The authors of randomized controlled trials will usually claim that they have met the randomization process criterion. However, sequence generation schemes differ and some schemes that are claimed to be randomized are not genuinely randomized. Even less well understood, and often more difficult to ascertain, is whether the allocation was really concealed. To detect the extent of control over selection bias, in a comparison between two Cochrane groups: oral health and otorhinolaryngology; and to describe the methods used to control for this bias. Cross-sectional study conducted in a public university in São Paulo, Brazil. The risk of selection bias in 1,714 records indexed in Medline database up to 2018 was assessed, independent of language and access. Two dimensions implicated in the allocation were considered: generation of the allocation sequence; and allocation concealment. We included 420 randomized controlled trials and all of them were evaluated to detect selection bias. In the sample studied, only 28 properly controlled the selection bias. Lack of control over selection bias was present in 80% of the studies evaluated in both groups. The two groups were similar regarding control over selection bias. They are also similar to the methods used. The dimension of allocation concealment appears to be a limiting factor with regard to production of randomized controlled trials with low risk of selection bias. The quality of reporting in studies on oral health and otorhinolaryngology is suboptimal and needs to be improved, in line with other fields of healthcare. Through using such trials, researchers have the assurance that the differences found between the groups evaluated truly result from the effectiveness of the intervention, given that the allocation is random, i.e. there is an equal distribution of prognoses between the groups.,,Randomized controlled trials (RCTs) are considered to be a powerful research design for evaluating the effects of healthcare interventions. They constituted one of the most important scientific advances during the 20,,,,The controls over the allocation implementation process include generation of a random allocation sequence and simultaneous allocation concealment.,,,The authors of RCTs will usually claim that they have met the randomization process criterion, in the title of the article or in the abstract. However, sequence generation schemes differ, and some schemes that are claimed to be randomized are not genuinely randomized.,,Even less well understood, and often more difficult to ascertain, is whether the allocation was really concealed. Allocation concealment is actually part of the randomization process and, while distinct from the method used to generate the randomized sequence, is essential to the success of randomization.,,,,,,,,,,,,,,,,,,,,,The idea of comparing data from different fields within healthcare is not new.The aims of this study were to detect the extent of control over selection bias through comparing different fields within healthcare: otorhinolaryngology and oral health; and to describe the methods used to control for this bias.This was a cross-sectional study in which the risk of selection bias of randomized controlled trials indexed in the Medline database was assessed.Primary studies with an RCT design in the fields of otorhinolaryngology  diseases) and oral healthcare that were published in journals and indexed in the Medline database were eligible, independent of language and access. A random sample was taken from these studies. These two fields of healthcare were chosen because of the similar numbers of Cochrane systematic reviews that have been published, for reasons of their anatomical and functional proximity and because they share healthcare problems.Since it was not possible to conduct a cohort study to evaluate the methods of randomized controlled trials, we chose to conduct two cross-over studies at two different time points: 2011-2013 and 2018-2020. Data from this second period have already begun to be collected and as soon as finalized will be compared and published. Thus, initially, approximately 755 potential RCTs in the oral health group and 959 potential RCTs in the ENT group were retrieved.The sample calculation was performed taking a margin of error of 5%, a difference between groups of 30% and a confidence interval of 95%, in the light of our working hypothesis. It was found that analysis on approximately 200 articles in each field would be necessary. A total of 420 RCTs were included, comprising 214 on ENT and 206 on oral health.To evaluate the allocation process, the Cochrane Collaboration risk-of-bias tool was used.The variable “risk of bias” was segmented into three possible responses: a) low risk of bias, meaning that the author controlled the entire allocation process, comprising random generation and allocation concealment, and therefore that this was an RCT with low risk of selection bias; b) uncertain risk of bias, meaning that the author did not report the allocation process comprising random generation and concealment of the allocation, or reported it in such a way that it was impossible to know for sure what the real situation of the allocation and concealment was; and c) high risk of bias, meaning that the author reported using an incorrect method for the allocation process.To identify RCTs in the ENT group, an electronic search strategy recommended by the Cochrane Ear, Nose and Throat Disorders Group was used, with the following search terms: ear nose throat; general ENT and head-and-neck cancer; nose and adenoids, pharynx, larynx and upper respiratory tract infection (URTI); salivary glands; and skull base and neck. This was combined with the Cochrane highly sensitive search strategies for identifying randomized trials in Medline . The samTo assess the risk of the RCTs, two independent reviewers classified the studies, to ensure that these trials could be replicated. The first was a medical researcher (CAF) who was an expert on methodology; and the second was a pharmacist who was an expert on epidemiology (VA). Disagreements were discussed with a third researcher, who was an expert on methodology, to establish a consensus (CASL).The statistical analyses were performed using the SPSS 19.0 software for Windows. The variable “risk of bias” was taken to be the ordinal and each group was taken to be the categorical variable. To ascertain differences between the groups within each dimension of the risk of bias, nonparametric test were used (Pearson chi-square and Mantel-Haenszel). The odds ratio (OR) was used to represent the chances between the groups evaluated. The significance level used in the tests was 5% , and tests with P-values less than 5% (P < 0.05) were taken to be statistically significant.The Cochrane strategy combined with the key words in the field of oral health recovered 755 records. From this universe, a sample of 206 RCTs was taken. All of these RCTs were evaluated to detect selection bias. In the sample studied, only 38 RCTs properly controlled selection bias .The Cochrane strategy combined with the key words in the field of ENT recovered 959 records. From this universe, a sample of 214 RCTs was taken. All of these RCTs were evaluated to detect selection bias. In the sample studied, only 28 RCTs properly controlled selection bias .The level of agreement between the reviewers was measured using the kappa statistical test. The result was satisfactory (kappa = 0.71).Different methods were used for generating the allocation process. Most of the authors used unrestricted randomization to generate the allocation sequence, like computer programs or tables or lists of random numbers. Flipping a coin was used only in the oral health group. Central randomization was used only in the ENT group. Some authors used restricted randomization, like randomization in blocks: this was seen both in the ENT group and in the oral health group. Only three authors used minimization in the ENT group and only two used minimization in the oral health group. Only one author used random allocation by drawing lots, and this was within oral health .Most of the authors used sealed numbered envelopes to accomplish allocation concealment. Only two studies used central allocation to achieve concealment in the ENT group and one study in the oral health group .Many study projects may control for large numbers of types of bias, but the means used for adequately applying the allocation process in order to control selection bias is precisely the feature that distinguishes RCTs from other types of study project.In the present study, it was found that selection bias was possible in most of the studies evaluated in both fields. The dimension of allocation concealment appears to be a limiting factor with regard to production of RCTs with low risk of bias, thus representing the main barrier against production of RCTs with control over selection bias. Only 16% of the studies were truly RCTs or enabled control over selection bias.,,,,,,,,The two groups were identical regarding control over selection bias and, thus, this appears not to be a condition relating only to the field of oral health. This result was unexpected, because some studiesSimilarly, Peters (2015) assessed the quality of reports and abstracts of RCTs within the literature relating to otorhinolaryngology and found that the quality of reporting of RCTs was suboptimal. This author showed that these articles did not report the allocation process sufficiently.The only study comparing medicine with dentistry was by Sjögren,,,,,,,,,,,,,,,,,,,,,,,,There is a dynamic movement towards enhancement of reports and specifically the quality of RCTs, within all fields.There was similarity between the fields regarding the methods used in the allocation process. Simple random allocation is the easiest and most basic approach towards providing unpredictability of treatment assignment. Good methods of generating random allocation sequences include using a random-numbers table or a computer software program to generate the random sequence. There are manual methods for achieving random allocation, such as tossing a coin, drawing lots or throwing dice. However, these manual methods in practice often become nonrandom, are difficult to implement and do not leave an audit trail.To achieve allocation concealment, opaque sealed envelopes were used in both groups. This method is usually considered acceptable, but it may be susceptible to manipulation. Central randomization is the preferred method.,Randomization reduces bias in clinical trials and provides a basis for ensuring the validity of data analysis using statistical testing. It usually just requires a table of random numbers. Simple randomization is adequate for large trials, while block randomization is a method for balancing equal numbers of patients in each treatment group. Stratification allows balanced distribution of one or more confounding prognostic variables among treatment groups to ensure that the groups have similar prognoses. Block randomization and stratification improve the validity of trials with smaller numbers of patients. Computer software facilitates randomization.,In relation to sequence and allocation concealment, ShulzThe search for the present analysis was made only in the PubMed database, and other medical databases were excluded. However, PubMed is one of the largest and most widely available databases: it is accessed through the National Institutes of Health (NIH).Efforts need to be made to focus on the allocation implementation process, using only a single step: generation of random allocation sequences and simultaneous implementation of the sequence in such a way that the allocation is concealed. The quality of reporting within the fields of oral health and ENT is suboptimal and needs to be improved so as to match the quality already attained in other fields of healthcare. It is of great importance to take these findings into account, in order to improve the level of evidence of future randomized controlled trials within all fields of healthcare.


