The burden and treatment of non-communicable diseases among healthcare workers in sub-Saharan Africa: a multi-country cross-sectional study.

Introduction: Non-communicable diseases (NCDs), the leading cause of death globally, are estimated to overtake communicable diseases in sub-Sahara Africa, where healthcare workers (HCWs) play a crucial role in prevention and treatment, but are in extreme shortage, thereby increasing the burden of NCDs among this specific population. To provide evidence for policy-making, we assessed the NCD burden, associated factors and treatment among HCWs in four sub-Saharan African countries. Materials and methods: We conducted a cross-sectional study across four sub-Saharan African countries [Côte d'Ivoire (CIV), Democratic Republic of the Congo (DRC), Madagascar (MDG), and Nigeria (NIG)] between February and December 2022. In a standardized questionnaire, sociodemographic, chronic disease and treatment data were self-reported. We estimated the prevalence of (1) at least one chronic disease, (2) hypertension, and used backward elimination logistic regression model to identify risk factors. Results: We recruited a total of 6,848 HCWs. The prevalence of at least one chronic disease ranged between 9.7% in NIG and 20.6% in MDG, the prevalence of hypertension between 5.4% in CIV and 11.3% in MDG. At most, reported treatment rates reached 36.5%. The odds of each of both outcomes increased with age (at least one chronic disease adjusted odds ratio: CIV: 1.04; DRC: 1.09; MDG: 1.06; NIG: 1.10; hypertension: CIV: 1.10; DRC: 1.31; MDG: 1.11; NIG: 1.11) and with BMI (at least one chronic disease: CIV: 1.10; DRC: 1.07; MDG: 1.06; NIG: 1.08; hypertension: CIV: 1.10; DRC: 1.66; MDG: 1.13; NIG: 1.07). Odds of both outcomes were lower among males, except in CIV. In NIG, the odds of both outcomes were higher among medical doctors and odds of hypertension were higher among those working in secondary care. In MDG, working in secondary care increased and working as auxiliary staff decreased the odds of at least one chronic disease. Conclusion: The prevalence of self-reported chronic disease varied across the four sub-Saharan countries with potentially very low treatment rates. We identified several individual (age, sex, and BMI) and occupational (profession, level of healthcare) factors that influence the odds of NCDs. These factors should be taken into account when developing interventions addressing the burden and management of NCDs among HCWs.

Long lasting anti-IgG chikungunya seropositivity in the Mayotte population will not be enough to prevent future outbreaks: A seroprevalence study, 2019.

Chikungunya is an arboviral disease causing arthralgia which may develop into a debilitating chronic arthritis. In Mayotte, a French overseas department in the Indian Ocean, a chikungunya outbreak was reported in 2006, affecting a third of the population. We aimed at assessing the chikungunya seroprevalence in this population, after over a decade from that epidemic. A multi-stage cross sectional household-based study exploring socio-demographic factors, and knowledge and attitude towards mosquito-borne disease prevention was carried out in 2019. Blood samples from participants aged 15-69 years were taken for chikungunya IgG serological testing. We analyzed associations between chikungunya serological status and selected factors using Poisson regression models, and estimated weighted and adjusted prevalence ratios (w/a PR). The weighted seroprevalence of chikungunya was 34.75% (n = 2853). Seropositivity for IgG anti-chikungunya virus was found associated with living in Mamoudzou (w/a PR = 1.49, 95%CI: 1.21-1.83) and North (w/a PR = 1.41, 95%CI: 1.08-1.84) sectors, being born in the Comoros islands (w/a PR = 1.30, 95%CI: 1.03-1.61), being a student or unpaid trainee (w/a PR = 1.35, 95%CI: 1.01-1.81), living in precarious housing (w/a PR = 1.30, 95%CI: 1.02-1.67), accessing water streams for bathing (w/a PR = 1.72, 95%CI: 1.1-2.7) and knowing that malaria is a mosquito-borne disease (w/a PR = 1.42, 95%CI: 1.21-1.83). Seropositivity was found inversely associated with high education level (w/a PR = 0.50, 95%CI: 0.29-0.86) and living in households with access to running water and toilets (w/a PR = 0.64, 95%CI: 0.51-0.80) (n = 1438). Our results indicate a long-lasting immunity from chikungunya exposure. However, the current population seroprevalence is not enough to protect from future outbreaks. Individuals naïve to chikungunya and living in precarious socio-economic conditions are likely to be at high risk of infection in future outbreaks. To prevent and prepare for future chikungunya epidemics, it is essential to address socio-economic inequalities as a priority, and to strengthen chikungunya surveillance in Mayotte.

