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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 Enteroaggregative E. coli (EAEC) have been associated with mildly inflammatory diarrhea in outbreaks and in travelers and have been increasingly recognized as enteric pathogens in young children with and without overt diarrhea. We examined the risk factors for EAEC infections and their associations with environmental enteropathy biomarkers and growth outcomes over the first two years of life in eight low-resource settings of the MAL-ED study. Methods EAEC infections were detected by PCR gene probes for aatA and aaiC virulence traits in 27,094 non-diarrheal surveillance stools and 7,692 diarrheal stools from 2,092 children in the MAL-ED birth cohort. We identified risk factors for EAEC and estimated the associations of EAEC with diarrhea, enteropathy biomarker concentrations, and both short-term (one to three months) and long-term (to two years of age) growth. Results Overall, 9,581 samples (27.5%) were positive for EAEC, and almost all children had at least one detection (94.8%) by two years of age. Exclusive breastfeeding, higher enrollment weight, and macrolide use within the preceding 15 days were protective. Although not associated with diarrhea, EAEC infections were weakly associated with biomarkers of intestinal inflammation and more strongly with reduced length at two years of age (LAZ difference associated with high frequency of EAEC detections: -0.30, 95% CI: -0.44, -0.16). Conclusions Asymptomatic EAEC infections were common early in life and were associated with linear growth shortfalls. Associations with intestinal inflammation were small in magnitude, but suggest a pathway for the growth impact. Increasing the duration of exclusive breastfeeding may help prevent these potentially inflammatory infections and reduce the long-term impact of early exposure to EAEC., Author summary Enteroaggregative E. coli (EAEC) are pathogens that infect the intestine and can cause diarrhea. They are also commonly identified among young children in low-resource settings, who can carry the pathogen without symptomatic diarrhea. We examined the risk factors for EAEC infections and their associations with child health outcomes over the first two years of life in eight low-resource settings of the MAL-ED study. EAEC infections were detected using molecular methods in more than 30,000 stools collected from 2,092 children in the MAL-ED study. We identified risk factors for EAEC and estimated the associations of EAEC with diarrhea, markers of intestinal health, and child growth. Almost all children were infected with EAEC at least once by two years of age. Exclusive breastfeeding, higher enrollment weight, and recent macrolide antibiotic use were protective against these infections. Although not associated with diarrhea in these children, EAEC infections were associated with intestinal inflammation and reduced length at two years of age. EAEC may impact child development, even in the absence of diarrhea, by causing intestinal inflammation and impairing child growth.

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.

Background Worldwide, more than 40% of the population is at risk from dengue and recent estimates suggest that up to 390 million dengue infections are acquired every year. The Eliminate Dengue (ED) Program is investigating the use of Wolbachia-infected, transmission-compromised, mosquitoes to reduce dengue transmission. Previous introductions of genetically-modified strategies for dengue vector control have generated controversy internationally by inadequately engaging host communities. Community Engagement (CE) was a key component of the ED Program’s initial open release trials in Queensland Australia. Their approach to CE was perceived as effective by the ED team’s senior leadership, members of its CE team, and by its funders, but if and why this was the case was unclear. We conducted a qualitative case study of the ED Program’s approach to CE to identify and critically examine its components, and to explain whether and how these efforts contributed to the support received by stakeholders. Methodology/Principal Findings In-depth semi-structured interviews were conducted with 24 participants with a range of experiences and perspectives related to the ED Program’s CE activities. Our analytic approach combined techniques of grounded theory and qualitative description. The ED Program’s approach to CE reflected four foundational features: 1) enabling conditions; 2) leadership; 3) core commitments and guiding values; and 4) formative social science research. These foundations informed five key operational practices: 1) building the CE team; 2) integrating CE into management practices; 3) discerning the community of stakeholders; 4) establishing and maintaining a presence in the community; and 5) socializing the technology and research strategy. We also demonstrate how these practices contributed to stakeholders’ willingness to support the trials. Conclusions/Significance Our case study has identified, and explained the functional relationships among, the critical features of the ED Program’s approach to CE. It has also illuminated how these features were meaningful to stakeholders and contributed to garnering support within the host communities for the open-release trials. Our findings reveal how translating ethical intentions into effective action is more socially complex than is currently reflected in the CE literature. Because our case study delineates the critical features of the ED Program’s approach to CE, it can serve as a framework for other programs to follow when designing their own strategies. And because the findings outline a theory of change for CE, it can also serve as a starting point for developing an evaluation framework for CE., Author Summary Community Engagement (CE) is gaining increasing recognition as an important dimension of biomedical, public health and global health research, including neglected tropical disease research. Yet, there has been little agreement about the specific goals of CE and about the best ways to design, conduct, and evaluate it. CE was an integral component of the ED Program’s initial open release trials in Queensland, Australia and our retrospective case study of their approach to CE in that setting helps explain why the ED program was well accepted in the host communities of the initial field trials. Our analysis has generated an empirically grounded framework for CE that explains the linkages between the foundational ethical and practical commitments made by the ED program and its funders and the specific operational practices adopted by the ED program, through which these commitments were realized. Our case study also identified how these practices were meaningful to stakeholders and contributed to their willingness to support the ED program, in general, and the open-release trials in particular. This framework provides research funders, investigators, implementation partners, policy makers, research ethics committees and host communities an example to follow when designing their CE strategies and assessing whether CE is being conducted to high ethical standards.