Since “Belt and Road Initiative” (BRI) of 2014, the number of foreigners in China has increased rapidly and China has become an importing country for immigrants, a change ongoing since the beginning of the 21st century. To respond to the rapidly increasing number of foreigners in China, the government frequently revised the immigration policies and issued new regulations for foreigners. However, scholars understand very little about how the foreigners perceive their integration into Chinese society or decide to pursue long-term residency or lawful permanent resident status. While some pioneering studies touch on this, with samples from the coastal megacities, no empirical evidence has been collected from smaller, inner cities. Three new findings about the foreigners in Xi’an, a major city in western China, fill this literature gap. First, the level of subjective social integration is largely influenced by the local networks. Second, the level of objective social integration depends largely on local and hometown networks. Third, the intention to obtain long-term and permanent residency in China is more evident in those foreigners who come from countries covered by the BRI and who consider China to be a better place to live than their home country. Why do foreigners come? How do they live among us? What factors persuade them to stay longer? Our intensive literature search finds that the theoretical and empirical answers to these questions came from observations of North American, European, and Oceanic countries, which led to macrolevel economic explanations, mesolevel insights into the family’s decision to migrate, and microlevel investigations of the migrants’ personal merits and social networks. In the view of contemporary Western scholars, China enters this overall pattern of international migration as a major source of emigrants, which was an accurate understanding of China from the late 19th century to the beginning of the 21st century. As a result, most of the social science researchers perceived those three areas of analysis in international migration to be unrelated to China as a target destination, and there is a clear lack of theoretical insight or data collection on the foreigners in China thus far.http://www.stats.gov.cn/tjsj/pcsj/rkpc/6rp/indexch.htm, accessed on 1 June 2022).The “Belt and Road Initiative” (BRI) of 2014 created more opportunities, unprecedented convenience, and stronger incentives for international students and employees to come to mainland China. The latest statistics demonstrate a totality of 500,000 international students and 900,000 foreign employees in mainland China [http://www.stats.gov.cn/tjsj/pcsj/rkpc/7rp/indexch.htm, accessed on 1 June 2022). This means that the number of foreigners increased by almost 50% in the last decade. The number of countries covered by BRI has been growing, and by the end of July 2022, China had signed more than 200 cooperation documents with 149 countries and 32 international organizations .The sixth national census of 2010 revealed 590,000 foreigners living in mainland China . Our study focuses closely on this expanding community of international immigrants in Xi’an, a city with a strong emphasis on Chinese tradition.Unlike Beijing, Shanghai, or Hong Kong, Xi’an is an unfamiliar name for most of the foreigners. As the provincial capital of Shaanxi, Xi’an is a large city of 12 million residents. Due to its geographical location, Xi’an has been the central hub of economic, political, cultural, and educational resources in China’s western inland since the very beginning of Chinese civilization. Xi’an was the political center of 13 dynasties of ancient China and served as the starting point of the Silk Road since the Han Dynasty. As the home of nine World Heritage Sites, Xi’an defines traditional Chinese culture. Since 2014, Xi’an has started to gain new momentum toward globalization and faster economic development, due to the arrival of the “Belt and Road Initiative” (or the “BRI”). The BRI has brought policy advantages to Xi’an by comprehensively deepening the reforms and opening up movement, such as bringing more international exposure to local history and culture, increasing investments in higher education, and creating more incentives to attract foreign direct investments (FDIs) and international joint ventures. As a result, Xi’an has seen an increasing number of foreigners. In 2017, the number of international students in Xi’an exceeded 10,000. On 4 May 2018, Chen Naixia, spokesperson and deputy secretary of the Higher Education Work Committee of the CPC Shaanxi Provincial Committee, introduced the number of international students in Shaanxi Province at a press conference held as part of a series on the theme of “Strengthening Cultural Construction and Demonstrating Cultural Confidence”, held by the Foreign Propaganda Office of the CPC Shaanxi Provincial Committee  from 2018, which was conducted for a month in the Xi’an Public Security Bureau Exit and Entry Administration. It was difficult to use probability sampling due to the specificity of the foreigner population. We collected questionnaires from every foreigner who came for business to the immigration hall for a month. The survey questionnaire was mainly for the foreigners who came to the hall for immigration formalities. The survey was available in more than fifteen languages, and there were a total of 837 valid responses. The object of this research was the foreigners in Xi’an who are over 18 years old; therefore, 817 valid samples were entered into the empirical model analysis after screening for missing values.The dependent variables of this research are the social integration and residence intention of the foreigners living in China. For social integration, we employed two indicators, subjective integration and objective integration. The subjective integration was measured using subjective willingness to interact with the Chinese by doing something together. It is measured by classic Bogardus Psychosocial Distance Scale, which specifically includes five items: “Are you willing to do the things listed below: chat with Chinese; work with Chinese; have Chinese neighbors; make friends with Chinese; marry Chinese; or let your children marry Chinese” . The objIt is difficult to measure residence intention objectively, since people’s intention is not only subjective but also unsteady or dynamic, that could change from time to time. Besides, it could show some inconsistencies between what people report as their intention to live or immigrate, and what they actually do (such as submit an application maybe years after). Therefore, we used two subjectively variables to analyze residence intention in this study: long-term residence intention and immigration intention. The former is a binary variable, whose values include residence intention and no residence intention. The latter is a multicategory variable, with values about nonimmigration intention, immigration intention before arriving in China, and immigration intention after arriving in China.The key independent variable of our study is social networks, which include local networks and hometown networks.The local network refers to the number of Chinese people who the foreigners know and connect with in China, which is divided into three categories: small (10 people and below); middle (11 to 50 people); and large (51 people and above). The hometown networks, which mean the connection with the friends and relatives from the home country in this study, consist mainly of the scale of the hometown networks, relatives’ experience, and relative companionship. Similarly, the size of the hometown networks is also divided into three categories, namely, small refers to a network of five or fewer people from their home country in China; middle refers to one of 6 to 50 people; and large refers to one of 51 or more people in China. Relatives’ experience refers to whether the relatives of foreigners have ever lived or worked in China. The companionship of relatives refers to whether the foreigner’s partner, children, parents, or relatives are currently living in China together.Additionally, this study focuses on the impact of three other dimensions of variables on the intention to stay: inclusive individual characteristics; social background in places of emigration; and living conditions in places of immigration. Individual characteristics include human capital variables and migration attribute variables. The social background in the emigration place mainly includes both home country variables and hometown attribute variables. The living conditions in the immigration place consist of integration variables and recognition variables, and the control variables of this study refer to