Correspondence
2
Horton R. Offline: Breaking the silence in nephrology. Lancet 2015; 385: 1058. Davids MR, Marais N, Jacobs JC. South African Renal Registry annual report 2012. Durban; South African Renal Society, 2014.
Frailty in sub-Saharan Africa Most high-income countries are called to urgently adapt their health-care systems to meet the new challenges arising from their ageing populations. Models of health-care services aimed at preventing age-related disabling disorders (including the design of screening and assessment instruments) are largely from high-income countries. Little consideration has been given to ageing and its resulting effects in low-income and middle-income regions. This absence of interest for the effects of ageing in low-income regions is worrying because these areas are not only highly populated (especially in absolute numbers), but also have the same demographic trends that characterise high-income countries. Although sub-Saharan Africa is the world’s poorest and youngest region,1 the ageing of its population is starting to represent a real issue for public health. Sub-Saharan Africa is a vast region with a population of 1·1 billion people. Its population of older people (aged ≥60 years) has steadily increased during the past decades and is projected to reach more than 67 million people by 2030.2 Moreover, life expectancy at age 60 years in sub-Saharan Africa is 16 years for women and 14 years for men, suggesting that a long old age is already a reality in this region.1,2 In this context, we find it frustrating that, to our knowledge, no study has reported the prevalence of frailty in sub-Saharan Africa. In parallel, this region is burdened by the high prevalence of communicable diseases (eg, HIV-AIDS), a high mortality rate in childhood, increasing prevalence of cardiovascular risk factors, and www.thelancet.com Vol 385 May 30, 2015
low literacy levels.3–5 All these factors represent different (and probably more immediate) priorities in public health agendas. However, the targeting of these disorders does not preclude a careful assessment of agerelated disorders, especially because taking action at a young age might improve the health status of the future generations of elderly people. The ageing of the world’s population suggests that changes to existing models of health care are needed to counteract the destabilising effects of age-related disorders on healthcare systems.6 At the same time, interventions should be developed against frailty and the resulting effects of ageing, especially in view of their feasibility and applicability of these in both high-income and low-income regions. The extension of preventive strategies to low-income and middle-income countries should be considered, at least for ethical reasons. However, too complicated, very population-specific, and expensive approaches could restrict the diffusion of prevention against age-related disorders in low-resource settings. For this reason the standardisation of screening, assessments, and intervention pro cedures should be reduced to simple and easily reproducible models, probably targeting the core of the ageing process (eg, the age-related loss of function). J-FD reports grants and personal fees from Novartis and IPSEN. MC reports grants from Pfizer, Sanofi, Servier, GlaxoSmithKline, Novartis, and Eli Lilly; and personal fees from Pfizer and Nestlé. MTT and CK-T declare no competing interests.
*Maturin Tabue Teguo, Callixte Kuate-Tegueu, Jean-François Dartigues, Matteo Cesari [email protected] Université de Bordeaux, Bordeaux, 33076, France (MTT, J-FD); Centre Hospitalier Villeneuve-sur-Lot, Villeneuve-sur-Lot, France (MTT); Université de Yaoundé I, Yaoundé, Cameroon (CK-T); Université de Toulouse III Paul Sabatier, Toulouse, France (MC); and Centre Hospitalier Universitaire de Toulouse, Toulouse, France (MC) 1
Aboderin IA, Beard JR. Older people’s health in sub-Saharan Africa. Lancet 2015; 385: e9–e11.
2
3
4
5
6
WHO. Good health adds life to years: global brief for World Health Day 2012. Geneva; World Health Organization, 2012. Institute for Health Metrics and Evaluation. Global health data exchange: global burden of disease 2010 study data. http://ghdx. healthdata.org/ (accessed April 10, 2015). Lowsky DJ, Olshansky SJ, Bhattacharya J, Goldman DP. Heterogeneity in healthy aging. J Gerontol A Biol Sci Med Sci 2014; 69: 640–49. Gureje O, Oladeji BD, Abiona T, Chatterjee S. Profile and determinants of successful aging in the Ibadan Study of Ageing. J Am Geriatr Soc 2014; 62: 836–42. British Geriatrics Society. Fit for frailty: consensus best practice guidance for the care of older people living with frailty in community and outpatient settings. London; British Geriatrics Society, 2014.
