Core principles of Malakit intervention for transferability in other contexts.

To eliminate malaria, all populations must be included. For those who are not reached by the health care system, specific interventions must be tailor-made. An innovative Malakit strategy, based on the distribution of self-diagnosis and self-treatment kits, has been evaluated in the Suriname-French Guiana- Amapá (Brazil) region. The results showed effectiveness and good acceptability. The Malakit intervention is complex and has many components. Its transferability requires adaptation to other populations and regions, while retaining the main features of the intervention. This article provides the keys to adapting, implementing and evaluating it in other contexts facing residual malaria in hard-to-reach and/or mobile populations. The process of transferring this intervention includes: diagnosis of the situation (malaria epidemiology, characteristics of the population affected) to define the relevance of the strategy; determination of the stakeholders and the framework of the intervention (research project or public health intervention); adaptation modalities (adaptation of the kit, training, distribution strategy); the role of community health workers and their need for training and supervision. Finally, evaluation needs are specified in relation to prospects for geographical or temporal extension. Malaria elimination is likely to increasingly involve marginalized people due to climate change and displacement of populations. Evaluation of the transferability and effectiveness of the Malakit strategy in new contexts will be essential to increase and refine the evidence of its value, and to decide whether it could be an additional tool in the arsenal recommended in future WHO guidelines.

From an interventional study to a national scale-up: lessons learned from the Malakit strategy at the French Guiana-Suriname border.

Scaling-up an experimental intervention is always a challenge. On the border between French Guiana, Brazil and Suriname, an interventional study demonstrated the effectiveness of distributing self-diagnosis and self-treatment kits (Malakits) to control malaria in mobile and hard-to-reach populations. Its integration into the Suriname's National Malaria Elimination Plan after a 2-year experiment faced numerous challenges, including human resources to cope with the additional workload of coordinators and to maintain the motivation of community health workers. The economic recession in Suriname, the Covid pandemic, and logistical issues also hampered the scale-up. Finally, thanks to the commitment of stakeholders in Suriname and French Guiana, the integration of Malakit distribution into the Surinamese national programme was proved possible.

Impact of Malakit intervention on perceptions, knowledge, attitudes, and practices related to malaria among workers in clandestine gold mines in French Guiana: results of multicentric cross-sectional surveys over time.

BACKGROUND: Clandestine gold miners remain key hosts for malaria in French Guiana (FG) and contribute to imported malaria cases in Suriname and Brazil. The Malakit intervention, implemented in FG borders with Suriname and Brazil, provided gold miners with training on malaria and kits for self-diagnosis and self-treatment. Having shown a likely impact on malaria transmission, Suriname has now implemented it in routine care for cross-border moving populations. However, a decrease in malaria transmission is frequently associated with a decrease in risk perception, knowledge, and good practices regarding malaria. This study aims to describe the evolution of the perceptions, knowledge, attitudes, and practices (KAP) related to malaria among clandestine gold miners between 2015 and 2019, and to estimate the impact of Malakit on the FG/Suriname border. METHODS: The primary outcome was the overall KAP score over time and among participants and not participants in the Malakit intervention. A propensity score matching analysis and an inverse probability of treatment weighing analysis were used to estimate the Average Treatment effect on the Treated and the Average Treatment Effect of Malakit, respectively. RESULTS: Perception and knowledge scores were significantly lower in 2019 compared to 2015 (- 0.27 and - 0.23 points, respectively, p < 0.001) while attitude and practice scores were higher (+ 0.16 and + 0.47 points, respectively, p < 0.001). The overall KAP score was significantly higher among participants in Malakit with both propensity score matching (+ 0.72 points, 95%IC [0.29; 1.15]) and inverse probability of treatment weighting analysis (+ 0.70 points, 95%IC [0.34; 1.05]). CONCLUSION: A decrease in perception and knowledge about malaria but an improvement of attitudes and practices as the incidence of malaria decreased are observed. The Malakit intervention seems to have a significant positive impact on the overall KAP related to malaria. The integration of this strategy into malaria control programmes could help to improve the KAP, even in areas where malaria is nearly eliminated, through optimal training and health empowerment. Trial registration ClinicalTrials.gov registration number: NCT03695770.