gender and age. The descriptive statistical results of all of the variables are shown in This study analyzes the influencing factors of international migrants’ subjective integration through the nested model . Among tAt the same time, this study analyzes the influencing factors of international immigrants’ objective integration (activity participation) through a nested model . SimilarAs shown in The second part of this research is based on an empirical analysis of the foreigners living in Xi’an; therefore, in the current context of the BRI, we have further analyzed the different influencing factors on the intention to stay between BRI countries and non-BRI countries. Notably, the samples of the BRI countries are based on the list of countries that have signed cooperation documents with China to jointly build the BRI, which was published on the official website of the Belt and Road Portal. From our data, 84% of the foreigners are from the countries along the Belt and Road, and 16% of the foreigners are from non-BRI countries. The analysis started by measuring long-term residence willingness and permanent residence willingness, and when processing, the permanent residence intention variable is turned into a binary variable, which means that its values include naturalization intention and not. It can be found that the foreigners from the BRI countries have higher long-term residence desires than the foreigners from the non-BRI countries. In particular, 55.08% of the foreigners from the non-BRI countries expressed their intention to stay in China for a long time, while 65.17% of the foreigners from the BRI countries had a long-term intention to stay in China. In terms of permanent residency intentions, the foreigners from the BRI countries show slightly higher levels than the foreigners from other countries. Specifically, 33.92% of the BRI foreigners have considered permanently immigrating to China, and 27.27% of the foreigners from non-BRI countries have the same intention.The previous migration experience of others in the hometown networks partly contributes to the facilitation of the foreigners’ migration and residence and reduces the cost of migration and integration, while local social interaction also promotes better integration into life in inflow places, thus leading to a higher willingness to stay in China for a long time.In addition, both the social background of the foreigner’s hometown and the condition of the inflow place have significant effects on their long-term residence intentions, which proves the role of the push and pull theory in international migrants’ residence decision-making. In particular, the foreigners from rural areas have a stronger intention to move permanently, and those with lower individual status identity have a stronger intention to stay for a long time. Xi’an, as a new first-tier city in China, attracts international migrants to China as its living and growing conditions improve. Regarding the place of immigration, the foreigners with a higher recognition of China also have a stronger tendency to stay in China in the long term. Furthermore, this paper finds that the younger foreigners are more likely to stay in China on a long-term basis.p < 0.01), suggesting that life around people of the same ethnicity provides social support and convenience to migrants. Conversely, there is no clear evidence in the current data indicating that interaction with the Chinese locals would influence their intention to naturalize.The social networks have a significant impact on the foreigners’ permanent residency intentions in China, with a focus on the role of hometown networks. Specifically, the foreigners whose relatives are currently together with them in China have a stronger intention to immigrate permanently before they come to China, and the presence of an intimate hometown network provides both emotional and economic support to migrants, which guarantees the stability of their lives. The foreigners with larger ethnic social networks locally are more willing to immigrate permanently after arriving in China (1.19, In addition, the migration of human capital, individual status identity, and recognition of Chinese people have significant effects on the foreigners’ willingness to immigrate permanently to China. Those foreigners who received an education in China after arrival are more likely to immigrate permanently to China, indicating that studying and living in China has enhanced the foreigners’ recognition of Chinese culture, which in turn leads to a stronger willingness to immigrate permanently. The foreigners who have basic Chinese language skills before coming to China also have a relatively strong desire to immigrate permanently.Based on a recent survey of the foreigners in Xi’an, this study explores the influences on the social integration and residence intentions of the foreigners in Western China. The key conclusions of the study are summarized as follows.First, the foreigners in western China, represented as Xi’an, do have some group characteristics. The group is relatively young, predominantly male, and generally equipped with some higher education, and the majority of them are international students who received their education there. Meanwhile, due to the BRI, a large percentage of the foreigners came from developing countries and Asian regions, and most of the foreigners have a high level of confidence about China’s future development and a high level of recognition of China’s development opportunities and security conditions.Second, the subjective integration intentions of the foreigners in Xi’an is high, while the objective integration level is relatively low. Most of them have come to China for only a short time, or relatively few times, and have smaller networks with Chinese people, which may limit their social integration. Both the quality of the subjective social integration and the objective social integration are influenced by their individual characteristics, structural characteristics, and especially their social networks. The local networks that connect with Chinese people have significant effects on the two regression models, and the hometown networks that connect the foreigners to their native friends influence their objective social integration.Third, the long-term residence intention of the foreigners is relatively high, but their intention to reside permanently is relatively low. While 60% of the foreigners preferred to continue to live in China in the future, only approximately 30% of the foreigners considered the intention to move permanently, which is consistent with recent research on the willingness of domestic migrants to settle permanently . In the The social networks, as a source of traction in the inflow regions, are an important factor influencing the willingness of the foreigners to stay in China. Companionship from one’s hometown and previous experience in China have significant effects on the long-term intentions of the foreigners, while relatives and family play an influential role in social support, thus facilitating settlement. At the same time, the two network types have different mechanisms of action on the intention to settle. That is, local social networks and social integration promote the foreigners’ preference for long-term residency, but when considering permanent residency, the social network of one’s own ethnicity is an important factor in promoting their intention to settle.Last, there are some limitations in this paper. The data used for the empirical analysis are cross-sectional survey data from 2018, and the recent enactment of the Foreigner Permanent Residence Regulations has generated much social debate; these conditions would have enabled a meaningful longitudinal comparative analysis using the latest survey data. Unfortunately, COVID-19 led to a severe restriction of international population mobility, and our foreigner survey project had to be suspended temporarily. We are interested in conducting studies, where possible, on the impact of the dramatic and unexpected event of COVID-19 on the integration, residence intentions, and immigrant intentions of international migrants. Does an outbreak reduce people’s social interactions, and does it also reduce their subjective and objective social integration? Did this outbreak reduce people’s mobility, did it also reduce people’s intention to migrate? In addition, we will combine qualitative and quantitative approaches as much as possible in our future research, utilizing quantitative research based on survey data to explore group patterns, and qualitative research to thoroughly explore the stories behind the representative individuals to effectively provide theoretical and data support for foreigner studies.


