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1.
Nature ; 575(7781): 119-129, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31695203

RESUMO

Vaccination against infectious diseases has changed the future of the human species, saving millions of lives every year, both children and adults, and providing major benefits to society as a whole. Here we show, however, that national and sub-national coverage of vaccination varies greatly and major unmet needs persist. Although scientific progress opens exciting perspectives in terms of new vaccines, the pathway from discovery to sustainable implementation can be long and difficult, from the financing, development and licensing to programme implementation and public acceptance. Immunization is one of the best investments in health and should remain a priority for research, industry, public health and society.


Assuntos
Desenvolvimento de Medicamentos/economia , Vacinação/tendências , Vacinas/imunologia , Vacinas/provisão & distribução , Animais , Humanos , Mortalidade , Filipinas/epidemiologia , Mudança Social , Vacinação/economia , Vacinas/economia
3.
Int Health ; 11(5): 334-337, 2019 09 02.
Artigo em Inglês | MEDLINE | ID: mdl-31385587

RESUMO

Recent disease outbreaks have demonstrated the severe health, economic and political crises that epidemics can trigger. The rate of emergence of infectious diseases is accelerating and, with deepening globalisation, pathogens are increasingly mobile. Yet the 2014-2015 West African Ebola epidemic exposed major gaps in the world's capacity to prevent and respond to epidemics. In the midst of the world's second largest ever recorded Ebola outbreak in the Democratic Republic of the Congo, we reflect on six of the many lessons learnt from the epidemic in West Africa, focusing on progress made and the challenges ahead in preparing for future threats. While Ebola and other emerging epidemics will remain a challenge in the years to come, by working in partnership with affected communities and across sectors, and by investing in robust health systems, it is within our power to be better prepared when they strike.


Assuntos
Surtos de Doenças/prevenção & controle , Epidemias/prevenção & controle , Saúde Global , Doença pelo Vírus Ebola/epidemiologia , África Ocidental/epidemiologia , República Democrática do Congo/epidemiologia , Humanos
4.
Nature ; 570(7760): 189-193, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31092927

RESUMO

HIV/AIDS is a leading cause of disease burden in sub-Saharan Africa. Existing evidence has demonstrated that there is substantial local variation in the prevalence of HIV; however, subnational variation has not been investigated at a high spatial resolution across the continent. Here we explore within-country variation at a 5 × 5-km resolution in sub-Saharan Africa by estimating the prevalence of HIV among adults (aged 15-49 years) and the corresponding number of people living with HIV from 2000 to 2017. Our analysis reveals substantial within-country variation in the prevalence of HIV throughout sub-Saharan Africa and local differences in both the direction and rate of change in HIV prevalence between 2000 and 2017, highlighting the degree to which important local differences are masked when examining trends at the country level. These fine-scale estimates of HIV prevalence across space and time provide an important tool for precisely targeting the interventions that are necessary to bringing HIV infections under control in sub-Saharan Africa.

6.
BMJ Glob Health ; 4(Suppl 2): e001179, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30815287

RESUMO

Diagnostics are fundamental for successful outbreak containment. In this supplement, 'Diagnostic preparedness for WHO Blueprint pathogens', we describe specific diagnostic challenges presented by selected priority pathogens most likely to cause future epidemics. Some challenges to diagnostic preparedness are common to all outbreak situations, as highlighted by recent outbreaks of Ebola, Zika and yellow fever. In this article, we review these overarching challenges and explore potential solutions. Challenges include fragmented and unreliable funding pathways, limited access to specimens and reagents, inadequate diagnostic testing capacity at both national and community levels of healthcare and lack of incentives for companies to develop and manufacture diagnostics for priority pathogens during non-outbreak periods. Addressing these challenges in an efficient and effective way will require multiple stakeholders-public and private-coordinated in implementing a holistic approach to diagnostics preparedness. All require strengthening of healthcare system diagnostic capacity (including surveillance and education of healthcare workers), establishment of sustainable financing and market strategies and integration of diagnostics with existing mechanisms. Identifying overlaps in diagnostic development needs across different priority pathogens would allow more timely and cost-effective use of resources than a pathogen by pathogen approach; target product profiles for diagnostics should be refined accordingly. We recommend the establishment of a global forum to bring together representatives from all key stakeholders required for the response to develop a coordinated implementation plan. In addition, we should explore if and how existing mechanisms to address challenges to the vaccines sector, such as Coalition for Epidemic Preparedness Innovations and Gavi, could be expanded to cover diagnostics.