Impact of a 5-Year Mass Drug Administration Programme for Soil-Transmitted Helminthiases on the Spatial Distribution of Childhood Anaemia in Burundi from 2007 to 2011.

Background: Childhood anaemia affects 1.8 billion people globally. Little is known about the long-term impact of mass drug administration (MDA) for the control of soil-transmitted helminthiases (STH) on the spatiotemporal variation of anaemia prevalence and severity. We describe the long-term spatiotemporal impact of a 5-year STH MDA programme (2007−2011) on the prevalence of anaemia and anaemia severity in school-aged children (SAC) in Burundi. Methodology/Principal Findings: We used annual haemoglobin concentration and STH data collected during 2007−2011 in 31 schools in Burundi. Spatial dependence in prevalence and severity of anaemia was assessed using semivariograms. Bayesian geostatistical models were developed to (a) quantify the role of STH (adjusted for other anaemia determinants) in the spatiotemporal distribution of anaemia prevalence/severity, and (b) predict the geographical variation of both outcomes across Burundi. Adjusted population data were used to estimate the geographical distribution of the number of SAC at risk of anaemia and with low and moderate/severe anaemia. Infections with Ascaris lumbricoides and Trichuris trichiura were positively and significantly associated with childhood anaemia; hookworm infections were not. A significant decrease in anaemia prevalence, from 40−50% (2008) to 10−20% (2011) was predicted in western areas. The predicted prevalence of low-severity anaemia decreased from 40−50% (2008) to <20% (2011) in southern and eastern areas. Moderate/high-severity anaemia was concentrated in western regions of Burundi, with pockets of moderate/high-severity anaemia in central and northern regions in 2008. The overall number of predicted anaemic children decreased from 443,657 (2008) to 232,304 (2011), with a resurgence after MDA disruption in 2010 (to 480,605). Prevalence of low- and moderate-severity anaemia was higher in boys than in girls. Conclusions/Significance: Despite ongoing MDA, the prevalence of anaemia in SAC remained high and increased in certain parts of the country. It is recommended that MDA programmes targeting STH are complemented with specific anaemia interventions.

Low vaccination coverage for human papillomavirus disease among young men who have sex with men, France, 2019.

BackgroundIn France, human papillomavirus (HPV) vaccination has been recommended in 2016 for men who have sex with men (MSM) up to age 26 years.AimWe aimed to estimate HPV vaccine coverage in 18-28 year-old MSM and identify uptake determinants.MethodsWe collected data on socio-demographic characteristics, sexual behaviour, sexually transmitted diseases (STI) screening and vaccination uptake using a voluntary cross-sectional online survey conducted in 2019 targeting MSM. We calculated coverage of at least one dose of HPV vaccine and prevalence ratios (PR) of determinants with 95% confidence intervals (CI) using Poisson regression.ResultsOf 9,469 respondents (age range: 18-28 years), 15% (95% CI: 14-16) reported being vaccinated for HPV. Coverage was significantly higher among MSM < 24 years (PR: 1.25; 95% CI: 1.13-1.39), with education level below university degree (PR: 1.12; 95% CI: 1.08-1.32), living in rural areas (PR: 1.21; 95% CI: 1.08-1.36), attending sex parties (PR: 1.12; 95% CI: 1.03-1.33), using HIV-related biomedical prevention methods (PR: 1.31; 95% CI: 1.12-1.54), with STI diagnosis (PR: 1.22; 95% CI: 1.08-1.38) and with hepatitis A or B vaccination (PR: 4.56; 95% CI: 3.63-5.81 vs PR: 3.35; 95% CI: 2.53-4.44).ConclusionsThe HPV vaccination uptake among MSM in France was not satisfactory. It was higher among MSM benefitting from other vaccinations and biomedical preventive methods against HIV, suggesting a synergistic effect of the national preventive sexual health recommendations for MSM. Further efforts to improve HPV vaccination coverage targeting MSM are warranted.

Nationwide Remapping of Schistosoma mansoni Infection in Rwanda Using Circulating Cathodic Antigen Rapid Test: Taking Steps toward Elimination.

