SummaryBackgroundKilled whole-cell oral cholera vaccines (kOCVs) are becoming a standard cholera control and prevention tool. However, vaccine efficacy and direct effectiveness estimates have varied, with differences in study design, location, follow-up duration, and vaccine composition posing challenges for public health decision making. We did a systematic review and meta-analysis to generate average estimates of kOCV efficacy and direct effectiveness from the available literature.MethodsFor this systematic review and meta-analysis, we searched PubMed, Embase, Scopus, and the Cochrane Review Library on July 9, 2016, and ISI Web of Science on July 11, 2016, for randomised controlled trials and observational studies that reported estimates of direct protection against medically attended confirmed cholera conferred by kOCVs. We included studies published on any date in English, Spanish, French, or Chinese. We extracted from the published reports the primary efficacy and effectiveness estimates from each study and also estimates according to number of vaccine doses, duration, and age group. The main study outcome was average efficacy and direct effectiveness of two kOCV doses, which we estimated with random-effect models. This study is registered with PROSPERO, number CRD42016048232.FindingsSeven trials (with 695 patients with cholera) and six observational studies (217 patients with cholera) met the inclusion criteria, with an average two-dose efficacy of 58% (95% CI 42–69, I2=58%) and effectiveness of 76% (62–85, I2=0). Average two-dose efficacy in children younger than 5 years (30% [95% CI 15–42], I2=0%) was lower than in those 5 years or older (64% [58–70], I2=0%; p<0·0001). Two-dose efficacy estimates of kOCV were similar during the first 2 years after vaccination, with estimates of 56% (95% CI 42–66, I2=45%) in the first year and 59% (49–67, I2=0) in the second year. The efficacy reduced to 39% (13 to 57, I2=48%) in the third year, and 26% (−46 to 63, I2=74%) in the fourth year.InterpretationTwo kOCV doses provide protection against cholera for at least 3 years. One kOCV dose provides at least short-term protection, which has important implications for outbreak management. kOCVs are effective tools for cholera control.FundingThe Bill & Melinda Gates Foundation.

BackgroundThe Syrian armed conflict is the worst humanitarian tragedy this century. With approximately 470,000 deaths and more than 13 million people displaced, the conflict continues to have a devastating impact on the health system and health outcomes within the country. Hundreds of international and national non-governmental organisations, as well as United Nations agencies have responded to the humanitarian crisis in Syria. While there has been significant attention on the challenges of meeting health needs of Syrian refugees in neighbouring countries such as Jordan, Lebanon and Turkey, very little has been documented about the humanitarian challenges within Syria, between 2013 and 2014 when non-governmental organisations operated in Syria with very little United Nations support or leadership, particularly around obtaining information to guide health responses in Syria.MethodsIn this study, we draw on our operational experience in Syria and analyse data collected for the humanitarian health response in contested and opposition-held areas of Syria in 2013–4 from Turkey, where the largest humanitarian operation for Syria was based. This is combined with academic literature and material from open-access reports.ResultsHumanitarian needs have consistently been most acute in contested and opposition-held areas of Syria due to break-down of Government of Syria services and intense warfare. Humanitarian organisations had to establish de novo data collection systems independent of the Government of Syria to provide essential services in opposition-held and contested areas of Syria. The use of technology such as social media was vital to facilitating remote data collection in Syria as many humanitarian agencies operated with a limited operational visibility given chronic levels of insecurity. Mortality data have been highly politicized and extremely difficult to verify, particularly in areas highly affected by the conflict, with shifting frontlines, populations, and allegiances.ConclusionsMore investment in data collection and use, technological investment in the use of M- and E-health, capacity building and strong technical and independent leadership should be a key priority for the humanitarian health response in Syria and other emergencies. Much more attention should be also given for the treatment gap for non-communicable diseases including mental disorders.

