Milestones to reach Hepatitis C Virus (HCV) elimination in Italy: From free-of-charge screening to regional roadmaps for an HCV-free nation.

Although Italy has been on track for Hepatitis C Virus (HCV) elimination since 2019, it fell off track due to the decrease in the number of treated patients. HCV elimination in Italy will be possible if immediate action is taken. A health policy was implemented beginning in 2021, consisting of screening among key populations and birth cohorts (1969-1989), estimated to have a high prevalence of undiagnosed individuals. The active screening requires regional governance that manages the processes' complexity integrating a well-organized network between territory assistance and hospital to achieve an effective HCV care cascade. This document aims to support the regional decision-making process by defining paths for screening and linkage-to-care. Implementing active screening strategies beyond a risk-based approach is required as a General Practitioners' task. Simplified paths must be drawn for the key populations screening. The infrastructure built for COVID-19 vaccination could be used also for HCV screening. According to a multidisciplinary care delivery, screening should be supplemented with rapid linkage-to-care and treatment of newly diagnosed patients. The realization of the proactive screening during the first two years is vital because it will define the tracks for the whole HCV cost-effective screening of 1948-1988 birth cohorts in Italy.

Las epidemias en La Pampa (Argentina), en perspectiva histórica* / The epidemics in La Pampa (Argentina), from a historical perspective

Resumen Este artículo describe el inicio de las preocupaciones sanitarias vinculadas a las epidemias ocurridas durante el siglo XX en La Pampa, provincia argentina. Las epidemias, como las de la viruela, fueron un estímulo para estas políticas que frecuentemente tuvieron origen en Buenos Aires, la capital del país. El contagio de muchas epidemias dependía de carencias de infraestructura: agua, desagüe y desecho adecuado de basuras, de la ausencia de un número suficiente de trabajadores de salud, de la presencia de vectores transmisores de enfermedades como los mosquitos y, en última instancia, de la pobreza. La experiencia histórica descrita en este texto resalta la importancia de analizar el impacto del SARS-CoV-2 más allá de las grandes ciudades.

Abstract This article describes the emergence of health concerns relating to the epidemics that occurred during the twentieth century in La Pampa, a province in Argentina. Epidemics such as smallpox drove such policies, which frequently originated in Buenos Aires, the country's capital. The spread of many epidemics was due to shortages: water, sewage and adequate refuse disposal, an insufficient number of health care workers, the presence of disease transmission vectors such as mosquitos, and, ultimately, poverty. The historical experience described in this text highlights the importance of analyzing the impact of SARS-CoV-2 beyond the big cities.

The road to cervical cancer elimination in Malaysia: Evaluation of the impact and cost-effectiveness of human papillomavirus screening with self-collection and digital registry support.

The WHO has launched a global strategy to eliminate cervical cancer through the scale-up of human papillomavirus (HPV) vaccination, cervical screening, and cervical cancer treatment. Malaysia has achieved high-coverage HPV vaccination since 2010, but coverage of the existing cytology-based program remains low. Pilot studies found HPV self-sampling was acceptable and effective, with high follow-up rates when a digital registry was used, and recently the Malaysian Government announced plans for a national HPV-based screening program. We therefore evaluated the impact of primary HPV screening with self-collection in Malaysia in the context of Malaysia's existing vaccination program. We used the "Policy1-Cervix" modeling platform to assess health outcomes, cost-effectiveness, resource use and cervical cancer elimination timing (the year when cervical cancer rates reach four cases per 100 000 women) of implementing primary HPV testing with self-collection, assuming 70% routine-screening coverage could be achieved. Based on available data, we assumed that compliance with follow-up was 90% when a digital registry was used, but that compliance with follow-up would be 50-75% without the use of a digital registry. We found that the current vaccination program would prevent 27 000 to 32 200 cervical cancer cases and 11 700 to 14 000 deaths by 2070. HPV testing with a digital registry was cost-effective (CER = $US 6953-7549 < $US 11 373[<1×GDP per capita]) and could prevent an additional 15 900 to 17 800 cases and 9700 to 10 600 deaths by 2070, expediting national elimination by 11 to 20 years, to 2055 to 2059. If HPV screening were implemented without a digital registry, there would be 1800 to 4900 fewer deaths averted by 2070 and the program would be less cost-effective. These results underline the importance of HPV testing as a key elimination pillar in Malaysia.

