Control In sub-Saharan Africa Research Articles

Burden of undiagnosed hypertension in sub-saharan Africa: a systematic review and meta-analysis.

The burden of hypertension in Sub-Saharan Africa has been increasing over the past few decades. However, a large proportion of the population with hypertension remains undiagnosed, untreated, or inadequately treated, contributing to the rising burden of cardiovascular disease in the region. We conducted a systematic review and meta-analysis to assess the recent burden of hypertension in Sub-Saharan Africa, based on studies published between 2000 and 2013. We pooled data from 33 surveys involving over 110 414 participants of mean age 40 years. Hypertension prevalence varied widely across the studies (range 15%-70%), partly because of differences in participant mean ages (31-76 years). The predicted prevalence of hypertension at mean participant ages of 30, 40, 50, and 60 years were 16%, 26%, 35%, and 44%, respectively, with a pooled prevalence of 30% (95% confidence interval, 27%-34%). Of those with hypertension, only between 7% and 56% (pooled prevalence: 27%; 95% confidence interval, 23%-31%) were aware of their hypertensive status before the surveys. Overall, 18% (95% confidence interval, 14%-22%) of individuals with hypertension were receiving treatment across the studies, and only 7% (95% confidence interval, 5%-8%) had controlled blood pressure. This review found a high prevalence of hypertension, as well as low percentage of hypertension awareness, treatment, and control in Sub-Saharan Africa, highlighting the need for implementation of timely and appropriate strategies for diagnosis, control, and prevention.

A cohort study of the effectiveness of insecticide-treated bed nets to prevent malaria in an area of moderate pyrethroid resistance, Malawi.

BackgroundInsecticide-treated bed nets (ITNs) are the cornerstone of malaria control in sub-Saharan Africa but their effectiveness may be compromised by the spread of pyrethroid resistance among malaria vectors. The objective of this investigation was to assess the effectiveness of ITNs to prevent malaria in an area of Malawi with moderate pyrethroid resistance.MethodsOne deltamethrin ITN was distributed in the study area for every two individuals in each household plus one extra ITN for households with an odd number of residents. A fixed cohort of 1,199 children aged six to 59 months was seen monthly for one year and at sick visits to measure malaria infection and use of ITNs. Insecticide resistance among malaria vectors was measured. The effect of ITN use on malaria incidence was assessed, adjusting for potential confounders using generalized estimating equations accounting for repeated measures.ResultsThere were 1,909 infections with Plasmodium falciparum over 905 person-years at risk (PYAR), resulting in an observed incidence of 2.1 infections per person-year (iPPY). ITNs were used during 97% of the PYAR. The main vector was Anopheles funestus: mortality in WHO tube assays after exposure to 0.05% deltamethrin was 38% (95% confidence interval (CI) 29–47), and resistance was due to elevated oxidase enzymes. After adjusting for potential confounders, the incidence of malaria infection among ITN users was 1.7 iPPY (95% CI 1.5-2.1) and among non-bed net users was 2.6 iPPY (95% CI 2.0-3.3). Use of ITNs reduced the incidence of malaria infection by 30% (rate ratio 0.7; 95% CI, 0.5-0.8) compared to no bed nets.ConclusionITNs significantly reduced the incidence of malaria infection in children in an area with moderate levels of pyrethroid resistance and considerable malaria transmission. This is the first study to show that ITNs provide protection in areas where pyrethroid-resistant An. funestus is the major malaria vector. Malaria control programmes should continue to distribute and promote ITNs in areas with low to moderate pyrethroid resistance; however, insecticide resistance may intensify further and it is not known whether ITNs will remain effective at higher levels of resistance. There is an urgent need to identify or develop new insecticides and technologies to limit the vulnerability of ITNs to insecticide resistance.

Cost-effectiveness of larviciding for urban malaria control in Tanzania.

