Persons 'never treated' in mass drug administration for lymphatic filariasis: identifying programmatic and research needs from a series of research review meetings 2020-2021

As neglected tropical disease programs rely on participation in rounds of mass drug administration (MDA), there is concern that individuals who have never been treated could contribute to ongoing transmission, posing a barrier to elimination. Previous research has suggested that the size and characteristics of the never-treated population may be important but have not been sufficiently explored. To address this critical knowledge gap, four meetings were held from December 2020 to May 2021 to compile expert knowledge on never treatment in lymphatic filariasis (LF) MDA programs. The meetings explored four questions: the number and proportion of people never treated, their sociodemographic characteristics, their infection status and the reasons why they were not treated. Meeting discussions noted key issues requiring further exploration, including how to standardize measurement of the never treated, adapt and use existing tools to capture never-treated data and ensure representation of never-treated people in data collection. Recognizing that patterns of never treatment are situation specific, participants noted measurement should be quick, inexpensive and focused on local solutions. Furthermore, programs should use existing data to generate mathematical models to understand what levels of never treatment may compromise LF elimination goals or trigger programmatic action.

Lessons from the Field: Integrated survey methodologies for neglected tropical diseases

The 2021–2030 Neglected Tropical Diseases road map calls for intensified cross-cutting approaches. By moving away from vertical programming, the integration of platforms and intervention delivery aims to improve efficiency, cost-effectiveness and programme coverage. Drawing on the direct experiences of the authors, this article outlines key elements for successful integrated surveys, the challenges encountered, as well as future opportunities and threats to such surveys. There are multiple advantages. Careful planning should ensure that integration does not result in a process that is less efficient, more expensive or that generates data driving less reliable decisions than conducting multiple disease-specific surveys.

The Importance of Failure: How Doing Impact Surveys That Fail Saves Trachoma Programs Money

Trachoma programs use annual antibiotic mass drug administration (MDA) in evaluation units (EUs) that generally encompass 100,000–250,000 people. After one, three, or five MDA rounds, programs undertake impact surveys. Where impact survey prevalence of trachomatous inflammation—follicular (TF) in 1- to 9-year-olds is ≥ 5%, ≥ 1 additional MDA rounds are recommended before resurvey. Impact survey costs, and the proportion of impact surveys returning TF prevalence ≥ 5% (the failure rate or, less pejoratively, the MDA continuation rate), therefore influence the cost of eliminating trachoma. We modeled, for illustrative EU sizes, the financial cost of undertaking MDA with and without conducting impact surveys. As an example, we retrospectively assessed how conducting impact surveys affected costs in the United Republic of Tanzania for 2017–2018. For EUs containing 100,000 people, the median (interquartile range) cost of continuing MDA without doing impact surveys is USD 28,957 (17,581–36,197) per EU per year, whereas continuing MDA solely where indicated by impact survey results costs USD 17,564 (12,158–21,694). If the mean EU population is 100,000, then continuing MDA without impact surveys becomes advantageous in financial cost terms only when the continuation rate exceeds 71%. For the United Republic of Tanzania in 2017–2018, doing impact surveys saved enough money to provide MDA for > 1,000,000 people. Although trachoma impact surveys have a nontrivial cost, they generally save money, providing EUs have > 50,000 inhabitants, the continuation rate is not excessive, and they generate reliable data. If all EUs pass their impact surveys, then we have waited too long to do them.

Engaging, Entertaining, and Educating Under-Served and At-Risk Youth with STEM-Based Activities

In recently constructing a curriculum for our Neuroscience major, a service-learning component was included that requires students to develop and present STEM-based activities to underserved 4^th-6^th grade children in an afterschool program. Though initially proposed with a primary goal of teaching children specific concepts in the field of neuroscience, efforts have gradually shifted towards simply increasing interest in, and enthusiasm for, STEM through interactive demonstrations. Most of the activities used incorporate neuroscience examples that are inherently intriguing and conceptually accessible to children. The present article briefly summarizes our experiences with enlisting college students as youth mentors, and having those students work within the community to establish a conducive setting for such a program. Insight is also offered into developing activities that might be successful for working with this particular population, including possible approaches to assessing effectiveness. Finally, specific examples for several activities are given.

