Corrigendum: Factors associated with COVID-19 vaccine confidence among primary care providers in Kazakhstan, March-April 2021.

[This corrects the article DOI: 10.3389/fpubh.2023.1245750.].

COVID-19 pandemic and other factors associated with unfavorable tuberculosis treatment outcomes-Almaty, Kazakhstan, 2018-2021.

Introduction: The COVID-19 pandemic negatively influenced the availability of tuberculosis (TB) services, such as detection, diagnosis and treatment, around the world, including Kazakhstan. We set out to estimate the COVID-19 pandemic influence on TB treatment outcomes by comparing outcomes among people starting treatment before the pandemic (2018-2019) and during the pandemic (2020-2021) and to determine risk factors associated with unfavorable outcomes. Methods: We conducted a retrospective cohort study among all people newly diagnosed with drug-sensitive pulmonary or extrapulmonary TB at least 18 years old who initiated treatment from 2018 to 2021 in Almaty. We abstracted data from the national electronic TB register. Unfavorable treatment outcomes were ineffective treatment, death, loss to follow-up, results not evaluated, and transferred. We used multivariable Poisson regression to calculate adjusted relative risk (aRR) and 95% confidence intervals (95%CI). Results: Among 1548 people newly diagnosed with TB during the study period, average age was 43 years (range 18-93) and 52% were male. The number of people initiating treatment was higher before than the pandemic (935 vs. 613, respectively). There was significantly different proportions before compared to during the pandemic for people diagnosed through routine screening (39% vs. 31%, p < 0.001), 60 years and older (16% vs. 22%, p = 0.005), and with diabetes (5% vs. 8%, p = 0.017). There was no difference in the proportion of HIV (8% in both periods). Unfavorable outcomes increased from 11 to 20% during the pandemic (aRR = 1.83; 95% CI: 1.44-2.31). Case fatality rose from 6 to 9% (p = 0.038). Risk factors for unfavorable TB treatment outcomes among all participants were being male (aRR = 1.44, 95%CI = 1.12-1.85), having HIV (aRR = 2.72, 95%CI = 1.99-3.72), having alcohol use disorder (aRR = 2.58, 95%CI = 1.83-3.62) and experiencing homelessness (aRR = 2.94, 95%CI = 1.80-4.80). Protective factors were being 18-39 years old (aRR = 0.33, 95%CI = 0.24-0.44) and 40-59 years old (aRR = 0.56, 95%CI = 0.41-0.75) compared to 60 years old and up. Conclusion: COVID-19 pandemic was associated with unfavorable treatment outcomes for people newly diagnosed with drug-sensitive TB in Almaty, Kazakhstan. People with fewer comorbidities were at increased risk. Results point to the need to maintain continuity of care for persons on TB treatment, especially those at higher risk for poor outcomes during periods of healthcare service disruption.

Therapies for people hospitalized with COVID-19 and alignment with national clinical guidelines in a large hospital, Almaty, Kazakhstan, 2020-2021.

