Integrating Social Determinants in Decision-Making Processes for Health: Insights from Conceptual Frameworks-the 3-D Commission.

The inclusion of social determinants of health offers a more comprehensive lens to fully appreciate and effectively address health. However, decision-makers across sectors still struggle to appropriately recognise and act upon these determinants, as illustrated by the ongoing COVID-19 pandemic. Consequently, improving the health of populations remains challenging. This paper seeks to draw insights from the literature to better understand decision-making processes affecting health and the potential to integrate data on social determinants. We summarised commonly cited conceptual approaches across all stages of the policy process, from agenda-setting to evaluation. Nine conceptual approaches were identified, including two frameworks, two models and five theories. From across the selected literature, it became clear that the context, the actors and the type of the health issue are critical variables in decision-making for health, a process that by nature is a dynamic and adaptable one. The majority of these conceptual approaches implicitly suggest a possible role for data on social determinants of health in decision-making. We suggest two main avenues to make the link more explicit: the use of data in giving health problems the appropriate visibility and credibility they require and the use of social determinants of health as a broader framing to more effectively attract the attention of a diverse group of decision-makers with the power to allocate resources. Social determinants of health present opportunities for decision-making, which can target modifiable factors influencing health-i.e. interventions to improve or reduce risks to population health. Future work is needed to build on this review and propose an improved, people-centred and evidence-informed decision-making tool that strongly and explicitly integrates data on social determinants of health.

Improving Decision-Making for Population Health in Nonhealth Sectors in Urban Environments: the Example of the Transportation Sector in Three Megacities-the 3-D Commission.

Noncommunicable diseases (NCDs) represent a significant global public health burden. As more countries experience both epidemiologic transition and increasing urbanization, it is clear that we need approaches to mitigate the growing burden of NCDs. Large and growing urban environments play an important role in shaping risk factors that influence NCDs, pointing to the ineluctable need to engage sectors beyond the health sector in these settings if we are to improve health. By way of one example, the transportation sector plays a critical role in building and sustaining health outcomes in urban environments in general and in megacities in particular. We conducted a qualitative comparative case study design. We compared Bus Rapid Transit (BRT) policies in 3 megacities-Lagos (Africa), Bogotá (South America), and Beijing (Asia). We examined the extent to which data on the social determinants of health, equity considerations, and multisectoral approaches were incorporated into local politics and the decision-making processes surrounding BRT. We found that all three megacities paid inadequate attention to health in their agenda-setting, despite having considerable healthy transportation policies in principle. BRT system policies have the opportunity to improve lifestyle choices for NCDs through a focus on safe, affordable, and effective forms of transportation. There are opportunities to improve decision-making for health by involving more available data for health, building on existing infrastructures, building stronger political leadership and commitments, and establishing formal frameworks to improve multisectoral collaborations within megacities. Future research will benefit from addressing the political and bureaucratic processes of using health data when designing public transportation services, the political and social obstacles involved, and the cross-national lessons that can be learned from other megacities.

"Top-down bottom-up" estimation of per capita cost of new-born care interventions in four regions of Ghana: beyond implementation to scalability and sustainability.

BACKGROUND: Limited financial, human and material health resources coupled with increasing demand for new-born care services require efficiency in health systems to maximize the available sources for improved health outcomes. Making Every Baby Count Initiative (MEBCI) implemented by local and international partners in 2013 in Ghana aimed at attaining neonatal mortality of 21 per 1000 livebirths by 2018 in four administrative regions in Ghana. MEBCI interventions benefited 4027 health providers, out of which 3453 (86%) were clinical healthcare staff. OBJECTIVE: Determine the per capita cost of the MEBCI interventions towards enhancing new-born care best practices through capacity trainings for frontline clinical and non-clinical staff. METHODS: Parameters for determining per capita cost of the new-born care interventions were estimated using expenditure on trainings, supervisions, monitoring and evaluation, advocacy, administrative/services and medical logistics. Data collection started in October 2017 and ended in September 2018. Data sources for the per capita cost estimations were invoices, expense reports and ledger books at the national, regional and district levels of the health system. RESULTS: Total of 4027 healthcare providers benefited from the MEBCI training activities comprising of 3453 clinical staff and 574 non-clinical personnel. Cumulative cost of implementing the MEBCI interventions did not necessarily match the cost per capita in staff capacity building; average cost per capita for all staff (clinical and non-clinical staff) was approximately US$ 982 compared to a per capita cost of US$ 799 for training only core clinical staff. Average cost per capita for all regions was approximately US$ 965 for all staff compared to US$ 777 per capita cost for only clinical staff. Per capita cost of training was relatively lower in regions with more staff than regions with lower numbers, perhaps due to economies of scale. CONCLUSION: The MEBCI intervention had a wide coverage in terms of training for frontline healthcare providers albeit the associated cost may be potentially unsustainable for Ghana's health system. Emerging digital training platforms could be leveraged to reduce per capita cost of training. Large-scale on-site batch-training approach could also be replaced with facility-based workshops using training of trainers (TOTs) approach to promote efficiency.

Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap.

Large disparities in maternal and neonatal mortality exist between low- and high-income countries. Mothers and babies continue to die at high rates in many countries despite substantial increases in facility birth. One reason for this may be the current design of health systems in most low-income countries where, unlike in high-income countries, a substantial proportion of births occur in primary care facilities that cannot offer definitive care for complications. We argue that the current inequity in care for childbirth is a global double standard that limits progress on maternal and newborn survival. We propose that health systems need to be redesigned to shift all deliveries to hospitals or other advanced care facilities to bring care in line with global best practice. Health system redesign will require investing in high-quality hospitals with excellent midwifery and obstetric care, boosting quality of primary care clinics for antenatal, postnatal, and newborn care, decreasing access and financial barriers, and mobilizing populations to demand high-quality care. Redesign is a structural reform that is contingent on political leadership that envisions a health system designed to deliver high-quality, respectful care to all women giving birth. Getting redesign right will require focused investments, local design and adaptation, and robust evaluation.

Level of confidence in and endorsement of the health system among internet users in 12 low-income and middle-income countries.

INTRODUCTION: People's confidence in and endorsement of the health system are key measures of system performance, yet are undermeasured in low-income and middle-income countries (LMICs). We explored the prevalence and predictors of these measures in 12 countries. METHODS: We conducted an internet survey in Argentina, China, Ghana, India, Indonesia, Kenya, Lebanon, Mexico, Morocco, Nigeria, Senegal and South Africa collecting demographics, ratings of quality, and confidence in and endorsement of the health system. We used multivariable logistic regression to assess the association between confidence/endorsement and self-reported quality of recent healthcare. RESULTS: Of 13 489 respondents, 62% reported a health visit in the past year. Applying population weights, 32% of these users were very confident that they could receive effective care if they were to 'become very sick tomorrow'; 30% endorsed the health system, that is, agreed that it 'works pretty well and only needs minor changes'. Reporting high quality in the last visit was associated with 4.48 and 2.69 greater odds of confidence (95% CI 3.64 to 5.52) and endorsement (95% CI 2.33 to 3.11). Having health insurance was positively associated with confidence and endorsement (adjusted odds ratio (AOR) 1.68, 95% CI 1.49 to 1.90 and AOR 1.34, 95% CI 1.22 to 1.48), while experiencing discrimination in healthcare was negatively associated (AOR 0.67, 95% CI 0.56 to 0.80 and AOR 0.63, 95% CI 0.53 to 0.76). CONCLUSION: Confidence and endorsement of the health system were low across 12 LMICs. This may hinder efforts to gain support for universal health coverage. Positive patient experience was strongly associated with confidence in and endorsement of the health system.

Evaluation of two newborn resuscitation training strategies in regional hospitals in Ghana.

AIM: In Ghana, institutional delivery has been emphasized to improve maternal and newborn outcomes. The Making Every Baby Count Initiative, a large coordinated training effort, aimed to improve newborn outcomes through government engagement and provider training across four regions of Ghana. Two newborn resuscitation training and evaluation approaches are described for front line newborn care providers at five regional hospitals. METHODS: A modified newborn resuscitation program was taught at the Greater Accra Regional Hospital (GARH) and evaluated with real-time resuscitation observations. A programmatic shift, led to a different approach being utilized in Sunyani, Koforidua, Ho and Kumasi South Regional Hospitals. This included Helping Babies Breathe (HBB) and Essential Care for Every Baby (ECEB) training followed by objective structured clinical examinations (OSCE) with manikins at fixed intervals. Data was collected on training outcomes, fresh stillbirth and institutional newborn mortality rates. RESULTS: Training was conducted for 412 newborn care providers. For 120 staff trained at GARH, resuscitation observations and chart review found improvements in conducting positive pressure ventilation. For 292 providers that received HBB and ECEB training, OSCE pass rates exceeded 90%, but follow-up decreased from 98% to 84% over time. A decrease in fresh stillbirth and institutional newborn mortality occurred at GARH (p â€‹< â€‹0.05), but not in the other four regional hospitals. CONCLUSION: Newborn resuscitation training is warranted in low-resource settings; however, the optimal training, monitoring and evaluation approach remains unclear, particularly in referral hospitals. Although, mortality reductions were observed at GARH, this cannot be solely attributed to newborn resuscitation training.

