Assessing the contributions of an urban population health initiative to shift political priority towards cardiovascular health: three case studies from Brazil, Mongolia and Senegal.

BACKGROUND: The urban population health initiative was designed as a multidisciplinary, multisector programme to address cardiovascular (CV) disease, specifically hypertension and its underlying causes in the cities of Ulaanbaatar, Mongolia; Dakar, Senegal; and São Paulo, Brazil. This article aims to provide an overview of the history and dynamics of CV disease policy making in the three countries, to present the policy reform contributions of the initiative and its role in the policy agenda-setting framework/process in each country and to identify the enablers and challenges to the initiative for doing so. METHODS: A qualitative case study was conducted for each setting from November 2020 to January 2021, comprised of a document review, semi-structured in-depth interviews and unstructured interviews with stakeholders involved in the initiative. The literature review included documents from the initiative and the peer-reviewed and grey literature with a total of 188 documents screened. Interviews were conducted with 21 stakeholders. Data collection and thematic analysis was guided by (i) the Kingdon multiple streams conceptual framework with the main themes being CV disease problems, policy, politics and the role of policy entrepreneurs; and (ii) the study question inquiring on the role of the urban population health initiative at the CV disease policy level and enabling and challenging factors to advancing CV disease policy. Data were thematically analysed using the Framework Method. RESULTS: Each setting was characterized by a high hypertension and CV disease burden combined with an aware and proactive political environment. Policy outcomes attributed to the initiative were updating the guidelines and/or algorithms of care for hypertension and including revised physical and nutritional education in school curricula, in each city. Overall, the urban health initiative's effects in the policy arena, were most prominent in Mongolia and Senegal, where the team effectively acted as policy entrepreneur, promoting the solutions/policies in alignment with the most pressing local problems and in strong involvement with the political actors. The initiative was also involved in improving access to CV disease drugs at primary health levels. Its success was influenced by the local governance structures, the proximity of the initiative to the policy makers and the local needs. In Brazil, needs were expressed predominantly in the clinical practice. CONCLUSIONS: This multi-country experience shows that, although the policy and political environment plays its role in shaping initiatives, often the local priority needs are the driving force behind wider change.

Uses of Social Determinants of Health Data to Address Cardiovascular Disease and Health Equity: A Scoping Review.

Background Cardiovascular disease is the leading cause of morbidity and mortality worldwide. Prior research suggests that social determinants of health have a compounding effect on health and are associated with cardiovascular disease. This scoping review explores what and how social determinants of health data are being used to address cardiovascular disease and improve health equity. Methods and Results After removing duplicate citations, the initial search yielded 4110 articles for screening, and 50 studies were identified for data extraction. Most studies relied on similar data sources for social determinants of health, including geocoded electronic health record data, national survey responses, and census data, and largely focused on health care access and quality, and the neighborhood and built environment. Most focused on developing interventions to improve health care access and quality or characterizing neighborhood risk and individual risk. Conclusions Given that few interventions addressed economic stability, education access and quality, or community context and social risk, the potential for harnessing social determinants of health data to reduce the burden of cardiovascular disease remains unrealized.

Rural-urban disparities in health outcomes, clinical care, health behaviors, and social determinants of health and an action-oriented, dynamic tool for visualizing them.

While rural-urban disparities in health and health outcomes have been demonstrated, because of their impact on (and intervenability to improve) health and health outcomes, we sought to examine cross-sectional and longitudinal inequities in health, clinical care, health behaviors, and social determinants of health (SDOH) between rural and non-rural counties in the pre-pandemic era (2015 to 2019), and to present a Health Equity Dashboard that can be used by policymakers and researchers to facilitate examining such disparities. Therefore, using data obtained from 2015-2022 County Health Rankings datasets, we used analysis of variance to examine differences in 33 county level attributes between rural and non-rural counties, calculated the change in values for each measure between 2015 and 2019, determined whether rural-urban disparities had widened, and used those data to create a Health Equity Dashboard that displays county-level individual measures or compilations of them. We followed STROBE guidelines in writing the manuscript. We found that rural counties overwhelmingly had worse measures of SDOH at the county level. With few exceptions, the measures we examined were getting worse between 2015 and 2019 in all counties, relatively more so in rural counties, resulting in the widening of rural-urban disparities in these measures. When rural-urban gaps narrowed, it tended to be in measures wherein rural counties were outperforming urban ones in the earlier period. In conclusion, our findings highlight the need for policymakers to prioritize rural settings for interventions designed to improve health outcomes, likely through improving health behaviors, clinical care, social and environmental factors, and physical environment attributes. Visualization tools can help guide policymakers and researchers with grounded information, communicate necessary data to engage relevant stakeholders, and track SDOH changes and health outcomes over time.

