Over 25 Years of Hope: Development of Lymphatic Filariasis Patient Support Groups in Haiti.

Support groups can create environments that are conducive to healing and well-being, particularly for persons with stigmatizing chronic diseases. In 1998, the support group concept was adapted in Haiti for persons with disabling lymphedema caused by lymphatic filariasis (LF). The project was developed with the expectation that the support group model conceived in the developed world be interpreted and modified by persons affected with lymphedema in the Haitian setting. Initiated with modest financial support within a research initiative to eliminate LF, a total of 50 "Hope Clubs" were formed from 1998 to 2023 across seven communes (districts) located in 3 of Haiti's 10 regional Departments. Documented benefits of the support groups included improved limb self-care, decreased incidence of inflammatory episodes (adenolymphangitis), enhanced self-efficacy, economic benefit through microenterprise, and improved quality of life. Despite challenges of funding shortfalls, natural disasters, and political insecurity, persistence of LF support groups in Haiti highlights the crucial role of group ownership by affected persons and the freedom to reinvent the support group concept in light of local social, cultural, and economic conditions.

A Mixed-Methods Evaluation of Mainstreaming Mass Drug Administration for Schistosomiasis and Soil-Transmitted Helminthiasis in Four Districts of Nigeria.

In Nigeria, mass drug administration (MDA) for schistosomiasis (SCH) and soil-transmitted helminthiasis (STH) has often been coordinated with other programs that receive greater external funding. As these programs reach stop MDA milestones, SCH and STH programs will likely need to transition implementation, or "mainstream," to domestic support. A mixed-methods study was conducted in four districts before (2021) and after (2022) mainstreaming to evaluate its impact on MDA coverage. Household surveys were done in 30 villages per district pre- and post-mainstreaming. All selected communities were eligible for STH treatment; around a third were eligible for SCH treatment. Mass drug administration was primarily conducted in schools. A total of 5,441 school-aged children were included in pre-mainstreaming and 5,789 were included in post-mainstreaming. Mass drug administration coverage was heterogeneous, but overall, mebendazole coverage declined nonsignificantly from 81% pre-mainstreaming to 76% post-mainstreaming (P = 0.09); praziquantel coverage declined significantly from 73% to 55% (P = 0.008). Coverage was significantly lower among unenrolled children or those reporting poor school attendance in nearly every survey. For the qualitative component, 173 interviews and 74 focus groups were conducted with diverse stakeholders. Respondents were deeply pessimistic about the future of MDA after mainstreaming and strongly supported a gradual transition to full government ownership. Participants formulated recommendations for effective mainstreaming: clear budget allocation by governments, robust and targeted training, trust building, and comprehensive advocacy. Although participants lacked confidence that SCH and STH programs could be sustained after reductions in external support, initial results indicate that MDA coverage can remain high 1 year into mainstreaming.

A pilot study to address the mental health of persons living with lymphatic filariasis in Léogâne, Haiti: Implementing a chronic disease self-management program using a stepped-wedge cluster design.