Implementation of a novel malaria management strategy based on self-testing and self-treatment in remote areas in the Amazon (Malakit): confronting a-priori assumptions with reality.

BACKGROUND: A novel strategy to combat malaria was tested using a methodology adapted to a complex setting in the Amazon region and a hard-to-reach, mobile community. The intervention strategy tested was the distribution, after training, of malaria self-management kits to gold miners who cross the Surinamese and Brazilian borders with French Guiana to work illegally in the remote mining sites in the forest of this French overseas entity. MAIN TEXT: This article aims at presenting all process and implementation outcomes following the Conceptual Framework of Implementation Fidelity i.e. adherence, including content and exposure, and moderators, comprising participant responsiveness, quality of delivery, facilitation strategies, and context. The information sources are the post-intervention survey, data collected longitudinally during the intervention, a qualitative study, data collected during an outreach mission to a remote gold mining site, supervisory visit reports, in-depth feedback from the project implementers, and videos self-recorded by facilitators based on opened ended questions. As expected, being part of or close to the study community was an essential condition to enable deliverers, referred to as "facilitators", to overcome the usual wariness of this gold mining population. Overall, the content of the intervention was in line with what was planned. With an estimated one third of the population reached, exposure was satisfactory considering the challenging context, but improvable by increasing ad hoc off-site distribution according to needs. Participant responsiveness was the main strength of the intervention, but could be enhanced by reducing the duration of the process to get a kit, which could be disincentive in some places. Regarding the quality of delivery, the main issue was the excess of information provided to participants rather than a lack of information, but this was corrected over time. The expected decrease in malaria incidence became a source of reduced interest in the kit. Expanding the scope of facilitators' responsibilities could be a suitable response. Better articulation with existing malaria management services is recommended to ensure sustainability. CONCLUSIONS: These findings supplement the evaluation outcomes for assessing the relevance of the strategy and provide useful information to perpetuate and transfer it in comparable contexts. TRIAL REGISTRATION: ClinicalTrials.gov.  NCT03695770 . 10/02/2018 "Retrospectively registered".

Setting-up a cross-border action-research project to control malaria in remote areas of the Amazon: describing the birth and milestones of a complex international project (Malakit).

BACKGROUND: In French Guiana, gold miners working illegally represents a major reservoir of malaria. This mobile population, mainly of Brazilian descent, enters the French Guianese forest from neighbouring countries, Suriname and Brazil. A complex and innovative intervention was piloted as a cooperation with the three involved countries involved to control malaria in this specific population. The principle was that health workers called "facilitators" provide the participants with a self-diagnosis and self-treatment kit along with adequate training and material to rapidly manage an episode of malaria symptoms on their own, when they find themselves isolated from health care services. METHODS: This paper describes the design, development, content of the intervention and players' organization of this multi-country project, the opportunities and constraints encountered, and the lessons learnt at this stage. RESULTS: The choice not to implement the usual "Test and Treat" approach within the community is mainly driven by regulatory reasons. The content of medical messages tends to balance the tension between thoroughness, accuracy and efficacy. The wide range of tools developed through a participatory approach was intended to cope with the challenges of the literacy level of the target population. Despite the difficulties encountered due to language, regulation differences and distance between partners, cooperation was fruitful, due to the complementary of stakeholders, their involvement at all important stages and regular face-to-face meetings. DISCUSSION AND CONCLUSION: This experience shows the feasibility of an ambitious project of action-research in a border malaria context, involving several countries and with a mobile and undocumented population. It reveals some factors of success which may be transferable in analogous settings.

Zika Virus Seroprevalence in Urban and Rural Areas of Suriname, 2017.