An observational, sequential analysis of the relationship between local economic distress and inequities in health outcomes, clinical care, health behaviors, and social determinants of health.

BACKGROUND: Socioeconomic status has long been associated with population health and health outcomes. While ameliorating social determinants of health may improve health, identifying and targeting areas where feasible interventions are most needed would help improve health equity. We sought to identify inequities in health and social determinants of health (SDOH) associated with local economic distress at the county-level. METHODS: For 3,131 counties in the 50 US states and Washington, DC (wherein approximately 325,711,203 people lived in 2019), we conducted a retrospective analysis of county-level data collected from County Health Rankings in two periods (centering around 2015 and 2019). We used ANOVA to compare thirty-three measures across five health and SDOH domains (Health Outcomes, Clinical Care, Health Behaviors, Physical Environment, and Social and Economic Factors) that were available in both periods, changes in measures between periods, and ratios of measures for the least to most prosperous counties across county-level prosperity quintiles, based on the Economic Innovation Group's 2015-2019 Distressed Community Index Scores. RESULTS: With seven exceptions, in both periods, we found a worsening of values with each progression from more to less prosperous counties, with least prosperous counties having the worst values (ANOVA p < 0.001 for all measures). Between 2015 and 2019, all except six measures progressively worsened when comparing higher to lower prosperity quintiles, and gaps between the least and most prosperous counties generally widened. CONCLUSIONS: In the late 2010s, the least prosperous US counties overwhelmingly had worse values in measures of Health Outcomes, Clinical Care, Health Behaviors, the Physical Environment, and Social and Economic Factors than more prosperous counties. Between 2015 and 2019, for most measures, inequities between the least and most prosperous counties widened. Our findings suggest that local economic prosperity may serve as a proxy for health and SDOH status of the community. Policymakers and leaders in public and private sectors might use long-term, targeted economic stimuli in low prosperity counties to generate local, community health benefits for vulnerable populations. Doing so could sustainably improve health; not doing so will continue to generate poor health outcomes and ever-widening economic disparities.

Population health impact and economic evaluation of the CARDIO4Cities approach to improve urban hypertension management.

Cardiovascular disease (CVD) is the leading cause of mortality worldwide, with 80% of that mortality occurring in low- and middle-income countries. Hypertension, its primary risk factor, can be effectively addressed through multisectoral, multi-intervention initiatives. However, evidence for the population-level impact on cardiovascular (CV) event rates and mortality, and the cost-effectiveness of such initiatives is scarce as long-term longitudinal data is often lacking. Here, we model the long-term population health impact and cost-effectiveness of a multisectoral urban population health initiative designed to reduce hypertension, conducted in Ulaanbaatar (Mongolia), Dakar (Senegal), and in the district of Itaquera in São Paulo (Brazil) in collaboration with the local governments. We based our analysis on cohort-level data among hypertensive patients on treatment and control rates from a real-world effectiveness study of the CARDIO4Cities approach (built on quality of care, early access, policy reform, data and digital, Intersectoral collaboration, and local ownership). We built a decision tree model to estimate the CV event rates during implementation (1-2 years) and a Markov model to project health outcomes over 10 years. We estimated the number of CV events averted and quality-adjusted life-years gained (QALYs through the initiative and assessed its cost-effectiveness based on the costs reported by the funder using the incremental cost effectiveness ratio (ICER) and published thresholds. A one-way sensitivity analysis was performed to assess the robustness of the results. The modelled patient cohorts included 10,075 patients treated for hypertension in Ulaanbaatar, 5,236 in Dakar, and 5,844 in São Paulo. We estimated that 3.3-12.8% of strokes and 3.0-12.0% of coronary heart disease (CHD) events were averted during 1-2 years of implementation in the three cities. We estimated that over the subsequent 10 years, 3.6-9.9% of strokes, 2.8-7.8% of CHD events, and 2.7-7.9% of premature deaths would be averted. The estimated ICER was USD 748 QALY gained in Ulaanbaatar, USD 3091 in Dakar, and USD 784 in São Paulo. With that, the intervention was estimated to be cost-effective in Ulaanbaatar and São Paulo. For Dakar, cost-effectiveness was met under WHO-CHOICE standards, but not under more conservative standards adjusted for purchasing power parity (PPP) and opportunity costs. The findings were robust to the sensitivity analysis. Our results provide evidence that the favorable impact of multisector systemic interventions designed to reduce the hypertension burden extend to long-term population-level CV health outcomes and are likely cost-effective. The CARDIO4Cities approach is predicted to be a cost-effective solution to alleviate the growing CVD burden in cities across the world.