How elimination of lymphatic filariasis as a public health problem in the Kingdom of Cambodia was achieved

BACKGROUND

Endemicity of lymphatic filariasis (LF) in Cambodia was proven in 1956 when microfilariae were detected in mosquitos in the Kratié province. In 2001, an extensive study confirmed the presence of both Brugia malayi and Wuchereria bancrofti microfilariae. In 2003, the Ministry of Health established a national task force to develop policies and strategies for controlling and eliminating neglected tropical diseases (NTDs), with the goal of eliminating LF by 2015. This article summarizes the work accomplished to eliminate LF as a public health problem in Cambodia.

METHODS

The National Program to Eliminate Lymphatic Filariasis made excellent progress in the goal towards elimination due to strong collaboration between ministries, intensive supervision by national staff, and advocacy for mobilization of internal and external resources. Mass drug administration (MDA) with diethylcarbamazine citrate and albendazole was conducted in six implementation units, achieving > 70% epidemiological coverage for five consecutive rounds, from 2005 to 2009. In 2006, in 14 provinces, healthcare workers developed a line list of lymphedema and hydrocele patients, many of whom were > 40 years old and had been affected by LF for many years. The national program also trained healthcare workers and provincial and district staff in morbidity management and disability prevention, and designated health centers to provide care for lymphedema and acute attack. Two reference hospitals were designated to administer hydrocele surgery.

RESULTS

Effectiveness of MDA was proven with transmission assessment surveys. These found that less than 1% of school children had antigenemia in 2010, which fell to 0% in both 2013 and 2015. A separate survey in one province in 2015 using Brugia Rapid tests to test for LF antibody found one child positive among 1677 children. The list of chronic LF patients was most recently updated and confirmed in 2011-2012, with 32 lymphoedema patients and 17 hydrocele patients listed. All lymphedema patients had been trained on self-management and all hydrocele patients had been offered free surgery.

CONCLUSIONS

Due to the success of the MDA and the development of health center capacity for patient care, along with benefits gained from socioeconomic improvements and other interventions against vector-borne diseases and NTDs, Cambodia was validated by the World Health Organization as achieving LF elimination as a public health problem in 2016.

Costs of Transmission Assessment Surveys to Provide Evidence for the Elimination of Lymphatic Filariasis

Background

To reach the global goal of elimination of lymphatic filariasis as a public health problem by 2020, national programs will have to implement a series of transmission assessment surveys (TAS) to determine prevalence of the disease by evaluation unit. It is expected that 4,671 surveys will be required by 2020. Planning in advance for the costs associated with these surveys is essential to ensure that the required resources are available for this essential program activity.

Methodology and Findings

Retrospective cost data was collected from reports from 13 countries which implemented a total of 105 TAS surveys following a standardized World Health Organization (WHO) protocol between 2012 and 2014. The median cost per survey was $21,170 (including the costs for rapid diagnostic tests [RDTs]) and $9,540 excluding those costs. Median cost per cluster sampled (without RDT costs) was $101. Analysis of costs (excluding RDTs) by category showed that the main cost drivers were personnel and travel.

Conclusion

Transmission assessment surveys are critical to collect evidence to validate elimination of LF as a public health problem. National programs and donors can use the costing results to adequately plan and forecast the resources required to undertake the necessary activities to conduct high-quality transmission assessment surveys.

As national programs are nearing elimination of lymphatic filariasis as a public health problem, questions have been raised about the cost of collecting the data necessary for documenting validation of elimination. A series of standardized population-based surveys is necessary to determine prevalence of infection in endemic areas. The authors retrospectively collected data on the costs of these surveys from 13 countries to determine median cost per survey and per cluster sampled. Costs were found to be comparable with other neglected tropical disease surveys. The major cost drivers were personnel and travel for supporting collection of data in the field. National programs and donors can use these results to plan and advocate more effectively for sufficient resources to support validation of elimination.

