Support to the Safe Motherhood Programme in Nepal: an integrated approach

Evidence gathered from 1997 to 2006 indicates progress in reducing maternal mortality in Nepal, but public health services are still constrained by resource and staff shortages, especially in rural areas. The five-year Support to the Safe Motherhood Programme builds on the experience of the Nepal Safer Motherhood Project (1997-2004). It is working with the Government of Nepal to build capacity to institute a minimum package of essential maternity services, linking evidence-based policy development with health system strengthening. It has supported long-term planning, working towards skilled attendance at every birth, safe blood supplies, staff training, building management capacity, improving monitoring systems and use of process indicators, promoting dialogue between women and providers on quality of care, and increasing equity and access at district level. An incentives scheme finances transport costs to a health facility for all pregnant women and incentives to health workers attending deliveries, with free services and subsidies to facilities in the poorest 25 districts. Despite bureaucracy, frequent transfer of key government staff and political instability, there has been progress in policy development, and public health sector expenditure has increased. For the future, a human resources strategy with career paths that encourage skilled staff to stay in the government service is key.     

Recombinant LSDV Strains in Asia: Vaccine Spillover or Natural Emergence?

From 2017 to 2019, several vaccine-like recombinant strains of lumpy skin disease virus (LSDV) were discovered in Kazakhstan and neighbouring regions of Russia and China. Shortly before their emergence, the authorities in Kazakhstan launched a mass vaccination campaign with the Neethling-based Lumpivax vaccine. Since none of the other countries in the affected region had used a homologous LSDV vaccine, it was soon suspected that the Lumpivax vaccine was the cause of these unusual LSDV strains. In this study, we performed a genome-wide molecular analysis to investigate the composition of two Lumpivax vaccine batches and to establish a possible link between the vaccine and the recent outbreaks. Although labelled as a pure Neethling-based LSDV vaccine, the Lumpivax vaccine appears to be a complex mixture of multiple CaPVs. Using an iterative enrichment/assembly strategy, we obtained the complete genomes of a Neethling-like LSDV vaccine strain, a KSGP-like LSDV vaccine strain and a Sudan-like GTPV strain. The same analysis also revealed the presence of several recombinant LSDV strains that were (almost) identical to the recently described vaccine-like LSDV strains. Based on their InDel/SNP signatures, the vaccine-like recombinant strains can be divided into four groups. Each group has a distinct breakpoint pattern resulting from multiple recombination events, with the number of genetic exchanges ranging from 126 to 146. The enormous divergence of the recombinant strains suggests that they arose during seed production. The recent emergence of vaccine-like LSDV strains in large parts of Asia is, therefore, most likely the result of a spillover from animals vaccinated with the Lumpivax vaccine.     

Mothers’ Selection of Future Primary Caregivers in Rural West Java,Indonesia

This study analyzes mothers’ preference of a future primary caregiver by using within-family analysis approach in the context of Sundanese population in rural West Java, Indonesia. This is a cross-sectional study involving healthy mothers (60–69 years old) with a perfect score of Instrumental Activity of Daily Living (IADL), and who had at least two living children. The within-family analysis of a selection of future caregivers was conducted based on the report from 177 mothers of their 904 children using multilevel modeling with binomial outcome. Being a daughter, older, emotionally the closest to the mother, having supported the mother in the past, being perceived as future bequest receiver, and being geographically closer to mother increased the chance of being selected as preferred future primary caregivers. There were also cross-level effects of socioeconomic status (SES) on the selection of future primary caregivers by mothers, where poor mothers tend to pick poor children as their future primary caregivers. The results were contrasted to the findings from a similar study conducted in the United States. In addition, the importance of knowledge about future care preference and its implications for intervention is discussed.     

Forget about forgetting: structural barriers and severe non-adherence to antiretroviral therapy

HIV infection is now clinically manageable with antiretroviral therapy (ART). However, a significant number of people with HIV do not benefit from ART because of non-adherence. This study examined the use of adherence strategies and barriers to adherence among persons at substantial risk for developing resistant virus (less than 75% adherent). People living with HIV (n?=?556) who were less than 95% adherent to ART completed computerized interviews, were screened for active drug use, provided medical records for HIV viral load, and completed unannounced pill counts to monitor ART adherence and an assessment of adherence barriers. Based on pill counts, participants were defined as severely non-adherent (≤75% medications taken) and moderately non-adherent (>75% and <95% adherent). Results showed a broad array of memory devices were used to no avail across non-adherence groups. Individuals who were severely non-adherent were significantly more likely to attribute missing medications due to substance use and structural barriers, including running out of medications, inability to get to pharmacy, and inability to afford medications. Results suggest that interventions focused on memory lapses will be insufficient and should rather concentrate on substance use treatment and providing case management to resolve structural barriers to adherence.