BackgroundLarviciding for malaria control can contribute to an Integrated Vector Management (IVM) approach. This intervention is currently supported in settings where breeding habitats are ‘few, fixed, and findable’, such as urban areas of sub-Saharan Africa, but the knowledge base regarding the cost-effectiveness of larviciding is non-existent.MethodsProgramme costs and effectiveness data were collected from the Dar es Salaam Urban Malaria Control Programme in Tanzania. Cost-effectiveness ratios (CER) were estimated from the provider and societal perspectives for standard indicators using different malaria transmission scenarios.ResultsCER for microbial larviciding were highly dependent on the assumed baseline malaria incidence rates. Using the societal perspective, net CER were estimated (in 2012 US dollars) at $43 (95% uncertainty intervals [UI]: $15-181) per disability-adjusted life year averted (DALY) when malaria incidence was 902 infections per 1,000 individuals, increasing to $545 (95% UI: $337-1,558) per DALY at an incidence of 122 per 1,000. Larviciding was shown to be cost-effective in Tanzania for incidences as low as 40 infections per 1,000 people per year.ConclusionThis is believed to be the first study to estimate the cost-effectiveness of larviciding for urban malaria control in sub-Saharan Africa. The results support the use of larviciding as a cost-effective intervention in urban areas and managers of national malaria control programme should consider this intervention as part of an IVM approach.Electronic supplementary materialThe online version of this article (doi:10.1186/1475-2875-13-477) contains supplementary material, which is available to authorized users.

What's next for tuberculosis control in sub-Saharan Africa?

The recent study from Malawi's Ministry of Health adds to an emerging body of literature from sub-Saharan Africa suggesting that antiretroviral therapy (ART) scale-up reduces the population burden of tuberculosis (TB).1,2 ART has this effect because it reduces the individual risk among people with human immunodeficiency virus (HIV) infection of developing tuberculosis and of transmitting HIV.3 This reduces both the number of people with HIV who develop TB and the number of people with HIV at risk of developing TB. However, people with HIV achieving viral suppression and immune recovery on ART may have higher rates of TB than people without HIV.4 Isoniazid preventive therapy could reduce the risk of TB further among people with HIV on ART.5 Systematic implemention of infection control measures such as ventilation, personal protective equipment and adequate spacing in all health facilities is required to reduce the risk of TB in all people, irrespective of HIV status. As countries in Sub-Saharan Africa improve ART coverage and implementation of the Three I's for HIV/TB, they will have to explore what else needs to be done to reduce the burden of TB in their population. Prompt diagnosis and treatment of active TB remain the foundation of an effective TB response. In recent years, the population effects of achieving high case detection and treatment success rates may have been masked by low ART coverage in sub-Saharan Africa. Given the emergence of drug-resistant TB and the high burden of smear-negative TB, new diagnostics and drugs may be needed to reduce the TB burden in some settings. This may include XpertTM MTB/RIF and bedaquiline.6 National surveillance will be helpful in understanding the relative contribution of achieving high coverage of TB diagnosis and treatment on individual and population outcomes. Many countries are going through epidemiological transition. Controlling emerging risk factors for developing TB, such as diabetes, alcohol use and smoking, may require collaboration across programmes. This could include expanding screening, counselling and access to essential interventions. Many countries are also urbanising and facing inequitable economic development. These trends may have implications for TB risk among people of low socio-economic status due to 1) increased exposure to TB through crowded living and working conditions, 2) malnutrition, 3) limited knowledge about protective health behaviours, 4) use of solid fuels for basic energy needs and 5) limited access to health services.7 Social development programmes and achieving universal health care coverage may thus have important effects on TB control.

A cluster-randomized trial of task shifting and blood pressure control in Ghana: study protocol.

