Tropical Health Matters

On August 20, 2024, esaayman posted this blog about Hepatitis C in the class blog of the course, Social and Behavioral Foundations of Primary Health Care at the Johns Hopkins Bloomberg School of Public Health.

Hepatitis C remains a significant public health burden in South Africa, disproportionately affecting people who inject drugs, with the highest prevalences, monitored by the South African Community Epidemiological Network on Drug Use and the National Institute for Communicable Diseases, ranging from 68% to 94% in Tshwane. Despite national guidelines and an action plan for viral hepatitis recommending direct acting antiviral therapy and point-of-care technology use for hepatitis c management in people who inject drugs since 2019, with treatment registration by SAHPRA since 2020, access remains limited. The essential medicines list restricts treatment to tertiary level liver clinics. These clinics are often inaccessible to people who inject drugs due stigma, and stringent abstinence-based criteria for treatment.

_{Community hepatitis C screening at Sediba Hope Medical Centre (Source: SHMC, 2024)}

While community-based HIV-focused harm reduction services, such as opioid agonist therapy, exist, they are primarily managed by donor-funded civil society organizations, with limited integration into public healthcare systems. The City of Tshwane’s health department in partnership with the University of Pretoria initiated opioid agonist therapy services at primary care level in 2016, however with limited resources allocated, hepatitis c screening and treatment remains sporadic. A local pilot study, offered by Sediba Hope Medical Centre, a public-private partnership-based clinic for marginalized communities, has demonstrated successful community-based hepatitis c treatment integration, signalling for sustained access to care at the appropriate level.

_{HIV and viral hepatitis prevalence in South Africa (Source: INHSU, 2021)}

Improved access to treatment within the city would require purposeful implementation of hepatitis c treatment guidelines alongside best practices from harm reduction guidelines and national action plans. This includes training of primary care providers to manage uncomplicated cases, further supported by specialist through existing mentoring platforms. To strengthen clear referral pathways, collaboration between liver clinics and community-based harm reduction and primary care facilities is required, building on the use of existing inter-facility referral applications and decentralized medication delivery options. Additionally, dedicated funds for adequate diagnostic tools, care coordination staff, and medication procurement should be considered on a national level, with the same urgency as with the HIV response. By implementing these strategies, Tshwane can expand access to hepatitis c treatment for people who inject drugs, thereby aiming to become the first South African city to achieve micro-elimination, averting adverse health outcomes for people who inject drugs. Implementation strategies and outcomes should be documented to inform increased treatment coverage nationally, further advocating for the consideration of direct acting antivirals for inclusion in the primary care essential medicines list.

According to MinahHAli, polio is still with us as seen in this posting about polio challenges in the class blog of the course, Social and Behavioral Foundations of Primary Health Care at the Johns Hopkins Bloomberg School of Public Health

Image Source: UNHCR

After a much-desired decrease of polio cases in Pakistan, the recent increase in cases reported has been alarming. This latest surge coincided with the Afghan Refugee Crisis in Pakistan, showcasing the impact of government policies in the success of polio eradication.

What is Polio? Polio, also known as poliomyelitis, is a viral disease which affects nerves in the spinal cord or brain stem leading to paralysis and death in some cases. Poliovirus rapidly spreads either via feces or droplets from coughing/sneezing. Polio mainly affects unvaccinated children.

Why are Polio vaccination initiatives focused on Pakistan and Afghanistan? Are all polio cases the same? Pakistan and Afghanistan are the last two countries in the world which consistently report polio cases. Despite spending $9.3 billion over the course of 10 years (2013-2023) polio cases remain present in Pakistan.  According to WHO, Polio cases in Afghanistan can be traced back to one variant: YB3A. However, recently polio cases in Pakistan are now also from YB3A variant.

Image Source: CNN

What is the Afghan Refugee Crisis and how is it fueling the spread of polio? Pakistan is the largest host country for Afghan refugees since 1979 post-Soviet invasion. In 2019, Ministry of National Health Services, Regulation and Coordination in Pakistan, along with UNHCR, promised healthcare which included polio vaccination to Afghan refugees. However, due to increased security threats recently near the Pak-Afghan border these efforts have stopped.

