Nils Hennig

Barriers to community case management of malaria in Saraya, Senegal: training, and supply-chains

BackgroundHealth workers in sub-Saharan Africa can now diagnose and treat malaria in the field, using rapid diagnostic tests and artemisinin-based combination therapy in areas without microscopy and widespread resistance to previously effective drugs.ObjectiveThis study evaluates communities’ perceptions of a new community case management of malaria programme in the district of Saraya, south-eastern Senegal, the effectiveness of lay health worker trainings, and the availability of rapid diagnostic tests and artemisinin-based combination therapy in the field.MethodsThe study employed qualitative and quantitative methods including focus groups with villagers, and pre- and post-training questionnaires with lay health workers.ResultsCommunities approved of the community case management programme, but expressed concern about other general barriers to care, particularly transportation challenges. Most lay health workers acquired important skills, but a sizeable minority did not understand the rapid diagnostic test algorithm and were not able to correctly prescribe arteminisin-based combination therapy soon after the training. Further, few women lay health workers participated in the programme. Finally, the study identified stock-outs of rapid tests and anti-malaria medication products in over half of the programme sites two months after the start of the programme, thought due to a regional shortage.ConclusionThis study identified barriers to implementation of the community case management of malaria programme in Saraya that include lay health worker training, low numbers of women participants, and generalized stock-outs. These barriers warrant investigation into possible solutions of relevance to community case management generally.

Determining and addressing obstacles to the effective use of long-lasting insecticide-impregnated nets in rural Tanzania.

BackgroundThe objective of this project was to achieve high, sustainable levels of net coverage in a village in rural Tanzania by combining free distribution of long-lasting insecticide-impregnated nets (LLINs) with community-tailored education. In Tanzania, malaria is the leading cause of morbidity and mortality. Although malaria bed nets have a well-established role in reducing disease burden, few rural households have access to nets, and effective use depends on personal practices and attitudes.MethodsFive practices and attitudes inconsistent with effective LLIN use were identified from household interviews (n = 10). A randomized survey of villagers (n = 132) verified local prevalence of these practices and attitudes. Community leaders held an educational session for two members of every household addressing these practice and attitudes, demonstrating proper LLIN use, and emphasizing behaviour modification. Attendees received one or two LLINs per household. Surveys distributed three weeks (n = 104) and 15 months (n = 104) post-intervention assessed corrected practices and attitudes. Project efficacy was defined by correction of baseline practices and attitudes as well as high rates of reported daily net use, with statistical significance determined by chi-square test.ResultsBaseline interviews and surveys revealed incorrect practices and attitudes regarding 1) use of nets in dry season, 2) need to retreat LLINs, 3) children napping under nets, 4) need to repair nets, and 5) net procurement as a priority, with 53- 88.6% incorrect responses (11.4-47% correct responses). A three-week follow-up demonstrated 83-95% correct responses. Fifteen-month follow-up showed statistically significant (p < 0.01) corrections from baseline in all five practice and attitudes (39.4-93.3% correct answers). 89.4% of respondents reported using their nets every night, and 93.3% affirmed purchase of nets as a financial priority.ConclusionsResults suggest that addressing community-specific practices and attitudes prior to LLIN distribution promotes consistent and correct use, and helps change attitudes towards bed nets as a preventative health measure. Future LLIN distributions can learn from the paradigm established in this project.

Academic Public Health and the Firearm Crisis: An Agenda for Action

The authors reflect on the need for members of the academic public health community in America to develop a social action strategy for dealing with a firearms-related crisis in the U.S. as of 2017, and it mentions gun control initiatives, business plans, and statistics regarding firearms-related deaths and suicides in America since 1900. U.S. President Donald Trumps views about gun rights are examined, along with collaborations and firearm research and scholarship in the country.

