Search

It is estimated that 1.5 billion people are infected with soil-transmitted helminths (STHs) worldwide. Re-infection occurs rapidly following deworming, and interruption of transmission is unlikely without complementary control efforts such as improvements in water, sanitation, and hygiene (WASH) access and behaviours.To assess the effectiveness of WASH interventions to prevent STH infection.We used standard, extensive Cochrane search methods. The latest search date was 19 October 2021.We included interventions to improve WASH access or practices in communities where STHs are endemic. We included randomized controlled trials (RCTs), as well as trials with an external control group where participants (or clusters) were allocated to different interventions using a non-random method (non-RCTs). We did not include observational study designs. Our primary outcome was prevalence of any STH infection. Prevalence of individual worms was a secondary outcome, including for Ascaris lumbricoides, Trichuris trichiura, hookworm (Ancylostoma duodenale or Necator americanus), or Strongyloides stercoralis. Intensity of infection, measured as a count of eggs per gram of faeces for each species, was another secondary outcome.Two review authors independently reviewed titles and abstracts and full-text records for eligibility, performed data extraction, and assessed risk of bias using the Cochrane risk of bias assessment tool for RCTs and the EPOC tool for non-RCTs. We used a random-effects meta-analysis to pool study estimates. We used Moran's I² statistic to assess heterogeneity and conducted subgroup analyses to explore sources of heterogeneity. We assessed the certainty of the evidence using the GRADE approach.We included 32 studies (16 RCTs and 16 non-RCTs) involving a total of 52,944 participants in the review. Twenty-two studies (14 RCTs (16 estimates) and eight non-RCTs (11 estimates)) reported on our primary outcome, prevalence of infection with at least one STH species. Twenty-one studies reported on the prevalence of A lumbricoides (12 RCTs and 9 non-RCTs); 17 on the prevalence of T trichiura (9 RCTs and 8 non-RCTs); 18 on the prevalence of hookworm (10 RCTs and 8 non-RCTs); and one on the prevalence of S stercoralis (1 non-RCT). Sixteen studies measured the intensity of infection for an individual STH type. Ten RCTs and five non-RCTs reported on the intensity of infection of A lumbricoides; eight RCTs and five non-RCTs measured the intensity of infection of T trichiura; and eight RCTs and five non-RCTs measured the intensity of hookworm infection. No studies reported on the intensity of infection of S stercoralis. The overall pooled effect estimates showed that the WASH interventions under study may result in a slight reduction of any STH infection, with an odds ratio (OR) of 0.86 amongst RCTs (95% confidence interval (CI) 0.74 to 1.01; moderate-certainty evidence) and an OR of 0.71 amongst non-RCTs (95% CI 0.54 to 0.94; low-certainty evidence). All six of the meta-analyses assessing individual worm infection amongst both RCTs and non-RCTs had pooled estimates in the preventive direction, although all CIs encapsulated the null, leaving the possibility of the null or even harmful effects; the certainty of the evidence ranged from very low to moderate. Individual studies assessing intensity of infection showed mixed evidence supporting WASH. Subgroup analyses focusing on narrow specific subsets of water, sanitation, and hygiene interventions did very little to elucidate which interventions might be better than others. Data on intensity of infection (e.g. faecal egg count) were reported in a variety of ways across studies, precluding the pooling of results for this outcome. We did not find any studies reporting adverse events resulting from the WASH interventions under study or from mass drug administration (MDA).Whilst the available evidence suggests that the WASH interventions under study may slightly protect against STH infection, WASH also serves as a broad preventive measure for many other diseases that have a faecal oral transmission route of transmission. As many of the studies were done in addition to MDA/deworming (i.e. MDA was ongoing in both the intervention and control arm), our data support WHO recommendations for implementation of improvements to basic sanitation and adequate access to safe water alongside MDA. The biological plausibility for improved access to WASH to interrupt transmission of STHs is clear, but WASH interventions as currently delivered have shown impacts that were lower than expected. There is a need for more rigorous and targeted implementation research and process evaluations in order that future WASH interventions can better provide benefit to users. Inconsistent reporting of the intensity of infection underscores the need to define the minimal, standard data that should be collected globally on STHs to enable pooled analyses and comparisons.

