Multimethod evaluation of health services integration for neglected tropical diseases requiring case management in Liberia.

INTRODUCTION: The WHO neglected tropical disease (NTD) roadmap stresses the importance of integrating NTDs requiring case management (CM) within the health system. The NTDs programme of Liberia is among the first to implement an integrated approach and evaluate its impact. METHODS: A retrospective study of three of five CM-NTD-endemic counties that implemented the integrated approach was compared with cluster-matched counties with non-integrated CM-NTD. We compared trends in CM-NTD integrated versus non-integrated county clusters. We conducted a pre-post comparison of WHO high-level outcomes using data collected during intervention years compared with baseline in control counties. Changes in health outcomes, effect sizes for different diseases and rate ratios with statistically significant differences were determined. Complementary qualitative research explored CM-NTD stakeholders' perceptions, analysed through the framework approach, which is a transparent, multistage approach for qualitative thematic interdisciplinary data analysis. RESULTS: The detection rates for all diseases combined improved significantly in the intervention compared with the control clusters. Besides leprosy, detection rates improved with large effects, over fourfold increase with statistically significant effects for individual diseases (p<0.000; 95% CI 3.5 to 5.4). Access to CM-NTD services increased in integrated counties by 71 facilities, compared with three facilities in non-integrated counties. Qualitative findings highlight training and supervision as inputs underpinning increases in case detection, but challenges with refresher training, medicine supply and incentives negatively impact quality, equity and access. CONCLUSIONS: Integrating CM-NTDs improves case detection, accessibility and availability of CM-NTD services, promoting universal health coverage. Early case detection and the quality of care need further strengthening.

Governing a pandemic: biopower and the COVID-19 response in Zimbabwe.

INTRODUCTION: The extraordinary explosion of state power towards the COVID-19 response has attracted scholarly and policy attention in relation to pandemic politics. This paper relies on Foucault's theoretical differentiation of the political management of epidemics to understand how governmental framing of COVID-19 reflects biopolitical powers and how power was mobilised to control the pandemic in Zimbabwe. METHODS: We conducted a scoping review of published literature, cabinet resolutions and statutory instruments related to COVID-19 in Zimbabwe. RESULTS: The COVID-19 response in Zimbabwe was shaped by four discursive frames: ignorance, denialism, securitisation and state sovereignty. A slew of COVID-19-related regulations and decrees were promulgated, including use of special presidential powers, typical of the leprosy model (sovereign power), a protracted and heavily policed lockdown was effected, typical of the plague model (disciplinary power) and throughout the pandemic, there was reference to statistical data to justify the response measures whilst vaccination emerged as a flagship strategy to control the pandemic, typical of the smallpox model (biopower). The securitisation frame had a large influence on the overall pandemic response, leading to an overly punitive application of disciplinary power and cases of infidelity to scientific evidence. On the other hand, a securitised, geopolitically oriented sovereignty model positively shaped a strong, generally well execucted, domestically financed vaccination (biopower) programme. CONCLUSIONS: The COVID-19 response in Zimbabwe was not just an exercise in biomedical science, rather it invoked wider governmentality aspects shaped by the country's own history, (geo) politics and various mechanisms of power. The study concludes that whilst epidemic securitisation by norm-setting institutions such as WHO is critical to stimulate international political action, the transnational diffusion of such charged frames needs to be viewed in relation to how policy makers filter the policy and political consequences of securitisation through the lenses of their ideological stances and its potential to hamper rather than bolster political action.

