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Eyre MT, Bulstra CA, Johnson O, de Vlas SJ, Diggle PJ, Fronterrè C, Coffeng LE. A Comparison of Markov and Mechanistic Models for Soil-Transmitted Helminth Prevalence Projections in the Context of Survey Design. Clin Infect Dis 2024; 78:S146-S152. [PMID: 38662703 PMCID: PMC11045013 DOI: 10.1093/cid/ciae022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
Globally, there are over 1 billion people infected with soil-transmitted helminths (STHs), mostly living in marginalized settings with inadequate sanitation in sub-Saharan Africa and Southeast Asia. The World Health Organization recommends an integrated approach to STH morbidity control through improved access to sanitation and hygiene education and the delivery of preventive chemotherapy (PC) to school-age children delivered through schools. Progress of STH control programs is currently estimated using a baseline (pre-PC) school-based prevalence survey and then monitored using periodical school-based prevalence surveys, known as Impact Assessment Surveys (IAS). We investigated whether integrating geostatistical methods with a Markov model or a mechanistic transmission model for projecting prevalence forward in time from baseline can improve IAS design strategies. To do this, we applied these 2 methods to prevalence data collected in Kenya, before evaluating and comparing their performance in accurately informing optimal survey design for a range of IAS sampling designs. We found that, although both approaches performed well, the mechanistic method more accurately projected prevalence over time and provided more accurate information for guiding survey design. Both methods performed less well in areas with persistent STH hotspots where prevalence did not decrease despite multiple rounds of PC. Our findings show that these methods can be useful tools for more efficient and accurate targeting of PC. The general framework built in this paper can also be used for projecting prevalence and informing survey design for other neglected tropical diseases.
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Affiliation(s)
- Max T Eyre
- Centre for Health Informatics, Computing and Statistics, Lancaster Medical School, Lancaster University, Lancaster, United Kingdom
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Caroline A Bulstra
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Heidelberg Institute of Global Health (HIGH), Heidelberg University Medical Center, Heidelberg, Germany
| | - Olatunji Johnson
- Department of Mathematics, University of Manchester, Manchester, United Kingdom
| | - Sake J de Vlas
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Peter J Diggle
- Centre for Health Informatics, Computing and Statistics, Lancaster Medical School, Lancaster University, Lancaster, United Kingdom
| | - Claudio Fronterrè
- Centre for Health Informatics, Computing and Statistics, Lancaster Medical School, Lancaster University, Lancaster, United Kingdom
| | - Luc E Coffeng
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Teufel F, Bulstra CA, Davies JI, Ali MK. Enhancing global access to diabetes medicines: policy lessons from the HIV response. Lancet Diabetes Endocrinol 2024; 12:88-90. [PMID: 38128554 DOI: 10.1016/s2213-8587(23)00359-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 11/21/2023] [Indexed: 12/23/2023]
Affiliation(s)
- Felix Teufel
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA; Emory Global Diabetes Research Center of the Woodruff Health Sciences Center and Emory University, Atlanta, GA, USA.
| | - Caroline A Bulstra
- Health Systems Innovation Lab, Department of Global Health and Population, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA; Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany
| | - Justine I Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK; MRC/Wits Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Mohammed K Ali
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA; Emory Global Diabetes Research Center of the Woodruff Health Sciences Center and Emory University, Atlanta, GA, USA; Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, GA, USA
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Starck T, Dambach P, Rouamba T, Tinto H, Osier F, Oldenburg CE, Adam M, Bärnighausen T, Jaenisch T, Bulstra CA. The effect of malaria on childhood anemia in a quasi-experimental study of 7,384 twins from 23 Sub-Saharan African countries. Front Public Health 2022; 10:1009865. [PMID: 36561861 PMCID: PMC9766366 DOI: 10.3389/fpubh.2022.1009865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/18/2022] [Indexed: 12/12/2022] Open
Abstract
Background Young children in Sub-Saharan Africa (SSA), particularly those from resource-limited settings, are heavily burdened by anemia and malaria. While malaria infected children frequently become anemic (hemoglobin < 110 g/L), anemia is a strongly multifactorial disease with many other risk factors than malaria. Due to the complex and often overlapping contributors to anemia, it remains challenging to isolate the true impact of malaria on population level hemoglobin concentrations. Methods We quantified the malaria-induced effect on hemoglobin levels in children under 5 years of age, leveraging data from 7,384 twins and other multiples, aged 6 to 59 months, from 57 nationally representative Demographic and Health Surveys (DHSs) from 23 SSA countries from 2006 to 2019. The quasi-experimental twin fixed-effect design let us minimize the impact of potential confounders that do not vary between twins. Results Our analyses of twins revealed a malaria-induced hemoglobin decrease in infected twins of 9 g/L (95% CI -10; -7, p<0.001). The relative risk of severe anemia was higher (RR = 3.01, 95% CI 1.79; 5.1, p<0.001) among malaria positive children, compared to malaria negative children. Conversely, malaria positive children are only half as likely to be non-anemic (RR = 0.51, 95% CI 0.43; 0.61, p<0.001). Conclusion Even after rigorous control for confounding through a twin fixed-effects study design, malaria substantially decreased hemoglobin levels among SSA twins, rendering them much more susceptible to severe anemia. This effect reflects the population-level effect of malaria on anemia.