Towards universal health coverage: what are the system requirements for effective large-scale community health worker programmes?

Against the background of efforts to strengthen health systems for universal health coverage and health equity, many African countries have been relying on lay members of the community, often referred to as community health workers (CHWs), to deliver primary healthcare services. Growing demand and great variability in definitions, roles, governance and funding of CHWs have prompted the need to revisit CHW programmes and provide guidance on the implementation of successful programmes at scale. Drawing on the synthesised evidence from two extensive literature reviews, this article determines foundational elements of functioning CHW programmes, focusing in particular on the systems requirements of large-scale programmes. It makes recommendations for the effective development of large-scale CHW programmes. The key foundational elements of successful CHW programmes identified are (1) embeddedness, connectivity and integration into the larger system of healthcare service delivery; (2) cadre differentiation and role clarity in order to maintain clear scopes of work and accountability; (3) sound programme design based on local contextual factors and effective people management; and (4) ongoing monitoring, learning and adapting based on accurate and timely local data in order to ensure optimal fit to local context since one size does not fit all. We conclude that CHWs are an investment in health systems strengthening and community resilience with enormous potential for contributing to universal health coverage and the sustainable development goals if well designed and managed. While the evidence base is uneven and mixed, it provides extensive insight and knowledge to strengthen, scale up and sustain CHW programmes throughout Africa.

Expectations of healthcare quality: A cross-sectional study of internet users in 12 low- and middle-income countries.

BACKGROUND: High satisfaction with healthcare is common in low- and middle-income countries (LMICs), despite widespread quality deficits. This may be due to low expectations because people lack knowledge about what constitutes good quality or are resigned about the quality of available services. METHODS AND FINDINGS: We fielded an internet survey in Argentina, China, Ghana, India, Indonesia, Kenya, Lebanon, Mexico, Morocco, Nigeria, Senegal, and South Africa in 2017 (N = 17,996). It included vignettes describing poor-quality services-inadequate technical or interpersonal care-for 2 conditions. After applying population weights, most of our respondents lived in urban areas (59%), had finished primary school (55%), and were under the age of 50 (75%). Just over half were men (51%), and the vast majority reported that they were in good health (73%). Over half (53%) of our study population rated the quality of vignettes describing poor-quality services as good or better. We used multilevel logistic regression and found that good ratings were associated with less education (no formal schooling versus university education; adjusted odds ratio [AOR] 2.22, 95% CI 1.90-2.59, P < 0.001), better self-reported health (excellent versus poor health; AOR 5.19, 95% CI 4.33-6.21, P < 0.001), history of discrimination in healthcare (AOR 1.47, 95% CI 1.36-1.57, P < 0.001), and male gender (AOR 1.32, 95% CI 1.23-1.41, P < 0.001). The survey did not reach nonusers of the internet thus only representing the internet-using population. CONCLUSIONS: Majorities of the internet-using public in 12 LMICs have low expectations of healthcare quality as evidenced by high ratings given to poor-quality care. Low expectations of health services likely dampen demand for quality, reduce pressure on systems to deliver quality care, and inflate satisfaction ratings. Policies and interventions to raise people's expectations of the quality of healthcare they receive should be considered in health system quality reforms.

Evaluating the impact of a hospital scale-up phase of a quality improvement intervention in Ghana on mortality for children under five.

