found to be stable throughout all tribes of Cynoglossoideae. In addition, the present study showed that diversification of Boraginaceae cannot be assigned to a single factor, such as pollen size, and the increased rate of diversification for species-rich groups (e.g. Cynoglossum) is not correlated with pollen size or shape evolution. The palynological data and patterns of character evolution presented in the study provide better resolution of the roles of geographical and ecological factors in the diversity and evolution of pollen grains of Boraginaceae, and provide suggestions for future palynological research across the family.

COVID-19 Outbreak Among Farmworkers - Okanogan County, Washington, May-August 2020.

Okanogan County, Washington, experienced increased community transmission of SARS-CoV-2, the virus that causes COVID-19, during summer 2020 (1). Multiple COVID-19 outbreaks occurred in agricultural settings, including a large outbreak among employees of a fruit grower during May-August. Because of this outbreak, Okanogan County Public Health and the Washington State Department of Health initiated one-time, on-site screening testing (2) of all orchard and warehouse employees in August 2020 and assessed risk factors for SARS-CoV-2 infection. Among 3,708 known orchard employees, a valid SARS-CoV-2 test result or information on COVID-19-like symptoms in the absence of a test was available for 3,013 (81%). Cumulative incidence of SARS-CoV-2 infection during approximately 3 months among tested orchard employees was 6%. Cumulative incidence was 12% in employees residing in the community, compared with 4% in employees residing in farmworker housing (p<0.001); point prevalence during the single screening testing event was 1% in both groups. Among 1,247 known warehouse employees, a valid result was available for 726 (58%). Cumulative incidence over approximately 3 months among tested warehouse employees was 23%, with substantial variation across job roles. Positive test results were received by 28% of employees who worked packing and sorting fruit, 24% of those in other roles in the packing and sorting area, 10% of forklift operators, 7% of employees in other warehouse roles, and 6% of office employees. Point prevalence among all warehouse workers was 1% at the screening testing event. Collaboration among employers, community groups, and public health authorities can reveal risk factors and help decrease farmworkers' risk for SARS-CoV-2 infection in the community and the workplace. Creation of a COVID-19 assessment and control plan by agricultural employers, with particular focus on indoor workers whose jobs limit physical distancing, could reduce workplace transmission.

Usage of and satisfaction with Integrated Community Case Management care in western Uganda: a cross-sectional survey.

BACKGROUND: In some areas of Uganda, village health workers (VHW) deliver Integrated Community Case Management (iCCM) care, providing initial assessment of children under 5 years of age as well as protocol-based treatment of malaria, pneumonia, and diarrhoea for eligible patients. Little is known about community perspectives on or satisfaction with iCCM care. This study examines usage of and satisfaction with iCCM care as well as potential associations between these outcomes and time required to travel to the household's preferred health facility. METHODS: A cross-sectional household survey was administered in a rural subcounty in western Uganda during December 2016, using a stratified random sampling approach in villages where iCCM care was available. Households were eligible if the household contained one or more children under 5 years of age. RESULTS: A total of 271 households across 8 villages were included in the final sample. Of these, 39% reported that it took over an hour to reach their preferred health facility, and 73% reported walking to the health facility; 92% stated they had seen a VHW for iCCM care in the past, and 55% had seen a VHW in the month prior to the survey. Of respondents whose households had sought iCCM care, 60% rated their overall experience as "very good" or "excellent," 97% stated they would seek iCCM care in the future, and 92% stated they were "confident" or "very confident" in the VHW's overall abilities. Longer travel time to the household's preferred health facility did not appear to be associated with higher propensity to seek iCCM care or higher overall satisfaction with iCCM care. CONCLUSIONS: In this setting, community usage of and satisfaction with iCCM care for malaria, pneumonia, and diarrhoea appears high overall. Ease of access to facility-based care did not appear to impact the choice to access iCCM care or satisfaction with iCCM care.

COVID-19 Case Investigation and Contact Tracing in Central Washington State, June-July 2020.