Improving care of migrants is key for viral hepatitis elimination in Europe.

By 2040, deaths from chronic viral hepatitis worldwide are projected to exceed those from human immunodeficiency virus infection, tuberculosis and malaria combined. The burden of this disease is predominantly carried by low-resource countries in Africa and Asia. In resource-rich countries, the epidemiological spread of viral hepatitis is partially driven by migrant movements from areas of high endemicity. In the last decade, Member States of the European Union and the European Economic Area have experienced an unprecedented influx of migrants, which has resulted in the polarization of political views about migration. In addition, the coronavirus disease 2019 pandemic has worsened the economic and health conditions of migrants and contributed to hostility to ensuring their health rights. Moreover, the implementation of hostile laws in some host nations has increased the vulnerability of marginalized migrant subgroups, such as asylum seekers and undocumented individuals. These developments have complicated the historical challenge of identifying high-risk migrant groups for screening and treatment. However, if European countries can apply the simplified assessment tools and diagnostic tests for viral hepatitis that have been used for decentralized screening and monitoring in resource-poor countries, the uptake of care by migrants could be dramatically increased. Given the global calls for the elimination of viral hepatitis, European nations should recognize the importance of treating this vulnerable migrant population. Political and health strategies need to be adapted to meet this challenge and help eliminate viral hepatitis globally.

D'ici 2040, les décès causés par l'hépatite virale chronique dans le monde devraient dépasser ceux dus à trois grandes maladies réunies: l'infection au virus de l'immunodéficience humaine, la tuberculose et la malaria. Le fardeau que représente cette affection repose surtout sur les pays disposant de ressources limitées en Afrique et en Asie. Dans les pays riches en ressources, la propagation épidémiologique de l'hépatite virale est en partie liée aux mouvements migratoires depuis les zones à endémicité élevée. Au cours de la dernière décennie, les États membres de l'Union européenne et l'Espace économique européen ont connu un afflux de migrants sans précédent qui a polarisé les opinions politiques concernant la migration. En outre, la pandémie de maladie à coronavirus 2019 a aggravé la situation économique et sanitaire des migrants, contribuant à l'animosité ambiante à l'égard du respect de leurs droits en matière de santé. L'adoption de lois hostiles dans certains pays d'accueil a également accru la vulnérabilité des sous-groupes de migrants marginalisés, tels que les demandeurs d'asile et les sans-papiers. Des conditions qui compliquent la tâche d'identification des groupes de migrants à haut risque pour le dépistage et le traitement. Néanmoins, si les pays européens pouvaient appliquer les outils d'évaluation simplifiés et les tests de diagnostic de l'hépatite virale, qui ont été employés pour la surveillance et le dépistage décentralisé dans les pays disposant de ressources limitées, la prise en charge des migrants pourrait nettement s'améliorer. Compte tenu des nombreux appels internationaux à éliminer l'hépatite virale, les nations européennes devraient reconnaître l'importance de soigner ces populations de migrants vulnérables. Les stratégies politiques et sanitaires doivent être adaptées afin de relever ce défi et de contribuer à éradiquer l'hépatite virale dans le monde.