Relationship between Body Mass Index and Physical Activity among Children from Low-Income Communities in Gqeberha, South Africa: A Cross-Sectional Study.

This study aimed to establish the prevalence of underweight, overweight and obesity, the level of moderate-to-vigorous physical activity (MVPA) and the association thereof among vulnerable children from low-income communities in South Africa. Cross-sectional data were collected from 916 children (467 boys and 449 girls) aged 8-13 years (x̄ = 10.4 ± 1.2 years) attending eight low-income schools in Gqeberha, South Africa. Measured outcomes included accelerometery-measured physical activity (PA), weight, height and body mass index (BMI). Analysis of variance was used to determine the mean difference of total MVPA stratified by sex and BMI classification. Overall, 13% of the cohort were underweight, 19% were overweight/obese and 64% engaged in 60 min of MVPA per day. Girls presented nearly twice the odds of being overweight or obese than boys (95% CI: 1.40-2.77). Underweight to normal-weight children (boys: OR = 3.89, 95% CI: 2.18-6.93; girls: OR = 1.78, 95% CI: 1.13-2.80) were more likely to engage in 60 min/day of MVPA than overweight to obese children. There is an inverse association between BMI categories and theduration of MVPA achieved per day. Special attention should be aimed at increasing awareness of healthy nutrition and promoting a variety of PA, especially among girls and children with excess weight.

Implementing a multisector public-private partnership to improve urban hypertension management in low-and middle- income countries.

BACKGROUND: Cardiovascular disease presents an increasing health burden to low- and middle-income countries. Although ample therapeutic options and care improvement frameworks exist to address its prime risk factor, hypertension, blood pressure control rates remain poor. We describe the results of an effectiveness study of a multisector urban population health initiative that targets hypertension in a real-world implementation setting in cities across three continents. The initiative followed the "CARDIO4Cities" approach (quality of Care, early Access, policy Reform, Data and digital technology, Intersectoral collaboration, and local Ownership). METHOD: The approach was applied in Ulaanbaatar in Mongolia, Dakar in Senegal, and São Paulo in Brazil. In each city, a portfolio of evidence-based practices was implemented, tailored to local priorities and available data. Outcomes were measured by extracting hypertension diagnosis, treatment and control rates from primary health records. Data from 18,997 patients with hypertension in primary health facilities were analyzed. RESULTS: Over one to two years of implementation, blood pressure control rates among enrolled patients receiving medication tripled in São Paulo (from 12·3% to 31·2%) and Dakar (from 6·7% to 19·4%) and increased six-fold in Ulaanbaatar (from 3·1% to 19·7%). CONCLUSIONS: This study provides first evidence that a multisectoral population health approach to implement known best-practices, supported by data and digital technologies, and relying on local buy-in and ownership, can improve hypertension control in high-burden urban primary care settings in low-and middle-income countries.

Improving hypertension awareness and management in Vietnam through a community-based model.

