World Health Organization Regional Office for the Western Pacific

This paper describes an action framework for countries with low tuberculosis (TB) incidence (<100 TB cases per million population) that are striving for TB elimination. The framework sets out priority interventions required for these countries to progress first towards "pre-elimination" (<10 cases per million) and eventually the elimination of TB as a public health problem (less than one case per million). TB epidemiology in most low-incidence countries is characterised by a low rate of transmission in the general population, occasional outbreaks, a majority of TB cases generated from progression of latent TB infection (LTBI) rather than local transmission, concentration to certain vulnerable and hard-to-reach risk groups, and challenges posed by cross-border migration. Common health system challenges are that political commitment, funding, clinical expertise and general awareness of TB diminishes as TB incidence falls. The framework presents a tailored response to these challenges, grouped into eight priority action areas: 1) ensure political commitment, funding and stewardship for planning and essential services; 2) address the most vulnerable and hard-to-reach groups; 3) address special needs of migrants and cross-border issues; 4) undertake screening for active TB and LTBI in TB contacts and selected high-risk groups, and provide appropriate treatment; 5) optimise the prevention and care of drug-resistant TB; 6) ensure continued surveillance, programme monitoring and evaluation and case-based data management; 7) invest in research and new tools; and 8) support global TB prevention, care and control. The overall approach needs to be multisectorial, focusing on equitable access to high-quality diagnosis and care, and on addressing the social determinants of TB. Because of increasing globalisation and population mobility, the response needs to have both national and global dimensions.

Latent tuberculosis infection (LTBI) is characterised by the presence of immune responses to previously acquired Mycobacterium tuberculosis infection without clinical evidence of active tuberculosis (TB). Here we report evidence-based guidelines from the World Health Organization for a public health approach to the management of LTBI in high risk individuals in countries with high or middle upper income and TB incidence of <100 per 100 000 per year. The guidelines strongly recommend systematic testing and treatment of LTBI in people living with HIV, adult and child contacts of pulmonary TB cases, patients initiating anti-tumour necrosis factor treatment, patients receiving dialysis, patients preparing for organ or haematological transplantation, and patients with silicosis. In prisoners, healthcare workers, immigrants from high TB burden countries, homeless persons and illicit drug users, systematic testing and treatment of LTBI is conditionally recommended, according to TB epidemiology and resource availability. Either commercial interferon-gamma release assays or Mantoux tuberculin skin testing could be used to test for LTBI. Chest radiography should be performed before LTBI treatment to rule out active TB disease. Recommended treatment regimens for LTBI include: 6 or 9 month isoniazid; 12 week rifapentine plus isoniazid; 3-4 month isoniazid plus rifampicin; or 3-4 month rifampicin alone.

BACKGROUND: Malaria rapid diagnostic tests (RDTs) offer significant potential to improve the diagnosis of malaria, and are playing an increasing role in malaria case management, control and elimination. Peru, along with other South American countries, is moving to introduce malaria RDTs as components of malaria control programmes supported by the Global Fund for AIDS, TB and malaria. The selection of the most suitable malaria RDTs is critical to the success of the programmes. METHODS: Eight of nine microscopy positive P. falciparum samples collected in Iquitos, Peru tested negative or weak positive using HRP2-detecting RDTs. These samples were tested for the presence of pfhrp2 and pfhrp3 and their flanking genes by PCR, as well as the presence of HRP proteins by ELISA. To investigate for geographic extent of HRP-deleted parasites and their temporal occurrence a retrospective study was undertaken on 148 microscopy positive P. falciparum samples collected in different areas of the Amazon region of Peru. FINDINGS: Eight of the nine isolates lacked the pfhrp2 and/or pfhrp3 genes and one or both flanking genes, and the absence of HRP was confirmed by ELISA. The retrospective study showed that 61 (41%) and 103 (70%) of the 148 samples lacked the pfhrp2 or pfhrp3 genes respectively, with 32 (21.6%) samples lacking both hrp genes. CONCLUSIONS: This is the first documentation of P. falciparum field isolates lacking pfhrp2 and/or pfhrp3. The high frequency and wide distribution of different parasites lacking pfhrp2 and/or pfhrp3 in widely dispersed areas in the Peruvian Amazon implies that malaria RDTs targeting HRP2 will fail to detect a high proportion of P. falciparum in malaria-endemic areas of Peru and should not be used. RDTs detecting parasite LDH or aldolase and quality microscopy should be use for malaria diagnosis in this region. There is an urgent need for investigation of the abundance and geographic distribution of these parasites in Peru and neighbouring countries.

BACKGROUND: In 2007 the World Health Organization (WHO) launched the global initiative to eliminate mother-to-child transmission of syphilis (congenital syphilis, or CS). To assess progress towards the goal of <50 CS cases per 100,000 live births, we generated regional and global estimates of maternal and congenital syphilis for 2016 and updated the 2012 estimates. METHODS: Maternal syphilis estimates were generated using the Spectrum-STI model, fitted to sentinel surveys and routine testing of pregnant women during antenatal care (ANC) and other representative population data. Global and regional estimates of CS used the same approach as previous WHO estimates. RESULTS: The estimated global maternal syphilis prevalence in 2016 was 0.69% (95% confidence interval: 0.57-0.81%) resulting in a global CS rate of 473 (385-561) per 100,000 live births and 661,000 (538,000-784,000) total CS cases, including 355,000 (290,000-419,000) adverse birth outcomes (ABO) and 306,000 (249,000-363,000) non-clinical CS cases (infants without clinical signs born to un-treated mothers). The ABOs included 143,000 early fetal deaths and stillbirths, 61,000 neonatal deaths, 41,000 preterm or low-birth weight births, and 109,000 infants with clinical CS. Of these ABOs- 203,000 (57%) occurred in pregnant women attending ANC but not screened for syphilis; 74,000 (21%) in mothers not enrolled in ANC, 55,000 (16%) in mothers screened but not treated, and 23,000 (6%) in mothers enrolled, screened and treated. The revised 2012 estimates were 0.70% (95% CI: 0.63-0.77%) maternal prevalence, and 748,000 CS cases (539 per 100,000 live births) including 397,000 (361,000-432,000) ABOs. The estimated decrease in CS case rates between 2012 and 2016 reflected increased access to ANC and to syphilis screening and treatment. CONCLUSIONS: Congenital syphilis decreased worldwide between 2012 and 2016, although maternal prevalence was stable. Achieving global CS elimination, however, will require improving access to early syphilis screening and treatment in ANC, clinically monitoring all women diagnosed with syphilis and their infants, improving partner management, and reducing syphilis prevalence in the general population by expanding testing, treatment and partner referral beyond ANC.