Inequalities in health by regime of affiliation to the health system in events of obligatory notification, Colombia, 2015 / Desigualdades en salud según régimen de afiliación y eventos notificados al Sistema de Vigilancia (Sivigila) en Colombia, 2015

Introduction: Inequalities in the health field are caused by the differences in the social and economic conditions, that influence the disease risk and the measures taken to treat the disease. Objective: We aimed to estimate the social inequalities in health in Colombia, according to the type of affiliation to the health system as a proxy of socioeconomic status. Materials and methods: We conducted a retrospective descriptive analysis calculating incidence rates age and sex adjusted for all mandatory reporting events using the affiliation regime (subsidized and contributory) as a socioeconomic proxy. Estimates were made at departmental level for 2015. Social inequalities were calculated in terms of absolute and relative gaps. Results: We found social inequalities in the occurrence of mandatory reporting events in population affiliated to the Colombian subsidized regime (poor population). In this population, 82.31 cases of Plasmodium falciparum malaria per 100,000 affiliates were reported more than those reported in the contributory regime. Regarding the relative gap, belonging to the subsidized regime increased by 31.74 times the risk of dying from malnutrition in children under 5 years of age. Other events such as those related to sexual and reproductive health (maternal mortality, gestational syphilis and congenital syphilis); neglected diseases and communicable diseases related to poverty (leprosy and tuberculosis), also showed profound inequalities. Conclusion: In Colombia there are inequalities by regime of affiliation to the health system. Measured socioeconomic status was a predictor of increased morbidity and premature mortality.

Introducción. Las desigualdades en salud se generan por diferencias en las condiciones sociales y económicas, lo cual influye en el riesgo de enfermar y la forma de enfrentar la enfermedad. Objetivo. Evaluar las desigualdades sociales en salud en Colombia, utilizando el tipo de afiliación al sistema de salud como un parámetro representativo (proxy) de la condición socioeconómica. Materiales y métodos. Se trata de un análisis descriptivo y retrospectivo en el que se calcularon las tasas específicas de incidencia, ajustadas por edad y sexo, para eventos de notificación obligatoria, utilizando el régimen de afiliación (subsidiado o contributivo) como variable representativa del nivel socioeconómico. Las estimaciones se hicieron a nivel departamental para el 2015. Las desigualdades sociales se calcularon en términos de brechas absolutas y relativas. Resultados. Se evidencian desigualdades sociales en la ocurrencia de eventos de notificación obligatoria, las cuales desfavorecen a la población afiliada al régimen subsidiado. En esta población, se reportaron 82,31 casos más de malaria Plasmodium falciparum por 100.000 afiliados, que los notificados en el régimen contributivo. Respecto a la brecha relativa, el pertenecer al régimen subsidiado se asocia con un aumento de 31,74 veces del riesgo de morir por desnutrición en menores de cinco años. Otros eventos también presentaron profundas desigualdades, como los relacionados con la salud sexual y reproductiva (mortalidad materna, sífilis gestacional y sífilis congénita), las enfermedades infecciosas y las enfermedades transmisibles relacionadas con la pobreza (lepra y tuberculosis). Conclusión. El tipo de afiliación al Sistema General de Seguridad Social en Salud en Colombia es un buen indicador del nivel socioeconómico, y es un factor predictor de mayor morbilidad y mortalidad prematura asociada con los factores determinantes sociales de la salud.

Explaining the successes and failures of tuberculosis treatment programs; a tale of two regions in rural eastern Uganda.

BACKGROUND: Optimally performing tuberculosis (TB) programs are characterized by treatment success rate (TSR) of at least 90%. In rural eastern Uganda, and elsewhere in sub Saharan Africa, TSR varies considerably across district TB programs and the reasons for the differences are unclear. This study explored factors associated with the low and high TSR across four districts in rural eastern Uganda. METHODS: We interviewed District TB and Leprosy Supervisors, Laboratory focal persons, and health facility TB focal persons from four districts in eastern Uganda as key informants. Interviews were audio recorded, transcribed verbatim, and imported into ATLAs.ti where thematic content analysis was performed and results were summarized into themes. RESULTS: The emerging themes were categorized as either facilitators of or barriers to treatment success. The emerging facilitators prevailing in the districts with high rates of treatment success were using data to make decisions and design interventions, continuous quality improvement, capacity building, and prioritization of better management of people with TB. The barriers common in districts with low rates of treatment success included lack of motivated and dedicated TB focal persons, scarce or no funding for implementing TB activities, and a poor implementation of community-based directly observed therapy short course. CONCLUSION: This study shows that several factors are associated with the differing rates of treatment success in rural eastern Uganda. These factors should be the focus for TB control programs in Uganda and similar settings in order to improve rates of treatment success.