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Affiliation(s)
- Tim Starck
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg, Germany,*Correspondence: Tim Starck
| | - Peter Dambach
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg, Germany
| | - Toussaint Rouamba
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Halidou Tinto
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Faith Osier
- Centre for Infectious Diseases, Parasitology, Heidelberg University Hospital, Heidelberg, Germany,KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - Catherine E. Oldenburg
- Francis I Proctor Foundation, University of California, San Francisco, San Francisco, CA, United States,Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, United States,Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States
| | - Maya Adam
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg, Germany,Deptartment of Pediatrics, Stanford School of Medicine, Stanford, CA, United States
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg, Germany,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States,Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa
| | - Thomas Jaenisch
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg, Germany,Center for Global Health, Colorado School of Public Health, Aurora, CO, United States,Department of Epidemiology, Colorado School of Public Health, Aurora, CO, United States
| | - Caroline A. Bulstra
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg, Germany,Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
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Kloek M, Bulstra CA, van Noord L, Al‐Hassany L, Cowan FM, Hontelez JAC. HIV prevalence among men who have sex with men, transgender women and cisgender male sex workers in sub-Saharan Africa: a systematic review and meta-analysis. J Int AIDS Soc 2022; 25:e26022. [PMID: 36419343 PMCID: PMC9684687 DOI: 10.1002/jia2.26022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 09/22/2022] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Developing effective targets, policies and services for key populations requires estimations of population sizes and HIV prevalence across countries and regions. We estimated the relative and absolute HIV prevalence among men who have sex with men (MSM), transgender women and men, and male and transgender sex workers (MSW and TGSW) in sub-Saharan African countries using peer-reviewed literature. METHODS We performed a systematic review of peer-reviewed studies assessing HIV prevalence in MSM, transgender women and men, MSW and TGSW in sub-Saharan Africa between 2010 and 2021, following PRISMA guidelines. We searched Embase, Medline Epub, Africa Index Medicus, Africa Journal Online, Web of Science and Google Scholar. We calculated HIV prevalence ratios (PRs) between the study prevalence, and the geospatial-, sex, time and age-matched general population prevalence. We extrapolated results for MSM and transgender women to estimate HIV prevalence and the number living with HIV for each country in sub-Saharan Africa using pooled review results, and regression approximations for countries with no peer-reviewed data. RESULTS AND DISCUSSION We found 44 articles assessing HIV prevalence in MSM, 10 in transgender women, five in MSW and zero in transgender men and TGSW. Prevalence among MSM and transgender women was significantly higher compared to the general population: PRs of 11.3 [CI: 9.9-12.9] for MSM and 8.1 [CI: 6.9-9.6] for transgender women in Western and Central Africa, and, respectively, 1.9 [CI: 1.7-2.0] and 2.1 [CI: 1.9-2.4] in Eastern and Southern Africa. Prevalence among MSW was significantly higher in both Nigeria (PR: 12.4 [CI: 7.3-21.0]) and Kenya (PR: 8.6 [CI: 4.6-15.6]). Extrapolating our findings for MSM and transgender women resulted in an estimated HIV prevalence of 15% or higher for about 60% of all sub-Saharan African countries for MSM, and for all but two countries for transgender women. CONCLUSIONS HIV prevalence among MSM and transgender women throughout sub-Saharan Africa is alarmingly high. This high prevalence, coupled with the specific risks and vulnerabilities faced by these populations, highlights the urgent need for risk-group-tailored prevention and treatment interventions across the sub-continent. There is a clear gap in knowledge on HIV prevalence among transgender men, MSW and TGSW in sub-Saharan Africa.