Non-communicable diseases (NCDs) were previously considered to only affect high-income countries. However, they now account for a very large burden in terms of both mortality and morbidity in low- and middle-income countries (LMICs), although little is known about the impact these diseases have on households in these countries. In this paper, we present a literature review on the costs imposed by NCDs on households in LMICs. We examine both the costs of obtaining medical care and the costs associated with being unable to work, while discussing the methodological issues of particular studies. The results suggest that NCDs pose a heavy financial burden on many affected households; poor households are the most financially affected when they seek care. Medicines are usually the largest component of costs and the use of originator brand medicines leads to higher than necessary expenses. In particular, in the treatment of diabetes, insulin--when required--represents an important source of spending for patients and their families. These financial costs deter many people suffering from NCDs from seeking the care they need. The limited health insurance coverage for NCDs is reflected in the low proportions of patients claiming reimbursement and the low reimbursement rates in existing insurance schemes. The costs associated with lost income-earning opportunities are also significant for many households. Therefore, NCDs impose a substantial financial burden on many households, including the poor in low-income countries. The financial costs of obtaining care also impose insurmountable barriers to access for some people, which illustrates the urgency of improving financial risk protection in health in LMIC settings and ensuring that NCDs are taken into account in these systems. In this paper, we identify areas where further research is needed to have a better view of the costs incurred by households because of NCDs; namely, the extension of the geographical scope, the inclusion of certain diseases hitherto little studied, the introduction of a time dimension, and more comparisons with acute illnesses.

BACKGROUND: Leptospirosis is a worldwide zoonotic infection that has been recognized for decades, but the problem of the disease has not been fully addressed, particularly in resource-poor, developing countries, where the major burden of the disease occurs. This paper presents an overview of the current situation of leptospirosis in the region. It describes the current trends in the epidemiology of leptospirosis, the existing surveillance systems, and presents the existing prevention and control programs in the Asia Pacific region. METHODS: Data on leptospirosis in each member country were sought from official national organizations, international public health organizations, online articles and the scientific literature. Papers were reviewed and relevant data were extracted. RESULTS: Leptospirosis is highly prevalent in the Asia Pacific region. Infections in developed countries arise mainly from occupational exposure, travel to endemic areas, recreational activities, or importation of domestic and wild animals, whereas outbreaks in developing countries are most frequently related to normal daily activities, over-crowding, poor sanitation and climatic conditions. CONCLUSION: In the Asia Pacific region, predominantly in developing countries, leptospirosis is largely a water-borne disease. Unless interventions to minimize exposure are aggressively implemented, the current global climate change will further aggravate the extent of the disease problem. Although trends indicate successful control of leptospirosis in some areas, there is no clear evidence that the disease has decreased in the last decade. The efficiency of surveillance systems and data collection varies significantly among the countries and areas within the region, leading to incomplete information in some instances. Thus, an accurate reflection of the true burden of the disease remains unknown.

Rising costs of antimalarial agents are increasing the demand for accurate diagnosis of malaria. Rapid diagnostic tests (RDTs) offer great potential to improve the diagnosis of malaria, particularly in remote areas. Many RDTs are based on the detection of Plasmodium falciparum histidine-rich protein (PfHRP) 2, but reports from field tests have questioned their sensitivity and reliability. We hypothesize that the variability in the results of PfHRP2-based RDTs is related to the variability in the target antigen. We tested this hypothesis by examining the genetic diversity of PfHRP2, which includes numerous amino acid repeats, in 75 P. falciparum lines and isolates originating from 19 countries and testing a subset of parasites by use of 2 PfHRP2-based RDTs. We observed extensive diversity in PfHRP2 sequences, both within and between countries. Logistic regression analysis indicated that 2 types of repeats were predictive of RDT detection sensitivity (87.5% accuracy), with predictions suggesting that only 84% of P. falciparum parasites in the Asia-Pacific region are likely to be detected at densities < or = 250 parasites/microL. Our data also indicated that PfHRP3 may play a role in the performance of PfHRP2-based RDTs. These findings provide an alternative explanation for the variable sensitivity in field tests of malaria RDTs that is not due to the quality of the RDTs.

The formulation of accurate clinical case definitions is an integral part of an effective process of public health surveillance. Although such definitions should, ideally, be based on a standardized and fixed collection of defining criteria, they often require revision to reflect new knowledge of the condition involved and improvements in diagnostic testing. Optimal case definitions also need to have a balance of sensitivity and specificity that reflects their intended use. After the 2009-2010 H1N1 influenza pandemic, the World Health Organization (WHO) initiated a technical consultation on global influenza surveillance. This prompted improvements in the sensitivity and specificity of the case definition for influenza - i.e. a respiratory disease that lacks uniquely defining symptomology. The revision process not only modified the definition of influenza-like illness, to include a simplified list of the criteria shown to be most predictive of influenza infection, but also clarified the language used for the definition, to enhance interpretability. To capture severe cases of influenza that required hospitalization, a new case definition was also developed for severe acute respiratory infection in all age groups. The new definitions have been found to capture more cases without compromising specificity. Despite the challenge still posed in the clinical separation of influenza from other respiratory infections, the global use of the new WHO case definitions should help determine global trends in the characteristics and transmission of influenza viruses and the associated disease burden.

