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Background Control of cutaneous leishmaniasis by public health systems in the Americas relies on case identification and treatment. Point-of-care diagnostics that can be performed by health workers within or near affected communities could effectively bring the health system to the resource-limited sites providing early diagnosis and treatment, reducing morbidity and the burden of disease. Methodology/principal findings A cross-sectional study was undertaken to evaluate the diagnostic test performance of Isothermal Recombinase Polymerase Amplification (RPA) targeting Leishmania kinetoplast DNA, coupled with a lateral flow (LF) immunochromatographic strip, in a field setting and a laboratory reference center. Minimally invasive swab and FTA filter paper samples were obtained by community health workers and highly trained technicians from ulcerated lesions of > 2 weeks’ evolution from 118 patients’ ≥ 2 years of age in the municipality of Tumaco, Nariño. Extracted DNA was processed by RPA-LF at a reference center or in a primary health facility in the field. Evaluation was based on a composite “gold standard” that included microscopy, culture, biopsy and real-time polymerase chain reaction detection of Leishmania 18S rDNA. Standard of care routine diagnostic tests were explored as comparators. Sensitivity and specificity of RPA-LF in the reference lab scenario were 87% (95%CI 74–94) and 86% (95%CI 74–97), respectively. In the field scenario, the sensitivity was 75% (95%CI 65–84) and specificity 89% (95%CI 78–99). Positive likelihood ratios in both scenarios were higher than 6 while negative likelihood ratios ranged to 0.2–0.3 supporting the usefulness of RPA-LF to rule-in and potentially to rule-out infection. Conclusions/significance The low complexity requirements of RPA-LF combined with non-invasive sampling support the feasibility of its utilization by community health workers with the goal of strengthening the diagnostic capacity for cutaneous leishmaniasis in Colombia. Trial registration ClinicalTrials.gov NCT04500873., Author summary Limited access to diagnosis is a critical determinant of the “neglect” that defines the so-called Neglected Tropical Diseases (NTDs) including cutaneous leishmaniasis. Diagnostic tests that can be performed close to and involve the participation of the affected communities would improve access to treatment as well as diagnosis. Using non-invasive swab and filter paper samples obtained by Community Health Workers, we evaluated the diagnostic performance of an innovative and technically simple molecular test: Isothermal Recombinase Polymerase Amplification (RPA) to detect Leishmania DNA, coupled with a lateral flow (LF) strip to read the results with the naked eye. The RPA-LF test demonstrated high sensitivity and specificity and capacity to rule in or rule out a diagnosis of cutaneous leishmaniasis in both an endemic field setting and reference laboratory. The findings encourage the further optimization of the test format for Point-of-Care diagnosis by health personnel and rural health workers in endemic settings.

Concerns have been raised regarding handling of Ebola virus contaminated wastewater, as well as the adequacy of proposed disinfection approaches. In the current study, we investigate the inactivation of Ebola virus in sterilized domestic wastewater utilizing sodium hypochlorite addition and pH adjustment. No viral inactivation was observed in the one-hour tests without sodium hypochlorite addition or pH adjustment. No virus was recovered after 20 seconds (i.e. 4.2 log10 unit inactivation to detection limit) following the addition of 5 and 10 mg L-1 sodium hypochlorite, which resulted in immediate free chlorine residuals of 0.52 and 1.11 mg L-1, respectively. The addition of 1 mg L-1 sodium hypochlorite resulted in an immediate free chlorine residual of 0.16 mg L-1, which inactivated 3.5 log10 units of Ebola virus in 20 seconds. Further inactivation was not evident due to the rapid consumption of the chlorine residual. Elevating the pH to 11.2 was found to significantly increase viral decay over ambient conditions. These results indicate the high susceptibility of the enveloped Ebola virus to disinfection in the presence of free chlorine in municipal wastewater; however, we caution that extension to more complex matrices (e.g. bodily fluids) will require additional verification., Author Summary Ebola virus infected individuals may generate up to nine liters of potentially infectious liquid waste per day. Previous recommendations were to directly dispose of this waste into a sanitary sewer or latrine; however, release of infectious virus raised the concern of environmental transmission through unintentional contact with contaminated wastewater. One possibility to reduce or eliminate the release of infectious virus is disinfection of Ebola virus contaminated liquid waste. A hurdle to making recommendations for liquid waste disinfection is the lack of data on disinfection efficacy. Here we demonstrate that Ebola virus in municipal wastewater is highly sensitive to disinfection in the presence of free chlorine. In addition, elevating the pH to 11.2 significantly increased the rate of decay over neutral pH conditions. These results provide a basis to develop recommendations for the disinfection of Ebola virus contaminated wastewater.

The expansion of urban ecosystems and climate change, both outcomes of massive lifestyle changes, contribute to a series of side effects such as environmental deterioration, spread of diseases, increased greenhouse gas emissions and introduction of invasive species. In the case of the Athens metropolitan area, an invasive mosquito species—the Asian tiger mosquito (Aedes albopictus)–has spread widely in the last decade. This spread is favoured within urban environments and is also affected by changing climatic trends. The Asian tiger mosquito is accompanied by risks of mosquito-borne diseases, greater nuisance levels, and increased expenses incurring for its confrontation. The main aims of this paper are (i) to estimate the various costs associated with the control of this invasive species, as well as its health and nuisance impacts, (ii) to evaluate the level of citizens’ well-being from averting these impacts and (iii) to record citizens’ and experts’ perceptions regarding alternative control measures. Evidence shows that experts tend to place a high value on mosquito control when associated with serious health risks, while citizens are more sensitive and concerned about the environmental impacts of control methods. The synthesis of results produced by the current study could act as a preliminary guide for the estimation of societal welfare from the confrontation of similar problems in the context of a complex ecosystem., Author summary This paper is based on several years’ collaboration among researchers from various disciplines, key health policy makers and stakeholders in an attempt to evaluate the economic dimensions related to the presence of the Asian Tiger Mosquito (Aedes albopictus) and the challenges of tackling mosquito-borne disease outbreaks in Greece and Southern Europe. Similar studies have been conducted and continue to be published in Europe and the USA examining the socioeconomic benefit from the implementation of relevant control and prevention strategies. These studies conclude that there are significant benefits related both to the reduction of nuisance levels and the reduction of the health risks posed by various mosquito species. In our case, the application of an updated economic analysis on the effectiveness of relevant public control and prevention programs provides essential information for public health decision-making, bearing in mind the significant restructuring of the public sector and the fiscal crisis apparent in the European South.

On March 17, 2017, the United Nations (UN) Security Council, backed by the consensus of its 193 member states, adopted Resolution 2344, which calls for strengthening regional economic cooperation through China’s Belt and Road (also called Silk Road) Initiative (BRI) [1]. Based on the cornerstones of peace and cooperation, openness and inclusiveness, and mutual learning and sharing benefit, this initiative was proposed by the Chinese government and is participated in by various parties. Its goal is to provide fundamental solutions to boost global economic development through enhancing policy coordination, facility connection, unimpeded trade, financial integration, and people-to-people bonds. The UN Secretary-General, Mr. Antonio Guterres, acknowledged that the BRI tallies with, and complements, the Sustainable Development Goals (SDGs) in terms of promoting inclusive development, strengthening exchange between countries, and benefiting people within the initiative’s scope [2]. The BRI currently involves 69 countries (mainly those named in the initial Belt and Road outreach and those having signed cooperation agreements), 70% of the world population in total, 30% of the global gross domestic product, and 75% of the world's energy reserves [2–4]. Although the BRI is primarily economic, it also includes important health dimensions. The Healthy China 2030 plan, promulgated in 2016, considers health as one of the national policy priorities, and the Memorandum of Understanding with the World Health Organization (WHO), signed in 2017, which promotes global health security and development along the terms of the initiative [5, 6]. Based on these agreements, the building of a Health Silk Road has become a core task leading to an extensive engagement in global health development [7, 8]. During the Belt and Road High-Level Meeting for Health Cooperation: Towards a Health Silk Road, held in August 2017 in Beijing, the Director-General of WHO, Dr Tedros Adhanom Ghebreyesus, positively commented on the initiative, saying that it may become the stimulus needed to drive our united activities towards universal health coverage (UHC) and that it contains the necessary fundamentals, such as infrastructure building, access to medicines, and human resources, needed to build a platform for sharing experience and promoting best practices [5]. The Health Silk Road concept establishes the importance of promoting cooperation among the related countries in the prevention and control of communicable diseases, medical system and policies, healthcare capacity building, staff training and exchange, traditional medicine, and health education as well as disaster relief, aid, and poverty reduction for health [1]. In this way, building the contextual Health Silk Road would advance political commitment to mobilise all resources for better health in the world. The world is currently witnessing increasingly complex epidemics as well as natural disasters with a rising impact on both human health and the economy [1]. Growing commercial trade and more frequent personal exchange following the implementation of the BRI may amplify infectious disease transmission or inadvertently introduce emerging infectious diseases, leading to an increased burden for local medical systems. Moreover, infectious diseases resulting from poverty disproportionately affect poor and marginalised communities, which remains a more serious hurdle to achieving the SDGs and UHC [9, 10]. This is the reason why the initiative has made the need to combat infectious diseases a priority for social and economic development. The implementation of the BRI is expected to facilitate progress in eliminating infectious diseases such as the acquired immunodeficiency syndrome (AIDS) caused by the human immunodeficiency virus (HIV), tuberculosis (TB), malaria, and 17 neglected tropical diseases (NTDs), which make up SDG 3.3. It has also gained the support of WHO, which has proposed a strategic cooperation with the BRI [5, 6, 11]. Taking the opportunities provided by this initiative, action for combating the diseases will be conducted through the sharing of information and experience and cooperative disease control programmes, including interventions and research innovation [5]. It will also mediate resources including the building of medical infrastructures, funding support, training of staff, and delivery of emergency healthcare [1, 10, 12]. The initiative provides guidance for stronger health collaboration, which should hopefully break the vicious cycle of poverty and infectious disease [13]. Delegates from the Joint UN Programme on HIV/AIDS (UNAIDS), the Global Fund (https://www.theglobalfund.org/en/), the Global Alliance for Vaccines and Immunisation (GAVI) (https://www.gavi.org/), and more than 30 countries participated in the Belt and Road High-Level Meeting for Health Cooperation, signed the Beijing Communique, and agreed to participate in building the Health Silk Road. As for the infectious diseases, cooperation on control and elimination has been the highest priority, together with mounting an effective response to disease outbreaks and reemerging infections [2]. However, details regarding how this should be carried out in practice have not yet been presented; in particular, we still lack proposals that take up the challenges, specify indicators of expected impact, and develop opportunities for collaboration in this area. The purpose of this paper is to analyse the existing spectrum of the main infectious diseases in epidemics (based on the Global Burden of Diseases [GBD] study of 2016 [14, 15]), the potential negative effect on the economy, and the challenges to elimination. The paper also aims to explore opportunities and a feasible approach of global disease control with specific consideration of the BRI.