Due to attacks on Pakistani soil which have been linked to Afghan terrorist groups, the Federal Government of Pakistan is currently forcibly relocated Afghan refugees back to Afghanistan. Due to this, many Afghans refugees refuse to seek healthcare in the fear of being reported and deported.

Why are the polio eradication programs failing? The political climate in Pakistan, especially in the Khyber Pakhtunkhwa province which borders Afghanistan, is tense; heightened insecurity, fueled with tribal conflicts amongst Pakistanis and Afghanis residing in the area is making polio vaccination programs “almost impossible”, according to polio eradication lead at Bill and Melinda Gates foundation.

By neglecting the on-going polio spread amongst Afghan refugees, Poliovirus is making its way into Pakistani citizens/communities.  It is imperative that the Ministry of National Health Services, Regulation and Coordination, as well as the provincial Khyber Pakhtunkhwa Government increase their efforts for polio vaccination- regardless of immigration status.

On August 20, 2024, Yasir Ahmed Posted this blog about polio challenges in the class blog of the course, Social and Behavioral Foundations of Primary Health Care at the Johns Hopkins Bloomberg School of Public Health

Pakistan and Afghanistan are the only countries in the world reporting wild type polio virus cases. Polio is a crippling disease that does not have any cure but it is preventable through immunization. The detection of wild-type virus in wastewater suggests 2024 target of ending all wild virus transmission will be missed. 6 cases were reported in 2023 and 14 have been reported this year so far.  According to a report by IMB, an estimated 300,000 children have been consistently missed in vaccination activities in Pakistan and in the East region of Afghanistan. Disinformation, false beliefs and mistrust on the government and administration, refusal, not understanding the importance of vaccines, and low general literacy and health literacy etc. are among the important factors contributing to these missed opportunities.

In addition to the above-mentioned factors, insecurity, movement across the porous 2400 kilometers long Pakistan-Afghan border, and poor water and sanitation and waste management are the contributing factors. I believe that the missed opportunities to reach and vaccinate these children has a major role in the spread of poliovirus along with poor water and sanitation in these areas.

The program uses four distinct risk tiers to classify areas according to the risk they present and to devise risk appropriate strategies. Core reservoir districts (or Tier 1 districts), high-risk districts (or Tier 2 districts), vulnerable districts (or Tier 3 districts), and low-risk districts (or Tier 4 districts). Most of the tier 1 and tier 2 areas are located on the western border aka Pakistan-Afghan border (upper parts on the map).

Pakistan Polio Eradication Program is an initiative that is driven by the largest surveillance network in the world (up to 339,521 trained and dedicated polio workers), quality data collection and analysis, behavioral change communication, laboratories, and epidemiologists and public health experts in Pakistan, working with experts and local and international stakeholders. The government started National Emergency Action Plan for Polio Eradication in 2010, which runs supplemental immunization activities on regular basis to reach every child in Pakistan. As a result, a huge decline in the number of polio cases is seen since the 90’s. The World Health Organization (WHO) and UNICEF along with other key partners of the Global Polio Eradication Initiative, has been a very supportive to the Government of Pakistan in polio eradication. Gavi the vaccine alliance, the Center of Disease Control (CDC), Rotary International, and Bill and Melinda Gates Foundation are important stakeholders that provides major financial, technical and field support.

A Polio-worker is pictured giving an oral polio vaccine during an immunization campaign.

Innovative approaches are required to reach the children missing vaccinations including:

• Expanding the network and improving data collection and surveillance, targeting the areas of high density with polio cases e.g., the tribal areas along the porous Pak-Afghan border.
• Mandatory vaccination at border crossing.
• Increased security for the polio workers.
• Taking local religious and community leaders and scholars on-board to counter disinformation and false beliefs.
• Continuation and strengthening of National Emergency Action Plan for Polio Eradication by the government of Pakistan.

Continued efforts and support from the local and international stakeholders as we are getting very close global polio eradication.

The challenges of maternal and child health is the theme of a posting by Dr Ashraf in the class blog of the course, Social and Behavioral Foundations of Primary Health Care at the Johns Hopkins Bloomberg School of Public Health.