7.
Trans R Soc Trop Med Hyg ; 112(12): 527-528, 2018 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-30137538

RESUMO

In the late 1970s, early investigations into the Ebola virus informed the world's understanding of what was then an unknown disease. One such study, published by Bowen and colleagues in 1978, laid the foundations for future research into its prevention and treatment. However, nearly four decades later, scientific progress had not translated into action on the ground with no approved drugs, no vaccines, and no diagnostic tests available when the 2014-15 outbreak began in West Africa. Encouragingly, it appears that we have learned important lessons from the 2014-2015 outbreak, with a swift and rigorous response to the most recent outbreaks in Équateur Province, Democratic Republic of Congo, including the deployment of a vaccine. Ebola will certainly remain a challenge in the years to come and we as the global health community must ensure that innovative research translates into policy and action on the ground, with the full participation of affected communities.


Assuntos
Ebolavirus/patogenicidade , Doença pelo Vírus Ebola/epidemiologia , Doença pelo Vírus Ebola/história , África Ocidental/epidemiologia , Surtos de Doenças/história , Doença pelo Vírus Ebola/diagnóstico , História do Século XX , História do Século XXI , Humanos
12.
AIDS Care ; 30(1): 103-115, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28679283

RESUMO

Non-communicable diseases (NCDs), including cardiovascular diseases (CVD), hypertension and diabetes together with HIV infection are among the major public health concerns worldwide. Health services for HIV and NCDs require health systems that provide for people's chronic care needs, which present an opportunity to coordinate efforts and create synergies between programs to benefit people living with HIV and/or AIDS and NCDs. This review included studies that reported service integration for HIV and/or AIDS with coronary heart diseases, chronic CVD, cerebrovascular diseases (stroke), hypertension or diabetes. We searched multiple databases from inception until October 2015. Articles were screened independently by two reviewers and assessed for risk of bias. 11,057 records were identified with 7,616 after duplicate removal. After screening titles and abstracts, 14 papers addressing 17 distinct interventions met the inclusion criteria. We categorized integration models by diseases (HIV with diabetes, HIV with hypertension and diabetes, HIV with CVD and finally HIV with hypertension and CVD and diabetes). Models also looked at integration from micro (patient focused integration) to macro (system level integrations). Most reported integration of hypertension and diabetes with HIV and AIDS services and described multidisciplinary collaboration, shared protocols, and incorporating screening activities into community campaigns. Integration took place exclusively at the meso-level, with no micro- or macro-level integrations described. Most were descriptive studies, with one cohort study reporting evaluative outcomes. Several innovative initiatives were identified and studies showed that CVD and HIV service integration is feasible. Integration should build on existing protocols and use the community as a locus for advocacy and health services, while promoting multidisciplinary teams, including greater involvement of pharmacists. There is a need for robust and well-designed studies at all levels - particularly macro-level studies, research looking at long-term outcomes of integration, and research in a more diverse range of countries.


Assuntos
Doenças Cardiovasculares/terapia , Doença Crônica/terapia , Prestação Integrada de Cuidados de Saúde/métodos , Prestação Integrada de Cuidados de Saúde/organização & administração , Diabetes Mellitus Tipo 2/terapia , Infecções por HIV/complicações , Hipertensão/terapia , Doenças Cardiovasculares/complicações , Diabetes Mellitus Tipo 2/complicações , Infecções por HIV/terapia , Humanos , Hipertensão/complicações
13.
J Infect Dis ; 217(2): 223-231, 2018 01 04.
Artigo em Inglês | MEDLINE | ID: mdl-29253164

RESUMO

The first reported outbreak of Ebola virus disease occurred in 1976 in Yambuku, Democratic Republic of Congo. Antibody responses in survivors 11 years after infection have been documented. However, this report is the first characterization of anti-Ebola virus antibody persistence and neutralization capacity 40 years after infection. Using ELISAs we measured survivor's immunological response to Ebola virus Zaire (EBOV) glycoprotein and nucleoprotein, and assessed VP40 reactivity. Neutralization of EBOV was measured using a pseudovirus approach and plaque reduction neutralization test with live EBOV. Some survivors from the original EBOV outbreak still harbor antibodies against all 3 measures. Interestingly, a subset of these survivors' serum antibodies could still neutralize live virus 40 years postinitial infection. These data provide the longest documentation of both anti-Ebola serological response and neutralization capacity within any survivor cohort, extending the known duration of response from 11 years postinfection to at least 40 years after symptomatic infection.