In response to the second surge of COVID-19 cases in Hawaii in the fall of 2020, the Hawaii State Department of Health Behavioral Health Administration led and contracted a coalition of agencies to plan and implement an isolation and quarantine facility placement service that included food, testing, and transportation assistance for a state capitol and major urban center. The goal of the program was to provide safe isolation and quarantine options for individual residents at risk of not being able to comply with isolation and quarantine mandates. Drawing upon historical lived experiences in planning and implementing the system for isolation and quarantine facilities, this qualitative public health case study report applies the plan-do-study-act (PDSA) improvement model and framework to review and summarize the implementation of this system. This case study also offers lessons for a unique opportunity for collaboration led by a public behavioral health leadership that expands upon traditionally narrow infectious disease control, by developing a continuum of care that not only addresses immediate COVID-19 concerns but also longer-term supports and services including housing, access to mental health services, and other social services. This case study highlights the role of a state agency in building a coalition of agencies, including a public university, to respond to the pandemic. The case study also discusses how continuous learning was executed to improve delivery of care. The coronavirus disease 2019 (COVID-19) pandemic, with much uncertainty of the trajectory at the start, created many challenges to effectively mitigate the spread of COVID-19 . TestingStarting 10 August 2020, the Hawaii State Department of Health Behavioral Health Administration (DOH BHA) was assigned the responsibility to lead the isolation and quarantine function to further contain and mitigate the spread of COVID-19 in the major urban center of Honolulu, Hawaii. Prior to the involvement of the DOH BHA in isolation and quarantine services, these services had been the domain and responsibility of the Disease Outbreak and Control Division, as well as of the Office of Public Health Preparedness in the DOH, units that are in separate administrations from the BHA. Thus, DOH BHA’s role in providing isolation and quarantine services was arguably novel in a state organization chart that has been long fragmented by biomedical categories ,5. RecogOther countries have utilized facilities such as hotels as an avenue toward rapid mitigation for the spread of COVID-19 ,7,8 alonDifferent strategies to use hotels as facility placement locations were adopted in other areas in the United States, e.g., in New York , as wellProper coordination and communication are vital toward effectiveness and efficiency of newly built systems for containment of COVID-19, as shown in Singapore . CommuniThe PDSA model is a standard reference model for quality improvement ,18. The Early on in August 2020, DOH BHA leadership recognized that no single agency had the capacity to provide all services needed for a comprehensive system of isolation and quarantine services encompassing transportation, food services, hotel, call center, case management, and so on. DOH BHA further recognized that the capacities developed during the pandemic could create “durable assets” that could benefit the public behavioral health system even after the pandemic’s resolution. DOH BHA established the priority and vision to address not only immediate COVID-19 needs but also ensure linkage to the continuum of care, including access to housing, behavioral health, mental health and substance use services, and other social services. Thus, DOH BHA recognized coordination and partnership of private and public agencies as essential. As DOH BHA had a structure already in place to address behavioral health, mental health, and substance use disorders, the vision was to incorporate and expand upon the existing DOH BHA infrastructure with the capabilities of handling isolation and quarantine for COVID-19 cases. DOH BHA established standards of what the system would provide including: (1) use of a call center to accept requests (Hawaii CARES), (2) 24/7 operation, (3) client placement in a hotel facility within four hours of client’s initial request, and (4) providing isolation and quarantine services to a benchmark of 9% of all COVID-19 cases, as 9% of Hawaii’s population lived in shared bedrooms and could not safely isolate [The DOH BHA was given less than one-week’s notification to plan the system. Despite the short time frame, the DOH BHA gathered a team of existing partner agencies through which it already had existing contracts that could be modified and adapted for expanded scope of services for COVID response for isolation and quarantine. DOH BHA was able to contract with private agencies under the emergency orders authorized by the governor, as well as the emergency authorizations under public procurement law. DOH BHA’s plan was then to create an online intake form and central call line that allowed for a triage team to appropriately connect clients to needed services, as well as to connect individuals to case managers onsite if a facility placement is needed that would then handle check-ins, daily wellness checks, and discharge . DOH BHADOH BHA relied on existing infrastructure to meet surge capacity. Hawaii CARES, an existing 24/7 call center for mental health and substance use disorders, was designated as the means to accept requests for isolation and quarantine. DOH BHA also relied on extending and modifying existing contracts with partnering agencies, rather than create new contracts. Finally, DOH BHA nimbly increased staff capacity through Hawaii CARES by the hiring of team members, including student employees, using the infrastructure of a public corporation (Research Corporation of the University of Hawaii) as part of the flagship public university system, the University of Hawaii, which was also skilled in the information technology, evaluation, and training needed to operate a call center.With the structure of the workflow set in place, various functional teams were made to serve specific functions and hold different responsibilities among each other. The implementation of the isolation and quarantine placement system depended on a unified entry gate for isolation and quarantine placement through a 24/7 call center. Callers seeking isolation and quarantine were triaged to an operator who could assist the caller to complete an isolation and quarantine request Qualtrics mobile-friendly web form. Qualtrics mobile-friendly web form, an online survey, was the available survey tool to the operations of the isolation and quarantine services during the emergency period for which existing security protocols had previously been signed. The form was revised multiple times throughout the emergency period to best suit the needs of the operations for delivering isolation and quarantine services. The exact number of edits to individual questions, question order, adding new questions, and deleting old questions was numerous and thus not counted due to the continuous nature of the operations requiring real-time feedback.Due to the need for timely response, the coordination team had to rely on whatever existing information technology infrastructure was available to them. This web form was then filled by healthcare and social service providers, the call center operators, and community members who guided them to specific forms depending on whichever role they had indicated at the beginning of the survey. Given the option at the end of the survey, anyone could provide feedback in an open-ended field about the form and workflow, which was then discussed through daily and weekly meetings with the leadership team that oversees the workflow consisting of DOH BHA administrators, clinic manager of the call center, leads for each team of the workflow, and stakeholders. The form was revised to be made as concise as possible.The data system used for tracking clients throughout the whole workflow process—request, triage, transportation, hotel, food, and discharge—evolved, initially starting with a Microsoft Excel sheet in a Microsoft Teams and later in December 2020 a Microsoft Dynamics 365 database.Initially, the Hawaii CARES isolation and quarantine care coordination team pulled data from the webform into the Excel tracking system. Triage team members then looked at newly added cases and determined epidemiologic eligibility for services, including whether the individual could not safely isolate at home, whether the individual was positive or awaiting test results, and so on, based on CDC guidance. The triage team then followed-up with the client and their entire profile to ensure proper placement. If the triage team deemed the client to need isolation and quarantine placement at an external facility, then the client case would be assigned to the hotel team, which viewed their profile to determine which facility best suited the individual profile and level of care needed .Once a facility was assigned to the client, the care coordination team informed the client of their assignment and how to check-in to the facility. If needed, the care coordination team also arranged transportation for the client, by communicating with the DOH BHA-contracted transportation team using encrypted communication modality. The driver then securely transported the clients from the pickup location to the assigned facility, where the client was connected to an assigned case manager and entered isolation and quarantine.The case manager would then screen to see if further services for medical or social problems were needed and would perform daily wellness checks and deliver meals three times a day. Upon completion of isolation or quarantine, case managers would then arrange transportation if needed and handle discharge. The triage team also facilitated testing if the client requested COVID-19 testing and were determined to be eligible. Eligible clients isolating or quarantining at home could request the triage team for food and supply delivery services to the client’s home, delivered by multiple partnering agencies.Throughout the implementation period, there was continuous learning of how to develop, change, and revise the workflow for improvement. Daily meetings were held to review the adequacy of the form and issues that may have occurred while placing individuals into isolation and quarantine. After consensus and if needed, the form would be revised and edited immediately after the daily meeting. Some of the learning that took place was to reduce confusion in patient placement, ensure timeliness in placement, and address specific case-by-case issues for patient placement that arose upon specific patient requests.Addressing the needs of vulnerable populations was a priority. Linguistic and cultural barriers challenged the ability of the system. To better support the linguistic needs of clients, the workflow was adapted through a partnership with a local community-based organization, We Are Oceania, as well as a national line to support translation. Linguistic and cultural competency continue to be an important area for capacity development for improved preparedness.Many individuals in need of isolation and quarantine experienced homelessness and behavioral health complications. Qualified case managers were stationed at each facility with each client screened to see if additional services were needed. Ongoing feedback from exit interviews was also used to improve the quality of services provided.Meetings with the functional teams, as well as meetings with external stakeholders, provided feedback for improvement throughout the implementation of the system. More than 3248 individuals between 12 August 2020 and 10 December 2020 were connected to isolation and quarantine, food, and/or testing services, and the target of providing services to individuals that exceeded more than 9% of all COVID-19 cases in the state was reached . Once gaThe act stage consisted of implementing new changes based on what was found throughout the study stage . StaffinThe use of the Excel spreadsheet became challenging as software was unstable with multiple concurrent users working on it at one time, potentially deleting another individual’s work if multiple people are working on the same cell. The transition to the Microsoft D365 system as a formal database helped ensure data stability through preventing these unexpected deletions from occurring and later reduced the care coordination team role. The changes were not implemented immediately, but progressively as communication with many teams took place.This article is a narrative case study that, like many qualitative case studies, lacks a comparison or counterfactual to help shed light on what might have happened in the absence of this program. Nevertheless, we note that prior to the expansion of isolation and quarantine hotels, the jurisdiction had only 60 beds procured for the city prior to DOH BHA implementing this system. Under DOH BHA leadership, up to 400 beds were procured and a system of coordination was established to operate the isolation and quarantine for smooth placement of clients.Future preparedness for rapid implementation of a system can be improved through staffing reserve capacity, technological capacity, and strategic collaboration with community-based organizations with linguistic and cultural competencies that address the needs of vulnerable populations.Hawaiʻi is a multicultural place where many different languages are spoken. Linguistic barriers have long challenged healthcare access, compounded by a lack of cultural competency of providers ,23. EnhaThe system benefited from using and building upon existing communication infrastructure, and a 24/7 call center specifically, for greater coordination during a pandemic .This case study also emphasized the role of a public university in managing and staffing a 24/7 call center that served as the care coordination team and central coordination hub for operations, working in close partnership with the health authority. When state government hiring infrastructure is limited in its ability to hire nimbly, the use of contractors including public universities can enable and ensure adequate staffing for a project that requires surge capacity .Use of feedback loops helped to improve the system through regular meetings internally and externally, as well as with quality assessments and exit surveys of clients who were discharged. Meetings were especially important when new problems emerged, or if there was a novel incident that needed to be addressed for which existing protocols were not sufficient. Constant review of the system with those coordinating the day-to-day operations and administration allowed various events and complicated obstacles to be quickly addressed and solved.With the intricacies of building a system infrastructure, simple communication with policymakers and community members was crucial to implement a new intake system . MoreoveThis implemented system described herein is notable for its role as a state behavioral health authority playing a role in COVID-19 activities, reflecting the potential to rely on partners outside of a traditional infectious disease or emergency medicine framework. By leveraging the public behavioral health system for a health response, this case study demonstrated the ability to mitigate the COVID-19 pandemic, as well as concurrent mental health issues . As suchFuture research would benefit from a comprehensive review of studies and experiences about isolation and quarantine hotels around the world. In particular, future research is needed to understand the ways in which behavioral health was integrated and coordinated as part of the COVID-19 response and the ways in which organizational structures and siloes hindered or helped to integrate these two challenges. This narrative historical case study is one innovative though small contribution. This case study reviews the PDSA model used to implement a COVID-19 isolation and quarantine facility system with the public behavioral health system as its foundation, as well as lessons learned and the implementation plan of one city in the United States that were not exclusively clinical or laboratory focused.Like many cities across the United States, Honolulu has been facing serious social challenges of homelessness and housing, mental health, and substance use, further exacerbated by the challenges of a COVID-19 pandemic and other infectious diseases, which have been a long-standing concern of Hawaii as a tropical location. There is a need for timely and accurate communication and coordination to address a variety of problems, not only COVID-19. This paper further contributes to the literature about the role of programs that address the social, economic, and psychological underpinnings that contribute to the risk of infectious disease spread.