OBJECTIVE: To evaluate participation in COVID-19 case investigation and contact tracing in central Washington State between June 15 and July 12, 2020. METHODS: In this retrospective observational evaluation we combined SARS-CoV-2 RT-PCR and antigen test reports from the Washington Disease Reporting System with community case investigation and contact tracing data for 3 health districts (comprising 5 counties) in central Washington State. All 3 health districts have large Hispanic communities disproportionately affected by COVID-19. RESULTS: Investigators attempted to call all referred individuals with COVID-19 (n = 4,987); 71% were interviewed. Of those asked about close contacts (n = 3,572), 68% reported having no close contacts, with similar proportions across ethnicity, sex, and age group. The 968 individuals with COVID-19 who named specific contacts (27% of those asked) reported a total of 2,293 contacts (mean of 2.4 contacts per individual with COVID-19); 85% of listed contacts participated in an interview. CONCLUSIONS: Most individuals with COVID-19 reported having no close contacts. Increasing community engagement and public messaging, as well as understanding and addressing barriers to participation, are crucial for CICT to contribute meaningfully to controlling the SARS-CoV-2 pandemic.

Quality of care in integrated community case management services in Bugoye, Uganda: a retrospective observational study.

BACKGROUND: Village health workers (VHWs) in five villages in Bugoye subcounty (Kasese District, Uganda) provide integrated community case management (iCCM) services, in which VHWs evaluate and treat malaria, pneumonia, and diarrhoea in children under 5 years of age. VHWs use a "Sick Child Job Aid" that guides them through the evaluation and treatment of these illnesses. A retrospective observational study was conducted to measure the quality of iCCM care provided by 23 VHWs in 5 villages in Bugoye subcounty over a 2-year period. METHODS: Patient characteristics and clinical services were summarized using existing aggregate programme data. Lot quality assurance sampling of individual patient records was used to estimate adherence to the iCCM algorithm, VHW-level quality (based on adherence to the iCCM protocol), and change over time in quality of care (using generalized estimating equations regression modelling). RESULTS: For each of 23 VHWs, 25 patient visits were randomly selected from a 2-year period after iCCM care initiation. In these visits, 97% (150) of patients with diarrhoea were treated with oral rehydration and zinc, 95% (216) of patients with pneumonia were treated with amoxicillin, and 94% (240) of patients with malaria were treated with artemisinin-based combination therapy or rectal artesunate. However, only 44% (44) of patients with a negative rapid test for malaria were appropriately referred to a health facility. Overall, 75% (434) of patients received all the correct evaluation and management steps. Only 9 (39%) of the 23 VHWs met the pre-determined LQAS threshold for high-quality care over the 2-year observation period. Quality of care increased significantly in the first 6 months after initiation of iCCM services (p = 0.003), and then plateaued during months 7-24. CONCLUSIONS: Quality of care was high for uncomplicated malaria, pneumonia and diarrhoea. Overall quality of care was lower, in part because VHWs often did not follow the guidelines to refer patients with fever who tested negative for malaria. Quality of care appears to improve in the initial months after iCCM implementation, as VHWs gain initial experience in iCCM care.

Isolation of the New Antiplasmodial Butanolide, Malleastrumolide A, from Malleastrum sp. (Meliaceae) from Madagascar.

An extract of Malleastrum sp. (Meliaceae) collected in Madagascar by the Madagascar International Cooperative Biodiversity Group was found to have antimalarial activity, with an IC50 value between 2.5 and 5 µg ml-1 . After purification by liquid-liquid partition, chromatography on a Diaion open column, C18 SPE and C18 reversed phase HPLC, the new butanolide, malleastrumolide A, was isolated. The structure of malleastrumolide A was determined by mass spectrometry, NMR, and ECD. The double bond position was determined by cross-metathesis and mass spectrometry. The compound has antiproliferative activity against the A2780 ovarian cancer cell line with an IC50 value of 17.4 µm and antiplasmodial activity against the drug-resistant Dd2 strain of Plasmodium falciparum with an IC50 value of 2.74 µm.

Monitoring iCCM referral systems: Bugoye Integrated Community Case Management Initiative (BIMI) in Uganda.

