Missed Plasmodium falciparum and Plasmodium vivax Mixed Infections in Ethiopia Threaten Malaria Elimination.

Plasmodium falciparum and Plasmodium vivax are co-endemic in Ethiopia. This study investigated whether mixed infections were missed by microscopy from a 2017 therapeutic efficacy study at two health facilities in Ethiopia. All patients (N = 304) were initially classified as having single-species P. falciparum (n = 148 samples) or P. vivax infections (n = 156). Dried blood spots were tested for Plasmodium antigens by bead-based multiplex assay for pan-Plasmodium aldolase, pan-Plasmodium lactate dehydrogenase, P. vivax lactate dehydrogenase, and histidine-rich protein 2. Of 304 blood samples, 13 (4.3%) contained both P. falciparum and P. vivax antigens and were analyzed by polymerase chain reaction for species-specific DNA. Of these 13 samples, five were confirmed by polymerase chain reaction for P. falciparum/P. vivax co-infection. One sample, initially classified as P. vivax by microscopy, was found to only have Plasmodium ovale DNA. Plasmodium falciparum/P. vivax mixed infections can be missed by microscopy even in the context of a therapeutic efficacy study with multiple trained readers.

Risk Factors Associated with the Alpine Multispecies Farming System in the Eradication of CAEV in South Tyrol, Italy.

South Tyrol has implemented, in 2007, a mandatory eradication program against Caprine Arthritis Encephalitis Virus (CAEV), a virus known to cause economic losses related to decreases in milk production and milk quality in goats, along with poor animal welfare and premature death. After a great initial decrease in the seroprevalence, the program has reached a tailing phase with scattered positivities. Potential risk factors associated with the multispecies farming system, a traditional approach in South Tyrol, are evaluated in this study, in order to better understand some of the potential causes leading to the tailing phenomenon. A statistically significant number of farms was selected for the present study, based on the risk factors evaluated. Even though there is no statistically significant association between the practices evaluated and the incidence of infection, the authors believe that it is important to highlight potential risks that may threaten the outcome of this eradication program.

Sensitivity of the acute flaccid paralysis surveillance system for poliovirus in South Africa, 2016-2019.

Introduction. Global poliovirus eradication is a public health emergency of international concern. The acute flaccid paralysis (AFP) surveillance programme in South Africa has been instrumental in eliminating polioviruses and keeping the country poliovirus free.Gap statement. The sensitivity of surveillance for polioviruses by every African country is of global interest in the effort to ensure global health security from poliovirus re-emergence.Aim. To describe the epidemiology of polioviruses from AFP cases and environmental samples in South Africa and to report the performance of the AFP surveillance system for the years 2016-2019 against targets established by the World Health Organization (WHO).Methods. Stool specimens from AFP or suspected AFP cases were received and tested as per WHO guidelines. Environmental samples were gathered from sites across the Gauteng province using the grab collection method. Concentration was effected by the two-phase polyethylene glycol method approved by the WHO. Suspected polioviruses were isolated in RD and/or L20B cell cultures through identification of typical cytopathic effects. The presence of polioviruses was confirmed by intratypic differentiation PCR. All polioviruses were sequenced using the Sanger method, and their VP1 gene analysed for mutations.Results. Data from 4597 samples (2385 cases) were analysed from the years 2016-2019. Two cases of immunodeficiency-associated vaccine-derived poliovirus (iVDPV) type 3 were detected in 2017 and 2018. A further 24 Sabin type 1 or type 3 polioviruses were detected for the 4 years. The national surveillance programme detected an average of 3.1 cases of AFP/100 000 individuals under 15 years old (2.8/100 000-3.5/100 000). The stool adequacy of the samples received was 53.0 % (47.0-55.0%), well below the WHO target of 80 % adequacy. More than 90 % of results were released from the laboratory within the turnaround time (96.6 %) and non-polio enteroviruses were detected in 11.6 % of all samples. Environmental surveillance detected non-polio enterovirus in 87.5 % of sewage samples and Sabin polioviruses in 12.5 % of samples.Conclusion. The AFP surveillance programme in South Africa is sensitive to detect polioviruses in South Africa and provided no evidence of wild poliovirus or VDPV circulation in the country.