In all four districts, late or poor diagnosis occurred due to a lack of qualified laboratory technicians and diagnostic equipment. This study reveals that the current Zambian healthcare system is not able to adequately handle rHAT cases. Targeted policies to improve staff training in rHAT disease detection and management are needed to ensure that sustainable elimination of this public health problem is achieved in line with global targets.Human African trypanosomiasis (HAT) is a neglected tropical disease that has not received much attention in Zambia and most of the countries in which it occurs. In this study, we assessed the adequacy of the healthcare delivery system in diagnosis and management of rHAT cases, the environmental factors associated with transmission, the population at risk and the geographical location of rHAT cases. Structured questionnaires, focus group discussions and key informant interviews were conducted among the affected communities and health workers. The study identified 64 cases of rHAT, of which 26 were identified through active surveillance and 38 through passive surveillance. We identified a significant association between knowledge of the vector for rHAT and knowledge of rHAT transmission ( Trypanosoma brucei rhodesiense and Trypanosoma brucei gambiense, with epidemics being recorded in rural parts of Africa [Glossina (tsetse flies) [T. b. gambiense (gHAT) form, humans are the main reservoir in the transmission cycle of the disease [T. b gambiense accounts for 98% of reported HAT cases. During the early stage of the disease, occurring several months to years after the initial bite by an infected fly, the parasites are confined to the blood and lymphatic circulation systems, whereas invasion of the central nervous system defines the late or chronic stage of gHAT [Trypanosoma brucei rhodesiense accounts for 2% of reported cases. Unlike gHAT, rHAT is relatively more acute, early-stage symptoms observed within weeks or months after a bite from an infected fly. Furthermore, rHAT progresses rapidly to invade the central nervous system [Human African trypanosomiasis (HAT) is a re-emerging public health problem caused by two protozoan parasitic infections, f Africa . These te flies) . In the  disease . Thus, t disease . T. b ga of gHAT ,6. Trypas system ,6.The global target is to eliminate HAT as a public health problem . HoweverZambia has 10 provinces, which are divided into 105 districts . AnotherThe aims of this study were to identify gaps in the adequacy of the healthcare delivery system in relation to the control and management of rHAT in the endemic foci of the disease in Zambia, to assess the population at-risk and to map the distribution of current rHAT cases in the Chama, Rufunsa, Mpika and Mambwe Districts of Zambia. We also examined the environmental factors associated with the transmission of rHAT in relation to the geographical location of cases and disease transmission. These aspects are not highlighted adequately in the available literature on Zambia. In a previous study , we repoResearch and ethical clearance was obtained from and granted by the University of Zambia Biomedical Research Ethics Committee (reference number 011-09-13). Written consent, including willingness to participate in the study, was obtained from each subject enrolled in the study. All participants were guaranteed confidentiality of their personal information at the individual level.In this study, we used the same dataset as in our previous study , which iThe three study provinces, Eastern, Muchinga and Lusaka, have a tropical climate with three distinct seasons per year, known as the hot–dry season, the rainy season and the cold–dry season . MuchingWe used passive and active surveillance systems to obtain the data used in the present study. Passive surveillance consisted of infected people self-presenting to fixed health facilities with standard reporting of disease information while receiving treatment. Active surveillance involved researchers or healthcare providers actively searching for rHAT cases and related information from communities or health institutions between 2013 and 2014 through carefully designed and approved study protocols .n = 4) and their health centres (n = 7) that recorded rHAT cases during the period under review were selected in the study districts. The University Teaching Hospital was purposively selected, as it is the final referral centre for all hospitals in Zambia for the management of rHAT. Separate questionnaires were used for patients and health workers. Pretesting of the questionnaires was conducted to identify and rectify problems that might arise for both respondents (care giver) and interviewers about question content. The questionnaire was developed and administered by the lead author between September and November 2014.To determine the characteristics of rHAT in previously and currently infected rHAT patients, we used data from hospital registers and/or surveyed health practitioners and the community. The study included all four districts  with active cases, their health centres and patients diagnosed with rHAT from 2004 to 2014. Only first-level district first hospitals , and no further follow-up for diagnostic testing was undertaken. However, from 2013 to 2014, passively diagnosed rHAT patients were confirmed as having rHAT using microscopy of Giemsa-stained buffy coat smears, polymerase chain reaction (PCR)  and/or lStructured questionnaires were administered to former and current rHAT patients or close relatives (care givers) in the case of a deceased person, as reported in . The strA questionnaire was administered to medical officers  for the purpose of assessing the adequacy of the healthcare delivery system for the management of rHAT at the district level. All professional health workers who had worked at any of the health centres in the four districts and were responsible for disease detection were included in the study. The criteria for determining the qualified staff at the health centres for the purpose of this study were working as a healthcare practitioner (HCP) and responsible for disease detection. Those who had worked for less than one year at a health centre and had no experience handling rHAT cases were not eligible. Information collected included the number of health personnel available for the diagnosis of rHAT, staff knowledge of rHAT and the availability of drugs and equipment to diagnose and manage rHAT. 6 people and <1 per 105 people), low (≥1 per 105 people and <1 per 104 people), moderate (≥1 per 104 people and <1 per 103 people), high (≥1 per 103 people and <1 per 102 people) or ‘very high’ (≥1 per 102 people). When a threshold of one HAT case per one million people per annum arises, the risk is considered “marginal”. Furthermore, when the risk categories are below the moderate level, i.e., low or very low, the objective of the WHO for the elimination of rHAT as a public health problem is met [We estimated the population at-risk using annual estimates for 2013 and 2014. According to the currently suggested methods for disease distribution and risk assessment at the national level, HAT elimination as a public health problem requires that fewer than 1 case/10,000 inhabitants/year (averaged over a five-year period) be reported from each health district . A 2022 m is met . To deteA Garmin version 10 geographical positioning system (GPS) receiver was used to collect waypoints to help determine the spatial distribution of all cases. An attempt was made to record the location of all the households with cases. However, poor road networks in the four districts and challenges in locating the households meant that not all locations could be recorded. The spatial resolution of the presented maps is relatively coarse so that households cannot be identified, and some locations overlay one another. Names of patients were not recorded, and strict confidentiality was adhered to throughout the study. Descriptive statistics were generated for all variables, and mapping was undertaken using ArcMap GIS version 10 . Shape files were obtained from the Zambia Statistics Agency (Zamstat), which is licenced under a creative commons licence.All structured interview data were entered and analysed using Excel™. Qualitative data from focus group discussions were entered into Microsoft Word™ and analysed manually based on accepted methods of coding and memo writing of qualitative data ,23,24. An = 64) were traced, and all were interviewed during, at most, two visits without the loss of any cases. A total 26 were identified through active surveillance, and were identified through 38 passive surveillance [In total, 64 rHAT cases were included in the study . Of theseillance .n = 64); there was a significant association between identifying the vector for rHAT and knowledge of rHAT transmission according to Fisher’s exact test . The analysis also indicated (n = 64) that there was no association between knowledge of rHAT and previous experience with an rHAT . The overall number of people able to identify tsetse as the vector and aware of rHAT transmission was 57 , Rufunsa (Lukwipa and Shikabeta), Mpika  and Chama (Kamufupu) districts did not have laboratory staff able to detect rHAT. The referral centres for Mambwe , Rufunsa  and Chama  had microscopes for disease diagnosis. None of the referral centres and rural health centre staff had attended refresher courses for rHAT detection. None of the referral centres had drugs for the treatment of the disease at the time of the visit. This could have been because the rural health centres did not