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In this cluster-randomized trial conducted in Indonesia, deployment of mosquitoes infected with the w Mel strain of Wolbachia pipientis resulted in fewer symptomatic, virologically confirmed dengue infections and hospitalizations among residents.

Background Expanding HIV services by decentralizing provision to primary care raises a possible concern of HIV-related stigma and discrimination (SAD) from health care workers (HCWs) as new service points gain experience in HIV care delivery during early implementation. We surveyed indicators and examined the correlates of HIV-related SAD among HCWs in a decentralizing district of rural Gunungkidul, Indonesia. Methods We conducted a cross-sectional survey on a random stratified sample of 234 HCWs in 14 public health facilities (one district hospital, 13 primary health centers [PHC]) during the second year of decentralization roll-out in the district. We computed the prevalence of SAD indicators and used multivariable logistic regression to identify the correlates of these SAD indicators. Results The prevalence of SAD among HCWs was similarly high between hospital and PHC HCWs for fear of HIV transmission (~71%) and perceived negative image of PHIV (~75%). Hospital HCWs exhibited somewhat lower avoidance of service duties (52.6% vs . 63.7%; p = 0.088) with weak evidence of a difference and significantly higher levels of discriminatory practice (96.1% vs . 85.6%; p = 0.009) than those working in PHCs. Recent interactions with PLHIV and receipt of training lowered the odds of fear of HIV transmission ( p < 0.021). However, the odds of avoiding care duties increased with receipt of training ( p =0.003) and decreased for hospital HCWs ( p = 0.030). HIV knowledge lowered the odds of discriminatory practice ( p = 0.002), but hospital facility and nurse/midwife cadres were associated with increased odds of discriminatory practices ( p < 0.021). No significant correlate was found for perceived negative image of PLHIV. Conclusion HIV-related SAD among HCWs can be prevalent during early decentralization, highlighting the need for timely or preparatory interventions with a focus on building the capacity of hospital and non-physician workforce for positive patient-provider interactions when delivering HIV care.

Background In order to improve malaria burden estimates in low transmission settings, more sensitive tools and efficient sampling strategies are required. This study evaluated the use of serological measures from repeated health facility-based cross-sectional surveys to investigate Plasmodium falciparum and Plasmodium vivax transmission dynamics in an area nearing elimination in Indonesia. Methods Quarterly surveys were conducted in eight public health facilities in Kulon Progo District, Indonesia, from May 2017 to April 2018. Demographic data were collected from all clinic patients and their companions, with household coordinates collected using participatory mapping methods. In addition to standard microscopy tests, bead-based serological assays were performed on finger-prick bloodspot samples from 9453 people. Seroconversion rates (SCR, i.e. the proportion of people in the population who are expected to seroconvert per year) were estimated by fitting a simple reversible catalytic model to seroprevalence data. Mixed effects logistic regression was used to examine factors associated with malaria exposure, and spatial analysis was performed to identify areas with clustering of high antibody responses. Results Parasite prevalence by microscopy was extremely low (0.06% (95% confidence interval 0.03–0.14, n  = 6) and 0 for P. vivax and P. falciparum , respectively). However, spatial analysis of P. vivax antibody responses identified high-risk areas that were subsequently the site of a P. vivax outbreak in August 2017 (62 cases detected through passive and reactive detection systems). These areas overlapped with P. falciparum high-risk areas and were detected in each survey. General low transmission was confirmed by the SCR estimated from a pool of the four surveys in people aged 15 years old and under (0.020 (95% confidence interval 0.017–0.024) and 0.005 (95% confidence interval 0.003–0.008) for P. vivax and P. falciparum , respectively). The SCR estimates in those over 15 years old were 0.066 (95% confidence interval 0.041–0.105) and 0.032 (95% confidence interval 0.015–0.069) for P. vivax and P. falciparum , respectively. Conclusions These findings demonstrate the potential use of health facility-based serological surveillance to better identify and target areas still receptive to malaria in an elimination setting. Further implementation research is needed to enable integration of these methods with existing surveillance systems.

Background Identifying fine-scale spatial patterns of disease is essential for effective disease control and elimination programmes. In low resource areas without formal addresses, novel strategies are needed to locate residences of individuals attending health facilities in order to efficiently map disease patterns. We aimed to assess the use of Android tablet-based applications containing high resolution maps to geolocate individual residences, whilst comparing the functionality, usability and cost of three software packages designed to collect spatial information. Results Using Open Data Kit GeoODK, we designed and piloted an electronic questionnaire for rolling cross sectional surveys of health facility attendees as part of a malaria elimination campaign in two predominantly rural sites in the Rizal, Palawan, the Philippines and Kulon Progo Regency, Yogyakarta, Indonesia. The majority of health workers were able to use the tablets effectively, including locating participant households on electronic maps. For all households sampled (n = 603), health facility workers were able to retrospectively find the participant household using the Global Positioning System (GPS) coordinates and data collected by tablet computers. Median distance between actual house locations and points collected on the tablet was 116 m (IQR 42–368) in Rizal and 493 m (IQR 258–886) in Kulon Progo Regency. Accuracy varied between health facilities and decreased in less populated areas with fewer prominent landmarks. Conclusions Results demonstrate the utility of this approach to develop real-time high-resolution maps of disease in resource-poor environments. This method provides an attractive approach for quickly obtaining spatial information on individuals presenting at health facilities in resource poor areas where formal addresses are unavailable and internet connectivity is limited. Further research is needed on how to integrate these with other health data management systems and implement in a wider operational context.