BACKGROUND: In Uganda, over half of under-five child mortality is attributed to three infectious diseases: malaria, pneumonia and diarrhoea. Integrated community case management (iCCM) trains village health workers (VHWs) to provide in-home diagnosis and treatment of these common childhood illnesses. For severely ill children, iCCM relies on a functioning referral system to ensure timely treatment at a health facility. However, referral completion rates vary widely among iCCM programmes and are difficult to monitor. The Bugoye Integrated Community Case Management Initiative (BIMI) is an iCCM programme operating in Bugoye sub-county, Uganda. This case study describes BIMI's experience with monitoring referral completion at Bugoye Health Centre III (BHC), and outlines improvements to be made within iCCM referral systems. METHODS: This study triangulated multiple data sources to evaluate the strengths and gaps in the BIMI referral system. Three quantitative data sources were reviewed: (1) VHW report of referred patients, (2) referral forms found at BHC, and (3) BHC patient records. These data sources were collated and triangulated from January-December 2014. The goal was to determine if patients were completing their referrals and if referrals were adequately documented using routine data sources. RESULTS: From January-December 2014, there were 268 patients referred to BHC, as documented by VHWs. However, only 52 of these patients had referral forms stored at BHC. Of the 52 referral forms found, 22 of these patients were also found in BHC register books recorded by clinic staff. Thus, the study found a mismatch between VHW reports of patient referrals and the referral visits documented at BHC. This discrepancy may indicate several gaps: (1) referred patients may not be completing their referral, (2) referral forms may be getting lost at BHC, and, (3) referred patients may be going to other health facilities or drug shops, rather than BHC, for their referral. CONCLUSIONS: This study demonstrates the challenges of effectively monitoring iCCM referral completion, given identified limitations such as discordant data sources, incomplete record keeping and lack of unique identifiers. There is a need to innovate and improve the ways by which referral compliance is monitored using routine data, in order to improve the percentage of referrals completed. Through research and field experience, this study proposes programmatic and technological solutions to rectify these gaps within iCCM programmes facing similar challenges. With improved monitoring, VHWs will be empowered to increase referral completion, allowing critically ill children to access needed health services.

Antimalarial 5,6-Dihydro-α-pyrones from Cryptocarya rigidifolia: Related Bicyclic Tetrahydro-α-Pyrones Are Artifacts1.

Antimalarial bioassay-guided fractionation of an EtOH extract of the root wood of Cryptocarya rigidifolia (Lauraceae) led to the isolation of the five new 5,6-dihydro-α-pyrones cryptorigidifoliols A-E (1-5) and the six bicyclic tetrahydro-α-pyrone derivatives cryptorigidifoliols F-K (6-11). The structure elucidations of all compounds were made on the basis of the interpretation of spectroscopic data and chemical derivatization, and the relative and absolute configurations were determined by NOESY, electronic circular dichroism (ECD), and (1)H NMR analysis of α-methoxyphenylacetyl (MPA) derivatives. The bicyclic tetrahydro-α-pyrone derivatives were identified as products of acid-catalyzed intramolecular Michael addition of the 5,6-dihydro-α-pyrones in the presence of silica gel. A structure-activity relationship study suggested that the presence of an α,ß-unsaturated carbonyl moiety is not essential for potent antimalarial activity.

Molecular delimitations in the Ehretiaceae (Boraginales).

Major taxa of Ehretiaceae (including parasitic Lennoaceae) have not all been included in previous molecular phylogenetic analyses. As a result, the generic limits and their circumscriptions have not been satisfactorily resolved, despite its importance for floristic studies. To clarify which monophyletic groups can be recognized within the Ehretiaceae, sequences from one nuclear (ITS) and three plastid loci (rps16, trnL-trnF, trnS-trnG) were obtained from 67 accessions tentatively assigned to the Ehretiaceae (including 91 new GenBank entries) and covering the known diversity of the group. In phylogenetic analyses, Ehretiaceae were monophyletic when Lennoaceae were included and segregated into nine monophyletic lineages that correspond to accepted, morphologically distinct taxonomic units, namely Bourreria (s.l., paraphyletic in its current circumscription if not including Hilsenbergia), monotypic Cortesia, Ehretia (s.l., paraphyletic in its current circumscription if not including Carmona and Rotula), Halgania, monotypic Lennoa, Lepidocordia, Pholisma, Rochefortia, and Tiquilia. Bourreria and Ehretia have representatives in both the Old World and the New World, but all other taxa are restricted to the tropical and subtropical Americas (Cortesia, Lennoa, Lepidocordia, Pholisma, Rochefortia, Tiquilia) or Australia (Halgania). The historical biogeography of Ehretiaceae can be explained by few colonization events. The molecular trees are also discussed with respect to fruit evolution, where the fusion of endocarp parts may have taken place several times independently.

From capsules to nutlets-phylogenetic relationships in the Boraginales.