Background: Clinical practice guidelines were continually changing during the COVID-19 pandemic to reflect the best available evidence for a novel virus. In Kazakhstan, the national clinical guidelines for COVID-19 patient care were regularly modified and it was not known if and to what extent these guidelines were being followed in practice. Methods: We conducted a sub-analysis of data collected from an observational study among people hospitalized with COVID-19 in a large infectious disease hospital in Almaty in four cross-sections of increased COVID-19 incidence: T1 (1 June-30 August 2020); T2 (1 October-31 December 2020); T3 (1 April-31 May 2021); and T4 (1 July-26 October 2021). Modifications to the national COVID-19 treatment guidelines were identified and clinical data were abstracted from electronic medical records. We assessed frequency of antibiotic, glucocorticoid, anticoagulant, and antiviral administered in each period and determined if these aligned with national clinical guidelines. We used multivariable logistic regression to compare practices across periods. Results: Six modifications were made to national COVID-19 treatment guidelines during this study. Of 1,146 people hospitalized with COVID-19, 14% were in T1, 14% in T2, 22% in T3, and 50% in T4. Anticoagulant treatment was administered to 87% (range: 56%-95%), antibiotic treatment to 60% (range: 58%-64%), glucocorticoid to 55% (range: 43%-64%) and antiviral therapy 15% (range: 7%-22%). Majority of treatments were not aligned with national guidelines, including 98% of anticoagulant use, 95% of antibiotic use, 56% of glucocorticoid use, and 56% of antiviral use. There were no significant changes in practice following changes in guidelines for antibiotic use (64% in T1 to 58% in T2, p = 0.30). There was significant increase in use of anticoagulant (84% in T2 vs. 95% in T3, p < 0.01), glucocorticoid (43% in T2 vs. 64% in T3, p < 0.01), and antiviral treatment (7% in T3 vs. 15% in T4, p < 0.01) after guidelines updates. Conclusion: The majority of treatments administered to people hospitalized with COVID-19 in four periods of high incidence in Almaty were not aligned with updated clinical guidelines. Antibiotic misuse was markedly high throughout. Increased awareness and training on clinical practice guidelines as updates are released may help improve adoption of evidence-based practices.

Factors associated with COVID-19 vaccine confidence among primary care providers in Kazakhstan, March-April 2021.

Introduction: Vaccination is a critical public health intervention, and vaccine hesitancy is a major threat. Globally, confidence in COVID-19 vaccines has been low, and rates of routine immunizations decreased during the COVID-19 pandemic. Because healthcare providers are a trusted source of information on vaccination in Kazakhstan, it was vital to understand their knowledge, attitudes and practices (KAP) related to both routine and COVID-19 vaccines. Methods: From March to April 2021, we conducted a cross-sectional study among the healthcare providers responsible for vaccination in 54 primary care facilities in three cities in Kazakhstan. All consenting providers anonymously completed structured online questionnaires at their place of work. A provider was classified as having COVID-19 vaccine confidence if they planned to get a COVID-19 vaccine, believed that COVID-19 vaccines are important to protect their community and either believed the vaccine was important to protect themselves or believed that getting a vaccine was safer than getting COVID-19. Statistical analysis included chi-square, Spearman's rank correlation coefficient, and Poisson regression. Results: Of 1,461 providers, 30% had COVID-19 vaccine confidence, 40% did not, and 30% would refuse vaccination. Participants were mostly female (92%) and ≤ 35 years old (57%). Additionally, 65% were nurses, 25% were family physicians, and 10% were pediatricians. Adequate KAP for routine vaccines was low (22, 17, and 32%, respectively). Adequate knowledge was highest among pediatricians (42%) and family physicians (28%) and lowest among nurses (17%). Misconceptions about vaccines were high; 54% believed that influenza vaccines cause flu, and 57% believed that there is a scientifically proven association between vaccination and autism and multiple sclerosis. About half (45%) of the practitioners felt confident answering patient vaccine-related concerns. In adjusted models, COVID-19 vaccine confidence was positively associated with adequate knowledge of vaccines (prevalence ratio: 1.2, 95% confidence interval: 1.0-1.4) and adequate attitudes related to routine vaccines (3.1, 2.7-3.6). Conclusion: Our study uncovers critical areas for interventions to improve KAP related to routine immunizations and COVID-19 vaccine confidence among providers in Kazakhstan. The complex relationship between KAP of routine vaccines and COVID-19 vaccine confidence underscores the importance of addressing vaccine hesitancy more broadly and not focusing solely on COVID-19.

Excess deaths directly and indirectly attributable to COVID-19 using routinely reported mortality data, Bishkek, Kyrgyzstan, 2020: a cross-sectional study.