Despite the global efforts in research, training, and control over the years, tropical diseases remain a major cause of ill-health in poor populations. An estimated 2.7 billion people living on less than US$2 per day, in both rural and impoverished urban areas of low-income countries, are affected [1], [2]. Thirteen neglected tropical diseases alone account for 534,000 deaths each year and the loss of 57 million disability-adjusted life years (DALYs) [3]. It has been the poverty of the affected populations that remains one of the biggest challenges to the research and development of new health products reliant largely on a market-based approach [4]. Moreover, apart from their vote at the World Health Assembly, many developing countries had little say in setting research priorities. The prevailing paradigm in research, as in development, was one of donor and recipient [5]. One of the key tenets of the Special Programme for Research and Training in Tropical Diseases (TDR)'s strategy has been to counter this imbalance by focusing on the health priorities from a developing country's perspective and the public health need and giving a voice to these priorities by engaging with the researchers and populations most affected [6]. In this article, we give some examples of how the TDR approach of a wide engagement of stakeholders has helped develop a more equitable research agenda that TDR has used for its own funding decisions, but even more importantly, this approach has helped shape the global research agenda on neglected infectious diseases of poverty by creating new collaborations and attracting greater research and implementation support from international funders and governments.

Background The lack of capacity in laboratory systems is a major barrier to achieving the aims of the London Declaration (2012) on neglected tropical diseases (NTDs). To counter this, capacity strengthening initiatives have been carried out in NTD laboratories worldwide. Many of these initiatives focus on individuals' skills or institutional processes and structures ignoring the crucial interactions between the laboratory and the wider national and international context. Furthermore, rigorous methods to assess these initiatives once they have been implemented are scarce. To address these gaps we developed a set of assessment and monitoring tools that can be used to determine the capacities required and achieved by laboratory systems at the individual, organizational, and national/international levels to support the control of NTDs. Methodology and principal findings We developed a set of qualitative and quantitative assessment and monitoring tools based on published evidence on optimal laboratory capacity. We implemented the tools with laboratory managers in Ghana, Malawi, Kenya, and Sri Lanka. Using the tools enabled us to identify strengths and gaps in the laboratory systems from the following perspectives: laboratory quality benchmarked against ISO 15189 standards, the potential for the laboratories to provide support to national and regional NTD control programmes, and the laboratory's position within relevant national and international networks and collaborations. Conclusion We have developed a set of mixed methods assessment and monitoring tools based on evidence derived from the components needed to strengthen the capacity of laboratory systems to control NTDs. Our tools help to systematically assess and monitor individual, organizational, and wider system level capacity of laboratory systems for NTD control and can be applied in different country contexts., Author Summary Capacity strengthening activities such as technical training for staff, student research project supervision, and equipment provision are being carried out in laboratories worldwide as part of the global effort to control neglected tropical diseases (NTDs). However, these activities often focus on developing the skill sets of an individual and are not being thoroughly monitored and assessed. To address these gaps we developed a set of monitoring and assessment tools that can be used to determine the capacities required and achieved by laboratory systems to support the control of NTDs. The tools simultaneously focus on individuals (e.g., technicians, students, researchers), organisations (e.g., universities, research institutions, clinical facilities), national governments, and international agencies. Using the tools highlighted the strengths and limitations of each laboratory system in addition to the role of the laboratory regionally and internationally. We used the tools in Kenya, Ghana, Malawi and Sri Lanka, and concluded that our tools can be adapted and tailored to use in other countries and laboratories.

Background Chagas disease is a vector-borne parasitic disease of major public health importance. Current prevention efforts are based on triatomine vector control to reduce transmission to humans. Success of vector control interventions depends on their acceptability and value to affected communities. We aimed to identify opportunities for and barriers to improved vector control strategies in the Yucatan peninsula, Mexico. Methodology/principal findings We employed a sequence of qualitative and quantitative research methods to investigate knowledge, attitudes and practices surrounding Chagas disease, triatomines and vector control in three rural communities. Our combined data show that community members are well aware of triatomines and are knowledgeable about their habits. However, most have a limited understanding of the transmission dynamics and clinical manifestations of Chagas disease. While triatomine control is not a priority for community members, they frequently use domestic insecticide products including insecticide spray, mosquito coils and plug-in repellents. Families spend about $32 US per year on these products. Alternative methods such as yard cleaning and window screens are perceived as desirable and potentially more effective. Screens are nonetheless described as unaffordable, in spite of a cost comparable to the average annual spending on insecticide products. Conclusion/Significance Further education campaigns and possibly financing schemes may lead families to redirect their current vector control spending from insecticide products to window screens. Also, synergism with mosquito control efforts should be further explored to motivate community involvement and ensure sustainability of Chagas disease vector control., Author Summary Chagas disease is an important parasitic disease transmitted by triatomine bugs. Current prevention efforts are based on eliminating triatomines from homes to reduce disease transmission to humans. However, the success of these control interventions depends on their acceptability and value to affected communities. We aimed to identify opportunities for and barriers to triatomine control strategies in the Yucatan peninsula, Mexico. We used a sequence of group discussion, interviews, and a survey to investigate the perception and knowledge of communities on Chagas disease and triatomines in three villages from the Yucatan peninsula, Mexico. Inhabitants are rather familiar with triatomine bugs, but do not associate well these bugs with Chagas disease and its clinical manifestations. Mosquito rather than triatomine control is a common preoccupation, and households frequently use insecticide spray, mosquito coils and plug-in repellents, spending about $32 US per year on these products. Alternative methods such as yard cleaning and window screens are perceived as desirable and potentially more effective. Screens are nonetheless described as unaffordable. The promotion of education campaigns and possibly financing schemes could help families to redirect their current spending from insecticide products to window screens. Also, synergism with mosquito control efforts should be further explored to motivate community involvement and ensure sustainability of Chagas disease vector control.