The field standard for the detection of Schistosoma mansoni infection is Kato-Katz (KK), although it misses many active infections, especially light infections. In 2014, a reassessment of S. mansoni prevalence was conducted in Rwanda using the more sensitive point-of-care circulating cathodic antigen (POC-CCA) rapid assay. A total of 19,371 children from 399 schools were selected for testing for single urine CCA. Of these, 8,697 children from 175 schools were also tested with single stool double-slide KK. Samples from eight of these 175 schools were tested again with CCA and additionally with the highly specific and sensitive up-converting phosphor-lateral flow circulating anodic antigen (UCP-LF CAA) assay. Latent class analysis was applied to all four test results to assess sensitivity and specificity of POC-CCA and estimate the proportion of trace results from Rwanda likely to be true infections. The overall prevalence of S. mansoni infection in Rwanda when CCA trace results were considered negative was 7.4% (school interquartile range [IQR] 0-8%) and 36.1% (school IQR 20-47%) when trace was considered positive. Prevalence by KK was 2.0% with a mean intensity of infection of 1.66 eggs per gram. The proportion of active infections among children diagnosed with CCA trace was estimated by statistical analysis at 61% (Bayesian credibility interval: 50-72%). These results indicate that S. mansoni infection is still widespread in Rwanda and prevalence is much underestimated by KK testing. Circulating cathodic antigen is an affordable alternative to KK and more suitable for measuring S. mansoni prevalence in low-intensity regions.

Circulating Anodic Antigen (CAA): A Highly Sensitive Diagnostic Biomarker to Detect Active Schistosoma Infections-Improvement and Use during SCORE.

The Schistosomiasis Consortium for Operational Research and Evaluation (SCORE) was funded in 2008 to conduct research that would support country schistosomiasis control programs. As schistosomiasis prevalence decreases in many places and elimination is increasingly within reach, a sensitive and specific test to detect infection with Schistosoma mansoni and Schistosoma haematobium has become a pressing need. After obtaining broad input, SCORE supported Leiden University Medical Center (LUMC) to modify the serum-based antigen assay for use with urine, simplify the assay, and improve its sensitivity. The urine assay eventually contributed to several of the larger SCORE studies. For example, in Zanzibar, we demonstrated that urine filtration, the standard parasite egg detection diagnostic test for S. haematobium, greatly underestimated prevalence in low-prevalence settings. In Burundi and Rwanda, the circulating anodic antigen (CAA) assay provided critical information about the limitations of the stool-based Kato-Katz parasite egg-detection assay for S. mansoni in low-prevalence settings. Other SCORE-supported CAA work demonstrated that frozen, banked urine specimens yielded similar results to fresh ones; pooling of specimens may be a useful, cost-effective approach for surveillance in some settings; and the assay can be performed in local laboratories equipped with adequate centrifuge capacity. These improvements in the assay continue to be of use to researchers around the world. However, additional work will be needed if widespread dissemination of the CAA assay is to occur, for example, by building capacity in places besides LUMC and commercialization of the assay. Here, we review the evolution of the CAA assay format during the SCORE period with emphasis on urine-based applications.

Evaluation, Validation, and Recognition of the Point-of-Care Circulating Cathodic Antigen, Urine-Based Assay for Mapping Schistosoma mansoni Infections.

Efforts to control Schistosoma mansoni infection depend on the ability of programs to effectively detect and quantify infection levels and adjust programmatic approaches based on these levels and program goals. One of the three major objectives of the Schistosomiasis Consortium for Operational Research and Evaluation (SCORE) has been to develop and/or evaluate tools that would assist Neglected Tropical Disease program managers in accomplishing this fundamental task. The advent of a widely available point-of-care (POC) assay to detect schistosome circulating cathodic antigen (CCA) in urine with a rapid diagnostic test (the POC-CCA) in 2008 led SCORE and others to conduct multiple evaluations of this assay, comparing it with the Kato-Katz (KK) stool microscopy assay-the standard used for more than 45 years. This article describes multiple SCORE-funded studies comparing the POC-CCA and KK assays, the pros and cons of these assays, the use of the POC-CCA assay for mapping of S. mansoni infections in areas across the spectrum of prevalence levels, and the validation and recognition that the POC-CCA, although not infallible, is a highly useful tool to detect low-intensity infections in low-to-moderate prevalence areas. Such an assay is critical, as control programs succeed in driving down prevalence and intensity and seek to either maintain control or move to elimination of transmission of S. mansoni.

Can direct smear results that are routinely collected at health centre level be used for monitoring the impact of mass drug administration with praziquantel on schistosomiasis in Burundi? A preliminary assessment.