In 2015-2016, a Zika virus (ZIKV) outbreak occurred in the Americas. In 2017, we conducted a ZIKV serosurvey in Suriname in which 770 participants were recruited from 1 urban area and 2 rural villages in the tropical rainforest. All collected samples were tested for presence of ZIKV antibodies using a ZIKV immunoglobulin G enzyme-linked immunosorbent assay and a virus neutralization assay. We found that 35.1% of the participants had neutralizing antibodies against ZIKV. In 1 remote village in the rainforest, 24.5% of the participants had neutralizing antibodies against ZIKV, suggesting that ZIKV was widely spread across Suriname.

Malakit: an innovative pilot project to self-diagnose and self-treat malaria among illegal gold miners in the Guiana Shield.

BACKGROUND: Illegal gold miners in French Guiana, a French overseas territory ('département') located in Amazonia, often carry malaria parasites (up to 46.8%). While the Guiana Shield Region aims at malaria elimination, the high prevalence of Plasmodium in this hard-to-reach population in conjunction with frequent incorrect use of artemisinin-based anti-malarials could favour the emergence of resistant parasites. Due to geographical and regulatory issues in French Guiana, usual malaria control strategies cannot be implemented in this particular context. Therefore, new strategies targeting this specific population in the forest are required. METHODS: Numerous discussions among health institutions and scientific partners from French Guiana, Brazil and Suriname have led to an innovative project based on the distribution of kits for self-diagnosis and self-treatment of Plasmodium infections. The kit-distribution will be implemented at "resting sites", which are areas across the border of French Guiana regularly frequented by gold miners. The main objective is to increase the appropriate use and complete malaria treatment after a positive malaria diagnosis with a rapid test, which will be evaluated with before-and-after cross-sectional studies. Monitoring indicators will be collected from health mediators at the time of kit distribution and during subsequent visits, and from illegal gold miners themselves, through a smartphone application. The project funding is multisource, including Ministries of Health of the three countries, WHO/PAHO, and the European Union. RESULTS: This project will start in April 2018 as a 18 month pilot study led by the Clinical Investigation Centre of Cayenne. Results should be available at the end of 2019. DISCUSSION: This innovative approach may have several limitations which should be taken into account, as potential side effects, kit misuse or resale, declarative main criteria, or no Plasmodium vivax curative treatment. Close monitoring is thus needed. CONCLUSIONS: This project may be the best available solution to a specific and important public health challenge in the Guiana Shield. If the use of self-diagnosis and self-treatment approach is effective, this strategy could be sustained by health institutions in the region.

Molecular Profile of Malaria Drug Resistance Markers of Plasmodium falciparum in Suriname.

In Suriname, an artesunate monotherapy therapeutic efficacy trial was recently conducted to evaluate partial artemisinin resistance emerging in Plasmodium falciparum We genotyped the PfK13 propeller domain of P. falciparum in 40 samples as well as other mutations proposed to be associated with artemisinin-resistant mutants. We did not find any mutations previously associated with artemisinin resistance in Southeast Asia, but we found fixed resistance mutations for chloroquine (CQ) and sulfadoxine-pyrimethamine. Additionally, the PfCRT C350R mutation, associated with reversal of CQ resistance and piperaquine-selective pressure, was present in 62% of the samples. Our results from neutral microsatellite data also confirmed a high parasite gene flow in the Guiana Shield. Although recruiting participants for therapeutic efficacy studies is challenging in areas where malaria endemicity is very low due to the low number of malaria cases reported, conducting these studies along with molecular surveillance remains essential for the monitoring of artemisinin-resistant alleles and for the characterization of the population structure of P. falciparum in areas targeted for malaria elimination.

Population movements and the HIV cascade in recently diagnosed patients at the French Guiana -Suriname border.

Border areas are particular "hot spots" generating high levels of HIV vulnerability and facing great challenges to control epidemics. The objective of this study is to describe the sociodemographic, clinical and biological profiles of newly HIV diagnosed people at the French Guiana - Suriname border, to construct an HIV care cascade and compare it with the Surinamese one. HIV-patients aged over 15 years newly diagnosed in western French Guiana in 2011 and 2012 were included in a retrospective cohort study. Patients were identified using different sources (n = 121). The male-to-female ratio was 0.8, 85% of the patients were of foreign origin, 72% were undocumented migrants, 21% were living in Suriname and 48% had baseline CD4 cell counts <200 cells/mm3. After one year, 34% were lost to follow-up, 54% received treatment, 34% had controlled viremia and 6% died. We observed a disappointing HIV cascade, like that of Suriname, requiring to develop a coordinated healthcare offer on both sides of the border. Targeted efforts through a bi-national collaboration are needed to address the specific issues of cross-border patients to reach the 90*3 UNAIDS's diagnosis, link to care and treatment targets and better control the local epidemic.