BACKGROUND: Neglected tropical diseases (NTDs) inflict significant comorbid disability on the most vulnerable communities; yet interventions targeting the mental health of affected communities are lacking. A pilot study to assess the effectiveness of a chronic disease self-management program (CDSMP) was introduced to lymphatic filariasis peer support groups in Léogâne, Haiti. METHODS: Using a closed-cohort stepped-wedge cluster trial design, Hope Clubs were assigned into Arm 1 (n=118 members) and Arm 2 (n=92). Household surveys, measuring self-rated health, depression, disease self-efficacy, perceived social support, and quality of life, were conducted at baseline (before CDSMP); midpoint (after Arm 1/before Arm 2 completed CDSMP); and endpoint (after CDSMP). Non-Hope Club member patients (n=74) were evaluated at baseline for comparison. RESULTS: Fifty percent of Hope Club members (Arm 1: 48.3%, Arm 2: 52.2%) screened positive for depression at baseline, compared with 36.5% of non-Hope Club members. No statistically significant differences were found in outcome measures between intervention observation periods. At endpoint, depressive illness reduced to 28.7% (Arm 1) and 27.6% (Arm 2). CONCLUSIONS: The intervention was feasible to integrate into Hope Clubs, showed overall positive effects and reduced depressive symptoms. More studies are needed to evaluate the efficacy of implementing CDSMP in the NTD context. CONTEXTE: Les maladies tropicales négligées (MTN) infligent d'importantes incapacités comorbides aux communautés les plus vulnérables; pourtant, les interventions ciblant la santé mentale des communautés affectées font défaut. Une étude pilote visant à évaluer l'efficacité d'un programme d'autogestion des maladies chroniques (CDSMP) a été introduite dans des groupes de soutien par les pairs pour la filariose lymphatique à Léogâne, en Haïti. MÉTHODES: Dans le cadre d'un essai en grappe à cohorte fermée, les clubs Hope ont été répartis entre le bras 1 (n=118 membres) et le bras 2 (n=92). Des enquêtes auprès des ménages, mesurant l'auto-évaluation de la santé, la dépression, l'auto-efficacité face à la maladie, le soutien social perçu et la qualité de vie, ont été menées au départ (avant le CDSMP), à mi-parcours (après que le bras 1 / avant que le bras 2 ait terminé le CDSMP) et à la fin (après le CDSMP). Les patients non membres du Hope Club (n=74) ont été évalués au début de l'étude à des fins de comparaison. RÉSULTATS: Cinquante pourcent des membres du Hope Club (bras 1 : 48,3%, bras 2 : 52,2%) ont été dépistés positifs pour la dépression au début de l'étude, contre 36,5% des non-membres du Hope Club. Aucune différence statistiquement significative n'a été constatée dans les mesures des résultats entre les périodes d'observation de l'intervention. À la fin de l'étude, la maladie dépressive était réduite à 28,7% (bras 1) et 27,6% (bras 2). CONCLUSIONS: L'intervention a pu être intégrée dans les clubs Hope, elle a montré des effets globalement positifs et a permis de réduire les symptômes dépressifs. D'autres études sont nécessaires pour évaluer l'efficacité de la mise en œuvre du CDSMP dans le contexte des MTD. ANTECEDENTES: Las enfermedades tropicales desatendidas (ETDs) infligen una importante discapacidad comórbida a las comunidades más vulnerables; sin embargo, faltan intervenciones dirigidas a la salud mental de las comunidades afectadas. Se introdujo un estudio piloto para evaluar la eficacia de un programa de autogestión de enfermedades crónicas (CDSMP, por sus siglas en inglés) en grupos de apoyo entre pares de filariasis linfática en Léogâne, Haití. MÉTODOS: Utilizando un diseño de ensayo por conglomerados de cohortes cerradas escalonadas, los Clubes Esperanza fueron asignados al Grupo 1 (n=118 miembros) y al Grupo 2 (n=92). Se realizaron encuestas en los hogares para medir la autoevaluación de la salud, la depresión, la autoeficacia frente a la enfermedad, el apoyo social percibido y la calidad de vida en la línea de base (antes del CDSMP), en el punto medio (después de que el Grupo 1/antes de que el Grupo 2 completara el CDSMP) y en el punto final (después del CDSMP). Los pacientes que no pertenecían al Club Esperanza (n=74) fueron evaluados al inicio del estudio a modo de comparación. RESULTADOS: El 50% de los miembros del Club Esperanza (Grupo 1: 48,3%, Grupo 2: 52,2%) dieron positivo en depresión al inicio del estudio, en comparación con el 36,5% de los no miembros del Club Esperanza. No se encontraron diferencias estadísticamente significativas en las medidas de resultado entre los periodos de observación de la intervención. Al final, la enfermedad depresiva se redujo al 28,7% (Grupo 1) y al 27,6% (Grupo 2). CONCLUSIONES: La intervención fue factible de integrar en los Clubes Esperanza, mostróefectos positivos generales y redujo los síntomas depresivos. Se necesitan más estudios para evaluar la eficacia de la aplicación del CDSMP en el contexto de las ETD.

Integrated Prevalence Assessment of Wuchereria bancrofti and Onchocerca volvulus in Three Co-Endemic Districts of Gambella Region, Ethiopia.

Lymphatic filariasis (LF) and onchocerciasis (OV) are among the neglected tropical diseases (NTD) targeted for elimination in Ethiopia. We used a transmission assessment survey (TAS-1) to evaluate the serological status of OV in three co-endemic districts in Gambella simultaneously. During May and June 2019, blood samples were collected from 6- to 7-year-old children who were randomly selected through standard community-based TAS methodology. Children were tested for both circulating filarial antigen (CFA) for LF via filariasis test strip and for Onchocerca volvulus 16 (Ov16) antibody for OV via laboratory-based ELISA. A total of 3,377 children from 150 villages in the three districts were tested; 1,823 (54.0%) were male. All three districts had CFA results below the critical threshold for stopping LF mass drug administration (MDA). In contrast, 40 children (1.2%) were positive for Ov16 antibody, well above the WHO's OV stop MDA threshold of 0.1%. The integrated assessment indicated two programmatic decisions: stop MDA for LF and continue MDA for OV. Accordingly, albendazole MDA was discontinued in the districts but ivermectin MDA continued. This integrated assessment showed that a random sample for TAS can give important information about OV transmission status in co-endemic areas.

Was lockdown worth it? community perspectives and experiences of the Covid-19 pandemic in remote southwestern Haiti.