Background In 2016, after 8 years of twice-annual nationwide preventive chemotherapy (PC) administration to school-age children (SAC), the Bangladesh Ministry of Health & Family Welfare (MOHFW) sought improved impact and intervention monitoring data to assess progress toward the newly adopted goal of eliminating soil-transmitted helminthiasis (STH) as a public health problem. Methods We surveyed four Bangladeshi districts between August and October 2017. We conducted a multi-stage, cluster-sample, household survey which produced equal-probability samples for preschool-age children (PSAC; 1–4 years), SAC (5–14 years), and adults (≥ 15 years). Standardized questionnaires were administered, using Android-based smart phones running an Open Data Kit application. Stool samples were collected and testing for STH prevalence and infection intensity used the Kato-Katz technique. Results In all, 4318 stool samples were collected from 7164 participants. Estimates of STH prevalence by risk group in three of the four surveyed districts ranged from 3.4 to 5.0%, all with upper, 1-sided 95% confidence limits 50% prevalence in at least one risk group. Among all tested specimens, Ascaris lumbricoides was the most common STH parasite [8.2% (n = 352)], followed by Trichuris trichiura [0.9% (n = 37)], and hookworm [0.6% (n = 27)]. In each district, PC coverage among SAC was above the 75% program target but did not exceed 45% among PSAC in any district. Improved sanitation at home, school, or work was over 90% in all districts. Conclusions In the three low-prevalence districts, the MOHFW is considering decreasing the frequency of mass drug administration, per World Health Organization (WHO) guidelines. Also, the MOHFW will focus programmatic resources and supervisory efforts on Sirajganj District. Despite considering WHO guidance, the MOHFW will not expand PC administration to women of reproductive age partly due to the low prevalence of hookworm and T. trichiura, the STH parasites that contribute most to morbidity in that risk group. Data collected from surveys such as ours would help effectively guide future STH control efforts in Bangladesh and elsewhere.

Background : The aim of this review was to summarize the data on HIV/AIDS epidemiology and affected populations in Ghana and to describe the United States President’s Emergency Plan for Emergency Relief’s (PEPFAR) response to the epidemic. Design : We conducted a literature review focusing on PEPFAR’s contribution to the HIV response in Ghana. Additionally, we summarized the epidemiology of HIV. We searched both peer-reviewed and grey literature. Setting : Ghana Results : Overall, HIV prevalence in Ghana is 1.6% with regional variation. Key populations (KPs) are disproportionately affected by HIV in the country. FSW and their clients, and MSM, account for 28% of all new infections. PEPFAR provides technical assistance (TA) to Ghana to maximize the quality, coverage and impact of the national HIV/AIDS response. To ensure adequate supply of antiretrovirals (ARVs), in 2016-2017, PEPFAR invested $23.7 million as a onetime supplemental funding to support Ghana’s ARV treatment program. In addition, the National AIDS Control Programme in collaboration with PEPFAR is implementing a scale up of viral load testing. PEPFAR is also implementing a comprehensive package of prevention services in five regions to help reach MSM and FSW and to expand HIV testing services for KPs. Conclusions : Ghana is making changes at both policy and program level in the fight against HIV/AIDS and is working towards achieving the UNAIDS’ 90-90-90 targets. PEPFAR is providing TA to ensure these goals can be achieved. Funding : This manuscript has been supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (CDC). Keywords : HIV, epidemic, Ghana, PEPFAR

Highlights • Health systems in the least developed, fragile, and conflict-affected countries (LDFCAC) are chronically underfunded and are often sustained largely by international development assistance. • The perception of the impact of coronavirus disease 2019 (COVID-19) in LDFCAC populations is likely to be dwarfed by their experience with other existential threats, such as the daily need to find food for their families, violence, or even death from conflicts. • LDFCAC must have access to tests, treatments, and vaccines as they become available in developed countries. • As long as human mobility cannot be adequately curtailed, circulating severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in LDFCAC will become a permanent threat. • There is an urgent need in LDFCAC for funds to expand testing and contact-tracing, and when feasible, for the use of proximity-tracing technology and apps that allow people to self-report symptoms and confirmed infections., The relentless spread of coronavirus disease 2019 (COVID-19) and its penetration into the least developed, fragile, and conflict-affected countries (LDFCAC) is a certainty. Expansion of the pandemic will be expedited by factors such as an abundance of at-risk populations, inadequate COVID-19 mitigation efforts, sheer inability to comply with community mitigation strategies, and constrained national preparedness. This situation will reduce the benefits achieved through decades of disease control and health promotion measures, and the economic progress made during periods of global development. Without interventions, and as soon as international travel and trade resume, reservoirs of COVID-19 and other vaccine-preventable diseases in LDFCAC will continue ‘feeding’ developed countries with repeated infection seeds. Assuring LDFCAC equity in access to medical countermeasures, funds to mitigate the pandemic, and a paradigm change in the global development agenda, similar to the post-World War II Marshall Plan for Europe, are urgently needed. We argue for a paradigm change in strategy, including a new global pandemic financing mechanism for COVID-19 and other future pandemics. This approach should assist LDFCAC in gaining access to and membership of a global interdisciplinary pandemic taskforce to enable in-country plans to train, leverage, and maintain essential functioning and also to utilize and enhance surveillance and early detection capabilities. Such a task force will be able to build on and expand research into the management of pandemics, protect vulnerable populations through international laws/treaties, and reinforce and align the development agenda to prevent and mitigate future pandemics. Lifting LDFCAC from COVID-related failure will offer the global community the best economic dividends of the century.