The first officially documented management of the mentally ill in China was in the Tang Dynasty (618–907 AD), when homeless widows, orphans and the mentally ill were cared for in the Bei Tian Fang, a type of charity facility administrated by monks 1. The first western style psychiatric hospital for the homeless mentally ill was established and funded in 1898 by an American missionary, John Kerr, in what is currently the Guangzhou Brain Hospital. In the next 50 years, psychiatric hospitals were built very slowly in a limited number of large cities. The number of psychiatrists gradually increased to 100, and the number of beds gradually amounted to 1,000. After the founding of the People's Republic of China in 1949, psychiatric hospitals were gradually built in every province. The role of these early provincial hospitals was to maintain social security and stability. Following the first National Mental Health Meeting in 1958, community mental health work started in Beijing, Shanghai, Hunan, Sichuan and Jiangsu. Facilities were established in these areas to train professionals and to develop work plans for the prevention and treatment of psychoses, including early detection and treatment and relapse prevention 2. Though community mental health programs almost ceased during the Cultural Revolution (1966–1976), work-rehabilitation centers for patients with psychoses and caring networks were organized by neighborhood committees (the lowest level of governmental facilities) in Shanghai 3, and a treatment model for 256 patients with schizophrenia and their families was developed in a suburb of Beijing 4. In the 1980s, the health, civil affairs and public security sectors set up a three-tier network (at city, district/county and street/town levels) for the prevention and treatment of psychoses. Successful experiences with treatment models, such as work-rehabilitation centers in urban communities in Shanghai and Shenyang, and family-based therapy in rural areas in Haidian District in Beijing and Yantai Shangdong, were extended to other places 2. With the economic reform, hospitals were encouraged, as part of the market economy, to make a profit. Financially dependent mental health rehabilitation facilities closed or were transformed into small-scale psychiatric hospitals. In Shanghai, before 1990, there was at least one community-level rehabilitation facility in each district or town. By June 2004, the numbers of these facilities had decreased by 62% 5. By the late 1990s, some psychiatrists started to doubt the rationale for large hospital-based and profit-making models for mental health service delivery, and the Ministry of Health began to reconsider principles and approaches for mental health care. Through advocacy by the Ministry, senior ranked officials facilitated the establishment of a mental health plan. In November 1999, a high-level mental health seminar was convened by ten Chinese Ministries and the World Health Organization (WHO) in Beijing. The meeting resulted in a declaration that all levels of government would improve their leadership for and support of mental health care, strengthen inter-sectoral collaboration and cooperation, establish a mental health strategy and action plan, facilitate the enactment of a national mental health law, and protect patients’ rights 6. The first National Mental Health Plan (2002–2010) was signed by the Ministries of Health, Public Security and Civil Affairs, and China Disabled Persons’ Federation (CDPF) in April 2002. It identified a series of detailed targets and indices to achieve the main goals of: a) establishing an effective system of mental health care led by the government with the participation and cooperation of other sectors; b) accelerating the process of mental health legislation development and implementation; c) improving the knowledge and raising the awareness of mental health among all citizens; d) strengthening mental health services to decrease burden and disability; and e) developing human resources for mental health services and enhancing the capacity of current psychiatric hospitals 7. In August 2004, the Proposal on Further Strengthening Mental Health Work was approved by the Ministries of Health, Education, Public Security, Civil Affairs, Justice and Finance, and the CDPF. This proposal provides explicit instructions on interventions for psychological and behavioral problems for key population subgroups (including children and adolescents, women, the elderly and victims of disasters), treatment and rehabilitation of mental disorders, research on mental health and surveillance of mental disorders, and the protection of the rights of the mentally ill. The Proposal serves as the de facto Chinese national mental health policy. The mental health service model proposed in the above two documents is led by psychiatric hospitals, supported by departments of psychiatry in general hospitals, community-based health facilities and rehabilitation centres. In a large epidemiological study carried out in four provinces (Shandong, Zhejiang, Qinghai and Gansu) from 2001 to 2005, the adjusted 1-month prevalence of any mental disorder in people aged 18 years or older was 17.5% (95% CI 16.6–18.5), and that of psychotic disorders was 1.0% (95% CI 0.8–1.1) 8. In health economic terms, the estimated total disability adjusted life years (DALYs) of ten psychiatric conditions, including unipolar depressive disorder, bipolar disorder, schizophrenia, alcohol use disorders, Alzheimer's and other dementias, drug use disorders, post-traumatic stress disorder, obsessive-compulsive disorder, panic disorder, and insomnia (primary), was 253,851,896 years in China in 2004 9. This translates into a loss of gross domestic product (GDP) amounting to a country-wide total of CNY 2,681 billion, with schizophrenia and bipolar disorder accounting for CNY 532 billion. The huge burden of mental disorders highlights the pressing need for improved mental health services. However, similar to most countries, the rate of treatment gap of those with mental disorders is unacceptably high in China, with 91.8% of all individuals with any diagnosis of mental disorders never seeking help. For psychotic disorders, 27.6% never sought help and 12.0% saw non-mental health professionals only 8. The vast majority of mental health professionals in China are psychiatrists or psychiatric nurses, with few clinical psychologists and social workers, and no occupational therapists. Psychiatrists and licensed psychiatric nurses are accredited by the Ministry of Health, psychological counselors by the Ministry of Human Resources and Social Security, and psychotherapists by both Ministries. In 2004, there were 16,103 licensed psychiatrists and psychiatric registrars (1.24/100,000 population) and 24,793 licensed psychiatric nurses (1.91/100,000 population) 9. Relative to the global average mental health workforce (i.e., 4.15 psychiatrists and 12.97 psychiatric nurses per 100,000 population respectively) 10, mental health human resources in China are quite limited. The shortage of skilled mental health professionals represents one of the most critical issues facing the Chinese mental health system currently. In 2004, there were 557 psychiatric hospitals. Among them, 359 (64.5%) had 100 or more beds, and 44 (7.9%) had 500 or more beds. The total number of psychiatric beds was 129,314, i.e. 1.00/10,000 population 11, which is significantly lower than the global average of 4.36/10,000 psychiatric beds 10. China does not organize its services in catchment areas. Specialist mental health services remain the predominant component of the system. China's community-based mental health system was largely eliminated with the introduction of the market economy. Therefore, mental health service provision has become primarily hospital-based. Patients can access tertiary psychiatric hospitals directly, bypassing the primary and secondary health care levels. This partly reflects the disproportionate concentration of health resources in large cities. The funding model for the mental health system is complex, with hospital inpatient services provided by three ministries, Health, Civil Affairs and Public Security, while other facilities are administered under other ministries. According to the WHO, only 2.35% of the total health budget is spent on mental health and less than 15% of the population has health insurance that includes coverage of psychiatric disorders 10. China is undergoing a rapid change, with an economic growth rate of 7.5–13.0% per annum in the last ten years 12. However, the growth in wealth has not been equitably distributed, resulting in an increasing gap between the rich and the poor. It is evident that those with the greatest socio-economic disadvantage are often those with the highest mental health care needs 13. In October 2003, supported by the Ministry of Health, an application process was initiated for specialized public health projects that would have investment from the Ministry of Finance. All relevant public health sectors were active in developing appropriate models with critical indicators and drafting proposals for funding. Although several approaches and different models were considered, the mental health sector was yet to identify a suitable and practical model for China. A delegation led by Guihua Xu (Vice Director of China Centre for Disease Control) and three psychiatrists, Xin Yu, Hong Ma and Jin Liu from Peking University Institute of Mental Health, visited Melbourne, in order to build knowledge and understanding of the Victorian community mental health service system. The delegates and their Australian hosts also began to analyze the concept of community in China, and to investigate possible ways to integrate mental health care into secondary and tertiary facilities in the country. Complemented by other international exchanges with the USA, Norway, Thailand, Japan, UK and Germany, and guided by international benchmarks on mental health services by WHO and previous experiences in community mental health in China, a mental health sector model for reform emerged. The model has at its core a patient-centered approach that is community-based, seamless, function-oriented and multi-disciplinary. Due to China's vast, multi-ethnic and diverse population, social harmony and stability is a well recognized concern for the Chinese government. The focus on psychoses, especially those associated with violent or socially disruptive behaviours, was considered as a critical step to engage government in mental health issues. Although community-based mental health services were the long-term goal, current lack of resources and capacity in community mental health and primary mental health, combined with the difficulty in attracting mental health professionals to work in the community, meant that a different, less ambitious and more targeted model needed to be followed initially. An integrated hospital and community treatment model for psychoses was suggested, and a pilot project that included monitoring, intervention, prevention and rehabilitation management of psychoses was proposed. In September 2004, after competing with over fifty proposals and supported by a group of leading sociologists, economists and psychiatrists in China, the program for mental health service reform was the only non-communicable disease program included in China's national public health program. This event became a major historical milestone for China: mental health became officially included into public health. The mental health reform program formally received support from Ministry of Finance in December 2004, and was named the 686 Program after its initial funding of CNY 6.86 million. The National Centre for Mental Health of China located at Peking University Institute of Mental Health was authorized to be the implementing facility for this program by the Ministry of Health. The project was overseen by a national working group as well as an international advisory group with experts mainly from the University of Melbourne. By early 2005, 60 demonstration sites were established, with one urban and one rural area in each of the 30 provinces of China, covering a population of 43 million. The priority in the first year was to build a capable mental health workforce through an extensive training program. A two-level training mode was adopted, first at the national level utilizing a train-the-trainer approach, and then with trained trainers delivering the programs at the provincial level. The contents of the training included guidance on project management, standardized treatment protocols, case management, information management, family education, and the training of police and neighborhood committees. In 2006, the 686 Program incorporated an intervention component into the training program, which was then called the National Continuing Management and Intervention Program for Psychoses. The aim was to consolidate the reform through the key provisions of continuity of care, treatment accessibility, and equitable mental health care. Four types of psychoses were included: schizophrenia, bipolar disorder, delusional disorder, and schizoaffective disorder. Patients screened for possible psychosis were referred from psychiatric hospitals or departments, the CDPF, community and village health centres, and neighborhood or village committees. These patients were subsequently examined by psychiatrists, and those who met diagnostic criteria for psychotic disorders were evaluated for their risk of violence based on a 0 to 5 score scale established by the national working group. The patients at risk of violence received monthly follow-up and, if they were socio-economically disadvantaged, were provided with free medication, laboratory tests, and a subsidy for hospitalization. About 5% of patients who received free medications were treatment refractory and were therefore provided with second generation antipsychotics, mainly risperidone. In the event of any psychiatric emergencies or severe cases of medication side effects, the program provided free crisis management. Moreover, as some patients were physically restrained or chained at home, the program provided support for the unlocking and freeing of these patients, and hospitalization when necessary. After hospitalization, if patients lacked finances to pay for treatment, they were included in the free services mentioned above. A key challenge for successful implementation of the 686 Program was the limited capacity of the workforce to deliver the program at the local level. To meet this enormous challenge, a tripartite training program was collaboratively developed in 2007 by the Peking University Institute of Mental Health, the University of Melbourne and the Chinese University of Hong Kong. The primary aim of the program was to train up multi-skilled case workers by: a) developing understanding of the key principles of community-based mental health care in general and case b) practical in developing service plans to and continuity of c) appropriate ways to build with the families and d) to work in and e) to and for principles from health social occupational a set of knowledge and for case management was A key for the training program was to a rehabilitation focus in a community to a of community mental health facilities hospitals, training centres, mental health support and by the community mental health provided for such clinical The program needed to build that included different sectors and facilities into the mental health service including local health, civil public the and In a total of facilities in this program, including 44 provincial hospitals, hospitals, hospitals, urban community health urban community health village urban neighborhood committees and village committees. A mental health was also By the of a total of for the program. Among who were mainly for the patients and leading community for case for who mainly crisis intervention for for psychiatrists for psychiatric nurses for and at different levels for from the police in demonstration sites that the number of violent from in to in of and that of major violent from to of By the of general population in were by this program. A total of patients were patients received follow-up (the average follow-up in demonstration sites was patients received free medication, free crisis management interventions were and patients were a subsidy for restrained patients were In the first year of the 686 a total of training were and people were including psychiatrists, psychiatric nurses, community case community workers, public security and family To 500 mental health professionals from in China have in tripartite program training of ten mental health professionals from China have had practical training in Hong and more than 100 hospital and of mental health departments have study in Melbourne. of the most of the program has been in the area of This has the greatest on long-term with the 686 national on mental health have been the on of National Mental Health Work to improve and reform mental health work the Work the first in Chinese mental were in the of the the of Health hospitals were to be improved as part of public health service capacity the on of Public Health which the management of psychoses was included as one of national public health service and the on Management of which of different sectors in the management of psychoses, and the relevant were A government is an for in a of in China. However, the and the of the mental health problems as well as the are the of mental health All of mental health services in China and of this be the mental health service system development and service in China of the main problems are the is huge in China. Although national are quite and a among provinces and in of and levels. In some rich and or the mental health service system is provinces or cities. However, in some western the reform process is by and lack of resources and In those the national mental health become Resources are not between the community and psychiatric hospitals. Though community mental health is as part of the of public health and national funding has been to each to and up of the patients at community general lack knowledge and for these In the next two or three years, CNY to the of psychiatric hospitals that are often located in less and the funding primarily based on psychiatric hospital beds than care received from and treatment This hospitals to be in community services. In social insurance only the of hospitalization, leading more patients to use inpatient services. are psychoses. It is from the social stability of psychosis treatment and management is the priority of the government. However, to the lack of relevant and is under the of mentally Social and resources the treatment rate of patients with psychoses. However, of psychosis is or patients’ levels are are yet to be is less The focus on psychosis management psychiatry less are to be trained as psychiatrists, and psychiatric hospitals professionals with levels of education, training and The is to psychiatric facilities into health in which are as This from training in with other sectors is Although the of each relevant or sector has been in cooperation and collaboration is not or established, with the health and mental health sectors working in in areas. In a with government such as China, mental health development needs and support from government at all levels. this the mental health sector to the management of psychoses by In China needs to develop awareness of the of and their role in social resources and services for mentally ill patients in the community to their in urban areas and village in rural areas training in order to and develop care plans for four types of psychotic patients to the 686 at the primary care and to up patients at least four per the large number of patients with mental disorders in China, community and care for most patients needs to be and be supported to care in the community for their mentally ill The limited of funding only support the and of in the national program, the mental health facilities that these professionals have to make a in order to pay their Mental health service for psychoses be provided by the government as of the service or insurance for the support and investment in clinical and health research are to establish treatment and that are relevant in a Chinese Moreover, economic from the of and long-term and for patients with mental disorders are needed to and provided by the Social Security This reform program in China is with in years by the WHO and supported by other international In the WHO that develop community-based services for people with mental disorders This has been by a for action to scale up services for people with mental disorders the development of the Mental Health the of the and the in World The work on the 686 Program and other in China are in and in mental health service However, mental health services in China, as in and have a to to meet the of mental health care in the research provides relevant information to in the of effective and health services However, of this work to national and international is by the of from in psychiatric work by has a level of by China well as and of these countries, and no in the and is by a psychiatric in the main international supported action to improve of and research the of from this and similar The World and the the of the of have the to this Although China's mental health service reform has only on psychoses the scale of the reform, and the numbers of psychiatric patients a and ambitious program, which has had to huge The reform began than the reform of general health care in China, and is with the Chinese public health strategy and the for to the WHO With of needs and development of appropriate public health of effective strengthening of human of and China be in a to build and strengthen a national community mental health system and service for the of the mental health of its Jin Liu and Hong Ma to this and Xin is the The and for their and support to mental health reform in China, and for to the and as to also all those who have or in the establishment implementation of the 686