Para 2040, se prevé que las muertes por hepatitis vírica crónica en todo el mundo superen a las causadas por la infección del virus de la inmunodeficiencia humana, la tuberculosis y la malaria juntas. La carga de esta enfermedad recae sobre todo en los países con recursos limitados de África y Asia. En los países ricos en recursos, la propagación epidemiológica de las hepatitis víricas se debe en parte a los movimientos migratorios desde las zonas altamente endémicas. En la última década, los Estados miembros de la Unión Europea y del Espacio Económico Europeo han experimentado una afluencia de inmigrantes sin precedentes, lo que ha polarizado las opiniones políticas sobre la inmigración. Además, la pandemia de la enfermedad del coronavirus de 2019 ha empeorado las condiciones económicas y sanitarias de los inmigrantes y ha contribuido a la hostilidad para garantizar sus derechos sanitarios. Además, la aplicación de leyes hostiles en algunas naciones de acogida ha aumentado la vulnerabilidad de subgrupos de inmigrantes marginados, como los solicitantes de asilo y los indocumentados. Estos acontecimientos han complicado el reto histórico de identificar a los grupos de inmigrantes de alto riesgo para su detección y tratamiento. Sin embargo, si los países europeos pueden aplicar las herramientas de evaluación y las pruebas de diagnóstico simplificadas para la hepatitis vírica que se han utilizado para el cribado y el seguimiento descentralizados en los países con pocos recursos, la aceptación de la atención por parte de los inmigrantes podría aumentar drásticamente. Dados los llamamientos mundiales para la eliminación de la hepatitis vírica, las naciones europeas deberían reconocer la importancia de tratar a esta población inmigrante vulnerable. Es necesario adaptar las estrategias políticas y sanitarias para hacer frente a este reto y ayudar a eliminar la hepatitis vírica a nivel mundial.

Innovations in Hepatitis C Screening and Treatment.

New therapies offer hope for a cure to millions of persons living with hepatitis C virus (HCV) infection. HCV elimination is a global goal that will be difficult to achieve using the traditional paradigms of diagnosis and care. The current standard has evolved toward universal HCV screening and treatment, to achieve elimination goals. There are several steps between HCV diagnosis and cure with major barriers along the way. Innovative models of care can address barriers to better serve hardly reached populations and scale national efforts in the United States and abroad. Herein, we highlight innovative models of HCV care that aid in our progress toward HCV elimination.

Reduced incidence of hepatitis C in 9 villages in rural Egypt: Progress towards national elimination goals.

BACKGROUND & AIMS: Egypt has a major HCV burden and a well established treatment programme, with an ambitious goal of HCV elimination. Our aim was to assess the impact of a comprehensive HCV prevention, test and treat programme on the incidence of new HCV infections in 9 villages in rural Egypt. METHODS: An HCV "educate, test and treat" project was implemented in 73 villages across 7 governorates in Egypt between 06/2015 and 06/2018. In 2018, in 9 of the villages we re-tested individuals who originally tested HCV antibody (HCV-Ab) and HBsAg negative using rapid diagnostic tests (RDTs); confirmatory HCV RNA testing was performed for positive cases. The incidence rate per 1,000 person-years (py) was calculated, and risk factors for incident HCV infections assessed through an interviewer-administered questionnaire in 1:3 age- and gender-matched cases and controls. RESULTS: Out of 20,490 individuals who originally tested HCV-Ab negative in the 9 villages during the 2015-2016 implementation of the "educate, test and treat" programme, 19,816 (96.7%) were re-tested in 2018. Over a median of 2.4 years (IQR 2.1-2.7), there were 19 new HCV infections all of which were HCV RNA positive (incidence rate 0.37/1,000 py) (95% CI 0.24-0.59). Compared to a previous estimate of incidence in the Nile Delta region (2.4/1,000 py) from 2006, there was a substantial reduction in overall incidence of new HCV infections. Exposures through surgery (odds ratio 51; 95% CI 3.5-740.1) and dental procedures (odds ratio 23.8; 95% CI 2.9-194.9) were significant independent predictors of incident infections. CONCLUSIONS: This is the first study to show a substantial reduction in incidence of new HCV infections in a sample of the general population in Egypt following attainment of high testing and treatment coverage. New infections were significantly associated with healthcare-associated exposures. LAY SUMMARY: Egypt has a major national HCV testing and treatment programme with the goal of eliminating HCV infection. We assessed the impact of a comprehensive HCV prevention, test and treat programme in 73 villages that achieved high coverage of testing and treatment on the subsequent incidence of new HCV infections in nine of the villages. We re-tested people who were previously HCV antibody negative and found that the rate of new HCV infections was greatly reduced compared to previous estimates. We also found that exposure through surgery and dental procedures were associated with these new infections. This highlights the importance of continued strengthening of infection control and prevention measures, alongside treatment scale-up.

