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BackgroundThe immunization system in the Democratic Republic of the Congo faces many challenges, including persistent large-scale outbreaks of polio, measles, and yellow fever; a large number of unvaccinated children for all antigens; minimal and delayed funding; and poor use of immunization data at all levels. In response, the Expanded Programme on Immunization within the Ministry of Health (MOH) collaborated with global partners to develop a revitalization strategy for the routine immunization (RI) system called the Mashako Plan.Mashako plan design and developmentThe Mashako Plan aimed to increase full immunization coverage in children aged 12-23 months by 15 percentage points overall in 9 of 26 provinces within 18 months of implementation. In 2018, we conducted a diagnostic review and identified gaps in coordination, service delivery, vaccine availability, real-time monitoring, and evaluation as key areas for intervention to improve the RI system. Five interventions were then implemented in the 9 identified provinces.DiscussionAccording to the 2020 vaccine coverage survey, full immunization coverage increased to 56.4%, and Penta3/DTP3 increased to 71.1% across the Mashako Plan provinces; the initial objective of the plan was reached and additional improvements in key service delivery indicators had been achieved. Increases in immunization sessions held per month, national stock of pentavalent vaccine, and supervision visits conducted demonstrate that simple, measurable changes at all levels can quickly improve immunization systems. Despite short-term improvements in all indicators tracked, challenges remain in vaccine availability, regular funding of immunization activities, systematic provision of immunization services, and ensuring long-term sustainability.ConclusionsStrong commitment of MOH staff combined with partner involvement enabled the improvement of the entire system. A simple set of interventions and indicators focused the energy of managers on discrete actions to improve outcomes. Further exploration of the results is necessary to determine the long-term impact and generate all-level engagement for sustainable success in all provinces.

Enteric helminths form intimate physical connections with the intestinal epithelium, yet their ability to directly alter epithelial stem cell fate has not been resolved. Here we demonstrate that infection of mice with the parasite Heligmosomoides polygyrus bakeri (Hpb) reprograms the intestinal epithelium into a fetal-like state marked by the emergence of Clusterin-expressing revival stem cells (revSCs). Organoid-based studies using parasite-derived excretory-secretory products reveal that Hpb-mediated revSC generation occurs independently of host-derived immune signals and inhibits type 2 cytokine–driven differentiation of secretory epithelial lineages that promote their expulsion. Reciprocally, type 2 cytokine signals limit revSC differentiation and, consequently, Hpb fitness, indicating that helminths compete with their host for control of the intestinal stem cell compartment to promote continuation of their life cycle.

Aims To identify implementation barriers and facilitators to the adoption and implementation of programs that provide opioid agonist treatments (OAT) with methadone and buprenorphine to treat opioid use disorder in jails and prisons in the United States DESIGN: Qualitative analysis: semi-structured interviews were conducted, and thematic analyses of transcripts and notes were done using a hybrid inductive/deductive coding approach SETTING: Jails and prisons in the United States PARTICIPANTS: From August 2019 to January 2020, we conducted 20 key informant interviews with 35 individuals representing 19 carceral systems that both initiate and maintain OAT. Measurements Interviews covered four domains: (1) program adoption; (2) policy influence on implementation; (3) program structure; and (4) program outcomes. Findings Stigma among staff, particularly medical staff, challenged program adoption, but reduced over time as staff were exposed to the program. Regulations on OAT dispensation, such as licensing requirements and prescribing limits, were key challenges to program implementation and shaped program structure. Dispensing medication required significant staff, time and space. Facilities were further challenged to overcome stigma and concerns about diversion, as OAT medication is often treated as contraband in carceral settings. Some systems deviated from evidence-based treatment by limiting OAT dosage to low levels, requiring counseling for participation and requiring detoxification before medication initiation. Despite these challenges, early adopters felt strongly that other jails and prisons in the United States should provide OAT and that legislation and litigation may soon force OAT expansion in these carceral settings. Conclusions Despite identifying regulatory and logistical challenges, early adopters of opioid agonist treatment (OAT) programs in US jails and prisons provide examples that demonstrate that OAT programs can successfully be implemented in carceral settings with tailoring to the specific context.

Enteric helminths form intimate physical connections with the intestinal epithelium, yet their ability to directly alter epithelial stem cell fate has not been resolved. Here we demonstrate that infection of mice with the symbiotic parasite Heligmosomoides polygyrus bakeri (Hbp), reprograms the intestinal epithelium into a fetal-like state marked by the emergence of Clusterin-expressing revival stem cells (revSCs). Organoid-based studies using parasite-derived excretory/secretory products reveal that Hpb-mediated revSC generation occurs independent of host-derived immune signals and inhibits type 2 cytokine-driven differentiation of secretory epithelial lineages that promote their expulsion. Reciprocally, type 2 cytokine signals limit revSC differentiation and, consequently, Hpb fitness indicating that helminths compete with their host for control of the intestinal stem cell niche to promote continuation of their life cycle.

OBJECTIVES: To describe how the novel coronavirus (COVID-19) pandemic has affected opioid agonist treatment (OAT) programs in jails and prisons. METHODS: In May 2020, we conducted an online survey of 19 carceral systems that provided methadone and/or buprenorphine treatment for incarcerated populations before COVID-19. Eleven survey items examined challenges and changes to these programs as a result of the pandemic. Sixteen of 19 programs (84%) responded to the survey. RESULTS: Ten out of 16 systems reported downsizing their OAT programs. Seven of 16 systems made changes to medication dispensation processes. Half of systems report challenges implementing physical distancing (n = 8), and/or obtaining personal protective equipment (n = 8). In 13 out of 16 systems some OAT program participants were released early due to COVID-19 infection risk. CONCLUSIONS: Jails and prisons with existing OAT programs have curtailed their operations in the context of the COVID-19 pandemic. Given the robust evidence base around OAT for treating opioid use disorder and averting overdose deaths, guidance is needed on maintaining and ramping up medication access as carceral facilities grapple with implementing COVID-19 mitigation.

Background Four million individuals in the U.S. criminal-legal system are supervised in the community under probation or parole. Sentences to community supervision often mandate participation in substance use treatment. Yet evidence-based treatment with medication (i.e., methadone, buprenorphine, or naltrexone) is rarely offered to people under community supervision with opioid use disorder (OUD). This qualitative study explores the structural and organizational factors shaping OUD medication treatment use in community supervision. Methods We conducted in-depth interviews with 31 community supervision professionals. Thematic analysis characterized interview participants’ perceptions of the key factors shaping use of OUD medications in community supervision. Findings Findings indicate that authorities making decisions about OUD treatment include community supervision agencies, treatment providers, judges and courts, and jails and prisons. Agencies with more rehabilitative cultural orientations are more forgiving of relapse and supportive of OUD medications. Punishment/enforcement orientations align with an emphasis on surveillance and drug testing, which can inhibit medication treatment and interrupt continuity of care. Community supervision agencies generally reported deference to the recommendations of substance use treatment providers regarding the details of treatment, including the use of medication. Given that most treatment providers do not offer OUD medication, community supervision agencies must develop a sophisticated understanding of the various services offered by local treatment providers to tailor referrals accordingly, a responsibility for which they may be inadequately trained. Conclusions Efforts to improve engagement with medication treatment in U.S. community supervision settings could have a significant impact on reincarceration, morbidity, and mortality among individuals with OUD under supervision.