Lymphatic filariasis in Papua New Guinea: distribution at district level and impact of mass drug administration, 1980 to 2011

BACKGROUND

Lymphatic filariasis (LF) caused by Wuchereria bancrofti is present at high prevalence in some parts of Papua New Guinea. However, there has been no rigorous data-based representative assessment of nationwide prevalence of LF. The LF programme has been daunted by the scope of the problem, and progress on mass drug administration (MDA) has been slow and lacking in resources.

METHODS

A systematic literature review identified LF surveys in Papua New Guinea between 1980 and 2011. Results were extracted by location, time period and test used (blood slide, immunochromatographic test (ICT) or Og4C3 ELISA) and combined by district. Three criteria schemes based on the Global Programme to Eliminate Lymphatic Filariasis guidelines, with modifications, were developed to classify and prioritize districts by prevalence level. Results of repeated surveys in the same sites were used to investigate the impact of MDA on LF prevalence over the time period.

RESULTS

There were 312 distinct survey sites identified in 80 of the 89 districts over the 31-year period. The overall LF prevalence in the sites tested was estimated at 18.5 to 27.5% by blood slide for microfilariae (Mf), 10.1% to 12.9% by ICT and 45.4% to 48.8% by Og4C3. Biases in site selection towards areas with LF, and change in type of assay used, affected the prevalence estimates, but overall decline in prevalence over the time period was observed. Depending on the criteria used, 34 to 36 districts (population 2.7 to 2.9 million) were classed as high endemic (≥5% prevalence), 15 to 25 districts (1.7 to 1.9 million) as low endemic (<5%) and 20 to 31 (1.3 to 2.2 million) as non-endemic. Nine districts (0.7 million) had no information. The strong impact of MDA, especially on microfilaria (Mf) prevalence, was noted in sites with repeat surveys.

CONCLUSIONS

This analytical review of past surveys of LF in Papua New Guinea enables better estimation of the national burden, identifies gaps in knowledge, quantifies and locates the population at risk, and can be used to predict the likely impact of MDA and/or vector control. Better targeting of districts by level of prevalence will strengthen the control programme, facilitate monitoring of the disease trend and increase the likelihood of reaching the target of LF elimination by 2020.

Costs of integrated mass drug administration for neglected tropical diseases in Haiti

We conducted a cost analysis of Haiti's Ministry of Public Health and Population neglected tropical disease program, Projet des Maladies Tropicales Negligées and collected data for 9 of 55 communes participating in the May 2008-April 2009 mass drug administration (MDA). The Projet des Maladies Tropicales Negligées Program partnered with IMA World Health and Hôpital Ste. Croix to implement MDA for treatment of lymphatic filariasis and soil-transmitted helminthiasis by using once a year treatment with albendazole and diethylcarbamazine in a population of approximately 8 million persons. Methods included analyzing partner financial records and conducting retrospective surveys of personnel. In the nine communes, 633,261 persons were treated at a cost of U.S. $0.64 per person, which included the cost of donated drugs, and at a cost of U.S. $0.42 per person treated, when excluding donated drug costs. The MDA for lymphatic filariasis in Haiti began in 2000, with the treatment of 105,750 persons at a cost per person of U.S. $2.23. The decrease in cost per person treated is the result of cumulative implementation experience and economies of scale.