Multiple family-level subdivisions of Boraginales have been proposed in the past. The relationships of several constituent genera have been enigmatic, including Codon (Codonaceae), Hoplestigma (Hoplestigmataceae), Pholisma (Lennoaceae), Vahlia (Vahliaceae), and Wellstedia (Wellstediaceae), all of which are included in the present study. We present a molecular analysis with four chloroplast loci, including 89 ingroup taxa and a broad outgroup sampling in the asterids. The genus Vahlia is excluded from Boraginales and appears to represent an early branching lineage of Lamiales. The study provides a well supported topology for the relationships within Boraginales, including all of the genera with previously unclear relationships. Within Boraginales, two major clades are recognized, with "herbaceaous" Boraginales I resolved as [Codonaceae,[Wellstediaceae,[Boraginaceae]]] and "woody" Boraginales II resolved as [Hydrophyllaceae I,[Hydrophyllaceae II,[Heliotropiaceae,[Cordiaceae,[Ehretiaceae,Lennoaceae]]]]. A close relationship between Ehretiaceae and Lennoaceae is well supported, but the exact placement of Lennoaceae remains unresolved. The Cordiaceae lineage includes the monotypic genus Coldenia and the aberrant western and central African genus Hoplestigma. Woody Boraginales II are retrieved in two highly supported clades. Hydrophyllaceae are retrieved in two separate clades, but with poor support. There appear to be clear morphological progressions in vegetative, floral, and fruit morphology in both major Boraginales lineages. Thus capsular fruits are found in the first branching lineages of both clades, whereas reduced seed numbers in indehiscent fruits predominate in the more derived phylogenetic positions. Based on these results, we advocate the recognition of eight morphologically well defined clades in the order, namely Boraginaceae s.str., Codonaceae, Cordiaceae (incl. Coldenia and Hoplestigmataceae), Ehretiaceae (incl. Lennoaceae), Heliotropiaceae, Hydrophyllaceae I and Hydrophyllaceae II, and Wellstediaceae.

Patient satisfaction with HIV/AIDS care at private clinics in Dar es Salaam, Tanzania.

Health system responsiveness (HSR) measures quality of care from the patient's perspective, an important component of ensuring adherence to medication and care among HIV patients. We examined HSR in private clinics serving HIV patients in Dar es Salaam, Tanzania. We surveyed 640 patients, 18 or older receiving care at one of 10 participating clinics, examining socioeconomic factors, HIV regimen, and self-reported experience with access and care at the clinic. Ordered logistic regression, adjusted for clustering of the clinic sites, was used to measure the relationships between age, gender, education, site size, and overall quality of care rating, as well as between the different HSR domains and overall rating. Overall, patients reported high levels of satisfaction with care received. Confidentiality, communication, and respect were particularly highly rated, while timeliness received lower ratings despite relatively short wait times, perhaps indicating high expectations when receiving care at a private clinic. Respect, confidentiality, and promptness were significantly associated with overall rating of health care, while provider skills and communication were not significantly associated. Patients reported that quality of service and confidentiality, rather than convenience of location, were the most important factors in their choice of a clinic. Site size (patient volume) was also positively correlated with patient satisfaction. Our findings suggest that, in the setting of urban private-sector clinics, flexible clinics hours, prompt services, and efforts to improve respect, privacy and confidentiality may prove more helpful in increasing visit adherence than geographic accessibility. While a responsive health system is valuable in its own right, more work is needed to confirm that improvements in HSR in fact lead to improved adherence to care.

A process evaluation of performance-based incentives for village health workers in Kisoro district, Uganda.

BACKGROUND: Designing effective incentive systems for village health workers (VHWs) represents a longstanding policy issue with substantial impact on the success and sustainability of VHW programs. Using performance-based incentives (PBI) for VHWs is an approach that has been proposed and implemented in some programs, but has not received adequate review and evaluation in the peer-reviewed literature. We conducted a process evaluation examining the use of PBI for VHWs in Kisoro, Uganda. In this system, VHWs are paid based on 20 indicators, divided among routine follow-up visits, health education activities, new patient identifications, sanitation coverage, and uptake of priority health services. METHODS: Surveys of VHWs (n = 30) and program supervisors (n = 7) were conducted to assess acceptability and feasibility. Interviews were conducted with all 8 program supervisors and with 6 purposively selected VHWs to gain a deeper understanding of their views on the PBI system. Program budget records were used to assess the costs of the program. Detailed payment records were used to assess the fairness of the PBI system with respect to VHWs' gender, education level, and village location. RESULTS: In surveys and interviews, supervisors expressed high satisfaction with the PBI system, though some supervisors expressed concerns about possible negative effects from the variation in payments between VHWs and the uncertainty of reward for effort. VHWs perceived the system as generally fair, and preferred it to the previous payment system, but expressed a desire to be paid more. The annual program cost was $516 per VHW, with each VHW covering an average of 115 households. VHWs covering more households tended to earn more. There was some evidence that female gender was associated with higher earnings. Education level and proximity to the district hospital did not appear to be associated with earnings under the PBI system. CONCLUSIONS: In a one-year pilot of PBI within a small VHW program, both VHWs and supervisors found the PBI system acceptable and motivating. VHWs with relatively limited formal education were able to master the PBI system. Further research is needed to determine the long-term effects and scalability of PBI, as well as the effects across varied contexts.