Feasibility and Effectiveness Studies with Oral Vaccination of Free-Roaming Dogs against Rabies in Thailand.

(1) Background: Thailand has made significant progress in reducing the number of human and animal rabies cases. However, control and elimination of the last remaining pockets of dog-mediated rabies have shown to be burdensome, predominantly as a result of the large numbers of free-roaming dogs without an owner that cannot be restrained without special efforts and therefore remain unvaccinated. To reach these dogs, the feasibility, and benefits of oral rabies vaccination (ORV) as a complementary tool has been examined under field conditions. (2) Methods: ORV of dogs was tested in five study areas of four provinces in Thailand. In these areas, sites with free-roaming dogs were identified with the support of local municipal workers and dog caretakers. ORV teams visited each of five study areas and distributed rabies vaccine (SPBN GASGAS) in three bait formats that were offered to the dogs using a hand-out and retrieval model. The three bait types tested included: egg-flavored baits, egg-flavored baits pasted with commercially available cat liquid snack, and boiled-intestine baits. A dog offered a vaccine bait was considered vaccinated when the discarded sachet was perforated or if a dog chewed vaccine bait at least 5 times before it swallowed the bait, including the sachet. (3) Results: A total of 2444 free-roaming dogs considered inaccessible for parenteral vaccination were identified at 338 sites. As not all dogs were approachable, 79.0% were offered a bait; of these dogs, 91.6% accepted the bait and subsequently 83.0% were considered successfully vaccinated. (4) Conclusion: Overall, 65.6% of the free-roaming dogs at these sites were successfully vaccinated by the oral route. Such a significant increase of the vaccination coverage of the free-roaming dog population could interrupt the rabies transmission cycle and offers a unique opportunity to reach the goal to eliminate dog-mediated human rabies in Thailand by 2030.

Rapid Screening for Non-falciparum Malaria in Elimination Settings Using Multiplex Antigen and Antibody Detection: Post Hoc Identification of Plasmodium malariae in an Infant in Haiti.

Haiti is targeting malaria elimination by 2025. The Grand'Anse department in southwestern Haiti experiences one-third to half of all nationally reported Plasmodium falciparum cases. Although there are historical reports of Plasmodium vivax and Plasmodium malariae, today, non-falciparum infections would remain undetected because of extensive use of falciparum-specific histidine-rich protein 2 (HRP2) rapid diagnostic tests (RDT) at health facilities. A recent case-control study was conducted in Grand'Anse to identify risk factors for P. falciparum infection using HRP2-based RDTs (n = 1,107). Post hoc multiplex Plasmodium antigenemia and antibody (IgG) detection by multiplex bead assay revealed one blood sample positive for pan-Plasmodium aldolase, negative for P. falciparum HRP2, and positive for IgG antibodies to P. malariae. Based on this finding, we selected 52 samples with possible P. malariae infection using IgG and antigenemia data and confirmed infection status by species-specific PCR. We confirmed one P. malariae infection in a 6-month-old infant without travel history. Congenital P. malariae could not be excluded. However, our finding-in combination with historical reports of P. malariae-warrants further investigation into the presence and possible extent of non-falciparum malaria in Haiti. Furthermore, we showed the use of multiplex Plasmodium antigen and IgG detection in selecting samples of interest for subsequent PCR analysis, thereby reducing costs as opposed to testing all available samples by PCR. This is of specific use in low-transmission or eliminating settings where infections are rare.

Towards the elimination of Plasmodium vivax malaria: Implementing the radical cure.

In this review for the Vivax malaria collection, Kamala Thriemer and colleagues explore efforts to eliminate P. vivax malaria.

Achieving global malaria eradication in changing landscapes.