BACKGROUND: Intestinal schistosomiasis is still a public health problem in Burundi. Since 2008, annual mass drug administration with praziquantel has been rolled out in 11 endemic districts. The national programme relies on school-based surveys with kato-katz to monitor the impact of mass drug administration. We explored whether routine data on intestinal schistosomiasis as determined by direct fecal smears at health centre level could be used. METHODS: From the Burundian National Health Information System, we collected routine incidence data on intestinal schistosomiasis as determined by direct smear examination in all 45 sanitary districts during 2011-2015. A temporal trends analysis was performed using a mixed negative binomial regression. Sanitary districts with mass drug administration campaigns with praziquantel (n = 11) were compared with those without (n = 34). In addition, prevalence data on intestinal schistosomiasis based on kato-katz results from a school-based national mapping in 2014 were compared with the incidence data in health centres based on direct smear results, in the same 45 sanitary districts. RESULTS: In the 11 sanitary districts applying mass drug administration with praziquantel, the incidence rate decreased significantly for the years 2014 (ß2014 = - 0.826, P = 0.010) and 2015 (ß2015 = - 1.294, P < 0.001) and for the five-year period (ß = - 0.286, P < 0.001), whereas in the 34 districts where mass drug administration was not delivered, there was no significant decrease over time (ß = - 0.087, P = 0.219). In most of the 45 sanitary districts, the low prevalence based on kato-katz in school children was confirmed by low incidence rates based on direct smears in the health centres. CONCLUSIONS: National Health Information System surveillance data, based on routinely collected direct smear results at health centre level, may be able to monitor the impact of mass drug administration with praziquantel on intestinal schistosomiasis in Burundi. Control and elimination of intestinal schistosomiasis call for integration of adequate diagnosis and treatment into routine activities of primary health care facilities, as recommended by the World Health Organization since more than 20 years. When moving towards elimination, more sensitive tests, such as the point-of-care circulating cathodic antigen assay are desirable.

Parasite associations predict infection risk: incorporating co-infections in predictive models for neglected tropical diseases.

BACKGROUND: Schistosomiasis and infection by soil-transmitted helminths are some of the world's most prevalent neglected tropical diseases. Infection by more than one parasite (co-infection) is common and can contribute to clinical morbidity in children. Geostatistical analyses of parasite infection data are key for developing mass drug administration strategies, yet most methods ignore co-infections when estimating risk. Infection status for multiple parasites can act as a useful proxy for data-poor individual-level or environmental risk factors while avoiding regression dilution bias. Conditional random fields (CRF) is a multivariate graphical network method that opens new doors in parasite risk mapping by (i) predicting co-infections with high accuracy; (ii) isolating associations among parasites; and (iii) quantifying how these associations change across landscapes. METHODS: We built a spatial CRF to estimate infection risks for Ascaris lumbricoides, Trichuris trichiura, hookworms (Ancylostoma duodenale and Necator americanus) and Schistosoma mansoni using data from a national survey of Rwandan schoolchildren. We used an ensemble learning approach to generate spatial predictions by simulating from the CRF's posterior distribution with a multivariate boosted regression tree that captured non-linear relationships between predictors and covariance in infection risks. This CRF ensemble was compared against single parasite gradient boosted machines to assess each model's performance and prediction uncertainty. RESULTS: Parasite co-infections were common, with 19.57% of children infected with at least two parasites. The CRF ensemble achieved higher predictive power than single-parasite models by improving estimates of co-infection prevalence at the individual level and classifying schools into World Health Organization treatment categories with greater accuracy. The CRF uncovered important environmental and demographic predictors of parasite infection probabilities. Yet even after capturing demographic and environmental risk factors, the presences or absences of other parasites were strong predictors of individual-level infection risk. Spatial predictions delineated high-risk regions in need of anthelminthic treatment interventions, including areas with higher than expected co-infection prevalence. CONCLUSIONS: Monitoring studies routinely screen for multiple parasites, yet statistical models generally ignore this multivariate data when assessing risk factors and designing treatment guidelines. Multivariate approaches can be instrumental in the global effort to reduce and eventually eliminate neglected helminth infections in developing countries.

Gender-related factors affecting health seeking for neglected tropical diseases: findings from a qualitative study in Ethiopia.

BACKGROUND: Despite known gender-specific differences in terms of prevalence, transmission and exposure to neglected tropical diseases (NTDs), there is limited discussion of the influence of gender in NTD programmes and interventions. There is a paucity of research on how gender interacts with NTD service provision and uptake. This study, part of broader implementation research in Ethiopia, applied a gender lens to health seeking for five NTDs: lymphatic filariasis, podoconiosis, schistosomiasis, soil-transmitted helminth infection and trachoma. METHODOLOGY/PRINCIPAL FINDINGS: The study was conducted in a district of the Southern Nations, Nationalities, and Peoples' Region of Ethiopia where the five NTDs are prevalent. A qualitative methodology was adopted to explore participants' perspectives and experiences. Data generation methods included 20 interviews and four focus group discussions. Community members, volunteer Health Development Army leaders, Health Extension Workers and a range of health workers at the health post, health centre and hospital level (n = 59) were purposively sampled. Interviews and focus group discussions were audio recorded, transcribed verbatim into English then analysed through open coding, drawing on constant comparative methods. Gender related factors affected care seeking for NTDs and were described as reasons for not seeking care, delayed care seeking and treating NTDs with natural remedies. Women faced additional challenges in seeking health care due to gender inequalities and power dynamics in their domestic partnerships. Participants recommended raising community awareness about NTDs, however this remains problematic due to gender and social norms around appropriate discourse with members of the opposite gender. CONCLUSIONS/SIGNIFICANCE: The findings from this study provide crucial insights into how gender interacts with accessing health services, at different levels of the health system. If we are committed to leaving no one behind and achieving universal health coverage, it is essential to address gender disparities to access and utilisation of interventions delivered by national NTD programmes.

