A framework for evaluating health system surveillance sensitivity to support public health decision-making for malaria elimination: a case study from Indonesia.

BACKGROUND: The effectiveness of a surveillance system to detect infections in the population is paramount when confirming elimination. Estimating the sensitivity of a surveillance system requires identifying key steps in the care-seeking cascade, from initial infection to confirmed diagnosis, and quantifying the probability of appropriate action at each stage. Using malaria as an example, a framework was developed to estimate the sensitivity of key components of the malaria surveillance cascade. METHODS: Parameters to quantify the sensitivity of the surveillance system were derived from monthly malaria case data over a period of 36 months and semi-quantitative surveys in 46 health facilities on Java Island, Indonesia. Parameters were informed by the collected empirical data and estimated by modelling the flow of an infected individual through the system using a Bayesian framework. A model-driven health system survey was designed to collect empirical data to inform parameter estimates in the surveillance cascade. RESULTS: Heterogeneity across health facilities was observed in the estimated probability of care-seeking (range = 0.01-0.21, mean ± sd = 0.09 ± 0.05) and testing for malaria (range = 0.00-1.00, mean ± sd = 0.16 ± 0.29). Care-seeking was higher at facilities regularly providing antimalarial drugs (Odds Ratio [OR] = 2.98, 95% Credible Intervals [CI]: 1.54-3.16). Predictably, the availability of functioning microscopy equipment was associated with increased odds of being tested for malaria (OR = 7.33, 95% CI = 20.61). CONCLUSIONS: The methods for estimating facility-level malaria surveillance sensitivity presented here can help provide a benchmark for what constitutes a strong system. The proposed approach also enables programs to identify components of the health system that can be improved to strengthen surveillance and support public-health decision-making.

A participatory approach to address within-country cross-border malaria: the case of Menoreh Hills in Java, Indonesia.

BACKGROUND: Malaria remains a significant public health issue in Indonesia. Most of the endemic areas are in the eastern parts of Indonesia, but there are a few remaining foci of persistent endemic malaria in Java, particularly in Menoreh Hills, a region bordering three districts of two provinces on this island. Despite a commitment to build a partnership to eliminate cross-border malaria, there is a lack of understanding of how this partnership might be translated into an implementable strategic plan. The study aims to provide evidence of how a participatory approach was used to strengthen the cross-border collaboration and stakeholders' capacity to develop a joint strategic, operational, and costing plan for cross-border malaria elimination. METHODS: A participatory action research was conducted from January to August 2017, involving participants from the village, district, provincial, and national levels. This study was conducted in seven phases, including document review, focus group discussions (FGDs), planning and costing workshops, and a dissemination meeting. A total of 44 participants from primary health centres (PHC) and 27 representatives of affected villages in three districts, 16 participants from the district and provincial malaria programmes and planning bureaus, and 11 participants from the national level were involved in the processes. Data on priority issues, costing, programme coverage, and administration were collected. Thematic coding and feedback were used for analysis. RESULTS: Problems identified by stakeholders included low community awareness and participation in malaria prevention, high mobility across three districts, lack of financial and human resources, lack of inter-district coordination, and poor implementation of migration surveillance. Cross-border strategies identified to address malaria were improving cross-border migration surveillance, strengthening the network, governance, and advocacy of malaria control implementation across borders, and developing the malaria information system. A working group composed of the three districts' representatives authorized to decide on cross-border issues will be created. CONCLUSIONS: The participatory approach was applicable in cross-border malaria planning for within-country settings and useful in enhancing stakeholders' capacities as implementers. While done in a participatory way, the joint plan crafted was a non-binding agreement; stakeholders should advocate to ensure adequate funds are poured into mobilizing the programme.

Scaling up public health interventions: case study of the polio immunization program in Indonesia.