The estimated 50 million nomadic pastoralists in Africa are among the most “hard-to-reach” populations for health-service delivery. While data are limited, some studies have identified these communities as potential disease reservoirs relevant to neglected tropical disease programs, particularly those slated for elimination and eradication. Although previous literature has emphasized the role of these populations’ mobility, the full range of factors influencing health service utilization has not been examined systematically. We systematically reviewed empirical literature on health services uptake among African nomadic pastoralists from seven online journal databases. Papers meeting inclusion criteria were reviewed using STROBE- and PRISMA-derived guidelines. Study characteristics were summarized quantitatively, and 10 key themes were identified through inductive qualitative coding. One-hundred two papers published between 1974–2019 presenting data from 16 African countries met our inclusion criteria. Among the indicators of study-reporting quality, limitations (37%) and data analysis were most frequently omitted (18%). We identified supply- and demand-side influences on health services uptake that related to geographic access (79%); service quality (90%); disease-specific knowledge and awareness of health services (59%); patient costs (35%); contextual tailoring of interventions (75%); social structure and gender (50%); subjects’ beliefs, behaviors, and attitudes (43%); political will (14%); social, political, and armed conflict (30%); and community agency (10%). A range of context-specific factors beyond distance to facilities or population mobility affects health service uptake. Approaches tailored to the nomadic pastoralist lifeway, e.g., that integrated human and veterinary health service delivery (a.k.a., “One Health”) and initiatives that engaged communities in program design to address social structures were especially promising. Better causal theorization, transdisciplinary and participatory research methods, clearer operational definitions and improved measurement of nomadic pastoralism, and key factors influencing uptake, will improve our understanding of how to increase accessibility, acceptability, quality and equity of health services to nomadic pastoralist populations., Author summary There are approximately 50 million nomadic pastoralists in Africa for whom there is little data on healthcare access and utilization. This data scarcity presents a challenge to prevent, treat and control neglected tropical diseases and design the health service delivery mechanisms through which these objectives can be met. Examining a range of studies conducted over a 45-year period, we identified supply- and demand-side influences on health services uptake in ten thematic areas. These included physical proximity to, and quality of, health services; monetary and opportunity costs of accessing care; and societal and gender norms governing power dynamics within nomadic pastoralist groups as well as those between them and health care providers. The knowledge, attitudes and practices of health care providers and health seekers also played a role in utilization, as did hegemonic factors including “political will” and varying degrees of social conflict. NTD research topics included guinea worm, lymphatic filariasis, rabies, soil-transmitted helminths, tuberculosis (bovine and human), cholera, and rift valley fever. Studies pertaining to community-directed initiatives and “One Health” approaches offered promising solutions to increase service uptake. We recommend ways to strengthen future research on this subject to improve health service delivery to, and uptake among, nomadic pastoralist populations.

In recent years, an increased focus has been placed upon the possibility of the elimination of soil-transmitted helminth (STH) transmission using various interventions including mass drug administration. The primary diagnostic tool recommended by the WHO is the detection of STH eggs in stool using the Kato-Katz (KK) method. However, detecting infected individuals using this method becomes increasingly difficult as the intensity of infection decreases. Newer techniques, such as qPCR, have been shown to have greater sensitivity than KK, especially at low prevalence. However, the impact of using qPCR on elimination thresholds is yet to be investigated. In this paper, we aim to quantify how the sensitivity of these two diagnostic tools affects the optimal prevalence threshold at which to declare the interruption of transmission with a defined level of confidence. A stochastic, individual-based STH transmission model was used in this study to simulate the transmission dynamics of Ascaris and hookworm. Data from a Kenyan deworming study were used to parameterize the diagnostic model which was based on egg detection probabilities. The positive and negative predictive values (PPV and NPV) were calculated to assess the quality of any given threshold, with the optimal threshold value taken to be that at which both were maximised. The threshold prevalence of infection values for declaring elimination of Ascaris transmission were 6% and 12% for KK and qPCR respectively. For hookworm, these threshold values are lower at 0.5% and 2% respectively. Diagnostic tests with greater sensitivity are becoming increasingly important as we approach the elimination of STH transmission in some regions of the world. For declaring the elimination of transmission, using qPCR to diagnose STH infection results in the definition of a higher prevalence, than when KK is used., Author summary Soil-transmitted helminths are categorised as a neglected tropical disease and comprise four dominant species (two hookworms, Trichuris trichuria & Ascaris lumbricoides) that affect the poorest people in the world. The World Health Organisation (WHO) has made great strides in reducing the morbidity induced by STH infections in pre-school aged and school-aged children through mass drug administration. Many countries are now considering moving from morbidity reduction in school-aged children to community-wide treatment with the aim of transmission elimination. These helminths reproduce sexually within a human host and therefore both male and female worms must be present to produce fertilized eggs. The density of female and male worms below which mating success is too low to sustain parasite populations is defined as the ‘breakpoint’ in transmission. Both the prevalence and intensity of infection are very low as this breakpoint is approached when worm numbers are highly aggregated in their distribution within the human host population. Consequently, it becomes increasingly challenging to identify infected individuals using standard microscopic diagnostic tools (such as Kato-Katz). New and more sensitive molecular diagnostics tools, such as qPCR, are a necessity in settings where communities are moving towards the interruption of transmission. This paper demonstrates that the threshold to declare interruption of transmission is 50% lower when microscopic techniques are applied compared with molecular techniques.

Background Leprosy is a condition that has long been associated with stigma and discrimination, even when infected persons have been cured. This paper describes stigma and discrimination as viewed by caregivers who are associated with people affected by leprosy in Ghana. Methods A qualitative interview with semi-structured interviews were conducted for twenty caregivers. Results Findings indicated that caregivers were of the view that people affected by leprosy in Ghana are stigmatized and discriminated against by the larger society thus making their movements and interactions restricted to the Leprosarium. Besides, employments opportunities are unavailable to them thus making them exposed to financial challenges. The livelihood Empowerment Against poverty (LEAP) money given them is not sufficient for their daily upkeep. Conclusion People affected by leprosy in Ghana are stigmatized and therefore find it difficult to interact freely with the public. The associated physical deformities with the disease also tend to impede their ability to relate to the general public. The LEAP cash given to people affected by leprosy is helpful however, it could be enhanced to keep pace with prevailing economic conditions in the country., Author summary In Ghana, the social interpretation of leprosy regardless of the language, culture and tradition engenders stigmatization and discrimination that leads to social rejection and exclusion of persons who have been cured of the disease. Often, these persons are cared for by relatives who happen to live with them in a confined place. From the views of these caregivers, this paper identifies areas of stigmatizing and discriminatory tendencies against people affected by leprosy who reside in a Leprosarium in Accra, the capital city. It is expected that persons suffering from such neglected tropical disease would be empowered to enable them go about their daily routines without the fear of being rejected. Besides, the intensification of public education about curing tendencies of stigma becomes paramount.

Introduction Dengue is a rapidly emerging vector-borne Neglected Tropical Disease, with a 30-fold increase in the number of cases reported since 1960. The economic cost of the illness is measured in the billions of dollars annually. Environmental change and unplanned urbanization are conspiring to raise the health and economic cost even further beyond the reach of health systems and households. The health-sector response has depended in large part on control of the Aedes aegypti and Ae. albopictus (mosquito) vectors. The cost-effectiveness of the first-ever dengue vaccine remains to be evaluated in the field. In this paper, we examine how it might affect the cost-effectiveness of sustained vector control. Methods We employ a dynamic Markov model of the effects of vector control on dengue in both vectors and humans over a 15-year period, in six countries: Brazil, Columbia, Malaysia, Mexico, the Philippines, and Thailand. We evaluate the cost (direct medical costs and control programme costs) and cost-effectiveness of sustained vector control, outbreak response and/or medical case management, in the presence of a (hypothetical) highly targeted and low cost immunization strategy using a (non-hypothetical) medium-efficacy vaccine. Results Sustained vector control using existing technologies would cost little more than outbreak response, given the associated costs of medical case management. If sustained use of existing or upcoming technologies (of similar price) reduce vector populations by 70–90%, the cost per disability-adjusted life year averted is 2013 US$ 679–1331 (best estimates) relative to no intervention. Sustained vector control could be highly cost-effective even with less effective technologies (50–70% reduction in vector populations) and in the presence of a highly targeted and low cost immunization strategy using a medium-efficacy vaccine. Discussion Economic evaluation of the first-ever dengue vaccine is ongoing. However, even under very optimistic assumptions about a highly targeted and low cost immunization strategy, our results suggest that sustained vector control will continue to play an important role in mitigating the impact of environmental change and urbanization on human health. If additional benefits for the control of other Aedes borne diseases, such as Chikungunya, yellow fever and Zika fever are taken into account, the investment case is even stronger. High-burden endemic countries should proceed to map populations to be covered by sustained vector control., Author summary Transmitted by the Aedes mosquito, dengue affects more than 100 countries and is rapidly emerging as the leading vector-borne disease. There has been a 30-fold increase in the number of cases reported since 1960. The cost of the illness to the health system and to society at large is estimated at several billions of dollars annually. The health sector response has depended in large part on controlling mosquito populations during outbreaks. Recently, the first-ever dengue vaccine received regulatory approval for use in several countries. However, its roll-out and long-term impact still needs to be evaluated in the field. In this paper, we examine how the introduction of this vaccine might alter the investment case for sustained effort to control mosquitoes. To our knowledge, this is the first economic evaluation of mosquito control in the era of the dengue vaccine. We model the cost and effects of mosquito control in Brazil, Columbia, Malaysia, Mexico, the Philippines, and Thailand. We evaluate the cost-effectiveness of mosquito control in the presence of a vaccine that does not offer full protection to all individuals. Our results suggest that sustained mosquito control will continue to be cost-effective, even if roll-out of the current vaccine is highly targeted and low-cost. These results support current global policies and strategies for the prevention and control of dengue.

