A description and evaluation of an educational programme for North West England GP trainees who have multiple fails in the Clinical Skills Assessment (CSA).

Background and aims: Trainees who have failed the Clinical Skills Assessment (CSA) component of the Membership of the Royal College of General Practitioners (MRCGP) licensing examination present an educational challenge. This study describes a CSA resit programme and evaluates the outcomes when doctors reattempt the CSA. Methods: We delivered an educational programme to trainees in North West England who were resitting the CSA in 2016 and 2017: the majority were undertaking periods of additional training time. After the programme, we compared their CSA pass rates with national pass rates. Results were stratified by the number of previous attempts and source of primary medical qualification. Results: The trainees who took part in this programme had pass rates that exceeded national pass rates. Results were particularly encouraging for the group of International Medical Graduates (IMGs) who had previously failed the CSA two or more times. Conclusions: We suggest several possible explanations for these results. All trainees reappraised their learning needs, using educational tools written by CSA assessors. The programme was delivered by experienced, trained educators working with both trainee and trainer in order to produce shared educational plans. The training community's commitment to support trainees improved their confidence and motivation.

Neglected tropical diseases: progress towards addressing the chronic pandemic.

The concept of neglected tropical diseases (NTDs) emerged more than a decade ago and has been recognised as a valid way to categorise diseases that affect the poorest individuals. Substantial progress in control and elimination has been achieved and policy momentum has been generated through continued bilateral, philanthropic, and non-governmental development organisation (NGDO) support, and donations of drugs from pharmaceutical companies. WHO has defined a Roadmap to reach 2020 targets, which was endorsed by member states in a World Health Assembly Resolution in 2013. NTDs have been included within the Sustainable Development Goal targets and are a crucial component of universal health coverage, conceptualised as "leaving no one behind". WHO reported that more than 1 billion people in 88 countries have benefited from preventive chemotherapy in 2014. The research agenda has defined the need for affordable products (diagnostics, drugs and insecticides). However challenges such as insecurity and weak health systems continue to prevail in the poorest countries, inhibiting progress in scaling up and also in achieving Roadmap goals.

The changing global landscape of health and disease: addressing challenges and opportunities for sustaining progress towards control and elimination of neglected tropical diseases (NTDs).

The drive to control neglected tropical diseases (NTDs) has had many successes but to reach defined targets new approaches are required. Over the last decade, NTD control programmes have benefitted from increased resources, and from effective partnerships and long-term pharmaceutical donations. Although the NTD agenda is broader than those diseases of parasitic aetiology there has been a massive up-scaling of the delivery of medicines to some billion people annually. Recipients are often the poorest, with the aspiration that NTD programmes are key to universal health coverage as reflected within the 2030 United Nations sustainable development goals (SDGs). To reach elimination targets, the community will need to adapt global events and changing policy environments to ensure programmes are responsive and can sustain progress towards NTD targets. Innovative thinking embedded within regional and national health systems is needed. Policy makers, managers and frontline health workers are the mediators between challenge and change at global and local levels. This paper attempts to address the challenges to end the chronic pandemic of NTDs and achieve the SDG targets. It concludes with a conceptual framework that illustrates the interactions between these key challenges and opportunities and emphasizes the health system as a critical mediator.

The feasibility of eliminating podoconiosis.

Podoconiosis is an inflammatory disease caused by prolonged contact with irritant minerals in soil. Major symptoms include swelling of the lower limb (lymphoedema) and acute pain. The disease has major social and economic consequences through stigma and loss of productivity. In the last five years there has been good progress in podoconiosis research and control. Addressing poverty at household level and infrastructure development such as roads, water and urbanization can all help to reduce podoconiosis incidence. Specific control methods include the use of footwear, regular foot hygiene and floor coverings. Secondary and tertiary prevention are based on the management of the lymphoedema-related morbidity and include foot hygiene, foot care, wound care, compression, exercises, elevation of the legs and treatment of acute infections. Certain endemic countries are taking the initiative to include podoconiosis in their national plans for the control of neglected tropical diseases and to scale up interventions against the disease. Advocacy is needed for provision of shoes as a health intervention. We suggest case definitions and elimination targets as a starting point for elimination of the disease.