Rural areas in Bangladesh, like Zakiganj, a subdistrict located in northeastern border region of Sylhet district, continue to face significant health challenges despite the nation’s overall progress in healthcare. With a population of approximately 250,000, Zakiganj is served by only one 50-beded government health center. The inadequate infrastructure, shortage of trained healthcare providers and low healthcare services contributes to the higher maternal and infant mortality rates compared to surrounding regions.

The photo shoes a community health worker of PRF visiting a household during surveillance, Zakiganj. According to UNICEF, in 2014, Sylhet had the lowest disparities in key maternal and newborn health interventions compared to most districts in Bangladesh. This is of great concern and requires policy level discussions with key stakeholders and intervention to improve maternal and child health.

The statistics are provided from Maternal and Newborn Health Disparities, Bangladesh, UNICEF.To address these issues, we advocate for enhanced policy measures focusing on increasing healthcare funding, expanding the number of healthcare facilities, improving infrastructure, and implementing comprehensive training programs for healthcare workers. Such measures can ensure that mothers and children in Zakiganj receive the quality care they need. Even newborn health care is possible in rural areas like Zakiganj.

Key stakeholders in this advocacy would include the Ministry of Health and Family Welfare, UNICEF Bangladesh, Projahnmo Research Foundation, PRF, World Health Organization (https://www.who.int/bangladesh ), BRAC, and Save the Children Bangladesh. Each organization brings unique strengths to the table, starting from policy implementation to providing technical support, quality training to health care workers and on ground services. Their collaboration and support is essential for a holistic approach to improving health outcomes in this region.

Call for Action:

We urge the Ministry of Health and Family Welfare to prioritize maternal and child health in Zakiganj by increasing funding and resources. Collaborating with organizations like PRF and BRAC will provide the necessary evidence including their years of research in this region, and pilot programs to support these policy changes. Immediate action is very important to reduce mortality rates and improve the overall health of mothers and children in rural Zakiganj.

Mickelder Kercy (mkercy1) posted this entry on lead exposure in Haiti in the class blog of the course, Social and Behavioral Foundations of Primary Health Care at the Johns Hopkins Bloomberg School of Public Health

Graph Data Source: American Heart Association

Recent studies conducted in Haiti revealed that lead exposure increases the risk of hypertension, a major cardiovascular or non-communicable disease. Among children, lead is responsible for several mental and behavioral disorders. Sources of lead exposure includes contaminated drinking water, paint, and batteries.

Laws have been enacted to regulate the prevention and management of exposure to environmental toxicants. These laws mandate institutions to supply safe water, ministry of health to provide adequate care, and companies to sell and safely dispose of their products without harm to population members. Currently, these overarching laws are not being implemented due to political instability, poor governance at the national and municipality levels, and deteriorating socio-economic conditions nationwide.

Several initiatives have been taken that could address lead exposure in Haiti:

• The Ministry of the Environment (MdE) sought the financial assistance of the Global Environment Facility (GEF) to improve the drinking water system.
• The Global Environment Facility (GEF) has allocated $4.5 million from the Least Developed Countries Fund (LDCF) to the Ministry of the Environment project to help strengthen policies, regulatory bodies, and organizations in support of the management, supply, and access to clean drinking water (SDG 6) in Haiti starting 2023.
• The Presidential Transitional Council (CPT) plans to budget $7,590,221 for waste management in the capital of Haiti.

Current initiatives are promising stirring up among population members the optimistic view that they could signal a departure from decades of inefficiency and ineffectiveness in government affairs. As recommended,

• The Ministry of the Environment (MdE) and Presidential Transitional Council (CPT) should demonstrate accountability, transparency, and proficiency in current projects.
• The Presidential Transitional Council (CPT) should prioritize waste management according to international standards in the triage and disposal of hazardous wastes such as lead-based batteries.
• The Ministry of Public Health and Population (MSPP) should promote lead exposure prevention in businesses and at the population level, and management across all primary health care facilities.
• Sustainable lead exposure mitigation is a necessity. Based on current human capital and financial resources, the MdE and MSPP could potentially seek out-of-country technical assistance from
  • The Lead Exposure Elimination Project to inventory lead-based paints and reformulate them into safer products nationwide, and

The Pure Earth to train employees in the Initial Site Screening (ISS) protocol application to update current maps of lead contaminated sites across all 10 departments in Haiti.