BACKGROUND: The scaling up of public health interventions has received greater attention in recent years; however, there remains paucity of systematic investigations of the scaling up processes. We aim to investigate the overall process, actors and contexts of polio immunization scaling up in Indonesia from 1988 until 2018. METHODS: A mixed method study with sequential explanatory design was conducted. We carried out a quantitative survey of 323 actors involved in the polio program at national and sub-national levels, followed by Key Informant Interviews (KII)s. Document review was also carried out to construct a timeline of the polio eradication program with milestones. We carried out descriptive statistical analysis of quantitative data and thematic analysis of qualitative data. RESULTS: The scaling up of polio immunization in Indonesia started as a vertical expansion approach led by the Ministry of Health within a centralized health system. The coverage of immunization increased dramatically from 5% in the earlier 80s to 67.5% in 1987; incremental increases followed until achieving Universal Child Immunization (UCI) in 1990 and subsequently 95% coverage in 1995. Engagement of stakeholders and funding made the scaling up of polio immunization a priority. There was also substantial multisector involvement, including institutions and communities. Local area monitoring (LAM) and integrated health posts (Posyandu) were key to the polio immunization implementation strategy. Challenges for scaling up during this centralized period included cold chain infrastructure and limited experience in carrying out mass campaigns. Scaling up during the decentralized era was slower due to expansion in the number of provinces and districts. Moreover, there were challenges such as the negative perception of immunization side-effects, staff turnover, and the unsmooth transition of centralization towards decentralization. CONCLUSION: Vertical scaling up of polio immunization program intervention was successful during the centralized era, with involvement of the president as a role model and the engine of multi sector actors. Posyandu (integrated health posts) played an important role, yet its revitalization after the reform-decentralization era has not been optimum.

Ensuring sustainability of polio immunization in health system transition: lessons from the polio eradication initiative in Indonesia.

BACKGROUND: Sustaining an effective evidence-based health intervention will maximize its impact on public health. Political and governmental reforms impacted on immunization program sustainability both positively and negatively. This study aims to explore the sustainability of polio immunization in a decentralized health system taking lessons learned from a polio eradication initiative in Indonesia. METHODS: We collected qualitative data through in-depth interviews with 27 key informants from various backgrounds at district, provincial, and national levels, consisting of frontline workers, managers, and Non-government Organizations (NGOs). We conducted thematic analysis and triangulated using document reviews. We also conducted member checking and peer debriefing to ensure trustworthiness. RESULTS: Competing priority was identified as the significant challenge to sustain government commitment for polio immunization and AFP surveillance during the transition toward a decentralized health system. Variation of local government capacities has also affected immunization delivery and commitment at the sub-national level government. The government reform has led to a more democratic society, facilitating vaccine rejection and hesitancy. The multi-sector partnership played a significant role in maintaining polio immunization coverage. Strong and continuous advocacy and campaign were essential to raising awareness of the community and policymakers to keep polio in the agenda and to maintain the high polio immunization coverage. CONCLUSION: Competing priority was the major factor affecting high polio immunization coverage during the decentralization transition. Strong advocacy is needed at every level, from district to national level, to keep polio immunization prioritized.

Sampling method for surveying complex and multi-institutional partnerships: lessons from the Global Polio Eradication Initiative.

BACKGROUND: Complex global initiatives, like the Global Polio Eradication Initiative (GPEI), have prevented millions of paralyses and improved the health status of diverse populations. Despite the logistical challenges these initiatives must overcome at several levels, scant methods exist for systematically identifying and reaching a range of actors involved in their implementation. As a result, efforts to document the lessons learned from such initiatives are often incomplete. This paper describes the development and application of the Synthesis and Translation of Research and Innovations from Polio Eradication (STRIPE) systematic approach for identifying a comprehensive sample of actors involved in the GPEI. RESULTS: The survey for collecting lessons learned from the GPEI was conducted at the global level and within seven countries that represented GPEI operational contexts. Standard organizational and operational levels, as well as goals of program activities, were defined across contexts. Each survey iteration followed similar methodologies to theorize a target population or "universe" of all polio-related actors in the study area, enumerate a source population of specific individuals within the target population, and administer the survey to individuals within the source population. Based on the systematic approach used to obtain a comprehensive sample for lessons learned in GPEI, steps for obtaining a comprehensive sample for studying complex initiatives can be summarized as follows: (i) State research goal(s); (ii) Describe the program of interest; (iii) Define a sampling universe to meet these criteria; (iv) Estimate the size of the sampling universe; (v) Enumerate a source population within the universe that can be feasibly reached for sampling; (vi) Sample from the source population; and (vii) Reflect on the process to determine strength of inferences drawn. CONCLUSIONS: The application of these methods can inform future evaluations of complex public health initiatives, resulting in better adoption of lessons learned, ultimately improving efficacy and efficiency, and resulting in significant health gains. Their use to administer the STRIPE lessons learned survey reflects experiences related to implementation challenges and strategies used to overcome barriers from actors across an extensive range of organizational, programming, and contextual settings.