Desigualdades en salud según régimen de afiliación y eventos notificados al Sistema de Vigilancia (Sivigila) en Colombia, 2015 / Inequalities in health by regime of affiliation to the health system in events of obligatory notification, Colombia, 2015

Introducción. Las desigualdades en salud se generan por diferencias en las condiciones sociales y económicas, lo cual influye en el riesgo de enfermar y la forma de enfrentar la enfermedad. Objetivo. Evaluar las desigualdades sociales en salud en Colombia, utilizando el tipo de afiliación al sistema de salud como un parámetro representativo (proxy) de la condición socioeconómica. Materiales y métodos. Se trata de un análisis descriptivo y retrospectivo en el que se calcularon las tasas específicas de incidencia, ajustadas por edad y sexo, para eventos de notificación obligatoria, utilizando el régimen de afiliación (subsidiado o contributivo) como variable representativa del nivel socioeconómico. Las estimaciones se hicieron a nivel departamental para el 2015. Las desigualdades sociales se calcularon en términos de brechas absolutas y relativas. Resultados. Se evidencian desigualdades sociales en la ocurrencia de eventos de notificación obligatoria, las cuales desfavorecen a la población afiliada al régimen subsidiado. En esta población, se reportaron 82,31 casos más de malaria Plasmodium falciparum por 100.000 afiliados, que los notificados en el régimen contributivo. Respecto a la brecha relativa, el pertenecer al régimen subsidiado se asocia con un aumento de 31,74 veces del riesgo de morir por desnutrición en menores de cinco años. Otros eventos también presentaron profundas desigualdades, como los relacionados con la salud sexual y reproductiva (mortalidad materna, sífilis gestacional y sífilis congénita), las enfermedades infecciosas y las enfermedades transmisibles relacionadas con la pobreza (lepra y tuberculosis). Conclusión. El tipo de afiliación al Sistema General de Seguridad Social en Salud en Colombia es un buen indicador del nivel socioeconómico, y es un factor predictor de mayor morbilidad y mortalidad prematura asociada con los factores determinantes sociales de la salud.

Introduction: Inequalities in the health field are caused by the differences in the social and economic conditions, that influence the disease risk and the measures taken to treat the disease. Objective: We aimed to estimate the social inequalities in health in Colombia, according to the type of affiliation to the health system as a proxy of socioeconomic status. Materials and methods: We conducted a retrospective descriptive analysis calculating incidence rates age and sex adjusted for all mandatory reporting events using the affiliation regime (subsidized and contributory) as a socioeconomic proxy. Estimates were made at departmental level for 2015. Social inequalities were calculated in terms of absolute and relative gaps. Results: We found social inequalities in the occurrence of mandatory reporting events in population affiliated to the Colombian subsidized regime (poor population). In this population, 82.31 cases of Plasmodium falciparum malaria per 100,000 affiliates were reported more than those reported in the contributory regime. Regarding the relative gap, belonging to the subsidized regime increased by 31.74 times the risk of dying from malnutrition in children under 5 years of age. Other events such as those related to sexual and reproductive health (maternal mortality, gestational syphilis and congenital syphilis); neglected diseases and communicable diseases related to poverty (leprosy and tuberculosis), also showed profound inequalities. Conclusion: In Colombia there are inequalities by regime of affiliation to the health system. Measured socioeconomic status was a predictor of increased morbidity and premature mortality.

Gridlock from diagnosis to treatment of multidrug-resistant tuberculosis in Tanzania: low accessibility of molecular diagnostic services and lack of healthcare worker empowerment in 28 districts of 5 high burden TB regions with mixed methods evaluation.