The effect of cell density on the maturation and contractile ability of muscle derived cells in a 3D tissue-engineered skeletal muscle model and determination of the cellular and mechanical stimuli required for the synthesis of a postural phenotype

The successful engineering of a truly biomimetic model of skeletal muscle could have a significant impact on a number of biomedical disciplines. Although a variety of techniques are currently being developed, there is, as of yet, no widely available and easily reproducible culture system for the synthesis of 3D artificial muscle tissues. In attempting to generate such a model it is essential to optimise any protocol in order to generate a tissue that best represents the in vivo environment. Since the maturation of muscle derived cells in culture is critically dependent on density, a major factor to be addressed in the development of these models is the ideal concentration at which to seed cells in order to generate an optimal response. In studying the effect of cell density on the performance of cells in an established 3D collagen based model of skeletal muscle, we demonstrate that an optimum density does exist in terms of peak force generation and myogenic gene expression data. Greater densities however, lead to the formation of a more physiologically relevant tissue with a phenotype characteristic of slow, postural muscle.

Morbidity management in the Global Programme to Eliminate Lymphatic Filariasis: a review of the scientific literature

The Global Programme to Eliminate Lymphatic Filariasis (GPELF) has two major goals: to interrupt transmission of the parasite and to provide care for those who suffer the devastating clinical manifestations of the disease (morbidity control). This latter goal addresses three filariasis-related conditions: acute inflammatory episodes; lymphoedema; and hydrocele. Research during the last decade has confirmed the importance of bacteria as a cause of acute inflammatory episodes in filariasis-endemic areas, known as acute dermatolymphangioadenitis (ADLA). Current lymphoedema management strategies are based on the central role of ADLA as a trigger for lymphoedema progression. Simple intervention packages are in use that have resulted in dramatic reductions in ADLA rates, a lower prevalence of chronic inflammatory cells in the dermis and subdermis, and improvement in quality of life. During the past decade, the socioeconomic impact of ADLA and lymphoedema in filariasis-endemic areas has received increasing attention. Numerous operational research questions remain to be answered regarding how best to optimize, scale up, monitor, and evaluate lymphoedema management programmes. Of the clinical manifestations targeted by the GPELF, hydrocele has been the focus of the least attention. Basic information is lacking on the effectiveness and complications of hydrocele surgery and risk of post-operative hydrocele recurrence in filariasis-endemic areas. Data on the impact of mass administration of antifilarial drugs on filarial morbidity are inconsistent. Several studies report reductions in acute inflammatory episodes, lymphoedema, and/or hydrocele following mass drug administration, but other studies report no such association. Assessing the public health impact of mass treatment with antifilarial drugs is important for programme advocacy and morbidity control strategies. Thus, although our knowledge of filariasis-related morbidity and its treatment has expanded in recent years, much work remains to be done to address the needs of more than 40 million persons who suffer worldwide from these conditions.

Projected benefits from integrating NTD programs in sub-Saharan Africa

The integration of preventive chemotherapy programs (PCPs) targeting multiple neglected tropical diseases (NTDs) with similar strategic approaches offers opportunities for enhanced cost-effectiveness. To estimate the potential cost savings and health outcomes of integrated programs, the data available for five NTDs (lymphatic filariasis, onchocerciasis, intestinal helminthiasis, schistosomiasis and trachoma) can be used to define eligible target populations, the probable overlap of at-risk populations, and the cost per person treated in stand-alone and integrated programs. If all targets for 2006 in sub-Saharan Africa are met, then savings of 26-47% can be projected from such integration (a cost of US dollar 58-81 million versus dollar 110 million for stand-alone PCPs). These first estimates can be refined as empirical data become available from integrated PCPs in the future.