On August 18, 2024 Aprotim Cory Bhowmik posted this entry on Dengue in the class blog of the course, Social and Behavioral Foundations of Primary Health Care at the Johns Hopkins Bloomberg School of Public Health

Dengue is an illness that we are not too familiar with in the United States, but it can have severe and sometimes deadly effects, including fever, fatigue, body aches, lymphadenopathy, and an increased chance of bleeding. This disease is spread by the Dengue virus, which is carried by the Aedes aegypti mosquito. West Bengal, a state in India, has become infamous for being a hub of Dengue infection. In 2022, with a population of over 100 million people, West Bengal had over 60,000 cases and 30 deaths.

Photo: A clinic with patients being treated for Dengue infection. (Romita Datta, India Today)

Since insect-borne diseases such as malaria are also common in this region, the people have thorough knowledge of how Dengue is spread and how mosquito nets and insect spray can be effective. Despite the daily use of these measures, however, Dengue continues to have a strong hold on the community due to (1) the presence of bodies of water that attract mosquitoes and (2) the presence of unsanitary sites (e.g., trash accumulation).

So, what can be done? The resolution would require steps to eliminate unwanted bodies of water and reduce sites of trash accumulation. Some government departments have addressed these issues:

• Department of Panchayats and Rural Development: surveys 300 households per week on cleanliness for Dengue prevention
• Department of Environment: has projects on pollution, coastal management, and biodiversity–but not Dengue prevention
• Urban Affairs and Municipal Affairs Department: surveys households regularly
• Department of Health: discusses treatment, but not prevention, of Dengue infection

However, these departments have either (1) nonspecific descriptions of their actions to decrease Dengue infection or (2) have no results documented. In order to decrease the incidence of Dengue, it would be prudent to press the most active department — Panchayats and Rural Development– on the results of their surveys and whether cleanliness has actually improved.

Irrespective of these results, there has been no data showing a decrease in Dengue infection in West Bengal as a whole. A reasonable proposal would be to incentivize the cleaning of unsanitary sites and inappropriate bodies of water by giving tax cuts to those that comply and/or levying fines for non-adherence. This reward system is common in many parts of the world, and unless concrete steps like incentivization are taken, Dengue infections will not decrease anytime soon.

As President Jimmy Carter nears his 100th birthday, his opponent of nearly four decades, guinea worm disease, is nearing its end. By emphasizing the importance of data and surveillance, the Carter Center has found no reported cases in the first three months of 2024, and only 14 cases in 2023.

The effort to eliminate the disease has been approaching zero annual cases for a decade, but the remote settings where the worm is found coupled with civil strife have made this water borne pathogen a challenging opponent. The remaining cases have been confined to Sahelian countries where clean water is always in short supply and is more serious now with climate change. To add to the challenges, domestic dogs that share seasonal ponds with their humans have also become a reservoir of guinea worm in places like Chad.

The coming months will provide crucial evidence on elimination progress in these countries where the advent of the rainy season when small ponds begin to fill and the small crustaceans that serve as vector or intermediate for the worm larvae emerge. This is a time in which people who might have swallowed the infected crustaceans from local ponds last year may experience the emergence of a subcutaneous worm that may have been growing for the past year. Hopefully 2024 and President Carter’s 100th year will mark the end of guinea worm either with no new dates, or if a few do emerge, they are quickly identified and contained so the affected person does not enter a water source with an open ulcer.

Lack of safe and clean water remains a serious problem throughout the region and always poses a threat for the reintroduction of guinea worm in the 200 countries that have already certified elimination. Progress for human development demands that we continue the fight for safe and reliable water even after there is no more guinea worm.

The class blog for Social and Behavioral Foundations of PHC features a posting by Alice Calhoun on the importance of pilot implementation of the new malaria vaccine in Kenya. Her comments are found below.

