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Artemether-lumefantrine-amodiaquine or artesunate-amodiaquine combined with single low-dose primaquine to reduce Plasmodium falciparum malaria transmission in Ouélessébougou, Mali: a five-arm, phase 2, single-blind, randomised controlled trial.
Get PDFBACKGROUND: Triple artemisinin-based combination therapies (TACTs) can delay the spread of antimalarial drug resistance. Artesunate-amodiaquine is widely used for uncomplicated Plasmodium falciparum malaria. We therefore aimed to determine the safety and efficacy of artemether-lumefantrine-amodiaquine and artesunate-amodiaquine with and without single low-dose primaquine for reducing gametocyte carriage and transmission to mosquitoes. METHODS: We did a five-arm, single-blind, phase 2 randomised controlled trial at the Ouélessébougou Clinical Research Unit of the Malaria Research and Training Centre of the University of Sciences, Techniques and Technologies of Bamako in Mali. Eligible participants were aged 10-50 years, with asymptomatic P falciparum microscopy-detected gametocyte carriage. Eligible participants were randomly allocated (1:1:1:1:1) to receive either artemether-lumefantrine, artemether-lumefantrine-amodiaquine, artemether-lumefantrine-amodiaquine plus primaquine, artesunate-amodiaquine, or artesunate-amodiaquine plus primaquine. Treatment regimens were administered on days 0, 1, and 2; primaquine was given as a single dose on day 0. All staff except the trial pharmacist and participants were masked to the treatment allocation. The primary outcome was the median percentage change in mosquito infection rate between pretreatment and 2 days after treatment initiation, assessed by direct membrane feeding assay. Data were analysed using a per-protocol analysis. This study is registered with ClinicalTrials.gov, NCT05550909. FINDINGS: Between Oct 16, 2022, and Dec 28, 2022, a total of 1249 individuals were screened; of whom, 100 were enrolled and randomly assigned to one of the five treatment groups (20 per group). Before treatment, 61 (61%) of 100 participants were infectious to mosquitoes, with a median of 7·3% (IQR 3·2 to 23·5) of mosquitoes becoming infected. Among infectious participants, the median percentage reduction in mosquito infection rate between pretreatment and 2 days after treatment was 100% (IQR 100 to 100) in the artemether-lumefantrine (p=0·0018), artemether-lumefantrine-amodiaquine (p=0·0018), and artemether-lumefantrine-amodiaquine plus primaquine (p=0·0009) treatment groups. In the artesunate-amodiaquine group the median percentage reduction in mosquito infection rate was only 32% (IQR -10·9 to 79·4; p=0·19), whereas a 100% median reduction was seen in the artesunate-amodiaquine plus primaquine group (IQR 100 to 100; p=0·0009). At day 2, two (10%) of 20 participants in the artemether-lumefantrine group, two (11%) of 19 in the artemether-lumefantrine-amodiaquine group, and 15 (75%) of 20 in the artesunate-amodiaquine group infected any number of mosquitoes whereas no infected mosquitoes were observed at this timepoint in the groups with primaquine. 85 (85%) of 100 participants had a total of 262 adverse events during follow-up; of which, 181 (69%) were categorised as mild and 81 (31%) as moderate. No serious adverse events were reported. INTERPRETATION: Our findings support the effectiveness of artemether-lumefantrine alone or as part of TACT for preventing nearly all human-mosquito malaria parasite transmission within 48 h. By contrast, substantial transmission was observed following treatment with artesunate-amodiaquine. The addition of a single low dose of primaquine blocks transmission to mosquitoes rapidly regardless of schizonticide. FUNDING: Bill & Melinda Gates Foundation
Distribution and viability of ocular and non-ocular Chlamydia trachomatis in households in a trachoma-endemic community in Oromia, Ethiopia.