Pneumonia surveillance in Thailand: current practice and future needs

We reviewed reported pneumonia cases and deaths in Thailand since 1975 to evaluate the pneumonia surveillance system. In Sa Kaeo Province, we analyzed 3 years in detail (1999--2001) from electronic surveillance data, and compared deaths reported through surveillance to death certificate data in 1999 and 2000. In addition, we interviewed surveillance personnel who collected the data from all 7 hospitals and from a 10% random sample of health centers. Since the mid-1980s, reported illnesses and deaths from pneumonia have been increasing. In Sa Kaeo, an average of 925 pneumonia cases were reported each year, for an estimated average annual incidence of 211 per 100,000. The age-specific incidence peaked at 1,418 per 100,000 in children less than 5 years. In 1999 and 2000, there were 7 and 6 pneumonia deaths, respectively, reported through the surveillance system, compared with 28 and 53, respectively, reported by death certificate. Sixty-two (82%) of the 72 surveillance personnel reported receiving some training, but most of this was informal. Although written criteria to diagnose pneumonia were established in 1996, those who report cases did not know these criteria. A combination of physician, nurse, and public health workers diagnoses were used. According to the written criteria, cases of suspect or rule out pneumonia should be reported, but when asked about specific examples only 79% of persons interviewed said they would report "tuberculosis with pneumonia" and 44% would report "bronchitis, rule out pneumonia." Seventy-four percent of persons interviewed completed the surveillance report within one day of patient admission.

Hurricane effects on a shallow lake ecosystem and its response to a controlled manipulation of water level

In order to reverse the damage to aquatic plant communities caused by multiple years of high water levels in Lake Okeechobee, Florida (U.S.), the Governing Board of the South Florida Water Management District (SFWMD) authorized a "managed recession" to substantially lower the surface elevation of the lake in spring 2000. The operation was intended to achieve lower water levels for at least 8 weeks during the summer growing season, and was predicted to result in a large-scale recovery of submerged vascular plants. We treated this operation as a whole ecosystem experiment, and assessed ecological responses using data from an existing network of water quality and submerged plant monitoring sites. As a result of large-scale discharges of water from the lake, coupled with losses to evaporation and to water supply deliveries to agriculture and other regional users, the lake surface elevation receded by approximately 1 m between April and June. Water depths in shoreline areas that historically supported submerged plant communities declined from near 1.5 m to below 0.5 m. Low water levels persisted for the entire summer. Despite shallow depths, the initial response (in June 2000) of submerged plants was very limited and water remained highly turbid (due at first to abiotic seston and later to phytoplankton blooms). Turbidity decreased in July and the biomass of plants increased. However, submerged plant biomass did not exceed levels observed during summer 1999 (when water depths were greater) until August. Furthermore, a vascular plant-dominated assemblage (Vallisneria, Potamogeton, and Hydrilla) that occurred in 1999 was replaced with a community of nearly 98% Chara spp. (a macro-alga) in 2000. Hence, the lake"s submerged plant community appeared to revert to an earlier successional stage despite what appeared to be better conditions for growth. To explain this unexpected response, we evaluated the impacts that Hurricane Irene may have had on the lake in the previous autumn. In mid-October 1999, this category 1 hurricane passed just to the south of the lake, with wind velocities over the lake surface reaching 90 km h(-1) at their peak. Output from a three-dimensional hydrodynamic/sediment transport model indicates that during the storm, current velocities in surface waters of the lake increased from near 5 cm s(-1) to as high as 100 cm s(-1). These strong velocities were associated with large-scale uplifting and horizontal transport of fine- grained sediments from the lake bottom. Water quality data collected after the storm confirmed that the hurricane resulted in lake-wide nutrient and suspended solids concentrations far in excess of those previously documented for a 10-year data set. These conditions persisted through the winter months and may have negatively impacted plants that remained in the lake at the end of the 1999 growing season. The results demonstrate that in shallow lakes, unpredictable external forces, such as hurricanes, can play a major role in ecosystem dynamics. In regions where these events are common (e.g., the tropics and subtropics), consideration should be given to how they might affect long-term lake management programs.

Role delineation study of pediatric nurse practitioners: a national study of practice responsibilities and trends in role functions

INTRODUCTION

This study explored the current practice responsibilities of pediatric nurse practitioners (PNPs) from a national perspective Educational preparation, geographic region of practice, years of employment as a PNP, type of employment setting, and full-time versus part-time employment were examined.

METHOD

From a randomly selected sample (N = 997), a total of 387 respondents returned their questionnaire, resulting in 325 usable questionnaires.