Assuntos
Anticorpos Neutralizantes/sangue , Anticorpos Antivirais/sangue , Surtos de Doenças , Ebolavirus/imunologia , Doença pelo Vírus Ebola/imunologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Antígenos Virais/imunologia , República Democrática do Congo/epidemiologia , Ensaio de Imunoadsorção Enzimática , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Testes de Neutralização , Inquéritos e Questionários , Sobreviventes , Fatores de Tempo , Ensaio de Placa Viral , Adulto Jovem
14.
Health Policy Plan ; 32(suppl_4): iv27-iv47, 2017 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-29106512

RESUMO

Background: The frequency in which HIV and AIDS and mental health problems co-exist, and the complex bi-directional relationship between them, highlights the need for effective care models combining services for HIV and mental health. Here, we present a systematic review that synthesizes the literature on interventions and approaches integrating these services. Methods: This review was part of a larger systematic review on integration of services for HIV and non-communicable diseases. Eligible studies included those that described or evaluated an intervention or approach aimed at integrating HIV and mental health care. We searched multiple databases from inception until October 2015, independently screened articles identified for inclusion, conducted data extraction, and assessed evaluative papers for risk of bias. Results: Forty-five articles were eligible for this review. We identified three models of integration at the meso and micro levels: single-facility integration, multi-facility integration, and integrated care coordinated by a non-physician case manager. Single-site integration enhances multidisciplinary coordination and reduces access barriers for patients. However, the practicality and cost-effectiveness of providing a full continuum of specialized care on-site for patients with complex needs is arguable. Integration based on a collaborative network of specialized agencies may serve those with multiple co-morbidities but fragmented and poorly coordinated care can pose barriers. Integrated care coordinated by a single case manager can enable continuity of care for patients but requires appropriate training and support for case managers. Involving patients as key actors in facilitating integration within their own treatment plan is a promising approach. Conclusion: This review identified much diversity in integration models combining HIV and mental health services, which are shown to have potential in yielding positive patient and service delivery outcomes when implemented within appropriate contexts. Our review revealed a lack of research in low- and middle- income countries, and was limited to most studies being descriptive. Overall, studies that seek to evaluate and compare integration models in terms of long-term outcomes and cost-effectiveness are needed, particularly at the health system level and in regions with high HIV and AIDS burden.


Assuntos
Prestação Integrada de Cuidados de Saúde/métodos , Prestação Integrada de Cuidados de Saúde/organização & administração , Infecções por HIV/terapia , Serviços de Saúde Mental/organização & administração , Gerentes de Casos , Países Desenvolvidos , Humanos
15.
Lancet ; 390(10113): 2662-2672, 2017 Dec 16.
Artigo em Inglês | MEDLINE | ID: mdl-29031848

RESUMO

BACKGROUND: Predicting when and where pathogens will emerge is difficult, yet, as shown by the recent Ebola and Zika epidemics, effective and timely responses are key. It is therefore crucial to transition from reactive to proactive responses for these pathogens. To better identify priorities for outbreak mitigation and prevention, we developed a cohesive framework combining disparate methods and data sources, and assessed subnational pandemic potential for four viral haemorrhagic fevers in Africa, Crimean-Congo haemorrhagic fever, Ebola virus disease, Lassa fever, and Marburg virus disease. METHODS: In this multistage analysis, we quantified three stages underlying the potential of widespread viral haemorrhagic fever epidemics. Environmental suitability maps were used to define stage 1, index-case potential, which assesses populations at risk of infection due to spillover from zoonotic hosts or vectors, identifying where index cases could present. Stage 2, outbreak potential, iterates upon an existing framework, the Index for Risk Management, to measure potential for secondary spread in people within specific communities. For stage 3, epidemic potential, we combined local and international scale connectivity assessments with stage 2 to evaluate possible spread of local outbreaks nationally, regionally, and internationally. FINDINGS: We found epidemic potential to vary within Africa, with regions where viral haemorrhagic fever outbreaks have previously occurred (eg, western Africa) and areas currently considered non-endemic (eg, Cameroon and Ethiopia) both ranking highly. Tracking transitions between stages showed how an index case can escalate into a widespread epidemic in the absence of intervention (eg, Nigeria and Guinea). Our analysis showed Chad, Somalia, and South Sudan to be highly susceptible to any outbreak at subnational levels. INTERPRETATION: Our analysis provides a unified assessment of potential epidemic trajectories, with the aim of allowing national and international agencies to pre-emptively evaluate needs and target resources. Within each country, our framework identifies at-risk subnational locations in which to improve surveillance, diagnostic capabilities, and health systems in parallel with the design of policies for optimal responses at each stage. In conjunction with pandemic preparedness activities, assessments such as ours can identify regions where needs and provisions do not align, and thus should be targeted for future strengthening and support. FUNDING: Paul G Allen Family Foundation, Bill & Melinda Gates Foundation, Wellcome Trust, UK Department for International Development.