Background The Bangladesh Lymphatic Filariasis (LF) Elimination Programme has made significant progress in interrupting transmission through mass drug administration (MDA) and has now focussed its efforts on scaling up managing morbidity and preventing disability (MMDP) activities to deliver the minimum package of care to people affected by LF clinical conditions. This paper highlights the Bangladesh LF Programme’s success in conducting a large-scale cross-sectional survey to determine the number of people affected by lymphoedema and hydrocoele, which enabled clinical risk maps to be developed for targeted interventions across the 34 endemic districts (19 high endemic; 15 low endemic). Methodology/Principal findings In the 19 high endemic districts, 8,145 community clinic staff were trained to identify and report patients in their catchment area. In the 15 low endemic districts, a team of 10 trained field assistants conducted active case finding with cases reported via a SMS mHealth tool. Disease burden and prevalence maps were developed, with morbidity hotspots identified at sub-district level based on a combination of the highest prevalence rates per 100,000 and case-density rates per square kilometre (km2). The relationship between morbidity and baseline microfilaria (mf) prevalence was also examined. In total 43,678 cases were identified in the 19 high endemic districts; 30,616 limb lymphoedema (70.1%; female 55.3%), 12,824 hydrocoele (29.4%), and 238 breast/female genital swelling (0.5%). Rangpur Division reported the highest cases numbers and prevalence of lymphoedema (26,781 cases, 195 per 100,000) and hydrocoele (11661 cases, 169.6 per 100,000), with lymphoedema predominately affecting females (n = 21,652). Rangpur and Lalmonirhat Districts reported the highest case numbers (n = 11,199), and prevalence (569 per 100,000) respectively, with five overlapping lymphoedema and hydrocoele sub-district hotspots. In the 15 low endemic districts, 732 cases were identified; 661 lymphoedema (90.2%; female 39.6%), 56 hydrocoele (7.8%), and 15 both conditions (2.0%). Spearman’s correlation analysis found morbidity and mf prevalence significantly positively correlated (r = 0.904; p, Author summary The Global Programme to Eliminate Lymphatic Filariasis (GPELF) requires lymphatic filariasis (LF) endemic countries, such as Bangladesh, to estimate the number of lymphoedema and hydrocoele cases in order to deliver the minimum package of care required to control morbidity and reduce patient suffering. This paper highlights the Bangladesh LF Elimination Programme’s progress in training more than 8000 community health workers to identify more than 44,000 cases across 34 endemic districts where approximately 70 million people are at risk. The morbidity data collected enabled the creation of a national database and a series of risk maps of lymphoedema and hydrocoele to be developed, which highlighted the significant burden in northern Rangpur Division, especially of lymphoedema among female patients. The Bangladesh LF Elimination Programme’s efforts to identify LF cases across all endemic districts represents one of the most comprehensive national databases on LF clinical cases in the world. It provides an informative database for health workers to use in the delivery of the minimum package of care and a template for other countries to adopt and develop national strategies to manage morbidity and prevent disability as recommended by GPELF.

Background Scabies is a common dermatological condition, affecting more than 130 million people at any time. To evaluate and/or predict the effectiveness and cost-effectiveness of scabies interventions, disease transmission modelling can be used. Objective To review published scabies models and data to inform the design of a comprehensive scabies transmission modelling framework to evaluate the cost-effectiveness of scabies interventions. Methods Systematic literature search in PubMed, Medline, Embase, CINAHL, and the Cochrane Library identified scabies studies published since the year 2000. Selected papers included modelling studies and studies on the life cycle of scabies mites, patient quality of life and resource use. Reference lists of reviews were used to identify any papers missed through the search strategy. Strengths and limitations of identified scabies models were evaluated and used to design a modelling framework. Potential model inputs were identified and discussed. Findings Four scabies models were published: a Markov decision tree, two compartmental models, and an agent-based, network-dependent Monte Carlo model. None of the models specifically addressed crusted scabies, which is associated with high morbidity, mortality, and increased transmission. There is a lack of reliable, comprehensive information about scabies biology and the impact this disease has on patients and society. Discussion Clinicians and health economists working in the field of scabies are encouraged to use the current review to inform disease transmission modelling and economic evaluations on interventions against scabies., Author summary Scabies is a neglected tropical disease affecting more than 130 million people, with major costs on health care systems worldwide. While effective treatments exist, it is unknown which treatment strategies result in the best outcomes against the lowest costs, and to what extent this differs between communities. Health economic modelling can help answer these questions, but has rarely been used in this disease area. This review discusses all available scabies transmission models (n = 4), and uses them to create a new, comprehensive modelling framework. This framework can be used as aid for creating a scabies transmission model, the details of which will be determined by the context (population) and the question being addressed. The current paper also reviews the data that is needed to inform scabies modelling: on scabies biology, quality of life and resource use. Unfortunately, available data is limited and particularly data on crusted scabies (associated with high morbidity and mortality rates) is rare. With this review, we hope to assist researchers and policy makers to predict and/or evaluate the cost-effectiveness of interventions against scabies in their population(s) of interest. To tackle scabies, it is key to use effective treatment strategies in a cost-effective and sustainable way. The models and data described in this review, may help researchers, clinicians and funding bodies to facilitate this.

Background Over the last decade, implementation research and a science of global health delivery have emerged as important vehicles to improve the effectiveness of interventions. Efforts to control neglected tropical diseases (NTD) operate in challenging circumstances and with marginalized populations, making attention to context-specific details particularly relevant. Socio-anthropological insights have much to offer a science of NTD delivery. In this paper, an accessible and actionable framework for understanding NTD intervention effectiveness, based on socio-anthropological research, is presented and its utility for program planning and monitoring and evaluation is outlined. Methodology/Principal findings The framework was developed inductively by comparatively analyzing three rapid ethnographic studies undertaken in Eastern Africa (2010–2013) on three different large-scale NTD interventions: rabies elimination in Tanzania, sleeping sickness control in Uganda and the prevention of parasitic worms in Zambia. The framework includes five “intervention domains” where the effectiveness of these interventions was negotiated and determined at the local level. This involves: 1) the terrain of intervention (including seasonality and geographical variability); 2) community agency (including local knowledge, risk perceptions, behaviors, leadership and social pressure); 3) the strategies and incentives of field staff (skills, motivations, capabilities and support); 4) the socio-materiality of technology (characteristics of intervention tools and the adoption process itself); and 5) the governance of interventions (policy narratives, available expertise, bureaucracy, politics and the utilization of knowledge). The paper illustrates the importance of each of these domains by drawing on the case study research, presenting lessons learnt and practical recommendations for how such insights could improve intervention delivery. Conclusions/Significance To help close the gap between efficacy and effectiveness in NTD programs, it is important that field staff: 1) generate meaningful knowledge about contextual factors; 2) use this knowledge to tailor field strategies; and 3) create routine mechanisms to account for the dynamic process of implementation itself. The framework presented here offers a simple analytical tool to strengthen these knowledge-to-action relationships existing project planning tools, drawing on the insights of socio-anthropology., Author summary Many efficacious tools exist to control NTDs, but effectively moving these tools and approaches from the boardroom to the village is a complicated socio-political process. In the era of Sustainable Development Goals, global health has become more focused on improving the delivery of existing interventions. Greater attention to implementation research, including the value of social science perspectives, has followed in an effort to build a science of global health delivery. This paper presents an accessible and actionable socio-anthropological framework for understanding the effectiveness factors of NTD interventions. The framework was developed by comparatively analyzing three large-scale NTD interventions in Eastern Africa: rabies elimination in Tanzania, sleeping sickness control in Uganda and the prevention of parasitic worms in Zambia. The framework includes five “intervention domains” where the effectiveness of these interventions was determined: 1) the terrain of intervention; 2) community agency; 3) the strategies and incentives of field staff; 4) the socio-materiality of technology; and 5) the governance of interventions. The paper illustrates the importance of each of these domains, presenting lessons learnt and practical recommendations. As a flexible analytical tool, the framework could be integrated into the planning and implementation process itself, bringing the insights of socio-anthropological approaches into an emerging science of NTD delivery.

Background In the Cameroon, previous efforts to identify Buruli ulcer (BU) through the mobilization of community health workers (CHWs) yielded poor results. In this paper, we describe the successful creation of a BU community of practice (BUCOP) in Bankim, Cameroon composed of hospital staff, former patients, CHWs, and traditional healers. Methods and principle findings All seven stages of a well-defined formative research process were conducted during three phases of research carried out by a team of social scientists working closely with Bankim hospital staff. Phase one ethnographic research generated interventions tested in a phase two proof of concept study followed by a three- year pilot project. In phase three the pilot project was evaluated. An outcome evaluation documented a significant rise in BU detection, especially category I cases, and a shift in case referral. Trained CHW and traditional healers initially referred most suspected cases of BU to Bankim hospital. Over time, household members exposed to an innovative and culturally sensitive outreach education program referred the greatest number of suspected cases. Laboratory confirmation of suspected BU cases referred by community stakeholders was above 30%. An impact and process evaluation found that sustained collaboration between health staff, CHWs, and traditional healers had been achieved. CHWs came to play a more active role in organizing BU outreach activities, which increased their social status. Traditional healers found they gained more from collaboration than they lost from referral. Conclusion/ Significance Setting up lines of communication, and promoting collaboration and trust between community stakeholders and health staff is essential to the control of neglected tropical diseases. It is also essential to health system strengthening and emerging disease preparedness. The BUCOP model described in this paper holds great promise for bringing communities together to solve pressing health problems in a culturally sensitive manner., Author summary Buruli ulcer (BU) is a neglected tropical disease primarily found in West Africa largely effecting the rural poor. BU has a known cause and cure, but an unknown route of transmission and a poorly understood incubation period. If not treated early and in a timely manner, BU often progresses to an advanced state requiring surgery and prolonged wound care. In the Cameroon, previous efforts to mobilize community health workers and educate community members to identify cases of BU yielded poor results. In this paper, we describe steps undertaken to create a successful BU community of practice (BUCOP) composed of community stakeholders working in concert with clinic staff. The success of the BUCOP was measured in terms of numbers of suspected BU cases referred and confirmed, a decline in treatment drop out, and sustained collaboration among stakeholders both during and following the pilot project. Pilot project success is attributed to an innovative and culturally sensitive approach to BU outreach education, increased levels of patient assistance, and mutual respect among BUCOP members for what each stakeholder contributed to BU detection, treatment, psychosocial support, and spiritual protection.

The neglected tropical diseases (NTDs) affect hundreds of millions of people, predominantly in rural, often difficult-to-access areas, poorly served by national health services. Here, we review the contributions of 4.8 million community-directed distributors (CDDs) of medicines over 2 decades in 146,000 communities in 27 sub-Saharan African countries to control or eliminate onchocerciasis and lymphatic filariasis (LF). We examine their role in the control of other NTDs, malaria, HIV/AIDS interventions, immunisation campaigns, and support to overstretched health service personnel. We are of the opinion that CDDs as community selected, trained, and experienced “foot soldiers,” some of whom were involved in the Ebola outbreak responses at the community level in Liberia, if retrained, can assist community leaders and support health workers (HWs) in the ongoing Coronavirus Disease 2019 (COVID-19) crisis. The review highlights the improved treatment coverage where there are women CDDs, the benefits and lessons from the work of CDDs, their long-term engagement, and the challenges they face in healthcare delivery. It underscores the value of utilising the CDD model for strong community engagement and recommends the model, with some review, to hasten the achievement of the NTD 2030 goal and assist the health system cope with evolving epidemics and other challenges. We propose that, based on the unprecedented progress made in the control of NTDs directly linked to community engagement and contributions of CDDs “foot soldiers,” they deserve regional and global recognition. We also suggest that the World Health Organization (WHO) and other international stakeholders promote policy and guidance for countries to adapt this model for the elimination of NTDs and to strengthen national health services. This will enhance the accomplishment of some Sustainable Development Goals (SDGs) by 2030 in sub-Saharan Africa., Author summary Community-directed distributors (CDDs), sometimes known as community health workers (CHWs), have proved to be critical in the delivery of medicines and other tools for the control of neglected tropical diseases (NTDs), prevention of malaria, and other beneficial health interventions. The distributors are the unsung heroes and heroines without whom the health of hundreds of thousands of communities in rural Africa would be worse than it is today. In this paper, we document more than 2 decades (1997–2019) of the contributions of 146,000 communities and 4.8 million CDDs of medicines for NTDs, unpaid or minimally compensated, some have provided 18 years of uninterrupted service. We report on the burden of work and their perspectives of the challenges involved in mass drug administration (MDA) across 27 countries in sub-Saharan Africa. We suggest that they have not been adequately recognised and that harnessing such community human resources could contribute to improving health system’s responses to the ongoing Coronavirus Disease 2019 (COVID-19) crisis. We recommend policy measures for a wider application of existing networks of CDDs by countries’ health systems to consolidate and accelerate the achievements made as well as for the attainment of the goals set forth in the newly developed World Health Organization (WHO) NTD Roadmap.