Yellow fever in a traveller returning from Suriname to the Netherlands, March 2017.

A Dutch traveller returning from Suriname in early March 2017, presented with fever and severe acute liver injury. Yellow fever was diagnosed by (q)RT-PCR and sequencing. During hospital stay, the patient's condition deteriorated and she developed hepatic encephalopathy requiring transfer to the intensive care. Although yellow fever has not been reported in the last four decades in Suriname, vaccination is recommended by the World Health Organization for visitors to this country.

Prevalence of Plasmodium spp. in illegal gold miners in French Guiana in 2015: a hidden but critical malaria reservoir.

BACKGROUND: Malaria is endemic in French Guiana, an overseas territory of France on the Guiana Shield. Since 2005, notified malaria cases are decreasing. However, new data show that malaria affects many Brazilian gold miners working illegally in French Guiana, the majority of whom are not counted in official data. In addition, one major concern is the usual practice of improper self-treatment in this mining population, raising fear of the development of anti-malarial resistance. This prospective study, conducted in 2015, aimed to estimate the prevalence of Plasmodium spp. in illegal gold miners working in French Guiana. METHODS: The recruitment of gold miners was carried out in resting sites along the French Guiana-Suriname border, where they go for supplies, medical care or leisure. After recording agreement, three malaria diagnostic methods were performed: rapid diagnostic test, microscopy and PCR. RESULTS: Among 421 persons recruited in the study, malaria prevalence, detected by nested-PCR, was 22.3 % (CI [18.3-26.3], n = 94/421) of which 84 % were asymptomatic. CONCLUSIONS: This significant malaria reservoir in a mobile and illegal population with difficult access to a health care system raises the threat of artemisinin resistance and puts the population of the Guiana Shield at risk of new transmission foci while countries of the region aim at malaria elimination. Even though French legislation may hamper dealing with this population, France must face the reality of malaria in illegal gold miners in order to meet its commitment to malaria elimination.

Improving disseminated histoplasmosis diagnosis in HIV/AIDS patients in Suriname: The role of a urine lateral flow assay.

Histoplasmosis is a frequent cause of infections in people living with HIV/AIDS (PLWHA). This study introduces the application of a Histoplasma capsulatum urine antigen lateral flow assay (LFA) for diagnosing disseminated histoplasmosis in PLWHA in Suriname. The LFA's diagnostic accuracy was compared with the current diagnostic approach, aiming to assess whether this test resulted in improved early detection and management. Additionally, the prevalence of histoplasmosis among advanced stage HIV patients without clinical suspicion of infection was evaluated using the same LFA. In total, 98 patients were included in the study, of which 58 were classified as "possible disseminated histoplasmosis (DH)" based on clinical criteria and 40 as "controls". Of these possible DH cases, only 19 (32.7%) had a positive LFA. During the study, decisions for treatment were made without the treating physician being aware of the LFA result. Only 55% of the patients who started treatment for histoplasmosis based on clinical criteria had a positive LFA, and 21% of untreated patients had a positive LFA. This study shows that combining clinical signs with LFA results enhances diagnostic accuracy and is cost effective, resulting in better treatment decisions.

Cooperation for malaria control and elimination in the Guiana Shield.

The Guiana Shield, a small region of South America, is currently one of the main hotspots of malaria transmission on the continent. This Amazonian area is characterised by remarkable socioeconomic, cultural, health, and political heterogeneity and a high degree of regional and cross-border population mobility, which has contributed to the increase of malaria in the region in the past few years. In this context, regional cooperation to control malaria represents both a challenge and an indispensable initiative. This Viewpoint advocates for the creation of a regional cooperative mechanism for the elimination of malaria in the Guiana Shield. This strategy would help address operational and political obstacles to successful technical cooperation in the region and could contribute to reversing the regional upsurge in malaria incidence through creating a functional international control and elimination partnership.