Public experiences of COVID-19 pandemic lockdown differed dramatically between countries and socio-economic groups. Low-income countries raise unique empirical and ethical concerns about (1) the balance between benefits and social harms and (2) how explanatory disease models and everyday life realities influenced the experience and interpretation of lockdown itself. In this paper, we present qualitative data on community perceptions and experiences of the pandemic from a remote area of Haiti, with a focus on the 2020 lockdown. We conducted in-depth interviews with 30 community leaders in Grand'Anse Department, southwest Haiti, at two time periods: May 2020 and October-December 2021. We divide our results into five sections. First, our analysis showed that lockdown was widely considered ineffective at controlling COVID-19. Despite the lack of testing, community leaders believed most of the local population had caught COVID-19 in the first half of 2020, with limited reported mortality. Public concern about the pandemic largely ended at this time, overtaken by other socio-economic and political crises. Second, we found that popular explanations for the low fatality rate were related to various coping strategies: the strength of people's immune systems, use of natural prophylactic folk teas, beliefs about the virus, spiritual protections and the tropical weather. Third, we found that lockdown was widely seen to have not been appropriate for the Haitian context due to various challenges with compliance in the face of socio-economic vulnerability. Fourth, we found strong negative feelings about the social consequences of lockdown measures, which lasted from March-August 2020, including adverse effects on: food security, household income, education, health, and psychosocial well-being. Finally, these perceptions and experiences reinforced popular ideas that lockdown had been imposed by elites for financial and/or political gain, something that was also reflected in the discourse about the low vaccine acceptance rate. Our study showed that pandemic respiratory virus response in Haiti should better balance restrictive non-pharmaceutical interventions (NPIs) with existing socio-economic vulnerability. Local socio-behavioral dynamics and risk perceptions decrease the overall effectiveness of NPIs in fragile states and alternatives to lockdown, such as shielding the most vulnerable, are likely to be a more appropriate strategy.

Acceptability, Feasibility, Drug Safety, and Effectiveness of a Pilot Mass Drug Administration with a Single Round of Sulfadoxine-Pyrimethamine Plus Primaquine and Indoor Residual Spraying in Communities with Malaria Transmission in Haiti, 2018.

For a malaria elimination strategy, Haiti's National Malaria Control Program piloted a mass drug administration (MDA) with indoor residual spraying (IRS) in 12 high-transmission areas across five communes after implementing community case management and strengthened surveillance. The MDA distributed sulfadoxine-pyrimethamine and single low-dose primaquine to eligible residents during house visits. The IRS campaign applied pirimiphos-methyl insecticide on walls of eligible houses. Pre- and post-campaign cross-sectional surveys were conducted to assess acceptability, feasibility, drug safety, and effectiveness of the combined interventions. Stated acceptability for MDA before the campaign was 99.2%; MDA coverage estimated at 10 weeks post-campaign was 89.6%. Similarly, stated acceptability of IRS at baseline was 99.9%; however, household IRS coverage was 48.9% because of the high number of ineligible houses. Effectiveness measured by Plasmodium falciparum prevalence at baseline and 10 weeks post-campaign were similar: 1.31% versus 1.43%, respectively. Prevalence of serological markers were similar at 10 weeks post-campaign compared with baseline, and increased at 6 months. No severe adverse events associated with the MDA were identified in the pilot; there were severe adverse events in a separate, subsequent campaign. Both MDA and IRS are acceptable and feasible interventions in Haiti. Although a significant impact of a single round of MDA/IRS on malaria transmission was not found using a standard pre- and post-intervention comparison, it is possible there was blunting of the peak transmission. Seasonal malaria transmission patterns, suboptimal IRS coverage, and low baseline parasitemia may have limited the effectiveness or the ability to measure effectiveness.

Evaluating a community engagement model for malaria elimination in Haiti: lessons from the community health council project (2019-2021).

BACKGROUND: Community engagement (CE) plays a critical role in malaria control and elimination. CE approaches vary substantially, with more participatory programmes requiring higher levels of adaptive management. This study evaluates the effectiveness of a volunteer-based CE programme developed in Haiti in 2018. The approach was based on local leaders organizing and implementing monthly anti-malaria activities in their communities, and was implemented as part of Malaria Zero Consortium activities. METHODS: This programme evaluation draws on quantitative and qualitative data collected from 23 Community Health Councils (CHCs) over a two-year period (2019-2021) in Grand'Anse department, a malaria hotspot region in Haiti. RESULTS: Monthly monitoring data showed that 100% of the 23 CHCs remained functional over the two-year period, with an average of 0.90 monthly meetings held with an 85% attendance rate. A high degree of transparency and diversity in membership helped create strong planning and involvement from members. CHCs conducted an average of 1.6 community-based activities per month, directly engaging an average of 123 people per month. High levels of fluctuation in monthly activities were indicative of local ownership and self-organization. This included school and church sensitization, environmental sanitation campaigns, mass education, support for case referrals and community mobilization during mass drug administration (MDA) and indoor residual spraying (IRS) campaigns. Members drew on the tradition of konbit (mutual self-help), local histories of health and development campaigns and a lexicon of "solidarity" in difficult times as they negotiated their agency as community volunteers. Small incentives played both symbolic and supportive roles. Some level of politicization was viewed as inevitable, even beneficial. Rumours about financial and political profiteering of CHC volunteers took time to dispel while the tendency towards vertical planning in malaria control created conditions that excluded CHCs from some activities. This generated resentment from members who felt sidelined by the government malaria programme. CONCLUSION: The CHC model was effective in promoting group solidarity and community-based anti-malaria activities over a two-year period in Haiti. With the end of the Malaria Zero Consortium in early 2021, there is now an opportunity to better integrate this programme into the primary healthcare system, evaluate the impact of the CHCs on malaria epidemiology, and promote the greater integration of CHCs with active surveillance and response activities.