Mapping Schistosoma mansoni endemicity in Rwanda: a critical assessment of geographical disparities arising from circulating cathodic antigen versus Kato-Katz diagnostics.

BACKGROUND: Schistosomiasis is a neglected tropical disease caused by Schistosoma parasites. Intervention relies on identifying high-risk regions, yet rapid Schistosoma diagnostics (Kato-Katz stool assays (KK) and circulating cathodic antigen urine assays (CCA)) yield different prevalence estimates. We mapped S. mansoni prevalence and delineated at-risk regions using a survey of schoolchildren in Rwanda, where S. mansoni is an endemic parasite. We asked if different diagnostics resulted in disparities in projected infection risk. METHODS: Infection data was obtained from a 2014 Rwandan school-based survey that used KK and CCA diagnostics. Across 386 schools screened by CCA (N = 19,217). To allow for uncertainty when interpreting ambiguous CCA trace readings, which accounted for 28.8% of total test results, we generated two presence-absence datasets: CCA trace as positive and CCA trace as negative. Samples (N = 9,175) from 185 schools were also screened by KK. We included land surface temperature (LST) and the Normalized Difference Vegetation and Normalized Difference Water Indices (NDVI, NDWI) as predictors in geostatistical regressions. FINDINGS: Across 8,647 children tested by both methods, prevalence was 35.93% for CCA trace as positive, 7.21% for CCA trace as negative and 1.95% for KK. LST was identified as a risk factor using KK, whereas NDVI was a risk factor for CCA models. Models predicted high endemicity in Northern and Western regions of Rwanda, though the CCA trace as positive model identified additional high-risk areas that were overlooked by the other methods. Estimates of current burden for children at highest risk (boys aged 5-9 years) varied by an order of magnitude, with 671,856 boys projected to be infected by CCA trace as positive and only 60,453 projected by CCA trace as negative results. CONCLUSIONS: Our findings show that people in Rwanda's Northern, Western and capital regions are at high risk of S. mansoni infection. However, variation in identification of environmental risk factors and delineation of at-risk regions using different diagnostics likely provides confusing messages to disease intervention managers. Further research and statistical analyses, such as latent class analysis, can be used to improve CCA result classification and assess its use in guiding treatment regimes.

Integration of schistosomiasis control activities within the primary health care system: a critical review.

BACKGROUND: Schistosomiasis is a chronic disease linked to poverty and is widely endemic, particularly in sub-Saharan Africa. For decades, the World Health Organization has called for a larger role of the primary health care system in schistosomiasis control, and its integration within the routine activities of primary health care facilities. Here, we reviewed existing studies on the integration of schistosomiasis control measures within the primary health care system, more precisely at the health centre, and we analysed their outcomes. METHODS: An online search of studies published via PubMed and Embase databases was carried out until December 2017. Keywords were used to identify articles related to the integration of schistosomiasis control within the primary health care system, especially at the health centre level. Studies on integration of the following control measures were included: diagnosis and treatment, supplemented or not with (i) health education; (ii) snail control; and (iii) clean water supply and sanitation. A qualitative review was undertaken. To conclude on the effectiveness of an intervention, intermediate outcomes (knowledge, attitude and practice, coverage, access to health care) and distal outcomes (prevalence, incidence, mortality) were considered, and pre/post-intervention results were compared. RESULTS: Of 569 records found, 11 met the inclusion criteria. Studies were classified in three groups, according to the control measures they included. Integration of diagnosis and treatment, and health education in the first group resulted in an improvement of knowledge level of care providers, access to health care and health care seeking behaviour of the community. However, no positive effect was observed on the knowledge level of symptoms and modes of transmission at the community level. Most studies in the second group (with snail control as additional measure) and the third group (with clean water supply and sanitation as additional measure) showed a positive effect on schistosomiasis prevalence and incidence post-intervention, independent of the additional control measures implemented. CONCLUSIONS: The results of this review suggest a positive impact of integration of schistosomiasis control within the primary health care system. However, more robust studies are needed, especially in resource-limited regions, for conclusive evidence on the effectiveness and the sustainability of this strategy.