Evaluation of the Cherokee Nation Hepatitis C Virus Elimination Program in the First 22 Months of Implementation.

Importance: In 2019, hepatitis C virus (HCV) infection contributed to more deaths in the US than 60 other notifiable infectious diseases combined. The incidence of and mortality associated with HCV infection are highest among American Indian and Alaska Native individuals. Objective: To evaluate the association of the Cherokee Nation (CN) HCV elimination program with each element of the cascade of care: HCV screening, linkage to care, treatment, and cure. Design, Setting, and Participants: This cohort study used data from the CN Health Services (CNHS), which serves approximately 132 000 American Indian and Alaska Native individuals residing in the 14-county CN reservation in rural northeastern Oklahoma. Data from the first 22 months of implementation (November 1, 2015, to August 31, 2017) of an HCV elimination program were compared with those from the pre-elimination program period (October 1, 2012, to October 31, 2015). The analysis included American Indian and Alaska Native individuals aged 20 to 69 years who accessed care through the CNHS between October 1, 2012, and August 31, 2017. Cure data were recorded through April 15, 2018. Exposure: The CN HCV elimination program. Main Outcomes and Measures: The main outcomes were the proportions of the population screened for HCV, diagnosed with current HCV infection, linked to care, treated, and cured during the initial 22 months of the elimination program period and the pre-elimination program period. Data from electronic health records and an HCV treatment database were analyzed. The cumulative incidence of HCV infection in this population was estimated using bayesian analyses. Results: Among the 74 039 eligible individuals accessing care during the elimination program period, the mean (SD) age was 36.0 (13.5) years and 55.9% were women. From the pre-elimination program period to the elimination program period, first-time HCV screening coverage increased from 20.9% to 38.2%, and identification of current HCV infection and treatment in newly screened individuals increased from a mean (SD) of 170 (40) per year to 244 (4) per year and a mean of 95 (133) per year to 215 (9) per year, respectively. During the implementation period, of the 793 individuals with current HCV infection accessing the CNHS, 664 were evaluated (83.7%), 394 (59.3%) initiated treatment, and 335 (85.0%) had documented cure. In less than 2 years, the 85% 3-year goal was reached for cure (85.0%), and the goal for linkage to care was nearly reached (83.7%), whereas screening (44.1%) and treatment initiation (59.3%) required more time and resources. Conclusions and Relevance: This cohort study found that after 22 months of implementation, the CNHS community-based HCV elimination program was associated with an improved cascade of care. The facilitators and lessons learned in this program may be useful to other organizations planning similar programs.

Tailored screening and dedicated funding for direct acting antiviral drugs: how to keep Italy on the road to hepatitis C virus elimination?

BACKGROUND AND AIMS: Hepatitis C virus (HCV) elimination for Italy is an ambitious, but achievable goal. In Italy, there is political will, which aims to achieve the World Health Organization (WHO) elimination goals recognizing the need to identify undiagnosed individuals in key high-risk groups and in the general population, however there is concern regarding HCV treatment implementation in Italian Regions. METHODS: A modelling analysis was conducted, using the "Italy Polaris" model, to forecast the impact of different HCV treatment rates in achieving the HCV elimination goals in Italy. The model assessed two treatment scenarios: 2018 Scenario and 2019 Scenario, using the annually HCV treatment rate in Italy. RESULTS: Considering a high treatment rate, as assumed by the 2018 Scenario, all HCV elimination targets would be achieved. Considering the 2019 Scenario, in which a decreasing number of newly diagnosed individuals and as consequence, a decline in the number of treated patients, were assumed, only the 65% HCV mortality reduction would be an achievable goal in Italy. The other elimination targets could be achievable over 7 years later than the year 2030. CONCLUSIONS: Establishing an ad hoc fund for DAAs for each Italian Region, binding resources both for case finding, through active screening and activities for rapid linkage to care and treatment, is of paramount importance, in order to keep Italy on track to achieve the WHO elimination targets by 2030.

Achieving Hepatitis C Elimination By Using Person-Centered, Nurse-Led Models of Care: A Discussion of Four International Case Studies.