Intravenous artesunate plus oral dihydroartemisinin-piperaquine or intravenous quinine plus oral quinine for optimum treatment of severe malaria: lesson learnt from a field hospital in Timika, Papua, Indonesia.

BACKGROUND: Intravenous artesunate and its follow on full course dihydroartemisinin-piperaquine are the standard treatment for severe malaria in Indonesia. The current policy suggests that intravenous and oral quinine could be used when standard therapy is not available. Its pragmatic use of both treatment combinations in a field hospital is evaluated. METHODS: A retrospective study among hospitalized malaria patients receiving intravenous anti-malarial treatments at Mitra Masyarakat Hospital, Timika from April 2004 to December 2013 was conducted. The length of hospital stay (LoS) and the risk of malaria recurrence within 28 days after hospital admission were compared between patients receiving intravenous artesunate and oral dihydroartemisinin-piperaquine (Iv Art + DHP) and those receiving intravenous and oral quinine (Iv + Oral Qu). RESULTS: Of 10,514 patients requiring intravenous therapy, 2759 received Iv + Oral Qu and 7755 received Iv Art + DHP. Plasmodium falciparum infection accounted for 65.8% (6915), while Plasmodium vivax, Mixed infections, Plasmodium malariae and Plasmodium ovale were accounted for 17.0% (1789), 16.4% (1729), 0.8% (79) and 0.01% (2) of the infections, respectively. The majority of severe malaria hospital admissions were highland Papuans (78.0%, 8201/10,501). In total 49% (5158) of patients were older than 15 years and 3463 (32.9%) were children under 5 years old. The median LoS was shorter in patients receiving intravenous artesunate compared to those treated with intravenous quinine (median = 2 [IQR 1-3] versus 3 days [IQR 2-4], p < 0.0001). Patients treated with intravenous quinine had higher risk of being hospitalized longer than 2 days (aOR of 1.70 [95% CI 1.54-1.88], p < 0.0001). The risk of recurrences within 28 days after hospital admission was 1.94 times higher (95% CI aHR 1.57-2.39, p < 0.0001) in patients receiving intravenous quinine with follow on oral quinine treatment than in patients treated with DHP after intravenous artesunate therapy. CONCLUSIONS: Intravenous artesunate reduced the LoS of malaria patients and in combination with DHP reduced the risk of malaria recurrence within 28 days after hospital admission compared to those with Iv + Oral Qu treatment. Thus, ensuring continuous supply of intravenous artesunate and artemisinin-based combination therapy (ACT) should be a priority.

Acceptability and feasibility of delegating HIV counseling and testing for TB patients to community health workers in the Philippines: a mixed methods study.

BACKGROUND: The Philippines has a high burden of TB and HIV, yet the WHO estimates that only 13% of Filipino TB patients know their HIV status. This is partly attributable to the lack of trained HIV counselors and medical technologists (or laboratory technicians) at the primary healthcare level. In Africa where resources and manpower are also scarce, TB/HIV care is already delegated to community health workers. Evidence is scant however about the acceptability and feasibility of engaging community health workers to provide HIV counseling and testing (HCT) among TB patients in the Philippines. The objective of this paper is to describe and assess the acceptability and feasibility of delegating HCT among TB patients to barangay (community) health workers (BHWs) in the Philippines. METHODS: Mixed methods study that utilized surveys with patients (n = 89), BHWs (n = 81), and ten focus group discussions with key stakeholders (n = 49) in San Jose del Monte, a city with high HIV prevalence. A facility assessment (n = 17) was done using a modified version of WHO-Service Availability and Readiness Assessment questionnaire to assess feasibility (scale of 1 to 4) while acceptability from the perspective of patients and BHWs was determined using surveys. RESULTS: Only 47% of TB patients agreed to receive HIV counseling from BHWs, while 30% agreed to receive HIV testing. Doctors were preferred by patients as HIV counselors, while medical technologists were preferred as HIV test providers. Two out of three BHWs also disagreed to provide HCT but the same number felt that they could provide HCT if additional trainings were given to them. In the group discussions, BHWs preferred to only provide HIV counseling. Stakeholders said that only select BHWs who meet certain criteria should provide HIV counseling. Program managers and stakeholders rated delegation of HCT to BHWs as moderately feasible. CONCLUSIONS: Delegation of both HIV counseling and testing among TB patients to BHWs is feasible, but only delegation of HIV counseling is acceptable. Further studies are needed to guide revision of Philippine HCT policies to accommodate lay HIV counselors, and strengthen the mechanisms for delivering integrated TB and HIV services especially at the primary healthcare level.