BackgroundCountries in sub-Saharan Africa (SSA) are experiencing an epidemic of cardiovascular disease (CVD) propelled by rapidly increasing rates of hypertension. Barriers to hypertension control in SSA include poor access to care and high out-of-pocket costs. Although SSA bears 24% of the global disease burden, it has only 3% of the global health workforce. Given such limited resources, cost-effective strategies, such as task shifting, are needed to mitigate the rising CVD epidemic in SSA. Ghana, a country in SSA with an established community health worker program integrated within a national health insurance scheme provides an ideal platform to evaluate implementation of the World Health Organization (WHO) task-shifting strategy. This study will evaluate the comparative effectiveness of the implementation of the WHO Package targeted at CV risk assessment versus provision of health insurance coverage, on blood pressure (BP) reduction.MethodsUsing a cluster randomized design, 32 community health centers (CHCs) and district hospitals in Ghana will be randomized to either the intervention group (16 CHCs) or the control group (16 CHCs). A total of 640 patients with uncomplicated hypertension (BP 140–179/90–99 mm Hg and absence of target organ damage) will be enrolled in this study (20 patients per CHC). The intervention consists of WHO Package of CV risk assessment, patient education, initiation and titration of antihypertensive medications, behavioral counseling on lifestyle behaviors, and medication adherence every three months for 12 months. The primary outcome is the mean change in systolic BP from baseline to 12 months. The secondary outcomes are rates of BP control at 12 months; levels of physical activity, percent change in weight, and dietary intake of fruits and vegetables at 12 months; and sustainability of intervention effects at 24 months. All outcomes will be assessed at baseline, six months and 12 months. Trained community health nurses will deliver the intervention as part of Ghana’s community-based health planning and services (CHPS) program.DiscussionFindings from this study will provide policy makers and other stakeholders needed information to recommend scalable and cost-effective policy with respect to comprehensive CV risk reduction and hypertension control in resource-poor settings.Trial registrationNCT01802372.

A systematic review of missed opportunities for improving tuberculosis and HIV/AIDS control in Sub-saharan Africa: what is still missed by health experts?

In sub-Saharan Africa, HIV/AIDS and tuberculosis are major public health problems. In 2010, 64% of the 34 million of people infected with HIV were reported to be living in sub-Saharan Africa. Only 41% of eligible HIV-positive people had access to antiretroviral therapy (ART). Regarding tuberculosis, in 2010, the region had 12% of the world's population but reported 26% of the 8.8 million incident cases and 254000 tuberculosis-related deaths. This paper aims to review missed opportunities for improving HIV/AIDS and tuberculosis prevention and care. We conducted a systematic review in PubMed using the terms ‘missed’(Title) AND ‘opportunities’(Title). We included systematic review and original research articles done in sub-Saharan Africa on missed opportunities in HIV/AIDS and/or tuberculosis care. Missed opportunities for improving HIV/AIDS and/or tuberculosis care can be classified into five categories: i) patient and community; ii) health professional; iii) health facility; iv) local health system; and v) vertical programme (HIV/AIDS and/or tuberculosis control programmes). None of the reviewed studies identified any missed opportunities related to health system strengthening. Opportunities that are missed hamper tuberculosis and/or HIV/AIDS care in sub-Saharan Africa where health systems remain weak. What is still missing in the analysis of health experts is the acknowledgement that opportunities that are missed to strengthen health systems also undermine tuberculosis and HIV/AIDS prevention and care. Studying why these opportunities are missed will help to understand the rationales behind the missed opportunities, and customize adequate strategies to seize them and for effective diseases control.

The Consortium for NCD Prevention and Control in Sub-Saharan Africa (CNCD-Africa): from concept to practice.

CNCD-Africa was established in July 2009 in response to and in recognition of the continuously increasing burden of diseases such as injuries, non-communicable diseases (NCDs) and mental health in low- and middle-income countries, and specifically in countries of sub-Saharan Africa. CNCD-Africa aims to comprehensively address specific and common objectives while building capacity in the region to prevent and control NCDs. With support from key partners and funders, and a keen interest in opportunities to address NCDs from health promotion and equity perspectives, the Consortium has excelled in four key areas: convening; knowledge generation and sharing; advocacy; and networking. However, the path to successful and sustainable efforts remains laden with challenges and barriers. Retaining interest of network partners through flagship efforts and continued efforts to ascertain support from local and international partners with interest in NCDs across the region remain essential to CNCD-Africa core activities. A key lesson learnt from the early years of CNCD-Africa is that existing regional platforms can and should be used to showcase what is being done locally, and to share best practices and best-buys. In addition, partnerships and stakeholder involvement have been key for CNCD-Africa and are essential to NCD action. Sustaining such partnerships requires incentives for the various partners to keep actively involved in NCD action. This can be achieved through joint inception, project planning, implementation, monitoring and evaluation. Another ingredient for success seems to be innovative financing for NCD efforts, which is possible through the establishment and sustaining of regional and global partnerships that are robust, locally relevant and respond to country needs.