The Autonomous University of Yucatan is a major public university in Mexico, and the largest institution for superior education in the southern part of the country, with 772 academics attending over 20,000 students. It offers 43 undergraduate and 53 graduate programs in all areas of knowledge. On October 12, 1975, Dr. Alberto Rosado G. Canton, rector of the University at this time, created the Biomedical Research Center to provide the institution with a leading facility to perform scientific medical research. The Center was named in honor of Dr. Hideyo Noguchi, the famous Japanese scientist who worked on yellow fever in the region from 1918–1920 and received a Doctorate Honoris Causa from the School of Medicine of the University in 1920. The Research Center initiated its activities with three departments: Tropical Pathology, headed by Dr. Jorge Zavala-Velazquez; Reproductive Health, headed by Dr. Thelma CetinaCanto; and Physiology, headed by Dr. Heriberto Arcila-Herrera. In 1976, the Center was strengthened by the incorporation of several researchers in social sciences, and renamed ‘‘Dr. Hideyo Noguchi’’ Regional Research Center. In 1987, it became organized in a Social Science and a Biomedical Unit, to accommodate wider research interests encompassing virology, microbiology, parasitology, reproductive health, human genetics, hematology, social medicine, neurosciences, regional development, Mayan identity and culture, and political and social processes. The department of Tropical Pathology initially pioneered some key research in Mexico and in the region in the area of tropical medicine and several neglected diseases. It also served as a seed for the training of several young researchers who contributed to the growth of the Research Center by becoming group leaders themselves in the following years, including Dr. Andrade-Narvaez, Dr. Puerto-Manzano, Dr. Farfan-Ale, and Dr. Barrera-Perez, and more recently Dr. Zavala-Castro, Dr. Garcia-Miss, Dr. Acosta-Vianna, and Dr. Vargas-Gonzalez, among others.

Summary The purpose of this paper is to encourage reflection among the global health research community and the research ethics community about how a wide range of ethical, social, and cultural (ESC) influences on the conduct, success, and impact of global health research can best be addressed by consultation services in research ethics (CSRE). We draw on lessons we have learned during our experiences with the ESC Program of the Grand Challenges in Global Health initiative to propose key features of CSRE that may prove useful for those designing or implementing similar programs.

Background The role of footwear in protection against a range of Neglected Tropical Diseases (NTDs) is gaining increasing attention. Better understanding of the behaviors that influence use of footwear will lead to improved ability to measure shoe use and will be important for those implementing footwear programs. Methodology/Principal Findings Using the PRECEDE-PROCEED model we assessed social, behavioral, environmental, educational and ecological needs influencing whether and when children wear shoes in a rural highland Ethiopian community endemic for podoconiosis. Information was gathered from 242 respondents using focus groups, semi-structured interviews and extended case studies. Shoe-wearing norms were said to be changing, with going barefoot increasingly seen as ‘shameful’. Shoes were thought to confer dignity as well as protection against injury and cold. However, many practical and social barriers prevented the desire to wear shoes from being translated into practice. Limited financial resources meant that people were neither able to purchase more than one pair of shoes to ensure their longevity nor afford shoes of the preferred quality. As a result of this limited access, shoes were typically preserved for special occasions and might not be provided for children until they reached a certain age. While some barriers (for example fit of shoe and fear of labeling through use of a certain type of shoe) may be applicable only to certain diseases, underlying structural level barriers related to poverty (for example price, quality, unsuitability for daily activities and low risk perception) are likely to be relevant to a range of NTDs. Conclusions/Significance Using well established conceptual models of health behavior adoption, we identified several barriers to shoe wearing that are amenable to intervention and which we anticipate will be of benefit to those considering NTD prevention through shoe distribution., Author Summary Consistently wearing shoes may help in preventing onset or progression of a wide range of Neglected Tropical Diseases (NTDs). This study assessed the factors that influenced shoe wearing behaviors among people living in a rural community in highland Ethiopia. In this community, a substantial proportion of people are at risk for podoconiosis, a debilitating lower leg condition that can be prevented by wearing shoes. We conducted semi-structured individual interviews, focus group discussions and extended case studies among 242 adults and systematically analyzed the information. We found that shoe wearing is intermittent, and that different factors such as cost and ability to use the shoes for certain activities (such as farming) influenced consistent shoe wearing for most people. Some factors (such as shoe size, fear of stigma) were more relevant for podoconiosis patients. Social norms were found to be increasingly supportive of shoe wearing, and children exhibited greater desire to wear shoes than adults. These findings have relevance for preventing development and progression of a variety of NTDs in a range of settings.