The US Cancer Moonshot initiative

Correspondence avoid surgery in rapidly progressive or chemo-insensitive disease. 4 Genotyping of pancreatic tumours via fine needle aspiration could influence the clinical management of pancreatic cancer. Fine-needle aspiration sequencing was used to identify subgroups of patients with specific actionable mutations related to resectable or locally advanced tumours. 5 In patients with radiologically resectable or borderline resectable tumours, preoperative fine-needle aspiration sequencing could distinguish between patients with a genetic pattern associated with micrometastatic tumours, who should undergo neoadjuvant therapy, and those with a truly localised disease that would be amenable to a surgery-first strategy. Michele Reni has served as a consultant for or on the advisory boards of Celgene, Boehringer-Ingelheim, Lilly, Genentech, Baxalta, Novocure, Astra-Zeneca, Pfizer, and Merck-Serono, and has received honoraria from Celgene. Massimo Falconi has received honoraria from Celgene, Ipsen and Novartis. The other authors declare no competing interests. *Stefano Crippa, Michele Reni, Gianpaolo Balzano, Claudio Doglioni, Massimo Falconi crippa1.stefano@hsr.it Division of Pancreatic Surgery, IRCCS San Raffaele Hospital, Milan, Italy (SC, GB, MF); Medical Oncology Department, IRCCS San Raffaele Hospital , Milan, Italy (MR); Department of Pathology, IRCCS San Raffaele Hospital , Milan, Italy (CD); Clinical and Translational Research Program on Pancreatic Cancer, IRCCS San Raffaele Hospital, Milan, Italy (SC, MR, GB, CD, MF) e178 Barreto SG, Windsor JA. Justifying vein resection with pancreatoduodenectomy. Lancet Oncol 2016; 17: e118–24 Giovinazzo F, Turri G, Katz MH, Heaton N, Ahmed I. Meta-analysis of benefit of portal-superior mesenteric vein resection in pancreatic resection for ductal adenocarcinoma. Br J Surg 2016; 103: 179–91. Bapat AA, Hostetter G, Von Hoff DD, Han H. Perineural invasion and associated pain in pancreatic cancer. Nat Rev Cancer 2011; Sohal DP, Walsh RM, Ramanathan RK, Khorana AA. Pancreatic adenocarcinoma: treating a systemic disease with systemic therapy. J Natl Cancer Inst 2014; 106: dju011 Valero V, Saunders TJ, He J, et al. Reliable detection of somatic mutations in fine needle aspirates of pancreatic cancer with next-generation sequencing: implications for surgical management. Ann Surg 2016; Author’s reply Stefano Crippa and colleagues, in responding to our manuscript, 1 agree that increasing the radicality of surgery for pancreatic ductal adenocarcinoma, including synchronous vein resection, is suspect. Indeed, a recent meta-analysis 2 indicates that synchronous vein resection, as reported, increases mortality and decreases survival. Crippa and colleagues put forward two interesting ideas that warrant further discussion. The first is that the surgery-first approach for pancreatic ductal adenocarcinoma might ultimately be retired, given that pancreatic ductal adenocarcinoma is usually systemic at presentation, local treatments have little effect, and neoadjuvant therapy has possible benefits. For now, the absence of high-level evidence for neoadjuvant therapy leaves largely theoretical benefits; namely that neoadjuvant therapy will reveal the biology (ie, those patients that can progress on neoadjuvant therapy will avoid futile surgery), or alter the biology (ie, those patients that are downstaged will become resectable). The preliminary results of the ALLIANCE trial 3 damages the lustre of these purported benefits with no improvement in the number of resections (10 [50%] of 20 patients who completed all preoperative therapy), and no rescue of aggressive tumour biology. This leads to the second idea, in which Crippa and colleagues suggest a biological (rather than radiological) basis for selecting patients for neoadjuvant therapy with a view to reduce the number of synchronous vein resections. Endoscopic ultrasonography- guided genotyping is a possible way to select subgroups of patients with heterogenous pancreatic ductal adenocarcinoma 4 who will benefit from neoadjuvant therapy. In support of this method, Hruban and colleagues 5 suggested that an intact SMAD4/DPC4 gene might be used to select surgery because there is lesser risk of distant metastases for this genotype. 6 In the future, we hope to more accurately select a subgroup of patients in whom a surgery-first approach, and even synchronous vein resection, is justified, but it is much more likely that precision neoadjuvant therapy will ultimately result in less radical surgery and the introduction of non-surgical techniques to support the response to neoadjuvant therapy. We declare no competing interests. Savio G Barreto, *John A Windsor j.windsor@auckland.ac.nz Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India (SGB); Hepatobiliary Pancreatic and Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand (JAW) Barreto S, Windsor J. Justifying vein resection with pancreatoduodenectomy. Lancet Oncol 2016; 17: e118–24. Giovinazzo F, Turri G, Katz MH, Heaton N, Ahmed I. Meta-analysis of benefits of portal-superior mesenteric vein resection in pancreatic resection for ductal adenocarcinoma. Br J Surg 2016; Varadhachary G, Fleming J, Crane C, et al. Phase II study of preoperation mFOLFIRINOX and chemoradiation for high-risk resectable and borderline resectable pancreatic adenocarcinoma. Proc Am Soc Clin Oncol 2015; 33 (suppl 3): abstr 362. Killock D. Pancreatic cancer: a problem quartered—new subtypes, new solutions? Nat Rev Clin Oncol 2016; 13: 201. Hruban RH, Adsay NV. Molecular classification of neoplasms of the pancreas. Hum Pathol Iacobuzio-Donahue CA, Fu B, Yachida S, et al. DPC4 gene status of the primary carcinoma correlates with patterns of failure in patients with pancreatic cancer. J Clin Oncol 2009; The US Cancer Moonshot initiative We recently sent the following letter to Vice President of the USA, Joe Biden, to state that we, as Deans and Directors of Public Health schools and programmes around the USA, strongly support the goals of the Cancer Moonshot initiative to www.thelancet.com/oncology Vol 17 May 2016

Health worker perceptions of integrating mobile phones into community case management of malaria in Saraya, Senegal

BACKGROUND Although community case management of malaria increases access to life-saving care in isolated settings, it contends with many logistical challenges. Mobile phone health information technology may present an opportunity to address a number of these barriers. METHODS Using the wireless adaptation of the technology acceptance model, this study assessed availability, ease of use, usefulness, and job relevance of mobile phones by health workers in Saraya, Senegal. RESULTS This study conducted seven key informant interviews with government health workers, and three focus groups and 76 surveys with lay health workers. Principal findings included that mobile phones are already widely available and used, and that participants valued using phones to address training, stock management, programme reporting, and transportation challenges. CONCLUSIONS By documenting widespread use of mobile phones and health worker perceptions of their most useful applications, this paper provides a framework for their integration into the community case management of malaria programme in Saraya, Senegal.

