Policy stakeholder perspectives on barriers and facilitators to launching a community-wide mass drug administration program for soil-transmitted helminths

Background:Recent evidence suggests that soil-transmitted helminth(STH)transmission interruption may be feasible through community-wide mass drug administration(cMDA)that deworms community members of all ages.A change from school-based deworming to cMDA will require reconfiguring of STH programs in endemic countries.We conducted formative qualitative research in Benin,India,and Malawi to identify barriers and facilitators to successfully launching a cMDA program from the policy-stakeholder perspective.Methods:We conducted 40 key informant interviews with policy stakeholders identified as critical change agents at national,state/district,and sub-district levels.Participants included World Health Organization country office staff,implementing partners,and national and sub-national government officials.We used the Consolidated Framework for Implementation Research to guide data collection,coding,and analysis.Heat maps were used to organize coded data and differentiate perceived facilitators and barriers to launching cMDA by stakeholder.Results:Key facilitators to launching a cMDA program included availability of high-quality,tailored sensitization materials,and human and material resources that could be leveraged from previous MDA campaigns.Key barriers included the potential to overburden existing health workers,uncertainty of external funding to sustain a cMDA program,and concerns about weak intragovernmental coordination to implement cMDA.Cross-cutting themes included the need for rigorous trial evidence on STH transmission interruption to gain confidence in cMDA,and implemen-tation evidence to effectively operationalize cMDA.Importantly,if policy stakeholders anticipate a cMDA program cannot be sustained due to cost and human resource barriers in the long term they may be less likely to support the launch of a program in the short term.Conclusions:Overall,policy stakeholders were optimistic about implementing cMDA primarily because they believe that the tools necessary to successfully implement cMDA are already available.Policy stakeholders in this study were cautiously optimistic about launching cMDA to achieve STH transmission interruption and believe that it is feasible to implement.However,launching cMDA as an alternative policy to school-based deworming will require addressing key resource and evidence barriers.

Moving beyond Wastewater:Perspectives on Environmental Surveillance of Infectious Diseases for Public Health Action in Low-Resource Settings

Although testing wastewater for public health surveillance has recently received significant attention in the United States,researchers and public health professionals have long realized the tremendous promise of environmental surveillance(ES),defined as tracking pathogens of interest in fecally contaminated surface waters,soil,or fomites,in low-resource settings for public health action.1,2 The power of ES in lowresource settings is most clearly illustrated with the over 30 years of well-established and standardized polio surveillance.As part of the Global Polio Eradication Initiative,the World Health Organization(WHO)has accredited 146 laboratories within the Global Polio Lab Network(GPLN).These facilities across 92 countries process over 8,000 wastewater or fecally contaminated surface water samples per year,in addition to over 220,000 stool samples annually.3 The data generated from the GPLN are closely linked to clear public health action related to targeted vaccination campaigns.The investment and adoption of ES for polio eradication efforts serves as a use-case for other targets of interest.To explore the current state of the field,the National Science Foundation-funded Research Coordination Network(RCN)on Wastewater Based Epidemiology for SARS-CoV-2 and Emerging Public Health Threats held a workshop in December 2023 to discuss the opportunities and challenges for ES in low-resource settings(Figure 1).Discussions during the workshop highlighted knowledge gaps,best-practices,target selection,academic/government/private partnerships and overall public health action and sustainability of these programs.