Coverage survey and lessons learned from a pre-emptive cholera vaccination campaign in urban and rural communities affected by landslides and floods in Freetown Sierra Leone.

BACKGROUND: On 14 August 2017, massive landslides and floods hit Freetown (Sierra Leone). More than 1,000 people lost their lives while approximately 6,000 people were displaced. The areas most affected included parts of the town with challenged access to basic water and sanitation facilities, with communal water sources likely contaminated by the disaster. To avert a possible cholera outbreak following this emergency, the Ministry of Health and Sanitation (MoHS), supported by the World Health Organization (WHO) and international partners, including Médecins Sans Frontières (MSF) and UNICEF, launched a two-dose pre-emptive vaccination campaign using Euvichol™, an oral cholera vaccine (OCV). METHODS: We conducted a stratified cluster survey to estimate vaccination coverage during the OCV campaign and also monitor adverse events. The study population - subsequently stratified by age group and residence area type (urban/rural) - included all individuals aged 1 year or older, living in one of the 25 communities targeted for vaccination. RESULTS: In total 3,115 households were visited, 7,189 individuals interviewed; 2,822 (39%) people in rural and 4,367 (61%) in urban areas. The two-dose vaccination coverage was 56% (95% confidence interval (CI): 51.0-61.5), 44% (95%CI: 35.2-53.0) in rural and 57% (95%CI: 51.6-62.8) in urban areas. Vaccination coverage with at least one dose was 82% (95%CI: 77.3-85.5), 61% (95%CI: 52.0-70.2) in rural and 83% (95%CI: 78.5-87.1) in urban areas. CONCLUSIONS: The Freetown OCV campaign exemplified a timely public health intervention to prevent a cholera outbreak, even if coverage was lower than expected. We hypothesised that vaccination coverage in Freetown was sufficient in providing at least short-term immunity to the population. However, long-term interventions to ensure access to safe water and sanitation are needed.

Changing sero-epidemiology of hepatitis A in Asia Pacific countries: A systematic review.

OBJECTIVES: Hepatitis A is a viral liver disease whose prevalence is associated with low socio-economic and hygiene levels due to its faecal-oral transmission. Severity increases with age, and immunity is life-long. Decreased endemicity could result in increased age and severity of cases. A literature review was conducted to describe changes in age-stratified hepatitis A seroprevalence in Asia Pacific countries from 1980 to 2016, and to identify gaps in the literature. The PRISMA guidelines were followed. METHODS: The PubMed database was searched for studies on age-specific hepatitis A seroprevalence in 17 Asia Pacific countries. All studies published in the English language, reporting human hepatitis A seroprevalence levels in any age group, were included. RESULTS: Seventy-three publications from 11 countries were identified. A trend of increasing age at first exposure over time was observed, particularly in developed countries such as Japan, Taiwan, Thailand, and Korea, suggesting a transition in terms of endemicity. CONCLUSIONS: Extensive gaps in the literature were identified between countries and year of publication, indicating the need for further research. Decreasing hepatitis A exposure and thus immunity conferred during childhood, may render older populations susceptible to infection. The public health and economic value of vaccination against hepatitis A should be assessed within this changing epidemiological context.

Evidence of High Out of Pocket Spending for HIV Care Leading to Catastrophic Expenditure for Affected Patients in Lao People's Democratic Republic.

BACKGROUND: The scaling up of antiviral treatment (ART) coverage in the past decade has increased access to care for numerous people living with HIV/AIDS (PLWHA) in low-resource settings. Out-of-pocket payments (OOPs) represent a barrier for healthcare access, adherence and ART effectiveness, and can be economically catastrophic for PLWHA and their family. We evaluated OOPs of PLWHA attending outpatient and inpatient care units and estimated the financial burden for their households in the Lao People's Democratic Republic. We assumed that such OOPs may result in catastrophic health expenses in this context with fragile economical balance and low health insurance coverage. METHODS: We conducted a cross-sectional survey of a randomized sample of routine outpatients and a prospective survey of consecutive new inpatients at two referral hospitals (Setthathirat in the capital city, Savannaket in the province). After obtaining informed consent, PLWHA were interviewed using a standardized 82-item questionnaire including information on socio-economic characteristics, disease history and coping strategies. All OOPs occurring during a routine visit or a hospital stay were recorded. Household capacity-to-pay (overall income minus essential expenses), direct and indirect OOPs, OOPs per outpatient visit and per inpatient stay as well as catastrophic spending (greater than or equal to 40% of the capacity-to-pay) were calculated. A multivariate analysis of factors associated with catastrophic spending was conducted. RESULTS: A total of 320 PLWHA [280 inpatients and 40 outpatients; 132 (41.2%) defined as poor, and 269 (84.1%) on ART] were enrolled. Monthly median household income, essential expenses and capacity-to-pay were US$147.0 (IQR: 86-242), $126 (IQR: 82-192) and $14 (IQR: 19-80), respectively. At the provincial hospital OOPs were higher during routine visits, but three fold lower during hospitalization than in the central hospital ($21.0 versus $18.5 and $110.8 versus $329.8 respectively (p<0.01). The most notable OOPs were related to transportation and to loss of income. A total of 150 patients (46.8%; 95%CI: 41.3-52.5) were affected by catastrophic health expenses; 36 outpatients (90.0%; 95%CI: 76.3-97.2) and 114 inpatients (40.7%; 95%CI: 34.9-46.7). A total of 141 (44.0%) patients had contracted loans, and 127 (39.6%) had to sell some of their assets. In the multivariate analysis, being of Lao Loum ethnic group (Coef.-1.4; p = 0.04); being poor (Coef. -1.0; p = 0.01) and living more than 100 km away from the hospital (Coef.-1.0; p = 0.002) were positively associated with catastrophic spending. Conversely being in the highest wealth quartile (Coef. 1.6; p<0.001), living alone (Coef. 1.1; p = 0.04), attending the provincial hospital (Coef. 1.0; p = 0.002), and being on ART (Coef.1.2; p = 0.003), were negatively associated with catastrophic spending. CONCLUSION: PLWHA's households face catastrophic OOPs that are not directly attributable to the cost of ART or to follow-up tests, particularly during a hospitalization period. Transportation, distance to healthcare and time spent at the health facility are the major contributors for OOPs and for indirect opportunity costs. Being on ART and attending the provincial hospital were associated with a lower risk of catastrophic spending. Decentralization of care, access to ART and alleviation of OOPs are crucial factors to successfully decrease the household burden of HIV-AIDS expenses.