Two new species of the hyperdiverse geometrid moth genus Eois (Lepidoptera, Geometridae, Larentiinae) from Ecuador, with descriptions of early stages.

The hyperdiverse geometrid genus Eois Hübner, estimated to encompass more than 1,000 species, is among the most species-rich genera in all of Lepidoptera. While the genus has attracted considerable attention from ecologists and evolutionary biologists in recent decades, limited progress has been made on its alpha taxonomy. This contribution focuses on the Olivacea clade, whose monophyly has been recognized previously through molecular analyses. We attempt to define the clade from a morphological perspective and recognize the following species based on morphology and genomic data: E.olivacea (Felder & Rogenhofer); E.pseudolivacea Doan, sp. nov.; E.auruda (Dognin), stat. rev.; E.beebei (Fletcher, 1952), stat. rev.; E.boliviensis (Dognin), stat. rev.; and E.parumsimii Doan, sp. nov. Descriptions and illustrations of the immature stages of E.pseudolivacea reared from Piper (Piperaceae) in Ecuador are provided.

Management of children with danger signs in integrated community case management care in rural southwestern Uganda (2014-2018).

BACKGROUND: In integrated community case management (iCCM) care, community health workers (CHWs) provide home-based management of fever, diarrhea and fast breathing for children aged <5 y. The iCCM protocol recommends that children with danger signs for severe illness are referred by CHWs to health facilities within their catchment area. This study examines the management of danger signs by CHWs implementing iCCM in a rural context. METHODS: A retrospective observational study that examined clinical records for all patients with danger signs evaluated by CHWs from March 2014 to December 2018 was conducted. RESULTS: In total, 229 children aged <5 y had been recorded as having a danger sign during 2014-2018. Of these children, 56% were males with a mean age of 25 (SD 16.9) mo, among whom 78% were referred by the CHWs as per the iCCM protocol. The age category of 12 to 35 mo had the highest numbers of prereferred and referred cases (54% and 46%, respectively). CONCLUSIONS: CHWs play a key role in early symptomatic detection, prereferral treatment and early referral of children aged <5 y. Danger signs among children aged <5 y, if left untreated, can result in death. A high proportion of the children with danger signs were referred as per the iCCM protocol. Continuous CHW training is emphasized to reduce the number of referral cases that are missed. More studies need to focus on children aged 12-35 mo and why they are the most referred category. Policymakers should occasionally revise iCCM guidelines to detail the types of danger signs and how CHWs can address these.

Selection and authentication of botanical materials for the development of analytical methods.

Herbal products, for example botanical dietary supplements, are widely used. Analytical methods are needed to ensure that botanical ingredients used in commercial products are correctly identified and that research materials are of adequate quality and are sufficiently characterized to enable research to be interpreted and replicated. Adulteration of botanical material in commerce is common for some species. The development of analytical methods for specific botanicals, and accurate reporting of research results, depend critically on correct identification of test materials. Conscious efforts must therefore be made to ensure that the botanical identity of test materials is rigorously confirmed and documented through preservation of vouchers, and that their geographic origin and handling are appropriate. Use of material with an associated herbarium voucher that can be botanically identified is always ideal. Indirect methods of authenticating bulk material in commerce, for example use of organoleptic, anatomical, chemical, or molecular characteristics, are not always acceptable for the chemist's purposes. Familiarity with botanical and pharmacognostic literature is necessary to determine what potential adulterants exist and how they may be distinguished.

Geographically skewed recruitment and COVID-19 seroprevalence estimates: a cross-sectional serosurveillance study and mathematical modelling analysis.