In 2008, Bangladesh initiated Preventive Chemotherapy (PCT) for school-age children (SAC) through bi-annual school-based mass drug administration (MDA) to control Soil-Transmitted Helminth (STH) infections. In 2016, the Ministry of Health and Family Welfare’s Program on Lymphatic Filariasis Elimination and STH (ELFSTH) initiated district-level community impact assessments with Children Without Worms (CWW) using standardized, population-based sampling to measure the post-intervention STH burden across all ages (≥ 1 yr) for the three STH species. The Integrated Community-based Survey for Program Monitoring (ICSPM) was developed by CWW and was used to survey 12 districts in Bangladesh from 2017–2020. We excluded the first two district data as piloting caused some sampling errors and combined the individual demographic and parasite-specific characteristics from the subsequent 10 districts, linking them with the laboratory data for collective analysis. Our analysis identified district-specific epidemiologic findings, important for program decisions. Of the 17,874 enrolled individuals, our results are based on 10,824 (61.0%) stool samples. Overall, the prevalence of any STH species was substantially reduced to 14% from 79.8% in 2005. The impact was similar across all ages. STH prevalence was 14% in 10 districts collectively, but remained high in four districts, despite their high reported PCT coverage in previous years. Among all, Bhola district was unique because it was the only district with high T.trichuris prevalence. Bangladesh successfully lowered STH prevalence across all ages despite targeting SAC only. Data from the survey indicate a significant number of adults and pre-school age children (PSAC) were self-deworming with purchased pills. This may account for the flat impact curve across all ages. Overall prevalence varied across surveyed districts, with persistent high transmission in the northeastern districts and a district in the central flood zone, indicating possible service and ecological factors. Discrepancies in the impact between districts highlight the need for district-level data to evaluate program implementation after consistent high PCT coverage., Author summary Bangladesh government conducted school-based mass drug administration (MDA) for over 10 years to control soil-transmitted helminth (STH) infections. School-based evaluations of MDA indicate a reduction in STH burden among school-aged children (SAC). To further assess the impact on the community, Children Without Worms and the Ministry of Health and Family Welfare’s Program on Lymphatic Filariasis Elimination and STH (ELFSTH) initiated district-level community impact surveys in 12 districts. We share the results from the latter 10 districts here (the first two pilots were excluded because of possible sampling errors). Our analysis of 10,824 interviews and stool samples from 10 districts showed an estimated 14% of community members infected with at least one species of STH. This finding is substantially lower than the baseline STH prevalence (79.8%) estimated in 2005. Bangladesh’s successful impact was achieved across all ages despite only treating SAC. Deworming source data showed significant numbers of adults and pre-school age children (PSAC) self-dewormed with locally purchased pills. Prevalence varied across the surveyed districts, with persistent high transmission in the northeastern districts and a district in the central flood zone, indicating possible ecological and service factors contributing to persistent infections. Variable impact across districts highlights the need for sub-national level data to evaluate program performance following the consistent high intervention and could be attributable to many additional factors.

The COVID-19 pandemic can no longer be mitigated by a nationwide approach of individual nations alone. Given its scale and accelerating expansion, COVID-19 requires a coordinated and simultaneous Whole- of-World approach that galvanizes clear global leadership and solidarity from all governments of the world. Considering an 'all hands-on deck' concept, we present a comprehensive list of tools and entities responsible for enabling them, as well a conceptual framework to achieve the maximum impact. The list is drawn from pandemic mitigation tools developed in response to past outbreaks including influenza, coronaviruses, and Ebola, and includes tools to minimize transmission in various settings including person-to-person, crowd, funerals, travel, workplace, and events and gatherings including business, social and religious venues. Included are the roles of individuals, communities, government and other sectors such as school systems, health, institutions, and business. While individuals and communities have significant responsibilities to prevent person-to-person transmission, other entities can play a significant role to enable individuals and communities to make use of the tools. Historic and current data indicate the role of political will, whole-of-government approach, and the role of early introduction of mitigation measures. There is also an urgent need to further elucidate the immunologic mechanisms underlying the epidemiological characteristics such as the low disease burden among women, and the role of COVID-19 in inducing Kawasaki-like syndromes in children. Understanding the role of and development of anti-inflammatory strategies based on our understanding of pro-inflammatory cytokines (IL1, IL-6) is also critical. Similarly, the role of oxygen therapy as an anti-inflammatory strategy is evident and access to oxygen therapy should be prioritized to avoid the aggravation of COVID-19 infection. We highlight the need for global solidarity to share both mitigation commodities and infrastructure between countries. Given the global reach of COVID-19 and potential for repeat waves of outbreaks, we call on all countries and communities to act synergistically and emphasize the need for synchronized pan-global mitigation efforts to minimize everyone's risk, to maximize collaboration, and to commit to shared progress.

