The Global Programme to Eliminate Lymphatic Filariasis (GPELF) was established with the ambitious goal of eliminating LF as a public health problem. The remarkable success of the GPELF over the past 2 decades in carrying out its principal strategy of scaling up and scaling down mass drug administration has relied first on the development of a rigorous monitoring and evaluation (M&E) framework and then the willingness of the World Health Organization and its community of partners to modify this framework in response to the practical experiences of national programmes. This flexibility was facilitated by the strong partnership that developed among researchers, LF programme managers and donors willing to support the necessary research agenda. This brief review summarizes the historical evolution of the GPELF M&E strategies and highlights current research needed to achieve the elimination goal.

INTRODUCTION: To monitor progress toward maternal and neonatal tetanus elimination (MNTE) in Cambodia, we conducted a nationwide serosurvey of tetanus immunity in 2012. METHODS: Multi-stage cluster sampling was used to select 2,154 women aged 15-39 years. Tetanus toxoid antibodies in sera were measured by gold-standard double antigen ELISA (DAE) and a novel multiplex bead assay (MBA). Antibody concentrations ≥0.01 IU/ml by DAE, or equivalent for MBA, were considered seroprotective. RESULTS: Estimated tetanus seroprotection was 88% (95% CI: 86%-89%); 64% (95% CI: 61%-67%) of women had antibody levels ≥1.0 IU/ml. Seroprotection was significantly lower (p <0.001) among women aged 15-19 years (63%) and 20-24 years (87%) compared with ≥25 years (96%), nulliparous compared with parous (71% vs. 97%), and living in the west compared with other regions (82% vs. 89%). The MBA showed high sensitivity (99% [95% CI: 98%-99%]) and specificity (92% [95% CI: 88%-95%]) compared with DAE. CONCLUSIONS: Findings were compatible with MNTE in Cambodia (≥80% protection). Tetanus immunity gaps should be addressed through strengthened routine immunization and targeted vaccination campaigns. Incorporating tetanus testing in national serosurveys using MBAs, which can measure immunity to multiple pathogens simultaneously, may be beneficial for monitoring MNTE.

BACKGROUND: Correct treatment of potentially life-threatening illnesses (PLTIs) in children under 5 years, such as malaria, pneumonia, and diarrhea, can substantially reduce mortality. The Integrated Management of Childhood Illness (IMCI) strategy has been shown to improve treatment of child illnesses, but multiple studies have shown that gaps in health worker performance remain after training. To better understand factors related to health worker performance, we analyzed 9,330 patient consultations in Benin from 2001-2002, after training one of the first cohorts of 32 health workers in IMCI. METHODS: With data abstracted from patient registers specially designed for IMCI-trained health workers, we examined associations between health facility-, health worker-, and patient-level factors and 10 case-management outcomes for PLTIs. RESULTS: Altogether, 63.6 % of children received treatment for all their PLTIs in accordance with IMCI guidelines, and 77.8 % received life-saving treatment (i.e., clinically effective treatment, even if not exactly in accordance with IMCI guidelines). Performance of individual health workers varied greatly, from 15-88 % of patients treated correctly, on average. Multivariate regression analyses identified several factors that might have influenced case-management quality, many outside a manager's direct control. Younger health workers significantly outperformed older ones, and infants received better care than older children. Children with danger signs, those with more complex illnesses, and those with anemia received worse care. Health worker supervision was associated with improved performance for some outcomes. CONCLUSIONS: A variety of factors, some outside the direct control of program managers, can influence health worker practices. An understanding of these influences can help inform the development of strategies to improve performance.

