Annual Rounds Research Articles

STI testing among young people attending music festivals in New South Wales, Australia: exploring the client segmentation concept in the 'Down to Test' program.

Background The 'Down to Test (DTT)' campaign is a sexually transmissible infection (STI) social marketing intervention delivered through outdoor music festival activations and supported by digital media communications in New South Wales, Australia. This paper investigates whether and how the tailored messages reached the intended audience. Methods Data was collected through three annual rounds of online surveys post campaign exposure, targeting young people (aged 15-29years) attending 14 music festivals in NSW from October 2017 to March 2020. Descriptive statistics, principal component analysis and multivariable logic regression were applied to identify the key client segment and factors associated with a strong intention for future STI screening. Results Of the 10044 participants with a valid urine specimen submitted, 261 (2.8%) tested positive for chlamydia. Altogether, 1776 participants (median age=22) self-completed the evaluation surveys online with more being female (73.4%) than male (26.2%). Participants were mostly Australian-born (89.5%), heterosexual (82.6%) and the majority being sexually active (96.7%). Rates of self-reported lifetime STI testing (70.4%) and intention for future STI screening ('definitely yes' in the next 12months, 39.0%) were also high. The most significant factor associated with future intention for STI testing is the Sexual Experience and Perception Factor (adjusted odds ratio [AOR]=2.02; 95%CI 1.76-2.32; P<0.001), followed by the Sexual Beliefs and Attitudes Factor (AOR=1.14; 95% CI 1.01-1.30; P<0.05). Conclusions The NSW state-wide DTT campaign has largely reached sexually active youth who are attentive to sexual health promotion messages and contributed to enhanced STI screening in a fun and peer-supportive environment.

Exploring the Impact of Lung Cancer Screening on Lung Cancer Mortality of Smokers With Obstructive Lung Disease: Analysis of the NLST-ACRIN Cohort

BackgroundLung Cancer (LC) screening with low dose chest computed tomography (LDCT) in smokers reduces LC mortality. Patients with Obstructive Lung Disease (OLD) are at high risk for LC. The potential effect of LC screening in this population is unknown. ObjectiveTo determine if screening with LDCT reduces LC mortality in smokers with spirometrically defined OLD. MethodsThe National Lung Screening Trial-American College of Radiology Imaging Network (NLST-ACRIN) study included 13,831 subjects (55–74 years of age with ≥30 pack-year history of smoking) that had a baseline spirometry. Randomly assigned to LDCT or Chest X-ray, all had 3 annual rounds of screening. LC mortality was compared between the LDCT and chest X-ray arms during the 1st year and at 6 years of follow up. Landmark analysis explored LC mortality differences between arms after the first year. ResultsFrom the 4584 subjects with OLD (FEV1/FVC <0.7), 152 (3.3%) died from LC. Multivariable analysis showed that screening trended to decrease LC mortality at 6 years (HR, 95%CI: 0.75, 0.55–1.04, p=0.09). During the 1st year no differences were found between arms (p=0.65). However, after this year, LDCT significantly decreased LC mortality (HR, 95%CI: 0.63, 0.44–0.91, p=0.01). The number needed to screen to avoid one LC death in these subjects was 108 while in those without OLD was 218. ConclusionsLC screening with LDCT in smokers with spirometrically diagnosed OLD, showed a trend to reduce lung cancer mortality but a study with a larger number of patients and with a more robust design would be needed to confirm these findings.

Prevalence and Correlates of Alcohol Consumption among Hill-Tribe Adolescents below the Legal Drinking Age-A Community-based Cross-Sectional Study in Northern Thailand.

Alcohol drinking has been prevalent among various hill tribes of northern Thailand due to their distinctively different lifestyles, traditions, cultures and beliefs than the general Thai population; the majority of these traditions involve annual rounds of customary rituals that make alcohol abundantly accessible to all age groups. To study the prevalence and predictors of alcohol use, a community-based analytical cross-sectional study was conducted between October 2017–September 2018 among 480 sampled adolescents aged 12 through 18 years drawn by stratified random sampling. A proprietary questionnaire developed by the researchers was used to collect the data which were analyzed using binary logistic regression. The prevalence of alcohol use in the previous 30 days was 46.7%. Drinking predictors were: having at least a drinking parent, drinking peers, ever been sent to buy alcohol, smoking, cordial relationship with peers, gambling, family violence experience, stress and leisure time company. Therefore, our results suggest that prevention interventions should be designed with a focus on discouraging parents from sending children to buy alcohol and drinking or smoking in their presence; to reduce both social and commercial access to alcohol, age limits should be imposed on alcohol intake at all ceremonious events, while strictly reinforcing the law that prohibits selling alcohol to minors.

Breast cancer screening in women at high risk of hereditary breast cancer: an Australian experience.