Nurse-led models of care are an important strategy in the management of patients with chronic disease because of the person-centered approach that allows the needs of the individual to be prioritized and addressed in accessible settings. Hepatitis C is caused by a blood-borne virus that can cause liver disease and liver cancer; it predominantly affects marginalized populations, including people who inject drugs. Since 2013, all oral, direct-acting antiviral regimens have been available to cure hepatitis C. Nurses are well placed to be involved in the delivery of hepatitis C testing and treatment because of their extensive reach within marginalized communities and holistic approach to patient care. Four case studies of nurse-led models of care operating in Australia, Canada, the United Kingdom, and the United States are presented to illustrate the important role nurses have in delivering accessible, person-centered hepatitis C testing and treatment. Each case study demonstrates the success of overcoming barriers to hepatitis C testing and treatment such as geographic isolation, incarceration, social marginalization, and inflexible healthcare systems. Achieving the global target to eliminate hepatitis C by 2030 will require the nursing profession to embrace its role as the first point of contact to the healthcare system for many members of marginalized communities potentially at risk of hepatitis C. Nurses are well placed to reduce barriers and facilitate access to healthcare by scaling up activities focused on hepatitis C testing and treatment.

Essential Components of a Public Health Tuberculosis Prevention, Control, and Elimination Program: Recommendations of the Advisory Council for the Elimination of Tuberculosis and the National Tuberculosis Controllers Association.

This report provides an introduction and reference tool for tuberculosis (TB) controllers regarding the essential components of a public health program to prevent, control, and eliminate TB. The Advisory Council for the Elimination of Tuberculosis and the National Tuberculosis Controllers Association recommendations in this report update those previously published (Advisory Council for the Elimination of Tuberculosis. Essential components of a tuberculosis prevention and control program. Recommendations of the Advisory Council for the Elimination of Tuberculosis. MMWR Recomm Rep 1995;44[No. RR-11]). The report has been written collaboratively on the basis of experience and expert opinion on approaches to organizing programs engaged in diagnosis, treatment, prevention, and surveillance for TB at state and local levels.This report reemphasizes the importance of well-established priority strategies for TB prevention and control: identification of and completion of treatment for persons with active TB disease; finding and screening persons who have had contact with TB patients; and screening, testing, and treatment of other selected persons and populations at high risk for latent TB infection (LTBI) and subsequent active TB disease.Health departments are responsible for public safety and population health. To meet their responsibilities, TB control programs should institute or ensure completion of numerous responsibilities and activities described in this report: preparing and maintaining an overall plan and policy for TB control; maintaining a surveillance system; collecting and analyzing data; participating in program evaluation and research; prioritizing TB control efforts; ensuring access to recommended laboratory and radiology tests; identifying, managing, and treating contacts and other persons at high risk for Mycobacterium tuberculosis infection; managing persons who have TB disease or who are being evaluated for TB disease; providing TB training and education; and collaborating in the coordination of patient care and other TB control activities. Descriptions of CDC-funded resources, tests for evaluation of persons with TB or LTBI, and treatment regimens for LTBI are provided (Supplementary Appendices; https://stacks.cdc.gov/view/cdc/90289).

Towards the trachoma elimination target in the Southern region of Ethiopia: How well is the SAFE strategy being implemented?

INTRODUCTION: Trachoma is one of the 20 neglected tropical diseases and a serious public health problem in Ethiopia. To reach the WHO elimination target by 2020, SAFE (Surgery, Antibiotics, Facial cleanliness, Environmental improvement) strategy has been implemented in the Southern Nations, Nationalities, and Peoples' Region (SNNPRs), Ethiopia. Scarce evidence exists regarding recent progress in achieving elimination of active trachoma (< 5%) and how well the SAFE strategy implemented. METHODOLOGY: A retrospective analysis of programmatic data in the period 2013-2018 was used. All trachoma endemic districts in SNNPR were included. Data collected from the Federal Ministry of Health on trachoma prevalence and SAFE strategy were analyzed. RESULTS: Out of 134 endemic districts, only 35 had their planned impact survey, of which only 11 districts achieved the elimination target. Six districts reverted backwards from eliminated status to low (1) or moderate (5) level. The median prevalence of active trachoma in these 35 districts was 10% in 2017/18. In 2017, the mean antibiotic treatment coverage was 90%, but only 56% and 68% of districts implemented and reported on "F" and "E" components, respectively. In the high prevalence districts, only 10% delivered their planned five rounds of Zithromax® mass distribution. CONCLUSIONS: These data showed a lack in planned impact surveys with only a limited number of districts reached the WHO elimination threshold by 2018. Lack of attention on high prevalent districts, and recent reversal of trachoma eliminated districts to moderate or low prevalence levels argue for urgent and prioritized implementation of the SAFE strategy.