The addition of mobile SMS effectively improves dengue prevention practices in community: an implementation study in Nepal.

BACKGROUND: Dengue is an emerging vector disease with frequent outbreaks in Nepal that pose a major threat to public health. Dengue control activities are mostly outbreak driven, and still lack systematic interventions while most people have poor health-related knowledge and practices. Mobile Short Message Service (SMS) represents a low-cost health promotion intervention that can enhance the dengue prevention knowledge and practices of the affected communities. This study aimed to explore the acceptability, appropriateness, and effectiveness of mobile SMS intervention in improving dengue control practices. METHODS: This study was an implementation research that used mixed-methods design with intervention. A total of 300 households were divided into three groups, i.e. one control group, one dengue prevention leaflet (DPL) only intervention group and one DPL with mobile SMS intervention group (DPL + SMS). We used a structured questionnaire to collect information regarding participants' knowledge and practice of dengue prevention. We conducted in-depth interviews with key informants to measure acceptability and appropriateness of intervention. Mean difference with standard deviation (SD), one-way ANOVA, paired t-test and regression analyses were used to assess the effectiveness of the interventions. Thematic analysis was used to assess the acceptability, and appropriateness as well as barriers and enablers of the intervention. RESULTS: The DPL + SMS intervention produced significantly higher mean knowledge difference (32.7 ± 13.7 SD vs. 13.3 ± 8.8 SD) and mean practice difference (27.9 ± 11.4 SD vs 4.9 ± 5.4 SD) compared to the DPL only group (p = 0.000). Multivariate analysis showed that the DPL + SMS intervention was effective to increase knowledge by 28.6 points and practice by 28.1 points compared to the control group. The intervention was perceived as acceptable and appropriate by the study participants and key stakeholders. Perceived barriers included reaching private network users and poor network in geographically remote areas, while enabling factors included mobile phone penetration, low cost, and shared responsibility. CONCLUSIONS: Mobile SMS is an effective, acceptable and appropriate health intervention to improve dengue prevention practices in communities. This intervention can be adopted as a promising tool for health education against dengue and other diseases.

Development of the Good Health Research Practice course: ensuring quality across all health research in humans.

Quality and ethics need to be embedded into all areas of research with human participants. Good Clinical Practice (GCP) guidelines are international ethical and scientific quality standards for designing, conducting, recording and reporting trials involving human participants. Compliance with GCP is expected to provide public assurance that the rights, safety and wellbeing of participants are protected and that the clinical research data are credible. However, whilst GCP guidelines, particularly their principles, are recommended across all research types, it is difficult for non-clinical trial research to fit in with the exacting requirements of GCP. There is therefore a need for guidance that allows health researchers to adhere to the principles of GCP, which will improve the quality and ethical conduct of all research involving human participants. These concerns have led to the development of the Good Health Research Practice (GHRP) course. Its goal is to ensure that research is conducted to the highest possible standards, similar to the conduct of trials to GCP. The GHRP course provides training and guidance to ensure quality and ethical conduct across all health-related research. The GHRP course has been run so far on eight occasions. Feedback from delegates has been overwhelmingly positive, with most delegates stating that the course was useful in developing their research protocols and documents. Whilst most training in research starts with a guideline, GHRP has started with a course and the experience gained over running the courses will be used to write a standardised guideline for the conduct of health-related research outside the realm of clinical trials, so that researchers, funders and ethics committees do not try to fit non-trials into clinical trials standards.

Reanalysis of cluster randomised trial data to account for exposure misclassification using a per-protocol and complier-restricted approach.