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Affiliation(s)
- Mariëlle Kloek
- Department of Public HealthErasmus MC, University Medical Center RotterdamRotterdamThe Netherlands
| | - Caroline A. Bulstra
- Department of Public HealthErasmus MC, University Medical Center RotterdamRotterdamThe Netherlands,Heidelberg Institute of Global HealthMedical Faculty and University HospitalHeidelberg UniversityHeidelbergGermany
| | - Laura van Noord
- Department of Public HealthErasmus MC, University Medical Center RotterdamRotterdamThe Netherlands
| | - Lina Al‐Hassany
- Department of Public HealthErasmus MC, University Medical Center RotterdamRotterdamThe Netherlands
| | - Frances M. Cowan
- Centre for Sexual Health and HIV AIDS Research (CeSHHAR) ZimbabweHarareZimbabwe,Department of International Public HealthLiverpool School of Tropical MedicineLiverpoolUK
| | - Jan A. C. Hontelez
- Department of Public HealthErasmus MC, University Medical Center RotterdamRotterdamThe Netherlands,Heidelberg Institute of Global HealthMedical Faculty and University HospitalHeidelberg UniversityHeidelbergGermany
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5
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Kloek M, Bulstra CA, Chabata ST, Fearon E, Taramusi I, de Vlas SJ, Cowan FM, Hontelez JAC. No increased HIV risk in general population near sex work sites: a nationally representative cross-sectional study in Zimbabwe. Trop Med Int Health 2022; 27:696-704. [PMID: 35687493 PMCID: PMC9545096 DOI: 10.1111/tmi.13791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Objectives Sex work sites have been hypothesised to be at the root of the observed heterogeneity in HIV prevalence in sub‐Saharan Africa. We determined if proximity to sex work sites is associated with HIV prevalence among the general population in Zimbabwe, a country with one of the highest HIV prevalence in the world. Methods In this cross‐sectional study we use a unique combination of nationally representative geolocated individual‐level data from 16,121 adults (age 15–49 years) from 400 sample locations and the locations of 55 sex work sites throughout Zimbabwe; covering an estimated 95% of all female sex workers (FSWs). We calculated the shortest distance by road from each survey sample location to the nearest sex work site, for all sites and by type of sex work site, and conducted univariate and multivariate multilevel logistic regressions to determine the association between distance to sex work sites and HIV seropositivity, controlling for age, sex, male circumcision status, number of lifetime sex partners, being a FSW client or being a stable partner of an FSW client. Results We found no significant association between HIV seroprevalence and proximity to the nearest sex work site among the general population in Zimbabwe, regardless of which type of site is closest (city site adjusted odds ratio [aOR] 1.010 [95% confidence interval {CI} 0.992–1.028]; economic growth point site aOR 0.982 [95% CI 0.962–1.002]; international site aOR 0.995 [95% CI 0.979–1.012]; seasonal site aOR 0.987 [95% CI 0.968–1.006] and transport site aOR 1.007 [95% CI 0.987–1.028]). Individual‐level indicators of sex work were significantly associated with HIV seropositivity: being an FSW client (aOR 1.445 [95% CI 1.188–1.745]); nine or more partners versus having one to three lifetime partners (aOR 2.072 [95% CI 1.654–2.596]). Conclusions Sex work sites do not seem to directly affect HIV prevalence among the general population in surrounding areas. Prevention and control interventions for HIV at these locations should primarily focus on sex workers and their clients, with special emphasis on including and retaining mobile sex workers and clients into services.
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Affiliation(s)
- Mariёlle Kloek
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Caroline A Bulstra
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg, Germany
| | - Sungai T Chabata
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Centre for Sexual Health and HIV/AIDS Research, Harare, Zimbabwe
| | - Elizabeth Fearon
- Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Sake J de Vlas
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Frances M Cowan
- Centre for Sexual Health and HIV/AIDS Research, Harare, Zimbabwe.,Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jan A C Hontelez
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg, Germany
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Abstract
Jan Hontelez and co-authors discuss the use of different types of evidence to inform HIV program integration.