Development of an implementation and evaluation strategy for the Australian 'Zero Childhood Cancer' (Zero) Program: a study protocol.

INTRODUCTION: Effective implementation of a research Program requires an actionable plan to guide execution. To assess the actionability and success of that plan, both scientific and implementation elements must be taken into account. The aim of this study is to assess the 'Zero Childhood Cancer Personalised Medicine Program' (the Zero Program), an Australian first-ever and most comprehensive personalised medicine programme for children with high-risk or relapsed cancer, in terms of its structure, process and implementational effect. METHODS AND ANALYSIS: We will assess Program delivery mechanisms. The development of the implementation and evaluation strategy will concentrate on the work of the Zero Program as a complex whole. This includes the structure of collaborative links across stakeholder groups involved in Program development and delivery, changes to collaborative relationships over time and the impact of group working on Program outcomes. We are applying a mixed-methods design including: a rapid ethnography (observations of stakeholder interactions and informal conversations), Program professionals' completion of a rapid health implementation proforma and a social network analysis. Formative evaluations of the implementation science effects, applying feedback techniques, for example, Formative Evaluation Feedback Loops and the Zero Program professionals' feedback, will determine where Program tailoring may be needed. A repeat of the social network analysis downstream will examine network changes over time, followed by an expert panel using the expert recommendations for implementing change to assess the integration of implementation strategies into the Program structure. A summative evaluation of the Program will bring the research elements together, leading to comprehensive data triangulation and determining the sustainability and implementational effects of Program delivery. ETHICS AND DISSEMINATION: Ethical approval for this study has been granted by Hunter New England Research Ethics Committee, New South Wales, Australia (approval ref: 2019/ETH12025). Knowledge translation will be achieved through publications, reports and conference presentations to healthcare professionals, patients, families and researchers. TRIAL REGISTRATION: NCT03336931; Pre-results.

Prevalence of Hepatitis C Virus in an Endemic Area of Thailand: Burden Assessment toward HCV Elimination.

Chronic hepatitis C virus (HCV) infection can lead to liver cirrhosis and hepatocellular carcinoma. To eliminate HCV infection in an endemic area, an epidemiological baseline of the current HCV infection in the population is required. We therefore aimed to evaluate the HCV burden in the Thai Province of Phetchabun, which has the highest HCV infection rate in the country. Toward this, a province-wide district-based representative sampling of 4,769 individuals ages 35-64 years previously shown to represent high-risk age-groups were tested for anti-HCV antibodies using the automated chemiluminescent microparticle assays. Active HCV infection and subsequent genotyping were determined from serologically reactive samples by amplification of the HCV core gene. We found that 6.9% (327/4,769) were anti-HCV positive, of which 75.8% (248/327) had detectable HCV RNA and 5.8% (19/327) were in the presence of hepatitis B virus coinfection. Nucleotide sequencing and phylogenetic analysis revealed that HCV genotype 6 was the most prevalent (41%, 101/248), followed by genotype 3 (31%, 78/248), and genotype 1 (28%, 69/248). Socioeconomic and demographic factors including male gender, education, and agricultural work were associated with HCV seropositivity. From these results, we defined the regional HCV genotypes and estimated the HCV burden necessary toward the implementation of pan-genotypic direct-acting antivirals, which may be appropriate and effective toward the diversity of genotypes identified in this study. Micro-elimination of HCV in Phetchabun may serve as a model for a more comprehensive coverage of HCV treatment in Thailand.