Chris Sattlberger/Science Photo Library
1
Onchocerciasis and lymphatic filariasis elimination in Africa: it’s about time About 164 million Africans are at risk of onchocerciasis, and for more than two decades, mass drug administration with ivermectin has been the primary drug to control it.1 In 2010, WHO and the World Bank African Programme for Onchocerciasis Control (APOC) announced a strategic transition from onchocerciasis morbidity control to Onchocerca volvulus transmission elimination and set an elimination goal of 2025 for most of Africa.1 Roughly 400 million Africans are at risk of lymphatic filariasis.1 The WHO Global Program to Eliminate Lymphatic Filariasis (GPELF) aims to eliminate lymphatic filariasis by 2020 and relies on at least 6 years of annual mass drug administration of a combination of ivermectin and albendazole to reach its goal and eliminate this public health problem. Unlike the onchocerciasis programme, which has maintained about 70% coverage of the people who need it, treatment coverage of lymphatic filariasis in Africa was only 32% in 2013.1 A massive scale-up is needed to achieve the 2020 target. One way to rapidly expand treatments of lymphatic filariasis is to
For the WHO Global Program to Eliminate Lymphatic Filariasis see http://www.who.int/ lymphatic_filariasis/disease/en/
2151
Correspondence
Published Online May 7, 2015 http://dx.doi.org/10.1016/ S0140-6736(15)60505-0
2152
integrate it with the onchocerciasis programme, since most onchocerciasis-endemic areas are coendemic for lymphatic filariasis.2 Of the nearly 1500 districts in Africa with functional mass drug administration programmes for onchocerciasis, only 513 (35%) districts are coendemic for lymphatic filariasis and are coimplementing treatment.3 Another 365 (25%) districts are known to be coendemic but were inexplicably unable to start treatment. Lymphatic filariasis has not been mapped in the remaining 588 districts.3 The inability of these programmes to work together to reach the simplest and most efficient road to scale up treatment for lymphatic filariasis is a lost opportunity. An ancillary benefit of scaling up treatment of lymphatic filariasis will be to accelerate the interruption of O volvulus transmission. As a control programme, APOC limited treatment of onchocerciasis to areas where infection prevalence was 40% or higher. However, as the focus turns to elimination, areas with low prevalence must be reconsidered for intervention because they are reservoirs of parasite transmission.4 As the GPELF expands treatment, lymphatic filariasisendemic districts bordering current onchocerciasis treatment zones will undoubtedly treat many such areas, contributing to onchocerciasis elimination. Specific challenges need to be addressed to better enable these two programmes to work together. As the GPELF expands into ivermectinnaive areas, a means for rapidly assessing the presence of O volvulus transmission is needed. This will involve replacing insensitive traditional diagnostic tests (skin snip microscopy, nodule palpation, and fly dissection) with newer, more sensitive tests, including serological diagnostic tests and PCR-based screening of vectors.4 WHO onchocerciasis elimination guidelines recommend these methods to verify elimination, and they have been used to verify elimination of
onchocerciasis in Latin American foci and transmission interruption in African foci.4–6 However, the serological tests should define the lowest threshold needed to support ongoing parasite transmission. Such O volvulus transmission thresholds should be operationally compatible with the current transmission assessment sample surveys for lymphatic filariasis. Clear guidance and additional funding for new treatment strategies (including twice-yearly treatment)6 are needed to accelerate onchocerciasis elimination and to address the problem of O volvulus and Loa loa coendemicity, where the risk of adverse events from microfilaricidal drugs has severely hampered progress.5 APOC was a highly successful, but overly vertical, control programme for onchocerciasis. Once APOC closes on Dec 31, 2015, the programmes that will continue the fight against onchocerciasis must focus on elimination rather than control, and integration rather than vertical programming. The international community has been presented with a unique opportunity to redefine how the lymphatic filariasis and onchocerciasis programmes should work together. Let us work quickly to improve the science, policy, and implementation of integrated programmes to eliminate these diseases from Africa. DSE is an employee of United States Agency for International Development (USAID), which has been a donor to APOC in the past. TRU has received personal fees from Mectizan Expert committee, outside the submitted work. FOR declares no competing interests. The views and opinions expressed are those of the authors and not necessarily the views and opinions of USAID.