Background Despite the availability of effective interventions and public recognition of the severity of the problem, rabies continues to suffer neglect by programme planners in India and other low and middle income countries. We investigate whether this state of ‘policy impasse’ is due to, at least in part, the research community not catering to the information needs of the policy makers. Methods & Findings Our objective was to review the research output on rabies from India and examine its alignment with national policy priorities. A systematic literature review of all rabies research articles published from India between 2001 and 2011 was conducted. The distribution of conducted research was compared to the findings of an earlier research prioritization exercise. It was found that a total of 93 research articles were published from India since 2001, out of which 61% consisted of laboratory based studies focussing on rabies virus. Animals were the least studied group, comprising only 8% of the research output. One third of the articles were published in three journals focussing on vaccines and infectious disease epidemiology and the top 4 institutions (2 each from the animal and human health sectors) collectively produced 49% of the national research output. Biomedical research related to development of new interventions dominated the total output as opposed to the identified priority domains of socio-politic-economic research, basic epidemiological research and research to improve existing interventions. Conclusion The paper highlights the gaps between rabies research and policy needs, and makes the case for developing a strategic research agenda that focusses on rabies control as an expected outcome., Author Summary Rabies is among the most widely spread zoonoses (diseases that are naturally transmitted between vertebrate animals and humans) in humans in most Asian, African and Latin American countries. Even though researchers have demonstrated effectiveness of strategies to control rabies at the population level, such as post exposure prophylaxis in humans and animal birth control and immunization among dogs, are well known, policy makers in most countries are hesitant to implement these strategies. This paper examines the disconnect that prevents the translation of scientific research outputs into effective policies. We contrasted the type of research papers published on rabies from India in the last eleven years with a previously identified set of priority research options. We found that most published research articles related to biomedical research focussing on development of new interventions. This was in contrast to policy and systems-related research and research to improve the performance of existing interventions that were identified as priority research options for India earlier. The findings of our study highlight the importance of moving beyond a purely researcher-driven agenda and suggest the need to promote research that has a vision of rabies control in the near future.

Globally, 40 million people live with the chronic effects of lymphatic filariasis (LF), making it the second leading cause of disability in the world. Despite this, there is limited research into the experiences of people living with the disease. This review summarises the research on the experiences of people living with LF disability. The review highlights the widespread social stigma and oppressive psychological issues that face most people living with LF-related disability. Physical manifestations of LF make daily activities and participation in community life difficult. The findings confirm the need for the Global Programme to Eliminate Lymphatic Filariasis (GPELF) to support morbidity management activities that address the complex biopsychosocial issues that people living with LF-related disability face.

Conducting research in an emergency situation, such as an outbreak of disease, poses ethical challenges. These challenges differ according to the type of research: epidemiologic or clinical, and for the latter, whether the disease outbreak can be anticipated in advance. We address these three situations, proposing different potential solutions for each. In an outbreak situation, public health authorities undertake a rapid response in an effort to document the existence and magnitude of a public health problem in the community and to implement appropriate measures to address the problem [1]. This rapid response will in some cases preclude the possibility of clearance by a research ethics committee since the time required to develop and submit a detailed research protocol and respond to any requested modifications by the committee, followed by re-review, would thwart the very purpose of the response. According to one prominent view, to require a full written protocol and submission to an ethics review board would not be in the interests of the individuals or the community because the resulting delays would frequently cause excess disease and death [2]. These authors suggest, however, that emergency response consent forms could be developed and used in these situations. Other individuals engaged in public health practice have voiced concern that subjecting their work to the routinely required “regulatory constraints imposed on research” would prevent flexible and timely approaches to situations such as disease outbreaks [3]. They argue that timeliness is a major requirement that would have to be counterbalanced with other ethical concerns. An example is that of pandemic influenza outbreaks, in which it is alleged that the review process would impair the ability of public health agencies to react in a timely manner. For researchers and public health agencies, therefore, the question is how to comply with the ethical requirement that research be approved by a properly constituted, independent ethical review committee (ERC) but still enable a prompt response when an outbreak occurs. If we concede that existing methods of ethical review are too protracted to be useful in outbreak situations, can alternative mechanisms be employed to ensure that such investigations undergo some type of ethical review? How can the rights and welfare of individuals be protected during investigations of disease outbreaks, and at the same time enable such investigations to be carried out expeditiously? In addition to review by a research ethics committee, a fundamental ethical requirement in research is to obtain informed consent from participants. Although not all research requires the informed consent of individual subjects, the vast majority of clinical research, most social and behavioral research, and some epidemiologic research must be carried out with the voluntary, informed consent of participants or their legally authorized representatives. In contrast, in many instances of public health practice, collection and use of information or human biological specimens can be conducted without a written informed consent document and without obtaining permission to store the samples for future use. However, a problem could arise if an investigator wants to use these samples, collected initially for public health purposes, for research. Current research practice calls for obtaining consent for the use of specimens in future research that may not be known at the time they are collected. Samples obtained in a non-research context without such provisions may require going back to get consent from sampled individuals, which could be logistically difficult, if not impossible. For example, samples with no identifying information could not be traced back to the individuals from whom they were obtained. Additionally, if a considerable time has elapsed between the collection of identifiable samples and the plan to use them in research, it could be difficult to locate the individuals. If researchers intend to use previously collected samples without going back to get consent, they must provide a justification in the protocol submitted to the research ethics committee. It is hard to see, even in non-research contexts, how human biological specimens could be obtained or even how individuals could be surveyed without first obtaining their permission to draw blood or to ask questions that may intrude on their privacy. Nevertheless, procedures for obtaining consent from individuals in an outbreak situation could depart from those typically used in other investigations and still be ethically acceptable. It is surely not necessary to include all 26 items listed as “essential information for prospective research subjects” in the CIOMS International Ethical Guidelines for Biomedical Research [4]. It is important, however, for investigators to ensure that individuals understand that what they are consenting to is research, and not routine activities carried out by public health practitioners during a disease outbreak. Nevertheless, ensuring a participant's understanding of the difference between public health practice and research may be complicated by the emotional distress that potential participants can experience during an outbreak situation. Although appropriate steps are needed when participants become vulnerable in such situations, that would not change the level of risk from minimal to more than minimal risk. The level of risk is determined by the procedures in the research proposal and not by the characteristics of the population. When populations are vulnerable for whatever reason, the approach to participants in research requires establishing safeguards or added protections. Such safeguards can range from specifying exclusion criteria for potential subjects in great distress to taking steps to work sensitively to protect the rights and interests of marginalized populations. An institutional review board (IRB) chair or designated reviewer can always request additional reviewers to ensure that vulnerable individuals are adequately protected.