As the COVID-19 pandemic continues to surge, the conjectured linkages between pandemics, fertility, and child health observed during the great depression of 1957 in the USA and the influenza pandemic of 1918 in the USA and Japan become highly relevant.1,2 From 1900s through 1970s, along with the economic and epidemiologic transitions, standardized child mortality from infectious diseases decreased by 90% overall, birth defects remained the leading cause of ill health, and fertility rates declined. Pre-COVID-19 fertility projections for 2020 indicate that 66 countries of the countries currently experience sub-replacement fertility (Figure), below the global average fertility of 2.3 and the sub-replacement fertility level of 2.1.3 The fertility rate of 2.1 as the sub-replacement level is derived from the assumption that, in a community, two children per women are required to replace parents and 0.1 child to make up for child mortality prior to becoming an adult. Fertility rate at or below 1.7 is considered severe (45 countries) because interventions (excluding immigration of populations with high fertility) are unlikely to achieve the 2.1 replacement target.Impact of Pandemics on Fertility and Child HealthPandemics can adversely affect both fertility and child survival.1,2 The mechanisms that linked pandemics with subsequent depressed fertility during the past pandemics include a combination of reduced conceptions and embryonic losses during the first month of pregnancy, individual level stress from pandemics and pandemic-related mortality, short-run instability from environmental shocks and economic volatility leading to decreased investment in the population size of future generations.Child development may be affected by community mitigation activities including home quarantine, social distancing, and closing of economic and travel activities, reduced access to child day care, interruption in schooling and nutrition opportunities for many children. These effects are amplified if the child is cared for by single parents or parents in employment categories such as the service sector that is immediately affected by mitigation strategies. We lack contemporary studies on the impact of these outcomes. Social and family structures during historic events differed greatly from that of today. In countries that experience sub replacement fertility, population of childbearing age is characterized by single households, increased mean age of women at first birth (higher order births), nuclear families, increased participation of women in the workforce, high percentage of dissolved family unions, and inadequate unemployment benefits and social support systems to support families.4,The evolution of the COVID-19 pandemic occurred in a condensed timeframe and SARS-CoV-2 related embryonic loss has not been reported. With the addition of COVID-19 related childhood multisystem inflammatory syndrome to birth defects (current burden in developed countries, 40 to 55 per 1000 live births5), the overall child morbidity will increase. The spread of COVID-19 and mortality has been significant among many of the countries that experience sub replacement fertility and the incidence is increasing in the younger ages as currently observed in the U.S. COVID -19. Mitigation efforts can adversely impact child survival and fertility decisions due to changes in ratio of workers to dependents, changes in the labor supply of working-age adults over time, and changes in the average level of schooling.Given that the countries that face sub-replacement fertility are also the leading drivers of innovation and productivity globally (figure)3,6, further stress on fertility in these countries will no doubt impact their economic security and contribution to global development in the next two decades.Actions to Improve Fertility and Improve Child Well BeingCountries in sub-replacement fertility status have explored social, economic, and policy interventions to reverse the trend. They include policies to balance work and family obligations, financial incentives (fertility boosters, monthly childcare benefit linked to family size), speed premium (financial incentives for delivery of second child within a given time frame), free childcare, and housing subsidies.7 Immigration played a major role in sustaining fertility rates at replaceable levels in the USA. The easing of the one-child policy in China in 2016 increased the number of births by 8% over 2015. Given that fertility change is a long-term cohort effect, influenced by various exogenous factors, select measures are unlikely to achieve long-term benefits unless a complete set of supportive interventions across the lifespan of the parents and child are implemented in concert.Unlike during historic events, COVID-19’s impact on fertility should be of concern for relevant countries. Efforts to aid population growth and health outcome of children born today are needed in high-risk countries so that many more women achieve healthy reproductive goals and their children achieve optimal health. We highlight 7 actions points below.Strengthen and expand newborn screening programs to identify and provide early intervention for birth defects and assure special care the affected children.Educate the public about steps that fathers and communities can take to support women to achieve healthy reproductive outcomes.At the policy level, use COVID-19 as an opportunity to advocate, develop and integrate to social programs and labor sector a comprehensive list of supportive interventions across the life span of the parent-child dyad.Integrate pre-conception care concepts to clinical practice to enable women of childbearing age to achieve optimal mental and physical health during COVID-19 and ensure a healthy balanced diet, including folic acid fortification or supplementation, correcting iodine deficiencies and avoiding teratogens such as alcohol and tobacco.Optimize maternal health through control of chronic diseases that increases a woman’s risk for both COVID-19 and adverse child outcomes.Among intrauterine and child survivors of COVID-19, monitor potential long term impact of COVID-19 throughout the child’s growth and development period.Assure the continuity and comprehensiveness of high-quality child education and social interaction opportunities through innovative virtual programs when in-person education is unavailable.With the aging of populations and the interconnectedness of our economies, COVID-19’s potential impact in countries that are already facing sub-replacement fertility should receive due consideration in programs aimed at improving the health of the mother and child. Doing so would be a necessity not only form a national security perspective, but from a long-term economic prosperity, not just for those countries at high risk, but for all countries.Summary (optional)Pandemics can adversely affect both fertility and child survival. The pathways include adverse biological outcomes (those caused as a direct result of infections on fetus, newborn, or children), ecological impact on fertility (due to indirect causes that leads to postponement or lack of reproduction), and as a result of unintended consequences of community mitigation on growth and development of children1-4 Globally 66 countries, mostly those the global innovation hubs with the highest per capita GDP, already have fertility rates below 2.1, of which 45 are at or below the irreversible rate of 1.7. As COVID-19 incidence is increasing in the younger ages, population growth plans to avert further deterioration of fertility and assure optimal health of children are needed in countries with sub-replacement fertility.Figure. Countries facing sub-replacement fertility (TFR