The intention-to-treat (ITT) analysis of the Applying Wolbachia to Eliminate Dengue (AWED) trial estimated a protective efficacy of 77.1% for participants resident in areas randomised to receive releases of wMel-infected Aedes aegypti mosquitoes, an emerging dengue preventive intervention. The limiting assumptions of ITT analyses in cluster randomised trials and the mobility of mosquitoes and humans across cluster boundaries indicate the primary analysis is likely to underestimate the full public health benefit. Using spatiotemporally-resolved data on the distribution of Wolbachia mosquitoes and on the mobility of AWED participants (n = 6306), we perform complier-restricted and per-protocol re-examinations of the efficacy of the Wolbachia intervention. Increased intervention efficacy was estimated in all analyses by the refined exposure measures. The complier-restricted analysis returned an estimated efficacy of 80.7% (95% CI 65.9, 89.0) and the per-protocol analysis estimated 82.7% (71.7, 88.4) efficacy when comparing participants with an estimated wMel exposure of ≥ 80% compared to those with <20%. These reanalyses demonstrate how human and mosquito movement can lead to underestimation of intervention effects in trials of vector interventions and indicate that the protective efficacy of Wolbachia is even higher than reported in the primary trial results.

Tuberculosis Case Finding in Kulon Progo District, Yogyakarta, Indonesia: Passive versus Active Case Finding Using Mobile Chest X-ray.

Active-case finding (ACF) using chest X-ray is an essential method of finding and diagnosing Tuberculosis (TB) cases that may be missed in Indonesia's routine TB case finding. This study compares active and passive TB case-finding strategies. A retrospective study of TB case notification was conducted. Data between 1 January and 31 December 2021, was used. The population in this study were TB cases notified from Kulon Progo District health facilities, including those found through routine activities or active-case findings. A total of 249 TB cases were diagnosed in Kulon Progo in 2021, and 102 (41%) were bacteriologically confirmed. The TB patients' ages ranged from 0 to 85 years (median 52, IQR 31-61). The majority of cases were male (59%, 147/249) and mostly among people aged 15-59 (61.4%, 153/249). The proportion of clinical TB diagnoses among cases found from active-case findings was 74.7% (68/91) while the proportion among passive-case findings was 50% (79/158). Active-case finding contributed 91 (36.5%) TB cases to the total cases detected in Kulon Progo in 2021. The use of chest X-rays in active-case findings likely contributed to the detection of a higher proportion of clinical TB than in passive-case findings.

"I pity the TB patient": a mixed methods study assessing the impact of the COVID-19 pandemic on TB services in two major Indonesian cities and distilling lessons for the future.

INTRODUCTION: In Indonesia, a country with around 280 million people and the second-highest tuberculosis (TB) incidence rate in the world, the impact of the COVID-19 pandemic on TB care needs careful assessment so that future response strategies can be strengthened. We conducted a study comparing TB testing and treatment rates before and during the first 2 years of the COVID-19 pandemic in Indonesia, and the reasons for any disruptions to care. METHODS: We conducted retrospective secondary data analysis and qualitative interviews in Yogyakarta and Bandung, Indonesia. Routine data on TB testing and treatment were sourced from the national TB information system operated by the Indonesian Ministry of Health. TB testing and treatment outcomes were compared between two time periods: pre-COVID (2018-19); and during COVID-19 (2020-21). In-depth interviews were conducted with patients and health workers to explore their experiences in accessing and providing TB services during the pandemic. RESULTS: There was a 45% (21 937/39 962) reduction in the number of patients tested for TB during the pandemic compared with pre-COVID-19, while the proportion of TB tests returning a positive result increased from 12% (4733/39 962) to 50% (10 945/21 937). The proportion of TB patients completing treatment increased by 2.6% during the pandemic, yet the proportion cured and the number of patients successfully treated both decreased (by 7% and 4.4%, respectively). Our qualitative interviews highlighted several factors influencing TB service access and delivery, including fear of being diagnosed with COVID-19 during TB-related clinic visits, fear of COVID-19 exposure among patients and health workers, healthcare facilities prioritising COVID-19 over other services, and mandatory mobility restrictions affecting both patients and health workers. CONCLUSION: The COVID-19 pandemic impacted TB testing and treatment outcomes in Bandung and Yogyakarta. Policymakers should consider these findings in designing strategies to ensure TB services are maintained and supported during future health crises.

A Systematic Review and Meta-analysis of the Impact of the COVID-19 Pandemic on Access to HIV Pre-exposure Prophylaxis: Lessons for Future Public Health Crises.