Challenges to malaria control and success stories in Africa

Abstract For centuries, malaria has remained a serious public health problem among the human population living in different malaria-transmission settings in sub-Saharan Africa. This region carries almost 90% of all global cases of malaria. Currently, a number of reports indicate that the population of malaria vectors and the percentage of malaria cases are declining in sub-Saharan Africa. The reports further indicate that the significant reduc-tions of malaria morbidity and mortality are more observed in high-risk groups, includ-ing pregnant women and children under the age of 5. The decline in malaria prevalence and transmission has been reported mostly in areas that received massive distributions of malaria-intervention tools and in areas where clinical trials have been conducted. However, the main challenges facing the success stories of malaria control in sub-Saharan Africa are the sustainability of the intervention programs, increase of malarial vector population, and malarial parasites’ resistance to insecticides, and artemisinin-based com-bination therapy. Here, we discuss a number of factors which in one way or another may potentially affect the gains so far achieved in the control of malaria in Africa.Copyright © Maralte. All rights reserved

Factoring Quality Laboratory Diagnosis into the Malaria Control Agenda for Sub-Saharan Africa

Recent progress in malaria control in sub-Saharan Africa has been achieved primarily through provision of insecticide-treated nets, indoor residual spraying, and antimalarial drugs. Although these interventions are important, proper case identification and accurate measurement of their impact depend on quality diagnostic testing. Current availability of diagnostic testing for malaria in sub-Saharan Africa is inadequate to support disease management, prevention programs, and surveillance needs. Challenges faced include a dearth of skilled workforce, inadequate health systems infrastructure, and lack of political will. A coordinated approach to providing pre-service clinical and laboratory training together with systems that support a scale-up of laboratory services could provide means not only for effective malaria case management but also, management of non-malaria febrile illnesses, disease surveillance, and accurate control program evaluation. A synthesis of the challenges faced in ensuring quality malaria testing and how to include this information in the malaria control and elimination agenda are presented.

A New Long-Lasting Indoor Residual Formulation of the Organophosphate Insecticide Pirimiphos Methyl for Prolonged Control of Pyrethroid-Resistant Mosquitoes: An Experimental Hut Trial in Benin

BackgroundIndoor residual spraying (IRS) is widely used for malaria transmission control in sub-Saharan Africa. Resistance to pyrethroids in the mosquito Anopheles gambiae is a growing problem. There is an urgent need to develop long-lasting alternative insecticides to reduce selection pressure for pyrethroid resistance and to provide control with a single IRS application in countries with long transmission seasons.MethodsTwo capsule suspension formulations (CS) of the organophosphate pirimiphos methyl were evaluated as IRS treatments in experimental huts in an area of Benin where the mosquitoes Anopheles gambiae and Culex quinquefasciatus are resistant to pyrethroids but susceptible to organophosphates. The CS formulations were tested alongside an emulsifiable concentrate (EC) formulation of pirimiphos methyl and a CS formulation of the pyrethroid lambdacyhalothrin.ResultsThe two CS formulations of pirimiphos methyl gave prolonged control of An. gambiae and Cx. quinquefasciatus. In cement huts application rates of 0.5 g/m2 induced high mortality of An. gambiae for almost a year: overall mortality rates 87% (95% CI 82–91%) and 92% (95% CI 88–94%). In mud huts application rates of 1 g/m2 induced high mortality of An. gambiae for 10 months: overall mortality rates 75% (95% CI 69–81%) and 76% (95% CI 68–83%). The EC formulation of pirimiphos methyl failed to control An. gambiae two months after spraying. The pyrethroid lambdacyhalothrin demonstrated prolonged residual activity in bioassay tests but failed to control pyrethroid resistant An. gambiae that entered the huts. Pirimiphos methyl CS was highly active against Culex quinquefasciatus and gave control for 10 months in cement huts and 6 months in mud huts.ConclusionPirimiphos methyl CS (Actellic 300 CS) applied at 1 g/m2 shows great promise for providing prolonged control of pyrethroid-resistant An gambiae and for delaying pyrethroid resistance. An alternative to DDT, giving year-round transmission control in sub-Saharan Africa is now a realistic prospect.