Background A mathematical model was designed to explore the impact of three strategies for better tuberculosis case finding. Strategies included: (1) reducing the number of tuberculosis patients who do not seek care; (2) reducing diagnostic delay; and (3) engaging non-DOTS providers in the referral of tuberculosis suspects to DOTS services in the Indonesian health system context. The impact of these strategies on tuberculosis mortality and treatment outcome was estimated using a mathematical model of the Indonesian health system. Methods The model consists of multiple compartments representing logical movement of a respiratory symptomatic (tuberculosis suspect) through the health system, including patient- and health system delays. Main outputs of the model are tuberculosis death rate and treatment outcome (i.e. full or partial cure). We quantified the model parameters for the Jogjakarta province context, using a two round Delphi survey with five Indonesian tuberculosis experts. Results The model validation shows that four critical model outputs (average duration of symptom onset to treatment, detection rate, cure rate, and death rate) were reasonably close to existing available data, erring towards more optimistic outcomes than are actually reported. The model predicted that an intervention to reduce the proportion of tuberculosis patients who never seek care would have the biggest impact on tuberculosis death prevention, while an intervention resulting in more referrals of tuberculosis suspects to DOTS facilities would yield higher cure rates. This finding is similar for situations where the alternative sector is a more important health resource, such as in most other parts of Indonesia. Conclusion We used mathematical modeling to explore the impact of Indonesian health system interventions on tuberculosis treatment outcome and deaths. Because detailed data were not available regarding the current Indonesian population, we relied on expert opinion to quantify the parameters. The fact that the model output showed similar results to epidemiological data suggests that the experts had an accurate understanding of this subject, thereby reassuring the quality of our predictions. The model highlighted the potential effectiveness of active case finding of tuberculosis patients with limited access to DOTS facilities in the developing country setting.

Worldwide, the 33 recognised megacities comprise approximately 7% of the global population, yet account for 20% COVID-19 deaths. The specific inequities and other factors within megacities that affect vulnerability to COVID-19 mortality remain poorly defined. We assessed individual, community-level and healthcare factors associated with COVID-19-related mortality in a megacity of Jakarta, Indonesia, during two epidemic waves spanning 2 March 2020 to 31 August 2021. This retrospective cohort included residents of Jakarta, Indonesia, with PCR-confirmed COVID-19. We extracted demographic, clinical, outcome (recovered or died), vaccine coverage data and disease prevalence from Jakarta Health Office surveillance records, and collected subdistrict level sociodemographics data from various official sources. We used multilevel logistic regression to examine individual, community and subdistrict-level healthcare factors and their associations with COVID-19 mortality. Of 705 503 cases with a definitive outcome by 31 August 2021, 694 706 (98.5%) recovered and 10 797 (1.5%) died. The median age was 36 years (IQR 24-50), 13.2% (93 459) were <18 years and 51.6% were female. The subdistrict level accounted for 1.5% of variance in mortality (p<0.0001). Mortality ranged from 0.9 to 1.8% by subdistrict. Individual-level factors associated with death were older age, male sex, comorbidities and age <5 years during the first wave (adjusted OR (aOR)) 1.56, 95% CI 1.04 to 2.35; reference: age 20-29 years). Community-level factors associated with death were poverty (aOR for the poorer quarter 1.35, 95% CI 1.17 to 1.55; reference: wealthiest quarter) and high population density (aOR for the highest density 1.34, 95% CI 1.14 to 2.58; reference: the lowest). Healthcare factor associated with death was low vaccine coverage (aOR for the lowest coverage 1.25, 95% CI 1.13 to 1.38; reference: the highest). In addition to individual risk factors, living in areas with high poverty and density, and low healthcare performance further increase the vulnerability of communities to COVID-19-associated death in urban low-resource settings.

The successful establishment of the wMel strain of Wolbachia for the control of arbovirus transmission by Aedes aegypti has been proposed and is being implemented in a number of countries. Here we describe the successful establishment of the wMel strain of Wolbachia in four sites in Yogyakarta, Indonesia. We demonstrate that Wolbachia can be successfully introgressed after transient releases of wMel-infected eggs or adult mosquitoes. We demonstrate that the approach is acceptable to communities and that Wolbachia maintains itself in the mosquito population once deployed. Finally, our data show that spreading rates of Wolbachia in the Indonesian setting are slow which may reflect more limited dispersal of Aedes aegypti than seen in other sites such as Cairns, Australia.