Background Nucleic acid amplification tests (NAATs) are increasingly being used as diagnostic tools for soil-transmitted helminths (STHs; Ascaris lumbricoides, Trichuris trichiura, Necator americanus, Ancylostoma duodenale and A. ceylanicum), Strongyloides stercoralis and Schistosoma in human stool. Currently, there is a large diversity of NAATs being applied, but an external quality assessment scheme (EQAS) for these diagnostics is lacking. An EQAS involves a blinded process where test results reported by a laboratory are compared to those reported by reference or expert laboratories, allowing for an objective assessment of the diagnostic performance of a laboratory. In the current study, we piloted an international EQAS for these helminths (i) to investigate the feasibility of designing and delivering an EQAS; (ii) to assess the diagnostic performance of laboratories; and (iii) to gain insights into the different NAAT protocols used. Methods and principal findings A panel of twelve stool samples and eight DNA samples was validated by six expert laboratories for the presence of six helminths (Ascaris, Trichuris, N. americanus, Ancylostoma, Strongyloides and Schistosoma). Subsequently this panel was sent to 15 globally dispersed laboratories. We found a high degree of diversity among the different DNA extraction and NAAT protocols. Although most laboratories performed well, we could clearly identify the laboratories that were poorly performing. Conclusions/Significance We showed the technical feasibility of an international EQAS for the NAAT of STHs, Strongyloides and Schistosoma. In addition, we documented that there are clear benefits for participating laboratories, as they can confirm and/or improve the diagnostic performance of their NAATs. Further research should aim to identify factors that explain poor performance of NAATs., Author summary Tests that detect parasite DNA in human stool are increasingly being used for the diagnosis of infections with intestinal worms, including schistosomiasis. To ensure the quality in diagnostic testing of these parasitic worms, it is important that laboratories evaluate the diagnostic performance of their DNA-based tests. This can best be achieved by participating in an external quality assessment scheme (EQAS). An EQAS involves a blinded process where test results reported by a laboratory are compared to those reported by reference or expert laboratories, allowing for an objective assessment of the diagnostic performance of a laboratory. Currently, such an EQAS for parasitic worms is lacking. We therefore piloted an international EQAS for the diagnosis of parasitic worms involving 15 laboratories in Africa, Asia, Australia, Europe, and North America. Although most laboratories performed well, we could clearly identify those laboratories that may need to improve their test protocol. We found that laboratories were using many different test protocols, and further research should aim to verify whether this has an impact on the performance of the diagnostic outcomes.