While population-based breast screening is a well-documented health strategy worldwide, very few centres offer breast-screening programmes specifically targeted at women at high risk of hereditary breast cancer. We present our experience with multimodality breast screening in a high-risk population. The outcomes from a familial breast cancer clinic at the North Brisbane BreastScreen Queensland Service providing a multimodality screening programme for high-risk women were reviewed from the prospectively maintained database between 2011 and 2018. Over the 8 years of study period, a total of 6686 annual screening rounds were performed for 823 asymptomatic women at high risk of hereditary breast cancer. As a result, 40 cancers were diagnosed including 25 invasive ductal cancers, three invasive lobular cancers, two invasive cancers with mixed ductal and lobular features and 10 ductal carcinomas in situ. Ultrasound and mammography detected 72.5% (29/40) and 55% (22/40) of the cancers, respectively. A total of 3672 magnetic resonance imaging studies were performed. Ten (25%) cancers were initially only seen on magnetic resonance imaging including seven invasive ductal cancers, one invasive lobular cancer and two high-grade ductal carcinomas in situ. The cancer detection rate for first-round screening was 13.3 cancers per 1000 women screened, with 4.9 cancers per 1000 women detected on subsequent-round screening. One interval cancer occurred in the study period. Multimodality breast screening of younger women at high risk of hereditary breast cancer is effective with the yield substantially exceeding the results from established breast screening programmes in older women. Co-location of this service within BreastScreen Australia efficiently shares resources.

Impact of annual and semi-annual mass drug administration for Lymphatic Filariasis and Onchocerciasis on Hookworm Infection in Côte d'Ivoire.

Mass Drug Administration (MDA) programs to eliminate Lymphatic Filariasis (LF) in western Africa use the anthelminthics ivermectin plus albendazole. These drugs have the potential to impact also Soil-Transmitted Helminth (STH) infections, since the drugs have a broad range of anthelminthic activity. Integration of preventive chemotherapy efforts for LF, onchocerciasis and STH is recommended by the World Health Organization (WHO) in order to avoid duplication of MDA and to reduce costs. The objective of the current study was to determine whether five semi-annual rounds of community-wide MDA to eliminate LF and onchocerciasis have a greater impact on STH than three annual rounds of MDA with similar compliance. The effects of MDA using ivermectin (IVM, 0.2 mg/kg) combined with albendazole (ALB, 400 mg) on the prevalence and intensity of hookworm infection were evaluated in the Abengourou (annual MDA) and Akoupé (semi-annual MDA) health Districts in eastern Côte d’Ivoire from 2014 to 2017. A cross-sectional approach was used together with mixed logistic regression, and mixed linear models. Subjects were tested for STH using the Kato-Katz technique before the first round of MDA and 12, 24, and 36 months after the first round of MDA. The mean self-reported MDA compliance assessed during the survey was 65%, and no difference was observed between treatment areas. These results were confirmed by an independent coverage survey as recommended by WHO. Hookworm was the most prevalent STH species in both areas (23.9% vs 12.4%) and the prevalence of other STH species was less than 1%. The crude prevalence of hookworm dropped significantly, from 23.9% to 5.5% (p <0.001, 77% reduction) in the annual MDA treatment area and from 12.4% to 1.9% (p <0.001, 85% reduction) in the semi-annual treatment area. The average intensity of hookworm infection decreased in the annual MDA area (406.2 epg to 118.3 epg), but not in the semi-annual MDA area (804.9 epg to 875.0 epg). Moderate and heavy infections (1% and 1.3% at baseline) were reduced to 0% and 0.4% in the annual and semi-annual treatment areas, respectively. Using a mixed logistic regression model, and after adjusting for baseline prevalence, only the year 2 re-examination showed a difference in prevalence between treatments (OR: 2.26 [95% CI: 1.03, 4.98], p = 0.043). Analysis of intensity of hookworm infection indicated also that treatment differences varied by follow-up visit. In conclusion twelve months after the last treatment cycle, three annual and five semi-annual rounds of community-wide MDA with the combination of IVM and ALB showed strong, but similar impact on hookworm prevalence and intensity in eastern Côte d’Ivoire. Therefore, an annual MDA regimen seems to be an efficient strategy to control hookworm infection in endemic areas with low and moderate infection prevalence.Trial registration: The study was registered at ClinicalTrial.gov under the number NTC02032043.