Even though conceptually, Tuberculosis (TB) is almost always curable, it is currently the world's leading infectious killer. Patients with pulmonary TB are the source of transmission. Approximately 23% of the world's population is believed to be latently infected with TB bacteria, and 5-15% of them will progress at any point in time to develop the disease. There was a global diagnostic gap of 2.9 million between notifications of new cases and the estimated number of incident cases, and Indonesia carries the third-highest of this gap. Therefore, screening TB among the community is of great importance to prevent further transmission and infection. The electronic nose for screening TB (eNose-TB) project is initiated in Yogyakarta, Indonesia, to screen TB by breath test with an electronic-nose that is easy-to-use, point-of-care, does not expose patients to radiation, and can be produced at low cost. The objectives of the two-phase planned project are to: 1) investigate the potential of an eNose-TB as a screening tool in Indonesia, in comparison with screening with clinical symptoms and chest radiology, which are currently used as a standard, and 2) analyze the time and cost of a screening algorithm with eNose-TB to obtain additional case detection. A cross-sectional study will be conducted in the first phase to validate the eNose-TB. The validation phase will involve 395 presumptive TB patients in the Surakarta General Hospital, Central Java. In the second phase, a cross-sectional research will be conducted, involving 1,383 adults and children in the municipality of Yogyakarta and Kulon Progo district of Yogyakarta Province. The findings will provide data concerning the sensitivity and specificity of the eNose-TB as a screening tool for tuberculosis, and the time and cost analysis of a screening algorithm with the eNose. NCT04567498; https://clinicaltrials.gov/.

Implementation fidelity is critical for the efficient delivery of health services including leprosy services. Healthcare providers are important in monitoring the disease's progression, managing complications, and cross-checking prescribed medications. This study explored implementation fidelity in leprosy care and support for disability prevention and management in Rupandehi district, Nepal. A qualitative case study design was adopted based on implementation research principles. From 25th February to 30th April 2024, data were collected through multiple sources and methods, including key informant interviews, focus group discussions, and observation. Semi-structured interview guidelines and qualitative checklists facilitated the data collection process. Participants were chosen using purposive and selective sampling methods. The data were inductively coded using qualitative analysis software. Thematic analysis was done with codes generated and aggregated to form sub-themes and develop themes. The study revealed that healthcare providers consistently adhered to national leprosy operational guidelines, ensuring sufficient fidelity by prompt multi-drug therapy, case diagnosis, complicated case referral, and regular follow-up. In contrast, poor adherence was demonstrated in the complication management of lepra reactions, ulcer cases, and self-care. The major barriers to leprosy services were financial hardship, complication management, pill burden, drug side effects, and institutional obstacles. In contrast, the facilitators to leprosy services included adequate human resources, treatment supporter's involvement, effective communications, external development partner's role, transportation incentives, and local government support. Healthcare providers demonstrated sufficient adherence to leprosy operational guidelines. While significant gaps were evident in complication management, addressing financial and systematic barriers and leveraging facilitators is essential to strengthening leprosy care and support for disability prevention and management.

Background Countries that declared free of malaria remain vulnerable to the reintroduction and re-establishment of malaria transmission, primarily triggered by the influx of imported malaria. This risk is particularly acute in regions with population movement from endemic zones, limited tracking capacity, or continued presence of competent vectors. Experiences from countries navigating these vulnerabilities can provide valuable lessons for regions currently progressing or sustaining malaria elimination. This study aims to present various strategies and lessons learned in controlling imported malaria and preventing its reintroduction in regions that have reached malaria elimination and maintenance. Methods A systematic literature search was conducted using the PRISMA ScR framework. Articles were retrieved from three databases (PubMed, Scopus, and ProQuest) and screened based on inclusion and exclusion criteria. The review focused on imported case surveillance, vector surveillance, vector controls, and other measures. Imported case surveillance comprised case detection, as well as case management, and preventive measures. Results Among the 149 articles reviewed, 24 were selected for in-depth analysis. Reintroduction events were primarily driven by imported cases from endemic areas, with contributing factors including cross-border population movements, conflicts in countries of origin, and international travel. Additionally, the presence of competent mosquito vectors and the expansion of breeding habitats have facilitated local transmission following importation. All studies implemented imported case surveillance, with case detection activities reported (21 articles) and case management (4 articles) studies. Additionally, some studies included mass drug administration (3 articles) and chemoprophylaxis interventions (3 articles). Several countries incorporated vector surveillance (6 articles), vector control measures (7 articles), and other activities such as cross-border initiatives (3 articles), health promotion (3 articles), and modelling studies (1 article). Conclusion The successful prevention of malaria reintroduction has been achieved in countries that implemented comprehensive imported malaria surveillance strategies. Lessons learned indicate that case-based surveillance alone is insufficient; it must be complemented with additional interventions and context-specific activities to ensure sustained elimination and prevent reintroduction.