Evidence of an increased incidence of day 3 parasitaemia in Suriname: an indicator of the emerging resistance of Plasmodium falciparum to artemether.

The emerging resistance to artemisinin derivatives that has been reported in South-East Asia led us to assess the efficacy of artemether-lumefantrine as the first line therapy for uncomplicated Plasmodium falciparum infections in Suriname. This drug assessment was performed according to the recommendations of the World Health Organization in 2011. The decreasing number of malaria cases in Suriname, which are currently limited to migrating populations and gold miners, precludes any conclusions on artemether efficacy because adequate numbers of patients with 28-day follow-up data are difficult to obtain. Therefore, a comparison of day 3 parasitaemia in a 2011 study and in a 2005/2006 study was used to detect the emergence of resistance to artemether. The prevalence of day 3 parasitaemia was assessed in a study in 2011 and was compared to that in a study in 2005/2006. The same protocol was used in both studies and artemether-lumefantrine was the study drug. Of 48 evaluable patients in 2011, 15 (31%) still had parasitaemia on day 3 compared to one (2%) out of 45 evaluable patients in 2005/2006. Overall, 11 evaluable patients in the 2011 study who were followed up until day 28 had negative slides and similar findings were obtained in all 38 evaluable patients in the 2005/2006 study. The significantly increased incidence of parasite persistence on day 3 may be an indication of emerging resistance to artemether.

COVID-19 and Vaccination: Knowledge, Attitudes and Practices of People Working on Illegal Gold Mining Sites in French Guiana.

INTRODUCTION: French Guiana is a French territory bordering Brazil and Suriname where the COVID-19 pandemic has severely strained the French Guianese health system. The people working on illegal gold mining sites in French Guiana, also known as garimpeiros, are mainly of Brazilian origin. Their health conditions are precarious, they live under the radar of the surveillance system and therefore, assessment of their health is quite challenging.. The objective of this study was to describe their knowledge, attitudes and practices regarding COVID-19 and vaccination against this infection. METHODS: We conducted an international multicenter cross-sectional survey between 1 March 2022 and 30 April 2022 in French Guiana and Suriname, using a structured questionnaire. RESULTS: Eighty persons were included, 95.0% of whom were Brazilian. Most had good general knowledge of COVID-19. Antibiotic prophylaxis had been practiced by 10.0% of participants. Forty-three people thought they had been infected with COVID-19 (53.8%). Self-medication was frequent, often with antibiotics (32.6%, mostlychloroquine, ivermectin or azithromycin) and most had not consulted a physician for symptoms of COVID-19. A majority (62.5%) had received at least one dose of vaccine. Those who were ever tested for COVID-19 were the most likely to be vaccinated (PR = 1.98, p = 0.009). CONCLUSIONS: Garimpeiros have a good level of knowledge about COVID-19 but the high consumption of antibiotics raises concerns about the selection of resistant bacteria. The vaccination rate was higher than that of the Guianese population. The most vaccinated individuals were those who had already taken a COVID test suggesting that these individuals had more exposure to the disease, were more health conscious, or had easier access to health centers.

Involving hard-to-reach populations is pivotal for the tailoring and implementation of an epidemiological study in cross-border communities of French Guiana and Suriname.