The Islamic Republic of Iran reported its first COVID-19 cases by 19th February 2020, since then it has become one of the most affected countries, with more than 73,000 cases and 4,585 deaths to this date. Spatial modeling could be used to approach an understanding of structural and sociodemographic factors that have impacted COVID-19 spread at a province-level in Iran. Therefore, in the present paper, we developed a spatial statistical approach to describe how COVID-19 cases are spatially distributed and to identify significant spatial clusters of cases and how socioeconomic and climatic features of Iranian provinces might predict the number of cases. The analyses are applied to cumulative cases of the disease from February 19th to March 18th. They correspond to obtaining maps associated with quartiles for rates of COVID-19 cases smoothed through a Bayesian technique and relative risks, the calculation of global (Moran’s I) and local indicators of spatial autocorrelation (LISA), both univariate and bivariate, to derive significant clustering, and the fit of a multivariate spatial lag model considering a set of variables potentially affecting the presence of the disease. We identified a cluster of provinces with significantly higher rates of COVID-19 cases around Tehran (p-value< 0.05), indicating that the COVID-19 spread within Iran was spatially correlated. Urbanized, highly connected provinces with older population structures and higher average temperatures were the most susceptible to present a higher number of COVID-19 cases (p-value < 0.05). Interestingly, literacy is a factor that is associated with a decrease in the number of cases (p-value < 0.05), which might be directly related to health literacy and compliance with public health measures. These features indicate that social distancing, protecting older adults, and vulnerable populations, as well as promoting health literacy, might be useful to reduce SARS-CoV-2 spread in Iran. One limitation of our analysis is that the most updated information we found concerning socioeconomic and climatic features is not for 2020, or even for a same year, so that the obtained associations should be interpreted with caution. Our approach could be applied to model COVID-19 outbreaks in other countries with similar characteristics or in case of an upturn in COVID-19 within Iran., Author summary Iran was among the first countries reporting a rapid increase in the number of COVID-19 cases. Spatial epidemiology is useful to study the spatial distribution of a disease and to identify factors associated with the number of cases of such disease. By applying these methods, we aimed to identify whether there are clusters of regions in Iran with high or low number of COVID-19 cases and the association of different factors with these numbers, considering spatial relationships and maps representing these associations. Interestingly, we found regions of high number of cases and that more COVID-19 cases were present in provinces with more urbanization, aging population, number of physicians, efficient communications, and greater average temperatures, whereas less COVID-19 cases were present in provinces with more literacy. This study allowed us to understand the spatial behavior of the disease and the importance of having adequate health policies, literacy campaigns, and disseminating health information to the population.

Background Sustainability within neglected tropical disease (NTD) programs is a complex and challenging issue. The need for a shared understanding about what sustainability means for NTD programs is more important than ever as stakeholders are currently realigning for the next decade of NTD programming with the launch of WHO’s new NTD roadmap for 2012–2030. The aim of this paper is to assess different perspectives to generate a working definition of sustainability for NTD programs. Methodology/Principal findings This study surveyed affiliates of the NTD NGO Network (NNN) about their definitions of sustainability and then analyzed the data using an inductive and deductive process. The research team drafted a sustainability statement based on the survey findings and then solicited and incorporated feedback on the statement from a diverse group of expert reviewers. The final statement includes a working definition of sustainability for NTD programs that highlights three key essential components to sustainability: domestic commitment, responsive resource mobilization, and accountability. Conclusions/Significance This research resulted in a sustainability statement, based on a survey and extensive consultation with stakeholders, that represents a starting point for shared understanding around the concept of sustainability for NTD programs. Future collaborative work should build off this definition and seek to incorporate indicators for sustainability into programmatic decision-making., Author summary The question of whether a global public health program can be sustainable is as important as whether that program is effective. While neglected tropical disease (NTD) programs have achieved tangible success in reducing the burden of NTDs over the past decade through a massive collaboration between global and local stakeholders, the achievement of global NTD control and elimination goals will depend in large part on whether these efforts are sustained. This study seeks to encourage more and better dialogue around NTD program sustainability by incorporating a wide variety of expert perspectives to create and propose a shared definition of sustainability upon which future NTD programming decisions can be made. The sustainability statement based on the findings from this study suggests that three essential components to NTD program sustainability are commitment from decision-makers within NTD-endemic countries, resource mobilization that is responsive to local needs, and enhanced mechanisms for accountability.

Background The number of new leprosy cases is declining globally, but the disability caused by leprosy remains an important disease burden. The chance of disability is increased by delayed case detection. This review focusses on the individual and community determinants of delayed leprosy case detection. Methods This study was conducted according to the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analysis). The study protocol is registered in PROSPERO (code: CRD42020189274). To identify determinants of delayed detection, data was collected from five electronic databases: Embase.com, Medline All Ovid, Web of Science, Cochrane CENTRAL, and the WHO Global Health Library. Results We included 27 papers from 4315 records assessed. They originated in twelve countries, had been published between January 1, 2000, and January 31, 2021, and described the factors related to delayed leprosy case detection, the duration of the delayed case, and the percentage of Grade 2 Disability (G2D). The median delay in detection ranged from 12 to 36 months, the mean delay ranged from 11.5 to 64.1 months, and the percentage of G2D ranged from 5.6 to 43.2%. Health-service-seeking behavior was the most common factor associated with delayed detection. The most common individual factors were older age, being male, having a lower disease-symptom perception, having multibacillary leprosy, and lack of knowledge. The most common socioeconomic factors were living in a rural area, performing agricultural labor, and being unemployed. Stigma was the most common social and community factor. Conclusions Delayed leprosy case detection is clearly correlated with increased disability and should therefore be a priority of leprosy programs. Interventions should focus on determinants of delayed case detection such as health-service-seeking behavior, and should consider relevant individual, socioeconomic, and community factors, including stigmatization. Further study is required of the health service-related factors contributing to delay., Author summary Leprosy remains an important public health problem with many new leprosy patients diagnosed with visible physical deformities, indicating a long delay in the detection of cases. For effective prevention programs, it is important to know the factors at the level of the individual and the community that contribute to the delay. We reviewed all published studies that reported individual and community factors related to delayed case detection in leprosy and included 27 studies in our analysis, published between January 1, 2000, and January 31, 2021. Health-service-seeking behavior was the most common factor associated with delay in case detection. The most common individual factors were older age, being male, having a lower disease-symptom perception, having multibacillary leprosy, and lack of knowledge about leprosy. The most common socioeconomic factors were living in a rural area, performing agricultural labor, and being unemployed. Stigma was the most common social and community factor associated with detection delay. The presence of physical disability in newly diagnosed leprosy patients is clearly related to the delay in detecting these patients. Leprosy control interventions should take factors related to detection delay into account more comprehensively. Also, there is a need to study health service-related factors that contribute to detection delay of leprosy patients.

Background Buruli ulcer disease (BUD) results in disabilities and deformities in the absence of early medical intervention. The extensive role of caregiving in BUD is widely acknowledged, however, associated caregiver burden is poorly understood. In this paper we assessed the burden which caregivers experience when supporting patients with BUD in Ghana. Method/ principal findings This qualitative study was conducted in 3 districts in Ghana between August and October 2019. 13 semi-structured interviews were conducted on caregivers of BUD patients in the local language of Twi. Data was translated into English, coded into broad themes, and direct content analysis approach was used to analyse results. The results show the caregivers face financial, psychological and health issues as a consequence of their caregiving role. Conclusion/ significance This study found significant caregiver burden on family members. It also highlighted the psychological burden caregivers experience and the limited knowledge of the disease within endemic communities. Further research is needed to quantify the caregiver burden of BUD at different economic levels in order to better understand the impact of possible caregiver interventions on patient outcomes., Author summary Buruli ulcer disease (BUD) is a stigmatizing skin condition caused by the bacteria, Mycobacterium ulcerans. The disease results in permanent functional limitations in the absence of early medical intervention. The disabling BUD conditions, financial constraints and frequent hospital visits support the role of caregiving for affected individuals. Caregiver burden is poorly understood although the role and need for caregiving is widely recognised in BUD. This study identified a previously unrecognized burden on the caregivers of BUD patients in 3 endemic districts in Ghana. Specifically, we identified significant financial and psychological pressure on affected families in meeting healthcare related costs and physical care while also providing for their own and other family members’ needs. We also highlight the emotional burden experienced by caregivers, their reduced work productivity, the barriers caregivers face in accessing healthcare with BUD patients and the limited support available for caregivers. Our study highlights the serious social consequences of BUD in Ghana. Further quantitative research within different economic regions affected by BUD is warranted to better understand the caregiver burden of BUD.