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Affiliation(s)
- Jan A. C. Hontelez
- Heidelberg Institute of Global Health (HIGH), Heidelberg University Medical Center, Heidelberg, Germany
- Department of Public Health, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Caroline A. Bulstra
- Heidelberg Institute of Global Health (HIGH), Heidelberg University Medical Center, Heidelberg, Germany
- Department of Public Health, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Anna Yakusik
- The Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland
| | - Erik Lamontagne
- The Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland
- Aix-Marseille School of Economics, CNRS, EHESS, Centrale Marseille, Aix-Marseille University, Les Milles, France
| | - Till W. Bärnighausen
- Heidelberg Institute of Global Health (HIGH), Heidelberg University Medical Center, Heidelberg, Germany
- Africa Health Research Institute (AHRI), Mtubatuba, South Africa
- Harvard Center for Population and Development Studies, Harvard University, Cambridge, Massachusetts, United States of America
| | - Rifat Atun
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
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7
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Bulstra CA, Hontelez JAC, Otto M, Stepanova A, Lamontagne E, Yakusik A, El-Sadr WM, Apollo T, Rabkin M, Atun R, Bärnighausen T. Integrating HIV services and other health services: A systematic review and meta-analysis. PLoS Med 2021; 18:e1003836. [PMID: 34752477 PMCID: PMC8577772 DOI: 10.1371/journal.pmed.1003836] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 10/05/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Integration of HIV services with other health services has been proposed as an important strategy to boost the sustainability of the global HIV response. We conducted a systematic and comprehensive synthesis of the existing scientific evidence on the impact of service integration on the HIV care cascade, health outcomes, and cost-effectiveness. METHODS AND FINDINGS We reviewed the global quantitative empirical evidence on integration published between 1 January 2010 and 10 September 2021. We included experimental and observational studies that featured both an integration intervention and a comparator in our review. Of the 7,118 unique peer-reviewed English-language studies that our search algorithm identified, 114 met all of our selection criteria for data extraction. Most of the studies (90) were conducted in sub-Saharan Africa, primarily in East Africa (55) and Southern Africa (24). The most common forms of integration were (i) HIV testing and counselling added to non-HIV services and (ii) non-HIV services added to antiretroviral therapy (ART). The most commonly integrated non-HIV services were maternal and child healthcare, tuberculosis testing and treatment, primary healthcare, family planning, and sexual and reproductive health services. Values for HIV care cascade outcomes tended to be better in integrated services: uptake of HIV testing and counselling (pooled risk ratio [RR] across 37 studies: 1.67 [95% CI 1.41-1.99], p < 0.001), ART initiation coverage (pooled RR across 19 studies: 1.42 [95% CI 1.16-1.75], p = 0.002), time until ART initiation (pooled RR across 5 studies: 0.45 [95% CI 0.20-1.00], p = 0.050), retention in HIV care (pooled RR across 19 studies: 1.68 [95% CI 1.05-2.69], p = 0.031), and viral suppression (pooled RR across 9 studies: 1.19 [95% CI 1.03-1.37], p = 0.025). Also, treatment success for non-HIV-related diseases and conditions and the uptake of non-HIV services were commonly higher in integrated services. We did not find any significant differences for the following outcomes in our meta-analyses: HIV testing yield, ART adherence, HIV-free survival among infants, and HIV and non-HIV mortality. We could not conduct meta-analyses for several outcomes (HIV infections averted, costs, and cost-effectiveness), because our systematic review did not identify sufficient poolable studies. Study limitations included possible publication bias of studies with significant or favourable findings and comparatively weak evidence from some world regions and on integration of services for key populations in the HIV response. CONCLUSIONS Integration of HIV services and other health services tends to improve health and health systems outcomes. Despite some scientific limitations, the global evidence shows that service integration can be a valuable strategy to boost the sustainability of the HIV response and contribute to the goal of 'ending AIDS by 2030', while simultaneously supporting progress towards universal health coverage.