OBJECTIVES: Studies on excess deaths (ED) show that reported deaths from COVID-19 underestimate death. To understand mortality for improved pandemic preparedness, we estimated ED directly and indirectly attributable to COVID-19 and ED by age groups. DESIGN: Cross-sectional study using routinely reported individual deaths data. SETTINGS: The 21 health facilities in Bishkek that register all city deaths. PARTICIPANTS: Residents of Bishkek who died in the city from 2015 to 2020. OUTCOME MEASURE: We report weekly and cumulative ED by age, sex and causes of death for 2020. EDs are the difference between observed and expected deaths. Expected deaths were calculated using the historical average and the upper bound of the 95% CI from 2015 to 2019. We calculated the percentage of deaths above expected using the upper bound of the 95% CI of expected deaths. COVID-19 deaths were laboratory confirmed (U07.1) or probable (U07.2 or unspecified pneumonia). RESULTS: Of 4660 deaths in 2020, we estimated 840-1042 ED (79-98 ED per 100 000 people). Deaths were 22% greater than expected. EDs were greater for men (28%) than for women (20%). EDs were observed in all age groups, with the highest ED (43%) among people 65-74 years of age. Hospital deaths were 45% higher than expected. During peak mortality (1 July -21 July), weekly ED was 267% above expected, and ED by disease-specific cause of death were above expected: 193% for ischaemic heart diseases, 52% for cerebrovascular diseases and 421% for lower respiratory diseases. COVID-19 was directly attributable to 69% of ED. CONCLUSION: Deaths directly and indirectly associated with the COVID-19 pandemic were markedly higher than reported, especially for older populations, in hospital settings, and during peak weeks of SARS-CoV-2 transmission. These ED estimates can support efforts to prioritise support for persons at greatest risk of dying during surges.

Effectiveness of four vaccines in preventing SARS-CoV-2 infection in Almaty, Kazakhstan in 2021: retrospective population-based cohort study.

Background: In February 2021 Kazakhstan began offering COVID-19 vaccines to adults. Breakthrough SARS-CoV-2 infections raised concerns about real-world vaccine effectiveness. We aimed to evaluate effectiveness of four vaccines against SARS-CoV-2 infection. Methods: We conducted a retrospective cohort analysis among adults in Almaty using aggregated vaccination data and individual-level breakthrough COVID-19 cases (≥14 days from 2nd dose) using national surveillance data. We ran time-adjusted Cox-proportional-hazards model with sensitivity analysis accounting for varying entry into vaccinated cohort to assess vaccine effectiveness for each vaccine (measured as 1-adjusted hazard ratios) using the unvaccinated population as reference (N = 565,390). We separately calculated daily cumulative hazards for COVID-19 breakthrough among vaccinated persons by age and vaccination month. Results: From February 22 to September 1, 2021, in Almaty, 747,558 (57%) adults were fully vaccinated (received 2 doses), and 108,324 COVID-19 cases (11,472 breakthrough) were registered. Vaccine effectiveness against infection was 79% [sensitivity estimates (SE): 74%-82%] for QazVac, 77% (SE: 71%-81%) for Sputnik V, 71% (SE: 69%-72%) for Hayat-Vax, and 70% (SE: 65%-72%) for CoronaVac. Among vaccinated persons, the 90-day follow-up cumulative hazard for breakthrough infection was 2.2%. Cumulative hazard was 2.9% among people aged ≥60 years versus 1.9% among persons aged 18-39 years (p < 0.001), and 1.2% for people vaccinated in February-May versus 3.3% in June-August (p < 0.001). Conclusion: Our analysis demonstrates high effectiveness of COVID-19 vaccines against infection in Almaty similar to other observational studies. Higher cumulative hazard of breakthrough among people ≥60 years of age and during variant surges warrants targeted booster vaccination campaigns.

Molecular Markers of Sulfadoxine-Pyrimethamine Resistance in Samples from Children with Uncomplicated Plasmodium falciparum at Three Sites in Angola in 2019.

