Vaccine Hesitancy in Sub-Saharan Africa in the Context of COVID-19 Vaccination Exercise: A Systematic Review.

Presently, the COVID-19 vaccine is seen as a means to an end in light of other challenges, such as vaccine inequity. Through COVID-19 Vaccines Global Access (COVAX), an initiative founded to guarantee fair and equitable distribution, vaccine hesitancy remains a critical component that needs to be addressed in sub-Saharan Africa. Utilizing a documentary search strategy and using the keywords and subject headings Utilitarianism and COVID-19 or Vaccine hesitancy and sub-Saharan Africa, this paper identified 67 publications from different databases (PubMed, Scopus and Web of Science), which were further screened by title and full text to achieve (n = 6) publications that were analyzed. The reviewed papers demonstrate that vaccine hesitancy occurs against a colonial backdrop of inequities in global health research, social-cultural complexities, poor community involvement and public distrust. All of these factors undermine the confidence that is crucial for sustaining collective immunity in vaccine programs. Even though mass vaccination programs are known to limit personal freedom, the exchange of information between healthcare professionals and citizens must be improved to encourage complete disclosure of vaccine information at the point of delivery. Moreover, addressing components of vaccine hesitancy should involve relying not on coercive public policies but on consistent ethical strategies that go beyond current healthcare ethics toward broader bioethics.

Local tips, global impact: community-driven measures as avenues of promoting inclusion in the control of neglected tropical diseases: a case study in Kenya.

BACKGROUND: Neglected tropical diseases (NTDs) affect poor populations with little or no 'political voice' to influence control activities. While most NTDs have interventions that work, the biggest challenge remains in delivering targeted interventions to affected populations residing in areas experiencing weak health systems. Despite the upward development trends in most countries of sub-Saharan Africa (SSA), the healthcare worker to population ratio remains exceptionally low, with some areas not served at all; thus, there is a need to involve other personnel for school and community-based healthcare approaches. Nonetheless, the current community-based programs suffer from inconsistent community participation due to a lack of coordinated response, and an expanded intervention agenda that lacks context-specific solutions applicable to rural, urban, and marginalized areas. METHODS: This research investigated the capacity of local communities to address the burden of NTDs. Informed by the social theory of human capability, the research collected primary qualitative data by conducting key informant interviews and focus group discussions of people infected or affected by NTDs. The interview data were collected and transcribed verbatim for thematic analysis using Nvivo version 12. RESULTS: Our findings reveal, first, a need for intersectoral collaboration between governments and affected populations for inclusive and sustainable NTD solutions. Second, a 'bottom-up' approach that enhances capacity building, sensitization, and behaviour change for improved uptake of NTD interventions. Third, the enforcement of Public Health Legislative Acts that mandates the reporting and treatment of NTDs such as leprosy. Fourth, the establishment of support groups and counseling services to assist persons suffering from debilitating and permanent effects of NTDs. CONCLUSIONS: Our research demonstrates the importance of human agency in encouraging new forms of participation leading to the co-production of inclusive and sustainable solutions against NTDs.

The use of non-pharmaceutical interventions for the prevention and control of schistosomiasis in sub-Saharan Africa: A systematic review.

Schistosomiasis remains a major cause of global parasitic morbidity. Current control strategies focus on pharmaceutical approaches using Mass Drug Administration (MDA) to distribute praziquantel in endemic areas of sub-Saharan Africa. Our paper systematically reviewed the literature on non-pharmaceutical interventions for enhanced schistosomiasis control. We conducted a systematic review of peer-reviewed English language literature using PubMed, Embase and Web of Science. Our search terms were limited to the year 2000 to March 2019 to reflect the period of the Millennium and Sustainable Development Goals. We initially identified 1733 publications, which were reduced to 1324 after screening by title and abstract. After the inclusion and exclusion criteria, a total of 1312 studies were excluded. Following this, we had a total of 12 articles, which we later screened by full text. Out of the twelve articles, seven were excluded for being systematic reviews or examining clinical and nutritional aspects of schistosomiasis control. We finally remained with five studies that met our inclusion criteria. Our paper indicates a gap in non-pharmaceutical based interventions for schistosomiasis control. We propose that future research addresses this gap by engaging communities in participatory approaches such as environmental sanitation, Water, Sanitation and Hygiene (WASH), health education and economic empowerment.

The Impact of Neglected Tropical Diseases (NTDs) on Women's Health and Wellbeing in Sub-Saharan Africa (SSA): A Case Study of Kenya.

Neglected Tropical Diseases (NTDs) trap individuals in a cycle of poverty through their devastating effects on health, wellbeing and social-economic capabilities that extend to other axes of inequity such as gender and/or ethnicity. Despite NTDs being regarded as equity tracers, little attention has been paid toward gender dynamics and relationships for gender-equitable access to NTD programs in sub-Saharan Africa (SSA). This paper examines the impact of NTDs on women's health and wellbeing in SSA using Kenya as a case study. This research is part of a larger research program designed to examine the impact of NTDs on the health and wellbeing of populations in Kenya. Thematic analysis of key informants' interviews (n = 21) and focus groups (n = 5) reveals first that NTDs disproportionately affect women and girls due to their assigned gender roles and responsibilities. Second, women face financial and time constraints when accessing health care due to diminished economic power and autonomy. Third, women suffer more from the related social consequences of NTDs (that is, stigma, discrimination and/or abandonment), which affects their health-seeking behavior. As such, we strongly suggest a gender lens when addressing NTD specific exposure, socio-economic inequities, and other gender dynamics that may hinder the successful delivery of NTD programs at the local and national levels.