Lung cancer screening intervals based on cancer risk

ObjectivesAs low-dose CT screening is gaining acceptance, focus is on increasing the efficiency of screening. One major consideration is to reduce the total number of annual rounds by increasing the interval between screening rounds. It has been suggested that longer intervals could be used for individuals who are at lower risk of lung cancer. In this study, we explored whether eligible participants in a program of LDCT screening who are at lower risk of lung cancer have less aggressive cancers than those at higher risk. MethodsWe retrospectively identified 118 participants in I-ELCAP database between 1992–2019 who had been screened using HIPAA-compliant protocols and had solid lung cancers diagnosed on an annual round of screening, 7–18 months after the prior round. Volume doubling time (VDT) for each cancer was calculated. Estimated risk of developing lung cancer was calculated using PLCOM2012 model. The strength of the relationship between VDT and individual PLCOM2012 scores was assessed by Pearson(r) and Spearman (ρ) correlation coefficients. ResultsVDTs were significantly different by cell-type (p < 0.0001); median VDT for small cell was 34.0 days, followed by other cell-types (61.8 days), squamous-cell (73.3 days), and adenocarcinoma (135.7 days). The median VDT for the 78 (66.1 %) Stage I lung cancers was significantly longer than the 40 Stage II + lung cancers (101.4 days vs. 45.5 days, p < 0.0001). None of the established lung cancer risk indicators (age, pack-years of smoking, or PLCOM2012 scores) were significant predictors of VDT or lung cancer stage. ConclusionNo significant relationship was demonstrated between risk of developing lung cancer (measured by risk models, age or smoking history) and lung cancer aggressiveness (measured by VDT, cell-type and Stage). This suggests that there is no evidence for determining intervals between repeat screenings using risk-based characteristics. It does not, however, exclude the possibility that future models may establish such a relationship.

Overdiagnosis in lung cancer screening: Estimates from the German Lung Cancer Screening Intervention Trial.

Overdiagnosis is a major potential harm of lung cancer screening; knowing its potential magnitude helps to optimize screening eligibility criteria. The German Lung Screening Intervention Trial ("LUSI") is a randomized trial among 4052 long-term smokers (2622 men), 50.3 to 71.9 years of age from the general population around Heidelberg, Germany, comparing five annual rounds of low-dose computed tomography (n = 2029) with a control arm without intervention (n = 2023). After a median follow-up of 9.77 years postrandomization and 5.73 years since last screening, 74 participants were diagnosed with lung cancer in the control arm and 90 in the screening arm: 69 during the active screening period; of which 63 screen-detected and 6 interval cancers. The excess cumulative incidence in the screening arm (N = 16) represented 25.4% (95% confidence interval: -11.3, 64.3] of screen-detected cancer cases (N = 63). Analyzed by histologic subtype, excess incidence in the screening arm appeared largely driven by adenocarcinomas. Statistical modeling yielded an estimated mean preclinical sojourn time (MPST) of 5.38 (4.76, 5.88) years and a screen-test sensitivity of 81.6 (74.4%, 88.8%) for lung cancer overall, all histologic subtypes combined. Based on modeling, we further estimated that about 48% (47.5% [43.2%, 50.7%]) of screen-detected tumors have a lead time ≥4 years, whereas about 33% (32.8% [28.4%, 36.1%]) have a lead time ≥6 years, 23% (22.6% [18.6%, 25.7%]) ≥8 years, 16% (15.6% [12.2%, 18.3%]) ≥10 years and 11% (10.7% [8.0%, 13.0%]) ≥12 years. The high proportions of tumors with relatively long lead times suggest a major risk of overdiagnosis for individuals with comparatively short remaining life expectancies.

Impact of a 3-year mass drug administration pilot project for taeniasis control in Madagascar.

Taenia solium is endemic in Madagascar and presents a significant burden on the population and the health system. The parasite cycles through humans who host the adult tapeworm, and pigs that host the larval stages. Accidental infection of humans may occur with the larval stages which encyst in the nervous central system causing neurocysticercosis, a major cause of seizure disorders and a public health problem. One of the interventions to facilitate the control of the disease is mass drug administration (MDA) of the human population with taeniacide. Here we describe a pilot project conducted in Antanifotsy district of Madagascar from 2015 to 2017 where three annual rounds of MDA (praziquantel, 10mg/Kg) were undertaken in 52 villages. Changes in the prevalence of taeniasis were assessed before, during and after the treatments. A total of 221,308 treatments were given to all eligible people above 5 years of age representing a 95% coverage of the targeted population. No major adverse effects were notified related to the implementation of the MDA. The prevalence of taeniasis was measured using Kato-Katz and copro-antigen techniques. Analyses undertaken combining the results of the Kato-Katz with copro-antigen, or using the Kato-Katz results alone, showed that there was a significant reduction in taeniasis 4 months after the last MDA, but 12 months later (16 months after the last MDA) the taeniasis prevalence had returned to its original levels. Results of the pilot project emphasize the need of a multi-sectorial One-Health approach for the sustained control of T. solium.

Loneliness, social support, social isolation and wellbeing among working age adults with and without disability: Cross-sectional study

BackgroundLoneliness is significantly related to health and wellbeing. However, there is little information on the prevalence of loneliness among people with disability or the association between disability, loneliness and wellbeing. Objective/hypothesisFor a nationally representative sample of adults (age 16–64) with/without disability, to examine exposure to three indicators of low social connectedness (loneliness, low perceived social support, social isolation), and to evaluate the association between low social connectedness and wellbeing. To test whether disability status moderated the relationship between low social connectedness and wellbeing. MethodsSecondary analysis of data from three annual rounds of the cross-sectional English Community Life Survey (CLS) 2016–19. ResultsPeople with disability experienced loneliness, low perceived social support and social isolation at significantly higher rates than people without disability. Effect sizes were significantly greater for loneliness. Disability was associated with lower wellbeing. With one exception, low social connectedness was associated with lower wellbeing. Again, effect sizes were significantly greater for loneliness. The prevalence of loneliness was highest among adults with disability who were younger, economically inactive, living in rented or other accommodation, living alone and with low levels of access to environmental assets. There was no evidence that disability status moderated the association between exposure to low social connectedness and low wellbeing. ConclusionsLoneliness was a particularly significant driver of poor wellbeing among people with disability. The relative independence between different indicators of social connectedness suggests that interventions to reduce loneliness will need to do more than simply increase rates of social contact or social support.