BACKGROUND: The 69th World Health Assembly endorsed the global health sector strategy on viral hepatitis to eliminate viral hepatitis as a public health threat by 2030. Achieving and measuring the 2030 targets requires a substantial increase in the capacity to test and treat viral hepatitis infections and a mechanism to monitor the progress of hepatitis elimination. This study aimed to identify the gaps in data availability or quality and create a new mechanism to monitor the progress of hepatitis elimination. METHODS: In 2020, using a questionnaire, we collected empirical, systematic, modelled, or surveyed data-reported by WHO country and WHO regional offices-on indicators of progress towards elimination of viral hepatitis, including burden of infection, incidence, mortality, and the cascade of care, and validated these data. FINDINGS: WHO received officially validated country-provided data from 130 countries or territories, and used partner-provided data for 70 countries or territories. We estimated that in 2019, globally, 295·9 million (3·8%) people were living with chronic hepatitis B virus (HBV) infection and 57·8 million (0·8%) people were living with chronic hepatitis C virus (HCV) infection. Globally, there were more than 3·0 million new infections with HBV and HCV and more than 1·1 million deaths due to the viruses in 2019. In 2019, 30·4 million (95% CI 24·3-38·0) individuals living with hepatitis B knew their infection status and 6·6 million (5·3-8·3) people diagnosed with hepatitis B received treatment. Among people with HCV infection, 15·2 million (95% CI 12·1-19·0) had been diagnosed between 2015 and 2019, and 9·4 million (7·5-11·7) people diagnosed with hepatitis C infection were treated with direct-acting antiviral drugs between 2015 and 2019. INTERPRETATION: There has been notable global progress towards hepatitis elimination. In 2019, 30·4 million (10·3%) people living with hepatitis B knew their infection status, which was slightly higher than in 2015 (22·0 million; 9·0%), and 6·6 million (22·7%) of those diagnosed with hepatitis B received treatment, compared with 1·7 million (8·0%) in 2015. Mortality from hepatitis C has declined since 2019, driven by an increase in HCV treatment ten times that of the strategy baseline. However, an estimated 89·7% of HBV infections and 78·6% of HCV infections remain undiagnosed. A new global strategy for 2022-30, based on these new estimates, should be implemented urgently to scale up the screening and treatment of viral hepatitis. FUNDING: World Health Organization.