Background: Hard-to-reach, vulnerable and cross-border populations are often disproportionately affected by communicable diseases. Epidemiological data on viral hepatitis in French Guiana and Suriname are available for urban areas, but not for remote communities. The Maroni River, which separates FG and Suriname, is home to Tribal and Indigenous communities. Reaching these populations is challenging due to logistical constraints, cultural and language barriers, and mistrust of outsiders. Objectives: We aimed to conduct an epidemiological study of viral hepatitis [Maroni Hepatites Virales (MaHeVi)] in this remote and complex area. Here, we describe the operational hurdles and solutions required to achieve this. Methods: We undertook a preliminary assessment of the area with local community leaders and health workers to gain approval of MaHeVi, acceptance of blood sampling, and suggestions for adapting the study to cultural and logistical constraints. Anthropological assessments were conducted through focus groups and interviews with key individuals to assess knowledge, beliefs and risk factors for VH. Results: MaHeVi was well received by the local communities. The approval of the community leaders was crucial for the implementation and acceptance of the study. The main adaptations were hiring community health mediators to overcome cultural and language differences, using blotting paper instead of venipuncture for logistical and acceptability reasons, and adapting communication materials. Conclusion: Careful preparation and tailoring of the communication materials and research protocol have enabled the successful implementation of the study. This process could be replicated in this area and transferred to other complex contexts combining borders, logistical hurdles and populations requiring cultural adaptations.

Automated and combined HIV, HBV, HCV, and syphilis testing among illegal gold miners in French Guiana using a standardized dried blood device.

Blood spotted onto filter paper can be easily collected outside healthcare facilities and shipped to a central laboratory for serological testing. However, dried blood testing generally requires manual processing for pre-analytical steps. In this study, we used a standardized blood collection device combined with an automated elution system to test illegal gold miners living in French Guiana for human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV) and syphilis. We included 378 participants, 102 females and 266 males, in three illegal gold mining resting sites. Blood collected on the Ser-Col device (Labonovum) was eluted using an automated system (SCAUT Ser-Col automation, Blok System Supply) and an automated analyzer (Alinity i, Abbott). Ser-Col results were compared to both plasma results, considered the gold standard, and to Dried blood Spot (DBS) results, considered the reference sampling method using dried blood. In plasma samples, two participants (0.5%) tested positive for HIV, six (1.5%) tested positive for hepatitis B surface antigen (HBsAg), eight were weakly positive for anti-HCV antibodies but negative for HCV RNA, and 47 tested positive for treponemal antibodies (12.4%), including 20 females (19.6%) and 27 males (9.8%, p= 0.010179). We observed a full concordance of Ser-Col and DBS results for HIV diagnosis compared to plasma results. Ser-Col and DBS samples tested positive in five HBsAg carriers and negative for one participant with a low HBsAg level in plasma (0.5 IU/mL). All participants tested negative for HCV in Ser-Col and DBS samples, including the eight participants who tested low positive for HCV antibodies and HCV RNA negative in plasma. Among syphilis seropositive participants, 41 (87.2%) and 40 (85.1%) tested positive for treponemal antibodies in Ser-Col and DBS samples, respectively. The Ser-Col method allows automated dried blood testing of HIV, HBV, HCV and syphilis with performances comparable to DBS. Automated approaches to test capillary blood transported on dried blood devices may facilitate large-scale surveys and improve testing of populations living in remote areas.

Ethnic differences in hepatitis A and E virus seroprevalence in patients attending the Emergency Department, Paramaribo, Suriname.

BACKGROUND: Hepatitis A virus (HAV) and hepatitis E virus (HEV) have enteric modes of transmission and are common causes of acute hepatitis in low- and middle-income countries. HEV is also characterised as a zoonotic infection and is prevalent in high-income countries. Data on HAV and HEV prevalence in Suriname, a middle-income country in South America, are scarce. METHODS: Serum samples of 944 and 949 randomly selected patients attending the Emergency Department at the Academic Hospital of Paramaribo, the capital of Suriname, were analysed for anti-HAV antibodies (anti-HAV) and anti-HEV antibodies (anti-HEV), respectively. Determinants of anti-HAV and anti-HEV positive serology were evaluated using multivariable logistic regression. RESULTS: Anti-HAV prevalence was 58.3% (95% CI 55.4 to 61.4%) and higher prevalence was independently associated with belonging to the Tribal or Indigenous population and older age. Anti-HEV prevalence was 3.7% (95% CI 2.6 to 5.0%) and higher prevalence was associated with Tribal and Creole ethnicity and older age. CONCLUSIONS: In Suriname, exposure to HAV is consistent with a very low endemic country and exposure to HEV was rare. Both viruses were more prevalent in specific ethnic groups. As anti-HAVantibodies were less frequently found in younger individuals, they could be susceptible to potential HAV outbreaks and might require HAV vaccination.