Sulfadoxine-pyrimethamine (SP) is used for prevention of malaria in pregnant women in Angola. We sequenced the Plasmodium falciparum dihydrofolate reductase (pfdhfr) and dihydropteroate synthase (pfdhps) genes, implicated in SP resistance, in samples collected during a 2019 study of artemisinin-based combination therapy efficacy in Benguela, Lunda Sul, and Zaire provinces. A total of 90 day 0 and day of failure samples were individually sequenced, while 508 day 0 samples from participants without recurrent parasitemia were pooled after DNA extraction into 61 pools. The N51I, C59R, and S108N pfdhfr mutations and A437G pfdhps mutations were present at high proportions in all provinces (weighted allele frequencies, 62% to 100%). The K540E pfdhps mutation was present at lower proportions (10% to 14%). The A581G pfdhps mutation was only observed in Zaire, at a 4.6% estimated prevalence. The I431V and A613S mutations were also only observed in Zaire, at a prevalence of 2.8% to 2.9%. The most common (27% to 66%) reconstructed haplotype in all three provinces was the canonical quadruple pfdhfr pfdhps mutant. The canonical quintuple mutant was absent in Lunda Sul and Benguela and present in 7.9% of samples in Zaire. A single canonical sextuple (2.6%) mutant was observed in Zaire Province. Proportions of the pfdhps K540E and A581G mutations were well below the World Health Organization thresholds for meaningful SP resistance (prevalence of 95% for K540E and 10% for A581G). Samples from therapeutic efficacy studies represent a convenient source of samples for monitoring SP resistance markers.

Outbreak of acute gastroenteritis associated with drinking water in rural Kazakhstan: A matched case-control study.

We conducted an outbreak investigation from June 3 to 15th in a rural village in northern Kazakhstan, after surveillance showed an increase in gastroenteritis. Cases were residents who presented for medical treatment for diarrhea, fever (>37.5 °C), vomiting, or weakness from May 14 to June 15, 2021. Controls were residents matched by age ±2 years at a ratio of two controls for every case. Cases and controls were interviewed using structured questionnaires. We abstracted clinical data from medical records. We mapped cases and assessed risk for disease using conditional multivariable logistic regression. We identified 154 cases of acute gastroenteritis (attack rate of ~26 per 1,000 inhabitants). Symptoms were diarrhea, fever, vomiting, weakness, and decreased appetite. Among cases that participated (n = 107), 74% reported having drank unboiled tap water vs 18% of controls (n = 219). This was the only risk factor associated with disease (adjusted odds ratio: 18; 95% CI 9-35). Drinking water from a dispenser or carbonated drinks was protective. The city has two water supply networks; cases were clustered (107 cases in 79 households) in one. The investigation found that monitoring of quality and safety of water according to national regulations had not been conducted since 2018. No fatalities occurred, and no associated cases were reported after our investigation. Results suggest that untreated tap water was the probable source of the outbreak. The water supply had been cleaned and disinfected twice by the facility 2 days before our investigation began. Recommendations were made for regular monitoring of water supply facilities with rapid public notification when issues are detected to reduce likelihood of future drinking water associated outbreaks.

Mass SARS-CoV-2 Testing in a Dormitory-Style Correctional Facility in Arkansas.

Objectives. To assess SARS-CoV-2 transmission within a correctional facility and recommend mitigation strategies.Methods. From April 29 to May 15, 2020, we established the point prevalence of COVID-19 among incarcerated persons and staff within a correctional facility in Arkansas. Participants provided respiratory specimens for SARS-CoV-2 testing and completed questionnaires on symptoms and factors associated with transmission.Results. Of 1647 incarcerated persons and 128 staff tested, 30.5% of incarcerated persons (range by housing unit = 0.0%-58.2%) and 2.3% of staff tested positive for SARS-CoV-2. Among those who tested positive and responded to symptom questions (431 incarcerated persons, 3 staff), 81.2% and 33.3% were asymptomatic, respectively. Most incarcerated persons (58.0%) reported wearing cloth face coverings 8 hours or less per day, and 63.3% reported close contact with someone other than their bunkmate.Conclusions. If testing remained limited to symptomatic individuals, fewer cases would have been detected or detection would have been delayed, allowing transmission to continue. Rapid implementation of mass testing and strict enforcement of infection prevention and control measures may be needed to mitigate spread of SARS-CoV-2 in this setting.