OBJECTIVE: To evaluate the scale-up phase of a national quality improvement initiative across hospitals in Southern Ghana. DESIGN: This evaluation used a comparison of pre- and post-intervention means to assess changes in outcomes over time. Multivariable interrupted time series analyses were performed to determine whether change categories (interventions) tested were associated with improvements in the outcomes. SETTING: Hospitals in Southern Ghana. PARTICIPANTS: The data sources were monthly outcome data from intervention hospitals along with program records. INTERVENTION: The project used a quality improvement approach whereby process failures were identified by health staff and process changes were implemented in hospitals and their corresponding communities. The three change categories were: timely care-seeking, prompt provision of care and adherence to protocols. MAIN OUTCOME MEASURES: Facility-level neonatal mortality, facility-level postneonatal infant mortality and facility-level postneonatal under-five mortality. RESULTS: There were significant improvements for two outcomes from the pre-intervention to the post-intervention phase. Postneonatal infant mortality dropped from 44.3 to 21.1 postneonatal infant deaths per 1000 admissions, while postneonatal under-five mortality fell from 23.1 to 11.8 postneonatal under-five deaths per 1000 admissions. The multivariable interrupted time series analysis indicated that over the long-term the prompt provision of care change category was significantly associated with reduced postneonatal under five mortality (ß = -0.0024, 95% CI -0.0051, 0.0003, P < 0.10). CONCLUSIONS: The reduced postneonatal under-five mortality achieved in this project gives support to the promotion of quality improvement as a means to achieve health impacts at scale.

Absence of an association between Plasmodium falciparum infection and post-ivermectin Loa-related non-neurologic serious adverse events.

Although ivermectin treatment can induce serious adverse events (SAEs) in individuals harboring high Loa loa microfilaremia (mf), not all patients with high mf levels develop such reactions, suggesting that cofactors may be involved. A study was conducted in Cameroon to investigate the possible role of Plasmodium coinfection at the time of ivermectin treatment in the development of SAEs. Before their first ivermectin treatment, thick smears were obtained from 4,175 individuals to determine the burden of Plasmodium sp., L. loa, and Mansonella perstans. After treatment, 18 (4.3 per 1,000) patients developed a non-neurologic SAE. Logistic regression analysis, adjusting for age, sex, P. falciparum infection, and M. perstans infection intensities, confirmed that L. loa mf was the main risk factor for SAEs. We found no evidence that coinfection with P. falciparum at the time of ivermectin treatment was associated with the occurrence of Loa-related SAEs in this population.

Impact evaluation of a quality improvement intervention on maternal and child health outcomes in Northern Ghana: early assessment of a national scale-up project.

OBJECTIVE: To evaluate the influence of the early phase of Project Fives Alive!, a national child survival improvement project, on key maternal and child health outcomes. DESIGN: The evaluation used multivariable interrupted time series analyses to determine whether change categories tested were associated with improvements in the outcomes of interest. PARTICIPANTS: The evaluation used program and outcome data from interventions focused on health-care staff in 27 facilities. SETTING: Northern Ghana. INTERVENTION: The project uses a quality improvement (QI) approach whereby process failures are identified by health staff and process changes are tested in the health facilities and corresponding communities to address those failures. MAIN OUTCOME MEASURES: The maternal health outcomes were early antenatal care attendance and skilled delivery, and the child health outcomes were underweight infants attending child wellness clinics, facility-level neonatal mortality and facility-level infant mortality. RESULTS: Postnatal care changes for the first 1-2 days of life (ß= 0.10, P = 0.07) and the first 6-7 days of life (ß = 0.10, P = 0.07) were associated with a higher rate of visits by underweight infants to child wellness clinics. There was an association between the early pregnancy identification change category with increased skilled delivery (ß = 1.36 P = 0.07). In addition, a greater number of change categories tested was associated with increased skilled delivery (ß = 0.05, P = 0.01). CONCLUSION: The QI approach of testing and implementing simple and low cost locally inspired changes has the potential to lead to improved health outcomes at scale both in Ghana and other low- and middle-income countries.

A nationwide quality improvement project to accelerate Ghana's progress toward Millennium Development Goal Four: design and implementation progress.