Hypertension prevalence in Vietnam is high, but few people are aware of their disease status. Detection, diagnosis, and treatment are limited, so new approaches are needed to improve awareness and manage the condition, especially at the primary health care level. The Communities for Healthy Hearts programme operated in four districts of Ho Chi Minh City, with the aim of increasing awareness and ensuring linkage to care. Interventions focused on extending services beyond health facilities to convenient community locations; training cadres of community volunteers to screen, refer, and follow up with clients; training health workers in facilities to diagnose, educate, and manage patients referred from the community; and supporting the process with digital case tracking. Community-based blood pressure screenings took place in client homes, commune health stations, and non-traditional sites such as coffee shops, dentists' offices, marketplaces, neighbourhood watch/security posts, and tailor shops. In total, 121,273 adults aged 40 and older were screened. Of these, 25.1% had elevated blood pressure or a previous hypertension diagnosis and were referred to health facilities. Of those referred, 56.2% were confirmed to have hypertension, and of those confirmed, 75.2% were treated. Of those treated, 51.0% achieved blood pressure control, a favourable outcome over past programmes.

Clustered cardiovascular disease risk among children aged 8-13 years from lower socioeconomic schools in Gqeberha, South Africa.

Objectives: To determine the prevalence of individual cardiovascular disease (CVD) risk factors and clustered CVD risk among children attending schools in periurban areas of Gqeberha and to investigate the independent association between clustered CVD risk, moderate to vigorous physical activity (MVPA) and cardiorespiratory fitness (CRF). Methods: Baseline data were collected in a cross-sectional analysis of 975 children aged 8-13 years. We measured the height, weight, waist circumference, blood pressure, fasting glucose, full lipid panel, 20 m shuttle run performance and accelerometry. The prevalence of individual risk factors was determined, and a clustered risk score (CRS) was constructed using principal component analysis. Children with an elevated CRS of 1 SD above the average CRS were considered 'at-risk'. Results: We found 424 children (43.3%) having at least one elevated CVD risk factor: 27.7% elevated triglycerides, 20.7% depressed high-density lipoprotein cholesterol and 15.9% elevated total cholesterol. An elevated clustered risk was identified in 17% (n=104) of the sample; girls exhibited a significantly higher CRS >1 SD than boys (p=0.036). The estimated odds of an elevated clustered risk are doubled every 2 mL/kg/min decrease in VO2max (95% CI 1.66 to 3.12) or every 49 min reduction in MVPA (95% CI 27 to 224). Conclusion: A relatively high prevalence of elevated individual and clustered CVD risk was identified. Our results have also confirmed the independent inverse association of the clustered CVD risk with physical activity and CRF. These indicate that increased levels of CRF or MVPA may aid in the prevention and reduction of elevated clustered CVD risk.

Practice Change Needed for the Identification of Pediatric Hypertension in Marginalized Populations: An Example From South Africa.

Introduction: Hypertension in children has increased globally over the past 20 years; yet, little is known about this issue among disadvantaged communities from low- and middle-income countries. Age-, sex-, and height-adjusted normative tables are the "gold" standard for the diagnosis and estimation of pediatric hypertension worldwide, but it is unclear whether the use of international standards is appropriate for all contexts. The purpose of this study was to evaluate and compare different international references to identify hypertension among South African school-aged children from disadvantaged communities. Methods: Blood pressure, weight, and height were measured in a cohort of 897 children aged 8-16 years from eight peri-urban schools in the Eastern Cape of South Africa. Cross-sectional prevalence of hypertension was calculated according to American, German, and global normative tables, as well as pseudo-normative data from the own study population. Isolated systolic hypertension and body mass index (BMI) were considered markers for cardiovascular disease. Multinomial logistic regression was used to compare the likelihood of blood pressure categorization with increasing BMI levels. Results: Hypertension prevalence ranged from 11.4% with the pseudo-normative study tables to 28.8% based on the German reference. Global guidelines showed the highest agreement both among international standards (92.5% with American guidelines) and with the study reference (72.5%). While the global and the American references presented higher systolic over diastolic hypertension rates (23.6 vs. 10.6% and 24.2 vs. 14.7%, respectively), the American guidelines predicted the highest increased risk for hypertension stage 2 [odds ratio, 1.72 (95% confidence interval: 1.43-2.07)] with raising levels of BMI. Conclusion: Our results support the heterogeneity of blood pressure estimates found in the South African literature, and highlight the underrepresentation of African children in international guidelines. We call for caution in the use of international standards in different contexts and advocate for the development of normative tables that are representative of the South African pediatric population necessary to ensure an accurate identification of hypertension both from the clinical and epidemiological perspective.