Land use and land cover changes, such as deforestation, agricultural expansion and urbanization, are one of the largest anthropogenic environmental changes globally. Recent initiatives to evaluate the feasibility of malaria eradication have highlighted impacts of landscape changes on malaria transmission and the potential of these changes to undermine malaria control and elimination efforts. Multisectoral approaches are needed to detect and minimize negative impacts of land use and land cover changes on malaria transmission while supporting development aiding malaria control, elimination and ultimately eradication. Pathways through which land use and land cover changes disrupt social and ecological systems to increase or decrease malaria risks are outlined, identifying priorities and opportunities for a global malaria eradication campaign. The impacts of land use and land cover changes on malaria transmission are complex and highly context-specific, with effects changing over time and space. Landscape changes are only one element of a complex development process with wider economic and social dimensions affecting human health and wellbeing. While deforestation and other landscape changes threaten to undermine malaria control efforts and have driven the emergence of zoonotic malaria, most of the malaria elimination successes have been underpinned by agricultural development and land management. Malaria eradication is not feasible without addressing these changing risks while, conversely, consideration of malaria impacts in land management decisions has the potential to significantly accelerate progress towards eradication. Multisectoral cooperation and approaches to linking malaria control and environmental science, such as conducting locally relevant ecological monitoring, integrating landscape data into malaria surveillance systems and designing environmental management strategies to reduce malaria burdens, are essential to achieve malaria eradication.

Risk factors for lymphatic filariasis and mass drug administration non-participation in Mandalay Region, Myanmar.

BACKGROUND: Myanmar commenced a lymphatic filariasis (LF) elimination programme in 2000. Whilst the country has made considerable progress since then, a number of districts have demonstrated persistent transmission after many rounds of mass drug administration (MDA). The causes of unsuccessful MDA have been examined elsewhere; however, there remains little information on the factors that contribute in Myanmar. METHODS: We conducted an analysis of factors associated with persistent infection, LF-related hydrocoele and MDA participation in an area with ongoing transmission in 2015. A cross-sectional household survey was undertaken in 24 villages across four townships of Mandalay Region. Participants were screened for circulating filarial antigen (CFA) using immunochromatographic tests and, if positive, for microfilaria by night-time thick blood slide. Individuals 15 year and older were assessed for filariasis morbidity (lymphoedema and, if male, hydrocoele) by ultrasound-assisted clinical examination. A pre-coded questionnaire was used to assess risk factors for LF and for non-participation (never taking MDA). Significant variables identified in univariate analyses were included in separate step-wise multivariate logistic regressions for each outcome. RESULTS: After adjustment for covariates and survey design, being CFA positive was significantly associated with age [odds ratio (OR) 1.03, 95% CI 1.01-1.06), per year], male gender (OR 3.14, 1.27-7.76), elevation (OR 0.96, 0.94-0.99, per metre) and the density of people per household room (OR 1.59, 1.31-1.92). LF-related hydrocoele was associated with age (OR 1.06, 1.03-1.09, per year) and residing in Amarapura Township (OR 8.93, 1.37-58.32). Never taking MDA was associated with male gender [OR 6.89 (2.13-22.28)] and age, particularly in females, with a significant interaction term. Overall, compared to those aged 30-44 years, the proportion never taking MDA was higher in all age groups (OR highest in those < 5 years and > 60 years, ranging from 3.37 to 12.82). Never taking MDA was also associated with residing in Amarapura township (OR 2.48, 1.15-5.31), moving to one's current village from another (OR 2.62, 1.12-6.11) and ever having declined medication (OR 11.82, 4.25-32.91). Decreased likelihood of never taking MDA was associated with a higher proportion of household members being present during the last MDA round (OR 0.16, 0.03-0.74) and the number visits by the MDA programme (OR 0.69, 0.48-1.00). CONCLUSIONS: These results contribute to the understanding of LF and MDA participation-related risk factors and will assist Myanmar to improve its elimination and morbidity management programmes.

Effects of the implementation of the HIV Treat All guidelines on key ART treatment outcomes in Namibia.