RESULTS

Years of experience as a PNP, setting of employment, geographic region, prescriptive authority, and subspecialty practice were significantly related to various health supervision and illness-focused activities performed by PNPs, as well as level of management responsibility. Anticipatory guidance supervision continues to be an integral part of the PNP role. PNPs report that they assume major responsibility for the health assessment and management of children with common pediatric illnesses as well as chronic illnesses and conditions.

DISCUSSION

The ability to prescribe prescription medications produced the greatest overall effect on PNP role activities and level of management responsibility. Years of experience exerted an interesting effect on role functions related to the overall health supervision and illness-focused activities in which PNPs engaged. Implications for the educational preparation of PNPs, the updating of national certification examinations, and planning for adequate numbers in the workforce to replace the cohort of retiring PNPs in the next 20 years are discussed.

Health issues for aboriginal youth: social and cultural factors associated with resilience

Research into Aboriginal health has tended to focus on the morbidity of babies and young children, or on the chronic illnesses of adults. Adolescent Aborigines are rarely the target of health research. While health services for Aboriginal people, even in remote areas, have improved enormously over the last few years with the provision of Aboriginal-controlled organizations, health services alone do not prevent the major causes of morbidity. In any case, young people, particularly adolescent boys, are poor users of these facilities. The major causes of adolescent Aboriginal morbidity and mortality are preventable: they have to do with ways of living, with the social, cultural and physical environments which surround adolescents. The paper draws on anthropological fieldwork which pays close attention to these issues. The paper examines the concept of 'adolescence' among Aboriginal groups, and explores the reasons for the resilience of some populations to a particular health problem, that of petrol sniffing among the young.

Nonradioactive DNA detection on Southern blots by enzymatically triggered chemiluminescence

A chemiluminescent reaction based on the deprotection of a phosphorylated phenyl dioxetane by alkaline phosphatase has recently been described (Schaap, A.P., 1988, J. Biolumin. Chemilumin. 2, 253). Light output is enhanced by intermolecular energy transfer to a micelle-solubilized fluorophore. This system is applied here to the detection of DNA probes on Southern blots. Enzyme solution assays which give an indication of sensitivity show that using this substrate 100 fg (0.7 amol) alkaline phosphatase can be detected on a luminescence plate reader (200 ms reading time). In a model Southern blotting system 180 fg HindIII digested lambda DNA was detected on film with homologous biotinylated DNA and a streptavidin-alkaline phosphatase complex. The single copy genes mos and raf-1, representing targets of 4.2 and 2.4 pg target DNA respectively, have also been detected in Southern-blotted human genomic DNA. A delay in reaching a plateau level of light output which is dependent on pH is observed but signal continues for at least 7 days. Typically, 12-h exposures to X-ray film were performed but once a steady-state light output had been achieved this time could be reduced to 2 h by preflashing film. This detection system represents a sensitive nonradioactive method, which is applicable not only to Southern blots but also to Northern and Western blots and any assay in which alkaline phosphatase is the label.

Nonradioactive nucleic acid detection by enhanced chemiluminescence using probes directly labeled with horseradish peroxidase

The use of nucleic acid probes directly labeled with horseradish peroxidase for detection of single copy sequences on Southern blots of human genomic DNA by enhanced chemiluminescence is described. Of the target sequences, 6 x 10(5) molecules (1 amol) have been detected on blue sensitive film using exposures of up to 60 min and probes of 0.3-5.1 kb. The chemiluminescent signal quantified using a cooled charge coupled device (CCD) camera is proportional to probe length for DNA probes in the range 50-3571 bases. The enzyme has no significant effect on the stability of a DNA/DNA hybrid formed with a 3571-base probe and target as determined by increasing the stringency of posthybridization washes by decreasing the concentration of a monovalent cation (NaCl) and by a Tm analysis. The kinetics of DNA hybridization have been analyzed by a cooled CCD camera to provide quantitative data. Ten nanograms per milliliter of probe may be used for an overnight hybridization. Southern blots can be reprobed using a DNA probe for the same or a different sequence without the necessity of stripping off the previously bound probe.