Mass drug administration with azithromycin for trachoma elimination and the population structure of Streptococcus pneumoniae in the nasopharynx

ObjectiveMass drug administration (MDA) with azithromycin for trachoma elimination reduces nasopharyngeal carriage of Streptococcus pneumoniae in the short term. We evaluated S. pneumoniae carried in the nasopharynx before and after a round of azithromycin MDA to determine whether MDA was associated with changes in pneumococcal population structure and resistance. MethodsWe analysed 514 pneumococcal whole genomes randomly selected from nasopharyngeal samples collected in two Gambian villages that received three annual rounds of MDA for trachoma elimination. The 514 samples represented 293 participants, of which 75% were children aged 0–9 years, isolated during three cross-sectional surveys (CSSs) conducted before the third round of MDA (CSS-1) and at 1 (CSS-2) and 6 (CSS-3) months after MDA. Bayesian Analysis of Population Structure (BAPS) was used to cluster related isolates by capturing variation in the core genome. Serotype and multilocus sequence type were inferred from the genotype. Antimicrobial resistance determinants were identified from assemblies, including known macrolide resistance genes. ResultsTwenty-seven BAPS clusters were assigned. These consisted of 81 sequence types (STs). Two BAPS clusters not observed in CSS-1 (n = 109) or CSS-2 (n = 69), increased in frequency in CSS-3 (n = 126); BAPS20 (8.73%, p 0.016) and BAPS22 (7.14%, p 0.032) but were not associated with antimicrobial resistance. Macrolide resistance within BAPS17 increased after treatment (CSS-1 n = 0/6, CSS-2/3 n = 5/5, p 0.002) and was carried on a mobile transposable element that also conferred resistance to tetracycline. DiscussionLimited changes in pneumococcal population structure were observed after the third round of MDA, suggesting treatment had little effect on the circulating lineages. An increase in macrolide resistance within one BAPS highlights the need for antimicrobial resistance surveillance in treated villages.

Moving towards malaria elimination in southern Mozambique: Cost and cost-effectiveness of mass drug administration combined with intensified malaria control.

As new combinations of interventions aiming at interrupting malaria transmission are under evaluation, understanding the associated economic costs and benefits is critical for decision-making. This study assessed the economic cost and cost-effectiveness of the Magude project, a malaria elimination initiative implemented in a district in southern Mozambique (i.e. Magude) between August 2015-June 2018. This project piloted a combination of two mass drug administration (MDA) rounds per year for two consecutive years, annual rounds of universal indoor residual spraying (IRS) and a strengthened surveillance and response system on the back of universal long-lasting insecticide treated net (LLIN) coverage and routine case management implemented by the National Malaria Control Program (NMCP). Although local transmission was not interrupted, the project achieved large reductions in the burden of malaria in the target district. We collected weekly economic data, estimated costs from the project implementer perspective and assessed the incremental cost-effectiveness ratio (ICER) associated with the Magude project as compared to routine malaria control activities, the counterfactual. We estimated disability-adjusted life years (DALYs) for malaria cases and deaths and assessed the variation of the ICER over time to capture the marginal costs and effectiveness associated with subsequent phases of project implementation. We used deterministic and probabilistic sensitivity analyses to account for uncertainty and built an alternative scenario by assuming the implementation of the interventions from a governmental perspective. Economic costs are provided in constant US$2015. After three years, the Magude project averted a total of 3,171 DALYs at an incremental cost of $2.89 million and an average yearly cost of $20.7 per targeted person. At an average cost of $19.4 per person treated per MDA round, the social mobilization and distribution of door-to-door MDA contributed to 53% of overall resources employed, with personnel and logistics being the main cost drivers. The ICER improved over time as a result of decreasing costs and improved effectiveness. The overall ICER was $987 (CI95% 968-1,006) per DALY averted, which is below the standard cost-effectiveness (CE) threshold of $1,404/DALY averted, three times the gross domestic product (GDP) per capita of Mozambique, but above the threshold of interventions considered highly cost-effective (one time the GDP per capita or $468/DALY averted) and above the recently suggested thresholds based on the health opportunity cost ($537 purchasing power parity/ DALY averted). A significantly lower ICER was obtained in the implementation scenario from a governmental perspective ($441/DALY averted). Despite the initial high costs and volume of resources associated with its implementation, MDA in combination with other existing malaria control interventions, can be a cost-effective strategy to drastically reduce transmission in areas of low to moderate transmission in sub-Saharan Africa. However, further studies are needed to understand the capacity of the health system and financial affordability to scale up such strategies at regional or national level.

