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Improving control of African schistosomiasis: towards effective use of rapid diagnostic tests within an appropriate disease surveillance model.
Transactions of the Royal Society of Tropical Medicine and Hygiene. 2009 Apr; 103(4):325-32.Contemporary control of schistosomiasis is typically reliant upon large-scale administration of praziquantel (PZQ) to school age children. Whilst PZQ treatment of each child is inexpensive, the direct and indirect costs of preventive chemotherapy for the whole school population are more substantive and, at the national level where many schools are targeted, maximising cost effectiveness and the health impact are essential requirements for ensuring longer-term sustainability (i.e. >5 years). To this end, the WHO has issued a set of treatment guidelines, inclusive of re-treatment schedules, such that, where possible, treatment decisions by school are based upon local disease prevalence as determined by parasitological and/or questionnaire methods. As each diagnostic method has known shortcomings, presumptive treatment of at-risk schools may initially be preferred, especially if the existing infrastructure for disease surveillance is poor. It is against this background of school-based preventive chemotherapy that a rapid diagnostic test (RDT) for schistosomiasis is most urgently needed, not only to improve initial disease surveillance but also to focus drug delivery better through time. In this paper, the development, evaluation and application of selected diagnostic tests are reviewed to identify barriers that impede progress, foremost of which is that a new disease surveillance and evaluation model is required where the in-country price of each RDT ideally needs to be less than US$1 to be cost effective both in the short- and long-term perspective.
Geneva, Switzerland, World Health Organization [WHO], 2007.  p.Since the advent of penicillin, syphilis is not only preventable but also treatable. Despite this, it remains a global problem with an estimated 12 million people infected each year. Pregnant women who are infected with syphilis can transmit the infection to their fetus, causing congenital syphilis with serious adverse effects on the pregnancy in up to 80% of the cases. Yet simple, cost-effective screening and treatment options could prevent and eventually eliminate congenital syphilis. With the current international focus on the Millennium Development Goals (MDGs), there exists a unique opportunity to mobilize action to prevent, and subsequently eliminate, congenital syphilis. Congenital syphilis is a serious but preventable disease, which can be eliminated through effective screening of pregnant women for syphilis and treatment of those infected. More newborn infants are affected by congenital syphilis than by any other neonatal infection, including human immunodeficiency virus (HIV) infection and tetanus, which are currently receiving global attention. Yet the burden of congenital syphilis is still under-appreciated at both international and national levels. Unlike many neonatal infections, congenital syphilis can be effectively prevented by testing and treatment of pregnant women, which also provides immediate benefits to the mother and allows potentially infected partners to be traced and offered treatment. It has been clearly shown that screening of pregnant women for reactive syphilis serology, followed by treatment of seropositive women, is a cost-effective, inexpensive and feasible intervention for the prevention of congenital syphilis and improvement of child health. In 1995, the Pan American Health Organization (PAHO) began a regional campaign to reduce the rate of congenital syphilis in the Americas to less than 50 cases per 100 000 live births. The strategy was to: (1) increase the availability of antenatal care; (2) establish routine serological testing for syphilis during antenatal careand at delivery; and (3) promote the rapid treatment of infected pregnant women. (excerpt)
JAMA. 2001 Sep 26; 286(12):1444.The 20th anniversary of the first diagnosis of HIV infection has come and gone. So has the razzmatazz surrounding the UN General Assembly's Special Session on AIDS in June. Headlines made when UN Secretary-General Kofi Annan appealed for the world to act on the global emergency AIDS represents have been superseded by other events. It's back to business as usual. Or is it? It must not be. The AIDS crisis is as real now as a few months ago, and it will continue to grow unless the world is constantly reminded of it and plans to stem the epidemic are turned into action. The recent focus on AIDS among the poorest countries of the world--in particular in Africa--may have given an impression that those who live in countries with stable or declining infection rates no longer need to worry. Recent infection figures in the United States showing disturbing increases in some population groups prove this is not so. And the effects of globalization mean that there no longer is such a thing as a localized health problem. The HIV/AIDS epidemic is a global emergency and it calls for global commitment and action. UN Secretary-General Annan recently asserted that "AIDS can no longer do its deadly work in the dark. The world has started to wake up." Frighteningly, it has taken 22 million deaths and 13 million orphaned children to act as a global alarm clock. Today, there are 36 million people living with HIV/AIDS. (author's)