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Affiliation(s)
- Caroline A. Bulstra
- Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
- * E-mail:
| | - Jan A. C. Hontelez
- Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Moritz Otto
- Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany
| | - Anna Stepanova
- Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany
| | - Erik Lamontagne
- Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
- Aix-Marseille School of Economics, CNRS, EHESS, Centrale Marseille, Aix-Marseille University, Les Milles, France
| | - Anna Yakusik
- Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
| | - Wafaa M. El-Sadr
- ICAP, Columbia University, New York, New York, United States of America
| | | | - Miriam Rabkin
- ICAP, Columbia University, New York, New York, United States of America
| | | | - Rifat Atun
- Harvard Center for Population and Development Studies, Harvard University, Cambridge, Massachusetts, United States of America
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany
- Harvard Center for Population and Development Studies, Harvard University, Cambridge, Massachusetts, United States of America
- Africa Health Research Institute, KwaZulu-Natal, South Africa
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Starck T, Bulstra CA, Tinto H, Rouamba T, Sie A, Jaenisch T, Bärnighausen T. The effect of malaria on haemoglobin concentrations: a nationally representative household fixed-effects study of 17,599 children under 5 years of age in Burkina Faso. Malar J 2021; 20:416. [PMID: 34688294 PMCID: PMC8542337 DOI: 10.1186/s12936-021-03948-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 10/08/2021] [Indexed: 11/22/2022] Open
Abstract
Background Although the association between malaria and anaemia is widely studied in patient cohorts, the population-representative causal effects of malaria on anaemia remain unknown. This study estimated the malaria-induced decrease in haemoglobin levels among young children in malaria-endemic Burkina Faso. Methods The study was based on pooled individual-level nationally representative health survey data (2010–2011, 2014, 2017–2018) from 17 599 children under 5 years of age. This data was used to estimate the effects of malaria on haemoglobin concentration, controlling for household fixed-effects, age, and sex in a series of regression analyses. The fixed-effects controlled for observed and unobserved confounding on the household level and allowed to determine the impact of malaria infection status on haemoglobin levels and anaemia prevalence. Furthermore, the diagnostic results from microscopy and rapid diagnostic tests were leveraged to provide a quasi-longitudinal perspective of acute and prolonged effects after malaria infection. Results The prevalence of both malaria (survey prevalence ranging from 17.4% to 65.2%) and anaemia (survey prevalence ranging from 74% to 88.2%) was very high in the included surveys. Malaria was estimated to significantly reduce haemoglobin levels, with an overall effect of − 7.5 g/dL (95% CI − 8.5, − 6.5). Acute malaria resulted in a − 7.7 g/dL (95% CI − 8.8, − 6.6) decrease in haemoglobin levels. Recent malaria without current parasitaemia decreased haemoglobin concentration by − 7.1 g/dL (95% CI − 8.3, − 5.9). The in-sample predicted prevalence of severe anaemia was 9.4% among malaria positives, but only 2.2% among children without malaria. Conclusion Malaria infection has a strong detrimental effect on haemoglobin levels among young children in Burkina Faso. This effect seems to carry over even after acute infection, indicating prolonged haemoglobin reductions even after successful parasite-elimination. The quasi-experimental fixed-effect approach adds a population level perspective to existing clinical evidence. Supplementary Information The online version contains supplementary material available at 10.1186/s12936-021-03948-z.
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Affiliation(s)
- Tim Starck
- Heidelberg Institute of Global Health, Heidelberg University Medical Cente, Heidelberg, Germany.