Results from a Knowledge, Attitudes, and Practices Survey in Two Malaria Transmission Foci of Santo Domingo, Dominican Republic.

Metropolitan Santo Domingo has accounted for a majority of reported malaria cases in the Dominican Republic in recent years. To inform malaria control and elimination efforts, a cross-sectional survey of malaria knowledge, attitudes, and practices collected 489 adult household-level questionnaires across 20 neighborhoods in the city's two main transmission foci, Los Tres Brazos (n = 286) and La Ciénaga (n = 203), in December 2020. Overall, most residents (69%) were aware of the problem of malaria in Santo Domingo, but less than half knew that mosquitos transmit the disease (46%) or took any correct preventative measure (45%). More residents of Los Tres Brazos, where malaria incidence is higher than in La Ciénaga, said that they had never been visited by active surveillance teams (80% versus 66%, respectively; P = 0.001), did not link mosquitos with malaria transmission (59% versus 48%, P = 0.013), and did not know medication can cure malaria (42% versus 27%, P = 0.005). Fewer residents of Los Tres Brazos said that malaria was a problem in their neighborhoods (43% versus 49%, P = 0.021) and fewer had mosquito bed nets in their homes (42% versus 60%, P < 0.001). The majority (75%) of questionnaire respondents in both foci did not have enough mosquito nets for all household residents. These findings demonstrate gaps in malaria knowledge and community-based interventions and highlight the need to improve community engagement for malaria elimination in affected areas of Santo Domingo.

Two Nigerian States (Plateau and Nasarawa) Have Eliminated Transmission of Human Onchocerciasis-A Report of Post-Ivermectin Mass Drug Administration Surveillance.

Transmission of Onchocerca volvulus (causing "river blindness") was interrupted in two states of Nigeria (Plateau and Nasarawa) in 2017 in accordance with 2016 WHO guidelines. Ivermectin mass drug administration was halted in January 2018, and posttreatment surveillance activities were conducted over a 3-year period. Vector Simulium damnosum s.l. flies were collected during the 2019 (39 sites) and 2020 (42 sites) transmission seasons. Head pools were tested by polymerase chain reaction for the presence of third-stage O. volvulus larvae; 15,585 flies were all negative, demonstrating an infective rate of < 1/2,000 with 95% confidence. In 2021, the Nigerian Federal Ministry of Health declared the two-state area as having eliminated transmission. Plateau and Nasarawa states are the first of 30 endemic states in Nigeria to have met the WHO criteria for onchocerciasis elimination. Post-elimination surveillance will need to continue given the risk of reintroduction of transmission from neighboring states.

Lymphatic filariasis elimination in the Dominican Republic: History, progress, and remaining steps.

Lymphatic filariasis (LF) is a mosquito-transmitted parasitic disease that is a leading cause of disability globally. The island of Hispaniola, which the Dominican Republic shares with Haiti, accounts for approximately 90% of LF cases in the Americas region. In 1998, the Dominican Ministry of Public Health created the Program to Eliminate Lymphatic Filariasis (PELF) with the goal of eliminating LF transmission by 2020. Baseline mapping revealed 19 (12% of total) endemic municipalities clustered into three geographic foci (Southwest, La Ciénaga and East), with a total at-risk population of 262,395 people. Beginning in 2002, PELF sequentially implemented mass drug administration (MDA) in these foci using albendazole and diethylcarbamazine (DEC). In total, 1,174,050 treatments were given over three to five annual rounds of house-to-house MDA per focus with a median coverage of 81.7% (range 67.4%-92.2%). By 2018, LF antigen prevalence was less than 2% in all foci, thus meeting criteria to stop MDA and begin post-treatment surveillance (PTS). This success has been achieved against a shifting landscape of limited domestic funding, competing domestic public health priorities, and sporadic external donor support. Remaining steps include the need to scale-up morbidity management and disability prevention services for LF and to continue PTS until LF transmission is interrupted across Hispaniola.

Prevalence of Diabetes, Prediabetes, and Associated Risk Factors Among Agricultural Village Residents in the Dominican Republic.

This study examined the prevalence and risk factors of prediabetes and type 2 diabetes among residents of agricultural settlement villages (bateyes) in the Dominican Republic. From March to April 2016, a cross-sectional, multi-stage cluster survey was conducted across the country's three agricultural regions (southwest, east, and north). At selected households, an adult completed a questionnaire to assess demographics, diabetes knowledge, and care, and two household residents of any age provided finger-prick blood samples that were analyzed for hemoglobin A1c (HbA1c). HbA1c was categorized as normal (< 5.7%), prediabetic (5.7-6.4%), or diabetic (≥ 6.5%). The prevalence rates of diabetes and prediabetes were 8.6% (95% confidence interval [CI], 6.2-11.8%) and 20.4% (95% CI, 17.9-23.2%), respectively, among all participants (N = 1293; median age, 35 years; range, 2-96 years), and 10.0% (95% CI, 7.2-13.8%) and 20.0% (95% CI, 17.4-23.0%), respectively, among adults 18 years or older (N = 730). The average age of participants with diabetes was 47.2 years. The average age of participants with prediabetes was 40.7 years. Among adult questionnaire respondents, 64.8% of all participants and 39.4% of patients with diabetes had not been tested for diabetes previously. Among patients with diabetes, 28.4% were previously diagnosed; 1.2% of prediabetes patients were previously diagnosed. Half (50.7%) of the respondents had heard of diabetes. The majority (94.1%) of patients previously diagnosed with diabetes reported using diabetes medication. Among both undiagnosed and previously diagnosed patients with diabetes, diabetes knowledge, previous diabetes testing, and diabetes care-seeking were lowest among Haitian-born participants. A high burden of undiagnosed diabetes and deficiencies in diabetes knowledge, access to care, and diagnosis exist among all batey inhabitants, but most acutely among Haitians. Improvements will require a multi-sectoral approach.

