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.