La podoconiose est une maladie inflammatoire provoquée par un contact prolongé avec des minéraux irritants présents dans le sol. Les principaux symptômes incluent un gonflement des membres inférieurs (lymphœdème) et une douleur aiguë. Cette maladie a d'importantes conséquences sociales et économiques, car elle entraîne stigmatisation et perte de productivité. Ces cinq dernières années ont été marquées par des progrès satisfaisants en matière de recherche sur la podoconiose et de contrôle de cette maladie. Combattre la pauvreté au niveau des foyers et développer des infrastructures routières, d'approvisionnement en eau et urbaines peut contribuer à réduire son incidence. Les méthodes de lutte contre la podoconiose incluent le port de chaussures, une bonne hygiène des pieds et des revêtements de sol. La prévention secondaire et la prévention tertiaire reposent sur la gestion de la morbidité liée aux lymphœdèmes et passent par l'hygiène des pieds, les soins des pieds, les soins des plaies, la compression, des exercices, l'élévation des jambes et le traitement des infections aigües. Certains pays où la podoconiose est endémique ont pris l'initiative de l'inclure dans leur plan national pour la lutte contre les maladies tropicales négligées et de multiplier les interventions contre cette maladie. Des actions de sensibilisation sont nécessaires en vue de la distribution de chaussures comme mesure sanitaire. Nous recommandons de préciser les définitions de cas et les objectifs d'élimination pour servir de point de départ à l'éradication de cette maladie.

La podoconiosis es una enfermedad inflamatoria causada por un contacto prolongado con sustancias minerales irritantes del suelo. Los síntomas principales incluyen la hinchazón de las extremidades inferiores (linfedema) y un dolor agudo. Dicha enfermedad comporta graves consecuencias tanto en el entorno social como económico, ya que provoca estigmas y pérdida de productividad. En los últimos cinco años ha habido progresos satisfactorios en la investigación y el control de la podoconiosis. El tratamiento de la pobreza a nivel doméstico y el desarrollo de infraestructuras como carreteras, riegos y en urbanización pueden ayudar a reducir los casos de podoconiosis. Entre los métodos de control específico se encuentran el uso de calzado, una buena higiene de los pies y recubrimientos para el suelo. La prevención secundaria y terciaria se basa en la gestión de la morbilidad relacionada con el linfedema, esto incluye una buena higiene de los pies y el cuidado de los mismos, la cura de las lesiones, ejercicios de compresión, elevar las piernas y tratar las infecciones agudas. Algunos países endémicos han tomado la iniciativa de incluir la podoconiosis en sus planes nacionales de control sobre enfermedades tropicales desatendidas y aumentar el número de intervenciones para afrontar dicha enfermedad. Se necesita ayuda para suministrar calzado en clave de intervención sanitaria. Nuestra sugerencia para abolir la enfermedad es empezar por definir los casos y eliminar los obstáculos.

Elimination of lymphatic filariasis as a public health problem in Malawi.