The Fourth External Review of the Special Programme for Research and Training in Tropical Diseases (TDR) took place between February 2005 and May 2006, led by Professor Abdallah Daar and colleagues [1]. Since its establishment in 1978, TDR has drawn heavily on the recommendations of its external reviews in order to shape its strategy and structures going forward [2]. This fourth review was particularly pertinent given the dramatically changed global health landscape that TDR finds itself in at the beginning of the 21st century.

In this issue of PLoS Neglected Tropical Diseases, Abdallah Daar and colleagues describe the fourth independent external analysis and evaluation of the Special Programme for Research and Training in Tropical Diseases (TDR) and summarize the findings resulting from the review [1]. The panel responsible for the review and report, which was chaired by Daar, recommends several critical areas of refocus and reorganization and calls for additional funding of TDR. In making its recommendations, the panel considers the changes that have taken place over the last decade. The most notable change was the unprecedented increase in funding, external to TDR, for research and control of tropical diseases and the accompanying establishment of product development partnerships (PDPs). The panel contends that TDR should increase its focus on research capacity strengthening, concentrate on neglected populations over neglected diseases, and strengthen its role in transdisciplinary research, particularly by augmenting its capacity in social sciences. In spite of TDR's clear successes and accomplishments since its inception, the panel concludes that TDR has not kept pace with a dynamic and changing world of global health research. The panel also concludes that TDR has not established itself as a credible partner with other leading funders, and is in danger of being marginalized to the point of ineffectiveness in addressing potentially critical gaps in tropical disease research. The review suggests that in its current form, TDR is overly bureaucratic and poorly aligned with the World Health Organization (WHO), that it has insufficient funds and flexibility to carry out its mandate, and that it is not readily able to adapt to the rapidly evolving and dynamic global health landscape. In order to ensure that TDR takes its proper role in supporting research and development (R&D) and training and to capitalize on the tremendous support the organization has among a broad constituency, especially among scientists in disease-endemic countries, the report recommends that TDR focus its efforts in four specific areas: (1) stewardship, (2) expanded interventional research, (3) research capacity strengthening, and (4) R&D for physical products that are not otherwise supported. In doing so, and with the recognized need for substantial increases in funding, TDR must dramatically rethink its objectives and organization. It should also focus efforts on improved relationships with its sponsoring organizations and forge new interactions with organizations, especially public–private partnerships, with complementary interests in R&D and capacity building. In their response to Daar and colleagues' external review, Robert Ridley (the Director of TDR) and colleagues acknowledge many of the shortcomings identified in the review, and say that TDR has committed to a series of steps to improve and reorganize based on the evaluation's recommendations [2]. These steps include a revised strategic focus on knowledge management, an increased capacity building effort, and an enhanced focus on neglected areas such as some aspects of translational research. The external review contributed to TDR's new Ten Year Strategy and Business Plan approved by TDR's Joint Coordinating Board and endorsed by WHO. To implement the new strategy, Ridley et al. describe the development of “business lines” such as “BL3: Lead Discovery for Drugs” or “BL7: Accessible Quality Assured Diagnostics.” These business lines are supported by expert scientific advisory committees, and by necessity the business lines can be started or stopped depending on circumstances and the needs of the stakeholder community. It is envisioned that this business line model will provide a better means for TDR to make decisions and to respond to changing priorities. These business lines cover the full product development pathway from basic research through product development to research for access to interventions. They are viewed as a critical mechanism to decentralize TDR into discrete functional units (rather than to decentralize administratively) that is more responsive to changing environments and to the priorities of TDR's stakeholders. Ridley et al. correctly point out that TDR has played a key role in the establishment of PDPs, such as the Medicines for Malaria Venture. However, TDR's influence in this area has been overshadowed by others, and consequently TDR proposes to shift its focus from supporting PDPs to other areas where it can have greater influence and impact. TDR has made major contributions to the lives of those in the developing world and has supported scores of students and scientists from disease-endemic countries. With funding from UNICEF, the United Nations Development Programme, the World Bank, and WHO, TDR is considered the developing world's research arm. It is uniquely positioned to identify key areas in tropical disease research and training that are not being met by other funding agencies, and to seek to fill those gaps either through direct funding or by creating partnerships that leverage other investments. In recent years, there has been an increased recognition that the scientists, public health workers, and policy makers in disease-endemic countries should contribute to research priorities. TDR is in a position to make these voices heard in setting the priorities. Although TDR has had successes assisting in the establishment of PDPs, it has not fared so well in partnering with other donor agencies, and as such may be moving toward marginalization at a time when it could be playing a critical role in filling important research, training, and implementation gaps. The establishment of business lines is intended to functionally decentralize TDR and make it more responsive to its stakeholders. It will be important, however, to see how the business line concept is functionalized, how lines are initiated and terminated, how funding priorities are made across business lines, and what metrics will be established to measure the progress toward each business line's objectives. Are the business lines repackaged programs, or are they truly a new means of setting and managing research priorities? TDR's strengths and successes will need to be better marketed, and its credibility as a major player in the donor community will have to be strengthened. It will need to actively seek to establish better and more effective means to partner with others. It will need to identify those areas where it is uniquely positioned to make a significant impact and determine the measure of that success, both in terms of its longstanding and broad reach in partnership with the developing world and its ability to extend the impact of the efforts of other donors. The global health community and external landscape have changed dramatically since the establishment of TDR in 1978. TDR has made positive contributions to these changes. One thing is certain: the landscape will continue to change as research provides new opportunities to extend and improve the lives of those in the developing world; as innovations transition from bench to bedside; as new and exciting partners recognize the importance of contributing to the gargantuan effort needed; as new scientists from the developed and developing world enter into the scene; and as the priorities of the developing world change. TDR must be given the strength, flexibility, and resources to play a major role in extending progress in tropical disease research and training.