Get PDFBACKGROUND: We aimed to determine the household distribution and viability of Chlamydia trachomatis (Ct) from the eyes, face, and hands during the initial two visits of a year-long fortnightly cohort study in geographically defined adjacent households. METHODS/FINDINGS: We enrolled 298 individuals from 68 neighbouring households in Shashemene Woreda, Oromia, Ethiopia. All individuals above 2 years of age residing in these households were examined for signs of trachoma. Swab samples were taken from the conjunctiva, faces, and hands and analysed for the presence and viability of Ct. Ct viability was determined using reverse transcription (RT) PCR. At the initial visit, out of 298 individuals, 133 (44.5%) were children aged 2-9 years. Among these children, 27/133 (20.3%) had trachomatous inflammation-follicular (TF), while 8/133 (6.0%) had trachomatous inflammation-intense (TI). Ct (omcB or pORF2) was detected in 16/133 (12.0%) eye swabs, 14/105 (13.5%) face swabs, and 11/105 (10.5%) hand swabs from children aged 2-9 years. Among these children at visit one, 12/14 (85.7%) with Ct on faces and 9/11 (81.8%) with Ct on hands also had detectable ocular Ct. The severity of the disease worsened from the first visit to the second, and no participants showed clearance of the disease within the two-week period. Ct infection was associated with TF (P = 0.002) and TI (P = 0.060). At visit one, among children aged 2-9 years, viable Ct was detected in 12/16 (75.0%) ocular, 6/14 (42.9%) face, and 4/11 (36.4%) hand swab samples. All viable Ct detected on the faces and hands were identified from individuals with viable ocular infections. Among caregivers whose child tested positive for Ct on their hands, 3 caregivers also had Ct on their hands, accounting for 20% (3 out of 15). Additionally, among caregivers whose child tested positive for Ct on their faces, 2 caregivers had Ct on their faces, which accounts for 14.3% (2 out of 14). In two participants, we detected Ct on the hands of ocular-negative children at the initial visit and later detected ocular Ct at the second visit. CONCLUSION/SIGNIFICANCE: Using RT-qPCR assay to detect Ct omp2 mRNA to define viability offers a new, informative perspective of trachoma transmission in this community in Ethiopia. The presence of viable Ct on the faces and hands of individuals living in households with people with current ocular Ct infection supports the hypothesis that hands and faces are important routes for transmission of trachoma. This highlights the importance of targeted interventions to address these sites of Ct carriage to help interrupt transmission
Household economic impact of HIV-associated cryptococcal meningitis in five countries in Southern and Eastern Africa.
Get PDFINTRODUCTION: HIV-associated cryptococcal meningitis is the second leading cause of AIDS-related mortality. Cryptococcal meningitis is a poverty-related disease and the majority of cases occur in settings where resources are limited and access to quality care is often linked to an individual's ability to pay for services. We have previously demonstrated the efficacy, safety and cost-effectiveness of a single, high-dose liposomal amphotericin-based treatment regimen within the AMBITION-cm trial. Here, we present a five-country, within-trial analysis exploring the household economic impact of cryptococcal meningitis. METHODS: Eight hundred and ten participants were recruited into this sub-study in Botswana, Malawi, South Africa, Uganda and Zimbabwe between January 2018 and February 2021. We collected data on annual household expenditure, direct costs and indirect costs incurred prior to enrolment and during the 10-week trial period. Costs were inflated and converted to 2022 USD. We calculated out-of-pocket expenditure, lost income and catastrophic healthcare expenditure, defined as costs exceeding 20% of annual household expenditure. RESULTS: The average total out-of-pocket expenditure plus lost income prior to enrolment was 516 and 29.1% of annual household expenditure across all countries, ranging from 592 (64.2%) in Zimbabwe. More than half (296/581, 51.0%, 95% CI 46.9-55.0) of households experienced catastrophic healthcare expenditure by the end of the trial, ranging from 16.0% (13/81, 95% CI 7.9-24.2) in South Africa to 68.1% (156/229, 95% CI 62.0-74.2) in Uganda. CONCLUSIONS: This is the first study exploring the household economic impact experienced by those diagnosed with cryptococcal meningitis. The household economic impact of cryptococcal meningitis is high and more than half of households of individuals who survive experience catastrophic healthcare expenditure. It is likely these figures are higher outside of the research setting. This highlights the profound financial impact of this devastating infection and provides a rationale to offer financial and social protection to those affected. TRIAL REGISTRATION NUMBER: ISRCTN72509687
"Beyond the flood: Exploring the psychosocial consequences and resilience challenges in the aftermath of "El Niño" in Tumbes, Peru".