BACKGROUND: Lymphatic filariasis (LF) is a parasitic disease transmitted by mosquitoes, causing severe pain, disfiguring, and disabling clinical conditions such as lymphoedema and hydrocoele. LF is a global public health problem affecting 72 countries, primarily in Africa and Asia. Since 2000, the World Health Organization (WHO) has led the Global Programme to Eliminate Lymphatic Filariasis (GPELF) to support all endemic regions. This paper focuses on the achievements of the Malawi LF Elimination Programme between 2000 and 2020 to eliminate LF as a public health problem, making it the second sub-Saharan country to receive validation from the WHO. METHODOLOGY/PRINCIPAL FINDINGS: The Malawi LF Programme addressed the widespread prevalence of LF infection and disease across the country, using the recommended WHO GPELF strategies and operational research initiatives in collaboration with key national and international partners. First, to stop the spread of infection (i.e., interrupt transmission) and reduce the circulating filarial antigen prevalence from as high as 74.4% to below the critical threshold of 1-2% prevalence, mass drug administration (MDA) using a two-drug regime was implemented at high coverage rates (>65%) of the total population, with supplementary interventions from other programmes (e.g., malaria vector control). The decline in prevalence was monitored and confirmed over time using several impact assessment and post-treatment surveillance tools including the standard sentinel site, spot check, and transmission assessment surveys and alternative integrated, hotspot, and easy-access group surveys. Second, to alleviate suffering of the affected populations (i.e., control morbidity) the morbidity management and disability prevention (MMDP) package of care was implemented. Specifically, clinical case estimates were obtained via house-to-house patient searching activities; health personnel and patients were trained in self-care protocols for lymphoedema and/or referrals to hospitals for hydrocoele surgery; and the readiness and quality of treatment and services were assessed with new survey tools. CONCLUSIONS: Malawi's elimination of LF will ensure that future generations are not infected and suffer from the disfiguring and disabling disease. However, it will be critical that the Malawi LF Elimination programme remains vigilant, focussing on post-elimination surveillance and MMDP implementation and integration into routine health systems to support long-term sustainability and ongoing success. SUMMARY: Lymphatic filariasis, also known as elephantiasis, is a disabling, disfiguring, and painful disease caused by a parasite that infected mosquitoes transmit to millions of people worldwide. Since 2000, the Global Programme to Eliminate Lymphatic Filariasis (GPELF) has supported endemic countries such as Malawi in south-eastern Africa, to eliminate the disease as a public health problem. The Malawi National LF Elimination Programme has worked tirelessly over the past two decades to implement the GPELF recommended strategies to interrupt the transmission with a two-drug regime, and to alleviate suffering in patients with lymphoedema and/or hydrocoele through morbidity management and disability prevention. Additionally, the LF Programme has collaborated with national and international stakeholders to implement a range of supplementary operational research projects to address outstanding knowledge gaps and programmatic barriers. In 2020, the World Health Organisation validated that Malawi had successfully eliminated LF as a public health problem, making it the second country in sub-Saharan Africa to achieve this, which is remarkable given that Malawi previously had very high infection rates. The LF Programme now remains vigilant, putting its efforts towards post-elimination surveillance and the continued implementation of care for patients with chronic conditions. Malawi's elimination of LF will ensure that future generations are not affected by this devastating disease.

Mental health and neglected tropical diseases - the neglected dimension of burden: identifying the challenges and understanding the burden.

Mental health co-morbidity and the Neglected Tropical Diseases (NTDs) has been highlighted as a major component of the ill health. The impact of mental illness is considered to be significantly underestimated in the calculations of the overall Disability-Adjusted Life Years (DALYs). This commentary discusses the DALY burden of anxiety, depression and associated stigma of NTDs. The economic losses incurred as a result of mental health conditions is assessed, and the impact on caregivers and families. It recommends that mental health care is incorporated into NTDs programme planning and implementation. Priority research is the estimation of the NTD burden of depressive and anxiety disorders and neuropsychiatric conditions of NTDs and an evaluation of the economic costs of mental illness derived from NTDs causation.

Is the neglected tropical disease mass drug administration campaign approach an effective strategy to deliver universal health coverage? A case study of the Liberia neglected tropical disease programme.

BACKGROUND: Access to affordable, quality healthcare is the key element of universal health coverage (UHC). This study examines the effectiveness of the neglected tropical disease (NTD) mass drug administration (MDA) campaign approach as a means to deliver UHC, using the example of the Liberia national programme. METHODS: We first mapped the location of 3195 communities from the 2019 national MDA treatment data reporting record of Liberia. The association between coverage for onchocerciasis and lymphatic filariasis treatment achieved in these communities was then explored using a binomial geo-additive model. This model employed three key determinants for community 'remoteness': population density and the modelled travel time of communities to their supporting health facility and to their nearest major settlement. RESULTS: Maps produced highlight a small number of clusters of low treatment coverage in Liberia. Statistical analysis suggests there is a complex relationship between treatment coverage and geographic location. CONCLUSIONS: We accept the MDA campaign approach is a valid mechanism to reach geographically marginal communities and, as such, has the potential to deliver UHC. We recognise there are specific limitations requiring further study.

Mental distress and health-related quality of life in gambiense human African trypanosomiasis: a case-control study in the Democratic Republic of Congo.