The impact of Neglected Tropical Diseases (NTDs) on health and wellbeing in sub-Saharan Africa (SSA): A case study of Kenya.

Neglected Tropical Diseases (NTDs) remain endemic to many regions of sub-Saharan Africa (SSA) left behind by socioeconomic progress. As such, these diseases are markers of extreme poverty and inequity that are propagated by the political, economic, social, and cultural systems that affect health and wellbeing. As countries embrace and work towards achieving the Sustainable Development Goals (SDGs), the needs of such vulnerable populations need to be addressed in local and global arenas. The research uses primary qualitative data collected from five NTD endemic counties of Kenya: interviews key informants (n = 21) involved in NTD implementation programs and focus groups (n = 5) of affected individuals. Informed by theories of political ecology of health, the research focuses on post-devolution Kenya and identifies the political, economic, social, and cultural factors that propagate NTDs and their effects on health and wellbeing. Our findings indicate that structural factors such as competing political interests, health worker strikes, inadequate budgetary allocations, economic opportunity, marginalization, illiteracy, entrenched cultural norms and practices, poor access to water, sanitation and housing, all serve to propagate NTD transmission and subsequently affect the health and wellbeing of populations. As such, we recommend that post-devolution Kenya ensures local political, economic and socio-cultural structures are equitable, sensitive and responsive to the needs of all people. We also propose poverty alleviation through capacity building and empowerment as a means of tackling NTDs for sustained economic opportunity and productivity at the local and national level.

Is PCR the Next Reference Standard for the Diagnosis of Schistosoma in Stool? A Comparison with Microscopy in Senegal and Kenya.

BACKGROUND: The current reference test for the detection of S. mansoni in endemic areas is stool microscopy based on one or more Kato-Katz stool smears. However, stool microscopy has several shortcomings that greatly affect the efficacy of current schistosomiasis control programs. A highly specific multiplex real-time polymerase chain reaction (PCR) targeting the Schistosoma internal transcriber-spacer-2 sequence (ITS2) was developed by our group a few years ago, but so far this PCR has been applied mostly on urine samples. Here, we performed more in-depth evaluation of the ITS2 PCR as an alternative method to standard microscopy for the detection and quantification of Schistosoma spp. in stool samples. METHODOLOGY/PRINCIPAL FINDINGS: Microscopy and PCR were performed in a Senegalese community (n = 197) in an area with high S. mansoni transmission and co-occurrence of S. haematobium, and in Kenyan schoolchildren (n = 760) from an area with comparatively low S. mansoni transmission. Despite the differences in Schistosoma endemicity the PCR performed very similarly in both areas; 13-15% more infections were detected by PCR when comparing to microscopy of a single stool sample. Even when 2-3 stool samples were used for microscopy, PCR on one stool sample detected more infections, especially in people with light-intensity infections and in children from low-risk schools. The low prevalence of soil-transmitted helminthiasis in both populations was confirmed by an additional multiplex PCR. CONCLUSIONS/SIGNIFICANCE: The ITS2-based PCR was more sensitive than standard microscopy in detecting Schistosoma spp. This would be particularly useful for S. mansoni detection in low transmission areas, and post-control settings, and as such improve schistosomiasis control programs, epidemiological research, and quality control of microscopy. Moreover, it can be complemented with other (multiplex real-time) PCRs to detect a wider range of helminths and thus enhance effectiveness of current integrated control and elimination strategies for neglected tropical diseases.

Improved sensitivity of the urine CAA lateral-flow assay for diagnosing active Schistosoma infections by using larger sample volumes.

BACKGROUND: Accurate determination of Schistosoma infection rates in low endemic regions to examine progress towards interruption of transmission and elimination requires highly sensitive diagnostic tools. An existing lateral flow (LF) based test demonstrating ongoing infections through detection of worm circulating anodic antigen (CAA), was improved for sensitivity through implementation of a protocol allowing increased sample input. Urine is the preferred sample as collection is non-invasive and sample volume is generally not a restriction. METHODS: Centrifugal filtration devices provided a method to concentrate supernatant of urine samples extracted with trichloroacetic acid (TCA). For field trials a practical sample volume of 2 mL urine allowed detection of CAA down to 0.3 pg/mL. The method was evaluated on a set of urine samples (n = 113) from an S. mansoni endemic region (Kisumu, Kenya) and compared to stool microscopy (Kato Katz, KK). In this analysis true positivity was defined as a sample with either a positive KK or UCAA test. RESULTS: Implementation of the concentration method increased clinical sensitivity (Sn) from 44 to 98% when moving from the standard 10 µL (UCAA10 assay) to 2000 µL (UCAA2000 assay) urine sample input. Sn for KK varied between 23 and 35% for a duplicate KK (single stool, two slides) to 52% for a six-fold KK (three consecutive day stools, two slides). The UCAA2000 assay indicated 47 positive samples with CAA concentration above 0.3 pg/mL. The six-fold KK detected 25 egg positives; 1 sample with 2 eggs detected in the 6-fold KK was not identified with the UCAA2000 assay. CONCLUSIONS: Larger sample input increased Sn of the UCAA assay to a level indicating 'true' infection. Only a single 2 mL urine sample is needed, but analysing larger sample volumes could still increase test accuracy. The UCAA2000 test is an appropriate candidate for accurate identification of all infected individuals in low-endemic regions. Assay materials do not require refrigeration and collected urine samples may be stored and transported to central test laboratories without the need to be frozen.