Challenges and opportunities in cancer control in Africa: a perspective from the African Organisation for Research and Training in Cancer

Sub-Saharan Africa has a disproportionate burden of disease and faces a major public-health challenge from non-communicable diseases. Although infectious diseases continue to afflict Africa, the proportion of the overall disease burden in sub-Saharan Africa attributable to cancer is rising. The region is predicted to have a greater than 85% increase in cancer burden by 2030. Approaches to minimise the burden of cancer in sub-Saharan Africa in the past few years have had little success because of low awareness of the cancer burden and a poor understanding of the potential for cancer prevention. Success will not be easy, and will need partnerships and bridges to be built across countries, economies, and professions. A strategic approach to cancer control in sub-Saharan Africa is needed to build on what works there and what is unique to the region. It should ideally be situated within strong, robust, and sustainable health-care systems that offer quality health care to all people, irrespective of their social or economic standing. However, to achieve this will need new leadership, critical thinking, investment, and understanding. We discuss the present situation in sub-Saharan Africa and propose ideas to advance cancer control in the region, including the areas of cancer awareness, advocacy, research, workforce, care, training, and funding.

Rationale for short course primaquine in Africa to interrupt malaria transmission

Following the recent successes of malaria control in sub-Saharan Africa, the gametocytocidal drug primaquine needs evaluation as a tool to further reduce the transmission of Plasmodium falciparum malaria. The drug has scarcely been used in Africa because of concerns about its safety in people with glucose-6-phosphate dehydrogenase (G6PD) deficiency. The evidence base for the use of primaquine as a transmission blocker is limited by a lack of comparable clinical and parasitological endpoints between trials. In March 2012, a group of experts met in London to discuss the existing evidence on the ability of primaquine to block malaria transmission, to define the roadblocks to the use of primaquine in Africa and to develop a roadmap to enable its rapid, safe and effective deployment. The output of this meeting is a strategic plan to optimize trial design to reach desired goals efficiently. The roadmap includes suggestions for a series of phase 1, 2, 3 and 4 studies to address specific hurdles to primaquine’s deployment. These include ex-vivo studies on efficacy, primaquine pharmacokinetics and pharmacodynamics and dose escalation studies for safety in high-risk groups. Phase 3 community trials are proposed, along with Phase 4 studies to evaluate safety, particularly in pregnancy, through pharmacovigilance in areas where primaquine is already deployed. In parallel, efforts need to be made to address issues in drug supply and regulation, to map G6PD deficiency and to support the evaluation of alternative gametocytocidal compounds.

Challenges of controlling contagious bovine pleuropneumonia in sub-Saharan Africa

Contagious bovine pleuropneumonia (CBPP) is a disease of economic importance that is widely distributed in sub-Saharan African and contributes significantly to cattle morbidity and mortality. Control of CBPP offers a number of challenges as a result many developing countries in Africa are still struggling with this disease. In this study, we look at the challenges encountered in CBPP control in sub-Saharan Africa from the Zambian perspective. In conducting this study, we reviewed scientific literature and reports from the Ministry of Agriculture and Livestock and related animal institutions, and also made interviews with experts and key government officials involved in CBPP control in Zambia. Among the challenges identified for the successful control of CBPP were as follows: failure in the delivery of veterinary services, lack of a cattle identification system, natural phenomenon, livestock husbandry systems in the traditional sector, human movements, traditional practices among cattle farmers and cattle marketing systems. It was seen that the epidemiology of CBPP in Zambia is influenced by both ecological and anthological factors. Therefore, design and implementation of any control or eradication programme should be area/regional-dependent taking into account the different factors influencing disease transmission and maintenance.