BACKGROUND: Our understanding of the global scale of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection remains incomplete: Routine surveillance data underestimate infection and cannot infer on population immunity; there is a predominance of asymptomatic infections, and uneven access to diagnostics. We meta-analyzed SARS-CoV-2 seroprevalence studies, standardized to those described in the World Health Organization's Unity protocol (WHO Unity) for general population seroepidemiological studies, to estimate the extent of population infection and seropositivity to the virus 2 years into the pandemic. METHODS AND FINDINGS: We conducted a systematic review and meta-analysis, searching MEDLINE, Embase, Web of Science, preprints, and grey literature for SARS-CoV-2 seroprevalence published between January 1, 2020 and May 20, 2022. The review protocol is registered with PROSPERO (CRD42020183634). We included general population cross-sectional and cohort studies meeting an assay quality threshold (90% sensitivity, 97% specificity; exceptions for humanitarian settings). We excluded studies with an unclear or closed population sample frame. Eligible studies-those aligned with the WHO Unity protocol-were extracted and critically appraised in duplicate, with risk of bias evaluated using a modified Joanna Briggs Institute checklist. We meta-analyzed seroprevalence by country and month, pooling to estimate regional and global seroprevalence over time; compared seroprevalence from infection to confirmed cases to estimate underascertainment; meta-analyzed differences in seroprevalence between demographic subgroups such as age and sex; and identified national factors associated with seroprevalence using meta-regression. We identified 513 full texts reporting 965 distinct seroprevalence studies (41% low- and middle-income countries [LMICs]) sampling 5,346,069 participants between January 2020 and April 2022, including 459 low/moderate risk of bias studies with national/subnational scope in further analysis. By September 2021, global SARS-CoV-2 seroprevalence from infection or vaccination was 59.2%, 95% CI [56.1% to 62.2%]. Overall seroprevalence rose steeply in 2021 due to infection in some regions (e.g., 26.6% [24.6 to 28.8] to 86.7% [84.6% to 88.5%] in Africa in December 2021) and vaccination and infection in others (e.g., 9.6% [8.3% to 11.0%] in June 2020 to 95.9% [92.6% to 97.8%] in December 2021, in European high-income countries [HICs]). After the emergence of Omicron in March 2022, infection-induced seroprevalence rose to 47.9% [41.0% to 54.9%] in Europe HIC and 33.7% [31.6% to 36.0%] in Americas HIC. In 2021 Quarter Three (July to September), median seroprevalence to cumulative incidence ratios ranged from around 2:1 in the Americas and Europe HICs to over 100:1 in Africa (LMICs). Children 0 to 9 years and adults 60+ were at lower risk of seropositivity than adults 20 to 29 (p < 0.001 and p = 0.005, respectively). In a multivariable model using prevaccination data, stringent public health and social measures were associated with lower seroprevalence (p = 0.02). The main limitations of our methodology include that some estimates were driven by certain countries or populations being overrepresented. CONCLUSIONS: In this study, we observed that global seroprevalence has risen considerably over time and with regional variation; however, over one-third of the global population are seronegative to the SARS-CoV-2 virus. Our estimates of infections based on seroprevalence far exceed reported Coronavirus Disease 2019 (COVID-19) cases. Quality and standardized seroprevalence studies are essential to inform COVID-19 response, particularly in resource-limited regions.

