Conflict, community, and collaboration: shared implementation barriers and strategies in two polio endemic countries.

BACKGROUND: Afghanistan and Nigeria are two of the three remaining polio endemic countries. While these two countries have unique sociocultural characteristics, they share major polio risk factors. This paper describes the countries' shared contexts and highlights important lessons on implementing polio eradication activities among hard-to-reach populations relevant for future global health programs. METHODS: A grey literature review of the Global Polio Eradication Initiative (GPEI) followed by an online survey was conducted in both countries. The survey was targeted to individuals who have been involved continuously in polio eradication activities for 12 months or more since 1988. A sub-set of respondents from the survey was recruited for key-informant interviews (KII). The survey and KIIs were conducted between September 2018-April 2019. A cross-case comparison analysis was conducted to describe shared implementation challenges, strategies, and unintended consequences of polio eradication activities across these contexts. RESULTS: Five hundred thirteen and nine hundred twenty-one surveys were completed in Afghanistan and Nigeria respectively; 28 KIIs were conducted in Afghanistan and 29 in Nigeria. Major polio eradication activities in both countries include house-to-house campaigns, cross-border stations, outreach to mobile populations, and surveillance. Common barriers to these activities in both countries include civil unrest and conflict; competing political agendas; and vaccine refusal, fatigue, and mistrust, all of which are all bases for describing hard-to-reach populations. Both countries employed strategies to engage community leadership, political and religious groups through advocacy visits, and recruited community members to participate in program activities to address misconceptions and distrust. Recruitment of female workers has been necessary for accessing women and children in conservative communities. Synergy with other health programs has been valuable; health workers have improved knowledge of the communities they serve which is applicable to other initiatives. CONCLUSIONS: The power of community engagement at all levels (from leadership to membership) cannot be overstated, particularly in countries facing civil unrest and insecurity. Workforce motivation, community fatigue and mistrust, political priorities, and conflict are intricately interrelated. Community needs should be holistically assessed and addressed;programs must invest in the needs of health workers who engage in these long-term health programs, particularly in unsafe areas, to alleviate demotivation and fatigue.

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.

[Strategies for malaria elimination: an Afro-Colombian perspective]. / Estrategias para la eliminación de malaria: una perspectiva afro-colombiana.

OBJECTIVE: To describe strategies for malaria elimination based on the perception of Afro-Colombian residents in Guapi, in the context of the Integrated Management Strategy for the Promotion, Prevention and Control of Vector-Borne Diseases in Colombia (EGI-ETV). MATERIALS AND METHODS: Qualitative study based on focus group discourse analysis. Eight participants from the urban area of Guapi were divided into two groups. The first group included three female nursing assistants, and was called "women with more experience"; they were workers in the current health system and former Malaria Eradication Service officers. The second group was made up of female nursing assistants, and was called "women with limited experience"; they were workers in the current health system and were not directly trained in the malaria program. An inductive and interpretative analysis was performed. RESULTS: Eight subcategories emerged, framed in the EGI-EVT, making emphasis on promotion and prevention aimed at reducing malaria, especially in rural areas. This problem must be addressed comprehensively, including other health issues and social determinants that affect them, such as: basic sanitation, access to health services, lack of education, use of popular treatments, and lack of infrastructure, among others. CONCLUSION: Participants consider that malaria in Guapi can be reduced but not eliminated. This problem needs to be addressed from an institutional and community perspective, taking into account cultural differences, based on strategies that include community empowerment and administrative and institutional strengthening of the program.