No full textBACKGROUND: El Niño's impacts on health are widespread, but evidence of its psychosocial effects on historically affected communities is limited. We aimed to describe perceived mental health impacts, local barriers to psychological well-being, and challenges in accessing support post-El Niño in Tumbes, Peru. METHODS: Between May-June 2017, we conducted 27 semi-structured interviews and three focus groups in Spanish with 24 adult residents, including local authorities and residents from heavily and minimally El Niño affected areas. Data were analyzed thematically. RESULTS: Initially, participants minimized El Niño's mental health impact, claiming to be "accustomed" to it. However, most described specific cases of suffering, including socioeconomic struggles, feelings of lack of support, unfairness, and helplessness. Local authorities acknowledged inadequate support availability. Psychosocial distress was exacerbated by poverty, scarce work opportunities, and disproportionate effects on vulnerable groups. Contextual factors like corruption, underfunding of prevention, and lack of reconstruction led to despair and distrust of authorities. Participants identified responsibility gaps at different levels but rarely acknowledged their responsibility or suggested alternatives. Psychosocial problems, therapy availability, or community support programs were seldom mentioned, though mutual collaboration was highlighted as useful but non-existent. CONCLUSIONS: We found multiple interrelated issues in under-resourced post-disaster communities, highlighting the psychological burden of living "between disasters" and how socioeconomic distress and lack of support contribute to suffering. Beyond emergency aid, these communities require integrated care considering contextual and community-level distress, improving access to prevention and reconstruction activities, and addressing ongoing anxiety about future disasters to foster long-term resilience
Telemedicine Public Reimbursement Models for National and Subnational Jurisdictions: Scoping Review.
Get PDFBACKGROUND: Telemedicine has transformed health care delivery, offering improved access, efficiency, and potentially cost-effectiveness. However, wide-scale implementation is challenged due to multiple factors. Among these, reimbursements were reported to influence the scalability and sustainability of telemedicine. OBJECTIVE: This study aimed to examine current payment models and reimbursement coverage for telemedicine in any national and subnational jurisdictions to inform the development of reimbursement policy. METHODS: We conducted a scoping review using Arksey and O'Malley's 6-stage method, including sources that discussed telemedicine payment methods reimbursed by public payers. To supplement the limited results, particularly from low- and middle-income countries in Asia, we conducted 5 stakeholder interviews with telemedicine providers or those with experience in telemedicine reimbursement models who added insights for India, Nepal, and Taiwan. Data were synthesized narratively. RESULTS: We included 31 of 14,522 records screened. Most (n=22, 71%) records were published after 2020, were research studies (n=26, 84%), and discussed reimbursement in the United States (n=24, 77%). We categorized reimbursement coverage as the purpose of telemedicine, health conditions, patients' nonhealth conditions, service providers, interaction participants, interaction modes, and technology used. Payment methods varied widely and included fee-for-service, capitation, bundled payment, and value-based models. Varying telemedicine reimbursement models adopted by countries reflect health service and care objectives along with health system characteristics. Payment mechanisms were linked to telemedicine services or broader health care delivery, with each presenting unique advantages. CONCLUSIONS: Workable telemedicine reimbursement is a critical enabling factor in expanding health care access by incentivizing provider participation, ensuring financial sustainability, promoting equity in access, and aligning telemedicine with broader health goals. This review provides a starting point for countries in designing a telemedicine reimbursement model specific to population needs and health system capacity. Policy makers are encouraged to leverage these insights in adapting telemedicine reimbursement to their context
Global trends in urban forest irrigation: Environmental influences, challenges and opportunities for sustainable practices across 109 cities worldwide
Get PDFUrban forests are critical for climate adaptation and liveability, but effective irrigation management—key to their sustainability—remains poorly documented at the global scale. This study addresses this critical knowledge gap by analysing urban forest irrigation practices across 109 cities in 21 countries, offering one of the first global assessments of irrigation approaches, challenges, and opportunities. Using survey data, we examined water sources, irrigation frequency, constraints, and enabling conditions. Our results show that weather conditions were the leading factor influencing irrigation scheduling in 44 % of cities, while 56 % reported no formal water restrictions. Despite the importance of water conservation, 55 % of respondents reported having no water usage monitoring systems, and 73 % lacked financial incentives to promote water-efficient irrigation. A large majority (80 %) did not use recycled wastewater, and 58 % did not conduct water quality testing. Only 15 % of cities regularly used water-efficient irrigation technologies, and 47 % had no plans to implement smart systems. Over half (56 %) rated their current irrigation practices as only moderately successful. Budget constraints and infrastructure limitations were the most frequently reported challenges, followed by climate change-related concerns. While environmental variables such as mean annual temperature and irrigation need influenced specific practices, local governance and institutional actions had stronger effects. Cities in the Global South reported distinct strategies and constraints compared to those in the Global North. Our findings provide actionable insights for climate-resilient urban water strategies and underscore the need for targeted policies, capacity-building, and efficient technologies to enhance urban forest sustainability worldwide
Gene-Environment Interaction Affects Risk of Atopic Eczema: Population and In Vitro Studies.