Evaluation of morbidity in Schistosoma mansoni-positive primary and secondary school children after four years of mass drug administration of praziquantel in western Kenya

BackgroundWorld Health Organization guidelines recommend preventive chemotherapy with praziquantel to control morbidity due to schistosomiasis. The primary aim of this cross-sectional study was to determine if 4 years of annual mass drug administration (MDA) in primary and secondary schools lowered potential markers of morbidity in infected children 1 year after the final MDA compared to infected children prior to initial MDA intervention.MethodsBetween 2012 and 2016 all students in two primary and three secondary schools within three kilometers of Lake Victoria in western Kenya received annual mass praziquantel administration. To evaluate potential changes in morbidity we measured height, weight, mid-upper arm circumference, hemoglobin levels, abdominal ultrasound, and quality of life in children in these schools. This study compared two cross-sectional samples of Schistosoma mansoni egg-positive children: one at baseline and one at year five, 1 year after the fourth annual MDA. Data were analyzed for all ages (6–18 years old) and stratified by primary (6–12 years old) and secondary (12–18 years old) school groups.ResultsThe prevalence of multiple potential morbidity markers did not differ significantly between the egg-positive participants at baseline and those at 5 years by Mann Whitney nonparametric analysis and Fisher’s exact test for continuous and categorical data, respectively. There was a small but significantly higher score in school-related quality of life assessment by year five compared to baseline by Mann Whitney analysis (P = 0.048) in 13–18 year olds where malaria-negative. However, anemia was not positively impacted by four annual rounds of MDA, but registered a significant negative outcome.ConclusionsWe did not detect differences in morbidity markers measured in a population of those infected or re-infected after multiple MDA. This could have been due to their relative insensitivity or a failure of MDA to prevent morbidity among those who remain infected. High malaria transmission in this area and/or a lack of suitable methods to measure the more subtle functional morbidities caused by schistosomiasis could be a factor. Further research is needed to identify and develop well-defined, easily quantifiable S. mansoni morbidity markers for this age group.

Impact of Different Mass Drug Administration Strategies for Gaining and Sustaining Control of Schistosoma mansoni and Schistosoma haematobium Infection in Africa.

.This report summarizes the design and outcomes of randomized controlled operational research trials performed by the Bill & Melinda Gates Foundation–funded Schistosomiasis Consortium for Operational Research and Evaluation (SCORE) from 2009 to 2019. Their goal was to define the effectiveness and test the limitations of current WHO-recommended schistosomiasis control protocols by performing large-scale pragmatic trials to compare the impact of different schedules and coverage regimens of praziquantel mass drug administration (MDA). Although there were limitations to study designs and performance, analysis of their primary outcomes confirmed that all tested regimens of praziquantel MDA significantly reduced local Schistosoma infection prevalence and intensity among school-age children. Secondary analysis suggested that outcomes in locations receiving four annual rounds of MDA were better than those in communities that had treatment holiday years, in which no praziquantel MDA was given. Statistical significance of differences was obscured by a wider-than-expected variation in community-level responses to MDA, defining a persistent hot spot obstacle to MDA success. No MDA schedule led to elimination of infection, even in those communities that started at low prevalence of infection, and it is likely that programs aiming for elimination of transmission will need to add supplemental interventions (e.g., snail control, improvement in water, sanitation and hygiene, and behavior change interventions) to achieve that next stage of control. Recommendations for future implementation research, including exploration of the value of earlier program impact assessment combined with intensification of intervention in hot spot locations, are discussed.

Exploring the Impact of Lung Cancer Screening on Lung Cancer Mortality of Smokers With Obstructive Lung Disease: Analysis of the NLST-ACRIN Cohort

BackgroundLung Cancer (LC) screening with low dose chest computed tomography (LDCT) in smokers reduces LC mortality. Patients with Obstructive Lung Disease (OLD) are at high risk for LC. The potential effect of LC screening in this population is unknown. ObjectiveTo determine if screening with LDCT reduces LC mortality in smokers with spirometrically defined OLD. MethodsThe National Lung Screening Trial-American College of Radiology Imaging Network (NLST-ACRIN) study included 13,831 subjects (55–74 years of age with ≥30 pack-year history of smoking) that had a baseline spirometry. Randomly assigned to LDCT or Chest X-ray, all had 3 annual rounds of screening. LC mortality was compared between the LDCT and chest X-ray arms during the 1st year and at 6 years of follow up. Landmark analysis explored LC mortality differences between arms after the first year. ResultsFrom the 4584 subjects with OLD (FEV1/FVC <0.7), 152 (3.3%) died from LC. Multivariable analysis showed that screening trended to decrease LC mortality at 6 years (HR, 95%CI: 0.75, 0.55–1.04, p=0.09). During the 1st year no differences were found between arms (p=0.65). However, after this year, LDCT significantly decreased LC mortality (HR, 95%CI: 0.63, 0.44–0.91, p=0.01). The number needed to screen to avoid one LC death in these subjects was 108 while in those without OLD was 218. ConclusionsLC screening with LDCT in smokers with spirometrically diagnosed OLD, showed a trend to reduce lung cancer mortality but a study with a larger number of patients and with a more robust design would be needed to confirm these findings.