review the programme’s scientific and technical activities. TDR’s placement within the United Nations system provides close collaboration with country offices of not only the World Health Organization but also of other co-sponsoring agencies UNICEF and UNDP, and with the World Bank. As a consequence, those who are supported by TDR often work closely with disease control programmes as well as other international organizations. Regular reviews of TDR’s research capacity strengthening programmes have helped reorient the strategy as needed, shifting focus from institutional strengthening in the 1980s to human resources strengthening in the 1990s [1], as well as identifying the need to move to a more demand-driven model of national health research systems [4]. Over the years, TDR has continued to support multidisciplinary research, particularly to bring social science research and biomedical research together through different mechanisms [6], and has reinforced this effort through training in implementation research [7] and operations research [8].

Infectious diseases of poverty, also labeled tropical diseases or neglected tropical diseases (NTDs) and caused by pathogenic agents (viruses, bacteria, fungi, and other parasites), are viciously more prevalent among poor people. Though being preventable for the most part in a cost-effective way, they are devastating. These are, to name a few, Chagas disease, schistosomiasis, malaria, leprosy, visceral leishmaniasis, lymphatic filariasis, Buruli ulcer, and onchocerciasis. Besides the vicious circle these diseases maintain with dire conditions of poverty, an increased microbial resistance to some therapeutic drugs adds to the complexity of health disparities and human suffering among the socially disadvantaged, marginalized, and prejudiced against. Fostering virtuous circles (as opposed to vicious circles) against infections of poverty and putting the disenfranchised first are primary concerns for social scientists engaged with research into infectious diseases of poverty. The historical role of social science research into these diseases, its current impacts, substantial contributions, and opportunities and interests for future endeavors are the focus of this article. Persistent disruptions and their propensity to wholly hamper productivity, derail economic and social progress, and deny child development are part of the complex reality to look into. In forcing the displacement of populations and creating chaos, they increase the risk for the spread of infections and maintain the infected poor in a downward spiral of poverty through their capacity of securing the vicious relationship with NTDs. Rather than compassion for inequalities, vulnerabilities, deprivations and misery, or bad fate, foci such as social justice, preparedness, and empowerment are of utmost importance. The case for bridging the divide among scientific disciplines has been strongly made over the years by scholars and outside of academic institutions. Acknowledging the importance of interdisciplinary science and contemplating the need for funded multidisciplinary research is hopeful for broadening the expertise needed to tackle these multidimensional afflictions. However, it should also call for a cautious enthusiasm.