BACKGROUND: The extent to which neuropsychiatric sequelae affects the mental health status and quality of life of former gambiense human African trypanosomiasis (gHAT) patients is not known. METHODS: We assessed anxiety, depression and health-related quality of life (HRQoL) in 93 patients and their age- and sex-matched controls using the Hospital Anxiety and Depression Scale, Becks Depression Inventory and the 36-item Short Form Health Survey in structured interviews in the Vanga health zone in the Democratic Republic of Congo. Data were analysed using Stata version 14.0. The degree of association between neurologic sequelae and mental distress was evaluated using the Student's t-test and χ2 or Fisher's exact tests, where appropriate, with a p-value <0.05 deemed to be statistically significant. RESULTS: We found that neurological sequelae persisted in former patients at least 15 y after treatment. Depression (p<0.001) and anxiety (p=0.001) were significantly higher in former patients with neurologic sequelae. The mean quality-of-life (QoL) scores were significantly lower for patients than in controls in the physical, emotional and mental health domains. CONCLUSIONS: The presence of neurological sequelae leads to mental distress and a diminished QoL in former gHAT patients. Minimising neurologic sequelae and incorporating psychosocial interventions should be essential management goals for gHAT.

Socioeconomic aspects of neglected tropical diseases.

Although many examples of highly cost-effective interventions to control neglected tropical diseases exist, our understanding of the full economic effect that these diseases have on individuals, households, and nations needs to be improved to target interventions more effectively and equitably. We review data for the effect of neglected tropical diseases on a population's health and economy. We also present evidence on the costs, cost-effectiveness, and financing of strategies to monitor, control, or reduce morbidity and mortality associated with these diseases. We explore the potential for economies of scale and scope in terms of the costs and benefits of successfully delivering large-scale and integrated interventions. The low cost of neglected tropical disease control is driven by four factors: the commitment of pharmaceutical companies to provide free drugs; the scale of programmes; the opportunities for synergising delivery modes; and the often non-remunerated volunteer contribution of communities and teachers in drug distribution. Finally, we make suggestions for future economic research.

Long-term sequelae of congenital gambiense human African trypanosomiasis.

BACKGROUND: The clinical presentation of gambiense human African trypanosomias (gHAT) is generally considered to be the same among children and adults. In general, when describing the clinical presentation of children with gHAT, no differentiation is made between congenital gHAT and gHAT acquired later. There is a lack of knowledge regarding the signs and symptoms attributable to congenital gHAT and its long-term sequelae. METHODS: Following an evaluation of the hospital register for gHAT, the authors observed that six children born to mothers with gHAT during their pregnancies still had sequelae of the infection. The six mothers were interviewed about their respective pregnancies and the developmental history of the children borne to the infected mothers. Furthermore, the children then underwent a complete physical examination with a focus on neuropsychiatric signs and symptoms. RESULTS: Five of the six patients are still seriously disabled. Behavioral changes are present in four patients, tremor, speech impairment, involuntary movements and pathologic the Barrés test and Mingazzini test in three patients and convulsions, pyramidal signs and decreased muscle tonus in two patients. Two patients cannot work and one has a sphincter disorder. CONCLUSIONS: Our study suggests that congenital gHAT may lead to long-lasting sequelae in babies born to mothers treated after delivery. The risk of embryo toxicity of treatment of mothers with gHAT must be balanced against the risk of congenital gHAT with long-term sequelae.

Quantifying conflict zones as a challenge to certification of Guinea worm eradication in Africa: a new analytical approach.

OBJECTIVES: To quantify conflict events and access across countries that remain to be certified free of transmission of Dracunculus medinensis (Guinea worm disease) or require postcertification surveillance as part of the Guinea Worm Eradication Programme (GWEP). SETTING AND PARTICIPANTS: Populations living in Guinea worm affected areas across seven precertification countries and 13 postcertification sub-Saharan African countries. OUTCOME MEASURES: The number of conflict events and rates per 100 000 population, the main types of conflict and actors reported to be responsible for events were summarised and mapped across all countries. Chad and Mali were presented as case studies. Guinea worm information was based on GWEP reports. Conflict data were obtained from the Armed Conflict Location and Event Data Project. Maps were created using ArcGIS V.10.7 and access was measured as regional distance and time to cities. RESULTS: More than 980 000 conflict events were reported between 2000 and 2020, with a significant increase since 2018. The highest number and rates were reported in precertification Mali (n=2556; 13.0 per 100 000), South Sudan (n=2143; 19.4), Democratic Republic of Congo (n=7016; 8.1) and postcertification Nigeria (n=6903; 3.4), Central Africa Republic (n=1251; 26.4), Burkina Faso (n=2004; 9.7). Violence against civilians, protests and battles were most frequently reported with several different actors involved including Unidentified Armed Groups and Boko Haram. Chad and Mali had contracting epidemiological and conflict situations with affected regions up to 700 km from the capital or 10 hours to the nearest city. CONCLUSIONS: Understanding the spatial-temporal patterns of conflict events, identifying hotspots, the actors responsible and their sphere of influence is critical for the GWEP and other public health programmes to develop practical risk assessments, deliver essential health interventions, implement innovative surveillance, determine certification and meet the goals of eradication.