Reimagining leprosy elimination with AI analysis of a combination of skin lesion images with demographic and clinical data.

Background: Leprosy is an infectious disease that mostly affects underserved populations. Although it has been largely eliminated, still about 200'000 new patients are diagnosed annually. In the absence of a diagnostic test, clinical diagnosis is often delayed, potentially leading to irreversible neurological damage and its resulting stigma, as well as continued transmission. Accelerating diagnosis could significantly contribute to advancing global leprosy elimination. Digital and Artificial Intelligence (AI) driven technology has shown potential to augment health workers abilities in making faster and more accurate diagnosis, especially when using images such as in the fields of dermatology or ophthalmology. That made us start the quest for an AI-driven diagnosis assistant for leprosy, based on skin images. Methods: Here we describe the accuracy of an AI-enabled image-based diagnosis assistant for leprosy, called AI4Leprosy, based on a combination of skin images and clinical data, collected following a standardized process. In a Brazilian leprosy national referral center, 222 patients with leprosy or other dermatological conditions were included, and the 1229 collected skin images and 585 sets of metadata are stored in an open-source dataset for other researchers to exploit. Findings: We used this dataset to test whether a CNN-based AI algorithm could contribute to leprosy diagnosis and employed three AI models, testing images and metadata both independently and in combination. AI modeling indicated that the most important clinical signs are thermal sensitivity loss, nodules and papules, feet paresthesia, number of lesions and gender, but also scaling surface and pruritus that were negatively associated with leprosy. Using elastic-net logistic regression provided a high classification accuracy (90%) and an area under curve (AUC) of 96.46% for leprosy diagnosis. Interpretation: Future validation of these models is underway, gathering larger datasets from populations of different skin types and collecting images with smartphone cameras to mimic real world settings. We hope that the results of our research will lead to clinical solutions that help accelerate global leprosy elimination. Funding: This study was partially funded by Novartis Foundation and Microsoft (in-kind contribution).

Preventing leprosy with retrospective active case finding combined with single-dose rifampicin for contacts in a low endemic setting: results of the Leprosy Post-Exposure Prophylaxis program in Cambodia.

Post-exposure prophylaxis (PEP) with single-dose rifampicin (SDR) reduces the risk of developing leprosy among contacts of leprosy patients. Most evidence for the feasibility of the intervention is from highly endemic settings while low-endemic areas present unique challenges including reduced awareness of the disease among the population and in the health system, and the only sporadic occurrence of cases which together make defining any type of routine process challenging. We complemented the retrospective active case finding (RACF) approach with SDR administration to eligible contacts, and piloted the intervention across 31 operational districts in Cambodia. The aim was to demonstrate the feasibility of improving early case detection and administering SDR in a low endemic setting. The intervention focused on leprosy patients diagnosed since 2011 and was implemented between October 2016 - September 2019. The "drives" approach was employed to trace contacts: a trained team systematically contacted all eligible cases in a district, traced and screened contacts, and administered SDR. A total of 555 index patients were traced by the drive team, and 10,410 contacts in their household and 5 immediate neighbor houses listed. Among these contacts, 72.0% could be screened while most others were absent on the screening day. A total of 33 new leprosy cases were diagnosed and 6189 contacts received SDR (82.6% of the screened contacts). Sixty-one contacts refused SDR administration. We conclude that integrating PEP with SDR in RACF campaigns is feasible, and that this approach is appropriate in low resource and low endemic settings. Over time, evidence on whether or not the approach reduced leprosy transmission in Cambodia, may become clear.

Hypertension among South African children in disadvantaged areas and associations with physical activity, fitness, and cardiovascular risk markers: A cross-sectional study.