Background The Wolbachia strategy aims to manipulate mosquito populations to make them incapable of transmitting dengue viruses between people. To test its efficacy, this strategy requires field trials. Public consultation and engagement are recognized as critical to the future success of these programs, but questions remain regarding how to proceed. This paper reports on a case study where social research was used to design a community engagement framework for a new dengue control method, at a potential release site in central Vietnam. Methodology/Principal Findings The approach described here, draws on an anthropological methodology and uses both qualitative and quantitative methods to design an engagement framework tailored to the concerns, expectations, and socio-political setting of a potential trial release site for Wolbachia-infected Aedes aegypti mosquitoes. The process, research activities, key findings and how these were responded to are described. Safety of the method to humans and the environment was the most common and significant concern, followed by efficacy and impact on local lives. Residents expected to be fully informed and engaged about the science, the project, its safety, the release and who would be responsible should something go wrong. They desired a level of engagement that included regular updates and authorization from government and at least one member of every household at the release site. Conclusions/Significance Results demonstrate that social research can provide important and reliable insights into public concerns and expectations at a potential release site, as well as guidance on how these might be addressed. Findings support the argument that using research to develop more targeted, engagement frameworks can lead to more sensitive, thorough, culturally comprehensible and therefore ethical consultation processes. This approach has now been used successfully to seek public input and eventually support for releases Wolbachia-infected mosquitoes, in two different international settings - Australia and Vietnam., Author Summary In recent years, a number of new strategies using novel technologies for the control of dengue fever control have emerged. These strategies are notably different from their predecessors and not without controversy. Many also require open release field trials to test their efficacy. Public consultation and engagement are recognized as critical to the future success of these programs, but questions remain regarding how to proceed. In this paper we describe an approach to public engagement that uses social research to design an engagement framework and communication materials tailored to the concerns, expectations, and socio-political setting of potential trial release sites. This approach was developed and implemented in Australia (2008–2010) where the first publicly supported field trials occurred January 2011. We report here on the implementation of this approach in Vietnam (2009–2010) where the second release will occur in 2014. This paper describes the process, research activities, outcomes and key findings from the Vietnamese field site. It highlights key public concerns and expectations about engagement and authorization and shows how these were used to develop a more targeted, culturally appropriate and comprehensible engagement framework and communication materials. The paper demonstrates the viability of this approach to community engagement for new dengue control strategies, in a ‘developing’ country context.

Background This qualitative study aimed to provide an in-depth understanding of the meaning of dengue fever (DF) amongst people living in a dengue endemic region, dengue prevention and treatment-seeking behaviours. The Health Belief Model was used as a framework to explore and understand dengue prevention behaviours. Methods A total of 14 focus group discussions were conducted with 84 Malaysian citizens of different socio-demographic backgrounds between 16th December, 2011 and 12th May, 2012. Results The study revealed that awareness about DF and prevention measures were high. The pathophysiology of dengue especially dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS) were rarely known; as a result, it was seen as deadly by some but was also perceived as easily curable by others without a basis of understanding. Young adults and elderly participants had a low perception of susceptibility to DF. In general, the low perceived susceptibility emerged as two themes, namely a perceived natural ability to withstand infection and a low risk of being in contact with the dengue virus vector, Aedes spp. mosquitoes. The barriers to sustained self-prevention against dengue prevention that emerged in focus groups were: i) lack of self-efficacy, ii) lack of perceived benefit, iii) low perceived susceptibility, and iv) unsure perceived susceptibility. Low perceived benefit of continued dengue prevention practices was a result of lack of concerted action against dengue in their neighborhood. Traditional medical practices and home remedies were widely perceived and experienced as efficacious in treating DF. Conclusion Behavioural change towards attaining sustainability in dengue preventive practices may be enhanced by fostering comprehensive knowledge of dengue and a change in health beliefs. Wide use of unconventional therapy for DF warrants the need to enlighten the public to limit their reliance on unproven alternative treatments., Author Summary In-depth understanding of health beliefs and behaviors may provide insights into sustainable community-based dengue prevention and control. This study uses qualitative method to explore dengue prevention and treatment-seeking behaviours. Focus group discussions were conducted with Malaysian public of various demographic backgrounds in Klang Valley, Malaysia. General knowledge about dengue fever was good but many lack of knowledge of dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS). Many had low perceived susceptibility of getting dengue. Barriers to prevent dengue were categorised as low self efficacy to execute preventive measures, perceived lack benefit of individual preventive measures, and unsure susceptibility of getting dengue. Low perceived benefit of continued dengue prevention practices was a result of lack of concerted action against dengue in their neighborhood. Traditional medicinal practices, though unproven, were common and viewed as efficacious. The findings add valuable insights into how health beliefs could affect dengue prevention and control in endemic region.

Background Globally, more than 10 million people are infected with Trypanosoma cruzi, which causes about 20 000 annual deaths. Although Chagas disease is endemic to certain regions of Latin America, migratory flows have enabled its expansion into areas where it was previously unknown. Economic, social and cultural factors play a significant role in its presence and perpetuation. This systematic review aims to provide a comprehensive overview of qualitative research on Chagas disease, both in endemic and non-endemic countries. Methodology/Principal Findings Searches were carried out in ten databases, and the bibliographies of retrieved studies were examined. Data from thirty-three identified studies were extracted, and findings were analyzed and synthesized along key themes. Themes identified for endemic countries included: socio-structural determinants of Chagas disease; health practices; biomedical conceptions of Chagas disease; patient's experience; and institutional strategies adopted. Concerning non-endemic countries, identified issues related to access to health services and health seeking. Conclusions The emergence and perpetuation of Chagas disease depends largely on socio-cultural aspects influencing health. As most interventions do not address the clinical, environmental, social and cultural aspects jointly, an explicitly multidimensional approach, incorporating the experiences of those affected is a potential tool for the development of long-term successful programs. Further research is needed to evaluate this approach., Author Summary Social and cultural factors are increasingly recognized as relevant to the likelihood of infection with Chagas disease as well as the health seeking practices of those affected. In response, qualitative methods have been used more often to study such factors. This is the first systematic review to focus on the socio-cultural dimensions of Chagas disease. The findings suggest that transdisciplinary approaches, which incorporate preventive and treatment activities, and consider populations' living conditions and their culturally informed understandings of health, might be a tool to reduce Chagas disease incidence in the long-term.