Background Buruli ulcer [BU] is a chronic and debilitating neglected tropical skin disease caused by Mycobacterium ulcerans. The treatment of moderate to severe BU affects the well-being of entire households and places a strain on both gender relations within households and social relations with kin asked for various types of support. In this paper, we employ the conceptual lenses provided by the Household Production of Health approach to understanding the impact of illness on the household as a unit of analysis, gender studies, and social support related research to better understand BU health care decision making and the psychosocial experience of BU hospitalization. Methods An ethnography attentive to circumstance and the nested contexts within which stakeholders respond to BU was conducted employing semi-structured interviews, illness narratives, and case studies. An iterative process of data collection with preliminary analyses and reflection shaped subsequent interviews. Interviews were conducted with 45 women in households having a member afflicted with BU in two communes of Benin with high prevalence rates for BU. The first commune [ZE] has a well-established decentralized BU treatment program and a well-functioning referral network linked to the Allada reference hospital specializing in the care of BU and other chronic ulcers. The second commune [Ouinhi] is one of the last regions of the country to introduce a decentralized BU treatment program. A maximum variation purposeful sample was selected to identify information-rich health care decision cases for in-depth study. Principal findings Study results demonstrated that although men are the primary decision makers for healthcare decisions outside the home, women are largely responsible for arranging care for the afflicted in hospital in addition to managing their own households. A woman’s agency and ability to influence the decision-making process is largely based on whatever social support and substitute labor she can mobilize from her own network of kin relations. When support wanes, women are placed in a vulnerable position and often end up destitute. Decentralized BU treatment is preferred because it enables a woman to remain in her own household as a patient or caretaker of an ill family member while engaging in child care and petty revenue earing activities. Remaining in the hospital (a liminal space) as either patient or caretaker also renders a woman vulnerable to rumor and innuendo about sexual liaisons and constitutes a form of social risk. Social risk in some cases eclipses the physical risk of the disease in what we would describe as a hierarchy of risks. Conclusion This study illustrates the importance of decentralized treatment programs for NTDs such as BU. Such programs enable patients to remain in their homes while being treated, and do not displace women responsible for the welfare of the entire household. When women are displaced the well-being of the entire household is placed in jeopardy., Author summary In this gender-focused study of the neglected tropical disease Buruli ulcer (BU) in Benin, West Africa, we document how seeking care for BU is influenced by broad-based concerns about the household production of health and the availability of resources women can mobilize from their social support networks. Women and girls shoulder a disproportionate share of the burdens incurred by BU treatment and prefer decentralized treatment from local health stations to free hospital care. Long term and often-indeterminate residence in hospital threatens the integrity of households and results in marital stress, economic vulnerability, school and vocational training dropout, and loss of essential income-generating activities. The case study of BU clearly demonstrates the necessity of recognizing the household, and not just the patient, as a unit of analysis in public health and the need to consider the ripple effect of serious illness beyond the household to one’s social network. We draw attention to the fact that while men are the decision makers about health care in patrilineal Beninese society, a women’s agency in influencing decision making is tied to her accumulation of social capital, capital that is taxed by long term medical treatment weakening her safety net in the future.

School health and nutrition (SHN) programmes are recognized as a significant contributor to both health and education sector goals. The school system offers an ideal platform from which to deliver basic health interventions that target the most common health conditions affecting school-age children (SAC) in low-income countries, leading to improved participation and learning outcomes. However, governments require evidence to cost, design, and implement these programmes. In Ethiopia, prevalent health conditions affecting SAC's education participation and learning outcomes include infection with soil-transmitted helminths (STHs), hunger, and malnutrition. In recognition of the multiple issues affecting the health and education of SAC, the government has taken a proactive approach, coordinating an integrated SHN programme designed to be implemented in partnership and monitored and financed through a single, integrated mechanism. The programme, known as the Enhanced School Health Initiative (ESHI), integrates three complimentary health interventions: deworming; school feeding; and provision of a water, sanitation, and hygiene (WASH) package in schools, which in delivery aim to maximize the benefits of each of the individual components. Operational research surrounding the ESHI programme includes both qualitative and quantitative analyses. Here, we present an overview of the ESHI programme and its genesis. We also introduce three additional supporting papers that provide in-depth analyses of key findings, including the baseline situational analysis, the costs, and community perceptions of the programme. The findings from ESHI provide initial evidence to develop an understanding of the related costs and synergies of integrating multiple health interventions onto a single platform. The work has translated into strengthened institutional capacity and improved cross-sectoral coordination. The government is now committed to supporting 25 million school children in Ethiopia through SHN. The ESHI model serves as a reference point for other countries looking to scale up targeted SHN interventions.

Background Soil transmitted helminths (STH) are a common infection among pregnant women in areas with poor access to sanitation. Deworming medications are cheap and safe; however, the health benefit of deworming during pregnancy is not clear. Methods / Principal findings We created a retrospective cohort of more than 800,000 births from 95 Demographic and Health Survey datasets to estimate the impact of deworming medicine during routine antenatal care (ANC) on neonatal mortality and low birthweight. We first matched births on the probability of receiving deworming during ANC. We then modeled the birth outcomes with the matched group as a random intercept to estimate the effect of deworming during antenatal care after accounting for various risk factors. We also tested for effect modification of soil transmitted helminth prevalence on the impact of deworming during ANC. Receipt of deworming medication during ANC was associated with a 14% reduction in the risk of neonatal mortality (95% confidence interval = 10–17%, n = 797,772 births), with no difference between high and low transmission countries. In low transmission countries, we found an 11% reduction in the odds of low birth weight (95% confidence interval = 8–13%) for women receiving deworming medicine, and in high transmission countries, we found a 2% reduction in the odds of low birthweight (95% confidence interval = 0–5%). Conclusions / Significance These results suggest a substantial health benefit for deworming during ANC that may be even greater in countries with low STH transmission., Author summary Soil-transmitted helminths cause a significant burden of disease throughout the world, particularly in communities with limited access to sanitation facilities and clean drinking water. Deworming medicines effectively clear these parasites, are inexpensive, and are well tolerated. However the effectiveness of deworming medicines, particularly for pregnant women, has not been clearly demonstrated. In this paper we analyze more than 800,000 births to measure the effect that deworming medicine during pregnancy has on birth outcomes. When women receive deworming medicine during pregnancy we saw two specific benefits for the baby: first the risk of neonatal mortality (a baby’s death within first 4 weeks of life) decreases by an estimated 14%, and second, the odds of low birthweight were 11% lower in countries with lower transmission of soil-transmitted helminths. In countries with higher transmission of soil-transmitted helminths we saw no effect of deworming medicine on the odds of low birthweight. Given the results, resources leading to widescale distribution of deworming during pregnancy would have a positive effect on child survival and health.

This paper reports the prevalence and intensity of soil-transmitted helminth (STH) infections measured in Zimbabwe before and after a control intervention based on annual deworming of school-age children (SAC) conducted from 2012 to 2018. In 2010, epidemiological data were collected from 13 195 SAC in 255 randomly selected schools in all districts nationwide using, as diagnostic methods, the Kato–Katz and the formal ether stool concentration technique. At follow up, conducted in 2017, only Kato–Katz was performed; specimens were collected from 13 352 children in 336 schools. The data were evaluated using a geospatial approach. The national prevalence of STH infection in SAC was estimated at 5.8% at baseline, with 0.8% of infections of moderate and heavy intensity. Preventive chemotherapy (PC) targeted all 2.5 million children of school age enrolled in Zimbabwe, with coverage ranging from 49% to 85%. At follow up, national prevalence of STH in SAC was estimated at 0.8%; infections of moderate and heavy intensity almost disappeared (0.1% prevalence). As a result, Zimbabwe can suspend deworming activities in 54 districts and reduce the frequency of PC in the remaining six districts. The total amount of albendazole tablets needed will be approximately 100 000 a year., Author summary We analysed the impact of 6 years of preventive chemotherapy intervention by the Ministry of Health and Child Care of Zimbabwe (MoHCC) to control STH infections in Zimbabwe. We applied a geostatistical method to analyse the epidemiological data before and after the intervention. The results are interesting because they demonstrate a complete elimination of infection of moderate heavy intensity (that are considered the ones causing most of STH morbidity and a drastic reduction in prevalence that entails an estimated reduction of 90% in the need for anthelminthic medicines to maintain the situation and a consequent reduction in programme costs.

Introduction During the 2014 Ebola Virus Disease (EVD) epidemic, the Ebola-Tx trial evaluated the use of convalescent plasma (CP) in Guinea. The effectiveness of plasmapheresis trials depends on the recruitment of plasma donors. This paper describes what motivated or deterred EVD survivors to donate CP, providing insights for future plasmapheresis trials and epidemic preparedness. Methods This qualitative study, part of Ebola-Tx, researched and addressed emergent trial difficulties through interviewing, participant observation and focus group discussions. Sampling was theoretical and retroductive analysis was done in NVivo 10. Results Willingness or hesitance to participate in plasma donation depended on factors at the interface of pre-existing social dynamics; the impact of the disease and the consequent emergency response including the trial set-up. For volunteers, motivation to donate was mainly related to the feeling of social responsibility inspired by having survived EVD and to positive perceptions of plasmapheresis technology despite still unknown trial outcomes. Conversely, confidentiality concerns when volunteering due to stigmatization of survivors and perceived decrease in vital strength and in antibodies when donating, leading to fears of loss in protection against EVD, were main deterrents. The dynamic (dis)trust in Ebola Response Actors and in other survivors further determined willingness to participate and lead to the emergence/decline of rumours related to blood stealing and treatment effectiveness. Historic inter-ethnic relations in the health care setting further defined volunteering along socio-economic and ethnic lines. Finally, lack of follow-up and of dedicated care further impacted on motivation to volunteer. Conclusions Ebola-Tx was the first trial to solicit and evaluate blood-product donation as an experimental treatment on a large scale in Sub-Saharan Africa. An effective donation system requires directly engaging with emergent social barriers and providing an effective ethical response, including improved and transparent communication, effective follow-up after donation, assuring confidentiality and determining ethical incentives., Author summary During the 2014 West-African Ebola Virus Disease epidemic, the Ebola-Tx clinical trial in Guinea aimed to determine whether the administration of Ebola antibodies from the blood plasma of Ebola survivors could increase Ebola patients’ survival rate. Ebola-Tx was the first trial to solicit and evaluate blood-product donation as an experimental treatment on a large scale in Sub-Saharan Africa. In this qualitative study, part of the Ebola-Tx study, we report on factors of motivation and demotivation influencing Ebola survivors to donate their plasma. Understanding these factors is essential as the successful recruitment of this specific subgroup, providing the therapy itself, directly impacts the effectiveness of such a trial. We show that organizing an effective and ethical donation system requires directly engaging with emerging social barriers at the interface between pre-existing social dynamics, the impact of the disease, and the consequent emergency response including the trial set-up. These results provide insights that can be useful for future plasma trials but also for emergency clinical trials as part of general epidemic preparedness.