Since 2019, significant improvements in death rates and hospitalizations from malaria in young children have been made in Kenya after initiating the pilot malaria vaccine trial, Malaria Vaccine Implementation Programme (MVIP) involving children under 2 years old. Under the leadership and support from WHO, GAVI, and PATH and many other stakeholders, Kenya was able to benefit from the RTS,S vaccine that was developed for over 35 years by GlaxoSmithKline Pharmaceuticals. As the vaccination program continues in Western Kenya, parents in Vihiga County have noted that their children who have been vaccinated are less sick than their older siblings. The 4 part vaccination series typically begins at age 6 months with its completion at 24 months.

Malaria prevention must have a multi-faceted approach to be successful in eradicating this terrible disease from the community. This includes using insecticide treated bednets, indoor spraying, rapid diagnosis and treatment of active malaria, and malaria prevention during pregnancy. By using education and collaboration with groups such as the Kenya Malaria Youth Army, community health workers (CHW) are the key to disseminating information to the villages and encouraging mothers to complete the series for their children. CHW are also providing catch up vaccinations for other diseases while supporting the malaria campaign in Kenya by handing out bednets.

Now is the time for the Ministry of Health (MOH) to expand the vaccine program to all children under 5 years of age, some of whom missed out on the initial set of vaccines due to vaccine hesitancy during the COVID pandemic. The benefits have been seen by the community in Vihiga County and the attitudes of the mothers are now overwhelmingly positive. Due to the dedication of the CHW and the Immunization Coordinator, nurse Edith Anjere, Vihiga County has the highest rate of childhood immunization coverage in Kenya: up to 96% of children as surveyed in 2022.

Vihiga County is the perfect community to capture more children in the vaccination program since the health infrastructure is already in place as well as an openness in the community to continue vaccinating our children. The MOH can support this nationwide campaign against malaria by allowing other vulnerable children access to RTS,S in Vihiga County, serving as a model program for other counties. Kenya has been at the forefront of the malaria vaccination program and will continue to inspire other countries in Africa to work toward this goal of keeping our most vulnerable citizens healthier.

The term “vaccine hesitancy” is relatively new jargon that is defined in Wikipedia as, “… a delay in acceptance, or refusal, of vaccines despite the availability of vaccine services and supporting evidence.” The World Health Organization considers Vaccine Hesitancy among the top 10 threats to global public health. Vaccine hesitancy is primarily a matter of trust in institutions, technology, government, and health workers among others, according to Unfried and Priebe. Thus, hesitancy has social and political dimensions. This public health concern now extends into the realm of malaria control and elimination.

After many years of testing for efficacy and implementability, we now have two malaria vaccines. Therefore, it is not surprising that the issue of hesitancy has been identified as a potential challenge. Hussein et al. studied parents in Ghana and found that “About one-third (34.5%) of the parents were hesitant to give their children the R21/Matrix-M malaria vaccine,” even though “showed a high safety and efficacy level, and Ghana is the first country to approve this new vaccine.” It seems that parents who had not been getting routine vaccinations for their children were among those who were more hesitant.

The experience with door-to-door oral polio vaccine outreach campaigns from twenty plus years ago, shows that the general problem of avoidance or reluctance is nothing new,  but often rooted in political and cultural factors, according to Jegede. Covid-19 has shed new light on the problem as explained in the Lancet: “COVID-19 vaccines to low-income and middle-income countries (LMICs) is threatened by vaccine hesitancy. In Africa in particular, the low vaccine coverage and the ubiquitous vaccine hesitancy in a concerning proportion of the population undermine efforts to fight the COVID-19 pandemic.”

It should be noted that the term ‘hesitancy’ puts the blame for not vaccinating children and others on community members and health care consumers. When the expanded program on immunization started 50 years ago, there was recognition that reasons for seeking or not obtaining vaccines were multifaceted and included much more than consumer knowledge and attitudes. Health system factors and economic barriers were of equal concern. We need to return to those days when we took a holistic view on how to promote vaccine uptake.