More than half of the world’s population lives in places endemic for soil-transmitted helminths (STHs), and an estimated 1.45 billion people are infected. In 2017, the global burden of STH infection (Ascaris lumbricoides, hookworm, and Trichuris trichiura) was estimated at 1.9 million disability-adjusted life years (DALYs). Moderate and heavy infection intensity and chronic STH infection are associated with anemia, malnutrition, educational loss, and cognitive deficits, but recent systematic reviews and meta-analyses produced conflicting results on the impact of preventive chemotherapy (PC). The Soil-Transmitted Helminthiasis Advisory Committee (hereafter called “the Committee”) is a group of independent experts with a broad range of expertise. It is convened annually by Children Without Worms (CWW), an organization whose purpose is to utilize available evidence to identify best practices and opportunities for the prevention and control of STH infection. On November 1 and 2, 2017, the Committee met in Baltimore, Maryland, United States of America, in order to discuss the critical need to develop a data-driven guide to the STH endgame on late-stage program functioning, processes, and surveillance. The focus was on research and field experiences from countries approaching the “elimination of STH infection as a public health problem” after consecutive years of PC and countries that are now considering scaling down their PC frequency but may be concerned about infection rebound. Emphasis was placed on interim recommendations for monitoring and decision-making for national program managers desiring to achieve the World Health Organization (WHO) goal of eliminating STH infection as a public health problem by 2020, particularly related to STH infections in risk groups other than school-age children (SAC), namely preschool-age children (PSAC) and women of reproductive age (WRA) [8]. The following is the Committee’s recommendations stemming from the Baltimore meeting in November 2017. It complements and updates the publication derived by the Committee’s meeting a year earlier in Basel, Switzerland, and was instrumental in shaping the agenda for the October 2018 meeting, convened jointly by CWW and WHO, with recommendations to be reported elsewhere. Fil: Freeman, Matthew C.. University of Emory; Estados Unidos Fil: Akogun, Oladele. Modibbo Adama University of Technology; Nigeria Fil: Belizario, Vicente. University of The Philippines Manila; Filipinas Fil: Brooker, Simon J.. Bill And Melinda Gates Foundation; Estados Unidos Fil: Gyorkos, Theresa W.. McGill University; Canadá Fil: Imtiaz, Rubina. The Task Force for Global Health; Estados Unidos Fil: Krolewiecki, Alejandro Javier. Universidad Nacional de Salta. Sede Regional Orán. Instituto de Investigación de Enfermedades Tropicales; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Salta; Argentina Fil: Lee, Seung Hwa. Save the Children; Estados Unidos Fil: Matendechero, Sultani H.. Ministry of Health; Kenia Fil: Pullan, Rachel L.. London School of Hygiene & Tropical Medicine; Reino Unido Fil: Utzinger, Jürg. Swiss Tropical and Public Health Institute; Suiza. University of Basel; Suiza

On May 22, 2001, a resolution passed during the 54th World Health Assembly (WHA 54.19) took an historic step toward reducing the morbidity and mortality associated with the world’s most common parasitic worm (helminth) infections . Indeed, an estimated 1.45 billion individuals are infected with soil-transmitted helminths worldwide. The soil-transmitted helminths primarily comprise hookworm (Ancylostoma duodenale and Necator americanus), roundworm (Ascaris lumbricoides), and whipworm (Trichuris trichiura). Taken together, soil-transmitted helminthiasis accounts for a global burden of over 3.3 million disability-adjusted life years and is associated with anemia, malnutrition, and impaired physical and cognitive development. As the primary recommendation to eliminate soil-transmitted helminthiasis as a public health problem, WHA 54.19 called for improved water and sanitation to reduce transmission and urged that 3 high-risk groups receive regular treatment with anthelmintic drugs: preschool-aged children (PSAC), school-aged children (SAC), and women of reproductive age (WRA). Fil: Becker, Sören L.. Swiss Tropical And Public Health Institute; Suiza Fil: Liwanag, Harvy Joy. Universidad de Basilea; Suiza. Swiss Tropical And Public Health Institute; Suiza Fil: Snyder, Jedidiah S.. The Task Force For Global Health; Estados Unidos. University of Emory; Estados Unidos Fil: Akogun, Oladele. Modibbo Adama University Of Technology; Nigeria Fil: Belizario, Vicente. University Of The Philippines; Filipinas Fil: Freeman, Matthew C.. University of Emory; Estados Unidos Fil: Gyorkos, Theresa W.. McGill University; Canadá Fil: Imtiaz, Rubina. The Task Force For Global Health; Estados Unidos Fil: Keiser, Jennifer. Swiss Tropical And Public Health Institute; Suiza Fil: Krolewiecki, Alejandro Javier. Universidad Nacional de Salta. Sede Regional Orán. Instituto de Investigación de Enfermedades Tropicales; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: Levecke, Bruno. University of Ghent; Bélgica Fil: Mwandawiro, Charles. Kenya Medical Research Institute; Kenia Fil: Pullan, Rachel L.. London School Of Hygiene And Tropical Medicine; Reino Unido Fil: Addiss, David G.. The Task Force For Global Health; Estados Unidos Fil: Utzinger, Jürg. Swiss Tropical And Public Health Institute; Suiza