OBJETIVO: Describir las estrategias para la eliminación de la malaria a partir de la percepción de pobladores afro-colombianos residentes en Guapi en el contexto de la Estrategia de Gestión Integrada para la promoción, prevención y control de las Enfermedades Transmitidas por Vectores en Colombia (EGI). MÉTODOS: Estudio de tipo cualitativo basado en el análisis de discurso de grupos focales. Ocho participantes residentes en zona urbana de Guapi, divididas en dos grupos: el primero correspondió a tres mujeres auxiliares de enfermería, denominadas "mujeres con mayor experiencia", trabajadoras en el actual sistema de salud y funcionarias del antiguo Servicio de Erradicación de la Malaria. El segundo correspondió a cinco mujeres auxiliares de enfermería, denominadas "mujeres con limitada experiencia", trabajadoras en el actual sistema de salud y no tuvieron formación directa con el programa de malaria. Análisis inductivo e interpretativo. RESULTADOS: Emergieron ocho subcategorias enmarcadas en la EGI, con énfasis en la promoción y prevención orientadas a disminuir la malaria, especialmente en el área rural. El abordaje del problema debe hacerse de forma integral incluyendo otras problemáticas en salud y determinantes sociales que los afectan como: saneamiento básico, acceso al servicio de salud, falta de educación, uso de tratamientos populares, fragilidad de infraestructura, entre otros. CONCLUSIÓN: Las participantes consideran que la malaria en Guapi se puede reducir pero no eliminar. Se requiere abordar este problema desde una perspectiva institucional y comunitaria, teniendo en cuenta las diferencias culturales, a partir de estrategias que incluyan el empoderamiento comunitario y fortalecimiento administrativo e institucional del programa.

The Micro-Elimination Approach to Eliminating Hepatitis C: Strategic and Operational Considerations.

The introduction of efficacious new hepatitis C virus (HCV) treatments galvanized the World Health Organization to define ambitious targets for eliminating HCV as a public health threat by 2030. Formidable obstacles to reaching this goal can best be overcome through a micro-elimination approach, which entails pursuing elimination goals in discrete populations through multi-stakeholder initiatives that tailor interventions to the needs of these populations. Micro-elimination is less daunting, less complex, and less costly than full-scale, country-level initiatives to eliminate HCV, and it can build momentum by producing small victories that inspire more ambitious efforts. The micro-elimination approach encourages stakeholders who are most knowledgeable about specific populations to engage with each other and also promotes the uptake of new models of care. Examples of micro-elimination target populations include medical patients, people who inject drugs, migrants, and prisoners, although candidate populations can be expected to vary greatly in different countries and subnational areas.

Threats to the Effectiveness of Malaria Treatment.

In reaction to the speed and ease with which a high level of resistance against P. falciparum was induced in vivo in a mouse NOD/SCID IL-Ry-/- model by sub-therapeutic doses of artesunate [2], this text begins a plea for concrete measures to limit the risk of eventually appearing the same phenomenon in the field, including a strengthening of the fight against the use of artesunate oral monotherapy, tablet often under-dosed or artemisinin herbal tea and the adoption of more reliable and more efficient means than those currently used to detect the emergence of resistance earlier and a relaunch of the search for new antimalarials.

Childhood TB: can the End TB Strategy deliver?

The accelerated reductions in global TB incidence required to achieve the End TB Strategy goal will result in reductions in the burden of childhood TB. Contact screening and preventive therapy have emerged as important components of TB burden reduction, and family-centered approaches could be an effective route in delivering these activities. Lack of accurate diagnostics for children remains a critical barrier and a need remains for better collaborative and supportive links between the child health and TB control sectors. Irrespective of whether the ambitious targets can be achieved, the unprecedented opportunities provided by the End TB Strategy must be embraced.

Origin of malaria cases: a 7-year audit of global trends in indigenous and imported cases in relation to malaria elimination.

BACKGROUND: Countries in the different stages of pre-elimination, elimination, and prevention of reintroduction are required to report the number of indigenous and imported malaria cases to the World Health Organization (WHO). However, these data have not been systematically analysed at the global level. OBJECTIVE: For the period 2007 to 2013, we aimed to report on 1) the proportion of countries providing data on the origin of malaria cases and 2) the origin of malaria cases in countries classified as being in the stages of pre-elimination, elimination and prevention of reintroduction. DESIGN: An observational study using annual data reported through routine health information systems to the WHO Global Malaria Programme between 2007 and 2013. RESULTS: For all countries classified as being in pre-elimination, elimination, and prevention of reintroduction in the year 2013, there has been a substantial decrease in the total number of indigenous malaria cases, from more than 15,000 cases reported in 2007 to less than 4,000 cases reported in 2013. However, the total number of imported malaria cases has increased over that time period, from 5,600 imported cases in 2007 to approximately 6,800 in 2013. CONCLUSIONS: Vigilant monitoring of the numbers of imported and indigenous malaria cases at national and global levels as well as appropriate strategies to target these cases will be critical to achieve malaria eradication.