| | - Caroline A Bulstra
- Heidelberg Institute of Global Health, Heidelberg University Medical Cente, Heidelberg, Germany.,Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Halidou Tinto
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Toussaint Rouamba
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Ali Sie
- National Institute of Public Health (INSP), Nouna Health Research Centre (CRSN), Nouna, Burkina Faso
| | - Thomas Jaenisch
- Heidelberg Institute of Global Health, Heidelberg University Medical Cente, Heidelberg, Germany.,Center for Global Health, Colorado School of Public Health, Aurora, USA.,Department of Epidemiology, Colorado School of Public Health, Aurora, USA
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University Medical Cente, Heidelberg, Germany.,Harvard Center for Population and Development Studies, Boston, USA.,Africa Health Research Institute (AHRI), Durban, KwaZulu-Natal, South Africa
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9
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Le Rutte EA, van der Wilt LS, Bulstra CA, Nieboer D, Kontoroupis P, de Vlas SJ, Richardus JH. Incidence and geographical distribution of canine leishmaniosis in 2016-2017 in Spain and France. Vet Parasitol Reg Stud Reports 2021; 25:100613. [PMID: 34474806 DOI: 10.1016/j.vprsr.2021.100613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 07/27/2021] [Accepted: 08/02/2021] [Indexed: 11/16/2022]
Abstract
Leishmania infantum is transmitted by sand flies and causes visceral leishmaniasis (VL) in humans, as well as canine leishmaniosis (CanL) in dogs, the main reservoir of infection in Europe. The infection spread northwards in the last two decades, but case data are scarce, hindering monitoring and evaluation of incidence as is required by European WHO guidelines. We aim to identify the current geographical distribution of CanL incidence in Spain, which has been endemic for CanL, and France, where CanL is emerging. An online survey was conducted among veterinarians in Spain and France questioning CanL incidence in the years 2016-2017. These data were interpolated to estimate incidence in both countries using the geographical analysis ordinary kriging. Two hundred and seventy-three (273) veterinarians from 81 out of 148 French and Spanish districts completed the survey. The mean incidence in veterinary practices was 21 CanL cases per 1000 dogs during the past year, which was higher in Spain (31/1000 dogs/year) than in France (6/1000 dogs/year). Incidence rates were highest in south-eastern Spain, but sporadic cases were found up to the most northern regions of France. Our study confirms the northward spread of CanL in Spain and France, as the incidence rates were higher than reported in previous studies and cases were found in areas formerly considered non-endemic for L. infantum. Monitoring the reservoir of infection in dogs is essential for implementing timely and geographically-targeted interventions to prevent further spread of CanL and VL in Europe.
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Affiliation(s)
- Epke A Le Rutte
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000, CA, Rotterdam, the Netherlands.
| | - Lotte S van der Wilt
- Department of Epidemiology, University Medical Center, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands
| | - Caroline A Bulstra
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000, CA, Rotterdam, the Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000, CA, Rotterdam, the Netherlands
| | - Periklis Kontoroupis
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000, CA, Rotterdam, the Netherlands
| | - Sake J de Vlas
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000, CA, Rotterdam, the Netherlands
| | - Jan Hendrik Richardus
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000, CA, Rotterdam, the Netherlands
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Bulstra CA, Blok DJ, Alam K, Butlin CR, Roy JC, Bowers B, Nicholls P, de Vlas SJ, Richardus JH. Geospatial epidemiology of leprosy in northwest Bangladesh: a 20-year retrospective observational study. Infect Dis Poverty 2021; 10:36. [PMID: 33752751 PMCID: PMC7986508 DOI: 10.1186/s40249-021-00817-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 03/05/2021] [Indexed: 11/21/2022] Open
Abstract
Background Leprosy is known to be unevenly distributed between and within countries. High risk areas or ‘hotspots’ are potential targets for preventive interventions, but the underlying epidemiologic mechanisms that enable hotspots to emerge, are not yet fully understood. In this study, we identified and characterized leprosy hotspots in Bangladesh, a country with one of the highest leprosy endemicity levels globally. Methods We used data from four high-endemic districts in northwest Bangladesh including 20 623 registered cases between January 2000 and April 2019 (among ~ 7 million population). Incidences per union (smallest administrative unit) were calculated using geospatial population density estimates. A geospatial Poisson model was used to detect incidence hotspots over three (overlapping) 10-year timeframes: 2000–2009, 2005–2014 and 2010–2019. Ordinal regression models were used to assess whether patient characteristics were significantly different for cases outside hotspots, as compared to cases within weak (i.e., relative risk (RR) of one to two), medium (i.e., RR of two to three), and strong (i.e., RR higher than three) hotspots. Results New case detection rates dropped from 44/100 000 in 2000 to 10/100 000 in 2019. Statistically significant hotspots were identified during all timeframes and were often located at areas with high population densities. The RR for leprosy was up to 12 times higher for inhabitants of hotspots than for people living outside hotspots. Within strong hotspots (1930 cases among less than 1% of the population), significantly more child cases (i.e., below 15 years of age) were detected, indicating recent transmission. Cases in hotspots were not significantly more likely to be detected actively. Conclusions Leprosy showed a heterogeneous distribution with clear hotspots in northwest Bangladesh throughout a 20-year period of decreasing incidence. Findings confirm that leprosy hotspots represent areas of higher transmission activity and are not solely the result of active case finding strategies.![]() Supplementary Information The online version contains supplementary material available at 10.1186/s40249-021-00817-4.