have pharmacies but only dispensaries. Key respondents described the case management and common challenges associated diagnosis and low index of suspicion. It was highlighted that standard protocols for rHAT detection are used in all cases, and the prescribed drugs for treatment are suramin in the first stage and melarsoprol in the second stage: The standard protocol for detection of rHAT is used on all cases received at UTH. This involves screening for potential infection, diagnosing by establishing whether the parasite is present in the body fluids, and staging to determine the level of the disease’s progression. The second stage disease detection involves a lumbar puncture. The drug used for treatment of the first stage patient is suramin and in the second stage melarsoprol.The key respondents also explained some challenges associated with treatment of rHAT: A common challenge in the treatment of sleeping sickness is organ failure. A case was recorded of a 49 year old game ranger who was admitted to UTH hospital. His lung was normal and there was no leg swelling. Early stage HAT was detected by both microscopy and SRA-LAMP. Another example related to delays in diagnosis: A female adult aged 58 was admitted with fever and a reduced level of consciousness. On examination she was noted with lethargy and had an abnormal lung. However, late stage HAT was confirmed by microscopy and SRA-LAMP which was missed for several weeks while being treated for other conditions. Due to the delay in diagnosis, she died eight days after starting melarsoprol treatment. Not all HAT cases present the same signs and symptoms. This depends also on the index of suspicion from the onset of diagnosis.” Although it is recommended that patients come for review after completing the treatment, the key respondents indicated that this rarely happens at UTH: “It is also recommended that patients come for review at UTH. However, we have no record of a patient who came for review after being discharged. For example, we had a case of re-occurrence of infection in Rufunsa . This was after the patient was discharged from UTH. However, there has been no communication regarding the patients who are re-admitted at the various districts.The population at risk of rHAT cases and the associated land cover area in the four districts are described in The spatial distribution of households with rHAT cases in the four districts is shown in The cases of rHAT patients around the township occurred mostly in businessmen and women but included some teachers, who reported having crossed the game management areas at some point during their duties in the weeks preceding the onset of the disease. Teachers reported having crossed the game management area when they were assigned to attend to student examination in Mpika District, and businessmen (or women) reported crossing the game management area during the time they sold merchandise to communities in the rural parts of the district. In Mambwe District, all three reported cases of rHAT were concentrated one area, all occurring in fishermen working in the nearby river .In Mpika District, the 28 rHAT cases were concentrated in two main areas within the Chiefdom of Nabwalya: (i) Kazembe and Uzimbwa villages and (ii) Dombo Department of National Parks and Wildlife Camp .In Rufunsa District, the 11 rHAT cases were distributed mainly in three areas: (i) Shikabeta, (ii) Chomba and (iii) Lukwipa villages. These villages were all situated in game management areas .During the focus group discussions, community members observed that the number of tsetse flies had been increasing across all four districts, and they felt that there were no clear mechanisms to control transmission: The transmission of rHAT is also due to the game animals especially elephants and Buffalos. Encroachment of the human habitable land is very common. It’s not always the people who go in the game reserve areas. As a result, they come along with the tsetse flies and shed them in the communities. Currently, as residents we don’t see much of the mechanisms available to control the game animals they are elusive.The community members felt that several measures need to be undertaken to manage transmission. For instance, some members felt that tsetse fly control centres should be reintroduced for effective control and monitoring. Others felt that there should be a localised means to control game animals to avoid unwanted movements, and others explained that households near and within game management areas  should be supplied with effective tsetse repellents. Some community members also observed that the sprays (target) used against tsetse flies did not provide the necessary protection because children in the game management areas complained of tsetse bites, and they felt that these were more effective against mosquito bites.A total of 11 health facilities were covered in the study: six rural health centres and five hospitals, as shown in Systematic documentation was provided for the rHAT cases recorded in Rufunsa District from 2012 onward. The Rufunsa area was under the jurisdiction of Chongwe District prior to 2012, when it was designated as a district in its own right. Hence, there are no separate rHAT records for Rufunsa District before 2012. Health staff in Chama District also diagnosed rHAT cases, although no records of active surveillance by health staff were found for the disease . In MpikNone of the health centres visited in any of the study districts had any drugs for the treatment of rHAT. The process for requesting drugs was as follows: once a case was detected, a request was sent to UTH in Lusaka, followed by a request to the Ministry of Health, which, in turn, made a request to the WHO country office. The delivery period for the requested drugs was approximately 2−7 days, depending on transportation availability, which, at times, was not readily available. In this study, we examined the spatial distribution of cases of rHAT from 2004 to 2014 in four study districts in Zambia and investigated the adequacy of the healthcare system to deal with rHAT. We selected districts in which sporadic cases of rHAT were reported . The evin = 64. The low prevalence arises primarily because rHAT is a zoonosis that does not often spill over to the human host. Moreover, the number of cases is likely to be underestimated [The number of rHAT cases included in this study was stimated  due to ustimated . DespiteMost of the respondents (94%) across the gender, district and occupation categories had a general knowledge of rHAT transmission and the vector responsible for its transmission. The findings are similar to those reported by Bukachi et al. , who fouIn Chama District in Eastern Province, most rHAT patients from one village (Munyakanyaka village), crossed the Zambian border and sought treatment at Lumpi Mission Hospital, a referral centre in Malawi, which was outside our study area. The patients crossed the Zambian border because Chama District Hospital did not stock the drugs required to treat rHAT. In most cases, rHAT patients were referred to UTH, which is the largest tertiary hospital in Zambia. However, patients preferred to seek health services at the Malawian hospital, as it was much closer and more accessible to the local people in Chama District. Although Mambwe District has a well-equipped laboratory with one microscope and four laboratory specialists, no deliberate active rHAT surveillance took place in the district. Consequently, the true incidence of cases of the disease in the district was not available. In Mpika District, Chilonga Mission Hospital was found to be the only hospital and referral centre admitting rHAT patients for treatment. Antitrypanosomal drugs were administered by medical doctors, medical licentiates, clinical officers and trained nurses in this hospital. The referral centre for Rufunsa District was St. Luke’s Mission Hospital. Although rHAT cases were still referred to UTH, St. Luke’s Mission Hospital was able to handle rHAT cases emerging in the district. Antitrypanosomal drugs were available only at the district hospital upon request from UTH, which also had to make a request to the Ministry of Health. Disease-endemic countries, such as Zambia, are provided with drugs according to forecasts of usage. In non-disease-endemic countries, pharmacy services in hospitals diagnosing and treating rHAT must address requests for drugs to the WHO ,26. The We found that the Zambian healthcare delivery system was ill-equipped to handle rHAT cases, a situation also highlighted by Mulenga et al. . StandarOpportunities for refresher courses on zoonotic diseases were not provided to health staff in the studied areas, meaning that awareness and levels of competence remained low among health practitioners who manage rHAT (and other zoonotic diseases). Kunda et al.  similarlThe weakness of the public health system has cost implications for affected households, such as lost income when a person is seeking treatment, which increases the burden of the disease  on the household. According to Shaw et al. , decisioTo estimate the population at risk, we used annual estimates for 2013 and 2014. The period between 2013 and 2014 was a time of active surveillance of rHAT cases in the four investigated districts . Previous studies estimated sleeping sickness at the continental, regional and national levels based on the educated guesses and rough estimates of experts rather than using epidemiological evidence of the population at risk . Our stuThe epidemiological distribution of rHAT is affected by the presence of wild and domestic