Improving access to care and community health in Haiti with optimized community health worker placement

The national deployment of polyvalent community health workers (CHWs) is a constitutive part of the strategy initiated by the Ministry of Health to accelerate efforts towards universal health coverage in Haiti. Its implementation requires the planning of future recruitment and deployment activities for which mathematical modelling tools can provide useful support by exploring optimised placement scenarios based on access to care and population distribution. We combined existing gridded estimates of population and travel times with optimisation methods to derive theoretical CHW geographical placement scenarios including constraints on walking time and the number of people served per CHW. Four national-scale scenarios that align with total numbers of existing CHWs and that ensure that the walking time for each CHW does not exceed a predefined threshold are compared. The first scenario accounts for population distribution in rural and urban areas only, while the other three also incorporate in different ways the proximity of existing health centres. Comparing these scenarios to the current distribution, insufficient number of CHWs is systematically identified in several departments and gaps in access to health care are identified within all departments. These results highlight current suboptimal distribution of CHWs and emphasize the need to consider an optimal (re-)allocation.

Association between the proportion of Plasmodium falciparum and Plasmodium vivax infections detected by passive surveillance and the magnitude of the asymptomatic reservoir in the community: a pooled analysis of paired health facility and community data

BACKGROUND

Passively collected malaria case data are the foundation for public health decision making. However, because of population-level immunity, infections might not always be sufficiently symptomatic to prompt individuals to seek care. Understanding the proportion of all Plasmodium spp infections expected to be detected by the health system becomes particularly paramount in elimination settings. The aim of this study was to determine the association between the proportion of infections detected and transmission intensity for Plasmodium falciparum and Plasmodium vivax in several global endemic settings.

METHODS

The proportion of infections detected in routine malaria data, P(Detect), was derived from paired household cross-sectional survey and routinely collected malaria data within health facilities. P(Detect) was estimated using a Bayesian model in 431 clusters spanning the Americas, Africa, and Asia. The association between P(Detect) and malaria prevalence was assessed using log-linear regression models. Changes in P(Detect) over time were evaluated using data from 13 timepoints over 2 years from The Gambia.

FINDINGS

The median estimated P(Detect) across all clusters was 12·5% (IQR 5·3-25·0) for P falciparum and 10·1% (5·0-18·3) for P vivax and decreased as the estimated log-PCR community prevalence increased (adjusted odds ratio [OR] for P falciparum 0·63, 95% CI 0·57-0·69; adjusted OR for P vivax 0·52, 0·47-0·57). Factors associated with increasing P(Detect) included smaller catchment population size, high transmission season, improved care-seeking behaviour by infected individuals, and recent increases (within the previous year) in transmission intensity.

INTERPRETATION

The proportion of all infections detected within health systems increases once transmission intensity is sufficiently low. The likely explanation for P falciparum is that reduced exposure to infection leads to lower levels of protective immunity in the population, increasing the likelihood that infected individuals will become symptomatic and seek care. These factors might also be true for P vivax but a better understanding of the transmission biology is needed to attribute likely reasons for the observed trend. In low transmission and pre-elimination settings, enhancing access to care and improvements in care-seeking behaviour of infected individuals will lead to an increased proportion of infections detected in the community and might contribute to accelerating the interruption of transmission.

FUNDING

Wellcome Trust.

Effect of several interventions on the frequency of handwashing among elementary public school children

BACKGROUND

The purpose of this educational project was to assess the effect of several interventions on the frequency of handwashing among elementary public school children.

METHODS

Participants in this project were first-graders and fourth-graders from jurisdictions within a mid-Atlantic metropolitan area. Phase I included a baseline assessment of bathroom cleanliness as well as adequacy of supplies for handwashing in each school. During phase 2, the frequency of handwashing before lunch or after bathroom use was monitored and recorded during a 2-month period. The schools were separated into four groups: a peer education group, a hand wipes and instructional poster group, a combination of the education and hand wipes/poster groups, and a (control) comparison school.

RESULTS

Overall, a significant increase occurred in the proportion of handwashing frequency from preintervention to postintervention for each intervention group (wipes: 0.50 vs 0.66, p = 0.03; education only: 0.64 vs 0.72, p = 0.02; and education and wipes: 0.45 vs 0.67, p = 0.03) but not in the control group (0.42 vs 0.46, p = 0.26). When the first 3 weeks and the last 3 weeks after intervention were compared, handwashing frequency remained unchanged in the wipes only group (0.66 vs 0.66, p = 0.96), decreased in the education group (0.77 vs 0.65, p = 0.006), and increased in the education and wipes group (0.58 vs 0.75, p = 0.003), as well as in the control group (0.37 vs 0.52, p = 0.01).

CONCLUSION

Education combined with accessible convenient hand hygiene may result in a sustainable increase in the frequency of handwashing among elementary school children.