Therapeutic Efficacy of Artemether-Lumefantrine for the Treatment of Uncomplicated Plasmodium falciparum Malaria in Northern Ethiopia

Introduction. Multidrug resistance of Plasmodium falciparum is spreading throughout Africa. This has posed major challenges to malaria control in sub-Saharan Africa. Objective. The aim of the study was to evaluate the efficacy of artemether-lumefantrine for the treatment of uncomplicated Plasmodium falciparum malaria in North Ethiopia. Methods. This prospective study was undertaken during August–November 2009 on 71 malaria patients that fulfilled the inclusion criteria set by the WHO. Patients were followed up for 28 days. Thick and thin blood films were prepared by Giemsa stain for microscopy to determine parasite density. A standard six-dose regimen of artemether-lumefantrine was administered over three days and was followed up with clinical and parasitological evaluations over 28 days. Results. The cure rate (ACPR) was found to be high (97.2%) in this study. The parasite and fever clearance time was also rapid. Artemether-lumefantrine for the treatment of acute uncomplicated Plasmodium falciparum malaria in the study area showed 97.2% cure rate and only 2.8% failure rate. Conclusion. The result showed that the drug could continue as first line for the treatment of uncomplicated Plasmodium falciparum malaria in the study area. The efficacy of artemether-lumefantrine needs to be carefully monitored periodically in sentinel sites representing different areas of the country.

Measles control in Sub-Saharan Africa: South Africa as a case study

Due to intensified measles immunization efforts, measles mortality has decreased substantially worldwide, particularly in Sub-Saharan Africa (SSA). The World Health Organization (WHO) estimated a 92% decrease in measles-related deaths in the WHO AFRO region for the period 2000-2008. Recently, the AFRO region established a measles pre-elimination goal and experts have suggested engaging in a measles eradication campaign at the global level. However, recent large-scale outbreaks in many Sub-Saharan African countries present a challenge to measles control efforts. This paper examines measles immunization and the impact of measles supplemental immunization activities (SIAs) on routine immunization coverage in South Africa (SA). We reported on immunization coverage trends in SA for the period 2001-2010 at the province and district levels. The data included routine immunization for 1st and 2nd doses of measles vaccine (MCV1, MCV2), SIAs, 1st dose of Bacille Calmette-Guérin vaccine, 1st and 3rd doses of oral polio vaccine (OPV1, OPV3), 3rd dose of Diphtheria-Tetanus-Pertussis-Haemophilus-influenzae-B vaccine (DTP-Hib3), and the number of under-one-year-olds having completed a primary course of immunization (Imm1). A regression model looked at the SIA impact on routine coverage. Over the past decade, MCV1 and MCV2 coverage have increased nationally from 68% and 57% in 2001 to 95% and 83% in 2010, respectively. SIA coverage has remained at high levels, around 90%, over the same period. Substantial heterogeneity in MCV1 and MCV2 coverage is present across SA districts, with differences in coverage of 56% (MCV1) and 51% (MCV2) in 2010. In any given year, occurrence of SIAs was associated with a decrease in routine immunization coverage of MCV1, MCV2, OPV1, OPV3, DTP-Hib3, and Imm1, at the district level. The heterogeneity in measles vaccination coverage across SA districts challenges the goal of measles elimination in SA and SSA. The reduction in routine immunization coverage associated with the occurrence of SIAs raises the legitimate concern that SIAs may negatively impact health systems' functioning.

Challenges in malaria control in Sub-Saharan Africa: The vaccine perspective

Malaria is a life-threatening disease of public health importance, especially in sub-Saharan Africa. It is estimated that about 500 million cases of malaria occur annually and among these 1 million die annually. Children below five years and pregnant women are the most vulnerable groups. Several malaria control measures have been applied such as environmental improvements, use of insecticide impregnated nets, residual indoor spraying, early case detection and treatment with effective antimalarial drugs. However, the adaptation of vector and parasite has so far limited the effect of these interventions. The emergence of resistance against drugs and insecticides requires in response a steady stream of new interventions. Up to the beginning of this millennium, most sub-Saharan African countries have been using chloroquine (CQ) as the first-line antimalarial drug, which had to be replaced with sulphadoxine-pyrimethamine (SP) after resistant parasites had rendered CQ ineffective. Currently the first line treatment of malaria consists of combination therapy which includes an artemisinin derivative. The current approach appears robust but history has taught us to be alert and to expect resistance to emerge. There is a pressing need to develop and deploy complimentary strategies. Adding a protective vaccine to the existing control tools for malaria holds great promise yet no malaria vaccine has ever been licensed despite a large number of attempts. The complexity of malaria parasites and the ability of the parasite to suppress and evade immune responses are formidable challenges. Fortunately, there are several promising antimalarial vaccine candidates in the development pipeline. The most promising vaccine candidate is RTSS which is currently tested in various countries in sub-Saharan Africa, including two sites in Tanzania. There is a hope that malaria vaccines could be developed and deployed in malaria endemic communities. This article highlights the challenges of developing and deploying malaria vaccines.