Background: It is unknown to what extent the non-HIV population utilises laboratories supported by the President’s Emergency Plan for AIDS Relief (PEPFAR). Objectives: We aimed to describe the number and proportion of laboratory tests performed in 2009 and 2011 for patients referred from HIV and non-HIV services (NHSs )in a convenience sample collected from 127 laboratories supported by PEPFAR in Tanzania. We then compared changes in the proportions of tests performed for patients referred from NHSs in 2009 vs 2011. Methods: Haematology, chemistry, tuberculosis and syphilis test data were collected from available laboratory registers. Referral sources, including HIV services, NHSs, or lack of a documented referral source, were recorded. A generalised linear mixed model reported the odds that a test was from a NHS. Results: A total of 94 132 tests from 94 laboratories in 2009 and 157 343 tests from 101 laboratories in 2011 were recorded. Half of all tests lacked a documented referral source. Tests from NHSs constituted 42% (66 084) of all tests in 2011, compared with 31% (29 181) in 2009. A test in 2011 was twice as likely to have been referred from a NHS as in 2009 (adjusted odds ratio: 2.0 [95% confidence interval: 2.0–2.1]). Conclusion: Between 2009 and 2011, the number and proportion of tests from NHSs increased across all types of test. This finding may reflect increased documentation of NHS referrals or that the laboratory scale-up originally intended to service the HIV-positive population in Tanzania may be associated with a ‘spillover effect’ amongst the general population.

Field epidemiology training programs have been successful models to address a country's needs for a skilled public health workforce, partly due to their responsiveness to the countries' unique needs. The Centers for Disease Control and Prevention has partnered with ministries of health to strengthen their workforce through customized competency-based training programs. While desirable, emphasis on program flexibility can result in redundancy and inconsistency. To address this challenge, the ADDIE model (analysis, design, development, implementation, and evaluation) of instructional design was used by a cross-functional team to guide completion of a standard curriculum based on 15 competencies. The standard curriculum has supported the development and expansion of programs while still allowing for adaptation. This article describes the process that was used to develop the curriculum, which, together with needs assessment and evaluation, is crucial for successful training programs.

The Agency for Toxic Substances and Disease Registry analyzed concurrently collected data on environmental methyl parathion (MP) and urinary p-nitrophenol (PNP) at the request of the U.S. Environmental Protection Agency (U.S. EPA). The purpose of the analysis was to assess whether individuals' age or level of residential MP contamination might predict their urinary PNP level. Unlicensed pesticide applicators had sprayed residences in Mississippi with MP, which is approved as a pesticide only for outdoor agricultural use. Data were received from Mississippi for MP wipe sample levels for 409 homes and urinary PNP levels for 929 residents of the residences sampled. In addition to descriptive and bivariate analyses, ordinal logistic regression was performed after categorizing the data. Interpretation of results was limited by several identified data gaps and pre-existing data-quality issues. On the basis of the lessons learned from identified data gaps, specific recommendations were made to the U.S. EPA for improving future data collection methods for more meaningful exposure assessment in similar environmental contaminations. The recommended changes were successfully incorporated in subsequent data collected by other states that had experienced similar residential MP spraying.

Methyl parathion (MP), an organophosphate pesticide, was sprayed illegally for pest control in U.S. residences and businesses in Mississippi and Ohio. To evaluate the association between MP exposure and neurobehavioral development, children 6 years of age or younger at the time of the spraying and local comparison groups of unexposed children were assessed using the pediatric environmental neurobehavioral test battery (PENTB). The PENTB is composed of informant-based procedures (parent interview and questionnaires) and performance-based procedures (neurobehavioral tests for children 4 years of age or older) that evaluate each of the four broad domains (cognitive, motor, sensory, and affect) essential to neurobehavioral assessment. Children were classified as exposed or unexposed using urinary p-nitrophenol (PNP) levels and environmental wipe samples for MP. Exposure was defined as a urinary PNP level of greater than or equal to 100 ppb for the child or any other individual living in the household. Environmental wipe sample levels of greater than or equal to 150 g MP/100 cm2 and greater than or equal to 132.9 g MP/100 cm2 were used to define MP exposure for children living in Mississippi and Ohio, respectively. The PENTB was first administered in summer 1999 (year 1). The PENTB was readministered in summer 2000 (year 2) to children who participated in year 1 of the study. A description of the methods used in the study are presented. Results of data analyses for both years of the study will be presented in a separate publication.