Priorities in Recovering From a Lost Generation of Firearms Research

An editorial is presented which addresses firearms research in America as of 2018, and it mentions gun-related violence in the U.S., media coverage of mass shootings, and school shootings at places such as Marjory Stoneman Douglas High School shooting in Parkland, Florida. Lobbyists for the firearms industry are examined, along with support for gun safety reform. The U.S. Centers for Disease Control and Prevention (CDC) and population health research are assessed.

Predictors of antiretroviral therapy failure in an urban HIV/AIDS clinic in Addis Ababa, Ethiopia

6 www.thelancet.com/lancetgh Published Online April 8, 2016 Icahn School of Medicine at Mount Sinai, New York, NY, USA (K Niemeyer, A King MPH, N Henning MD); WWO/AHF Family Health Clinic, Addis Ababa, Ethiopia (S Mengistu MD) Correspondence to: Katherine Niemeyer, 50 E 98th Street, New York, NY 10029, USA katherinem.niemeyer@gmail. com Predictors of antiretroviral therapy failure in an urban HIV/AIDS clinic in Addis Ababa, Ethiopia Katherine Niemeyer, Akilah King, Sophie Mengistu, Nils Hennig Abstract Background With the federal scale-up of antiretroviral therapy (ART) in Ethiopia, survival and quality of life for people with HIV/AIDS has increased. However, some patients do not respond to ART. Failure to suppress viral replication leads to increased morbidity and mortality, making early diagnosis of treatment failure imperative for the reduction of negative outcomes for patients. In this quality improvement project, we aimed to fi nd predictors of treatment failure that can be used, with clinical and immunological monitoring, to guide diagnosis of fi rst-line ART failure.Background With the federal scale-up of antiretroviral therapy (ART) in Ethiopia, survival and quality of life for people with HIV/AIDS has increased. However, some patients do not respond to ART. Failure to suppress viral replication leads to increased morbidity and mortality, making early diagnosis of treatment failure imperative for the reduction of negative outcomes for patients. In this quality improvement project, we aimed to fi nd predictors of treatment failure that can be used, with clinical and immunological monitoring, to guide diagnosis of fi rst-line ART failure. Methods We undertook a retrospective chart review and analysed baseline characteristics of 55 male and female patients, aged 2–54 years, on second-line ART and 55 control patients matched for age, gender, and treatment who continued to respond to fi rst-line ART at the World Wide Orphans/AIDS Healthcare Foundation (WWO/AHF) Family Health Clinic in Addis Ababa, Ethiopia. We used bivariate analyses, and included signifi cant variables in logistic regression modelling. Findings Three factors were signifi cant predictors of treatment failure: the presence of at least 1 month of fair or poor adherence (OR 15·7, 95% CI 1·8–136·7; p=0·01); previous treatment at another clinic before the WWO/AHF Family Health Clinic (1·4, 1·2–13·7; p=0·02); and tuberculosis symptoms at baseline (3·6, 1·1–12·3; p=0·04). In adult patients (n=58), two separate factors were signifi cant predictors of treatment failure: non-use of soft drugs, such as marijuana and khat (0·02, 0·001–0·445; p=0·02), and low baseline CD4 count (0·985, 0·972–0·999; p=0·03) Interpretation Predictors of ART failure can be used for early identifi cation of patients at high risk of fi rst-line treatment failure. Subsequent rapid transition to second-line therapy could result in better outcomes and care for these patients at the WWO/AHF Family Health Clinic in Addis Ababa, Ethiopia. The association between non-use of soft drugs and failure of fi rst-line ART should be explored further. Funding Arnold Institute for Global Health, Icahn School of Medicine at Mount Sinai. Copyright

Culture, community networks, and HIV/AIDS outreach opportunities in a south Indian Siddha organization.

Summary Background: Gandeepam is an NGO in rural south India, with an HIV prevalence rate estimated at 2-7 times the national average. Aside from several outreach programs, Gandeepam practices Siddha medicine. Objective: Evaluate Gandeepams strengths and opportunities to promote HIV education. Design: Three weeks of observing clinic practice, meeting patients, and discussing organizational structure. A survey of attitudes toward HIV was completed. Results: Gandeepam reaches a broad cross-section of its community, and effectively disseminates information. No primary HIV prevention efforts were observed. Conclusion: Current strengths include an established network for information dissemination, and a strong community reputation. Tremendous social obstacles for disseminating effective HIV prevention messages remain.