Praziquantel: its use in control of schistosomiasis in sub-Saharan Africa and current research needs

Treatment with praziquantel (PZQ) has become virtually the sole basis of schistosomiasis control in sub-Saharan Africa and elsewhere, and the drug is reviewed here in the context of the increasing rate that it is being used for this purpose. Attention is drawn to our relative lack of knowledge about the mechanisms of action of PZQ at the molecular level, the need for more work to be done on schistosome isolates that have been collected recently from endemic areas rather than those maintained in laboratory conditions for long periods, and our reliance for experimental work mainly on Schistosoma mansoni, little work having been done on S. haematobium. There is no evidence that resistance to PZQ has been induced in African schistosomes as a result of its large-scale use on that continent to date, but there is also no assurance that PZQ and/or schistosomes are in any way unique and that resistant organisms will not be selected as a result of widespread drug usage. The failure of PZQ to produce complete cures in populations given a routine treatment should therefore solicit considerable concern. With few alternatives to PZQ currently available and/or on the horizon, methods to monitor drug-susceptibility in African schistosomes need to be devised and used to help ensure that this drug remains effective for as long a time as possible.

Knowledge of tuberculosis and its management practices among medical interns in a resource-poor setting: implications for disease control in sub-Saharan Africa

Knowledge of tuberculosis and its management practices among medical interns in a resource-poor setting: implications for disease control in sub-Saharan Africa

Recent progress in integrated neglected tropical disease control

Three years have passed since the publication of the first of a series of policy papers, which first highlighted the under-appreciated global burden of the neglected tropical diseases (NTDs) and then outlined a rationale for linking vertical control strategies for the seven most prevalent NTDs in a cost-effective pro-poor package of preventive chemotherapy. Since then, global advocacy for these conditions has increased and, with it, new funds for scale-up of integrated NTD control in sub-Saharan Africa. Recent speeches by the Director General of the World Health Organization at regional meetings have referred to NTDs as important global health priorities (www.who.int/dg/speeches/2007). Outlined here is a summary of the recent progress in global efforts to integrate NTD control, with an emphasis on the challenges that lie ahead.

Impact and Process Evaluation of Integrated Community and Clinic-Based HIV-1 Control: A Cluster-Randomised Trial in Eastern Zimbabwe

BackgroundHIV-1 control in sub-Saharan Africa requires cost-effective and sustainable programmes that promote behaviour change and reduce cofactor sexually transmitted infections (STIs) at the population and individual levels.Methods and FindingsWe measured the feasibility of community-based peer education, free condom distribution, income-generating projects, and clinic-based STI treatment and counselling services and evaluated their impact on the incidence of HIV-1 measured over a 3-y period in a cluster-randomised controlled trial in eastern Zimbabwe. Analysis of primary outcomes was on an intention-to-treat basis. The income-generating projects proved impossible to implement in the prevailing economic climate. Despite greater programme activity and knowledge in the intervention communities, the incidence rate ratio of HIV-1 was 1.27 (95% confidence interval [CI] 0.92–1.75) compared to the control communities. No evidence was found for reduced incidence of self-reported STI symptoms or high-risk sexual behaviour in the intervention communities. Males who attended programme meetings had lower HIV-1 incidence (incidence rate ratio 0.48, 95% CI 0.24–0.98), and fewer men who attended programme meetings reported unprotected sex with casual partners (odds ratio 0.45, 95% CI 0.28–0.75). More male STI patients in the intervention communities reported cessation of symptoms (odds ratio 2.49, 95% CI 1.21–5.12).ConclusionsIntegrated peer education, condom distribution, and syndromic STI management did not reduce population-level HIV-1 incidence in a declining epidemic, despite reducing HIV-1 incidence in the immediate male target group. Our results highlight the need to assess the community-level impact of interventions that are effective amongst targeted population sub-groups.