Evidence demonstrates that scale-up of HIV services has produced stronger health systems and, conversely, that stronger health systems were critical to the success of the HIV scale-up. Increased access to and effectiveness of HIV treatment and care programs, attention to long-term sustainability, and recognition of the importance of national governance, and country ownership of HIV programs have resulted in an increased focus on structures that compromise the broader health system. Based on a review published literature and expert opinion, the article proposes 4 key health systems strengthening issues as a means to promote sustainability and country ownership of President' sE mergency Plan for AIDS Relief and other global health initiatives. First, de- velopment partners need provide capacity building support and to recognize and align resources with national government health strategies and operational plans. Second, investments in human capital, particularly human resources for health, need to be guided by national institutions and supported to ensure the training and retention of skilled, qualified, and relevant health care providers. Third, a range of financing strategies, both new resources and improved efficiencies, need to be pursued as a means to create more fiscal space to ensure sustainable and self-reliant systems. Finally, service delivery models must adjust to recent advance- ments in areas of HIV prevention and treatment and aim to estab- lish evidence-based delivery models to reduce HIV transmission rates and the overall burden of disease. The article concludes that there needs to be ongoing efforts to identify and implement strate- gic health systems strengthening interventions and address the in- herent tension and debate over investments in health systems.

Until the early 1990s, most of Uganda's public health workforce obtained master's degrees from abroad. The responsibility for health training institutions has been shifting between the Ministry of Health and the Ministry of Education, although it is currently under the Ministry of Health, also the main employer of public health workers. The Ugandan Public Health School Without Walls is an innovative and sustainable model of worker development, conceived in 1994 in partnership with Makerere University, which houses the program; the Ministry of Health; and the development partners, notably, the Rockefeller Foundation, the Centers for Disease Control and Prevention (CDC), and the World Health Organization (WHO). Up to 145 professionals from medical, biologic, and social sciences have been trained in a 10-year period. The curriculum is flexible and is constantly reviewed and adapted to the local situation. The program is 75% field-based, during which trainees are placed in 15 district training sites under professional working conditions and they also rotate through various Ministry of Health programs, where they get hands-on training. The program emphasizes operational research, dissemination of findings to policymakers, and evidence-based management decisions, features that have translated into marked improvements in the quality of the delivery of health systems in the country. Students participate in both national and international outbreak investigations. Challenges include increasing the numbers of students to match the high demand and increasing the number of learning facilities. Ensuring effective mentorship, appropriate recruitment, career paths for graduates, and sustainability of the program with reduced donor funding are also problems. Other examples of international public health worker development initiated by WHO and its Communicable Disease Surveillance Response unit for development of training materials in partnership with CDC are the Lyon 2-year training program for laboratory specialists and epidemiologists, Global Outbreak Alert and Response Network, and various internships. The Council of State and Territorial Epidemiologists (CSTE) conducted an Epidemiology Capacity Assessment survey of all states and territories. As of November 2001, a total of 1,366 persons were employed as epidemiologists in the 44 responding state and territorial health departments; almost half (47.7%) of these epidemiologists were working in infectious disease. The survey found that 42% of all epidemiologists working in state and territorial health department have no formal academic training in that discipline. States reported that approximately 48% of epidemiologists work in infectious diseases (a figure that is close to optimal), but that the rest of the public health disciplines, such as chronic disease, maternal child health, occupational health, oral health, bioterrorism/emergency preparedness, injury, and environmental health, are far below optimal capacity; further, >60% of states epidemiologic funding support comes from federal sources. Most states reported having an insufficient number of epidemiology staff and resources to carry out essential public health services. In response to the training needs identified by this assessment, CSTE, CDC, and Association of Schools of Public Health developed a 2-year applied epidemiology training fellowship that places trainees in state health departments. CSTE hosted the first national epidemiology workforce summit in January 2004 to identify strategies for building epidemiologic capacity in the U.S. public health system. Infectious disease testing is one of the core capacities of public health laboratories. Such laboratories play a key role in supporting outbreak investigation and surveillance activities. Public health laboratory staff must meet unique requirements and posses technical skills that require a long learning curve. Staff also need to have the knowledge of public health principals and relevance of their work to public health activities. Special recruitment and retention issues are challenging the public health laboratory workforce, including increasing vacancy rates and an increasing demand for skilled workers in light of the Select Agent Rule. At the same time, technology is changing rapidly, with new tests emerging almost daily. Solutions offered were salary parity with the private sector, innovative training, creation of interest in laboratory sciences, and continuing education. The National Laboratory Training Network has helped by offering courses, and Emerging Infectious Diseases fellowships are also attracting new workers. In 2000, Association of Public Health Laboratories survey of state laboratory directors led to the "Green Book," which forecasts impending vacancies up to 40% in certain public health laboratory areas. This finding led to the development of the Center for Public Health Laboratory Leadership, which offers corrective courses and ventures.