Social determinants of health among people working on informal gold mines in French Guiana: a multicentre cross-sectional survey.

INTRODUCTION: Social determinants of health, such as living and working conditions, economical and environmental context and access to care, combine to impact the health of individuals and communities. In French Guiana (FG), the persons working in informal artisanal and small-scale gold mining in the rainforest are a particularly vulnerable population which lives in precarious conditions and far from the health system. Previous studies have demonstrated their high morbidity due to infectious diseases. This study aims to describe the social determinants of health in this specific population. METHODS: This international multicentre cross-sectional survey included people working on the informal FG gold mines at the crossing points located at both borders with Suriname and Brazil. After collecting written informed consent, a structured questionnaire was administered. RESULTS: From September to December 2022, 539 gold miners were included. These poorly educated migrants, mainly from Brazil (99.1%) did not have access to drinkable water (95.4%), lived in close contact with wild fauna by hunting, eating bushmeat or being bitten and were exposed to mercury by inhalation (58.8%) or ingestion (80.5%). They report frequent accidents (13.5%) and chronic treatment interruptions (26.6% of the 11.9% reporting chronic treatment). Half of them considered themselves in good health (56.4%). CONCLUSION: This study shows a singular combination of adverse exposures of gold miners working in FG such as zoonoses, heavy metal poisoning, aggression of wild fauna. For ethical as well as public health reasons, actions towards health equity must be considered at different levels: individual, community, environmental, systemic and global level. As end users of minerals, we must assume our responsibilities for the well-being of the extractors by including health in political decisions to engage together in global health. TRIAL REGISTRATION NUMBER: NCT05540470.

Training-of-trainers program for community health workers involved in an innovative and community-based intervention against malaria among goldminers in the Guiana shield: a quality and effectiveness evaluation.

Introduction: An innovative and community-based intervention is implemented in the Guiana Shield to eliminate malaria among people involved in artisanal and small-scale gold mining. The intervention consists of the distribution of malaria self-management kits to goldminers and the presumptive treatment for individuals at risk of carrying Plasmodium vivax hypnozoites. The intervention is possible owing to community health workers (CHWs) who are previously trained to master all intervention procedures, including health education activities and goldmining training. This study aimed to evaluate the training program provided to CHWs in terms of quality and effectiveness. Methods: A training-of-trainers program for CHWs has been developed based on the CDC framework. A mixed-method case study was implemented in two steps between February and March 2023. The evaluation was based on a knowledge survey, satisfaction test, observations, and semi-structured interviews. Quantitative and qualitative data were analyzed and triangulated. Results: A total of 20 CHWs participated in the training and the first-step evaluation. For the second step, four semi-structured interviews were conducted. The Qualitative data showed that group dynamics and adaptations were central elements of a high-quality training program. Quantitative analysis found that CHWs' satisfaction was elevated (> 4/5 overall), especially regarding format and learning results. Improvements in knowledge level demonstrated good effectiveness (pre-training vs. post-training, p < 0.05). Nevertheless, some difficulties persisted regarding tasks of the intervention procedure, such as informed consent and smartphone application procedures (with an inaccuracy rate of 29.2% and 16.7%, respectively). Further on-the-job training permitted to address these issues. The project team's previous experience and the Guiana Shield countries' commitment to the WHO-E-2025-initiative were identified as levers for the quality of the training, while the complexity of the project context was a challenge. Discussion: High-quality, effective, and appropriate training programs are required for effective and sustainable interventions involving CHW profiles. Training design is a crucial point to address to accomplish quality and effectiveness. The training-of-trainers model has been shown to allow a high level of satisfaction, good learning results, and satisfactory implementation in the field. Initial and continuing training is an indispensable continuum to sustain good practices in the field and CHWs' motivation. Training evaluation permits standardizing methods and facilitates transferability.