Geneva, Switzerland, UNAIDS, 1997 Nov. 7 p. (UNAIDS Best Practice Collection; UNAIDS Technical Update)Since 1985, HIV testing has been essential in securing the safety of blood supplies, monitoring the progress of the epidemic and diagnosing individuals infected with the virus. Various assays are now available, allowing testing strategies to be tailored to the epidemiological conditions and budgets of national health systems. New techniques -- including simple tests giving instant results -- hold great promise, but also raise some serious issues for governments and for individuals. HIV infection is most frequently diagnosed by detecting antibodies which the body produces as it tries to resist the virus. These antibodies usually begin to be produced within 3 to 8 weeks after the time of infection. The period following infection but before the antibodies become detectable is known as the .window period.. Antibodies are much easier to detect than the virus itself. It is sometimes possible to detect HIV antigen during the window period if, by coincidence, an individual is tested during the short peak of high levels of circulating virus particles. After this peak, the level of p24 antigen steeply declines to the point where it is no longer detectable. It fluctuates or rises steeply again, usually years later, when the clinical situation of the patient starts to deteriorate with the onset of AIDS. (excerpt)
BULLETIN OF THE WORLD HEALTH ORGANIZATION. 1998; 76(5):475-83.In 1995, the Russian Federation reported more than 85,000 new tuberculosis (TB) cases, a 69% increase over the lowest ever incidence of 34 cases per 100,000 population in 1991. However, many of the federation's TB control programs are based upon expensive, yet underfunded, strategies which use long, individualized treatment regimens. The authors compared the cost-effectiveness of the new World Health Organization (WHO) strategy implemented in the Ivanovo Oblast of case-finding among symptomatic patients and shorter treatment regimens, with the old strategy of actively screening the asymptomatic population and longer regimens. The cost per case cured was calculated at different levels of cure rate (45-95%) using 3 scenarios to describe the WHO strategy and a fourth scenario to describe the old strategy. The cost per case cured at an 85% cure rate level ranged from US$1197 using the WHO strategy to US$6293 using the old strategy. The cost per case detected ranged from US$1581 using the WHO strategy to US$4000 using the old strategy. Significant savings can therefore be realized from shifting toward the new WHO strategy.
[Unpublished] 1994 Sep. Presented at the 122nd Annual Meeting of the American Public Health Association [APHA], Washington, D.C., 1994. iii, 28 p.Tuberculosis (TB) is the leading cause of morbidity and mortality from an infectious disease and is responsible for 3.9 million deaths/year. The incidence and severity of TB are exacerbated by the rapid spread of HIV infections. In 1993, a USAID task force presented a report on the TB situation in less developed countries and recommended agency actions (no policy decisions have been made). The World Health Organization (WHO) subsequently requested USAID assistance for a broad range proposal to tackle the problem of TB and implied that WHO had developed a cost effective TB strategy. USAID requested the country evaluations WHO referred to in its proposal, and this report is based on a review of those data. The country reports reviewed are from Burundi, Comoros, Ethiopia, Guinea, Rwanda, Somalia, Tanzania, Malawi, Mozambique, Afghanistan, China, India, the Philippines, Brazil, Cuba, Nicaragua, Algeria. A summary is presented for each country report (except Afghanistan), overall findings are discussed, and unmet needs are identified. In general, the reports summarized from a variety of authors indicate that TB can be controlled through an extraordinary devotion of resources. Only Cuba treats TB as a socioeconomic problem; most of the other reviewers were entirely concerned with the medical aspects of the complex multidrug therapy approach and almost ignored that fact that patient compliance averaged only 30% unless there was massive donor support. It is concluded that the following needs must be met to address TB: 1) political commitment to TB control must be strong; 2) the cost of TB to economic security must be established; 3) the public understanding of TB must be enhanced; 4) the serious barriers to treatment must be addressed; 5) the health care delivery systems in developing countries must be strengthened; and 6) the capacities to support TB control must be increased. It was recommended that existing projects could be supplemented by a program which would cost US $2-5 million/year in order to address some unmet needs in the technical areas of training, research, and advocacy in developing countries.