The Global Polio Eradication Initiative (GPEI) was launched in 1988 with the aim of completely clearing wild polio viruses by 2000. More than three decades later, the goal has not been achieved, although spectacular advances have been made, with wild polio virus reported in only 2 countries in 2019. In spite of such progress, novel challenges have been added to the equation, most importantly outbreaks of vaccine-derived polio cases resulting from reversion to neurovirulence of attenuated vaccine virus, and insufficient coverage of vaccination. In the context of the latest discussions on malaria eradication, the GPEI experience provides more than a few lessons to the malaria field when considering a coordinated eradication campaign. The WHO Strategic Advisory Committee on Malaria Eradication (SAGme) stated in 2020 that in the context of more than 200 million malaria cases reported, eradication was far from reach in the near future and, therefore, efforts should remain focused on getting back on track to achieve the objectives set by the Global Technical Strategy against Malaria (2016–2030). Acknowledging the deep differences between both diseases and the stages they are in their path towards eradication, this paper draws from the history of GPEI and highlights relevant insights into what it takes to eradicate a pathogen in fields as varied as priority setting, global governance, strategy, community engagement, surveillance systems, and research. Above all, it shows the critical need for openness to change and adaptation as the biological, social and political contexts vary throughout the time an eradication campaign is ongoing. Since 1955, when the World Health Organization (WHO) launched the Global Malaria Eradication Programme (GMEP), assessments of the feasibility of reaching such an ambitious goal have experienced cyclical variations. Following the highest expectations from the potential impact of DDT spraying against malaria, which constituted the backbone of the GMEP, this programme was suspended in 1969 having achieved significant successes in vast areas of the world, but recognizing that eliminating malaria in Africa was impossible with the tools available at the time. Three decades followed with the focus on controlling malaria , until the aspiration of eradicating malaria parasites at a global level regained interest in the late 2000s , 4.Even with our most optimistic scenarios and projections, we face an unavoidable fact: using current tools, we will still have 11 million cases of malaria in Africa in 2050”, the report stated [malaria eradication by 2050 is a bold but attainable goal”. In order to achieve it, that report suggested critical aspects that would make eradication feasible, including strengthening programme management, improving the use of data for decision making, and investing in research and development in order to make available more impactful tools [Analysing current trends and challenges on the prospects of malaria eradication was precisely the task of the WHO Strategic Advisory Group on Malaria Eradication (SAGme), commissioned in 2016 by the former WHO Director General, Margaret Chan. In early 2020, the SAGme released its conclusions, unequivocally supporting the goal of a malaria-free world, while recognizing that it was far from reach and that immediate efforts should be best directed to getting back on track to achieve the 2030 goals set by the Global Technical Strategy against Malaria (2016–2030) (GTS). “ul tools .Both the SAGme and the Lancet Commission reports analysed how a variety of factors—biological, technical, financial, socio-economic, political, and environmental—and foreseen social, economic and environmental trends including urbanization, population growth, mobility and poverty, among others, may affect the evolution of malaria and, therefore, determine the feasibility of eradicating this disease. SAGme was also informed by a series of analysis on issues, such as WHO policy making process and other diseases eradication efforts. The Global Polio Eradication Initiative (GPEI) was among the analysed campaigns, in order to scrutinize what can be learned from an effort ongoing for more than 30 years.Achieving polio and malaria eradication require very different strategies, and both diseases differ in key biological and epidemiological characteristics. The GPEI has been ongoing for 32 years, and has decreased the number of reported cases by more than 99% since 1988. It is a WHO-led effort with an evolved governance structure which places countries, funders, organizations and non-governmental organizations in a complex landscape. While the number of new wild-type cases is extremely low and only detected in Afghanistan and Pakistan, with documented elimination of two of the three wild virus types, GPEI faces complex challenges including polio vaccine-strain derived outbreaks; sufficient access to the ideal vaccine/s for the late stage effort; and complex transition to sustainable post-eradication systems.Malaria cases, in comparison, had reduced significantly from 2000 to 2019, although progress had stagnated and the disease remains highly endemic, particularly in Africa. Not counting the potential impact of COVID-19 on the burden of malaria, the 2019 pre-pandemic data pointed to more than 200 million cases worldwide, plus an unmeasured reservoir in humans presenting with no or very mild symptoms, as