Mapping Soil-Transmitted Helminth Parasite Infection in Rwanda: Estimating Endemicity and Identifying At-Risk Populations.

Soil-transmitted helminth (STH) infections are globally distributed intestinal parasite infections caused by Ascaris lumbricoides, Trichuris trichiura, and hookworms (Ancylostoma duodenale and Necator americanus). STH infection constitutes a major public health threat, with heavy burdens observed in many of the world's tropical and subtropical regions. Mass drug administration and sanitation improvements can drastically reduce STH prevalence and associated morbidity. However, identifying targeted areas in need of treatment is hampered by a lack of knowledge on geographical and population-level risk factors. In this study, we applied Bayesian geostatistical modelling to data from a national school-based STH infection survey in Rwanda to (1) identify ecological and population-level risk factors and (2) provide comprehensive precision maps of infection burdens. Our results indicated that STH infections were heterogeneously distributed across the country and showed signatures of spatial clustering, though the magnitude of clustering varied among parasites. The highest rates of endemic clustering were attributed to A. lumbricoides infection. Concordant infection patterns among the three parasite groups highlighted populations currently most at-risk of morbidity. Population-dense areas in the Western and North-Western regions of Rwanda represent areas that have continued to exhibit high STH burden across two surveys and are likely in need of targeted interventions. Our maps support the need for an updated evaluation of STH endemicity in western Rwanda to evaluate progress in MDA efforts and identify communities that need further local interventions to further reduce morbidity caused by STH infections.

Capacity gaps in health facilities for case management of intestinal schistosomiasis and soil-transmitted helminthiasis in Burundi.

BACKGROUND: Schistosomiasis and soil-transmitted helminthiasis (STH) are endemic diseases in Burundi. STH control is integrated into health facilities (HF) across the country, but schistosomiasis control is not. The present study aimed to assess the capacity of HF for integrating intestinal schistosomiasis case management into their routine activities. In addition, the current capacity for HF-based STH case management was evaluated. METHODS: A random cluster survey was carried out in July 2014, in 65 HF located in Schistosoma mansoni and STH endemic areas. Data were collected by semi-quantitative questionnaires. Staff with different functions at the HF were interviewed (managers, care providers, heads of laboratory and pharmacy and data clerks). Data pertaining to knowledge of intestinal schistosomiasis and STH symptoms, human and material resources and availability and costs of diagnostic tests and treatment were collected. FINDINGS: Less than half of the 65 care providers mentioned one or more major symptoms of intestinal schistosomiasis (abdominal pain 43.1%, bloody diarrhoea 13.9% and bloody stool 7.7%). Few staff members (15.7%) received higher education, and less than 10% were trained in-job on intestinal schistosomiasis case management. Clinical guidelines and laboratory protocols for intestinal schistosomiasis diagnosis and treatment were available in one third of the HF. Diagnosis was performed by direct smear only. Praziquantel was not available in any of the HF. The results for STH were similar, except that major symptoms were more known and cited (abdominal pain 69.2% and diarrhoea 60%). Clinical guidelines were available in 61.5% of HF, and albendazole or mebendazole was available in all HF. CONCLUSIONS: The current capacity of HF for intestinal schistosomiasis and STH detection and management is inadequate. Treatment was not available for schistosomiasis. These issues need to be addressed to create an enabling environment for successful integration of intestinal schistosomiasis and STH case management into HF routine activities in Burundi for better control of these diseases.

Latent class analysis to evaluate performance of point-of-care CCA for low-intensity Schistosoma mansoni infections in Burundi.