BACKGROUND: This study aimed to help the Namibian government understand the impact of Treat All implementation (started on April 1, 2017) on key antiretroviral therapy (ART) outcomes, and how this transition impacts progress toward the UNAIDS's 90-90-90 HIV targets. METHODS: We collected clinical records from two separate cohorts (before and after treat-all) of ART patients in 10 high- and medium-volume facilities in 6 northern Namibia districts. Each cohort contains 12-month data on patients' scheduled appointments and visits, health status, and viral load results. We also measured patients' wait time and perceptions of service quality using exit interviews with 300 randomly selected patients (per round). We compared ART outcomes of the two cohorts: ART initiation within 7 days from diagnosis, loss to follow-up (LTFU), missed scheduled appointments for at least 30 days, and viral suppression using unadjusted and adjusted analyses. RESULTS: Among new ART clients (on ART for less than 3 months or had not yet initiated treatment as of the start date for the ART record review period), rapid ART initiation (within 7 days from diagnosis) was 5.2 times higher after Treat All than that among clients assessed before the policy took effect [AOR: 5.2 (3.8-6.9)]. However, LTFU was higher after Treat All roll-out compared to before Treat All [AOR: 1.9 (1.3-2.8)]. Established ART clients (on ART treatment for at least three months at the start date of the ART record review period) had over 3 times greater odds of achieving viral suppression after Treat All roll-out compared to established ART clients assessed before Treat All [AOR: 3.1 (1.6-5.9)]. CONCLUSIONS AND RECOMMENDATIONS: The findings indicate positive effect of the "Treat All" implementation on ART initiation and viral suppression, and negative effect on LTFU. Additionally, by April 2018, Namibia seems to have reached the UNAIDS's 90-90-90 targets.

Polio Amidst COVID-19 in Pakistan: What are the Efforts Being Made and Challenges at Hand?

Poliomyelitis, a crippling viral disease, has been affecting many children in Pakistan despite the numerous efforts that have been taken to curb its spread. The COVID-19 pandemic has halted mass polio vaccination campaigns globally, including Pakistan, resulting in a resurgence of new cases. Pakistan managed to flatten the COVID-19 curve from July to October that made three immunization drives possible, but the COVID-19 cases are on the rise again which can again complicate the polio situation in the country if left unmonitored. The efforts of Pakistan have been effective with no significant rise in polio cases in 2020 as compared with 2019. We discuss the numerous challenges faced by the polio eradication program in Pakistan. To help eliminate polio, Pakistan needs to enhance its efforts in the struggle against polio with the same zeal and stringency used to flatten the curve of COVID-19 in these challenging times.

[SWOT analysis of schistosomiasis elimination in Laos].

OBJECTIVE: To analyze the advantages, disadvantages, opportunities and challenges for schistosomiasis elimination in Laos, so as to propose the corresponding healthy policies and suggestions. METHODS: A SWOT analysis was performed to analyze the strength, weakness, opportunity and threat for the schistosomiasis elimination program in Laos, and the corresponding policy suggestions were proposed. RESULTS: The national schistosomiasis elimination program of Laos receives governmental emphases and great supports. A strategy based on mass drug administration was proposed and a sentinel site-bases surveillance system has been built for schistosomiasis elimination in Laos; however, there are several challenges for the national schistosomiasis elimination program in Laos, including insufficient financial supports, inadequate professional capability, weak schistosomiasis control awareness in community populations and difficulty in vector control. CONCLUSIONS: Persistent governmental leadership, increasing financial supports, strengthening professional team building and improving schistosomiasis control awareness in community populations are required to facilitate the progress towards schistosomiasis elimination in Laos.

Exploring factors affecting quality implementation of lymphatic filariasis mass drug administration in Bole and Central Gonja Districts in Northern Ghana.

Ghana has been implementing Mass Drug Administration (MDA) since the year 2001, and Lymphatic Filariasis transmission has been interrupted in 76 out of the 98 targeted districts. The remaining districts have a microfilaria prevalence above the 1% threshold needed for the interruption of transmission. This study assesses the level of lymphatic filariasis MDA coverage and explored factors affecting the quality of implementation of the MDA in the Bole and Central Gonja Districts of Northern Ghana. A concurrent mixed methods study design approach was used to provide both a quantitative and qualitative insight. A descriptive analysis was carried out, and the results are presented in tables and charts. The transcripts of the qualitative interviews were imported into Nvivo and framework methods of analysis were used. The results were summarized based on the themes and buttressed with narratives with key quotes presented within the texts. The overall MDA coverage in Central Gonja is 89.3% while that of Bole district is 82.9%. Refusal to ingest the drug and adverse drug reactions were higher in Bole district than the Central Gonja District. The persistent transmission of lymphatic filariasis in Bole District was characterized by poor community mobilization and sensitization, nonadherence to the directly observed treatment strategy, refusal to ingest the drug due to the fear of adverse drug reactions, inadequate knowledge and misconceptions about the disease. Reported mass drug administration coverage will not necessarily result into interruption of transmission of the disease without strict compliance to the directly observed treatment strategy, strong stakeholder engagement coupled with evidence-based context-specific multi-channel community education strategies with key educational messages on the cause of the disease and adverse drug reactions. While the clock for the elimination of lymphatic filariasis by the year 2020 and meeting of the Sustainable Development Goal 3 target 3.3 by 2030 is ticking, there is an urgent need for a concerted effort to improve the fidelity of the ongoing lymphatic filariasis MDA campaigns in the Bole District of Northern Ghana.