well as emerging challenges, such as resistance to insecticides, drugs and diagnostics.While polio eradication is based on mass vaccination and robust surveillance, the malaria tool kit is often used in a variety of combinations, making necessary more sophisticated tailoring of strategies to the specific social, environmental and epidemiological context. Both polio and malaria face financial challenges and competing global priorities.Extensive technical summaries and reports of the overall history of the extended polio eradication effort and polio science have been written. This paper instead focuses on key questions of the GPEI whose answers may be of relevance to the concept of a renewed malaria eradication effort, including decision-making and priority setting, governance structures, the role and integration of research into operational activities, the evolution and implementation of surveillance systems and the processes for community engagement in a global eradication endeavor. Thirty-two years of hard work against polio provide an array of lessons potentially useful to malaria and other disease eradication campaigns, building on the diversity of gains achieved and also the variety of setbacks encountered by the GPEI to date.As opposed to geographically limited ‘elimination’ endeavors, ‘eradication’ is the “permanent reduction to zero of the worldwide incidence of infection caused by a specific agent as a result of deliberate efforts”. Complete clearance of the infectious pathogen removes the risk of reintroduction, making unnecessary further intervention measures in any territory in the world .The history of coordinated, global efforts to eradicate infectious diseases goes back to the early days of the WHO. Founded in 1948, the WHO launched the global campaign to eradicate malaria in 1955, at a time in which political demand for malaria eradication was fueled by the high expectations on indoor residual spraying with the relatively new and long-lasting insecticide DDT, and the fear of losing its efficacy to emerging resistance as the key background for that decision. The programme, however, faced the opposition of leading malariologists, as well as of members of the World Health Assembly (WHA), including both the scarce independent African countries and the colonial powers on the continent. Critics questioned the feasibility and affordability of the strategy, and equally denounced the functional exclusion of Africa from the “global” plan. After successes in eliminating malaria from many countries—mostly from those that had already a positive tendency towards zero malaria cases—the programme was suspended in 1969, once interruption of transmission proved infeasible in Africa with a strategy based on DDT spraying and anti-malarial drugs [During the time the GMEP was ongoing, another global eradication campaign was conceived. The Smallpox Eradication Programme was launched in 1960, succeeding 20 years later when smallpox was officially declared eradicated thanks to massive vaccination and—in the latter stages—strong surveillance systems to guide targeted immunization campaigns . Today, Polio is a disease caused by 3 types of wild poliovirus that causes paralysis in one out of 200 infected people. The programme to eradicate it was launched in 1988 with the aim of stopping any transmission of wild polioviruses by the year 2000. Up to 2021, that goal has not been reached, although the reported number of wild type polio cases has diminished dramatically, from approximately 350,000 children paralyzed annually in 125 endemic countries in 1988, to 140 wild-type polio cases reported in 2020 only in Pakistan and Afghanistan.The delivery strategy adopted by the GPEI was massive vaccination with the Sabin Oral Vaccine (OPV) that contains live-attenuated polioviruses and is easy to manufacture at large scale and to administer, but has the rare risk of reversion to neurovirulence. OPV was chosen over the Salk Inactivated Polio Vaccine (IPV), which is injected, is costlier to manufacture and historically supply constrained, but has no risk of reversion to neurovirulence and is also safe and effective in specific populations such as immunocompromized patients.The major advances took place in the first 15 years of the programme. As early as 1994, the first major milestone was met, with polio declared eliminated from the Americas, a region with a long tradition in immunization and relatively robust health systems, which had set the elimination goal prior to the launch of the global effort . To datePolio eradication has proven much more challenging than with smallpox, given the large numbers of asymptomatic infections, the lack of a marker for previous vaccination that obliges the programme to re-vaccinate every child in repeated mass campaigns, and the fact that acute flaccid paralysis (AFP) can be caused by other viruses and conditions, which makes laboratory confirmation compulsory and leads to a lag between symptoms and confirmation of polio—all features not encountered by the smallpox eradication programme. On top of that, in the last few years, additional challenges have been added to the polio equation: the 140 wild poliomyelitis cases reported in 2020 meant an increase from the 33 cases reported two years earlier, an increase attributed to bans of house-to house vaccination campaigns in areas held by insurgency, and the impact of the