Impact of Community-Based Mass Testing and Treatment on Malaria Infection Prevalence in a High-Transmission Area of Western Kenya: A Cluster Randomized Controlled Trial.

Global gains toward malaria elimination have been heterogeneous and have recently stalled. Interventions targeting afebrile malaria infections may be needed to address residual transmission. We studied the efficacy of repeated rounds of community-based mass testing and treatment (MTaT) on malaria infection prevalence in western Kenya. Twenty clusters were randomly assigned to 3 rounds of MTaT per year for 2 years or control (standard of care for testing and treatment at public health facilities along with government-sponsored mass long-lasting insecticidal net [LLIN] distributions). During rounds, community health volunteers visited all households in intervention clusters and tested all consenting individuals with a rapid diagnostic test. Those positive were treated with dihydroartemisinin-piperaquine. Cross-sectional community infection prevalence surveys were performed in both study arms at baseline and each year after 3 rounds of MTaT. The primary outcome was the effect size of MTaT on parasite prevalence by microscopy between arms by year, adjusted for age, reported LLIN use, enhanced vegetative index, and socioeconomic status. Demographic and behavioral characteristics, including LLIN usage, were similar between arms at each survey. MTaT coverage across the 3 annual rounds ranged between 75.0% and 77.5% in year 1, and between 81.9% and 94.3% in year 2. The adjusted effect size of MTaT on the prevalence of parasitemia between arms was 0.93 (95% confidence interval [CI], .79-1.08) and 0.92 (95% CI, .76-1.10) after year 1 and year 2, respectively. MTaT performed 3 times per year over 2 years did not reduce malaria parasite prevalence in this high-transmission area. NCT02987270.

Assessing the Impact and Equity of an Integrated Rural Sanitation Approach: A Longitudinal Evaluation in 11 Sub-Saharan Africa and Asian Countries.

Few rural sanitation programs have documented large increases in sanitation coverage or have assessed if interventions equitably increase sanitation coverage for vulnerable groups. We characterize the impact of the Sustainable Sanitation and Hygiene for All (SSH4A) approach on key program WASH (water, sanitation, and hygiene) indicators, and also assess if these increases in WASH coverage are equitably reaching vulnerable groups. The SSH4A approach was administered in 12 program areas in 11 countries, including Bhutan, Ethiopia, Ghana, Indonesia, Kenya, Mozambique, Nepal, South Sudan, Tanzania, Uganda, and Zambia. Repeated cross-sectional household surveys were administered over four rounds at annual follow-up rounds from 2014 to 2018. Surveys were conducted in an average of 21,411 households at each round of data collection. Overall, sanitation coverage increased by 53 percentage points between baseline and the final round of data collection (95% CI: 52%, 54%). We estimate that 4.8 million people gained access to basic sanitation in these areas during the project period. Most countries also demonstrated movement up the sanitation ladder, in addition to increases in handwashing stations and safe disposal of child feces. When assessing equity—if sanitation coverage levels were similar comparing vulnerable and non-vulnerable groups—we observed that increases in coverage over time were generally comparable between vulnerable groups and non-vulnerable groups. However, the increase in sanitation coverage was slightly higher for higher wealth households compared to lower wealth households. Results from this study revealed a successful model of rural sanitation service delivery. However, further work should be done to explore the specific mechanisms that led to success of the intervention.

Evaluation of Prediction Models for Identifying Malignancy in Pulmonary Nodules Detected via Low-Dose Computed Tomography