BACKGROUND: Multidrug-resistant tuberculosis (MDR-TB) outcomes are adversely impacted by delay in diagnosis and treatment. METHODS: Mixed qualitative and quantitative approaches were utilized to identify healthcare system related barriers to implementation of molecular diagnostics for MDR-TB. Randomly sampled districts from the 5 highest TB burden regions were enrolled during the 4th quarter of 2016. District TB & Leprosy Coordinators (DTLCs), and District AIDS Coordinators (DACs) were interviewed, along with staff from all laboratories within the selected districts where molecular diagnostics tests for MDR-TB were performed. Furthermore, the 2015 registers were audited for all drug-susceptible but retreatment TB cases and TB collaborative practices in HIV clinics, as these patients were in principal targeted for drug susceptibility testing by rapid molecular diagnostics. RESULTS: Twenty-eight TB districts from the 5 regions had 399 patients reviewed for retreatment with a drug-susceptible regimen. Only 160 (40%) had specimens collected for drug-susceptibility testing, and of those specimens only 120 (75%) had results communicated back to the clinic. MDR-TB was diagnosed in 16 (13.3%) of the 120 specimens but only 12 total patients were ultimately referred for treatment. Furthermore, among the HIV/AIDS clinics served in 2015, the median number of clients with TB diagnosis was 92 cases [IQR 32-157] yet only 2 people living with HIV were diagnosed with MDR-TB throughout the surveyed districts. Furthermore, the districts generated 53 front-line healthcare workers for interviews. DTLCs with intermediate or no knowledge on the clinical application of XpertMTB/RIF were 3 (11%), and 10 (39%), and DACs with intermediate or no knowledge were 0 (0%) and 2 (8%) respectively (p = 0.02). Additionally, 11 (100%) of the laboratories surveyed had only the 4-module XpertMTB/RIF equipment. The median time that XpertMTB/RIF was not functional in the 12 months prior to the investigation was 2 months (IQR 1-4). CONCLUSIONS: Underutilization of molecular diagnostics in high-risk groups was a function of a lack of front-line healthcare workforce empowerment and training, and a lack of equipment access, which likely contributed to the observed delay in MDR-TB diagnosis in Tanzania.

Leprosy services in primary health care in India: comparative economic cost analysis of two public-health settings.

OBJECTIVES: The WHO recommends inclusion of post-exposure chemoprophylaxis with single-dose rifampicin in national leprosy control programmes. The objective was to estimate the cost of leprosy services at primary care level in two different public-health settings. METHODS: Ingredient-based costing was performed in eight primary health centres (PHCs) purposively selected in the Union Territory of Dadra and Nagar Haveli (DNH) and the Umbergaon block of Valsad district, Gujarat, India. All costs were bootstrapped, and to estimate the variation in total cost under uncertainty, a univariate sensitivity analysis was performed. RESULTS: The mean annual cost of providing leprosy services was USD 29 072 in the DNH PHC (95% CI: 22 125-36 020) and USD 11 082 in Umbergaon (95% CI: 8334-13 830). The single largest cost component was human resources: 79% in DNH and 83% in Umbergaon. The unit cost for screening the contact of a leprosy patient was USD 1 in DNH (95% CI: 0.8-1.2) and USD 0.3 in Umbergaon (95% CI: 0.2-0.4). In DNH, the unit cost of delivering single-dose of rifampicin (SDR) as chemoprophylaxis for contacts was USD 2.9 (95% CI: 2.5-3.7). CONCLUSIONS: The setting with an enhanced public-health financing system invests more in leprosy services than a setting with fewer financial resources. In terms of leprosy visits, the enhanced public-health system is hardly more expensive than the non-enhanced public-health system. The unit cost of contact screening is not high, favouring its sustainability in the programme.

Impact of community-based adherence support on treatment outcomes for tuberculosis, leprosy and HIV/AIDS-infected individuals in post-Ebola Liberia.