Assuntos
Febres Hemorrágicas Virais/epidemiologia , Pandemias , África/epidemiologia , Surtos de Doenças/estatística & dados numéricos , Epidemias/estatística & dados numéricos , Humanos , Pandemias/estatística & dados numéricos , Medição de Risco
16.
Health Policy Plan ; 32(suppl_4): iv13-iv26, 2017 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-28666336

RESUMO

Integration of services for patients with more than one diagnosed condition has intuitive appeal but it has been argued that the empirical evidence to support it is limited. We report the findings of a systematic review that sought to identify health system factors, extrinsic to the integration process, which either facilitated or hindered the integration of services for two common disorders, HIV and chronic non-communicable diseases. Findings were initially extracted and organized around a health system framework, followed by a thematic cross-cutting analysis and validation steps. Of the 150 articles included, 67% (n = 102) were from high-income countries. The articles explored integration with services for one or several chronic disorders, the most studied being alcohol or substance use disorders (47.7%), and mental health issues (29.5%). Four cross-cutting themes related to the health system were identified. The first and most common theme was the requirement for effective collaboration and coordination: formal and informal productive relationships throughout the system between providers and within teams, and between staff and patients. The second was the need for adequate and appropriately skilled and incentivized health workers-with the right expertise, training and operational support for the programme. The third was the need for supportive institutional structures and dedicated resources. The fourth was leadership in terms of political will, effective managerial oversight and organizational culture, indicating that actual implementation is as important as programme design. A fifth theme, outside the health system, but underpinning all aspects of the system operation, was that placing the patient at the centre of service delivery and responding holistically to their diverse needs. This was an important facilitator of integration. These findings confirm that integration processes in service delivery depend substantially for their success on characteristics of the health systems in which they are embedded.


Assuntos
Doença Crônica/terapia , Prestação Integrada de Cuidados de Saúde/organização & administração , Infecções por HIV/terapia , Integração de Sistemas , Comportamento Cooperativo , Humanos
17.
PLoS One ; 12(7): e0181156, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28732037

RESUMO

BACKGROUND: Cervical cancer is a major public health problem. Even though readily preventable, it is the fourth leading cause of death in women globally. Women living with HIV are at increased risk of invasive cervical cancer, highlighting the need for access to screening and treatment for this population. Integration of services has been proposed as an effective way of improving access to cervical cancer screening especially in areas of high HIV prevalence as well as lower resourced settings. This paper presents the results of a systematic review of programs integrating cervical cancer and HIV services globally, including feasibility, acceptability, clinical outcomes and facilitators for service delivery. METHODS: This is part of a larger systematic review on integration of services for HIV and non-communicable diseases. To be considered for inclusion studies had to report on programs to integrate cervical cancer and HIV services at the level of service delivery. We searched multiple databases including Global Health, Medline and Embase from inception until December 2015. Articles were screened independently by two reviewers for inclusion and data were extracted and assessed for risk of bias. MAIN RESULTS: 11,057 records were identified initially. 7,616 articles were screened by title and abstract for inclusion. A total of 21 papers reporting interventions integrating cervical cancer care and HIV services met the criteria for inclusion. All but one study described integration of cervical cancer screening services into existing HIV services. Most programs also offered treatment of minor lesions, a 'screen-and-treat' approach, with some also offering treatment of larger lesions within the same visit. Three distinct models of integration were identified. One model described integration within the same clinic through training of existing staff. Another model described integration through co-location of services, with the third model describing programs of integration through complex coordination across the care pathway. The studies suggested that integration of cervical cancer services with HIV services using all models was feasible and acceptable to patients. However, several barriers were reported, including high loss to follow up for further treatment, limited human-resources, and logistical and chain management support. Using visual screening methods can facilitate screening and treatment of minor to larger lesions in a single 'screen-and-treat' visit. Complex integration in a single-visit was shown to reduce loss to follow up. The use of existing health infrastructure and funding together with comprehensive staff training and supervision, community engagement and digital technology were some of the many other facilitators for integration reported across models. CONCLUSIONS: This review shows that integration of cervical cancer screening and treatment with HIV services using different models of service delivery is feasible as well as acceptable to women living with HIV. However, the descriptive nature of most papers and lack of data on the effect on long-term outcomes for HIV or cervical cancer limits the inference on the effectiveness of the integrated programs. There is a need for strengthening of health systems across the care continuum and for high quality studies evaluating the effect of integration on HIV as well as on cervical cancer outcomes.