*Darin S Evans, Thomas R Unnasch, Frank O Richards [email protected] USAID, Global Health, Washington, DC 20004, USA (DSE); University of South Florida, Tampa, FL, USA (TRU); and The Carter Center, Atlanta, GA, USA (FOR) 1
2
WHO/APOC. The World Health Organization Year 2014 Progress Report, 1st September 2013 to 31st August 2014. Ouagadougou, Burkina Faso: African Programme for Onchocerciasis Control, 2014. http://www. who.int/apoc/onchocerciasis/en/. WHO. Meeting of the international task force for disease eradication, January 2014. MMWR 2014; 89: 153–60.
3
4
5
6
WHO/APOC. Meeting report. Strategic review and planning meeting: onchocerciasis and lymphatic filariasis elimination in Africa. Ouagadougou, Burkina Faso: African Programme for Onchocerciasis Control, 2014. Oguttu D, Byamukama E, Katholi CR, et al. Serosurveillance to monitor onchocerciasis elimination: the Ugandan experience. Am J Trop Med Hyg 2014; 90: 339–45. Cupp EW, Sauerbrey M, Richards F. Elimination of human onchocerciasis: history of progress and current feasibility using ivermectin (Mectizan) monotherapy. Acta Trop 2011; 120 (suppl 1): S100–08. Katabarwa M, Richards F. Twice-yearly ivermectin for onchocerciasis: the time is now. Lancet Infect Dis 2014; 14: 373–74.
Department of Error Lees CC, Marlow N, van Wassenaer-Leemhuis A, et al, for the TRUFFLE study group. 2 year neurodevelopmental and intermediate perinatal outcomes in infants with very preterm fetal growth restriction (TRUFFLE): a randomised trial. Lancet 2015; 385: 2162–72—In the Findings section of this Article, the IQR for 30·7 weeks should be 29·1–32·1 and infants free of neuroimpairment in the late ductus changes group should read 133 [95%] of 140. In table 3, adjusted age of survivors at discharge should be given as median (IQR). In the Results, impairment in those allocated to DV p95 should be “12 (9%) of 131” and in those allocated to DV no A should be “seven (5%) of 140.” In the TRUFFLE study group, the eighth name should be “Inge-Lot van Haastert” and “Serena Rigano (University of Milan, Italy)” should be added to the study group. These corrections have been made to the online version as of May 7, 2015, and the printed Article is correct. Palmu AA, Jokinen J, Borys D, et al. Effectiveness of the ten-valent pneumococcal Haemophilus influenzae protein D conjugate vaccine (PHiD-CV10) against invasive pneumococcal disease: a cluster randomised trial. Lancet 2013; 381: 214–22—In the Results section of this Article, one reported serious adverse event should have been categorised as “possibly or definitely related to study vaccine” instead of listed under “remaining cases” (a child with diarrhoea, vomiting, and fever whose first two symptoms were considered not related to study vaccine, but whose fever was possibly related). Additionally, of the convulsions reported in the control group, two were non-febrile, rather than all being febrile. These corrections have been made to the online version as of May 29, 2015. Norheim OF, Jha P, Admasu K, et al. Avoiding 40% of the premature deaths in each country, 2010–30: review of national mortality trends to help quantify the UN Sustainable Development Goal for health. Lancet 2015; 385: 239–52—A statement for declaration of interests has been added, reporting that the authors had no competing interests. This correction has been made to the online version as of May 29, 2015.
www.thelancet.com Vol 385 May 30, 2015
2
Horton R. Offline: Breaking the silence in nephrology. Lancet 2015; 385: 1058. Davids MR, Marais N, Jacobs JC. South African Renal Registry annual report 2012. Durban; South African Renal Society, 2014.