Get PDFBACKGROUND: Multiple environmental and genetic factors play a role in the pathogenesis of atopic eczema (AE). We aimed to investigate gene-environment interactions (G × E) to improve understanding of the pathophysiology. METHODS: We analysed data from 16 European studies to test for interaction between the 24 most significant AE-associated loci identified from genome-wide association studies and 18 early-life environmental factors. We tested for replication using a further 10 studies and in vitro modeling to independently assess findings. RESULTS: The discovery analysis (including 25,339 individuals) showed suggestive evidence for interaction (p < 0.05) between seven environmental factors (antibiotic use, cat ownership, dog ownership, breastfeeding, elder sibling, smoking and washing practices) and at least one established variant for AE, 14 interactions in total. In the replication analysis (254,532 individuals) dog exposure × rs10214237 (on chromosome 5p13.2 near IL7R) was nominally significant (ORinteraction = 0.91 [0.83-0.99] p = 0.025), with a risk effect of the T allele observed only in those not exposed to dogs. A similar interaction with rs10214237 was observed for siblings in the discovery analysis (ORinteraction = 0.84 [0.75-0.94] p = 0.003), but replication analysis was under-powered (ORinteraction = 1.09 [0.82-1.46]). rs10214237 homozygous risk genotype is associated with lower IL-7R expression in human keratinocytes, and dog exposure modelled in vitro showed a differential response according to rs10214237 genotype. CONCLUSION: Interaction analysis and functional assessment provide preliminary evidence that early-life dog exposure may modify the genetic effect of rs10214237 on AE via IL7R, supporting observational epidemiology showing a protective effect for dog ownership. The lack of evidence for other G × E studied here implies only weak effects are likely to occur
Effective refractive error coverage in adults: a systematic review and meta-analysis of updated estimates from population-based surveys in 76 countries modelling the path towards the 2030 global target.
Get PDFBACKGROUND: In 2024, WHO included effective refractive error coverage (eREC) into the results framework of the 14th General Programme of Work, which sets a road map for global health and guides WHO's work between 2025 and 2028. eREC is a measure of both the availability and quality of refractive correction in a population. This study aimed to model global and regional estimates of eREC as of 2023 and evaluate progress towards the WHO global target of a 40 percentage-point absolute increase in eREC by 2030. METHODS: For this systematic review and meta-analysis, the Vision Loss Expert Group analysed data from 237 population-based eye surveys conducted in 76 countries since 2000, comprising 815 273 participants, to calculate eREC (met need / met need + undermet need + unmet need]) and the relative quality gap between eREC and REC ([REC - eREC] / REC × 100, where REC = [met + undermet need] / [met need + undermet need + unmet need]). An expert elicitation process was used to choose covariates for a Bayesian logistic regression model used to estimate eREC by country-age-sex grouping among adults aged 50 years and older. Country-age-sex group estimates were aggregated to provide estimates according to Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) super-regions. FINDINGS: Global eREC was estimated to be 65·8% (95% uncertainty interval [UI] 64·7-66·8) in 2023, 6 percentage points higher than in 2010 (eREC 59·8% [59·4-60·2]). There were marked differences in eREC between GBD super-regions in 2023, ranging from 84·0% (95% UI 83·0-85·0) in high-income countries to 28·3% (26·4-30·4) in sub-Saharan Africa. In all super-regions, eREC was lower in females than males, and decreased with increasing age among adults aged ≥50 years. Since 2000, the relative increase in eREC was 60·2% in sub-Saharan Africa, 45·7% in North Africa and the Middle East, 41·5% in southeast Asia, east Asia and Oceania, 40·3% in south Asia, 16·2% in Latin America and the Caribbean, 8·3% in central Europe, eastern Europe and central Asia, and 6·8% in the high-income super-region. The relative quality gap ranged from 2·9% to 78·3% across studies, with larger gaps characteristically in regions of lower eREC. Globally, the percentage of those with a refractive need that was undermet reduced between 2000 and 2023, from 10·0% (95% UI 9·5-10·5) to 5·3% (5·1-5·5). INTERPRETATION: The current trajectory of improvement in eREC and the relative quality gap are insufficient to meet the 2030 target. Global efforts to equitably increase spectacle coverage, such as the WHO SPECS 2030 initiative, and to address equity failings associated with geography, age, and sex, are crucial to accelerating progress towards the 2030 targets. No region is close to achieving universal coverage. FUNDING: WHO, Sightsavers, The Fred Hollows Foundation, Fondation Thea, University of Heidelberg, German Federal Ministry for Education and Research. TRANSLATIONS: For the French, Chinese and Spanish translations of the abstract see Supplementary Materials section
Current status of school vision screening-rationale, models, impact and challenges: a review.