Evaluation of point-of-contact circulating cathodic antigen assays for the detection of Schistosoma mansoni infection in low-, moderate-, and high-prevalence schools in western Kenya.

We evaluated the performance of a point-of-contact circulating cathodic antigen assay (POC-CCA) to detect schistosome infections in primary school children (N = 1,801) living in areas with low, moderate, and high Schistosoma mansoni prevalence in western Kenya. The commercially available assay (CCA-1) and a second, experimental formulation (CCA-2) were compared against Kato-Katz stool examinations and an anti-schistosome enzyme-linked immunosorbent assay (ELISA). A latent class model based on the four tests was used to establish "true infection status" in three different zones based on their distance from Lake Victoria. As a screening tool for community treatment according to World Health Organization (WHO) guidelines, the Kato-Katz examination was in closest agreement with the latent class model, followed by the experimental CCA-2, soluble adult worm antigen preparation (SWAP) ELISA, and CCA-1, which had high sensitivity compared with the other tests but was consistently the least specific. Our experience suggests that POC-CCA tests offer a field-friendly alternative to Kato-Katz, but need further interpretation for appropriate field use.

Cost analysis of tests for the detection of Schistosoma mansoni infection in children in western Kenya.

Financial resources tend to be limited in schistosomiasis endemic areas, forcing program managers to balance financial and scientific considerations when selecting detection assays. Therefore, we compared the costs of using single stool Kato-Katz, triplicate stool Kato-Katz, and point-of-contact circulating cathodic antigen (POC-CCA) assays for the detection of Schistosoma mansoni infection. Economic and financial costs were estimated from the viewpoint of a schistosomiasis control program using the ingredients approach. Costs related to specimen collection, sample processing and analysis, and treatment delivery were considered. Analysis inputs and assumptions were tested using one-way and two-way sensitivity analysis. The total per-person cost of performing the single Kato-Katz, triplicate Kato-Katz, and POC-CCA was US$6.89, US$17.54, and US$7.26, respectively. Major cost drivers included labor, transportation, and supplies. In addition, we provide a costing tool to guide program managers in evaluating detection costs in specific settings, as costs may vary temporally and spatially.

Assessment of quality of life as a tool for measuring morbidity due to Schistosoma mansoni infection and the impact of treatment.

Recently, health measurements have broadened to include the assessment of quality of life (QOL). This study was conducted to assess whether the short form of the World Health Organization (WHO) QOL questionnaire (WHOQOL-BREF) was an effective tool for measuring morbidity due to Schistosoma mansoni infection and whether it could detect an impact of treatment with praziquantel. A total of 724 adults 18-85 years of age were enrolled. At baseline, S. mansoni prevalence was 73.2% by stool examination and 75.4% by circulating cathodic antigen, and there was no association between infection status and WHOQOL-BREF scores. Six months after treatment, S. mansoni prevalence was lower and the proportion of persons with higher WHOQOL-BREF scores significantly increased among persons who were infected at baseline. However, a similar increase was observed in persons not infected at baseline. In areas of high prevalence, the WHOQOL-BREF may not be able to detect the benefits of schistosomiasis control programs.

Association between CD4+ T-lymphocyte counts and fecal excretion of Schistosoma mansoni eggs in patients coinfected with S. mansoni and human immunodeficiency virus before and after initiation of antiretroviral therapy.

Previously, we have shown that persons with human immunodeficiency virus 1 (HIV-1) infection and reduced CD4(+) T-lymphocyte counts excrete significantly fewer Schistosoma mansoni eggs than HIV-1-negative persons with similar intensities of schistosome infections. To determine how antiretroviral therapy (ART) might affect egg excretion, we conducted a study of HIV+ adults living in an area highly endemic for S. mansoni as they began an ART program. Fecal egg excretion and CD4(+) T-lymphocyte counts were evaluated at enrollment as well as 2 and 4 weeks after initiation of ART. Fourteen individuals who were Kato-Katz-negative at enrollment subsequently started excreting S. mansoni eggs accompanied by a significant increase in CD4(+) T lymphocytes (P = 0.004). Study participants who were S. mansoni egg-positive at enrollment and received both praziquantel and ART also showed significantly increased CD4(+) T-lymphocyte counts compared with baseline (P < 0.0001). Our data support a role for CD4(+) T lymphocytes in S. mansoni egg excretion.