Frailty in sub-Saharan Africa Most high-income countries are called to urgently adapt their health-care systems to meet the new challenges arising from their ageing populations. Models of health-care services aimed at preventing age-related disabling disorders (including the design of screening and assessment instruments) are largely from high-income countries. Little consideration has been given to ageing and its resulting effects in low-income and middle-income regions. This absence of interest for the effects of ageing in low-income regions is worrying because these areas are not only highly populated (especially in absolute numbers), but also have the same demographic trends that characterise high-income countries. Although sub-Saharan Africa is the world’s poorest and youngest region,1 the ageing of its population is starting to represent a real issue for public health. Sub-Saharan Africa is a vast region with a population of 1·1 billion people. Its population of older people (aged ≥60 years) has steadily increased during the past decades and is projected to reach more than 67 million people by 2030.2 Moreover, life expectancy at age 60 years in sub-Saharan Africa is 16 years for women and 14 years for men, suggesting that a long old age is already a reality in this region.1,2 In this context, we find it frustrating that, to our knowledge, no study has reported the prevalence of frailty in sub-Saharan Africa. In parallel, this region is burdened by the high prevalence of communicable diseases (eg, HIV-AIDS), a high mortality rate in childhood, increasing prevalence of cardiovascular risk factors, and www.thelancet.com Vol 385 May 30, 2015
low literacy levels.3–5 All these factors represent different (and probably more immediate) priorities in public health agendas. However, the targeting of these disorders does not preclude a careful assessment of agerelated disorders, especially because taking action at a young age might improve the health status of the future generations of elderly people. The ageing of the world’s population suggests that changes to existing models of health care are needed to counteract the destabilising effects of age-related disorders on healthcare systems.6 At the same time, interventions should be developed against frailty and the resulting effects of ageing, especially in view of their feasibility and applicability of these in both high-income and low-income regions. The extension of preventive strategies to low-income and middle-income countries should be considered, at least for ethical reasons. However, too complicated, very population-specific, and expensive approaches could restrict the diffusion of prevention against age-related disorders in low-resource settings. For this reason the standardisation of screening, assessments, and intervention pro cedures should be reduced to simple and easily reproducible models, probably targeting the core of the ageing process (eg, the age-related loss of function). J-FD reports grants and personal fees from Novartis and IPSEN. MC reports grants from Pfizer, Sanofi, Servier, GlaxoSmithKline, Novartis, and Eli Lilly; and personal fees from Pfizer and Nestlé. MTT and CK-T declare no competing interests.
*Maturin Tabue Teguo, Callixte Kuate-Tegueu, Jean-François Dartigues, Matteo Cesari [email protected] Université de Bordeaux, Bordeaux, 33076, France (MTT, J-FD); Centre Hospitalier Villeneuve-sur-Lot, Villeneuve-sur-Lot, France (MTT); Université de Yaoundé I, Yaoundé, Cameroon (CK-T); Université de Toulouse III Paul Sabatier, Toulouse, France (MC); and Centre Hospitalier Universitaire de Toulouse, Toulouse, France (MC) 1
Aboderin IA, Beard JR. Older people’s health in sub-Saharan Africa. Lancet 2015; 385: e9–e11.
2
3
4
5
6
WHO. Good health adds life to years: global brief for World Health Day 2012. Geneva; World Health Organization, 2012. Institute for Health Metrics and Evaluation. Global health data exchange: global burden of disease 2010 study data. http://ghdx. healthdata.org/ (accessed April 10, 2015). Lowsky DJ, Olshansky SJ, Bhattacharya J, Goldman DP. Heterogeneity in healthy aging. J Gerontol A Biol Sci Med Sci 2014; 69: 640–49. Gureje O, Oladeji BD, Abiona T, Chatterjee S. Profile and determinants of successful aging in the Ibadan Study of Ageing. J Am Geriatr Soc 2014; 62: 836–42. British Geriatrics Society. Fit for frailty: consensus best practice guidance for the care of older people living with frailty in community and outpatient settings. London; British Geriatrics Society, 2014.