Low engagement in HIV services and progress through the treatment cascade among key populations living with HIV in Mozambique: alarming gaps in knowledge of status.

BACKGROUND: Mozambique has a generalized HIV epidemic of 13.5% among the general population. Early modeling exercises in Mozambique estimate that key populations (KP), defined as men who have sex with men (MSM), female sex workers (FSW), and people who inject drugs (PWID), along with their partners account for about one third of all new infections. There is limited data describing the engagement of KP living with HIV in testing, care and treatment services. METHODS: We conducted a secondary data analysis of HIV-positive participants in the first Bio-behavioral Surveillance (BBS) surveys in Mozambique conducted 2011-2014 in order to assess service uptake and progress though the HIV treatment cascade among MSM, FSW, and PWID. Unweighted pooled estimates were calculated for each key population group. RESULTS: Among HIV-positive MSM, 63.2% of participants had ever received an HIV test, 8.8% were aware of their status, 6.1% reported having been linked to care, while 3.5% initiated ART and were currently on treatment. Of the HIV-infected FSW participants, 76.5% reported a previous HIV test and 22.4% were previously aware of their status. Linkage to care was reported by 20.1%, while 12.7% reported having initiated ART and 11.8% reported being on treatment at the time of the survey. Among HIV-infected PWID participants, 79.9% had previously received an HIV test, 63.2% were aware of their HIV status, and 49.0% reported being linked to care for their HIV infection. ART initiation was reported by 42.7% of participants, while 29.4% were on ART at the time of the survey. CONCLUSION: Among the three high risk populations in Mozambique, losses occurred throughout critical areas of service uptake with the most alarming breakpoint occurring at knowledge of HIV status. Special attention should be given to increasing HIV testing and linkage to ART treatment. Future surveys will provide the opportunity to monitor improvements across the cascade in line with global targets and should include viral load testing to guarantee a more complete picture of the treatment cascade.

Recognizing the hidden: strengthening the HIV surveillance system among key and priority populations in Mozambique.

High quality, representative data from HIV surveillance systems that have country ownership and commitment are critical for guiding national HIV responses, especially among key and priority populations given their disproportionate role in the transmission of the virus. Between 2011 to 2013, the Mozambique Ministry of Health has conducted five Biobehavioral Surveillance Surveys among key populations (female sex workers, men who has sex with men and people who inject drugs) and priority populations (long distance truck drives and miners) as part of the national HIV surveillance system. We describe the experience of strengthening the HIV surveillance system among those populations through the implementation of these surveys in Mozambique. We document the lessons learned through the impact on coordination and collaboration; workforce development and institutional capacity building; data use and dissemination; advocacy and policy impact; financial sustainability and community impact. Key lessons learned include the importance of multisectoral collaboration, vital role of data to support key populations visibility and advocacy efforts, and institutional capacity building of government agencies and key populations organizations. Given that traditional surveillance methodologies from routine data often do not capture these hidden populations, it will be important to ensure that Biobehavioral Surveillance Surveys are an integral part of ongoing HIV surveillance activities in Mozambique.