Operational issues and barriers to implementation of prevention of mother-to-child transmission of HIV (PMTCT) interventions in Sub-Saharan Africa.

Over the past 10 years substantial progress has been made in the implementation of prevention of mother-to-child transmission of HIV (PMTCT) interventions in Sub-Saharan Africa (SSA). In spite of this, new pediatric infections remain unacceptably high, contributing the majority (>90%) of the estimated 390,000 infections globally in 2010; and yet prolonged breastfeeding remains the norm and crucial to overall infant survival. However, there is reason for optimism given the 2010 World Health Organization PMTCT recommendations: to start HIV infected pregnant women with CD4 cell counts less than 350 cells/mm(3) on lifelong antiretroviral therapy (ART); and for mothers not eligible for ART to provide efficacious maternal and/or infant PMTCT antiretroviral (ARV) regimens to be taken during pregnancy, labor/delivery and through breastfeeding. Current attention is on whether to extend maternal ARVs for life once triple ARV PMTCT regimens are started. To dramatically reduce new pediatric infections, individual countries need to politically commit to rapid scale-up of a multi-pronged PMTCT effort: including primary prevention to reduce HIV incidence among women of reproductive age; increased access to family planning services; HIV screening of all pregnant and breastfeeding women followed by ART or ARVs for PMTCT; and comprehensive care for HIV affected families. Efforts to achieve population-level success in SSA need to critically address operational issues and challenges to implementation (health system) and utilization (social, economic and cultural barriers), at the country, health centre and client level that have led to the relatively slow progress in the scale-up of PMTCT strategies.

Implementation of an intersectoral program to eliminate human and canine rabies: the Bohol Rabies Prevention and Elimination Project.

BACKGROUND: The province of Bohol, located in the Visayas islands region in the Philippines has a human population of 1.13 million and was the 4th highest region for human rabies deaths in the country, averaging 10 per year, prior to the initiation of the Bohol Rabies Prevention and Elimination Project (BRPEP). AIMS: The BRPEP was initiated in 2007 with the goal of building a sustainable program that would prevent human rabies by eliminating rabies at its source, in dogs, by 2010. This goal was in line with the Philippine National Rabies Program whose objective is to eliminate rabies by 2020. METHODS: The intersectoral BRPEP was launched in 2007 and integrated the expertise and resources from the sectors of agriculture, public health and safety, education, environment, legal affairs, interior and local government. The program included: increasing local community involvement; implementing dog population control; conducting mass dog vaccination; improving dog bite management; instituting veterinary quarantine; and improving diagnostic capability, surveillance and monitoring. Funding was secured from the national government, provincial, municipal and village units, dog owners, NGOs, the regional office of the WHO, the UBS Optimus Foundation, and the Global Alliance for Rabies Control. The BRPEP was managed by the Bohol Rabies Prevention and Eradication Council (BRPEC) under the jurisdiction of the Governor of Bohol. Parallel organizations were created at the municipal level and village level. Community volunteers facilitated the institution of the program. Dog population surveys were conducted to plan for sufficient resources to vaccinate the required 70% of the dogs living in the province. Two island-wide mass vaccination campaigns were conducted followed by "catch up" vaccination campaigns. Registration of dogs was implemented including a small fee that was rolled back into the program to maintain sustainability. Children were educated by introducing rabies prevention modules into all elementary schools in Bohol. Existing public health legislation at the national, provincial, and municipal level strengthened the enforcement of activities. A Knowledge, Attitude and Practices (KAP) survey was conducted in 2009 to evaluate the educational knowledge of the population. Increased surveillance was instituted to ensure that dogs traveling into and out of the province were vaccinated against rabies. Human and animal cases of rabies were reported to provincial and national authorities. KEY RESULTS: Within the first 18 months of the BRPEP, human rabies deaths had decreased annually from 0.77 to 0.37 to zero per 100,000 population from 2007-2009. Between October 2008 and November 2010 no human and animal cases were detected. Increased surveillance on the island detected one suspected human rabies case in November 2010 and one confirmed case of canine rabies in April 2011. Two mass vaccination campaigns conducted in 2007 and 2008 successfully registered and vaccinated 44% and 70% of the dogs on the island. The additional surveillance activities enabled a mobilization of mop up vaccination activities in the region where the human and canine case was located. Due to the increased effective and continuous surveillance activities, rabies was stopped before it could spread to other areas on the island. The program costs totaled USD 450,000. Registration fees collected to maintain the program amounted to USD 105,740 and were re-allocated back into the community to sustain the program.