An organizational analysis of road traffic crash prevention to explain the difficulties of a national program in a low income country.

BACKGROUND: Road traffic crashes (RTC), that daily kill 3400 people and leave 15,000 with a permanent disability could be prevented through the implementation of safety programs developed in partnership with governments and institutions. The relationship between key stakeholders can be a crucial determinant to the effectiveness of road safety programs. This issue has rarely been addressed. We conducted a detailed organizational analysis of the stakeholders involved in road safety programs in Lao People's Democratic Republic (Lao PDR). METHODS: A case study was performed. The framework used was a snowball effect in which the characterization of all key stakeholders and the links between them, as well as the factors that led to these links, were determined. The effect of the relations between key stakeholders on the prevention of RTC was assessed through an analysis of the transactional, intangible and controlling factors that influence these relationships. RESULTS: The design and implementation of road safety programs in Lao PDR suffer from weak relationships between stakeholders and a poorly functional bicephal leadership between the Ministry of Public Works and Transport and the non-governmental organisation called Handicap International. This poor coordination between key stakeholders is evident, particularly in the area of collective action and is reinforced by a lack of interest from several different stakeholders. Most agencies do not prioritize road safety. Uneven distribution of funding is another contributing factor. Strengthening the leadership is crucial to the success of the program. Some organisations have skills, power the decision making and the allocation of resources in regards to road safety programs. Encouraging participation of these organizations through a more prominent position would thus result in a better collaboration. Non-monetary rewards would further help to strengthen collaborative work. CONCLUSION: The bicephal nature of the leadership of road safety programs proves detrimental, is associated with a weak coalition between stakeholders, and contributes to the declaimed poor effectiveness of the existing programs. The study has identified non-monetary and realistic means of strengthening the collaboration between key stakeholders. Stakeholders need to revise their interpretive schemes, in order to actively support the reinforcement of government leadership of road safety policies.

IgG1 as a potential biomarker of post-chemotherapeutic relapse in visceral leishmaniasis, and adaptation to a rapid diagnostic test.

BACKGROUND: Visceral leishmaniasis (VL), caused by protozoa of the Leishmania donovani complex, is a widespread parasitic disease of great public health importance; without effective chemotherapy symptomatic VL is usually fatal. Distinction of asymptomatic carriage from progressive disease and the prediction of relapse following treatment are hampered by the lack of prognostic biomarkers for use at point of care. METHODOLOGY/PRINCIPAL FINDINGS: All IgG subclass and IgG isotype antibody levels were determined using unpaired serum samples from Indian and Sudanese patients with differing clinical status of VL, which included pre-treatment active VL, post-treatment cured, post-treatment relapsed, and post kala-azar dermal leishmaniasis (PKDL), as well as seropositive (DAT and/or rK39) endemic healthy controls (EHCs) and seronegative EHCs. L. donovani antigen-specific IgG1 levels were significantly elevated in relapsed versus cured VL patients (p<0.0001). Using paired Indian VL sera, consistent with the known IgG1 half-life, IgG1 levels had not decreased significantly at day 30 after the start of treatment (p = 0.8304), but were dramatically decreased by 6 months compared to day 0 (p = 0.0032) or day 15 (p<0.0001) after start of treatment. Similarly, Sudanese sera taken soon after treatment did not show a significant change in the IgG1 levels (p = 0.3939). Two prototype lateral flow immunochromatographic rapid diagnostic tests (RDTs) were developed to detect IgG1 levels following VL treatment: more than 80% of the relapsed VL patients were IgG1 positive; at least 80% of the cured VL patients were IgG1 negative (p<0.0001). CONCLUSIONS/SIGNIFICANCE: Six months after treatment of active VL, elevated levels of specific IgG1 were associated with treatment failure and relapse, whereas no IgG1 or low levels were detected in cured VL patients. A lateral flow RDT was successfully developed to detect anti-Leishmania IgG1 as a potential biomarker of post-chemotherapeutic relapse.