Recognizing the hidden: strengthening the hiv surveillance system among key and priority populations in mozambique

High quality, representative data from HIV surveillance systems that have country ownership and commitment are critical for guiding national HIV responses, especially among key and priority populations given their disproportionate role in the transmission of the virus. Between 2011 to 2013, the Mozambique Ministry of Health has conducted five Biobehavioral Surveillance Surveys among key populations (female sex workers, men who has sex with men and people who inject drugs) and priority populations (long distance truck drives and miners) as part of the national HIV surveillance system. We describe the experience of strengthening the HIV surveillance system among those populations through the implementation of these surveys in Mozambique. We document the lessons learned through the impact on coordination and collaboration; workforce development and institutional capacity building; data use and dissemination; advocacy and policy impact; financial sustainability and community impact. Key lessons learned include the importance of multisectoral collaboration, vital role of data to support key populations visibility and advocacy efforts, and institutional capacity building of government agencies and key populations organizations. Given that traditional surveillance methodologies from routine data often do not capture these hidden populations, it will be important to ensure that Biobehavioral Surveillance Surveys are an integral part of ongoing HIV surveillance activities in Mozambique.

Continued Low Efficacy of Artemether-Lumefantrine in Angola in 2019.

Biennial therapeutic efficacy monitoring is a crucial activity for ensuring the efficacy of currently used artemisinin-based combination therapy in Angola. Children with acute uncomplicated Plasmodium falciparum infection in sentinel sites in the Benguela, Zaire, and Lunda Sul Provinces were treated with artemether-lumefantrine (AL) or artesunate-amodiaquine (ASAQ) and monitored for 28 days to assess clinical and parasitological responses. Molecular correction was performed using seven microsatellite markers. Samples from treatment failures were genotyped for the pfk13, pfcrt, and pfmdr1 genes. Day 3 clearance rates were ≥95% in all arms. Uncorrected day 28 Kaplan-Meier efficacy estimates ranged from 84.2 to 90.1% for the AL arms and 84.7 to 100% for the ASAQ arms. Corrected day 28 estimates were 87.6% (95% confidence interval [CI], 81 to 95%) for the AL arm in Lunda Sul, 92.2% (95% CI, 87 to 98%) for AL in Zaire, 95.6% (95% CI, 91 to 100%) for ASAQ in Zaire, 98.4% (95% CI, 96 to 100%) for AL in Benguela, and 100% for ASAQ in Benguela and Lunda Sul. All 103 analyzed samples had wild-type pfk13 sequences. The 76T pfcrt allele was found in most (92%; 11/12) ASAQ late-failure samples but in only 16% (4/25) of AL failure samples. The N86 pfmdr1 allele was found in 97% (34/35) of treatment failures. The AL efficacy in Lunda Sul was below the 90% World Health Organization threshold, the third time in four rounds that this threshold was crossed for an AL arm in Angola. In contrast, the observed ASAQ efficacy has not been below 95% to date in Angola, including this latest round.

Infection control response to an outbreak of OXA-23 carbapenemase-producing carbapenem-resistant Acinetobacter baumannii in a skilled nursing facility in Utah.

BACKGROUND: Antibiotic-resistant Acinetobacter species are a growing public health threat, yet are not nationally notifiable, and most states do not mandate reporting. Additionally, there are no standardized methods to detect Acinetobacter species colonization. METHODS: An outbreak of carbapenem-resistant Acinetobacter baumannii (CRAB) was identified at a Utah ventilator unit in a skilled nursing facility. An investigation was conducted to identify transmission modes in order to control spread of CRAB. Culture-based methods were used to identify patient colonization and environmental contamination in the facility. RESULTS: Of the 47 patients screened, OXA-23-producing CRAB were detected in 10 patients (21%), with 7 patients (15%) having been transferred from out-of-state facilities. Of patients who screened positive, 60% did not exhibit any signs or symptoms of active infection by chart review. A total of 38 environmental samples were collected and CRAB was recovered from 37% of those samples. Whole genome sequencing analyses of patient and environmental isolates suggested repeated CRAB introduction into the facility and highlighted the role of shared equipment in transmission. CONCLUSIONS: The investigation demonstrated this ventilated skilled nursing facility was an important reservoir for CRAB in the community and highlights the need for improved surveillance, strengthened infection control and inter-facility communication within and across states.