BACKGROUND: Partners In Health (PIH) committed to improving health care delivery in Maryland County, Liberia following the Ebola epidemic by employing 71 community health workers (CHWs) to provide treatment support to tuberculosis (TB), HIV and leprosy patients. PIH simultaneously deployed a socioeconomic assistance program with three core components: transportation reimbursement to clinics; food support; and additional social assistance in select cases. OBJECTIVE: This study aimed to evaluate how a CHW program for community treatment support and addressing socioeconomic barriers to care can impact patient outcomes in a post-conflict and post-epidemic context. METHODS: Retrospective observational study utilizing registry data from 513 TB, 447 HIV and 75 leprosy patients at three health facilities in Maryland County, Liberia. Treatment coverage and clinical outcomes for patient cohorts enrolled in the pre-intervention period (January 2015 to June 2015) and the post-intervention period (July 2015 to July 2017) are compared using logistic regression analyses. RESULTS: TB treatment coverage increased from 7.7% pre-intervention to 43.2% (p < 0.001) post-intervention and lost to follow-up (LTFU) rates decreased from 9.5% to 2.1% (p = 0.003). ART treatment coverage increased 3.8 percentage points (p = 0.03), with patient retention improving 63.9% to 86.1% (p < 0.001); a 6.0 percentage point decrease in HIV LTFU was also observed (p = 0.21). Despite an 84.3% treatment success rate observed for leprosy patients, pre-intervention data was largely unavailable and statistical significance could not be reached for any treatment outcomes pre-post intervention. CONCLUSIONS: The PIH approach to CHW community treatment support in Liberia demonstrates how, with the right inputs, excellent clinical outcomes are possible even in post-conflict and post-epidemic contexts. Care should be taken to position and support CHWs so that they have the opportunity to succeed, including full integration and recognition within the system, and the addition of clinical system improvements and social supports that are too often dismissed as unsustainable.

Introducing leprosy post-exposure prophylaxis into the health systems of India, Nepal and Indonesia: a case study.

BACKGROUND: Leprosy has a wide range of clinical and socio-economic consequences. India, Indonesia and Nepal contribute significantly to the global leprosy burden. After integration, the health systems are pivotal in leprosy service delivery. The Leprosy Post Exposure Prophylaxis (LPEP) program is ongoing to investigate the feasibility of providing single dose rifampicin (SDR) as post-exposure prophylaxis (PEP) to the contacts of leprosy cases in various health systems. We aim to compare national leprosy control programs, and adapted LPEP strategies in India, Nepal and Indonesia. The purpose is to establish a baseline of the health system's situation and document the subsequent adjustment of LPEP, which will provide the context for interpreting the LPEP results in future. METHODS: The study followed the multiple-case study design with single units of analysis. The data collection methods were direct observation, in-depth interviews and desk review. The study was divided into two phases, i.e. review of national leprosy programs and description of the LPEP program. The comparative analysis was performed using the WHO health system frameworks (2007). RESULTS: In all countries leprosy services including contact tracing is integrated into the health systems. The LPEP program is fully integrated into the established national leprosy programs, with SDR and increased documentation, which need major additions to standard procedures. PEP administration was widely perceived as well manageable, but the additional LPEP data collection was reported to increase workload in the first year. CONCLUSIONS: The findings of our study led to the recommendation that field-based leprosy research programs should keep health systems in focus. The national leprosy programs are diverse in terms of organizational hierarchy, human resource quantity and capacity. We conclude that PEP can be integrated into different health systems without major structural and personal changes, but provisions are necessary for the additional monitoring requirements.

The Ubiquity of Chronic Illness.

This is a review of five different books dealing with some aspect of what might be termed a "chronic illness" - Alzheimer's disease, lupus, addiction, erectile dysfunction, and leprosy. The array of different subjects examined in these books points to the negotiable limits of this hugely open category. What exactly constitutes an "illness"? Why not use a less biomedical term instead: "disturbance", "problem", or simply "condition"? And how are we to understand "chronic" - simply as the flipside of "acute" or "curable"?