Progress, challenges, and new opportunities for the prevention of mother-to-child transmission of HIV under the US President's Emergency Plan for AIDS Relief.

In June 2011, the Joint United Nations Programme on HIV/AIDS, the US President's Emergency Plan for AIDS Relief (PEPFAR), and other collaborators outlined a transformative plan to virtually eliminate pediatric AIDS worldwide. The ambitious targets of this initiative included a 90% reduction in new pediatric HIV infections and a 50% reduction in HIV-related maternal mortality--all by 2015. PEPFAR has made an unprecedented commitment to the expansion and improvement of prevention of mother-to-child HIV transmission (PMTCT) services globally and is expected to play a critical role in reaching the virtual elimination target. To date, PEPFAR has been instrumental in the success of many national programs, including expanded coverage of PMTCT services, an enhanced continuum of care between PMTCT and HIV care and treatment, provision of more efficacious regimens for antiretroviral prophylaxis, design of innovative but simplified PMTCT approaches, and development of new strategies to evaluate program effectiveness. These accomplishments have been made through collaborative efforts with host governments, United Nations agencies, other donors (eg, the Global Fund for AIDS, Tuberculosis, and Malaria), nongovernmental organizations, and private sector partners. To successfully meet the ambitious global targets to prevent new infant HIV infections, PEPFAR must continue to leverage the existing PMTCT platform, while developing innovative approaches to rapidly expand quality HIV services. PEPFAR must also carefully integrate PMTCT into the broader combination prevention agenda for HIV, so that real progress can be made toward an "AIDS-free generation" worldwide.

Malaria elimination: moving forward with spatial decision support systems.

Operational challenges facing contemporary malaria elimination have distinct geospatial elements including the need for high-resolution location-based surveillance, targeted prevention and response interventions, and effective delivery of essential services at optimum levels of coverage. Although mapping and geographical reconnaissance (GR) has traditionally played an important role in supporting malaria control and eradication, its full potential as an applied health systems tool has not yet been fully realised. As accessibility to global positioning system (GPS), geographic information system (GIS) and mobile computing technology increases, the role of an integrated spatial decision support system (SDSS) framework for supporting the increased operational demands of malaria elimination requires further exploration, validation and application; particularly in the context of resource-poor settings.

Prospects for malaria elimination in non-Amazonian regions of Latin America.

Latin America contributes 1-1.2 million clinical malaria cases to the global malaria burden of about 300 million per year. In 21 malaria endemic countries, the population at risk in this region represents less than 10% of the total population exposed worldwide. Factors such as rapid deforestation, inadequate agricultural practices, climate change, political instability, and both increasing parasite drug resistance and vector resistance to insecticides contribute to malaria transmission. Recently, several malaria endemic countries have experienced a significant reduction in numbers of malaria cases. This is most likely due to actions taken by National Malaria Control Programs (NMCP) with the support from international funding agencies. We describe here the research strategies and activities to be undertaken by the Centro Latino Americano de Investigación en Malaria (CLAIM), a new research center established for the non-Amazonian region of Latin America by the National Institute of Allergy and Infectious Diseases (NIAID). Throughout a network of countries in the region, initially including Colombia, Guatemala, Panama, and Peru, CLAIM will address major gaps in our understanding of changing malaria epidemiology, vector biology and control, and clinical malaria mainly due to Plasmodium vivax. In close partnership with NMCPs, CLAIM seeks to conduct research on how and why malaria is decreasing in many countries of the region as a basis for developing and implementing new strategies that will accelerate malaria elimination.