OBJECTIVES: Convenience sampling is an imperfect but important tool for seroprevalence studies. For COVID-19, local geographic variation in cases or vaccination can confound studies that rely on the geographically skewed recruitment inherent to convenience sampling. The objectives of this study were: (1) quantifying how geographically skewed recruitment influences SARS-CoV-2 seroprevalence estimates obtained via convenience sampling and (2) developing new methods that employ Global Positioning System (GPS)-derived foot traffic data to measure and minimise bias and uncertainty due to geographically skewed recruitment. DESIGN: We used data from a local convenience-sampled seroprevalence study to map the geographic distribution of study participants' reported home locations and compared this to the geographic distribution of reported COVID-19 cases across the study catchment area. Using a numerical simulation, we quantified bias and uncertainty in SARS-CoV-2 seroprevalence estimates obtained using different geographically skewed recruitment scenarios. We employed GPS-derived foot traffic data to estimate the geographic distribution of participants for different recruitment locations and used this data to identify recruitment locations that minimise bias and uncertainty in resulting seroprevalence estimates. RESULTS: The geographic distribution of participants in convenience-sampled seroprevalence surveys can be strongly skewed towards individuals living near the study recruitment location. Uncertainty in seroprevalence estimates increased when neighbourhoods with higher disease burden or larger populations were undersampled. Failure to account for undersampling or oversampling across neighbourhoods also resulted in biased seroprevalence estimates. GPS-derived foot traffic data correlated with the geographic distribution of serosurveillance study participants. CONCLUSIONS: Local geographic variation in seropositivity is an important concern in SARS-CoV-2 serosurveillance studies that rely on geographically skewed recruitment strategies. Using GPS-derived foot traffic data to select recruitment sites and recording participants' home locations can improve study design and interpretation.

Long-term quality of integrated community case management care for children in Bugoye Subcounty, Uganda: a retrospective observational study.

OBJECTIVE: Integrated community case management (iCCM) of childhood illness in Uganda involves protocol-based care of malaria, pneumonia and diarrhoea for children under 5 years old. This study assessed volunteer village health workers' (VHW) ability to provide correct iCCM care according to the national protocol and change in their performance over time since initial training. SETTING: VHWs affiliated with the Ugandan national programme provide community-based care in eight villages in Bugoye Subcounty, a rural area in Kasese District. The first cohort of VHWs began providing iCCM care in March 2013, the second cohort in July 2016. PARTICIPANTS: All children receiving iCCM care in 18 430 clinical encounters occurring between April 2014 and December 2018. PRIMARY AND SECONDARY OUTCOME MEASURES: The descriptive primary outcome measure was the proportion of patients receiving overall correct care, defined as adherence to the iCCM protocol for the presenting condition (hereafter quality of care). The analytic primary outcome was change in the odds of receiving correct care over time, assessed using logistic regression models with generalised estimating equations. Secondary outcome measures included a set of binary measures of adherence to specific elements of the iCCM protocol. Preplanned and final measures were the same. RESULTS: Overall, VHWs provided correct care in 74% of clinical encounters. For the first cohort of VHWs, regression modelling demonstrated a modest increase in quality of care until approximately 3 years after their initial iCCM training (OR 1.022 per month elapsed, 95% CI 1.005 to 1.038), followed by a modest decrease thereafter (OR 0.978 per month, 95% CI 0.970 to 0.986). For the second cohort, quality of care was essentially constant over time (OR 1.007 per month, 95% CI 0.989 to 1.025). CONCLUSION: Quality of care was relatively constant over time, though the trend towards decreasing quality of care after 3 years of providing iCCM care requires further monitoring.

Antiproliferative compounds of Cyphostemma greveana from a Madagascar dry forest.

Bioassay-guided fractionation of the EtOH extracts obtained from a plant identified as Cyphostemma greveana Desc. (Vitaceae) led to the identification of one macrolide, lasiodiplodin (1), three sesquiterpenoids, 12-hydroxy-15-oxoselina-4,11-diene (2), 1ß,6α-dihydroxyeudesm-4(15)-ene (3), and (7R*)-opposit-4(15)-ene-1ß,7-diol (5), and a new diterpenoid, 16,18-dihydroxykolavenic acid lactone (4). All the isolates were tested against the A2780 human ovarian cancer cell line, and compound 4 and a fraction containing 5 as the major constituent showed antiproliferative activities with IC(50) values of 0.44 µM (0.14 µg/ml) and 0.045 µg/ml, respectively. A partial synthesis of compound 5 was carried out, but the pure synthetic compound was inactive, indicating that the activity of the fraction containing it must be due to a very minor and as yet unidentified substance.