Childhood hypertension drives hypertension in later life; hence, assessing blood pressure in children is an important measure to determine current and future cardiovascular health. There is, however, a paucity of childhood blood pressure data, particularly for sub-Saharan Africa. This study explores blood pressure and associations with age, sex, socioeconomic status, physical activity, fitness, and cardiovascular risk markers. In the 'Disease, Activity and Schoolchildren's Health' (DASH) study, a cross-sectional analysis was conducted in disadvantaged neighbourhoods in the Eastern Cape province of South Africa. Assessments included blood pressure, accelerometer-measured physical activity, physical fitness, and cardiovascular risk markers. The study consisted of 785 children (383 boys, 402 girls, M = 12.4±0.9 years). Overall, 18% of the children were classified as hypertensive, while 20% were either overweight/obese, and almost four out of ten children did not meet global daily physical activity recommendations. Hypertensive children were more likely to be overweight/obese, χ2 (2,785) = 14.42, p < 0.01, but only if they did not meet physical activity recommendations, χ2 (2,295) = 11.93, p < 0.01. Considering the moderating effect which sufficient activity has on the relationship between hypertension and body weight, more emphasis should be placed on early primary health intervention and education strategies.

Fostering cardiovascular health at work - case study from Senegal.

BACKGROUND: Of the 15 million annual premature deaths from non-communicable diseases (NCDs), 85% occur in low- and middle-income countries (LMICs). Affecting individuals in the prime of their lives, NCDs impose severe economic damage to economies and businesses, owing to the high mortality and morbidity within the workforce. The Novartis Foundation urban health initiative, Better Hearts Better Cities, was designed to improve cardiovascular health in Dakar, Senegal through a combination of interventions including a workplace health program. In this study, we describe the labor policy environment in Senegal and the outcomes of a Novartis Foundation-supported multisector workplace health coalition bringing together volunteering private companies. METHODS: A mixed method design was applied between April 2018 and February 2020 to evaluate the workplace health program as a case study. Qualitative methods included a desk review of documents relevant to the Senegalese employment context and work environment and in-depth interviews with eight key informants including human resource representatives and physicians working in the participating companies. Quantitative methods involved an analysis of workplace health program indicators, including data on diagnosis, treatment and control of hypertension in employees, provided by the coalition companies, and a cost estimate of NCD-related ill-health as compared to the investment needed for hypertension screening and awareness raising events. RESULTS: Senegal has a legal and regulatory system that ensures employee protection, supports social security benefits, and promotes health and hygiene in companies. The Dakar Workplace Health Coalition comprised 18 companies, with a range of staff between 300 and 4'220, covering 36'268 employees in total. Interviews suggested that the main enablers for workplace program success were strong leadership support within the company and a central coordination mechanism for the program. The main barrier to monitor progress and outcomes was the reluctance of companies to share data. Four companies provided aggregated anonymized cohort data, documenting a total of 21'392 hypertension screenings and an increasing trend in blood pressure control (from 34% in Q4 2018 to 39% in Q2 2019) in employees who received antihypertensive treatment. CONCLUSION: Evidence on workplace health and wellness programs in Africa is scarce. This study highlights how private sector companies can play a significant role in improving cardiovascular population health in LMICs.

Leveraging data and AI to deliver on the promise of digital health.

Rising rates of NCDs threaten fragile healthcare systems in low- and middle-income countries. Fortunately, new digital technology provides tools to more effectively address the growing dual burden of disease. Two-thirds of the world's population subscribed to mobile services by the end of 2018, while the falling price of connectivity and the 5G networks rollout promise to accelerate the use of digital technology. Properly leveraged, we can employ digital solutions and applications to transform health systems from reactive to proactive and even preventive, helping people stay healthy. With artificial intelligence (AI), health systems can be made more predictive by detecting risk factors and helping health professionals respond faster to prevent disease. Yet this rapid pace of growth has also complicated the digital health landscape. Myriad digital health apps compete and overlap in the public and private sectors, and significant gaps in the collection and analysis of digital data threaten to leave some behind. Established in 2010, the Broadband Commission for Sustainable Development is led by ITU and UNESCO and advocates for the transformational impact of broadband technologies for development. Its working group on digital and AI in health, co-chaired by the Novartis Foundation and at different times Nokia, Intel and Microsoft, identifies best practices for countries to realize the potential of digital technology in health and care. Interviewing more than 100 key stakeholders and reviewing over 200 documents, the Working Group set out to identify common challenges that countries face in implementing digital health solutions, and to develop a framework that countries can use to build systems for supporting digital health solutions. Common challenges include a lack of coordination leading to fragmented digital health solutions; lack of systems and workforce capacity to manage data and digital technology, and inadequate financing to support digital health. The working group proposes six building blocks for digital health systems: formulate and execute a national digital health strategy; create policy and regulatory frameworks that support innovation while protecting security and privacy; ensure access to digital infrastructure; ensure interoperability of digital health system components; establish effective partnerships; and sustain adequate financing.