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Affiliation(s)
- Caroline A Bulstra
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands. .,Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg, Germany.
| | - David J Blok
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Khorshed Alam
- Rural Health Programme, The Leprosy Mission International Bangladesh, Nilphamari, Bangladesh
| | - C Ruth Butlin
- The Leprosy Mission England and Wales, Goldhay Way, Orton Goldhay, Peterborough, England
| | - Johan Chandra Roy
- Rural Health Programme, The Leprosy Mission International Bangladesh, Nilphamari, Bangladesh
| | - Bob Bowers
- Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | | | - Sake J de Vlas
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jan Hendrik Richardus
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Bulstra CA, Hontelez JAC, Giardina F, Steen R, Nagelkerke NJD, Bärnighausen T, de Vlas SJ. Mapping and characterising areas with high levels of HIV transmission in sub-Saharan Africa: A geospatial analysis of national survey data. PLoS Med 2020; 17:e1003042. [PMID: 32142509 PMCID: PMC7059914 DOI: 10.1371/journal.pmed.1003042] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 02/05/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND In the generalised epidemics of sub-Saharan Africa (SSA), human immunodeficiency virus (HIV) prevalence shows patterns of clustered micro-epidemics. We mapped and characterised these high-prevalence areas for young adults (15-29 years of age), as a proxy for areas with high levels of transmission, for 7 countries in Eastern and Southern Africa: Kenya, Malawi, Mozambique, Tanzania, Uganda, Zambia, and Zimbabwe. METHODS AND FINDINGS We used geolocated survey data from the most recent United States Agency for International Development (USAID) demographic and health surveys (DHSs) and AIDS indicator surveys (AISs) (collected between 2008-2009 and 2015-2016), which included about 113,000 adults-of which there were about 53,000 young adults (27,000 women, 28,000 men)-from over 3,500 sample locations. First, ordinary kriging was applied to predict HIV prevalence at unmeasured locations. Second, we explored to what extent behavioural, socioeconomic, and environmental factors explain HIV prevalence at the individual- and sample-location level, by developing a series of multilevel multivariable logistic regression models and geospatially visualising unexplained model heterogeneity. National-level HIV prevalence for young adults ranged from 2.2% in Tanzania to 7.7% in Mozambique. However, at the subnational level, we found areas with prevalence among young adults as high as 11% or 15% alternating with areas with prevalence between 0% and 2%, suggesting the existence of areas with high levels of transmission Overall, 15.6% of heterogeneity could be explained by an interplay of known behavioural, socioeconomic, and environmental factors. Maps of the interpolated random effect estimates show that environmental variables, representing indicators of economic activity, were most powerful in explaining high-prevalence areas. Main study limitations were the inability to infer causality due to the cross-sectional nature of the surveys and the likely under-sampling of key populations in the surveys. CONCLUSIONS We found that, among young adults, micro-epidemics of relatively high HIV prevalence alternate with areas of very low prevalence, clearly illustrating the existence of areas with high levels of transmission. These areas are partially characterised by high economic activity, relatively high socioeconomic status, and risky sexual behaviour. Localised HIV prevention interventions specifically tailored to the populations at risk will be essential to curb transmission. More fine-scale geospatial mapping of key populations,-such as sex workers and migrant populations-could help us further understand the drivers of these areas with high levels of transmission and help us determine how they fuel the generalised epidemics in SSA.