Chris Sattlberger/Science Photo Library
1
Onchocerciasis and lymphatic filariasis elimination in Africa: it’s about time About 164 million Africans are at risk of onchocerciasis, and for more than two decades, mass drug administration with ivermectin has been the primary drug to control it.1 In 2010, WHO and the World Bank African Programme for Onchocerciasis Control (APOC) announced a strategic transition from onchocerciasis morbidity control to Onchocerca volvulus transmission elimination and set an elimination goal of 2025 for most of Africa.1 Roughly 400 million Africans are at risk of lymphatic filariasis.1 The WHO Global Program to Eliminate Lymphatic Filariasis (GPELF) aims to eliminate lymphatic filariasis by 2020 and relies on at least 6 years of annual mass drug administration of a combination of ivermectin and albendazole to reach its goal and eliminate this public health problem. Unlike the onchocerciasis programme, which has maintained about 70% coverage of the people who need it, treatment coverage of lymphatic filariasis in Africa was only 32% in 2013.1 A massive scale-up is needed to achieve the 2020 target. One way to rapidly expand treatments of lymphatic filariasis is to
For the WHO Global Program to Eliminate Lymphatic Filariasis see http://www.who.int/ lymphatic_filariasis/disease/en/
2151
Correspondence
Published Online May 7, 2015 http://dx.doi.org/10.1016/ S0140-6736(15)60505-0
2152
integrate it with the onchocerciasis programme, since most onchocerciasis-endemic areas are coendemic for lymphatic filariasis.2 Of the nearly 1500 districts in Africa with functional mass drug administration programmes for onchocerciasis, only 513 (35%) districts are coendemic for lymphatic filariasis and are coimplementing treatment.3 Another 365 (25%) districts are known to be coendemic but were inexplicably unable to start treatment. Lymphatic filariasis has not been mapped in the remaining 588 districts.3 The inability of these programmes to work together to reach the simplest and most efficient road to scale up treatment for lymphatic filariasis is a lost opportunity. An ancillary benefit of scaling up treatment of lymphatic filariasis will be to accelerate the interruption of O volvulus transmission. As a control programme, APOC limited treatment of onchocerciasis to areas where infection prevalence was 40% or higher. However, as the focus turns to elimination, areas with low prevalence must be reconsidered for intervention because they are reservoirs of parasite transmission.4 As the GPELF expands treatment, lymphatic filariasisendemic districts bordering current onchocerciasis treatment zones will undoubtedly treat many such areas, contributing to onchocerciasis elimination. Specific challenges need to be addressed to better enable these two programmes to work together. As the GPELF expands into ivermectinnaive areas, a means for rapidly assessing the presence of O volvulus transmission is needed. This will involve replacing insensitive traditional diagnostic tests (skin snip microscopy, nodule palpation, and fly dissection) with newer, more sensitive tests, including serological diagnostic tests and PCR-based screening of vectors.4 WHO onchocerciasis elimination guidelines recommend these methods to verify elimination, and they have been used to verify elimination of
onchocerciasis in Latin American foci and transmission interruption in African foci.4–6 However, the serological tests should define the lowest threshold needed to support ongoing parasite transmission. Such O volvulus transmission thresholds should be operationally compatible with the current transmission assessment sample surveys for lymphatic filariasis. Clear guidance and additional funding for new treatment strategies (including twice-yearly treatment)6 are needed to accelerate onchocerciasis elimination and to address the problem of O volvulus and Loa loa coendemicity, where the risk of adverse events from microfilaricidal drugs has severely hampered progress.5 APOC was a highly successful, but overly vertical, control programme for onchocerciasis. Once APOC closes on Dec 31, 2015, the programmes that will continue the fight against onchocerciasis must focus on elimination rather than control, and integration rather than vertical programming. The international community has been presented with a unique opportunity to redefine how the lymphatic filariasis and onchocerciasis programmes should work together. Let us work quickly to improve the science, policy, and implementation of integrated programmes to eliminate these diseases from Africa. DSE is an employee of United States Agency for International Development (USAID), which has been a donor to APOC in the past. TRU has received personal fees from Mectizan Expert committee, outside the submitted work. FOR declares no competing interests. The views and opinions expressed are those of the authors and not necessarily the views and opinions of USAID.