BACKGROUND: The World Health Organization is committed to strengthening access to pre-exposure prophylaxis (PrEP) for HIV prevention and its integration into primary care services. Unfortunately, the COVID-19 pandemic has disrupted the delivery of primary care, including HIV-related services. To determine the extent of this disruption, we conducted a systematic review and meta-analysis of the changes in access to PrEP services during the pandemic and the reasons for these changes. METHODS: A search was conducted using PubMed, Scopus, Embase, PsycINFO, and Cinahl for studies published between January 2020 and January 2023. Selected articles described self-reported disruptions to PrEP service access associated with the COVID-19 pandemic or its responses. Pooled effect sizes were computed using a random-effects model. RESULTS: Thirteen studies involving 12,652 PrEP users were included in our analysis. The proportion of participants reporting a disruption in access to PrEP services during the COVID-19 pandemic ranged from 3% to 56%, with a pooled proportion of 21% (95% confidence intervals: 8% to 38%). Social restrictions, financial constraints, and limited health insurance coverage were key factors affecting access to PrEP services during the pandemic. CONCLUSIONS: To our knowledge, this is the first meta-analysis to quantify the extent of disruptions to accessing PrEP services because of the COVID-19 pandemic. To increase the ability of primary care services to maintain PrEP services during public health crises, a mixture of strategies is worth considering. These include multi-month PrEP prescriptions, telehealth services, deployment of peer support groups to provide a community-based service or home delivery, and provision of financial support interventions.

Seroprevalence of SARS-CoV-2 and risk factors in Bantul Regency in March-April 2021, Yogyakarta, Indonesia.

COVID-19 case counts in Indonesia inevitably underestimate the true cumulative incidence of infection due to limited diagnostic test availability, barriers to testing accessibility and asymptomatic infections. Therefore, community-based serological data is essential for understanding the true prevalence of infections. This study aims to estimate the seroprevalence of SARS-CoV-2 infection and factors related to the seropositivity in Bantul Regency, Yogyakarta, Indonesia. A cross-sectional study involving 425 individuals in 40 clusters was conducted between March and April 2021. Participants were interviewed using an e-questionnaire developed in the Kobo toolbox to collect information on socio-demographic, COVID-19 suggestive symptoms, history of COVID-19 diagnosis and COVID-19 vaccination status. A venous blood sample was collected from each participant and tested for immunoglobulin G (Ig-G) SARS-CoV-2 antibody titers using the enzyme-linked immunosorbent assay (ELISA). Seroprevalence was 31.1% in the Bantul Regency: 34.2% in semi-urban and 29.9% in urban villages. Participants in the 55-64 age group demonstrated the highest seroprevalence (43.7%; p = 0.00), with a higher risk compared to the other age group (aOR = 3.79; 95% CI, 1.46-9.85, p<0.05). Seroprevalence in the unvaccinated participants was 29.9%. Family clusters accounted for 10.6% of the total seropositive cases. No significant difference was observed between seropositivity status, preventive actions, and mobility. Higher seroprevalence in semi-urban rather than urban areas indicates a gap in health services access. Surveillance improvement through testing, tracing, and treatment, particularly in areas with lower access to health services, and more robust implementation of health protocols are necessary.

Utility of surveillance data for planning for dengue elimination in Yogyakarta, Indonesia: a scenario-tree modelling approach.

INTRODUCTION: Field trials and modelling studies suggest that elimination of dengue transmission may be possible through widespread release of Aedes aegypti mosquitoes infected with the insect bacterium Wolbachia pipientis (wMel strain), in conjunction with routine dengue control activities. This study aimed to develop a modelling framework to guide planning for the potential elimination of locally acquired dengue in Yogyakarta, a city of almost 400 000 people in Java, Indonesia. METHODS: A scenario-tree modelling approach was used to estimate the sensitivity of the dengue surveillance system (including routine hospital-based reporting and primary-care-based enhanced surveillance), and time required to demonstrate elimination of locally acquired dengue in Yogyakarta city, assuming the detected incidence of dengue decreases to zero in the future. Age and gender were included as risk factors for dengue, and detection nodes included the probability of seeking care, probability of sample collection and testing, diagnostic test sensitivity and probability of case notification. Parameter distributions were derived from health system data or estimated by expert opinion. Alternative simulations were defined based on changes to key parameter values, separately and in combination. RESULTS: For the default simulation, median surveillance system sensitivity was 0.131 (95% PI 0.111 to 0.152) per month. Median confidence in dengue elimination reached 80% after a minimum of 13 months of zero detected dengue cases and 90% confidence after 25 months, across different scenarios. The alternative simulations investigated produced relatively small changes in median system sensitivity and time to elimination. CONCLUSION: This study suggests that with a combination of hospital-based surveillance and enhanced clinic-based surveillance for dengue, an acceptable level of confidence (80% probability) in the elimination of locally acquired dengue can be reached within 2 years. Increasing the surveillance system sensitivity could shorten the time to first ascertainment of elimination of dengue and increase the level of confidence in elimination.