Malignancy prediction models based on participant-related characteristics and imaging parameters from low-dose computed tomography (CT) may improve decision-making regarding nodule management and diagnosis in lung cancer screening. To externally validate 5 malignancy prediction models that were developed in screening settings, compared with 3 models that were developed in clinical settings, in terms of discrimination and absolute risk calibration among participants in the German Lung Cancer Screening Intervention trial. In this population-based diagnostic study, malignancy probabilities were estimated by applying 8 prediction models to data from 1159 participants in the intervention arm of the Lung Cancer Screening Intervention trial, a randomized clinical trial conducted from October 23, 2007, to April 30, 2016, with ongoing follow-up. This analysis considers end points up to 1 year after individuals' last screening visit. Inclusion criteria for participants were at least 1 noncalcified pulmonary nodule detected on any of 5 annual screening visits, receiving a lung cancer diagnosis within the active screening phase of the Lung Cancer Screening Intervention trial, and an unequivocal identification of the malignant nodules. Data analysis was performed from February 1, 2019, through December 5, 2019. Five annual rounds of low-dose multislice CT. Discrimination ability and calibration of malignancy probabilities estimated by 5 models developed in data from screening studies (4 Pan-Canadian Early Detection of Lung Cancer Study [PanCan] models using a parsimonious approach including nodule spiculation [PanCan-1b] or a comprehensive approach including nodule spiculation [PanCan-2b], and PanCan-2b replacing the nodule diameter variable with mean diameter [PanCan-MD] or volume [PanCan-VOL], as well as a model developed by the UK Lung Cancer Screening trial) and 3 models developed in clinical settings (US Department of Veterans Affairs, Mayo Clinic, and Peking University People's Hospital). A total of 1159 participants (median [range] age, 57.63 [50.34-71.89] years; 763 [65.8%] men) with 3903 pulmonary nodules were included in this study. For nodules detected in the prevalence round of CT, the PanCan models showed excellent discrimination (PanCan-1b: area under the curve [AUC], 0.93 [95% CI, 0.87-0.99]; PanCan-2b: AUC, 0.94 [95% CI, 0.89-0.99]; PanCan-MD: AUC, 0.94 [95% CI, 0.91-0.98]; PanCan-VOL: AUC, 0.94 [95% CI, 0.90-0.98]), and all of the screening models except PanCan-MD and PanCan-VOL showed acceptable calibration (PanCan-1b: Spiegelhalter z = -1.081; P = .28; PanCan-2b: Spiegelhalter z = 0.436; P = .67; PanCan-MD: Spiegelhalter z = 3.888; P < .001; PanCan-VOL: Spiegelhalter z = 1.978; P = .05; UK Lung Cancer Screening trial: Spiegelhalter z = -1.076; P = .28), whereas the other models showed worse discrimination and calibration, from an AUC of 0.58 (95% CI, 0.46-0.70) for the UK Lung Cancer Screening trial model to an AUC of 0.89 (95% CI, 0.82-0.97) for the Mayo Clinic model. This diagnostic study found that PanCan models showed excellent discrimination and calibration in prevalence screenings, confirming their ability to improve nodule management in screening settings, although calibration to nodules detected in follow-up scans should be improved. The models developed by the Mayo Clinic, Peking University People's Hospital, Department of Veterans Affairs, and UK Lung Cancer Screening Trial did not perform as well.

Visual scoring of aortic valve calcifications on low-dose CT in lung cancer screening.

To evaluate risk factors for prevalence and progression of aortic valve calcification (AVC) in lung cancer screening participants and also to assess the sensitivity and reliability of visual AVCs on low-dose CT (LDCT) for predicting aortic stenosis (AS) in high-risk smokers. We reviewed 1225 consecutive participants in annual LDCT screening for lung cancer at the Mount Sinai Hospital between 2010 and 2017. Sensitivity and specificity of moderate/severe AVC score on LDCT to identify AS on echocardiogram were calculated for 126 participants who had both within 12months. Using regression analyses, risk factors for AVC at baseline, for progression, and for new AVC on annual rounds of screening were identified. Reliability of AVC assessment on LDCT was assessed by comparing visual AVC scores (1) with standard-dose, electrocardiography (ECG)-gated CT for 31 participants who had both within 12months and (2) with Agatston scores of 1225 participants and by determining (3) the intra-reader agreement of 1225 participants. Visual AVC scores on LDCT had substantial agreement with the severity of AS on echocardiography and substantial inter-observer and excellent intra-observer agreement. Sensitivity and specificity of moderate/severe visual AVC scores for moderate/severe AS on echocardiogram were 100% and 94%, respectively. Significant predictors for baseline AVC were male sex (OR = 2.52), age (OR10 years = 2.87), and coronary artery calcification score (OR = 1.18), the significant predictor for AVC progression after baseline was pack-years of smoking (HR10 packyears = 1.14), and significant predictors for new AVC on annual LDCT were male sex (HR = 1.51), age (HR10 years = 2.17), CAC (HR = 1.09) and BMI (HR = 1.06). AVC scores on LDCT should be documented, especially in lung cancer screening program. • LDCT screening for lung cancer provides an opportunity to identify lung cancer and cardiovascular disease in asymptomatic smokers. • Visual aortic valve calcification scores could be reliably evaluated on LDCT and had substantial agreement with the severity of aortic valve stenosis on echocardiography. • Sensitivity and specificity of moderate/severe visual AVC scores on LDCT for moderate/severe AS on echocardiogram were 100% and 94%, respectively.

Molecular xenomonitoring as a post-MDA surveillance tool for global programme to eliminate lymphatic filariasis: Field validation in an evaluation unit in India.