The long-term impact of the Leprosy Post-Exposure Prophylaxis (LPEP) program on leprosy incidence: A modelling study.

BACKGROUND: The Leprosy Post-Exposure Prophylaxis (LPEP) program explored the feasibility and impact of contact tracing and the provision of single dose rifampicin (SDR) to eligible contacts of newly diagnosed leprosy patients in Brazil, India, Indonesia, Myanmar, Nepal, Sri Lanka and Tanzania. As the impact of the programme is difficult to establish in the short term, we apply mathematical modelling to predict its long-term impact on the leprosy incidence. METHODOLOGY: The individual-based model SIMCOLEP was calibrated and validated to the historic leprosy incidence data in the study areas. For each area, we assessed two scenarios: 1) continuation of existing routine activities as in 2014; and 2) routine activities combined with LPEP starting in 2015. The number of contacts per index patient screened varied from 1 to 36 between areas. Projections were made until 2040. PRINCIPAL FINDINGS: In all areas, the LPEP program increased the number of detected cases in the first year(s) of the programme as compared to the routine programme, followed by a faster reduction afterwards with increasing benefit over time. LPEP could accelerate the reduction of the leprosy incidence by up to six years as compared to the routine programme. The impact of LPEP varied by area due to differences in the number of contacts per index patient included and differences in leprosy epidemiology and routine control programme. CONCLUSIONS: The LPEP program contributes significantly to the reduction of the leprosy incidence and could potentially accelerate the interruption of transmission. It would be advisable to include contact tracing/screening and SDR in routine leprosy programmes.

Leprosy post-exposure prophylaxis with single-dose rifampicin (LPEP): an international feasibility programme.

BACKGROUND: Innovative approaches are required for leprosy control to reduce cases and curb transmission of Mycobacterium leprae. Early case detection, contact screening, and chemoprophylaxis are the most promising tools. We aimed to generate evidence on the feasibility of integrating contact tracing and administration of single-dose rifampicin (SDR) into routine leprosy control activities. METHODS: The leprosy post-exposure prophylaxis (LPEP) programme was an international, multicentre feasibility study implemented within the leprosy control programmes of Brazil, India, Indonesia, Myanmar, Nepal, Sri Lanka, and Tanzania. LPEP explored the feasibility of combining three key interventions: systematically tracing contacts of individuals newly diagnosed with leprosy; screening the traced contacts for leprosy; and administering SDR to eligible contacts. Outcomes were assessed in terms of number of contacts traced, screened, and SDR administration rates. FINDINGS: Between Jan 1, 2015, and Aug 1, 2019, LPEP enrolled 9170 index patients and listed 179 769 contacts, of whom 174 782 (97·2%) were successfully traced and screened. Of those screened, 22 854 (13·1%) were excluded from SDR mainly because of health reasons and age. Among those excluded, 810 were confirmed as new patients (46 per 10 000 contacts screened). Among the eligible screened contacts, 1182 (0·7%) refused prophylactic treatment with SDR. Overall, SDR was administered to 151 928 (86·9%) screened contacts. No serious adverse events were reported. INTERPRETATION: Post-exposure prophylaxis with SDR is safe; can be integrated into different leprosy control programmes with minimal additional efforts once contact tracing has been established; and is generally well accepted by index patients, their contacts, and health-care workers. The programme has also invigorated local leprosy control through the availability of a prophylactic intervention; therefore, we recommend rolling out SDR in all settings where contact tracing and screening have been established. FUNDING: Novartis Foundation.