COVID-19 pandemic in the response capacity of health systems. Furthermore, the number of cases caused by ‘vaccine derived poliovirus’ reached 318 cases in 2019, occurring in 17 countries, most of them in Africa. These outbreaks result from the rare reversion to neurovirulence of live attenuated virus utilized in massive vaccination with OPV, and have been one of the deepest concerns for GPEI during the last years.Deciding whether to launch a global eradication effort has historically fostered most heated controversies. Following the malaria and smallpox experiences, establishment of the GPEI in 1988 was not an exception. The initiative was launched in the context of an intellectual rivalry between advocates of targeted eradication programmes of specific diseases, and those supporting slower and more integrated approaches to public health.Three decades ago, those experts against the selection of polio as the next disease targeted for eradication argued that measles was technically easier to eradicate and also had a higher mortality rate. A more robust criticism was the argument against the eradication approach overall, which stated that the smallpox programme had shown the importance of fully integrating immunization into primary health care and national immunization programmes. In fact, one of the earliest and most influential critics of the GPEI was Donald A. Henderson, former director of the smallpox eradication programme at WHO, who added his voice to others concerned that a new eradication campaign might de-prioritize core health interventions such as routine immunization systems, neonatal health, maternal mortality and diarrhoeal diseases, and could also displace emerging agendas, such as the HIV/AIDS , 17.more to do with the ideology of a small number of powerful and well placed players in global public health who were dedicated to the concept of eradication as perhaps the major tool for international public health” [The enthusiasm and strong commitment to the eradication approach of three individuals were instrumental in advocating for global polio eradication in the late 1980s. William Foege, former chief of smallpox eradication at the US Centers for Disease Control (CDC); Jim Grant, head of UNICEF, and Ciro de Quadros, head of immunization at the Panamerican Health Organization (PAHO). Their positions were so influential that some scholars have argued that the decision to launch the GPEI had “ health”  and who Against the critics’ voices and the low priority given to polio eradication by most countries, two additional factors supported the WHA endorsement of GPEI: the decision in 1985 by PAHO to embrace the goal of regional polio elimination in the Americas, and the resources made available by Rotary International, which in 1988 announced it had raised 247 million USD for polio eradication. Additional arguments supporting the GPEI included demonstrated elimination of polio in seven countries, and epidemiological modelling concluding that polio caused more long-term morbidity than any other preventable infectious disease , 19.The GPEI was approved by WHA without detailed technical analysis provided to attending Ministers, as some recall that the WHO technical committee to analyse the proposal had not met yet at the time of approval . Howeverad infinitum, and that every country in the world would benefit from stopping vaccinations once eradication occurs [Arguments around the launch of the GPEI did not put particular emphasis on the economic case for polio eradication, which later became one of the pillars for sustained engagement in the face of a costly programme that had been extended far beyond its target date. The core key argument to defend the GPEI from an economic point of view has been that eradication expenditures are temporary, while dropping prevention and control costs would accrue n occurs .Such economic arguments have been challenged in the context of tremendous increases in financial requirements since the original estimate of 155 million USD for the 1989–2000 period, an amount that was already higher than the ongoing support to EPI at the time. Over the following three decades, at determined points of time, resources devoted to polio eradication have reached up to 25% of the WHO budget; around 90% of WHO-funded immunization staff and infrastructure was supported by GPEI in Africa . In spitScience not only questioned the very feasibility of eradicating polio, but also suggested that the money and efforts directed towards this goal would be more effectively channeled into improved immunization programmes. “The question is, should WHO proceed with its current global eradication programme, in view of all the difficulties and uncertainties identified in this paper? Our answer is ‘No’”, the authors of the introductory piece stated [Among criticisms faced by the GPEI throughout its lifespan, one of the strongest appeared in 2006. A series of papers published by e stated . An impoe stated , 26.Despite controversies, the programme continued with additional WHA resolutions. In 2012, the WHA declared the completion of polio eradication a “programmatic emergency for global health”. The Polio Endgame Strategy 2019–2023 is the most recent strategic document of the initiative, and was accompanied by a new investment case that projected that eradicating polio would generate 14 billion USD in expected cumulative cost savings by 