Distribution of malaria patients seeking care in different types of health facilities during the implementation of National Malaria Elimination Programme.

BACKGROUND: China launched the National Malaria Elimination Programme (NMEP) in 2010 and set the goal that all health facilities should be able to diagnose malaria. Additionally, hospitals at all levels could treat malaria by 2015. To provide a reference for the control of imported malaria, a study was conducted on the distribution of malaria patients seeking care in different types of health facilities. METHODS: There were two data sources. One was obtained through the Infectious Diseases Information Reporting Management System (IDIRMS), which only contained the name of health facilities and the number of cases. The other was obtained through multistage stratified cluster sampling. Descriptive statistical analysis was used to investigate the distribution of malaria patients attending different types of health facilities (hospitals, township hospitals, and Centers for Disease Control and Prevention), hospital tiers (county-level, prefecture-level, and provincial-level), and hospital levels (primary, secondary, and tertiary). Chi-square test was also used to compare the proportions of patients seeking care outside their current residence region between different types of hospitals. Point maps were drawn to visualize the spatial distribution of hospitals reporting malaria cases, and flow maps were created to show the spatial flow of malaria patients by using the ArcGIS software. RESULTS: The proportions of malaria patients who sought care in hospitals, township hospitals, and Centers for Disease Control and Prevention were 81.7%, 14.7%, and 3.6%, respectively. For those who sought care in hospitals, the percentages of patients who sought care in provincial-level, prefecture-level and county-level hospitals were 17.4%, 60.5% and 22.1%, correspondingly; the proportions of patients who sought care in tertiary hospitals, secondary hospitals, and primary hospitals were 59.8%, 39.9%, and 0.3%, respectively. Moreover, the proportions of patients seeking care in hospitals within county and prefectural administrative areas were 18.2%, 63.4%, respectively. CONCLUSION: During the implementation of NMEP, malaria patients tended to seek care in tertiary hospitals and prefecture-level hospitals, and more than half of patients could be treated in hospitals in prefecture-level areas. In the current phase, it is necessary to establish referral system from county-level hospitals to higher-level hospitals for malaria treatment.

Implementation of test-and-treat with doxycycline and temephos ground larviciding as alternative strategies for accelerating onchocerciasis elimination in an area of loiasis co-endemicity: the COUNTDOWN consortium multi-disciplinary study protocol.

BACKGROUND: Onchocerciasis is a priority neglected tropical disease targeted for elimination by 2025. The standard strategy to combat onchocerciasis is annual Community-Directed Treatment with ivermectin (CDTi). Yet, high prevalence rates and transmission persist following > 12 rounds in South-West Cameroon. Challenges include programme coverage, adherence to, and acceptability of ivermectin in an area of Loa loa co-endemicity. Loiasis patients harbouring heavy infections are at risk of potentially fatal serious adverse events following CDTi. Alternative strategies are therefore needed to achieve onchocerciasis elimination where CDTi effectiveness is suboptimal. METHODS/DESIGN: We designed an implementation study to evaluate integrating World Health Organisation-endorsed alternative strategies for the elimination of onchocerciasis, namely test-and-treat with the macrofilaricide, doxycycline (TTd), and ground larviciding for suppression of blackfly vectors with the organophosphate temephos. A community-based controlled before-after intervention study will be conducted among > 2000 participants in 20 intervention (Meme River Basin) and 10 control (Indian River Basin) communities. The primary outcome measure is O. volvulus prevalence at follow-up 18-months post-treatment. The study involves four inter-disciplinary components: parasitology, entomology, applied social sciences and health economics. Onchocerciasis skin infection will be diagnosed by skin biopsy and Loa loa infection will be diagnosed by parasitological examination of finger-prick blood samples. A simultaneous clinical skin disease assessment will be made. Eligible skin-snip-positive individuals will be offered directly-observed treatment for 5 weeks with 100 mg/day doxycycline. Transmission assessments of onchocerciasis in the communities will be collected post-human landing catch of the local biting blackfly vector prior to ground larviciding with temephos every week (0.3 l/m3) until biting rate falls below 5/person/day. Qualitative research, including in-depth interviews and focus-group discussions will be used to assess acceptability and feasibility of the implemented alternative strategies among intervention recipients and providers. Health economics will assess the cost-effectiveness of the implemented interventions. CONCLUSIONS: Using a multidisciplinary approach, we aim to assess the effectiveness of TTd, alone or in combination with ground larviciding, following a single intervention round and scrutinise the acceptability and feasibility of implementing at scale in similar hotspots of onchocerciasis infection, to accelerate onchocerciasis elimination.