Soil-transmitted helminth (STH) infections are the most widespread of the neglected tropical diseases, primarily affecting marginalized populations in low- and middle-income countries. More than one billion people are currently infected with STHs. For the control of these infections, the World Health Organization (WHO) recommends an integrated approach, which includes access to appropriate sanitation, hygiene education, and preventive chemotherapy (i.e., large-scale, periodic distribution of anthelmintic drugs). Since 2010, WHO has coordinated two large donations of benzimidazoles to endemic countries. Thus far, more than 3.3 billion benzimidazole tablets have been distributed in schools for the control of STH infections, resulting in an important reduction in STH-attributable morbidity in children, while additional tablets have been distributed for the control of lymphatic filariasis. This paper (i) summarizes the progress of global STH control between 2008 to 2018 (based on over 690 reports submitted by endemic countries to WHO); (ii) provides regional and country details on preventive chemotherapy coverage; and (iii) indicates the targets identified by WHO for the next decade and the tools that should be developed to attain these targets. The main message is that STH-attributable morbidity can be averted with evidence-informed program planning, implementation, and monitoring. Caution will still need to be exercised in stopping control programs to avoid any rebound of prevalence and loss of accrued morbidity gains. Over the next decade, with increased country leadership and multi-sector engagement, the goal of eliminating STH infections as a public health problem can be achieved.

