The Ongoing Ebola Epidemic in the Democratic Republic of Congo, 2018-2019.

The international response to the evolving Ebola epidemic in eastern Democratic Republic of Congo (DRC) has had interim successes while facing ongoing difficulties. The outbreak has occurred in an area of intractable conflict among multiple armed groups at a time of contentious national elections. Despite porous international borders and considerable population movement, however, transmission has been confined to North Kivu and Ituri provinces. Factors potentially contributing to this containment include conduct of about 55 million screenings, surveillance of contacts (12,591 under surveillance currently), testing of 280 samples per day, provision of safe and dignified burials for most deaths, vaccination of high-risk people (112,485 vaccinated as of May 7, 2019), and medical treatment including four investigational therapies. Major challenges remain. Since late February 2019, a sharp rise in cases and increased transmission have been observed. These coincide with organized attacks by armed groups targeting response teams, deteriorating security, and the population's increasing distrust of the response effort. The risk of local and regional spread remains high given the high proportion of deaths occurring outside treatment facilities, relatively low proportions of new patients who were known contacts, ongoing nosocomial transmission, and persistent delays in detection and reporting. Stopping this epidemic will require the alignment of the principal political and armed groups in eastern DRC in support of the response.

Game changers: why did the scale-up of HIV treatment work despite weak health systems?

Game changers are radical innovations that result in fundamental and durable changes. The global HIV program scale-up witnessed over the past decade has included some innovations that are not well appreciated. The willingness to rapidly adopt and implement innovations, the flexibility and speed of program implementation, and the readiness to re-examine professional roles are just a few of such game changers. However, moving ahead, further work is needed to enhance the quality of programs, to energetically tackle HIV prevention, to build on this success, and to address other health threats that these same communities face.

Understanding barriers to emergency care in low-income countries: view from the front line.

INTRODUCTION: Morbidity and mortality due to acute but treatable conditions remain high in the developing world, as many significant barriers exist to providing emergency medical care. This study investigates these barriers in a rural region of Ethiopia. HYPOTHESIS: The limited capacity of frontline healthcare workers to diagnose and treat acute medical and surgical conditions represents a major barrier to the provision of emergency care in rural Ethiopia. METHODS: Health providers at a convenience sample of 16 rural health centers in the state of Tigray, Ethiopia completed a questionnaire designed to assess the availability of diagnostic and treatment modalities, the proximity and methods of transportation to referral facilities, and health providers' level of comfort in diagnosing and treating a variety of representative emergency medical conditions. RESULTS: Thirteen (81%) providers had only a very basic level of medical training, and seven (44%) lacked access to any diagnostic equipment. While most providers could offer oral rehydration solution (ORS), anti-pyretic medications, and antibiotics, none of the providers could offer blood transfusions or any form of surgery. Ten (63%) respondents stated that their patients had to travel >10 km from the health center to a referral hospital, with only a minority of patients having access to motorized transport. For the seven emergency conditions assessed, a majority of providers felt comfortable diagnosing these conditions, though fewer felt comfortable treating them. CONCLUSION: There is a significant need for both health worker training and improvements in transportation infrastructure in order to increase access to emergency medical care in rural areas of the developing world. Low-cost interventions that improve human capacity in a context-appropriate manner are warranted as transportation and hospital network capacity expansions are considered.

Can source reduction of mosquito larval habitat reduce malaria transmission in Tigray, Ethiopia?

The development of irrigation schemes by dam construction has led to an increased risk of malaria in Tigray, Ethiopia. We carried out a pilot study near a microdam to assess whether environmental management could reduce malaria transmission by Anopheles arabiensis, the main vector in Ethiopia. The study took place in Deba village, close to a dam; Maisheru village, situated 3-4 km away from the dam, acted as a control. Baseline entomological and clinical data were collected in both villages during the first 12 months. Source reduction, involving filling, draining and shading of potential mosquito-breeding habitats was carried out by the community of Deba in the second year and routine surveillance continued in both villages during the second year. Anopheles arabiensis was highly anthropophilic (Human Blood Index=0.73), biting early in the night before people went to bed. The major breeding habitats associated with the dam were areas of seepage at the dam base (28%), leaking irrigation canals (16%), pools that formed along the bed of streams from the dam (13%), and man-made pools (12%). In the pre-intervention year, 5.9-7.2 times more adult vectors were found in the dam village compared with the control village. There was a 3.1% higher prevalence of an enlarged spleen in children under 10 years in the dam village than in the control village during the pre-intervention period, but no statistically significant difference was found in the incidence of falciparum malaria between the two villages during the same period. Source reduction was associated with a 49% (95% CI=46.6-50.0) relative reduction in An. arabiensis adults in the dam village compared with the pre-intervention period. There were very few cases of malaria during the intervention period in both villages making it impossible to judge whether malaria incidence had been reduced. These preliminary findings suggest that in areas of low intensity transmission community-led larval control may be a cheap and effective method of controlling malaria. Further, large-scale studies are needed to confirm these findings.