The history of the neglected tropical disease movement.

The history of the neglected tropical disease movement is seen through the lens of authors who worked during the last 4 decades in different roles and in different settings, from Western-based laboratories to clinical roles in endemic countries and in critical policy roles in the World Health Organization (WHO). The authors seek to identify key players from the introduction of the word 'neglected' by the late Kenneth Warren in his Rockefeller Foundation-supported Great Neglected Diseases of Mankind movement through to the more recent developments after the London Declaration of 2012. The role of the various actors-endemic countries, major pharmaceutical companies, the WHO, non-government development organizations, bilateral donors and academia-are discussed. The critical events and decisions are highlighted that were essential enabling factors in creating a viable and successful movement and with a resultant massive global public health and antipoverty impact. The importance of advocacy is emphasized in creating the momentum to establish a globally recognized public health 'brand' as a target in the United Nations Sustainable Development Goals.

Neglected tropical diseases activities in Africa in the COVID-19 era: the need for a "hybrid" approach in COVID-endemic times.

With the coronavirus disease 2019 (COVID-19) pandemic showing no signs of abating, resuming neglected tropical disease (NTD) activities, particularly mass drug administration (MDA), is vital. Failure to resume activities will not only enhance the risk of NTD transmission, but will fail to leverage behaviour change messaging on the importance of hand and face washing and improved sanitation-a common strategy for several NTDs that also reduces the risk of COVID-19 spread. This so-called "hybrid approach" will demonstrate best practices for mitigating the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by incorporating physical distancing, use of masks, and frequent hand-washing in the delivery of medicines to endemic communities and support action against the transmission of the virus through water, sanitation and hygiene interventions promoted by NTD programmes. Unless MDA and morbidity management activities resume, achievement of NTD targets as projected in the WHO/NTD Roadmap (2021-2030) will be deferred, the aspirational goal of NTD programmes to enhance universal health coverage jeopardised and the call to 'leave no one behind' a hollow one. We outline what implementing this hybrid approach, which aims to strengthen health systems, and facilitate integration and cross-sector collaboration, can achieve based on work undertaken in several African countries.

Are current preventive chemotherapy strategies for controlling and eliminating neglected tropical diseases cost-effective?

Neglected tropical diseases (NTDs) remain a significant cause of morbidity and mortality in many low-income and middle-income countries. Several NTDs, namely lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminthiases (STH) and trachoma, are predominantly controlled by preventive chemotherapy (or mass drug administration), following recommendations set by the WHO. Over one billion people are now treated for NTDs with this strategy per year. However, further investment and increased domestic healthcare spending are urgently needed to continue these programmes. Consequently, it is vital that the cost-effectiveness of preventive chemotherapy is understood. We analyse the current estimates on the cost per disability-adjusted life year (DALY) of the preventive chemotherapy strategies predominantly used for these diseases and identify key evidence gaps that require further research. Overall, the reported estimates show that preventive chemotherapy is generally cost-effective, supporting WHO recommendations. More specifically, the cost per DALY averted estimates relating to community-wide preventive chemotherapy for lymphatic filariasis and onchocerciasis were particularly favourable when compared with other public health interventions. Cost per DALY averted estimates of school-based preventive chemotherapy for schistosomiasis and STH were also generally favourable but more variable. Notably, the broader socioeconomic benefits are likely not being fully captured by the DALYs averted metric. No estimates of cost per DALY averted relating to community-wide mass antibiotic treatment for trachoma were found, highlighting the need for further research. These findings are important for informing global health policy and support the need for continuing NTD control and elimination efforts.