A critical component of laboratory surveillance for measles is the genetic characterization of circulating wild-type viruses. The World Health Organization (WHO) Measles and Rubella Laboratory Network (LabNet), provides for standardized testing in 183 countries and supports genetic characterization of currently circulating strains of measles viruses. The goal of this report is to describe the lessons learned from nearly 20 years of virologic surveillance for measles, to describe the global databases for measles sequences, and to provide regional updates about measles genotypes detected by recent surveillance activities. Virologic surveillance for measles is now well established in all of the WHO regions, and most countries have conducted at least some baseline surveillance. The WHO Global Genotype Database contains >7000 genotype reports, and the Measles Nucleotide Surveillance (MeaNS) contains >4000 entries. This sequence information has proven to be extremely useful for tracking global transmission patterns and for documenting the interruption of transmission in some countries. The future challenges will be to develop quality control programs for molecular methods and to continue to expand virologic surveillance activities in all regions.

BACKGROUND: Because of reductions in the incidence of Plasmodium falciparum malaria in Laos, identification of the causes of fever in people without malaria, and discussion of the best empirical treatment options, are urgently needed. We aimed to identify the causes of non-malarial acute fever in patients in rural Laos. METHODS: For this prospective study, we recruited 1938 febrile patients, between May, 2008, and December, 2010, at Luang Namtha provincial hospital in northwest Laos (n=1390), and between September, 2008, and December, 2010, at Salavan provincial hospital in southern Laos (n=548). Eligible participants were aged 5-49 years with fever (≥38°C) lasting 8 days or less and were eligible for malaria testing by national guidelines. FINDINGS: With conservative definitions of cause, we assigned 799 (41%) patients a diagnosis. With exclusion of influenza, the top five diagnoses when only one aetiological agent per patient was identified were dengue (156 [8%] of 1927 patients), scrub typhus (122 [7%] of 1871), Japanese encephalitis virus (112 [6%] of 1924), leptospirosis (109 [6%] of 1934), and bacteraemia (43 [2%] of 1938). 115 (32%) of 358 patients at Luang Namtha hospital tested influenza PCR-positive between June and December, 2010, of which influenza B was the most frequently detected strain (n=121 [87%]). Disease frequency differed significantly between the two sites: Japanese encephalitis virus infection (p=0·04), typhoid (p=0·006), and leptospirosis (p=0·001) were more common at Luang Namtha, whereas dengue and malaria were more common at Salavan (all p<0·0001). With use of evidence from southeast Asia when possible, we estimated that azithromycin, doxycycline, ceftriaxone, and ofloxacin would have had significant efficacy for 258 (13%), 240 (12%), 154 (8%), and 41 (2%) of patients, respectively. INTERPRETATION: Our findings suggest that a wide range of treatable or preventable pathogens are implicated in non-malarial febrile illness in Laos. Empirical treatment with doxycycline for patients with undifferentiated fever and negative rapid diagnostic tests for malaria and dengue could be an appropriate strategy for rural health workers in Laos. FUNDING: Wellcome Trust, WHO-Western Pacific Region, Foundation for Innovative New Diagnostics, US Centers for Disease Control and Prevention

OBJECTIVE: To evaluate the relative cost-effectiveness in different sub-Saharan African settings of presumptive treatment, field-standard microscopy and rapid diagnostic tests (RDTs) to diagnose malaria. METHODS: We used a decision tree model and probabilistic sensitivity analysis applied to outpatients presenting at rural health facilities with suspected malaria. Costs and effects encompassed those for both patients positive on RDT (assuming artemisinin-based combination therapy) and febrile patients negative on RDT (assuming antibiotic treatment). Interventions were defined as cost-effective if they were less costly and more effective or had an incremental cost per disability-adjusted life year averted of less than US$ 150. Data were drawn from published and unpublished sources, supplemented with expert opinion. FINDINGS: RDTs were cost-effective compared with presumptive treatment up to high prevalences of Plasmodium falciparum parasitaemia. Decision-makers can be at least 50% confident of this result below 81% malaria prevalence, and 95% confident below 62% prevalence, a level seldom exceeded in practice. RDTs were more than 50% likely to be cost-saving below 58% prevalence. Relative to microscopy, RDTs were more than 85% likely to be cost-effective across all prevalence levels, reflecting their expected better accuracy under real-life conditions. Results were robust to extensive sensitivity analysis. The cost-effectiveness of RDTs mainly reflected improved treatment and health outcomes for non-malarial febrile illness, plus savings in antimalarial drug costs. Results were dependent on the assumption that prescribers used test results to guide treatment decisions. CONCLUSION: RDTs have the potential to be cost-effective in most parts of sub-Saharan Africa. Appropriate management of malaria and non-malarial febrile illnesses is required to reap the full benefits of these tests.

BACKGROUND: Data on insecticide use for vector control are essential for guiding pesticide management systems on judicious and appropriate use, resistance management, and reduction of risks to human health and the environment. OBJECTIVE: We studied the global use and trends of insecticide use for control of vector-borne diseases for the period 2000 through 2009. METHODS: A survey was distributed to countries with vector control programs to request national data on vector control insecticide use, excluding the use of long-lasting insecticidal nets (LNs). Data were received from 125 countries, representing 97% of the human populations of 143 targeted countries. RESULTS: The main disease targeted with insecticides was malaria, followed by dengue, leishmaniasis, and Chagas disease. The use of vector control insecticides was dominated by organochlorines [i.e., DDT (dichlorodiphenyltrichloroethane)] in terms of quantity applied (71% of total) and by pyrethroids in terms of the surface or area covered (81% of total). Global use of DDT for vector control, most of which was in India alone, was fairly constant during 2000 through 2009. In Africa, pyrethroid use increased in countries that also achieved high coverage for LNs, and DDT increased sharply until 2008 but dropped in 2009. CONCLUSIONS: The global use of DDT has not changed substantially since the Stockholm Convention went into effect. The dominance of pyrethroid use has major implications because of the spread of insecticide resistance with the potential to reduce the efficacy of LNs. Managing insecticide resistance should be coordinated between disease-specific programs and sectors of public health and agriculture within the context of an integrated vector management approach.