Impact of randomised wmel Wolbachia deployments on notified dengue cases and insecticide fogging for dengue control in Yogyakarta City.

BACKGROUND: Releases of Wolbachia (wMel)-infected Aedes aegypti mosquitoes significantly reduced the incidence of virologically confirmed dengue in a previous cluster randomised trial in Yogyakarta City, Indonesia. Following the trial, wMel releases were extended to the untreated control areas, to achieve city-wide coverage of Wolbachia. OBJECTIVE: In this predefined analysis, we evaluated the impact of the wMel deployments in Yogyakarta on dengue hemorrhagic fever (DHF) case notifications and on the frequency of perifocal insecticide spraying by public health teams. METHODS: Monthly counts of DHF cases notified to the Yogyakarta District Health Office between January 2006 and May 2022 were modelled as a function of time-varying local wMel treatment status (fully- and partially-treated vs untreated, and by quintile of wMel prevalence). The frequency of insecticide fogging in wMel-treated and untreated areas was analysed using negative binomial regression. RESULTS: Notified DHF incidence was 83% lower in fully treated vs untreated periods (IRR 0.17 [95% CI 0.14, 0.20]), and 78% lower in areas with 80-100% wMel prevalence compared to areas with 0-20% wMel (IRR 0.23 [0.17, 0.30]). A similar intervention effect was observed at 60-80% wMel prevalence as at 80-100% prevalence (76% vs 78% efficacy, respectively). Pre-intervention, insecticide fogging occurred at similar frequencies in areas later randomised to wMel-treated and untreated arms of the trial. After wMel deployment, fogging occurred significantly less frequently in treated areas (IRR 0.17 [0.10, 0.30]). CONCLUSIONS: Deployments of wMel-infected Aedes aegypti mosquitoes resulted in an 83% reduction in the application of perifocal insecticide spraying, consistent with lower dengue case notifications in wMel-treated areas. These results show that the Wolbachia intervention effect demonstrated previously in a cluster randomised trial was also measurable from routine surveillance data.

Diagnostic work-up and loss of tuberculosis suspects in Jogjakarta, Indonesia.

BACKGROUND: Early and accurate diagnosis of pulmonary tuberculosis (TB) is critical for successful TB control. To assist in the diagnosis of smear-negative pulmonary TB, the World Health Organisation (WHO) recommends the use of a diagnostic algorithm. Our study evaluated the implementation of the national tuberculosis programme's diagnostic algorithm in routine health care settings in Jogjakarta, Indonesia. The diagnostic algorithm is based on the WHO TB diagnostic algorithm, which had already been implemented in the health facilities. METHODS: We prospectively documented the diagnostic work-up of all new tuberculosis suspects until a diagnosis was reached. We used clinical audit forms to record each step chronologically. Data on the patient's gender, age, symptoms, examinations (types, dates, and results), and final diagnosis were collected. RESULTS: Information was recorded for 754 TB suspects; 43.5% of whom were lost during the diagnostic work-up in health centres, 0% in lung clinics. Among the TB suspects who completed diagnostic work-ups, 51.1% and 100.0% were diagnosed without following the national TB diagnostic algorithm in health centres and lung clinics, respectively. However, the work-up in the health centres and lung clinics generally conformed to international standards for tuberculosis care (ISTC). Diagnostic delays were significantly longer in health centres compared to lung clinics. CONCLUSIONS: The high rate of patients lost in health centres needs to be addressed through the implementation of TB suspect tracing and better programme supervision. The national TB algorithm needs to be revised and differentiated according to the level of care.