Serology with ML Flow test in health professionals from three different states of Brazil / Sorologia com o teste ML Flow em profissionais de saude em tres diferentes estados do Brasil

BACKGROUND: In highly endemic countries, transmission and sub-clinical infection of leprosy are likely and the disease manifests itself in individuals without any known close contact with a leprosy patient. Health workers are social contacts belonging to the same network (the Health System) and some of them share the same social environment (nursing assistants) as patients with known patients and / or carriers. OBJECTIVE: To identify ML Flow seropositivity among health professionals. METHODS: We conducted a cross-sectional study using a serological survey with the ML Flow test in 450 health professionals (doctors, nurses and nursing assistants), in order to detect seropositivity in areas of high and low endemicity in municipalities from three Brazilian states (RJ, MS and RS). RESULTS: The results showed general 16% seropositivity, higher in low endemic areas, regardless of whether there was direct care for leprosy patients. Paradoxically, a statistical association was observed between the area studied and seropositivity, as the place with the lowest endemicity (CA) had the highest seropositivity rate (p = 0.033). CONCLUSION: The authors suggest these results are associated with a presence of an unspecified link to bovine serum albumin (BSA), carrier of PGL-1 in the ML Flow test, and recommend expanded seroepidemiological research utilizing tests with human and bovine albumin. .

FUNDAMENTOS: Em países altamente endêmicos a transmissão e infecção sub-clínica da hanseníase provavelmente ocorrem e a doença se manifesta em indivíduos sem qualquer contato próximo conhecido com paciente com hanseníase. Os trabalhadores de saúde são contatos sociais que pertencem à mesma rede (Sistema de Saúde) e alguns deles compartilham o mesmo ambiente social (auxiliares de enfermagem) com pacientes conhecidos e/ou portadores. OBJETIVO: Conhecer a soropositividade ao ML Flow entre os profissionais de saúde. MÉTODOS: Foi realizado um estudo transversal através de inquérito sorológico com o teste ML Flow em 450 profissionais de saúde (médicos, enfermeiros e auxiliares de enfermagem) visando conhecer a soropositividade em áreas de alta e baixa endemicidade em municípios de três estados brasileiros (RS, MS e RJ). RESULTADOS: Os resultados mostraram 16% de soropositividade em geral, mais elevada na área de baixa endemicidade, independente da assistência direta a pacientes com hanseníase. Paradoxalmente foi observada associação estatística entre a área estudada e soropositividade, apontando o lugar de mais baixa endemicidade (CA) com o maior valor (p=0,033). CONCLUSÃO: os autores sugerem a presença de ligação inespecífica a soroalbumina bovina (BSA), carreadora do antígeno PGL-1 no teste ML Flow para explicar os resultados inesperados e recomendam testagem ampliada utilizando testes com albumina humana e bovina. .

Influência do aumento do acesso à atenção básica no comportamento da taxa de detecção de hanseníase de 1980 a 2006 / The influence of increased access to basic healthcare on the trends in Hansen's disease detection rate in Brazil from 1980 to 2006

A taxa de detecção da hanseníase no Brasil aumentou nas duas últimas décadas do século XX, sendo que a reforma sanitária ocorreu no mesmo período. A taxa de detecção é função da incidência real de casos e da agilidade diagnóstica do sistema de saúde. Utilizou-se a cobertura vacinal por BCG como uma variável procuradora do acesso à atenção primária em saúde. Uma regressão log-normal foi ajustada à taxa de detecção de 1980 a 2006, com o tempo, tempo ao quadrado e da cobertura do BCG como variáveis independentes, sendo positivo o coeficiente de regressão desta última variável, sugerindo que o comportamento da taxa de detecção da hanseníase refletiu a melhora de acesso à atenção primária no período estudado. A tendência de aumento da taxa de detecção se reverte em 2003, indicando o início de uma nova fase no controle da hanseníase.

Brazilian Hansen's disease detection rate rose during the 80s and 90s of the 20th century. The Brazilian health system reform happened during the same period. Detection rate is a function of the real incidence of cases and the diagnostic agility of the health system. Coverage of BCG immunization in infants was used as a proxy variable for primary healthcare coverage. A log-normal regression model of detection rate as a function of BCG coverage, time and time square was adjusted to data. The detection rate presents an upward trend throughout the period and with a downturn beginning in 2003. The model showed a statistically significant positive regression coefficient for BCG coverage, suggesting that detection rate behavior reflects the improvement of access to health care. The detection rate began a trend towards decline in 2003, indicating a new phase of Hansen's disease control.