In 2013, the WHO recommended that all member states aim to reduce population salt intake by 30% by 2025. The year 2019 represents the midpoint, making it a critical time to assess countries' progress towards this target. This review aims to identify all national salt reduction initiatives around the world in 2019, and to quantify countries' progress in achieving the salt reduction target. Relevant data were identified through searches of peer-reviewed and gray literature, supplemented with responses from prefilled country questionnaires sent to known country leads of salt reduction or salt champions, WHO regional representatives, and international experts to request further information. Core characteristics of each country's strategy, including evaluations of program impact, were extracted and summarized. A total of 96 national salt reduction initiatives were identified, representing a 28% increase in the number reported in 2014. About 90% of the initiatives were multifaceted in approach, and 60% had a regulatory component. Approaches include interventions in settings (n= 74), food reformulation (n = 68), consumer education (n = 50), front-of-pack labeling (n = 48), and salt taxation (n = 5). Since 2014, there has been an increase in the number of countries implementing each of the approaches, except consumer education. Data on program impact were limited. There were 3 countries that reported a substantial decrease (>2 g/day), 9 that reported a moderate decrease (1-2 g/day), and 5 that reported a slight decrease (<1 g/day) in the mean salt intake over time, but none have yet met the targeted 30% relative reduction in salt intake from baseline. In summary, there has been an increase in the number of salt reduction initiatives around the world since 2014. More countries are now opting for structural or regulatory approaches. However, efforts must be urgently accelerated and replicated in other countries and more rigorous monitoring and evaluation of strategies is needed to achieve the salt reduction target.

BACKGROUND: In May 2022, several countries with no history of sustained community transmission of mpox (formerly known as monkeypox) notified WHO of new mpox cases. These cases were soon followed by a large-scale outbreak, which unfolded across the world, driven by local, in-country transmission within previously unaffected countries. On July 23, 2022, WHO declared the outbreak a Public Health Emergency of International Concern. Here, we aim to describe the main epidemiological features of this outbreak, the largest reported to date. METHODS: In this analysis of global surveillance data we analysed data for all confirmed mpox cases reported by WHO Member States through the global surveillance system from Jan 1, 2022, to Jan 29, 2023. Data included daily aggregated numbers of mpox cases by country and a case reporting form (CRF) containing information on demographics, clinical presentation, epidemiological exposure factors, and laboratory testing. We used the data to (1) describe the key epidemiological and clinical features of cases; (2) analyse risk factors for hospitalisation (by multivariable mixed-effects binary logistic regression); and (3) retrospectively analyse transmission trends. Sequencing data from GISAID and GenBank were used to analyse monkeypox virus (MPXV) genetic diversity. FINDINGS: Data from 82 807 cases with submitted CRFs were included in the analysis. Cases were primarily due to clade IIb MPXV (mainly lineage B.1, followed by lineage A.2). The outbreak was driven by transmission among males (73 560 [96·4%] of 76 293 cases) who self-identify as men who have sex with men (25 938 [86·9%] of 29 854 cases). The most common reported route of transmission was sexual contact (14 941 [68·7%] of 21 749). 3927 (7·3%) of 54 117 cases were hospitalised, with increased odds for those aged younger than 5 years (adjusted odds ratio 2·12 [95% CI 1·32-3·40], p=0·0020), aged 65 years and older (1·54 [1·05-2·25], p=0·026), female cases (1·61 [1·35-1·91], p<0·0001), and for cases who are immunosuppressed either due to being HIV positive and immunosuppressed (2·00 [1·68-2·37], p<0·0001), or other immunocompromising conditions (3·47 [1·84-6·54], p=0·0001). INTERPRETATION: Continued global surveillance allowed WHO to monitor the epidemic, identify risk factors, and inform the public health response. The outbreak can be attributed to clade IIb MPXV spread by newly described modes of transmission. FUNDING: WHO Contingency Fund for Emergencies. TRANSLATIONS: For the French and Spanish translations of the abstract see Supplementary Materials section.

INTRODUCTION: Current SARS-CoV-2 containment measures rely on controlling viral transmission. Effective prioritization can be determined by understanding SARS-CoV-2 transmission dynamics. We conducted a systematic review and meta-analyses of the secondary attack rate (SAR) in household and healthcare settings. We also examined whether household transmission differed by symptom status of index case, adult and children, and relationship to index case. METHODS: We searched PubMed, medRxiv, and bioRxiv databases between January 1 and July 25, 2020. High-quality studies presenting original data for calculating point estimates and 95% confidence intervals (CI) were included. Random effects models were constructed to pool SAR in household and healthcare settings. Publication bias was assessed by funnel plots and Egger's meta-regression test. RESULTS: 43 studies met the inclusion criteria for household SAR, 18 for healthcare SAR, and 17 for other settings. The pooled household SAR was 18.1% (95% CI: 15.7%, 20.6%), with significant heterogeneity across studies ranging from 3.9% to 54.9%. SAR of symptomatic index cases was higher than asymptomatic cases (RR: 3.23; 95% CI: 1.46, 7.14). Adults showed higher susceptibility to infection than children (RR: 1.71; 95% CI: 1.35, 2.17). Spouses of index cases were more likely to be infected compared to other household contacts (RR: 2.39; 95% CI: 1.79, 3.19). In healthcare settings, SAR was estimated at 0.7% (95% CI: 0.4%, 1.0%). DISCUSSION: While aggressive contact tracing strategies may be appropriate early in an outbreak, as it progresses, measures should transition to account for setting-specific transmission risk. Quarantine may need to cover entire communities while tracing shifts to identifying transmission hotspots and vulnerable populations. Where possible, confirmed cases should be isolated away from the household.

Five human cases of infection with the simian malaria parasite Plasmodium knowlesi from Palawan, the Philippines, were confirmed by nested PCR. This study suggests that this zoonotic infection is found across a relatively wide area in Palawan and documents autochthonous cases in the country.