Low levels of vaccine overage go beyond trust. When the Wikipedia definition mentions “despite the availability” there is the assumption that in fact vaccines are available, which is a major logistics, economics, and systems challenge. Fortunately, Mutombo et al. in the Lancet stress the other factors for low vaccine coverage including “historical, structural, and other systemic dynamics that underpin vaccine hesitancy.” They address serious supply problems wherein the global community has not made a “firm commitment to expedite vaccine deployment to the African continent.” It is not surprising that Nigeria has the highest level of unmet demand for COVID-19 vaccines in the world. Wollburg et al. also note that “Many who are willing to get vaccinated are deterred by a lack of easy access to vaccines at the local level.”

Concerning the two malaria vaccines, UNICEF notes that “It is clear that the demand is very high and far surpasses the supply that is expected to become available.” Concerns revolve around production capacity, supply chain management, integration within the health system’s existing immunization programs, pricing, and partnerships. While it is useful to plan ways to counteract hesitancy, such efforts will not be relevant is there is inadequate supply to meet current and projected demand and needs. As Gavi explains, “partners will also work with countries to provide orientation and technical assistance to ensure quality planning and country readiness.”

Anthony AHUMIBE is a staff member of Nigeria CDC and presently a doctoral student at the Institute of Tropical Medicine, Nagasaki University, Nagasaki, Japan. Herein he examines the challenges posed by Lassa Fever to the West African region.

Following the West Africa Ebola epidemic of 2014, the global community has been preoccupied with Lassa fever, a zoonotic viral infection that has caused sickness and death in some communities in Nigeria, Liberia, Sierra Leone, and Guinea. Familiar challenges like absence of vaccine and point of care diagnostics are being handled through investments in research and development. There are, however, some imperceptible yet weighty challenges along the path of Lassa fever control.

The recent finding by Happi and colleagues shows that several species of household rodents, nonspecific to the familiar multimammate rats and other peri-urban small animals carry the Lassa virus and demonstrate that the virus is adapting. Conversely the economic turn of events in the endemic countries indicates that more people are moving into poverty and are unable to make proper hygiene choices. Furthermore, the expansion of city slums, and poor structured housing increases the opportunity for human contact with these rodents, thereby increasing rodents to human virus transmission.

The table derives from weekly reports published by NCDC. Nigeria Lassa fever data summary for Epi week 15, 2024 is compared with Epi Week 15 cumulative data in 2023 and 2024 (Courtesy: Nigeria CDC Situation report).

Related to the issue of homestead hygiene is the ineffective management of hospital waste in most of these communities. Many cases of Lassa fever slip through the cracks as malaria fever in health centres with limited capacity for molecular diagnosis.  After treatment, body fluid-stained dressings and disposables as well as serum and other body fluids are disposed as waste. The ineffectual medical waste management, so unsupervised, promotes fomite-rodent transmission and genetic spill-over to other species of household animals.

Citizens in the endemic countries share the same burden of poor health infrastructure and limited access to healthcare. For instance, only about 3% of adults aged 15-49 years have a form of health insurance. The high out-of-pocket expenditure required has caused increased hesitance in visiting hospital. As an alternative, many persons become victims of charlatans while genuine traditional healers who approach medical care blindly and without protective equipment become targets of infection and sources of transmission.

The photo (by author) shows the traditional sun drying of grated cassava for fufu meal. This exposure increases potential for Lassa fever transmission through contamination with rodent excreta.

The large trust deficit between the citizens and the political leaders owing to the several years of perceived economic and social mismanagement is also a great source of concern. Trust in the system by the people has been affirmed as necessary in advancing the cause of public health. Marcia McNutt and Michael Crow wrote in their op-ed, published in Issues in Science and Technology magazine that scientists and elected leaders need to earn citizens’ trust to win the war against misinformation and disinformation. Hesitancy in uptake of available countermeasures, appropriate risk perception and required behavioural change, seem imperiled in these communities due to the lack of trust in government and government institutions.

Finally, it is often assumed that every new infection cycle is initiated by human contact with rodent or rodent fluid. This does not consider however that the reinfection cycle could have started from a lab leak. Pathogen escape pathways are preponderant with many vials of remnant serum held unaccounted for in many public and private care institutions, some in community hospitals. This can only change if these countries develop a national system for accountability and repository of high-consequence pathogens.