Bangladesh has made significant progress towards elimination of visceral leishmaniasis, and is on track to achieve its target of less than one case per 10,000 inhabitants in each subdistrict in 2017. As the incidence of disease falls, it is likely that the political capital and financial resources dedicated towards the elimination of visceral leishmaniasis may decrease, raising the prospect of disease resurgence. Policy memos may play a crucial role during the transition of the elimination plan from the ‘attack’ to the ‘consolidation’ and ‘maintenance’ phases, highlighting key stakeholders and areas where ongoing investment is crucial. An example of a policy brief is outlined in this paper. The background to the current elimination efforts is highlighted, with emphasis on remaining uncertainties including the impact of disease reservoirs and sustainable surveillance strategies. A stakeholder map is provided outlining the current and projected future activities of key bodies. Identification of key stakeholders subsequently frames the discussion of three key policy recommendations in the Bangladeshi context for the transition to the consolidation and maintenance phases of the elimination program. Recommendations include determining optimal vector control and surveillance strategies, shifting the emphasis towards horizontal integration of disease programs, and prioritising remaining research questions with a focus on operational and technical capacity. Achieving elimination is as much a political as a scientific question. Integrating the discussion of key stakeholders with policy priorities and the research agenda provides a novel insight into potential pathways forwards in the elimination of visceral leishmaniasis in Bangladesh and in the rest of the Indian subcontinent., Author summary In this article, we examine the challenges of eliminating visceral leishmaniasis in Bangladesh from a policy perspective. Visceral leishmaniasis is a neglected tropical disease which causes significant morbidity and mortality, but recent efforts in Bangladesh, India and Nepal (the countries that used to have two-thirds of all cases in the world) have made significant headway in reducing the extent of the disease. However, ongoing concerted effort is needed to ensure that elimination of the disease is maintained in the long-term. This will require engagement and coordinated effort from a variety of stakeholders, including national and international policy makers, funders and implementers. We present the identified challenges, stakeholder map and potential solutions in the form of a policy brief to distill the key actors and actions that are necessary to maintain momentum towards elimination of visceral leishmaniasis. Such actions include determining optimal long-term vector control and surveillance strategies, and attempting to integrate the visceral leishmaniasis program into existing health systems. The research agenda should also be prioritised, with a focus on addressing operational and technical questions.

Background Uganda has reported five (5) Ebola virus disease outbreaks and three (3) Marburg virus disease outbreaks from 2000 to 2016. Peoples’ knowledge and attitude towards Ebola and Marburg virus disease impact on control and prevention measures especially during outbreaks. We describe knowledge and attitude towards Ebola and Marburg virus outbreaks in two affected communities in Uganda to inform future outbreak responses and help in the design of health education and communication messages. Methods The study was a community survey done in Luweero, Ibanda and Kamwenge districts that have experienced outbreaks of Ebola and Marburg virus diseases. Quantitative data were collected using a structured questionnaire and triangulated with qualitative participatory epidemiology techniques to gain a communities’ knowledge and attitude towards Ebola and Marburg virus disease. Results Out of 740 respondents, 48.5% (359/740) were categorized as being knowledgeable about Ebola and Marburg virus diseases, whereas 60.5% (448/740) were having a positive attitude towards control and prevention of Ebola and Marburg virus diseases. The mean knowledge and attitude percentage scores were 54.3 (SD = 23.5, 95%CI = 52.6–56.0) and 69.9 (SD = 16.9, 95%CI = 68.9–71.1) respectively. People educated beyond primary school were more likely to be knowledgeable about Ebola and Marburg virus disease than those who did not attain any formal education (OR = 3.6, 95%CI = 2.1–6.1). Qualitative data revealed that communities describe Ebola and Marburg virus diseases as very severe diseases with no cure and they believe the diseases spread so fast. Respondents reported fear and stigma suffered by survivors, their families and the broader community due to these diseases. Conclusion Communities in Uganda affected by filovirus outbreaks have moderate knowledge about these diseases and have a positive attitude towards practices to prevent and control Ebola and Marburg viral diseases. The public health sector should enhance this community knowledge gap to empower them more by supplying educational materials for epidemic preparedness in future using appropriate communication channels as proposed by the communities., Author summary Ebola Virus Disease (EVD) and Marburg Virus Disease (MVD) are caused by a family of viruses known as Filoviruses. When they occur, they cause high lethality among infected people, which causes panic to the population, as well as interfering with the health care delivery system, especially in developing countries. Usually, at the beginning of these infections, the affected communities tend to think that witchcraft or some bad luck has befallen their community. Because of limited knowledge about these diseases, it becomes hard for local authorities to institute control and prevention measures. We administered a questionnaire to individual participants and held focus group discussions to help us tease out the communities’ understanding of these diseases. We found that people have moderate knowledge about EVD and MVD, and a positive attitude towards the prevention and control measures instituted by health authorities in Uganda. However, they still reported stigma subjected to the survivors of these diseases and affected families at large. EVD still causes much fear which drives some of the irrational actions by communities during outbreaks. Communities highlighted early sensitization as a means of controlling outbreaks. We recommend the findings in this paper to public health authorities in epidemic-prone countries like Uganda to aid in control and epidemic preparedness of filovirus outbreaks.

Background Yaws is an infectious, debilitating and disfiguring disease of poverty that mainly affects children in rural communities in tropical areas. In Cameroon, mass-treatment campaigns carried out in the 1950s reduced yaws to such low levels that it was presumed the disease was eradicated. In 2010, an epidemiological study in Bankim Health District detected 29 cases of yaws. Five different means of detecting yaws in clinical and community settings were initiated in Bankim over the following five years. Methodology This observational study reviews data on the number of cases of yaws identified by each of the five yaws detection approaches: 1) passive yaws detection at local clinics after staff attended Neglected Tropical Disease awareness workshops, 2) community-based case detection carried out in remote communities by hospital staff who relied on community health workers to identify cases, 3) yaws screening following mass Buruli Ulcer outreach programs being piloted in the district, 4) school-based screening programs conducted as stand-alone and follow-up activities to mass outreach events, and 5) house to house active surveillance activities conducted in thirty-eight communities. Implementation of each of the four community-based approaches was observed by a team of health social scientists tasked with assessing the strengths and limitations of each detection method. Findings Eight hundred and fifteen cases of yaws were detected between 2012 and 2015. Only 7% were detected at local clinics. Small outreach programs and household surveys detected yaws in a broad spectrum of communities. The most successful means of yaws detection, accounting for over 70% of cases identified, were mass outreach programs and school based screenings in communities where yaws was detected. Conclusion The five interventions for detecting yaws had a synergistic effect and proved to be valuable components of a yaws eradication program. Well planned, culturally sensitive mass outreach educational programs accompanied by school-based programs proved to be particularly effective in Bankim. Including yaws detection in a Buruli Ulcer outreach program constituted a win-win situation, as the demonstration effect of yaws treatment (rapid cure) increased confidence in early Buruli ulcer treatment. Mass outreach programs functioned as magnets for both diseases as well as other kinds of chronic wounds that future outreach programs need to address., Author summary Yaws is an infectious and disfiguring disease of poverty primarily affecting children in rural communities in tropical areas. Yaws is easily treated by a single dose of antibiotics and is on the World Health Organization’s eradication list. Yaws was thought eradicated in the Cameroon in the 1950s following aggressive mass-treatment campaigns. In 2010, epidemiological research revealed a resurgence of the disease. This paper discusses the relative success of five different means of detecting yaws in rural areas of Bankim District between 2012 and 2015. While few cases of yaws were detected at local clinics during this time, many cases were detected in the community. The most successful means of detecting yaws were mass outreach programs designed to educate the public about neglected tropical diseases found in the region, and follow up school-based screening programs. These programs were supported by local chiefs and traditional healers and found to be the best way of increasing community awareness about yaws, motivating community health workers to participate in outreach, and fostering trust in the free medical treatment being provided.

The Global Program to Eliminate Lymphatic Filariasis (GPELF) advocates for the treatment of entire endemic communities, in order to achieve its elimination targets. LF is predominantly a rural disease, and achieving the required treatment coverage in these areas is much easier compared to urban areas that are more complex. In Ghana, parts of the Greater Accra Region with Accra as the capital city are also endemic for LF. Mass Drug Administration (MDA) in Accra started in 2006. However, after four years of treatment, the coverage has always been far below the 65% epidemiologic coverage for interrupting transmission. As such, there was a need to identify the reasons for poor treatment coverage and design specific strategies to improve the delivery of MDA. This study therefore set out to identify the opportunities and barriers for implementing MDA in urban settings, and to develop appropriate strategies for MDA in these settings. An experimental, exploratory study was undertaken in three districts in the Greater Accra region. The study identified various types of non-rural settings, the social structures, stakeholders and resources that could be employed for MDA. Qualitative assessment such as in-depth interviews (IDIs) and focus group discussions (FGDs) with community leaders, community members, health providers, NGOs and other stakeholders in the community was undertaken. The study was carried out in three phases: pre-intervention, intervention and post-intervention phases, to assess the profile of the urban areas and identify reasons for poor treatment coverage using both qualitative and quantitative research methods. The outcomes from the study revealed that, knowledge, attitudes and practices of community members to MDA improved slightly from the pre-intervention phase to the post-intervention phase, in the districts where the interventions were readily implemented by health workers. Many factors such as adequate leadership, funding, planning and community involvement, were identified as being important in improving implementation and coverage of MDA in the study districts. Implementing MDA in urban areas therefore needs to be given significant consideration and planning, if the required coverage rates are to be achieved. This paper, presents the recommendations and strategies for undertaking MDA in urban areas., Author summary The control of lymphatic filariasis depends on the treatment of entire endemic communities, ensuring that a greater proportion of the population is treated. In urban areas, this can be very difficult to achieve. In Ghana, parts of the Greater Accra Region, where the capital city is located, are also endemic for lymphatic filariasis. Treatment in these areas started in 2006, but the proportion of people treated has continuously been below the required programmatic coverage levels. To understand the reasons behind this, a study was undertaken in three endemic districts. The study was carried out in three stages; pre-treatment, treatment and post-treatment. Individuals and groups of people were interviewed in the pre-treatment phase, following which their concerns were used to plan and execute treatment activities. After treatment, some individuals were again interviewed to assess the effectiveness of the interventions. The results showed that the knowledge and behavior of community members towards the disease and treatment activities improved from the pre-treatment to the post-treatment reviews. Many factors were identified including, financial, management and leadership issues that should be considered when planning treatment activities in urban areas.

Introduction The Global Strategy to Eliminate Lymphatic Filiariasis (GFELF) through Mass Drug Administration (MDA) has been implemented in Ghana since the year 2000 and transmission has been interrupted in 76 of 98 endemic districts. To improve the MDA in the remaining districts with microfilaria (MF) prevalence above the 1% threshold for the interruption of transmission, there is a need to identify and implement appropriate quality improvement (QI) strategies. This paper describes the use of intervention mapping to select QI strategies to improve an existing evidence-based MDA program in Northern Ghana. Methods Due to the complexities associated with implementing evidence-based programs (EBP) such as the lymphatic filariasis MDA and variability in the context, an initial assessment to identify implementation bottlenecks associated with the quality of implementation of lymphatic filariasis MDA in the Bole District of Ghana was conducted using a mixed methods approach. Based on the findings of the initial assessment, a context specific QI strategy was designed and operationalized using intervention mapping strategy in terms of seven domains: actor, the action, action targets, temporality, dose, implementation outcomes addressed, and theoretical justification. Results The initial needs assessment shows that the persistent transmission of lymphatic filariasis in the Bole District is characterized by high levels of refusal to ingest the drug, high levels of reported adverse drug reactions, low MDA coverage at community level, poor adherence to the MDA protocol and non-participants’ responsiveness. Conclusion This study has shown that it is feasible to develop a context specific QI strategy for an existing evidence-based intervention based on an initial needs assessment through stakeholder participation using the IM approach. However, working (towards) QI requires more time than is usually available in public health service. Sufficient theoretical knowledge of implementation research and experience with technical IM experts must be available., Author summary Lymphatic Filariasis is a significant health problem threatening 1.1 billion people in 55 countries globally. After 18 years of implementing MDA in Ghana, LF transmission still persist in some districts with microfilaria prevalence level high above the threshold needed for the interruption of transmission of the disease. For Ghana to meet the 2020 NTDs deadline, it is important to identify context specific need-based QI strategies to make the drug accessible to all eligible individuals in the endemic communities. Hence, this study has demonstrated the feasibility of using IM to develop and implement a context specific QI strategy for an existing evidence-based intervention (LF MDA) towards elimination of lymphatic filariasis as a public health challenge in Bole District of Northern Ghana.