Rapid ethnographic assessment for potential anti-malarial mass drug administration in an outbreak area of Santo Domingo, Dominican Republic.

BACKGROUND: In the Dominican Republic, a recent outbreak of malaria in the capital, Santo Domingo, threatens efforts to eliminate the disease. Mass drug administration (MDA) has been proposed as one strategy to reduce transmission. The success of MDA is contingent upon high levels of acceptance among the target population. To inform the design of future MDA campaigns, this rapid ethnographic assessment examined malaria-related knowledge and attitudes toward malaria MDA among residents of a transmission focus in Santo Domingo. METHODS: In October 2019, a rapid ethnographic assessment was conducted in the Los Tres Brazos transmission focus, which had not previously received MDA. National malaria programme staff conducted 61 structured interviews with key informants, recorded observations, and held 72 informal conversations. Using a grounded theory approach, data were analysed during three workshop sessions with research team members. RESULTS: Among those who had heard of malaria in the structured interviews (n = 39/61; 64%), understanding of the disease was largely based on personal experience from past outbreaks or through word-of-mouth. Community health workers (promotores) were trusted for health information and malaria diagnosis more so than professional clinicians. No participant (0%) was familiar with malaria MDA. After learning about MDA, almost all study participants (92%) said that they would participate, seeing it as a way to care for their community. Reasons for not participating in future MDA included not trusting drug administrators, feeling reluctant to take unprescribed medicine, and fear of missing work. Additional identified challenges to MDA included reaching specific demographic groups, disseminating effective MDA campaign messages, and managing misinformation and political influence. CONCLUSION: Residents appear accepting of MDA despite a lack of prior familiarity. Successful MDA will depend on several factors: fostering relationships among community-based health workers, clinicians, community leaders, and others; developing clear health messages that use local terms and spreading them through a variety of media and social networks; and contextualizing MDA as part of a broader effort to promote community health.

Malaria outbreak response in urban Santo Domingo, Dominican Republic: lessons learned for community engagement.

Community engagement is crucial for public health initiatives, yet it remains an under-studied process within national disease elimination programs. This report shares key lessons learned for community engagement practices during a malaria outbreak response in the Los Tres Brazos neighborhood of urban Santo Domingo, Dominican Republic from 2015-2016. In this two-year period, 233 cases of malaria were reported-more than seven times the number of cases (31) reported in the previous two years. The initial outbreak response by the national malaria program emphasized "top-down" interventions such as active surveillance, vector control, and educative talks within the community. Despite a transient reduction in reported cases in mid-2015, transmission resurged at the end of 2015. The program responded by introducing active roles for trained community members that included door-to-door fever screening, testing with rapid diagnostic tests and treatment. Malaria cases declined significantly throughout 2016 and community-based active surveillance infrastructure helped to detect and limit a small episode of transmission in 2017. Results from qualitative research among community members revealed two key factors that facilitated their cooperation with community-based surveillance activities: motivation to help one's community; and trust among stakeholders (community health workers, their neighbors and other key figures in the community, and malaria program staff and leadership). This experience suggests that community-led interventions and the program's willingness to learn and adapt under changing circumstances can help control malaria transmission and pave the way for elimination.

La participación de la comunidad es crucial para las iniciativas de salud pública, pero sigue siendo un proceso poco estudiado dentro de los programas nacionales de eliminación de enfermedades. En este informe se presentan las principales lecciones aprendidas respecto de las prácticas de participación comunitaria durante la respuesta al brote de malaria en el barrio Los Tres Brazos de la zona urbana de Santo Domingo, República Dominicana, de 2015 a 2016. En este período de dos años se notificaron 233 casos de malaria, más de siete veces el número de casos (31) notificados en los dos años anteriores. La respuesta inicial al brote por parte del programa nacional de malaria hizo hincapié en intervenciones "de arriba abajo" como la vigilancia activa, el control de vectores y las charlas educativas dentro de la comunidad. A pesar de la reducción transitoria de los casos notificados hacia mediados de 2015, la transmisión resurgió a finales de ese año. El programa respondió introduciendo funciones activas para miembros de la comunidad capacitados que incluían la detección de fiebre de casa en casa, pruebas de diagnóstico rápido y tratamiento. Los casos de malaria disminuyeron significativamente durante 2016 y la infraestructura de vigilancia activa basada en la comunidad ayudó a detectar y contener un episodio pequeño de transmisión en 2017. Los resultados de la investigación cualitativa entre los miembros de la comunidad revelaron dos factores clave que facilitaron su cooperación con las actividades de vigilancia basadas en la comunidad: la motivación para ayudar a la propia comunidad y la confianza entre las partes interesadas (los trabajadores sanitarios de la comunidad, los vecinos y otros actores clave de la comunidad, y el personal y la dirección del programa de lucha contra la malaria). Esta experiencia indica que las intervenciones dirigidas por la comunidad y la voluntad del programa de aprender y adaptarse a las circunstancias cambiantes pueden ayudar a controlar la transmisión de la malaria y facilitar el camino para su eliminación.