Background In recent years, new strategies aimed at reducing the capacity of mosquito vectors to transmit dengue fever have emerged. As with earlier control methods, they will have to be employed in a diverse range of communities across the globe and into the main settings for disease transmission, the homes, businesses and public buildings of residents in dengue-affected areas. However, these strategies are notably different from previous methods and draw on technologies that are not without controversy. Public engagement and authorization are critical to the future success of these programs. Methodology/Principal Findings This paper reports on an Australian case study where long-term social research was used to enable participation and the design of an engagement strategy tailored specifically to the sociopolitical setting of a potential trial release site of Wolbachia-infected Aedes aegytpi mosquitoes. Central themes of the social research, methods used and conclusions drawn are briefly described. Results indicate that different communities are likely to have divergent expectations, concerns and cultural sensibilities with regard to participation, engagement and authorization. Conclusions/Significance The findings show that a range of issues need to be understood and taken into account to enable sensitive, ethical and effective engagement when seeking public support for new dengue control methods., Author Summary A number of new strategies are emerging to combat dengue fever. Many are notably different from earlier methods and not without controversy. Public participation, engagement, enablement and authorization are recognized as critical to the success of field trials and future use and acceptability of new strategies. It is well established in cultural anthropology and public health that interventions often fail because of a lack of understanding of the local context, lay knowledge of the disease, and community, local or regional expectations around engagement. In this paper we demonstrate the critical importance of using long-term social research to address these issues and to design engagement strategies and communication materials that are tailored specifically to the needs, expectations and concerns of residents at a potential release site. We report on the results of an extensive and systematic social research and engagement program undertaken in the two years prior to the first successful release of Wolbachia-infected Aedes aegypti mosquitoes in Cairns, northern Australia.

In this paper, the Disease Reference Group on Helminth Infections (DRG4), established in 2009 by the Special Programme for Research and Training in Tropical Diseases (TDR), with the mandate to review helminthiases research and identify research priorities and gaps, focuses on the environmental, social, behavioural, and political determinants of human helminth infections and outlines a research and development agenda for the socioeconomic and health systems research required for the development of sustainable control programmes. Using Stockols' social-ecological approach, we describe the role of various social (poverty, policy, stigma, culture, and migration) and environmental determinants (the home environment, water resources development, and climate change) in the perpetuation of helminthic diseases, as well as their impact as contextual factors on health promotion interventions through both the regular and community-based health systems. We examine these interactions in regard to community participation, intersectoral collaboration, gender, and possibilities for upscaling helminthic disease control and elimination programmes within the context of integrated and interdisciplinary approaches. The research agenda summarises major gaps that need to be addressed.

Between February 2005 and May 2006, we undertook an in-depth, broad-ranging, independent external review of The Special Programme for Research and Training in Tropical Diseases (TDR). TDR, based in Geneva, was created 30 years ago, with the World Health Organization as its executing agency and the World Bank and United Nations Development Programme (UNDP) as initial co-sponsors, with the United Nations Children's Fund (UNICEF) being added in 2003. Its mandate to address research and training in neglected tropical diseases made it a pioneer in its first two decades. But the landscape has changed enormously since its inception, with new sources of funding, different disease patterns, and greater capacity for research and training within disease-endemic countries. Therefore, the Joint Coordinating Board (JCB), TDR's main governing body, requested that this Fourth External Review focus on helping it develop a relevant vision for a future role in this shifting environment. We considered TDR's past and present performance, and its strengths and weaknesses, in order to suggest ways forward. Because of the nature of TDR's work, especially with its many partners, it is difficult adequately to capture the breadth and depth of its accomplishments in brief. We approached the review as a “case study” [1] guided by the principles of qualitative data collection and analysis. Data were obtained from previous external reviews, internal documents, a management review commissioned by the World Bank, two commissioned papers [2],[3], and other sources. Our main data, however, were from interviews with over 250 people, of whom about 150 were key informants from all major stakeholder groups who participated in face-to-face, in-depth, open-ended interviews, using an interview guide developed for this purpose. Interviewees included TDR staff, including its current director, Dr. Robert Ridley; members of its governing bodies; former directors (Drs. Adetokunbe Lucas [1976–86], Tore Godal [1986–98], and Carlos Morel [1998–2003]; staff of co-sponsor organizations, donor countries, funding agencies, public–private partnerships (PPPs), philanthropies and other global health organizations; countries' representatives; and TDR alumni. We visited various regions to talk to stakeholders and to study institutions, and examined cases illustrative of TDR's work and its relations with others working in global health research and training. Additionally, we made observations of the workings of its various governing bodies and advisory groups, and the Secretariat in Geneva, where our executive secretary was based. We began by asking, Is the original mandate of TDR still valid? Can others discharge this mandate better? What would happen if TDR ceased to exist? If it were to be re-invented for the future, what would the new TDR look like? TDR was given an opportunity to submit comments. These general questions were supplemented by specific ones tailored to particular informants. All were asked to give examples to support their views. The comprehensive material was submitted to a thematic content analysis on the basis of which a taxonomy of issues was developed. Further analyses built on this taxonomy and on continuing discussions and regular “reality checks” with informants. The final 130–page report was completed at the end of May 2006 and is now available on-line, both as a full report [4] and an executive summary [5].