Towards the trachoma elimination target in the Southern region of Ethiopia: How well is the SAFE strategy being implemented?

INTRODUCTION: Trachoma is one of the 20 neglected tropical diseases and a serious public health problem in Ethiopia. To reach the WHO elimination target by 2020, SAFE (Surgery, Antibiotics, Facial cleanliness, Environmental improvement) strategy has been implemented in the Southern Nations, Nationalities, and Peoples' Region (SNNPRs), Ethiopia. Scarce evidence exists regarding recent progress in achieving elimination of active trachoma (< 5%) and how well the SAFE strategy implemented. METHODOLOGY: A retrospective analysis of programmatic data in the period 2013-2018 was used. All trachoma endemic districts in SNNPR were included. Data collected from the Federal Ministry of Health on trachoma prevalence and SAFE strategy were analyzed. RESULTS: Out of 134 endemic districts, only 35 had their planned impact survey, of which only 11 districts achieved the elimination target. Six districts reverted backwards from eliminated status to low (1) or moderate (5) level. The median prevalence of active trachoma in these 35 districts was 10% in 2017/18. In 2017, the mean antibiotic treatment coverage was 90%, but only 56% and 68% of districts implemented and reported on "F" and "E" components, respectively. In the high prevalence districts, only 10% delivered their planned five rounds of Zithromax® mass distribution. CONCLUSIONS: These data showed a lack in planned impact surveys with only a limited number of districts reached the WHO elimination threshold by 2018. Lack of attention on high prevalent districts, and recent reversal of trachoma eliminated districts to moderate or low prevalence levels argue for urgent and prioritized implementation of the SAFE strategy.

The ethical case for global measles eradication-justice and the Rule of Rescue.

Measles causes a substantial disease burden for all countries, while mortality is greatest in underserved, marginalized populations. Global measles eradication is feasible and the strategies critically rely upon well-functioning national immunisation programs and surveillance systems. All six regions of the World Health Organisation have adopted measles elimination targets. The Rule of Rescue and the principle of justice leave no ethical place for health programs, governments, global public health bodies or donors to hide if they impede efforts to eradicate measles globally by not taking all necessary actions to establish a global eradication target and committing the resources essential to achieve this goal.

The African Region early experience with structures for the verification of measles elimination - a review.

Substantial progress has been achieved in the last two decades with the implementation of measles control strategies in the African Region. Elimination of measles is defined as the absence of endemic transmission in a defined geographical region or country for at least 12 months, as documented by a well-performing surveillance system. The framework for documenting elimination outlines five lines of evidence that should be utilized in documenting and assessing progress towards measles elimination. In March 2017, the WHO regional office for Africa developed and disseminated regional guidelines for the verification of measles elimination. As of May 2019, fourteen countries in the African Region have established national verification committees and 8 of these have begun to document progress toward measles elimination. Inadequate awareness, concerns about multiple technical committees for immunization work, inadequate funding and human resources, as well as gaps in data quality and in the implementation of measles elimination strategies have been challenges that hindered the establishment and documentation of progress by national verification committees. We recommend continuous capacity building and advocacy, technical assistance and networking to improve the work around the documentation of country progress towards measles elimination in the African Region.

Descriptive study of measles vaccination second dose reporting and barriers to improving coverage in six districts in Malawi.