Adverse events following immunization of COVID-19 vaccine among children aged 6-11 years.

Introduction: Starting in December 2021, the Indonesian Government has recommended inactivated SARS-CoV-2 vaccine (CoronaVac) for children aged 6-11 years. This study aims to determine the prevalence and determinant factors of adverse events following immunization (AEFI) of the first dose and the second dose of the COVID-19 vaccine among children aged 6-11 years old. Materials and methods: We conducted a cross-sectional study in Bantul District, Yogyakarta, Indonesia, in February-March 2022. Data were collected by trained interviews with 1,093 parents of children 6-11 years old who received the first dose and the second dose of the COVID-19 vaccine. Data were analyzed with chi-square and logistic regression. Results: The prevalence of AEFI in the first dose of the COVID-19 vaccine was 16.7%, while the second dose was 22.6%. The most common symptoms of AEFI at the first dose were local site pain and fever, while at the second dose were cough and cold. Determinants of AEFI of COVID-19 vaccination among children were girls with OR 1.31 (95% CI 1.0-1.7; P 0.04), mass-setting of vaccination with OR 0.70 (95% CI 0.5-0.9; P 0.01), the history of AEFI in childhood vaccination with OR 1.63 (95% CI 1.2-2.2; P < 0.01) and administering other vaccines within 1 month before COVID-19 vaccination, with OR 5.10 (95% CI 2.1-12.3 P < 0.01). Conclusion: The prevalence of AEFI in the first and the second dose of inactivated COVID-19 vaccine was comparable to that reported in the clinical trial study and the communities. Risk communication should be provided to the child and their parents regarding the risk of mild AEFI of the COVID-19 vaccine, especially for children with a history of AEFI in childhood vaccination and who received other vaccines containing the same adjuvant with CoronaVac within 1 month. A mass-setting of vaccination should be taken as an advantage to educate parents about the risk of AEFI and also about the reporting pathways.

Identifying forms of interventions towards cross border malaria in the Asia-Pacific region: a scoping review protocol.

INTRODUCTION: An ambitious epidemiology strategy has been set by the WHO, targeting malaria elimination for at least 35 countries in 2030. Challenges in preventing malaria cross borders require greater attention to achieve the elimination target. This scoping review aims to identify successful forms of interventions to control malaria transmission across national borders in the Asia-Pacific region. METHODS AND ANALYSIS: This scoping review will search four electronic databases (PubMed, ScienceDirect, EBSCOhost and ProQuest) limiting the time of publication to the last 10 years. Two independent reviewers will screen all titles and abstracts during the second stage. Study characteristics will be recorded; qualitative data will be extracted and evaluated, while quantitative data will be extracted and summarised. Overall, we will follow the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines. ETHICS AND DISSEMINATION: This scoping review has received ethical approval from the Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada. The results will be disseminated through peer-reviewed publications, conference presentations and policy briefs.

Disruption of spatiotemporal clustering in dengue cases by wMel Wolbachia in Yogyakarta, Indonesia.

Dengue exhibits focal clustering in households and neighborhoods, driven by local mosquito population dynamics, human population immunity, and fine scale human and mosquito movement. We tested the hypothesis that spatiotemporal clustering of homotypic dengue cases is disrupted by introduction of the arbovirus-blocking bacterium Wolbachia (wMel-strain) into the Aedes aegypti mosquito population. We analysed 318 serotyped and geolocated dengue cases (and 5921 test-negative controls) from a randomized controlled trial in Yogyakarta, Indonesia of wMel deployments. We find evidence of spatial clustering up to 300 m among the 265 dengue cases (3083 controls) in the untreated trial arm. Participant pairs enrolled within 30 days and 50 m had a 4.7-fold increase (compared to 95% CI on permutation-based null distribution: 0.1, 1.2) in the odds of being homotypic (i.e. potentially transmission-related) as compared to pairs occurring at any distance. In contrast, we find no evidence of spatiotemporal clustering among the 53 dengue cases (2838 controls) resident in the wMel-treated arm. Introgression of wMel Wolbachia into Aedes aegypti mosquito populations interrupts focal dengue virus transmission leading to reduced case incidence; the true intervention effect may be greater than the 77% efficacy measured in the primary analysis of the Yogyakarta trial.