QUALITY PROBLEM: The gap between evidence-based guidelines and practice of care is reflected, in low- and middle-income countries, by high rates of maternal and child mortality and limited effectiveness of large-scale programing to decrease those rates. CHOICE OF SOLUTION: We designed a phased, rapid, national scale-up quality improvement (QI) intervention to accelerate the achievement of Millennium Development Goal Four in Ghana. Our intervention promoted systems thinking, active participation of managers and frontline providers, generation and testing of local change ideas using iterative learning from transparent district and local data, local ownership and sustainability. IMPLEMENTATION: After 50 months of implementation, we have completed two prototype learning phases and have begun regional spread phases to all health facilities in all 38 districts of the three northernmost regions and all 29 Catholic hospitals in the remaining regions of the country. To accelerate the spread of improvement, we developed 'change packages' of rigorously tested process changes along the continuum of care from pregnancy to age 5 in both inpatient and outpatient settings. LESSONS LEARNED: The primary successes for the project so far include broad and deep adoption of QI by local stakeholders for improving system performance, widespread capacitation of leaders, managers and frontline providers in QI methods, incorporation of local ideas into change packages and successful scale-up to approximately 25% of the country's districts in 3 years. Implementation challenges include variable leadership uptake and commitment at the district level, delays due to recruiting and scheduling barriers, weak data systems and repeated QI training due to high staff turnover.

Monitoring rare serious adverse events from a new treatment and testing for a difference from historical controls.

BACKGROUND: We detail the design of a study to monitor the safety of including albendazole to an existing treatment regimen to eliminate lymphatic filariasis. We wish to show that this new regimen does not increase the rate of a rare serious adverse event (SAE) compared to the old regimen. Controlled but small clinical trials have not detected any increase in the SAE using albendazole, and it is known to have added benefits; therefore, it is unethical to randomize patients to the old regimen. PURPOSE: A sample size for the new regimen is needed to test that the new rate of SAE is noninferior to the historic rate. If the new regimen does have an inferior rate of SAE then we wish to stop the study early. This setup is different from traditional early stopping for efficacy and futility. In that traditional case, the two stopping decisions are relative to the same null hypothesis of equality, while in our setup, we have two different null hypotheses: the noninferiority null and the equality null. When testing the former, we need not stop early if the new regimen appears better because no subjects are receiving the old regimen anymore anyway. When testing the equality of SAE rates, however, we want to stop early if the new regimen has a significantly higher rate of SAE. METHODS: We create a design that uses an exact difference in proportions test for testing noninferiority, but calculates maximal sample size based on conditional power which treats the historical rates as true rates. The design allows for early stopping if the new treatment appears inferior with respect to SAE rate but makes no corrections for multiple testing. We explore the properties of this naive design without assuming the historical rates are known. RESULTS: For our example, we show that our naive design strategy bounds the type I error of the noninferiority hypothesis in all cases and bounds it for the equality hypothesis at 0.05, as long as the true SAE rate is <0.00015. The same design has unconditional power for the noninferiority hypothesis greater than the nominal 80% as long as the true SAE rate for both regimens are <0.00025. LIMITATIONS: The type I and power results above hold only for our historical sample size of 17,877. We expect similar type I and power properties to hold with studies with SAE rates similar or less (i.e., < 0.00015) and historical sample sizes similar or smaller. CONCLUSIONS: Our design for comparing very rare historical SAE rates to SAE rates of a new treatment has large power to conclude noninferiority of the new treatment SAE rate when both rates are equal, but allows early stopping if the new SAE rates are worse.

Randomized, controlled, double-blind trial with ivermectin on Loa loa microfilaraemia: efficacy of a low dose (approximately 25 microg/kg) versus current standard dose (150 microg/kg).

Neurological serious adverse events (SAEs) following ivermectin treatment may occur in individuals harbouring high Loa loa microfilarial densities and are of major concern in the context of mass ivermectin distributions organized in Africa for onchocerciasis and lymphatic filariasis control. As those SAEs are induced by the rapid and massive microfilaricidal effect of a standard dose of ivermectin (150 microg/kg), we performed a randomized, controlled, double-blind trial to determine whether ivermectin given as: (a) a single low dose of 1.5mg (i.e. 25 microg/kg for a 60 kg person); or (b) two doses of 1.5mg given at a 2 week interval leads to a more progressive decrease in Loa microfilarial loads compared with the standard dosage. A low dose of ivermectin brought about a significantly smaller decrease in Loa microfilaraemia than the standard dose. However, this decrease was not sufficiently different from that obtained after the standard dose to be acceptable to public health programmes, which require a wide safety margin. A second low dose of ivermectin given 15 days after the first dose did not lead to a further decrease in Loa microfilaraemia. Lastly, the variability in the response observed in the group treated with 25 microg/kg suggests that even lower doses would have no effect on a significant number of patients. Ivermectin given at a low dose (

The Mectizan Donation Program - highlights from 2005.