Progress toward Elimination of Trachoma as a Public Health Problem in Seven Localities in the Republic of Sudan: Results from Population-Based Surveys.

Trachoma is the leading cause of infectious blindness in the world. After baseline surveys demonstrated that Sudan was endemic for trachoma, the Sudan Federal Ministry of Health (FMOH) Trachoma Control Program conducted trachoma prevention and treatment interventions in endemic localities. The Sudan FMOH conducted population-based trachoma prevalence surveys between September 2016 and April 2017 in seven localities across five states of Sudan to document current trachoma prevalence estimates and measure water, sanitation, and hygiene (WASH) indicators. Children aged 1-9 years were examined for five clinical signs of trachoma, and participants of all ages were examined for trachomatous trichiasis (TT). A household questionnaire was administered to gather demographic and WASH-related information. The prevalence of trachomatous inflammation-follicular (TF) in children aged 1-9 years ranged from 0.4% (95% CI: 0.1-1.1%) to 6.4% (95% CI: 3.3-11.9%). Trachomatous trichiasis in those aged 15 years and older ranged from 0.1% (95% CI: 0.0-0.6%) to a high of 4.4% (95% CI: 2.1-9.1%). Of seven localities surveyed, four localities had achieved the elimination threshold of less than 5% TF in children aged 1-9 years. Six localities still required interventions to achieve less than 0.2% TT in those aged 15 years and older. The presence of latrine ranged from a low of 10.8% (95% CI: 5.2-21.1%) to 88.4% (CI: 81.5-93.0%) and clean face among children ranged between 69.5% (95% CI: 63.5-75.0%) and 87.5% (95% CI: 81.2-91.9%). These results demonstrate that Sudan is within reach of eliminating trachoma as a public health problem.

Progress to Eliminate Trachoma as a Public Health Problem in Amhara National Regional State, Ethiopia: Results of 152 Population-Based Surveys.

At baseline in 2006, Amhara National Regional State, Ethiopia, was the most trachoma-endemic region in the country. Trachoma impact surveys (TIS) were conducted in all districts between 2010 and 2015, following 3-5 years of intervention with the WHO-recommended SAFE (surgery, antibiotics, facial cleanliness, and environmental improvement) strategy. A multistage cluster random sampling design was used to estimate the district-level prevalence of trachoma. In total, 1,887 clusters in 152 districts were surveyed, from which 208,265 individuals from 66,089 households were examined for clinical signs of trachoma. The regional prevalence of trachomatous inflammation-follicular (TF) and trachomatous inflammation-intense among children aged 1-9 years was 25.9% (95% CI: 24.9-26.9) and 5.5% (95% CI: 5.2-6.0), respectively. The prevalence of trachomatous scarring and trachomatous trichiasis among adults aged ≥ 15 years was 12.9% (95% CI: 12.2-13.6) and 3.9% (95% CI: 3.7-4.1), respectively. Among children aged 1-9 years, 76.5% (95% CI: 75.3-77.7) presented with a clean face; 66.2% (95% CI: 64.1-68.2) of households had access to water within 30 minutes round-trip, 48.1% (95% CI: 45.5-50.6) used an improved water source, and 46.2% (95% CI: 44.8-47.5) had evidence of a used latrine. Nine districts had a prevalence of TF below the elimination threshold of 5%. In hyperendemic areas, 3-5 years of implementation of SAFE is insufficient to achieve trachoma elimination as a public health problem; additional years of SAFE and several rounds of TIS will be required before trachoma is eliminated.