BACKGROUND: Programs for control of soil-transmitted helminth (STH) infections are increasingly evaluating national mass drug administration (MDA) interventions. However, "unprogrammed deworming" (receipt of deworming drugs outside of nationally-run STH control programs) occurs frequently. Failure to account for these activities may compromise evaluations of MDA effectiveness. METHODS: We used a cross-sectional study design to evaluate STH infection and unprogrammed deworming among infants (aged 6-11 months), preschool-aged children (PSAC, aged 1-4 years), and school-aged children (SAC, aged 5-14 years) in Kibera, Kenya, an informal settlement not currently receiving nationally-run MDA for STH. STH infection was assessed by triplicate Kato-Katz. We asked heads of households with randomly-selected children about past-year receipt and source(s) of deworming drugs. Local non-governmental organizations (NGOs) and school staff participating in school-based deworming were interviewed to collect information on drug coverage. RESULTS: Of 679 children (18 infants, 184 PSAC, and 477 SAC) evaluated, 377 (55%) reported receiving at least one unprogrammed deworming treatment during the past year. PSAC primarily received treatments from chemists (48.3%) or healthcare centers (37.7%); SAC most commonly received treatments at school (55.0%). Four NGOs reported past-year deworming activities at 47 of >150 schools attended by children in our study area. Past-year deworming was negatively associated with any-STH infection (34.8% vs 45.4%, p = 0.005). SAC whose most recent deworming medication was sourced from a chemist were more often infected with Trichuris (38.0%) than those who received their most recent treatment from a health center (17.3%) or school (23.1%) (p = 0.05). CONCLUSION: Unprogrammed deworming was received by more than half of children in our study area, from multiple sources. Both individual-level treatment and unprogrammed preventive chemotherapy may serve an important public health function, particularly in the absence of programmed deworming; however, they may also lead to an overestimation of programmed MDA effectiveness. A standardized, validated tool is needed to assess unprogrammed deworming.

OBJECTIVE: Training health workers to use Integrated Management of Childhood Illness (IMCI) guidelines can improve care for ill children in outpatient settings in developing countries. However, even after IMCI training, important performance gaps exist. One potential reason is that the effect of training can rapidly wane. Our aim was to determine if the performance of IMCI-trained health workers deteriorated over 3 years. METHODS: We studied two departments in Benin. First, we performed a record review of 32 IMCI-trained health workers during the first year of IMCI implementation (2001-2002). Second, we analysed data from cross-sectional health facility surveys from 2001 to 2004 that represented the entire study area. Primary outcomes were the proportion of children under 5 years old with potentially life-threatening illnesses who received either recommended or adequate treatment, and among all children, an index of overall guideline adherence. Secondary outcomes reflected the treatment of individual diseases. Outcomes were calculated monthly, and time trends were evaluated with regression modelling. RESULTS: The record review included 9393 consultations, and the surveys included 411 consultations performed by 105 health workers. For both data sources, performance trends were essentially flat for nearly all outcomes. Absolute levels of performance revealed substantial performance gaps. CONCLUSIONS: We found no evidence that performance declined over 3 years after IMCI training. However, important performance gaps found immediately after IMCI training persisted and should be addressed. (2012 Blackwell Publishing Ltd.)

OBJECTIVE: In developing countries, supervision is a widely recognized strategy for improving health worker performance; and anecdotally, maintaining regular, high-quality supervision is difficult. However, remarkably little research has explored in depth why supervision is so challenging. METHODS: In the context of a trial to improve health worker adherence to Integrated Management of Childhood Illness (IMCI) guidelines and strengthen supervision in southeastern Benin, we used record reviews, focus group discussions, key informant interviews, and cross-sectional surveys to examine the supervision process. FINDINGS: Initially, little IMCI supervision occurred. The frequency increased substantially after implementing a series of workshops, but then deteriorated. Quantitative and qualitative data revealed obstacles to supervision at multiple levels of the health system. Based on supervisors' opinions, the main problems were: poor coordination; inadequate management skills and ineffective management teams; a lack of motivation; problems related to decentralization; health workers sometimes resisting IMCI implementation; and less priority given to IMCI supervision because of incentives for non-supervision activities, a lack of leadership, and an expectation of integrated supervision. To this list, based on our observations, we add: the increasing supervision workload, time required for non-supervision activities, project interventions not always being implemented as planned, and the loss of particularly effective supervisors. In terms of correctly completing steps of the supervision process, the quality of supervision was generally good. CONCLUSIONS: Managers should monitor supervision, understand the evolving influences on supervision, and use their resources and authority to both promote supervision and remove impediments to supervision. Support from leaders can be crucial, thus donors and politicians should help make supervision a true priority. As with front-line clinicians, supervisors are health workers who need support. We emphasize the importance of research to identify effective and affordable strategies for improving supervision frequency and quality. (ClinicalTrials.gov number NCT00510679.).