Through the Mectizan Donation Program, Merck & Co., Inc. has donated Mectizan (ivermectin, MSD) for the treatment of onchocerciasis worldwide since 1987. Mectizan has also been donated for the elimination of lymphatic filariasis (LF) since 1998 in African countries and in Yemen where onchocerciasis and LF are co-endemic; for LF elimination programs, Mectizan is co-administered with albendazole, which is donated by GlaxoSmithKline. The Mectizan Donation Program works in collaboration with the Mectizan Expert Committee/Albendazole Coordination, its scientific advisory committee. In 2005, a total of 62,201,310 treatments of Mectizan for onchocerciasis were approved for delivery via mass treatment programs in Africa, Latin America, and Yemen. Seventy-seven percent and 20% of these treatments for onchocerciasis were for countries included in the African Programme for Onchocerciasis Control (APOC) and the former-Onchocerciasis Control Programme in West Africa (OCP), respectively. The remaining 3% of treatments approved were for the six onchocerciasis endemic countries in Latin America, where mass treatment is carried out twice-yearly with the goal of completely eliminating morbidity and eventually transmission of infection, and for Yemen. All 33 onchocerciasis endemic countries where mass treatment with Mectizan is indicated have ongoing mass treatment programs. In 2005, 42,052,583 treatments of co-administered albendazole and Mectizan were approved for national Programs to Eliminate LF (PELFs) in Africa and Yemen. There are ongoing PELFs using albendazole and Mectizan in nine African countries and Yemen; these represent 35% of the total number of countries expected to require the co-administration of these two chemotherapeutic agents for LF elimination. In Africa, the expansion of existing PELFs and the initiation of new ones have been hampered by lack of resources, technical difficulties with the mapping of LF endemicity, and the co-endemicity of LF and loiasis. Included in this review are recommendations recently put forward for the co-administration of albendazole and Mectizan in areas endemic for LF, loiasis, and onchocerciasis.

Editorial: Global elimination of lymphatic filariasis: fact or fantasy?

In 1997, the World Health Assembly resolved to eliminate lymphatic filariasis as a public health problem by the year 2020. By the end of 2004, almost half of the 83 endemic countries had initiated national programmes, providing mass drug administration to an at risk population of approximately 435 million. This remarkable achievement is the result of an enormous amount of technical, financial and political support from public and private sectors at the community, national, regional and global level. As the global programme to eliminate lymphatic filariasis enters its second quarter of operations, there are substantial opportunities to be taken and critical challenges to be addressed. These are the focus of this editorial.

Variation in incidence of serious adverse events after onchocerciasis treatment with ivermectin in areas of Cameroon co-endemic for loiasis.

OBJECTIVE: To determine the incidence of serious adverse events (SAEs) after mass treatment with ivermectin in areas co-endemic for loiasis and onchocerciasis, and to identify potential risk factors associated with the development of these SAEs, in particular encephalopathic SAEs. METHODS: We retrospectively analysed SAEs reported to have occurred between 1 December 1998 and 30 November 1999 in central-southern Cameroon by chart review, interview and examination of a subset of patients. RESULTS: The overall incidence of SAEs for the three provinces studied was 6 per 100,000. However, for Central Province alone the incidence of SAEs was 2.7 per 10,000 overall, and 1.9 per 10,000 for encephalopathic SAEs associated with Loa loa microfilaremia (PLERM). The corresponding rates for the most severely affected district within Central Province (Okola) were 10.5 per 10,000 and 9.2 per 10,000 respectively. Symptoms began within the first 24-48 h of ivermectin administration but there was a delay of approximately 48-84 h in seeking help after the onset of symptoms. First-time exposure to ivermectin was associated with development of PLERM. CONCLUSION: In Cameroon, the incidence of SAEs following ivermectin administration in general, and PLERM cases in particular, varies substantially by district within the areas co-endemic for loiasis and onchocerciasis. More intense surveillance and monitoring in the first 2 days after mass distribution in ivermectin-naïve populations would assist in early recognition, referral and management of these cases. The increased reporting of SAEs from Okola is unexpected and warrants further investigation. Research is urgently needed to find a reliable screening tool to exclude individuals (rather than communities) at risk of PLERM from the mass treatment program.