Population Size Estimate of Men Who Have Sex With Men, Female Sex Workers, and People Who Inject Drugs in Mozambique: A Multiple Methods Approach.

BACKGROUND: Accurate estimates of key population size are necessary to design programs and policies to prevent and reduce new HIV infections and to monitor the dynamics of the epidemic. The first bio-behavioral surveillance surveys, with population size estimation activities, were conducted in Mozambique in 2010 to 2014. METHODS: We used multiple methods-sequential sampling, unique object, unique event, and service multipliers-to estimate the numbers of men who have sex with men (MSM), female sex workers (FSW), and people who inject drugs (PWID) living in major cities in Mozambique. Results were applied to population sizes to estimate the number of people living with HIV and those unaware of their status. RESULTS: Our results suggest that Maputo has 5182 MSM, which constitutes 1.0% of the adult male population (plausibility bounds, 0.5%-2.6%); Beira, 1796 (1.4%, 1.0%-2.2%); and Nampula, 874 (0.6%, 0.4%-1.6%). The number of FSW population is 1514 (0.6%; plausibility bounds, 0.4%-1.6% of adult female city population) in Maputo, 2616 (2.2%, 1.3%-6.0%) in Beira, and 2052 (1.4%, 0.8%-5.9%) in Nampula. The number of people who inject drugs is 2518 (0.4%; plausibility bounds, 0.3%-0.5% of adult male city population) in Maputo and 1982 (1.2%, 0.6%-1.9%) in Nampula. People living with HIV ranged from 25 to 497 MSM, 382 to 664 FSW, and 712 to 1340 PWID, whereas people living with HIV unaware of their HIV positive serostatus ranged from 24 to 486 MSM, 327 to 552 FSW, and 265 to 468 PWID. CONCLUSIONS: Although estimates generally fell within the range of those from the literature, the triangulation of survey and programmatic data over time will increasingly refine population size estimates and support the optimal allocation of limited resources.

Access to and use of health and social services among people who inject drugs in two urban areas of Mozambique, 2014: qualitative results from a formative assessment.

BACKGROUND: Prior to 2014, data about health seeking behaviors or service uptake for People who inject drugs (PWID) in Mozambique did not exist. We present the results from the formative assessment component of the Biological and Behavioral Survey (BBS). METHODS: Standardized interview guides were used during key informant interviews (KII) and focus group discussions (FGD) in Maputo and Nampula/Nacala to discuss issues related to risk behaviors and access to and utilization of health and social services by PWID. The target sample size was not defined a priori, but instead KII and FGD were conducted until responses reached saturation. Data analysis was based on the principles of grounded theory related to qualitative research. RESULTS: Eighty-eight respondents, ages 15 to 60, participated in KIIs and FGDs. Participants were majority male from diverse income and education levels and included current and former PWID, non-injection drug users, health and social service providers, peer educators, and community health workers. Respondents reported that PWID engage in high-risk behaviors such as needle and syringe sharing, exchange of sex for drugs or money, and low condom use. According to participants, PWID would rather rent, share or borrow injection equipment at shooting galleries than purchase them due to stigma, fear of criminalization, transportation and purchase costs, restricted pharmacy hours, personal preference for needle sharing, and immediacy of drug need. Barriers to access and utilization of health and social services include distance, the limited availability of programs for PWID, lack of knowledge of the few programs that exist, concerns about the quality of care provided by health providers, lack of readiness as a result of addiction and perceived stigma related to the use of mental health services offering treatment to PWID. CONCLUSIONS: Mozambique urgently needs to establish specialized harm reduction programs for PWID and improve awareness of available resources. Services should be located in hot spot areas to address issues related to distance, transportation and the planning required for safe injection. Specific attention should go to the creation of PWID-focused health and social services outside of state-sponsored psychiatric treatment centers.