Malaria outbreak response in urban Santo Domingo, Dominican Republic: lessons learned for community engagement

[ABSTRACT]. Community engagement is crucial for public health initiatives, yet it remains an under-studied process within national disease elimination programs. This report shares key lessons learned for community engagement practices during a malaria outbreak response in the Los Tres Brazos neighborhood of urban Santo Domingo, Dominican Republic from 2015-2016. In this two-year period, 233 cases of malaria were reported—more than seven times the number of cases (31) reported in the previous two years. The initial outbreak response by the national malaria program emphasized “top-down” interventions such as active surveillance, vector control, and educative talks within the community. Despite a transient reduction in reported cases in mid-2015, transmission resurged at the end of 2015. The program responded by introducing active roles for trained community members that included door-to-door fever screening, testing with rapid diagnostic tests and treatment. Malaria cases declined significantly throughout 2016 and community-based active surveillance infrastructure helped to detect and limit a small episode of transmission in 2017. Results from qualitative research among community members revealed two key factors that facilitated their cooperation with community-based surveillance activities: motivation to help one’s community; and trust among stakeholders (community health workers, their neighbors and other key figures in the community, and malaria program staff and leadership). This experience suggests that community-led interventions and the program’s willingness to learn and adapt under changing circumstances can help control malaria transmission and pave the way for elimination.

[RESUMEN]. La participación de la comunidad es crucial para las iniciativas de salud pública, pero sigue siendo un proceso poco estudiado dentro de los programas nacionales de eliminación de enfermedades. En este informe se presentan las principales lecciones aprendidas respecto de las prácticas de participación comunitaria durante la respuesta al brote de malaria en el barrio Los Tres Brazos de la zona urbana de Santo Domingo, República Dominicana, de 2015 a 2016. En este período de dos años se notificaron 233 casos de malaria, más de siete veces el número de casos (31) notificados en los dos años anteriores. La respuesta inicial al brote por parte del programa nacional de malaria hizo hincapié en intervenciones "de arriba abajo" como la vigilancia activa, el control de vectores y las charlas educativas dentro de la comunidad. A pesar de la reducción transitoria de los casos notificados hacia mediados de 2015, la transmisión resurgió a finales de ese año. El programa respondió introduciendo funciones activas para miembros de la comunidad capacitados que incluían la detección de fiebre de casa en casa, pruebas de diagnóstico rápido y tratamiento. Los casos de malaria disminuyeron significativamente durante 2016 y la infraestructura de vigilancia activa basada en la comunidad ayudó a detectar y contener un episodio pequeño de transmisión en 2017. Los resultados de la investigación cualitativa entre los miembros de la comunidad revelaron dos factores clave que facilitaron su cooperación con las actividades de vigilancia basadas en la comunidad: la motivación para ayudar a la propia comunidad y la confianza entre las partes interesadas (los trabajadores sanitarios de la comunidad, los vecinos y otros actores clave de la comunidad, y el personal y la dirección del programa de lucha contra la malaria). Esta experiencia indica que las intervenciones dirigidas por la comunidad y la voluntad del programa de aprender y adaptarse a las circunstancias cambiantes pueden ayudar a controlar la transmisión de la malaria y facilitar el camino para su eliminación.

Post-Treatment Surveillance for Lymphatic Filariasis in Plateau and Nasarawa States, Nigeria: Results of Transmission Assessment Surveys.

Following the halt of mass drug administration (MDA) for lymphatic filariasis (LF), the WHO recommends at least 4 years of post-treatment surveillance (PTS) to confirm that transmission recrudescence or importation does not occur. The primary means of evaluation during PTS is repeated transmission assessment surveys (TASs) conducted at 2- to 3-year intervals after TAS-1 stop-MDA surveys. This study reports the results of TAS-2 and TAS-3 surveys in Plateau and Nasarawa states (pop. 6.9 million) of Nigeria divided into a minimum of seven evaluation units (EUs) per TAS. A total of 26,536 first- and second-year primary school children (approximately 6-7 years old) were tested for circulating filarial antigen (CFA) between 2014 and 2017. Of 12,313 children tested in TAS-2 surveys, only five (0.04%) were CFA positive, with no more than two positive samples from any one EU, which was below the critical value of 20 per EU. Of 14,240 children tested in TAS-3 surveys, none (0%) were CFA positive. These results indicate that LF transmission remains below sustainable transmission levels and suggest that elimination of transmission has been achieved in Plateau and Nasarawa, Nigeria.