Get PDFUncorrected refractive error is the leading cause of vision impairment in children globally, and studies have demonstrated that spectacle correction addresses the large majority of childhood vision impairment. Furthermore, trial evidence illustrates the beneficial impact of spectacles on learning, with effect sizes exceeding that of other school health interventions. While it is established that good vision is important for learning and optimising childhood development and quality of life, many countries lack healthcare systems that provide vision screening or universal access to eyecare for all citizens. This review examined school vision screening across several regions/countries, focusing on conditions that should be targeted and the corresponding interventions. The range of international models, the status of global refractive service coverage and measures needed for improvement are discussed. Vision screening protocols need to effectively detect vision impairment, seamlessly connect with intervention services to deliver spectacles and signpost for future access to eyecare. Conditions which may not be treatable with spectacles alone, including amblyopia, strabismus and other ocular diseases, also warrant signposting for treatment. The vision community must unite to urge governments to invest in building service capacity; allocating the necessary resources and effectively developing public health systems to support vision screening and access to eyecare. Schools play a crucial role in enabling population-based vision screening and need to be supported with eyecare interventions and resources. This will ensure optimised approaches to correct avoidable vision loss and provide children with the educational and health outcomes they deserve
Home energy efficiency improvements and health: observational before-and-after study of Dublin's Warmth & Wellbeing pilot scheme.
Get PDFBACKGROUND: The Warmth & Wellbeing pilot scheme provided home energy efficiency measures to people aged 55 years and over with chronic respiratory conditions in Dublin, Ireland from 2016 to 2020. We performed an observational study to evaluate the impact of the pilot scheme on health and well-being. METHODS: 955 people were recruited to the research, of which 545 had the following before-and-after data: self-reported general health and winter thermal comfort through a questionnaire and the EuroQol-5 Dimension (EQ-5D), St George's Respiratory Questionnaire (SGRQ) and 36-Item Short Form Survey (SF-36) instruments, and monthly drug prescriptions. We analysed before-and-after differences using standard parametric methods. RESULTS: Health service contacts decreased after intervention, with general practitioner consultations over 6 months decreasing by 1.10 (95% CI 0.75, 1.44) and emergency room visits for respiratory conditions decreasing by 0.13 (95% CI 0.06, 0.21). Participants reported improvements in thermal comfort, temperature control, ability to pay fuel bills and comfort with inviting visitors to their home. There were improvements in physical health, general health, energy/fatigue and social well-being across most dimensions of EQ-5D, SGRQ and SF-36. For example, the EQ-5D summary score decreased by 5.36 (95% CI 2.68, 8.04). Monthly drug prescriptions in the year before intervention decreased by 0.14 (95% CI 0.06, 0.23) in the year afterwards. Most changes persisted for at least 2 years. CONCLUSIONS: Dublin's Warmth & Wellbeing pilot scheme resulted in improvements in self-reported health and probable reductions in health service contacts and drug prescriptions. The health rationale supports targeted home energy efficiency programmes as part of climate change and energy objectives