BackgroundConventional diagnosis of malaria has relied upon either clinical diagnosis or microscopic examination of peripheral blood smears. These methods, if not carried out exactly, easily result in the over- or under-diagnosis of malaria. The reliability and accuracy of malaria RDTs, even in extremely challenging health care settings, have made them a staple in malaria control programmes. Using the setting of a pilot introduction of malaria RDTs in Greater Garissa, North Eastern Province, Kenya, this study aims to identify and understand perceptions regarding malaria diagnosis, with a particular focus on RDTs, and treatment among community members and health care workers (HCWs).MethodsThe study was conducted in five districts of Garissa County. Focus group discussions (FGD) were performed with community members that were recruited from health facilities (HFs) supported by the MENTOR Initiative. In-depth interviews (IDIs) and FGDs with HCWs were also carried out. Interview transcripts were then coded and analysed for major themes. Two researchers reviewed all codes, first separately and then together, discussed the specific categories, and finally characterized, described, and agreed upon major important themes.ResultsThirty-four FGDs were carried out with a range of two to eight participants (median of four). Of 157 community members, 103 (65.6%) were women. The majority of participants were illiterate and the highest level of education was secondary school. Some 76% of participants were of Somali ethnicity. Whilst community members and HCWs demonstrated knowledge of aspects of malaria transmission, prevention, diagnosis, and treatment, gaps and misconceptions were identified. Poor adherence to negative RDT results, unfamiliarity and distrust of RDTs, and an inconsistent RDT supply were the main challenges to become apparent in FGDs and IDIs.ConclusionGaps in knowledge or incorrect beliefs exist in Greater Garissa and have the potential to act as barriers to complete and correct malaria case management. Addressing these knowledge gaps requires comprehensive education campaigns and a reliable and constant RDT supply. The results of this study highlight education and supply chain as key factors to be addressed in order to make large scale roll out of RDTs as successful and effective as possible.

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Objective To evaluate the use of reproductive health care and incidence of paediatric HIV infection during the expansion of antiretroviral therapy and services for the prevention of mother-tochild transmission in rural Malawi, and the influence of integration of these HIV-related services into general health services.Design Descriptive analysis.Setting Thyolo District, with a population of 600 000, an HIV prevalence of 21% and a total fertility rate of 5.7 in 2004.Population Women attending reproductive health services care in 2005 and 2010.Methods Review of facility records and databases for routine monitoring.Main outcome measures Use of antenatal, intrapartum, postpartum, family planning and sexually transmitted infection services; incidence of HIV infection in infants born to mothers who received prevention of mother-to-child transmission care.Results There was a marked increase in the uptake of perinatal care: pregnant women in 2010 were 50% more likely to attend at least one antenatal visit (RR 1.50, 95% CI 1.48-1.51); were twice as likely to deliver at a healthcare facility (RR 2.05, 95% CI 2.01-2.08); and were more than four times as likely to present for postpartum care (RR 4.40,. Family planning consultations increased by 40% and the number of women receiving treatment for sexually transmitted infections doubled. Between 2007 and 2010, the number of HIV-exposed infants who underwent testing for HIV went up from 421 to 1599/year, and the proportion testing positive decreased from 13.3 to 5.0%; infants were 62% less likely to test HIV positive (RR 0.38, 95% CI 0.27-0.52).Conclusions During the expansion and integration of HIV care, the use of reproductive health services increased and the outcomes of infants born to HIV-infected mothers improved. HIV care may be successfully integrated into broader reproductive health services.

This article presents a unique approach to HIV/AIDS training in resource-poor settings that incorporates the use of standardized patients (SPs). Integrated Management of Adolescent and Adult Illness (IMAI) is a World Health Organization health systems strengthening initiative with a strong emphasis on training health workers in the management of common diseases and conditions. In IMAI, SPs are called Expert Patient-Trainers (EPTs) to emphasize their role in the training of health workers. EPTs were first used in IMAI training in Uganda in 2004. Since then, the method has been adopted by a number of other countries in Africa, Latin America, and Asia. EPTs are usually recruited from groups of people living with HIV/AIDS. In the classroom, EPTs discuss living with HIV and help participants understand HIV as it affects patients. Course participants spend approximately two hours per day in "skill stations," multiple-station assessments consisting of one-on-one encounters with EPTs. In each encounter, the health worker interacts with an EPT portraying a standardized case. Instructions on how to portray each case provide only broad outlines of the major clinical and counseling points; the EPT is expected to use his or her own life experiences to fill in emotional details. Course facilitators noted that health workers were often initially skeptical about EPTs, but this generally turned to enthusiasm after participating in the skill stations. EPTs benefited from the sense of being part of the training team, the satisfaction of improving the skills of health workers, and learning more about their illness.

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