Clinical Sequelae Associated with Unresolved Tropical Splenomegaly in a Cohort of Recently Resettled Congolese Refugees in the United States-Multiple States, 2015-2018.

Tropical splenomegaly is often associated with malaria and schistosomiasis. In 2014 and 2015, 145 Congolese refugees in western Uganda diagnosed with splenomegaly during predeparture medical examinations underwent enhanced screening for various etiologies. After anecdotal reports of unresolved splenomegaly and complications after U.S. arrival, patients were reassessed to describe long-term clinical progression after arrival in the United States. Post-arrival medical information was obtained through medical chart abstraction in collaboration with state health partners in nine participating states. We evaluated observed splenomegaly duration and associated clinical sequelae between 130 case patients from eastern Congo and 102 controls through adjusted hierarchical Poisson models, accounting for familial clustering. Of the 130 case patients, 95 (73.1%) had detectable splenomegaly after arrival. Of the 85 patients with records beyond 6 months, 45 (52.9%) had persistent splenomegaly, with a median persistence of 14.7 months (range 6.0-27.9 months). Of the 112 patients with available results, 65 (58.0%) patients had evidence of malaria infection, and the mean splenomegaly duration did not differ by Plasmodium species. Refugees with splenomegaly on arrival were 43% more likely to have anemia (adjusted relative risk [aRR]: 1.43, 95% CI: 1.04-1.97). Those with persistent splenomegaly were 60% more likely (adjusted relative risk [aRR]: 1.60, 95% CI: 1.15-2.23) to have a hematologic abnormality, particularly thrombocytopenia (aRR: 5.53, 95% CI: 1.73-17.62), and elevated alkaline phosphatase (aRR: 1.57, 95% CI: 1.03-2.40). Many patients experienced persistent splenomegaly, contradicting literature describing resolution after treatment and removal from an endemic setting. Other possible etiologies should be investigated and effective treatment, beyond treatment for malaria and schistosomiasis, explored.

Artemether-Lumefantrine Efficacy for the Treatment of Uncomplicated Plasmodium falciparum Malaria in Choco, Colombia after 8 Years as First-Line Treatment.

Artemether-lumefantrine (AL) is the first-line treatment for uncomplicated Plasmodium falciparum infection in Colombia. To assess AL efficacy for uncomplicated falciparum malaria in Quibdo, Choco, Colombia, we conducted a 28-day therapeutic efficacy study (TES) following the WHO guidelines. From July 2018 to February 2019, febrile patients aged 5-65 years with microscopy-confirmed P. falciparum mono-infection and asexual parasite density of 250-100,000 parasites/µL were enrolled and treated with a supervised 3-day course of AL. The primary endpoint was adequate clinical and parasitological response (ACPR) on day 28. We attempted to use polymerase chain reaction (PCR) genotyping to differentiate reinfection and recrudescence, and conducted genetic testing for antimalarial resistance-associated genes. Eighty-eight patients consented and were enrolled; four were lost to follow-up or missed treatment doses. Therefore, 84 (95.5%) participants reached a valid endpoint: treatment failure or ACPR. No patient remained microscopy positive for malaria on day 3, evidence of delayed parasite clearance and artemisinin resistance. One patient had recurrent infection (12 parasites/µL) on day 28. Uncorrected ACPR rate was 98.8% (83/84) (95% CI: 93.5-100%). The recurrent infection sample did not amplify during molecular testing, giving a PCR-corrected ACPR of 100% (83/83) (95% CI: 95.7-100%). No P. falciparum kelch 13 polymorphisms associated with artemisinin resistance were identified. Our results support high AL efficacy for falciparum malaria in Choco. Because of the time required to conduct TESs in low-endemic settings, it is important to consider complementary alternatives to monitor antimalarial efficacy and resistance.