The long-term impact of the leprosy post-exposure prophylaxis (LPEP) program on leprosy incidence: a modelling study

The Leprosy Post-Exposure Prophylaxis (LPEP) program explored the feasibility and impact of contact tracing and the provision of SDR to eligible contacts of newly diagnosed leprosy patients in states or districts of Brazil, India, Indonesia, Myanmar, Nepal, Sri Lanka and Tanzania. This study investigated the long-term impact of the LPEP program on the leprosy new case detection rate (NCDR). Our results show that LPEP could reduce the NCDR beyond the impact of the routine leprosy control programme and that many new cases could be prevented. The benefit of LPEP increases gradually over time. LPEP could accelerate the time of reaching predicted NCDR levels of 2040 under routine program by up to six years. Furthermore, we highlighted how the impact varies between countries due to differences in the number of contacts per index patient screened and differences in leprosy epidemiology and national control programme. Generally, including both household contacts and neighbours (> 20 contacts per index patient) would yield the highest impact.

Leprosy post-exposure prophylaxis with single-dose rifampicin (LPEP): an international feasibility programme

Background: Innovative approaches are required for leprosy control to reduce cases and curb transmission of Mycobacterium leprae. Early case detection, contact screening, and chemoprophylaxis are the most promising tools. We aimed to generate evidence on the feasibility of integrating contact tracing and administration of single-dose rifampicin (SDR) into routine leprosy control activities. Methods The leprosy post-exposure prophylaxis (LPEP) programme was an international, multicentre feasibility study implemented within the leprosy control programmes of Brazil, India, Indonesia, Myanmar, Nepal, Sri Lanka, and Tanzania. LPEP explored the feasibility of combining three key interventions: systematically tracing contacts of individuals newly diagnosed with leprosy; screening the traced contacts for leprosy; and administering SDR to eligible contacts. Outcomes were assessed in terms of number of contacts traced, screened, and SDR administration rates. Findings Between Jan 1, 2015, and Aug 1, 2019, LPEP enrolled 9170 index patients and listed 179 769 contacts, of whom 174782 (97·2%) were successfully traced and screened. Of those screened, 22 854 (13·1%) were excluded from SDR mainly because of health reasons and age. Among those excluded, 810 were confirmed as new patients (46 per 10 000 contacts screened). Among the eligible screened contacts, 1182 (0·7%) refused prophylactic treatment with SDR. Overall, SDR was administered to 151 928 (86·9%) screened contacts. No serious adverse events were reported. Interpretation Post-exposure prophylaxis with SDR is safe; can be integrated into different leprosy control programmes with minimal additional efforts once contact tracing has been established; and is generally well accepted by index patients, their contacts, and health-care workers. The programme has also invigorated local leprosy control through the availability of a prophylactic intervention; therefore, we recommend rolling out SDR in all settings where contact tracing and screening have been established(AU).

Association between physical activity, cardiorespiratory fitness and clustered cardiovascular risk in South African children from disadvantaged communities: results from a cross-sectional study.

BACKGROUND/AIM: Physical inactivity (PIA) is a growing global health problem and evidence suggests that PIA is a key driver for cardiovascular and chronic diseases. Recent data from South Africa revealed that only about half of the children achieved recommended daily physical activity (PA) levels. Assessing the intensity of PA in children from low socioeconomic communities in low-income and middle-income countries is important to estimate the extent of cardiovascular risk and overall impact on health. METHODS: We conducted a cross-sectional survey in eight quintile 3 primary schools in disadvantaged communities in the Port Elizabeth region, South Africa. Children aged 10-15 years were subjected to PA, blood pressure, cholesterol, blood glucose and skinfold thickness assessments. Cardiovascular risk markers were converted into standardised z-scores and summed, to obtain a clustered cardiovascular risk score. RESULTS: Overall, 650 children had complete data records. 40.8% of the children did not meet recommended PA levels (ie, logged <60 min of moderate-to-vigorous physical activity (MVPA) per day). If quartiles were developed based on children's cardiorespiratory fitness (CRF) and MVPA levels, a significant difference was found in clustered cardiovascular risk among children in the highest versus lowest fitness (p<0.001) or MVPA (p<0.001) quartiles. CONCLUSIONS: CRF and objectively assessed PA are closely linked with children's clustered cardiovascular risk. Given that 4 out of 10 South African schoolchildren from marginalised communities do not meet international PA recommendations, efforts should be made to ensure that promoting a physically active lifestyle is recognised as an important educational goal in primary schools. TRIAL REGISTRATION NUMBERS: ISRCTN68411960 and H14-HEA-HMS-002.