animals, such as livestock and dogs, which can act as disease reservoirs ,34. As tPlasmodium falciparum) and rHAT using stained blood film microscopy, has caused considerable dependency on rapid diagnostic tests for malaria detection. The use of these tests for malaria detection means that blood smears are less commonly examined, and the likelihood of diagnosing rHAT is reduced. The use of the microscopic stained blood film method for malaria has additional benefits; it is cheap and enables the person performing the diagnosis to score parasite density, identify the different Plasmodium species, differentiate sexual (gametocytes) from asexual stages and avoid accidental detection of other haemoparasites, such as trypanosomes in the blood smear [Early and accurate diagnosis of rHAT is critical for effective management of the disease . Howeverod smear . As suchod smear ,33. On t(i)Enhancement of rHAT (and its transmission dynamics) advocacy and sensitisation among both health personnel and local communities in tsetse-inhabited rural areas. This is expected to increase the suspicion index among health workers and promote earlier reporting of suspicious cases to health centres by local communities;(ii)Governments in tsetse-inhabited regions should be urged to invest in basic diagnostic equipment, such as microscopes for detection of various haemoparasites, including plasmodium and trypanosome parasites, as well as detection of ectoparasites and endoparasites. Each rural health centre should have at least one microscope and a trained technician, who should attend refresher courses regularly. Both (i) and (ii) are ingredients of early and accurate detection of rHAT cases, which should lead eventually to successful case management with minimal complications;(iii)In referral centres with advanced diagnostic capacity, regular screening of domestic animals, wildlife and tsetse flies for trypanosome species by means of microscopy and more sensitive molecular tests such as PCR and, in particular, the user-friendly and cost-effective LAMP, should be encouraged;(iv)T. b. rhodesiense, local communities and their domestic animals should be discouraged from encroaching into game management areas and national parks in order to minimise interactions with wildlife and tsetse flies. Furthermore, local communities should be sensitised to the dangers of poaching and related activities, which expose them to tsetse bites, and the management of rHAT should be considered when developing management plans for game management areas;Because wild animals are natural reservoirs of (v)Health workers in rural health centres should be trained in basic record keeping and its significance in management and control of diseases, including rHAT;(vi)Governments in tsetse-inhabited regions should be encouraged to invest in effective tsetse control measures, such as insecticide-impregnated targets or aerial spraying with pyrethroids. Considering that rHAT is a transboundary disease, countries sharing boundaries in such regions should work closely and conduct such activities jointly to more sustainably control tsetse flies and subsequently rHAT.Currently, implementing effective case management algorithms in the study areas is challenging . Due to Primary healthcare systems face challenges in the treatment of rHAT, partially due to inadequacies of the current treatment options, which are considered scarce, toxic, ineffective and difficult to administer for stage 2 of rHAT. However, the development of a new treatment called fexinidazole, a 2-substituted 5-nitroimidazole rediscovered by the Drugs for Neglected Diseases initiative (DNDi), could provide significant help in these rural areas, where there are no skilled human resources or pharmacies to stock and dispense drugs . FexinidDue to the scarcity of resources in Africa, especially in rural remote areas, where the disease is often found, such as in Zambia, the challenges of disease diagnosis are significant. As such, some infected individuals may die before they can be diagnosed and treated . Early dThe geographical distribution of rHAT is expected to be sensitive to human population growth and naïve animals . MoreoveUnder-reporting and poor data management of rHAT cases in the four investigated districts, as highlighted by Fèvre et al.  and MwiiT. b. rhodesiense in humans and domestic and wild animals, as well as the tsetse vector in tsetse-infested areas, particularly in areas reporting rHAT cases. A One Health approach may help to combine the necessary intervention programmes aimed at eliminating rHAT as a public health problem. We conclude that improvement in detection, recording/reporting and access to curative drugs is necessary in Zambia.The healthcare delivery system in Zambia was found to be ill-equipped to handle rHAT cases in the studied districts in terms of both physical resources, such as laboratories, and human resources, including training. There is an urgent need to improve rHAT advocacy and sensitisation, disease detection and management, and policies regarding human resource management. There is also a need for continuous surveillance of


In the United States, from 1999 to 2019, opioid overdose, either regularly prescribed or illegally acquired, was the cause of death for nearly 500,000 people. In addition to this pronounced mortality burden that has increased gradually over time, opioid overdose has significant morbidity with severe risks and side effects. As a result, opioid misuse is a cause for concern and is considered an epidemic. This article examines the trends and consequences of the opioid epidemic presented in recent international literature, reflecting on the causes of this phenomenon and the possible strategies to address it. The detailed analysis of 33 international articles highlights numerous impacts in the social, public health, economic, and political spheres. The prescription opioid epidemic is an almost exclusively North American problem. This phenomenon should be carefully evaluated from a healthcare systems perspective, for consequential risks and harms of aggressive opioid prescription practices for pain management. Appropriate policies are required to manage opioid use and prevent abuse efficiently. Examples of proper policies vary, such as the use of validated questionnaires for the early identification of patients at risk of addiction, the effective use of regional and national prescription monitoring programs, and the proper dissemination and translation of knowledge to highlight the risks of prescription opioid abuse. Opioids are a class of substances that inhibit the transmission of painful stimuli . They arFrom 1999 to 2019 in the United States, opioid overdose from both regularly prescribed and illegally acquired drugs was the cause of death for nearly 500,000 people . These dThe first wave occurred in the 1990s with the increase in opioid prescriptions and prescription-related deaths from overdoses of natural and semi-synthetic opioids . The secIn patients undergoing treatment with opioid drugs, excluding cases of maladministration or self-administration, we must distinguish two conditions of misuse or abuse for two classes of substances. The two forms of abuse are: (1) abuse by a patient newly addicted, following prescription with continuous use of opioids at non-prescription dosages; and (2) abuse by a patient previously addicted to the use of opioids.For the classes of substances, the following are recognized: (1) prescribed opioid drugs; and (2) illegally acquired opioid drugs.There are various possible reasons underlying the opioid epidemic. As evidenced in recent literature, opioid prescriptions for pain relief have increased ,13,14,15The opioid epidemic is a theme that has recorded over 4350 contributions on the PubMed scientific dataset in the last ten years, with a growing trend that has seen 1117 articles in the year 2020 alone.In countries other than the United States, opioids are underprescribed ,24. AlthStarting from the premises above, this literature review aims to seek international evidence on opioid abuse to prevent and combat opioid addiction, especially as a monitor to those countries that find themselves in an underprescription stage.The article offers a critical analysis of the literature in the context of the opioid epidemic, suggesting practice and research avenues for health professionals, decision makers, and scholars.A structured literature review  was condResearch question (RQ): What are the trends and consequences of opioid misuse analyzed in the recent literature?The first search string used concerned the words “Opioid” and “Epidemic” in addition to “Trend” and “Consequences”, searched in the Abstract, Title, and Keywords (Keywords Plus on Web of Science); this led to 830 documents results on Scopus and 260 on Web of Science. Fifty-six duplicates were found and removed, leading to 1034 total results. The research was then refined to include only articles, journals, and reviews in English, published between 2017 and 2022 in both datasets. The new analysis yielded 54 results on Scopus and 66 on Web of Science, leading to 117 total documents excluding duplicates. All the contributions were found, and all the abstracts were read and analyzed by two authors (HB and FD) to ensure eligibility. Thirty-three papers were eligible after analysis and focused on the topic under investigation. The selected articles were analyzed using a coding framework with nodes derived from previous studies in knowledge management in the public sector  and healSpecifically, some of the nodes borrowed from previous studies