Assuntos
Infecções por HIV/complicações , Infecções por HIV/terapia , Neoplasias do Colo do Útero/complicações , Neoplasias do Colo do Útero/terapia , Feminino , Humanos
18.
Int J Gynaecol Obstet ; 138 Suppl 1: 4-6, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28691327

RESUMO

The outlook for elimination of the scourge of cervical cancer is bright, because we now have the tools to achieve this goal. In recent years human papillomavirus (HPV) vaccination in high-income countries has resulted in dramatic decreases in HPV infection and associated cervical disease. If all countries with a substantial burden of disease introduce the vaccine nationally, we can protect the vast majority of women and girls most at risk. For women who are beyond the vaccination target age, progress has been made in screening and treatment for cervical precancer, but we must accelerate this momentum to reduce incidence and mortality worldwide to the very low rates found in wealthier countries. Human and financial resources must be increased and directed to programs that follow best practices and reach all women, including the marginalized or disadvantaged. Seven key actions are recommended. Now is the time for action at national, regional, and global levels.


Assuntos
Vacinação em Massa , Infecções por Papillomavirus/prevenção & controle , Vacinas contra Papillomavirus/provisão & distribução , Neoplasias do Colo do Útero/prevenção & controle , Feminino , Saúde Global , Implementação de Plano de Saúde , Humanos , Saúde da Mulher
19.
J Int AIDS Soc ; 20(1): 21585, 2017 05 30.
Artigo em Inglês | MEDLINE | ID: mdl-28692211

RESUMO

INTRODUCTION: Substance use is an important risk factor for HIV, with both concentrated in certain vulnerable and marginalized populations. Although their management differs, there may be opportunities to integrate services for substance use and HIV. In this paper we systematically review evidence from studies that sought to integrate care for people living with HIV and substance use problems. METHODS: Studies were included if they evaluated service integration for substance use and HIV. We searched multiple databases from inception until October 2015. Articles were screened independently by two reviewers and assessed for risk of bias. RESULTS AND DISCUSSION: 11,057 records were identified, with 7616 after removal of duplicates. After screening titles and abstracts, 51 met the inclusion criteria. Integration models were categorized by location (HIV, substance use and other facilities), level of integration from mirco (integrated care delivered to individuals) to macro (system level integrations) and degree of integration from least (screening and counselling only) to most (care for HIV, substance use and/or other illnesses at the same facility). Most reported descriptive or cohort studies; in four randomized control trials integrated activities improved patient outcomes. There is potential for integrating services at all facility types, including mobile health services. While services offering screening only can achieve synergies, there are benefits from delivering integrated treatment for HIV and substance use, including ease of referral to other mental health and social services. CONCLUSIONS: Our review used a wide range of databases and conference archives to increase representation of papers from low- and middle-income countries. Limitations include the overrepresentation of studies from the United States, and the descriptive nature of the majority of papers. The evidence reviewed shows that greater integration offers important benefits in both patient and service outcomes but further research and outcome reporting is needed to better understand innovative and holistic care models at the complex intersection of substance use and HIV services.


Assuntos
Aconselhamento , Infecções por HIV/terapia , Transtornos Relacionados ao Uso de Substâncias/terapia , Prestação Integrada de Cuidados de Saúde , Infecções por HIV/prevenção & controle , Humanos
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