*Darin S Evans, Thomas R Unnasch, Frank O Richards [email protected] USAID, Global Health, Washington, DC 20004, USA (DSE); University of South Florida, Tampa, FL, USA (TRU); and The Carter Center, Atlanta, GA, USA (FOR) 1
2
WHO/APOC. The World Health Organization Year 2014 Progress Report, 1st September 2013 to 31st August 2014. Ouagadougou, Burkina Faso: African Programme for Onchocerciasis Control, 2014. http://www. who.int/apoc/onchocerciasis/en/. WHO. Meeting of the international task force for disease eradication, January 2014. MMWR 2014; 89: 153–60.
3
4
5
6
WHO/APOC. Meeting report. Strategic review and planning meeting: onchocerciasis and lymphatic filariasis elimination in Africa. Ouagadougou, Burkina Faso: African Programme for Onchocerciasis Control, 2014. Oguttu D, Byamukama E, Katholi CR, et al. Serosurveillance to monitor onchocerciasis elimination: the Ugandan experience. Am J Trop Med Hyg 2014; 90: 339–45. Cupp EW, Sauerbrey M, Richards F. Elimination of human onchocerciasis: history of progress and current feasibility using ivermectin (Mectizan) monotherapy. Acta Trop 2011; 120 (suppl 1): S100–08. Katabarwa M, Richards F. Twice-yearly ivermectin for onchocerciasis: the time is now. Lancet Infect Dis 2014; 14: 373–74.
Department of Error Lees CC, Marlow N, van Wassenaer-Leemhuis A, et al, for the TRUFFLE study group. 2 year neurodevelopmental and intermediate perinatal outcomes in infants with very preterm fetal growth restriction (TRUFFLE): a randomised trial. Lancet 2015; 385: 2162–72—In the Findings section of this Article, the IQR for 30·7 weeks should be 29·1–32·1 and infants free of neuroimpairment in the late ductus changes group should read 133 [95%] of 140. In table 3, adjusted age of survivors at discharge should be given as median (IQR). In the Results, impairment in those allocated to DV p95 should be “12 (9%) of 131” and in those allocated to DV no A should be “seven (5%) of 140.” In the TRUFFLE study group, the eighth name should be “Inge-Lot van Haastert” and “Serena Rigano (University of Milan, Italy)” should be added to the study group. These corrections have been made to the online version as of May 7, 2015, and the printed Article is correct. Palmu AA, Jokinen J, Borys D, et al. Effectiveness of the ten-valent pneumococcal Haemophilus influenzae protein D conjugate vaccine (PHiD-CV10) against invasive pneumococcal disease: a cluster randomised trial. Lancet 2013; 381: 214–22—In the Results section of this Article, one reported serious adverse event should have been categorised as “possibly or definitely related to study vaccine” instead of listed under “remaining cases” (a child with diarrhoea, vomiting, and fever whose first two symptoms were considered not related to study vaccine, but whose fever was possibly related). Additionally, of the convulsions reported in the control group, two were non-febrile, rather than all being febrile. These corrections have been made to the online version as of May 29, 2015. Norheim OF, Jha P, Admasu K, et al. Avoiding 40% of the premature deaths in each country, 2010–30: review of national mortality trends to help quantify the UN Sustainable Development Goal for health. Lancet 2015; 385: 239–52—A statement for declaration of interests has been added, reporting that the authors had no competing interests. This correction has been made to the online version as of May 29, 2015.
www.thelancet.com Vol 385 May 30, 2015