Background Reducing social distance between hospital staff and patients and establishing clear lines of communication is a major challenge when providing in-patient care for people afflicted by Buruli ulcer (BU) and chronic ulcers. Research on hospitals as therapeutic communities is virtually non-existent in Africa and is currently being called for by medical anthropologists working in the field of health service and policy planning. This paper describes a pioneering attempt to establish a therapeutic community for patients suffering from BU and other chronic ulcers requiring long term hospital care in Benin. Methods A six-month pilot project was undertaken with the objectives of establishing a therapeutic community and evaluating its impact on practitioner and patient relations. The project was designed and implemented by a team of social scientists working in concert with the current and previous director of a hospital serving patients suffering from advanced stage BU and other chronic ulcers. Qualitative research initially investigated patients’ understanding of their illness and its treatment, identified questions patients had about their hospitalization, and ascertained their level of social support. Newly designed question–answer health education sessions were developed. Following these hospital wide education sessions, open forums were held each week to provide an opportunity for patients and hospital staff to express concerns and render sources of discontent transparent. Patient group representatives then met with hospital staff to problem solve issues in a non-confrontational manner. Psychosocial support for individual patients was provided in a second intervention which took the form of drop-in counseling sessions with social scientists trained to serve as therapy facilitators and culture brokers. Results Interviews with patients revealed that most patients had very little information about the identity of their illness and the duration of their treatment. This knowledge gap surprised clinic staff members, who assumed someone had provided this information. Individual counseling and weekly education sessions corrected this information gap and reduced patient concerns about their treatment and the status of their healing process. This led to positive changes in staff–patient interactions. There was widespread consensus among both patients and staff that the quality of communication had increased significantly. Open forums providing an opportunity for patients and staff to air grievances were likewise popular and patient representative meetings resulted in productive problem solving supported by the hospital administration. Some systemic problems, however, remained persistent challenges. Patients with ulcers unrelated to BU questioned why BU patients were receiving preferential treatment, given special medicines, and charged less for their care. The idea of subsidized treatment for one disease and not another was hard to justify, especially given that BU is not contagious. Conclusion This pilot project illustrates the basic principles necessary for transforming long term residential hospitals into therapeutic communities. Although the focus of this case study was patients suffering from chronic ulcers, the model presented is relevant for other types of patients with cultural adaptation., Author Summary Little is known about communication patterns and social relations between health staff and long -term patients in African hospitals. An ethnography of a reference hospital treating patients afflicted with Buruli Ulcer (BU) and other chronic ulcers in Benin was conducted. Sources of psychosocial distress and communication patterns compromising quality of care were documented. Based on this research, an intervention was mounted to transform the hospital into a higher functioning therapeutic community. Question: answer education sessions were introduced to provide patients the opportunity to inquire about their illness, it’s treatment and trajectory; weekly open- forums were established to give patients and hospital staff a chance to air grievances; patient representatives met with hospital staff to resolve problems in a non-confrontational manner, and psychosocial support for individual patients was provided through drop-in counseling sessions with social scientists in residence. Patients reported positive changes in the quality of their care and interactions with care providers, care providers reported that the problem solving process instituted was productive, and hospital administrators actively supported efforts to improve social relations and lines of communication. Systemic problems related to perceptions of preferential treatment for BU patients provided subsidized treatment supported by a national program remained contentious.

In a previous article, we outlined the efforts of the Neglected Tropical Diseases (NTD) lobby to overcome the diseases' snub in the 2000 Millennium Development Goals (MDGs) and to campaign for inclusion in the post-2015 development agenda [1]. In doing so, we noted the extraordinary achievements made by the lobby despite its view from outside of the MDG juggernaut, which singled out just three diseases for special consideration (HIV/AIDS, Malaria, and, latterly, Tuberculosis), leaving a group of previously disparate diseases to be formulated within a plan for inclusion. The plan resulted in a three-pronged attack forged on advocacy, policy, and science. The NTD lobby has grown significantly since the original 2003 WHO/Deutsche Gesellschaft fur Technische Zusammenarbeit (GTZ) meetings were convened to float the idea that the NTDs should be reconceptualised and tackled as a group moving forward. The original core group—Peter J. Hotez, David Molyneux, and Alan Fenwick (along with WHO’s Lorenzo Savioli and others)—has since been joined by representation from academia (e.g., PLOS Neglected Tropical Diseases), the third sector (e.g., the Global Network, the Neglected Tropical Disease Non-Governmental Development Organization Network), the pharmaceutical industry, donor agencies, and the philanthropic sector (cf. Uniting to Combat NTDs). The lobby is also formally supported by the World Health Organisation (through the WHO Roadmap [2] and WHA Resolution 66.12 [3]) and by the disease endemic country governments that have signed the Addis Ababa NTD Commitment. Yet, despite boasting swelling ranks and a number of sizeable achievements in the intervening period—for instance the landmark London Declaration—the NTD lobby has remained interested in the more mainstream development agenda. The advocacy goal has always been the formal inclusion of NTDs in the successor framework to the Millennium Development Goals: the post-2015 Sustainable Development Agenda. On 1 January 2016, the Sustainable Development Goals (SDGs or Global Goals) came into force. The particulars of the goals were finalised at the United Nations summit in September 2015, and, as hoped, NTDs gained a special mention in goal 3.3: "By 2030, end the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases and combat hepatitis, waterborne diseases, and other communicable diseases" (p 16) [4]. But what is this mention worth and what are its implications? The SDGs are similar to the MDGs in that they represent time-bound targets and retain a focus on ending world poverty, but they break with the original eight MDGs in terms of their colossal scope. Composed of 17 goals and 169 targets, the SDGs are the result of an extensive three-year consultation involving multiple perspectives from government, civil society, expert groups, the private sector, and individuals. The MDGs were regularly critiqued as restricted in focus and top-down, something which cannot be levelled against the SDGs. But might the warning of the High-Level Panel that originally drafted the framework document have been ignored—"The international community will need to ensure that a single, sustainable framework agenda is not overloaded with too many priorities. A product of compromise rather than decisions…"? (p 14) [5]. The post-2015 vision—as articulated through the SDGs—is to create a single universal agenda in which the social, economic, and environmental dimensions of sustainability are integrated. Whereas the MDGs were criticised for targeting the low-hanging fruit, the post-2015 agenda is underpinned by the tenet “leave no one behind.” As the UN summit drew closer in 2015, we noted how this principle, coupled with the post-2015 focus on environmental issues, provided a number of advocacy issues behind which the NTD lobby began to position itself: equity, poverty, water sanitation and hygiene (WASH), climate change, quality education, NTD-related disability, and nutrition. In this paper, we reflect on the NTD lobby’s efforts to gain traction in the wide-ranging post-2015 agenda by making the case that NTDs are crosscutting and by lobbying for NTD indicators.

During 2011 a large outbreak of typhoid fever affected an estimated 1430 people in Kikwit, Democratic Republic of Congo. The outbreak started in military camps in the city but then spread to the general population. This paper reports the results of an ecological analysis and a case-control study undertaken to examine water and other possible transmission pathways. Attack rates were determined for health areas and risk ratios were estimated with respect to spatial exposures. Approximately 15 months after the outbreak, demographic, environmental and exposure data were collected for 320 cases and 640 controls residing in the worst affected areas, using a structured interview questionnaire. Unadjusted and adjusted odds ratios were estimated. Complete data were available for 956 respondents. Residents of areas with water supplied via gravity on the mains network were at much greater risk of disease acquisition (risk ratio = 6.20, 95%CI 3.39–11.35) than residents of areas not supplied by this mains network. In the case control study, typhoid was found to be associated with ever using tap water from the municipal supply (OR = 4.29, 95% CI 2.20–8.38). Visible urine or faeces in the latrine was also associated with increased risk of typhoid and having chosen a water source because it is protected was negatively associated. Knowledge that washing hands can prevent typhoid fever, and stated habit of handwashing habits before cooking or after toileting was associated with increased risk of disease. However, observed associations between handwashing or plate-sharing with disease risk could very likely be due to recall bias. This outbreak of typhoid fever was strongly associated with drinking water from the municipal drinking water supply, based on the descriptive and analytic epidemiology and the finding of high levels of faecal contamination of drinking water. Future outbreaks of potentially waterborne disease need an integrated response that includes epidemiology and environmental microbiology during early stages of the outbreak., Author summary There was a large outbreak of typhoid fever in Kikwit, DRC, in late 2011. The outbreak started in military camps in the city but then spread to the general population. Multiple investigations were undertaken to understand how the disease spread. The worst affected areas of the city were mapped and compared to the water network. In early 2013, demographic and exposure data were collected for 320 cases and 640 controls residing in the worst affected areas, using a structured interview questionnaire to try to better understand individual risk factors. Residents of areas with water supplied via a gravity fed network were about six times more likely to have been ill with typhoid fever than residents of areas not supplied by the mains network. The most important individual risk factor was ever using tap water. Visible urine or faeces increased risk of getting typhoid but having chosen a water source because it is protected was linked to lower risk. Not handwashing and regularly sharing plates of food were also linked to less illness, but these findings may be especially subject to recall bias. The water network was also found to be heavily contaminated, including with faecal bacteria of human origin in multiple microbiological studies. Spatial, microbiological and case-control studies all implicate the water supplies in Kikwit to be unsafe and linked to spread of typhoid fever in 2011. Improvements to the mains water network in Kikwit are urgently needed to prevent future typhoid fever outbreaks.