INTRODUCTION: Malawi's National Immunization Program introduced a second routine dose of measles containing vaccine (MCV2) in 2015 but found coverage lagging. We assessed data quality and gaps in service delivery. METHODS: Investigators used a modified data quality audit in 6 low performing districts accompanied by questionnaires for health facilities (HF) and households with children with >1 vaccination. RESULTS: MCV2 doses administered according to source were: 733 in registers, 2364 in reports, 1655 in district reports, 2761 in the electronic database. There was 77% agreement regarding status for MCV2 between the register and the home-based record (HBR). Drop-out differences were found between HF according to the practice of waiting for a minimum number of children to open an MCV vial, canceling sessions due to stock-out and requesting payment for a home-based record. Eighty one percent (81%) of children whose caregivers knew 2 doses were needed had received MCV2 vs fifty eight (58%) of children whose caregivers didn't know. Sixty two (62%) of children who were charged for HBR received MCV2 vs 78% reporting no charge. CONCLUSION: The drop-out between the first and second doses of MCV was high and inconsistent with elimination goals. The quality of administrative data in these 6 districts was found to be poor. This investigation found that session cancelation, charging for HBR and lack of caregiver knowledge affected completion of the vaccination series. The authors recommend program improvements in these areas to increase uptake of MCV2 and improved reporting practices at all levels of the system.

The impact of a prolonged ebola outbreak on measles elimination activities in Guinea, Liberia and Sierra Leone, 2014-2015.

INTRODUCTION: Guinea, Sierra Leone and Liberia have attained significant reduction in measles incidence between 2004 and 2013. The Ebola outbreak in 2014-2015 in West Africa caused significant disruption of the health service delivery in the three worst affected countries. The magnitude of the impact on the immunization program has not been well documented. METHODS: We reviewed national routine immunization administrative coverage data as well as measles surveillance performance and measles epidemiology in the years before, during and after the EVD outbreak in Guinea, Liberia, Sierra Leone. RESULTS: Both Liberia and Guinea experienced a sharp decline of more than 25% in the monthly number of children vaccinated against measles in 2014 and 2015 as compared to the previous years, while there was no reported decline in Sierra Leone. Guinea and Liberia experienced a decline in measles surveillance activity and performance indicators in 2014 and 2015. During this period, there was an increase in measles incidence and a decline in the mean age of measles cases reported in Liberia and Sierra Leone. Guinea started reporting high measles incidence in 2016. All three countries organized measles supplemental immunization activities by June 2015. Liberia achieved 99% administrative coverage, while Guinea and Sierra Leone attained 90.6% and 97.2% coverage respectively. There were no severe adverse events reported during these mass vaccination activities. The disruptive effect of the Ebola outbreak on immunization services was especially evident in Guinea and Liberia. Our review of the reported administrative vaccination coverage at national level does not show significant decline in measles first dose vaccination coverage in Sierra Leone as compared to other reports. This may be due to inaccuracies in coverage monitoring and data quality problems. The increases in measles transmission and incidence in these three countries can be explained by the rapid accumulation of susceptible children. Despite the organization of mass vaccination activities, measles incidence through 2017 has remained higher than the pre-Ebola period in all three countries. CONCLUSION: The Ebola outbreak in West Africa significantly affected measles vaccination coverage rates in two of the three worst affected countries, and led to persistent gaps in coverage, along with high measles incidence that was documented until two years after the end of the Ebola outbreak. Liberia and Sierra Leone have demonstrated coverage improvements after the end of the Ebola outbreak.

Recent setbacks in measles elimination: the importance of investing in innovations for immunizations.

The recent setbacks in efforts to achieve measles elimination goals are alarming. To reverse the current trends, it is imperative that the global health community urgently intensify efforts and make resource commitments to implement evidence-based elimination strategies fully, including supporting research and innovations. The Immunization Agenda 2030: A Global Strategy to Leave No One Behind (IA2030) is the new global guidance document that builds on lessons learned and progress made toward the GVAP goals, includes research and innovation as a core strategic priority, and identifies measles as a "tracer" for improving immunisation services and strengthening primary health care systems. To achieve vaccination coverage and equity targets that leave no one behind, and accelerate progress toward disease eradication and elimination goals, sustained and predictable investments are needed for the identified research and innovations priorities for the new decade.