BackgroundLymphatic filariasis (LF) is targeted for elimination by the year 2020. As of 2017, 67 of the 72 endemic countries have implemented annual Mass Drug Administration (MDA) for interrupting LF transmission. Transmission Assessment Survey (TAS) is the recommended protocol to evaluate the impact of MDA and to decide when to stop MDA in an Evaluation Unit (EU, population ≤2 million). As the human infection levels go down with repeated MDA rounds, it becomes a challenge to select the appropriate survey methods to assess transmission interruption. This study validates a standard protocol for molecular xenomonitoring of infection in vectors (MX) at an EU as a complementary tool for TAS to stop MDA and its utility for post-MDA or post-validation surveillance.MethodologyThe study was conducted in Cuddalore district, Tamil Nadu, India, which was found eligible for TAS after 15 annual rounds of MDA (4 with DEC alone and 11 with DEC plus albendazole). The district was divided into two EUs as per the TAS protocol and one EU was randomly selected for the study. A two-stage cluster design vector sampling, developed and validated at a sub-district level, was implemented in 30 randomly selected clusters in the EU. Female Culex quinquefasciatus were collected placing gravid traps overnight (1800–0600 hrs) inside the premises of systematically selected households. Pools of 20–25 blood-fed, semi-gravid and gravid Cx. quinquefasciatus were subjected to real-time quantitative PCR (polymerase chain reaction) assay for detecting Wuchereria bancrofti DNA. Pool infection rate (% of pools positive for W. bancrofti DNA), and the estimated prevalence of W. bancrofti DNA in mosquitoes and its 95% confidence interval were calculated. Additionally, in these 30 clusters, microfilaria (Mf) survey among individuals >5 years old was carried out. School-based TAS was conducted using Immunochromatographic Card Test (ICT) in the EU. Prepared itemized cost-menu for different cost components of MX survey and TAS were estimated and compared.ResultsMX survey showed that only 11 (3.1%) of the 358 pools (8850 Cx.quinquefasciatus females), collected from 30 clusters, were found positive for W. bancrofti DNA. The estimated vector infection rate was 0.13% (95% CI: 0.07–0.22%), below the provisional threshold (0.25%) for transmission interruption. Of 1578 children tested in the TAS, only four (0.25%) were positive for filarial antigenemia, and it is well below the critical cut-off (18 positives) for stopping MDA. Among 9804 persons tested in the 30 clusters, only four were found positive for Mf (0.04%; 95% CI: 0.01–0.1%). The Mf-prevalence was <1% threshold for transmission interruption in humans. The estimated costs for TAS and MX per EU were $14,104 USD and $14,259 USD respectively.ConclusionsThe result of MX protocol was in good agreement with that of TAS, providing evidence to recommend MX as a complementary tool to TAS to decide on stopping MDA. MX can also be a potential surveillance tool for post-MDA and post-validation phases as it could detect sites with residual infection and risk of resurgence of transmission. MX is economically feasible as its cost is slightly higher than that of TAS.

Sustained preventive chemotherapy for soil-transmitted helminthiases leads to reduction in prevalence and anthelminthic tablets required

BackgroundThe goal of soil-transmitted helminthiases (STH) control programmes is to eliminate STH-associated morbidity in the target population by reducing the prevalence of moderate- and heavy-intensity infections and the overall STH infection prevalence mainly through preventive chemotherapy (PC) with either albendazole or mebendazole. Endemic countries should measure the success of their control programmes through regular epidemiological assessments. We evaluated changes in STH prevalence in countries that conducted effective PC coverage for STH to guide changes in the frequency of PC rounds and the number of tablets needed.MethodsWe selected countries from World Health Organization (WHO)‘s Preventive Chemotherapy and Transmission control (PCT) databank that conducted ≥5 years of PC with effective coverage for school-age children (SAC) and extracted STH baseline and impact assessment data using the WHO Epidemiological Data Reporting Form, Ministry of Health reports and/or peer-reviewed publications. We used pooled and weighted means to plot the prevalence of infection with any STH and with each STH species at baseline and after ≥5 years of PC with effective coverage. Finally, using the WHO STH decision tree, we estimated the reduction in the number of tablets needed.ResultsFifteen countries in four WHO regions conducted annual or semi-annual rounds of PC for STH for 5 years or more and collected data before and after interventions. At baseline, the pooled prevalence was 48.9% (33.1–64.7%) for any STH, 23.2% (13.7–32.7%) for Ascaris lumbricoides, 21.01% (9.7–32.3%) for Trichuris trichiura and 18.2% (10.9–25.5%) for hookworm infections, while after ≥5 years of PC for STH, the prevalence was 14.3% (7.3–21.3%) for any STH, 6.9% (1.3–12.5%) for A. lumbricoides, 5.3% (1.06–9.6%) for T. trichiura and 8.1% (4.0–12.2%) for hookworm infections.ConclusionsCountries endemic for STH have made tremendous progress in reducing STH-associated morbidity, but very few countries have data to demonstrate that progress. In this study, the data show that nine countries should adapt their PC strategies and the frequency of PC rounds to yield a 36% reduction in drug needs. The study also highlights the importance of impact assessment surveys to adapt control strategies according to STH prevalence.