Introduction Assessment of attitudes of health care professionals is important as negative attitude could constitute a major deterrent to care-seeking by persons affected by neglected tropical diseases (NTDs) such as leprosy. Leprosy continues to pose a major disease burden in India with an annual new case detection rate of 10.17 per 100,000 population. This paper reports on the development and validation of a culturally appropriate scale to measure attitude of health care providers (HCPs) towards persons affected by leprosy in Tamil Nadu, India. Methodology/Principal findings The Affective, Behavioural and Cognitive (ABC) model of attitudes guided the development of the scale. Steps in scale development included qualitative interviews and focus group discussions with medical officers and paramedical staff selected from high prevalence districts in Tamil Nadu, India which informed the development of the draft scale. Reviews of existing attitude questionnaires in related areas further contributed to scale development and together helped to generate a large pool of items which was then subjected to Thurston’s scaling method for selection of items from this pool. Face and content validity were obtained, following which internal consistency and test, re-test reliability were assessed. Scaling exercise resulted in 11 items being discarded from an initial pool of 38, owing to the poor agreement among experts regarding relevance. Face and content validity were good with experts endorsing relevance and applicability of items. The intra-class correlation coefficient (ICC) for test re-test reliability of the 27 item scale was 0.6 (95% CI: 0.20–0.78) indicating marginal intra-class correlation. The overall Cronbach’s alpha was 0.85 while the alphas for each of the affective and behavioural components was good at 0.78 and 0.69 respectively indicating a good degree of consistency and homogeneity between items but the alpha for the cognitive component was low at 0.53. Conclusions The ABC model of attitudes guided the development of the scale, ensured a mix of 27 items tapping into the three domains of Affect, Behaviour and Cognition which best explained the attitude construct. With good validity and alphas for each of the affective, behavioural components and overall alpha estimates, this scale can be a valuable tool to provide accurate estimates of the true attitudes held by HCPs. This, in turn, would be useful to obtain insights for appropriate intervention programmes that would help change negative attitudes of HCPs towards persons affected by leprosy. With some adaptations, the scales can be validated for other NTDs as well., Author summary Leprosy is an infectious disease caused by the Mycobacterium leprae and is one of the major causes of preventable disability. Early diagnosis and prompt treatment of all new cases of leprosy remain the key strategies for leprosy control as it would prevent nerve damage, disability and reduce the transmission of the disease. People affected by leprosy often experience severe stigmatization because of an adverse social judgment about the disease or its disabling consequences. This neglected tropical disease continues to pose a major disease burden in India. Despite the availability of health facilities there continue to be barriers towards leprosy diagnosis and early treatment. Assessment of attitudes of health care professionals is important as negative attitude could constitute a major deterrent to care-seeking by persons affected by leprosy. Researchers developed and validated a culturally appropriate scale to measure attitudes of health care providers towards persons affected by leprosy in Tamil Nadu, India. The scale would be useful to obtain insights of attitudes of health care professionals to plan appropriate programmes that would help to promote positive attitudes of healthcare providers towards persons affected by leprosy.

Background Lymphedema is a debilitating and disfiguring sequela of an overwhelmed lymphatic system. The most common causes of secondary lymphedema are lymphatic filariasis (LF), a vector-borne, parasitic disease endemic in 73 tropical countries, and treatment for cancer in developed countries. Lymphedema is incurable and requires life-long care so identification of effective lymphedema management is imperative to improve quality of life, reduce the burden on family resources and benefit the local community. This review was conducted to evaluate the evidence for effective lymphedema self-care strategies that might be applicable to management of all types of secondary lymphedema. Methodology/Principal Findings Searches were conducted in Medline, CINAHL and Scopus databases in March 2015. Included studies reported before and after measures of lymphedema status or frequency of acute infections. The methodological quality was assessed using the appropriate Critical Appraisal Skills Program checklist. Descriptive synthesis and meta-analysis were used to evaluate effectiveness of the outcomes reported. Twenty-eight papers were included; two RCTs were found to have strong methodology, and overall 57% of studies were rated as methodologically weak. Evidence from filariasis-related lymphedema (FR-LE) studies indicated that hygiene-centred self-care reduced the frequency and duration of acute episodes by 54%, and in cancer-related lymphedema (CR-LE) home-based exercise including deep breathing delivered significant volume reductions over standard self-care alone. Intensity of training in self-care practices and frequency of monitoring improved outcomes. Cultural and economic factors and access to health care services influenced the type of intervention delivered and how outcomes were measured. Conclusions/Significance There is evidence to support the adoption of remedial exercises in the management of FR-LE and for a greater emphasis on self-treatment practices for people with CR-LE. Empowerment of people with lymphedema to care for themselves with access to supportive professional assistance has the capacity to optimise self-management practices and improve outcomes from limited health resources., Author Summary Secondary lymphedema is a major cause of disability worldwide. The most common causes are treatment for cancer or infection with lymphatic filariasis. In both cases, the lymphatic system is damaged and unable to perform its normal function of removing extracellular fluid and wastes. Protein rich fluid accumulates in the affected area, and if left untreated may progress to ‘elephantiasis’, which is characterised by a grossly enlarged limb and thickening of the skin. Lymphedema is incurable, requires lifelong care, and psychosocial support, but early intervention and good self-management practices can halt progression, preserve quality of life and maintain the ability to participate in normal work and social activities. Current approaches to treatment vary depending on the setting. In developed countries, cancer related lymphoedema is therapist-based and aims to intervene early and prevent disease progression. Lymphatic filariasis related lymphedema is associated with poverty, affecting people living in developing countries where minimal intervention is recommended or available for early stages. By identifying useful practices that can be transferred across cultural and economic borders, people living with lymphedema can be empowered to care for themselves and improve their long term outcomes.

Such labeling of some neglected tropical diseases as ‘‘stigmatizing’’ may indeed increase political commitment to these diseases [2], but it also bears some risks. Research can easily end up confirming previous assumptions, i.e., that it is the social stigma associated with the disease that leads to socialisolation, hampers access to care, and reduces treatment adherence. Although this may be the case, in contexts with high levels of poverty and poor health services, other factors, such as high treatment costs, tedious travel to health centers, and long hospital admittances, must not be ignored. In fact, the task of social science research is to scrutinize all possible explanations, without being blinded by the apparently obvious. Moreover, a narrow focus on stigma is not only a methodological pitfall, but it is also a dangerous way of taking responsibility for poor health care attendance away from the political and economic domains and placing the blame on ‘‘culture’’. The aim of this paper is to caution against an all too euphoric use of ‘‘stigma’’ in neglected tropical diseases research. In order to prevent losing sight of the variety of possible explanatory options, we encourage the use of a ‘‘falsificationist’’ approach with systematic hypothesis testing that incorporates,butis not restricted to, stigma.

Background Strongyloides stercoralis infects human hosts mainly through skin contact with contaminated soil. The result is strongyloidiasis, a parasitic disease, with a unique cycle of auto-infection causing a variety of symptoms and signs, with possible fatality from hyper-infection. Australian Indigenous community members, often living in rural and remote settings, are exposed to and infected with S. stercoralis. The aim of this review is to determine barriers to control of strongyloidiasis. The purpose is to contribute to the development of initiatives for prevention, early detection and effective treatment of strongyloidiasis. Methodology/Principle Findings Systematic search reviewing research published 2012 and earlier was conducted. Research articles discussing aspects of strongyloidiasis, context of infection and overall health in Indigenous Australians were reviewed. Based on the PRISMA statement, the systematic search of health databases, Academic Search Premier, Informit, Medline, PubMed, AMED, CINAHL, Health Source Nursing and Academic was conducted. Key search terms included strongyloidiasis, Indigenous, Australia, health, and community. 340 articles were retrieved with 16 original research articles published between 1969 and 2006 meeting criteria. Review found barriers to control defined across three key themes, (1) health status, (2) socioeconomic status, and (3) health care literacy and procedures. Conclusions/Significance This study identifies five points of intervention: (1) develop reporting protocols between health care system and communities; (2) test all Indigenous Australian patients, immunocompromised patients and those exposed to areas with S. stercoralis; (3) health professionals require detailed information on strongyloidiasis and potential for exposure to Indigenous Australian people; (4) to establish testing and treatment initiatives within communities; and (5) to measure and report prevalence rates specific to communities and to act with initiatives based on these results. By defining barriers to control of strongyloidiasis in Australian Indigenous people, improved outcomes of prevention, treatment of strongyloidiasis and increased health overall are attainable., Author Summary Strongyloides stercoralis, a nematode parasite, has a well-documented history of infecting human hosts in tropic and subtropic regions mainly through skin contact with inhabited soil. The result is strongyloidiasis, a human parasitic disease, with a unique cycle of auto-infection contributing to a variety of symptoms, of which, hyper-infection causing fatality may occur. In Australia, Indigenous community members often located in rural and remote settings, are exposed to and infected with strongyloides. Previous researchers report strongyloidiasis as a recurrent health issue for Indigenous Australians. This is a systematic review to determine the barriers to control for this pernicious pathogen. Barriers to control can be defined across three key themes: (1) health status, (2) socioeconomic status, and (3) health care literacy and procedure. By conceptualizing these barriers and addressing steps to control as outlined in this study, there is potential for improvement in prevention and treatment outcomes of strongyloidiasis and subsequently, overall health for Australian Indigenous people. This study contributes to furthering prevention and treatment of strongyloidiasis, increasing exposure to the issue of strongyloidiasis in Australian Indigenous people. It is the intent of this paper to express the need to have continued research and further health policy directed specifically to eradicate strongyloidiasis in Australian Indigenous communities.

Background Ningxia is located in western People's Republic of China, which is hyperendemic for human cystic echinococcosis (CE) throughout the entire area with alveolar echinococcosis (AE) hyperendemic in the south. This is in part due to its underdeveloped economy. Despite the recent rapid growth in P.R. China's economy, medical expenditure for hospitalization of echinococcosis cases has become one of the major poverty generators in rural Ningxia, resulting in a significant social problem. Methodology/Principal Findings We reviewed the 2000 inpatient records with liver CE in surgical departments of hospitals from north, central and south Ningxia for the period 1996–2002. We carried out an analysis of health care expenditure of inpatient treatment in public hospitals, and examined the financial inequalities relating to human echinococcosis and the variation in per capita income between various socioeconomic groups with different levels of gross domestic product for different years. Hospital charges for Yinchuan, NHAR's capital city in the north, increased approximately 35-fold more than the annual income of rural farmers with the result that they preferred to seek health care in local county hospitals, despite higher quality and more efficient treatment and diagnosis available in the city. Household income levels thus strongly influenced the choice of health care provider and the additional expense impeded access of poor people to better quality treatment. Conclusions/Significance Information on socioeconomic problems arising from echinococcosis, which adds considerably to the burden on patient families and communities, needs to be collected as a prerequisite for developing policies to tackle the disease in rural Ningxia., Author Summary This paper compares medical expenditure for hospital treatment of echinococcosis in NHAR, western People's Republic of China, for different years, different regions and different socioeconomic groups. The results show that the level of household income strongly influences health care decisions. This study represents an effort to determine the effect of hospital charges for inpatient treatment of echinococcosis on the choice of provider in NHAR, and quantitatively examines this topic for the rural poor. The findings show that low income individuals from rural areas opted to visit a local county hospital rather than an urban hospital for hydatid surgery despite the inferior infrastructure, personnel and general health care facilities available. There are a number of policy implications. For example, enhancing the quality and service of county hospitals in rural areas will benefit those with lower incomes, thus improving access of rural residents to health facilities for higher quality diagnosis and efficient treatment. Thus, we advocate that government policy should be to increase investment in health care in poor rural areas, and to launch relevant medical aid projects to help those in poverty.