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Affiliation(s)
- Caroline A. Bulstra
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany
| | - Jan A. C. Hontelez
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany
| | - Federica Giardina
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Richard Steen
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nico J. D. Nagelkerke
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa
| | - Sake J. de Vlas
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Abstract
The rapid scale-up of antiretroviral treatment (ART) for HIV since the mid-2000s, mostly through disease-specific or "vertical" programmes, has been a highly successful undertaking, which averted millions of deaths and prevented many new infections. However, the dynamics of the HIV epidemic and changing political and financial commitment to fight the disease will likely require new models for the delivery of ART over the coming decades if the promises of universal treatment are to be met. Delivery model innovations for ART are intended to improve both the effectiveness and efficiency of the HIV treatment cascade, reaching new people who require ART and providing ART to more people without an increase in resources. We describe twelve models for ART delivery, which could be achieved through five categories of delivery innovations: integrating ART ("vertical ART plus", "partially-integrated ART" and "fully-integrated ART"); modifying steps in the ART value chain ("professional task-shifted ART", "people task-shifted ART" and "technology-supported ART"); eliminating steps in the ART value chain ("immediate ART" and "less frequent ART pick-up"); changing ART locations ("private-sector ART", "traditional-sector ART" and "ART outside the health sector"); and keeping the status quo ("vertical ART"). The different delivery model innovations are not mutually exclusive and several could be combined, such as "vertical ART plus" with "task-shifted ART". Suitability of the models will highly depend on local and national contexts, including existing health systems resources, available funding, and type of HIV epidemic. Future implementation research needs to identify which models are the best fit for different contexts.
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Affiliation(s)
- Caroline A Bulstra
- Erasmus Medical Centre, Department of Public Health, Rotterdam, The Netherlands.,Institute of Global Health, University of Heidelberg, Germany
| | - Jan Ac Hontelez
- Erasmus Medical Centre, Department of Public Health, Rotterdam, The Netherlands.,Institute of Global Health, University of Heidelberg, Germany
| | - Osondu Ogbuoji
- Center for Policy Impact in Global Health, Duke University, Durham, USA
| | - Till Bärnighausen
- Institute of Global Health, University of Heidelberg, Germany.,Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, USA.,Africa Health Research Institute, Durban, South Africa
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Bulstra CA, Le Rutte EA, Malaviya P, Hasker EC, Coffeng LE, Picado A, Singh OP, Boelaert MC, de Vlas SJ, Sundar S. Visceral leishmaniasis: Spatiotemporal heterogeneity and drivers underlying the hotspots in Muzaffarpur, Bihar, India. PLoS Negl Trop Dis 2018; 12:e0006888. [PMID: 30521529 PMCID: PMC6283467 DOI: 10.1371/journal.pntd.0006888] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 10/01/2018] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Despite the overall decrease in visceral leishmaniasis (VL) incidence on the Indian subcontinent, there remain spatiotemporal clusters or 'hotspots' of new cases. The characteristics of these hotspots, underlying transmission dynamics, and their importance for shaping control strategies are not yet fully understood and are investigated in this study for a VL endemic area of ~100,000 inhabitants in Bihar, India between 2007-2015. METHODOLOGY/PRINCIPAL FINDINGS VL incidence (cases/10,000/year) dropped from 12.3 in 2007 to 0.9 in 2015, which is just below the World Health Organizations' threshold for elimination as a public health problem. Clustering of VL was assessed between subvillages (hamlets), using multiple geospatial and (spatio)temporal autocorrelation and hotspot analyses. One to three hotspots were identified each year, often persisting for 1-5 successive years with a modal radius of ~500m. The relative risk of having VL was 5-86 times higher for inhabitants of hotspots, compared to those living outside hotspots. Hotspots harbour significantly more households from the two lowest asset quintiles (as proxy for socio-economic status). Overall, children and young adelescents (5-14 years) have the highest risk for VL, but within hotspots and at the start of outbreaks, older age groups (35+ years) show a comparable high risk. CONCLUSIONS/SIGNIFICANCE This study demonstrates significant spatiotemporal heterogeneity in VL incidence at subdistrict level. The association between poverty and hotspots confirms that VL is a disease of 'the poorest of the poor' and age patterns suggest a potential role of waning immunity as underlying driver of hotspots. The recommended insecticide spraying radius of 500m around detected VL cases corresponds to the modal hotspot radius found in this study. Additional data on immunity and asymptomatic infection, and the development of spatiotemporally explicit transmission models that simulate hotspot dynamics and predict the impact of interventions at the smaller geographical scale will be crucial tools in sustaining elimination.
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Affiliation(s)
- Caroline A. Bulstra
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Epke A. Le Rutte
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Paritosh Malaviya
- Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Epco C. Hasker
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Luc E. Coffeng
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Albert Picado
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Om Prakash Singh
- Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Marleen C. Boelaert
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Sake J. de Vlas
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Shyam Sundar
- Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
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