concern the authors’ classification, division of academic and non-academic/practitioners, geographical areas of the research, research methodology, level of impact, and stakeholders involved. Other nodes related to the study objective were added to the framework with an open-coding approach . In partConsidering the 33 articles analyzed, just over half were published by academic authors, namely those physicians or researchers holding  an academic position. All the authors’ affiliations were carefully checked to understand the eventual academic engagement and position. When the job role was not clear , the names were searched online to understand the eventual academic engagement. About a third of the outputs were generated in a collaboration between academic authors and professionals, namely physicians, without any academic roles. Five contributions were generated only by the work of practitioners without involving people from the academia.Three-quarters of the contributions analyzed are quantitative studies (27 contributions), of which five are survey-based. The remaining quarter (6 references) is qualitative, including two literature reviews. The reference area is practically mono-geographic: 28 of the 33 contributions refer to studies conducted in the United States, with one in Canada. The remaining four papers are not linked to a specific location.Concerning the topics, the twin epidemic is the most discussed, with 8 references. The twin epidemic refers to the phenomenon when a different addiction is accompanied by that of opioids. Another topic focuses on the effects on children of addicted mothers (5 references). These children face the consequences such as post-birth care due to neonatal abstinence syndrome. Three contributions deal with the effects when it comes to First Aid/Emergency Rooms (ER) access. The papers underline how ER accesses are higher in the places analyzed where the use of opiates is widespread. Nineteen of the contributions, on the other hand, are placed in a more generic area, not going into the specifics of a particular sector.Concerning the most relevant impacts, the analysis allowed to group such outcomes into three distinct categories: the social, health, and public health sphere; the medical sphere; and the economic, justice and political sphere. Influences from the social and public health sphere include the illegal use of methamphetamine and fentanyl ,49, and As for the stakeholders, Regarding the numerous strategies recommended to deal with the phenomenon, among the most cited, it emerges the clear urge to enhance training and information for both healthcare providers and patients ,53,54,57In the articles, testimonies also stress the worrying extent of the phenomenon, as in the case of Scorsone and colleagues , who cit“I always said I would never do that [share needles]. (…) and then that’s when it happens. (…) This one time, I was in jail–I didn’t have anything, and I shot up in jail like an idiot. I didn’t know that everybody had hep C.”Other strategies suggested by multiple contributions are to implement programs to treat opioid addiction ,34,40,46“(…) the results of this study can be used to inform counties considering implementing naloxone programs, an important medication used to reverse opiate overdose.”Five contributions argue that it is desirable to proceed with multidisciplinary approaches to address the problem, starting from a complete overview and joining the forces and potential of several institutions and professions ,47,51,55“I know that I personally do my best to monitor for signs of misuse or abuse and to counsel as necessary, but I don’t have access to patient charts, histories or diagnosis or to the attention of the patient as physicians do.”“(…) traditional utilization management approaches appeared to be ineffective in slowing the spread of the epidemic. We believed more could be done. We also recognized that no single entity could do this alone. We began working with many partners (…) coordinating teams internally, including our medical policy, pharmacy, and fraud teams, (…)”The literature on opioid use and its consequences is mainly concentrated in the United States. This may lead to the conclusion that the opioid epidemic is primarily confined to this geographical area . The reaUnderstanding the developments, consequences, and containment strategies of this phenomenon is relevant to all countries in a phase of underprescription. The North American epidemic and its impacts serve as a warning for implementing policies to avoid the consequences of inappropriate opioid use.Concerning the analysis of the results acquired in the selected literature and future lines of study, the articles in the sample show that the number of collaborations between clinicians and scholars is significant. This brings out an essential collaborative effort between academia and professionals in the field. Furthermore, the research methods used vary, and this denotes the possibility of interpreting the phenomenon in a multifaced way.Moreover, it is necessary to underline the data relating to the twin epidemic phenomenon and the numerous contributions that report adverse effects in the pediatric field.The international literature reveals various intervention opportunities ranging from training to research, from economic support to a variation in the pharmacological approach . The in-depth study conducted with this review underlines the need to work further on real-world data and scientific contributions to increase the knowledge of the phenomenon. Real-world data will allow for monitoring opioid prescriptions to relate to, and compare, what has been observed in the literature. A knowledge translation approach  should bIt should be noted that all these initiatives must consider the rights of patients to receive adequate analgesia and avoid chronic pain, for which opioids are particularly effective. Physicians and other healthcare professionals should balance the patients’ right to analgesia and the need to prevent the overuse and abuse of opioids . As mentOther considerations may arise, concentrating not only on what the literature reports, but what is missing, such as prevention strategies. In the 1990s, knowledge translation was employed to make young adults and kids aware of the risks and dangers of heroin. However, these practices are no longer in use. Involving adolescents and young adults in the dialogue with dedicated programs may be a strategy to educate them on the dangers of opioid misuse. Moreover, the internet now represents a source of information, but it also offers opportunities to acquire illegal drugs from online stores, or legal ones without a valid prescription . Opioid-Finally, when referring to the main stakeholders, most of the papers included in the sample do not report the general population. Indeed, the literature focuses on patients, clinicians, or health institutions trying to prevent or fight the phenomenon. As mentioned above, patients may eventually need opioids for pain relief because of a chronic disease or an acute phase. Therefore, education to understand the risk of addiction and the need to follow prescriptions may be relevant. As for children and young adults, prevention campaigns may represent an option for the general population to be fully aware of the phenomenon. According to the main theories about change in human behaviours , it wouLike all pieces of research, ours is not without limitations. Although the primary scientific datasets have been investigated according to a rigorous methodology, some relevant contributions may have been excluded. The topic is immense, and further efforts could include enlarging the number of enquired datasets and keywords. Machine Learning algorithms could also be used to select the most relevant contributions and ensure better coverage. Moreover, given the importance of the topic to the general population and healthcare system in several countries, other sources could have been added, including reports, guidelines, and recommendations from primary scientific societies, public health bodies, and other non-profit organizations devoted to the cause. Moreover, the multifaced and complex dynamics of the phenomenon require constant updating since results may not be applicable to other geographical contexts or situations. The analysis of the so-called “grey” literature and the investigation of country-specific factors may lead to new research avenues for scholars and practitioners like healthcare policymakers engaged in the topic.Health decision makers from all over the globe can benefit from the studies on the US opioid epidemic to learn and be inspired and warned by the American experience, its risks, costs, and outcomes. Our literature review has allowed detection of the principal risks and dangers and identified feasible strategies to limit and prevent the phenomenon, including training, dedicated research funds, alternative drugs, and other therapies. Considering the adverse outcomes for the population and the healthcare system in cases of overdose, additional measures should be employed for the early identification of patients at risk of addiction. From such a perspective, the diffusion of personal health electronic records is crucial to ensure effective knowledge transfer among all healthcare professionals taking care of a patient who could be at higher risk of becoming addicted.Prevention is another relevant strategy to actively involve patients and citizens through adequate dissemination and translation of knowledge to highlight the risks of overdose or abuse of opioid drugs.