BACKGROUND: Kato-Katz examination of stool smears is the field-standard method for detecting Schistosoma mansoni infection. However, Kato-Katz misses many active infections, especially of light intensity. Point-of-care circulating cathodic antigen (CCA) is an alternative field diagnostic that is more sensitive than Kato-Katz when intensity is low, but interpretation of CCA-trace results is unclear. To evaluate trace results, we tested urine and stool specimens from 398 pupils from eight schools in Burundi using four approaches: two in Burundi and two in a laboratory in Leiden, the Netherlands. In Burundi, we used Kato-Katz and point-of-care CCA (CCAB). In Leiden, we repeated the CCA (CCAL) and also used Up-Converting Phosphor Circulating Anodic Antigen (CAA). METHODS: We applied Bayesian latent class analyses (LCA), first considering CCA traces as negative and then as positive. We used the LCA output to estimate validity of the prevalence estimates of each test in comparison to the population-level infection prevalence and estimated the proportion of trace results that were likely true positives. RESULTS: Kato-Katz yielded the lowest prevalence (6.8%), and CCAB with trace considered positive yielded the highest (53.5%). There were many more trace results recorded by CCA in Burundi (32.4%) than in Leiden (2.3%). Estimated prevalence with CAA was 46.5%. LCA indicated that Kato-Katz had the lowest sensitivity: 15.9% [Bayesian Credible Interval (BCI): 9.2-23.5%] with CCA-trace considered negative and 15.0% with trace as positive (BCI: 9.6-21.4%), implying that Kato-Katz missed approximately 85% of infections. CCAB underestimated disease prevalence when trace was considered negative and overestimated disease prevalence when trace was considered positive, by approximately 12 percentage points each way, and CAA overestimated prevalence in both models. Our results suggest that approximately 52.2% (BCI: 37.8-5.8%) of the CCAB trace readings were true infections. CONCLUSIONS: Whether measured in the laboratory or the field, CCA outperformed Kato-Katz at the low infection intensities in Burundi. CCA with trace as negative likely missed many infections, whereas CCA with trace as positive overestimated prevalence. In the absence of a field-friendly gold standard diagnostic, the use of a variety of diagnostics with differing properties will become increasingly important as programs move towards elimination of schistosomiasis. It is clear that CCA is a valuable tool for the detection and mapping of S. mansoni infection in the field and CAA may be a valuable field tool in the future.

Spatiotemporal distribution and population at risk of soil-transmitted helminth infections following an eight-year school-based deworming programme in Burundi, 2007-2014.

BACKGROUND: Investigating the effect of successive annual deworming rounds on the spatiotemporal distribution of infection prevalence and numbers at risk for soil-transmitted helminths (STHs) can help identify communities nearing elimination and those needing further interventions. In this study, we aim to quantify the impact of an 8-year mass drug administration (MDA) programme (from 2007 to 2014) on the spatiotemporal distribution of prevalence of STH infections and to estimate the number of school-aged children infected with STHs in Burundi. METHODS: During annual longitudinal school-based surveys in Burundi between 2007 and 2011, STH infection and anthropometric data for a total of 40,656 children were collected; these data were supplemented with data from a national survey conducted in 2014. Bayesian model based geostatistics (MBG) were used to generate predictive prevalence maps for each STH species and year. The numbers of children at-risk of infection per district between 2008 and 2014 were estimated as the product of the predictive prevalence maps and population density maps. RESULTS: Overall, the degree of spatial clustering of STH infections decreased between 2008 and 2011; in 2014 the geographical clusters of all STH infections reappeared. The reduction in prevalence was small for Ascaris lumbricoides and Trichuris trichiura in the centre and central north of the country. Our predictive prevalence maps for hookworm indicate a reduction in prevalence along the periphery of the country. The predicted number of children infected with any STH species decreased substantially between 2007 and 2011, but in 2014 there was an increase in the predicted number of children infected with A. lumbricoides and T. trichiura. In 2014, the districts with the highest predicted number of children infected with A. lumbricoides, T. trichiura and hookworms were Kibuye district (n = 128,903), Mabayi district (n = 35,302) and Kiremba (n = 87,511), respectively. CONCLUSIONS: While the MDA programme in Burundi resulted in a reduction in STH prevalence, this reduction was spatiotemporally heterogeneous, with some pockets of high prevalence remaining, suggesting that treatment coverage and complementary interventions should be evaluated to improve impact.

Neglected tropical diseases: exploring long term practical approaches to achieve sustainable disease elimination and beyond.

BACKGROUND: Remarkable progress has been made in the fight against neglected tropical diseases, but new challenges have emerged. Innovative diagnostics, better drugs and new insecticides are often identified as the priority; however, access to these new tools may not be sufficient to achieve and sustain disease elimination, if certain challenges and priorities are not considered. MAIN BODY: The authors summarise key operational challenges, and based on these, identify two major priorities: strengthening the capacity of the primary health care health system in correctly diagnosing and managing neglected tropical diseases; and establishing an effective disease surveillance process. Five steps are proposed as concrete actions to build an effective primary health care service for neglected tropical diseases, and a health management information system capable of accurately reporting these diseases. Community engagement and formalization of community health workers role are proposed as essential components of these steps. Shift of financial support from disease oriented programmes to disease integrated interventions, improved access to international guidelines for primary health care staff, and availability of donated drugs in health care structures are also suggested as key elements of the proposed process. CONCLUSION: The authors conclude that failure to address these priorities now may lead to further challenges on the long path towards neglected tropical disease elimination and beyond.