The Interruption of Transmission of Human Onchocerciasis by an Annual Mass Drug Administration Program in Plateau and Nasarawa States, Nigeria.

Plateau and Nasarawa states in central Nigeria were endemic for onchocerciasis. The rural populations of these two states received annual ivermectin mass drug administration (MDA) for a period of 8-26 years (1992-2017). Ivermectin combined with albendazole was given for 8-13 of these years for lymphatic filariasis (LF); the LF MDA program successfully concluded in 2012, but ivermectin MDA continued in areas known to have a baseline meso-/hyperendemic onchocerciasis. In 2017, serological and entomological assessments were undertaken to determine if MDA for onchocerciasis could be stopped in accordance with the current WHO guidelines. Surveys were conducted in 39 sites that included testing 5- to < 10-year-old resident children by using ELISA for OV16 IgG4 antibodies, and Onchocerca volvulus O150 pooled polymerase chain reaction (PCR) testing of Simulium damnosum s.l. vector heads. Only two of 6,262 children were OV16 positive, and none of 19,056 vector heads were positive for parasite DNA. Therefore, both states were able to meet WHO stop-MDA thresholds of an infection rate in children of < 0.1% and a rate of infective blackflies of <1/2,000, with 95% statistical confidence. Transmission of onchocerciasis was declared interrupted in Plateau and Nasarawa states by the Federal Ministry of Health, and 2.2 million ivermectin treatments/year were stopped in 2018. Post-treatment Surveillance was launched focusing on entomological monitoring on borders with neighboring onchocerciasis-endemic states. An apparent positive impact of the LF MDA program on eliminating hypo-endemic onchocerciasis was observed. This is the first stop-MDA decision for onchocerciasis in Nigeria and the largest single stop-MDA decision for onchocerciasis yet reported. This achievement, along with the process used in adapting and implementing the 2016 WHO stop-MDA guidelines, will be important as a potential model for decision makers and national onchocerciasis elimination committees in other African countries that are charged with advancing their programs.

Perceived discrimination in bateyes of the Dominican Republic: results from the Everyday Discrimination Scale and implications for public health programs.

BACKGROUND: Discrimination is a major driver of health disparities among minority groups and can impede the reach of public health programs. In the Dominican Republic, residents of bateyes, or agricultural 'company towns,' often face barriers to health care. This study examined the extent of perceived discrimination among batey populations and places the findings within the context of disease elimination efforts. METHODS: In March-April 2016, a stratified, multi-stage cluster survey that included the 9-item Everyday Discrimination Scale (EDS) was conducted among residents (n = 768) of bateyes across the Dominican Republic. Exploratory factor analysis, differential item functioning, and linear and logistic regression were used to assess associations between EDS scores, ethnic group status, reasons for discrimination, and healthcare-seeking behavior. RESULTS: Three ethnic groups were identified in the population: Haitian-born persons (42.5%), Dominican-born persons with Haitian descent (25.5%), and Dominican-born persons without Haitian descent (32.0%). Mean EDS scores (range 0-45) were highest among persons born in Haiti (18.2, 95% confidence interval [CI] = 16.4-20.1), followed by persons with Haitian descent (16.5, 95% CI = 14.9-18.0), and those without Haitian descent (13.3, 95% CI = 12.1-14.5). Higher EDS scores were significantly associated with Haitian birth (ß = 6.8, 95% CI = 4.2-9.4; p < 0.001) and Haitian descent (ß = 6.1, 95% CI = 3.2-9.0; p < 0.001). Most respondents (71.5%) had scores high enough to elicit reasons for their discrimination. Regardless of ethnic group, poverty was a common reason for discrimination, but Haitian-born and Haitian-descended people also attributed discrimination to their origin, documentation status, or skin color. EDS scores were not significantly associated with differences in reported care-seeking for recent fever (ß = 1.7, 95% CI = - 1.4-4.9; p = 0.278). CONCLUSION: Perceived discrimination is common among batey residents of all backgrounds but highest among Haitian-born people. Discrimination did not appear to be a primary barrier to care-seeking, suggesting other explanations for reduced care-seeking among Haitian populations. Public health community engagement strategies should avoid exacerbating stigma, build active participation in programs, and work towards community ownership of disease control and elimination goals.

Prevalence of malaria and lymphatic filariasis in bateyes of the Dominican Republic.