Mass drug administration in Central Equatoria, South Sudan: results and suggestions for future distributions.

Background: South Sudan has rolled out a neglected tropical disease programme, which envisaged deworming campaigns in states endemic for soil transmitted helminth infections and schistosomiasis. Methods: In 2016, two deworming campaigns targeting school-age children were performed in Central Equatoria. Distribution sites were set up in primary schools, Boma Health Initiative headquarters, health centres and markets. Training, radio adverts and community meetings were performed before the campaigns. Results and Conclusions: Central Equatoria implemented the first helminth infections and schistosomiasis treatment campaign, achieving a satisfactory programme coverage (>90%). Setting up drug distribution sites and engaging the Boma Health Initiative are recommended approaches for future campaigns.

Countrywide Reassessment of Schistosoma mansoni Infection in Burundi Using a Urine-Circulating Cathodic Antigen Rapid Test: Informing the National Control Program.

Following implementation of the national control program, a reassessment of Schistosoma mansoni prevalence was conducted in Burundi to determine the feasibility of moving toward elimination. A countrywide cluster-randomized cross-sectional study was performed in May 2014. At least 25 schools were sampled from each of five eco-epidemiological risk zones for schistosomiasis. Fifty randomly selected children 13-14 years of age per school were included for a single urine-circulating cathodic antigen (CCA) rapid test and, in a subset of schools, for duplicate Kato-Katz slide preparation from a single stool sample. A total of 17,331 children from 347 schools were tested using CCA. The overall prevalence of S. mansoni infection, when CCA trace results were considered negative, was 13.5% (zone range [zr] = 4.6-17.8%), and when CCA trace results were considered positive, it was 42.8% (zr = 34.3-49.9%). In 170 schools, prevalence of this infection determined using Kato-Katz method was 1.5% (zr = 0-2.7%). The overall mean intensity of S. mansoni infection determined using Kato-Katz was 0.85 eggs per gram (standard deviation = 10.86). A majority of schools (84%) were classified as non-endemic (prevalence = 0) using Kato-Katz; however, a similar proportion of schools were classified as endemic when CCA trace results were considered negative (85%) and nearly all (98%) were endemic when CCA trace results were considered positive. The findings of this nationwide reassessment using a CCA rapid test indicate that Schistosoma infection is still widespread in Burundi, although its average intensity is probably low. Further evidence is now needed to determine the association between CCA rapid test positivity and low-intensity disease transmission.

The impact of an 8-year mass drug administration programme on prevalence, intensity and co-infections of soil-transmitted helminthiases in Burundi.

BACKGROUND: Soil-transmitted helminth (STH) infections are amongst the most prevalent infections in the world. Mass drug administration (MDA) programmes have become the most commonly used national interventions for endemic countries to achieve elimination. This paper aims to describe the effect of an 8-year MDA programme on the prevalence, intensity of infection and co-infection of STH in Burundi from 2007 to 2014 and critically appraise the trajectory towards STH elimination in the country. RESULTS: Annual STH parasitological surveys (specifically, a "pilot study" from 2007 to 2011, an "extension study" from 2008 to 2011, and a "national reassessment" in 2014; n = 27,658 children), showed a significant drop in prevalence of infection with any STH ("pooled STH") between baseline and 2011 in both studies, falling from 32 to 16 % in the pilot study, and from 35 to 16 % in the extension study. Most STH infections were of low intensity according to WHO classification. The national reassessment in 2014 showed that prevalence of pooled STH remained significantly below the prevalence in 2007 in both studies but there was no further decrease in STH prevalence from 2011 levels during this time. Spatial dependence analysis showed that prevalence of Trichuris trichiura and Ascaris lumbricoides had a tendency to cluster over the years, whilst only trends in spatial dependence were evident for hookworm infections. Spatial dependence fluctuated over the course of the programme for Ascaris lumbricoides and Trichuris trichiura. However, spatial trends in spatial dependence were evident in 2010 for Ascaris lumbricoides. Analysis of spatial clustering of intensity of infection and heavy infections revealed that the intensity changed over time for all parasites. Heavy intensity was only evident in Ascaris lumbricoides for 2008 and did not appear in proceeding years and other parasites. CONCLUSIONS: These results demonstrate that sustained annual MDA significantly reduced the prevalence of STH infection in school-age children but was unable to achieve elimination. Additionally, significant decline in prevalence was accompanied by a drop in spatial clustering of infection indicators across all sites from 2008. The lack of consistency in the results of the spatial dependence analysis highlights that MDA programmes can interrupt the normal transmission dynamics of STH parasites.