BACKGROUND: The island of Hispaniola, shared by Haiti and the Dominican Republic (DR), is the only remaining malaria-endemic island in the Caribbean and accounts for 95% of the lymphatic filariasis (LF) burden in the Americas. Both countries aim to eliminate the diseases by 2020. Migration from Haiti, where both diseases are more prevalent, may promote transmission in the DR. Historically, Haitian migrant labourers live in rural Dominican agricultural 'company towns' called bateyes, many of which received mass drug administration (MDA) for LF elimination. This study sought to determine the prevalence of malaria and LF in bateyes of the DR and to describe related risk factors for disease. METHODS: From March to April 2016, a cross-sectional, cluster survey was conducted across Dominican bateyes stratified into three regions: southwest, north and east. A household questionnaire (n = 776), captured demographics, ethnic origin, mobility patterns, malaria intervention coverage, and knowledge, and recent fever and treatment-seeking. Two individuals per household (n = 1418) were tested for malaria parasites by microscopy and rapid diagnostic test (RDT) and LF antigen by filariasis test strip (FTS). Population-level estimates and confidence intervals (CI) were computed adjusting for the survey design. Two-sided t-tests compared differences in knowledge scores. RESULTS: No (0%) blood sample was Plasmodium-positive by microscopy or RDT. Six individuals were FTS-positive (0.5%; 95% CI: 0.2-1.5), but none (0%) of these were microfilariae-positive. Most batey residents were born in the DR (57.8%), documented (85.0%), and permanent residents (85.1%). Very few respondents (9.4%) reported travel to Haiti in the past year. Overall, half (53.8%) of respondents owned a bed net, and 82.3% of net owners reported using it the previous night. Indoor residual spraying (IRS) differed by region (range: 4.7%-61.2%). Most of those with recent fever sought care (56.0%), yet only 30.5% of those seeking care were tested for malaria. Compared to Dominican-born populations, Haitian-born respondents more frequently reported recent fever, did not seek care for the fever, had not heard of malaria, and could not name symptoms or prevention methods. CONCLUSIONS: Malaria and LF transmission appear absent or extremely low in Dominican bateyes, which are a mixture of Haitian and Dominican residents. Travel to Haiti is rare, meaning risk of malaria and LF importation is low. Addressing identified gaps in intervention coverage, malaria knowledge, treatment seeking and service delivery will improve the quality of surveillance for these diseases, particularly among marginalized populations and promote island-wide elimination.

"Wherever doctors cannot reach, the sunshine can": overcoming potential barriers to malaria elimination interventions in Haiti.

BACKGROUND: Haiti and the Dominican Republic, the only two Caribbean countries with endemic malaria transmission, are committed to eliminating malaria. With a Plasmodium falciparum prevalence under 1% and a highly focal transmission, the efforts towards elimination in Haiti will include several community-based interventions that must be tailored to the local sociocultural context to increase their uptake. However, little is known about local community perceptions regarding malaria and the planned elimination interventions. The aim of this study is to develop a robust understanding of how to tailor, implement and promote malaria elimination strategies in Haiti. METHODS: A cross-sectional qualitative study was conducted December 2015-August 2016 in Grande-Anse and the North Department in Haiti. Data collection included key informant interviews (n = 51), in-depth interviews (n = 15) and focus group discussions (n = 14) with health workers, traditional healers, teachers, priests or pastors, informal community leaders, public officials, and community members. Following a grounded theory approach, transcripts were coded and analysed using content analysis. Coded text was sorted by the types of interventions under consideration by the malaria elimination programme. RESULTS: The level of knowledge about malaria was low. Many participants noted community beliefs about malaria being caused by magical phenomena in addition to vector-borne transmission. Participants described malaria as a problem rooted in the environment, with vector control the most noted method of prevention. Though participants noted malaria a severe disease, it ranked lower than other health problems perceived as more acute. Access barriers to healthcare were described including a lack of bed nets. Some distrust about pills, tests, and foreigners in general was expressed, and in few cases linked to previous experience with malaria campaigns under dictatorial regimes. CONCLUSIONS: There are several potential barriers and opportunities to implement community-based malaria elimination interventions in rural Haiti. Elimination efforts should include the collaboration of voodoo priests and other traditional healers, be coupled with solutions to wider community concerns or other health interventions, and learn from previous or similar programmes, such as the campaign to eliminate lymphatic filariasis. It is essential to engage with communities and gain their trust to successfully implement targeted aggressive elimination activities.

Building Trust through Lymphatic Filariasis Elimination: A Platform to Address Social Exclusion and Human Rights in the Dominican Republic.

Hispaniola, the Caribbean island that includes the countries of Haiti and the Dominican Republic (DR), accounts for 90% of lymphatic filariasis (LF) in the Americas. Both countries have committed to LF elimination by 2020. In the DR, LF occurs mainly in bateyes, or company towns that historically hosted migrant laborers from Haiti. A legacy of anti-Haitian discrimination as well as the 2013 Sentencia, which stripped generations of Haitian-descended Dominicans of their citizenship, ensure that this population remains legally, economically, and socially marginalized. Despite this context, the country's LF elimination program (PELF) has worked in bateyes to eliminate LF through health education and annual drug treatment to interrupt parasite transmission. Based on interviews with batey residents and observations of PELF activities from February-April 2016, this study describes local understandings of social exclusion alongside the PELF community-based approach. The Sentencia reinforced a common perception shared by batey residents: that their lives were unimportant, even unrecognized, in Dominican society. At the same time, the government-run PELF has generated trust in government health activities and partially counteracts some of the effects of social exclusion. These findings suggest that neglected tropical disease (NTD) programs can not only improve the health of marginalized populations, but also create a platform for improving human rights.