2050, when compared to the costs countries would incur to control the virus indefinitely. Moreover, according to this report, in 2019 the global effort to eradicate polio had already saved more than 27 billion USD in health costs since 1988.The investment case took into consideration novel circumstances, including the persistence of vaccine derived polio outbreaks and the evidence that immunosuppressed individuals can excrete vaccine virus for years (both conditions that made necessary continuation of immunization campaigns). On the other hand, replacing OPV with IPV, something already done by rich countries that had eliminated polio where the risk of disease was so low that the risk-benefit ratio shifted to providing the safest, albeit more expensive, vaccine possible, has now been accepted as part of the transition plan for the GPEI, and will require significant investments in order to ensure vaccine supply, as well as programme shifts to implement an injectable vaccine at the global level , 27–29.The long duration of the GPEI has triggered evolutions in the governance framework with additional partners, funders and challenges added throughout the three decades of the initiative.The WHA resolution that established the GPEI defined a WHO-led, headquarters model, with a coordinator that reported directly to the WHO Director General. The overall strategy of the programme is the responsibility of the WHA, whose resolutions engage WHO Member States that are in turn responsible for implementation against the strategic plans, and achieving the objectives.Leading partners of the initiative were originally WHO, UNICEF, the CDC and Rotary International. The Bill & Melinda Gates Foundation and GAVI, the Vaccine Alliance, were added to the group later. In 2020, these six agencies formed the Polio Oversight Board (POB), chaired by WHO Director General and constitutes one of the three leadership structures of the GPEI, together with the Strategy Committee (SC) and the Finance and Accountability Committee (FAC). The SC has the double responsibility of setting the programme strategy and coordinating implementation and management tasks through the Management Groups, which have responsibilities in the fields of Finance, Immunization Systems, Advocacy & Communications, Eradication, and Outbreak and Containment. A group dedicated to enabling the use of a novel oral polio vaccine type 2, which has lower risk of reverting to neurovirulence and has been developed to respond to outbreaks of vaccine-derived polio cases, was recently added to the management team. In addition to the three core structures, other governing bodies include the Global Polio Partners Group, which fosters engagement and support to polio eradication at the political and financial levels, and various technical advisory groups. The structure is complemented by supporting organizations, such as the Stop Transmission of Polio (STOP) programme, developed by CDC and the WHO in order to train and mobilize additional human resources to provide technical assistance to polio-endemic countries, and the Rotary-supported National Polio Plus Committees, which contribute with health interventions concomitant to the polio vaccination campaigns –34.In 2010, the Independent Monitoring Board (IMB) was established to replace the original Advisory Committee on Poliomyelitis Eradication, as a means to “break the deadlock” which the programme faced after a decade of stagnation in progress and the identified need for substantial programmatic changes. Since then, the IMB operates under the premise of complete independence and freedom to provide advice both at country and programme level, although it has no authority to make programmatic changes itself. Based on IMB recommendations, national or subnational polio eradication task forces, chaired by the president or prime minister, were established to provide oversight and ensure appropriate management and accountability. The IMB has pointed out challenging issues to the GPEI governance structure, including the reluctance of countries to share data, power imbalance, and the need to be more open to a wider group of stakeholders. In 2013, this body stated that “if a billion-dollar-a-year emergency global health programme were established from scratch today, its management structure would look nothing like that of the GPEI”. It is relevant to note that no substantive changes followed the statement, in the belief that there was a defined and limited timeframe to eradication , 35, 36.A critical issue related to governance of an eradication programme is how it relates to the rest of the health system. At the original launch of the GPEI, camps were split between those who believed the first task was to support weak health systems, and those that believed that vertical systems were critical for eradication. While polio eradication was originally implemented through EPI in order to ensure a certain level of integration, the need to develop unique surveillance systems and conduct additional vaccination campaigns each year led to its detachment from the routine vaccination programmes. In terms of governance, the programme similarly evolved to funding committed polio staff to support country actions, as well as deliver within each country independently from the routine immunization programme.increased collaboration with other health actors to help strengthen immunization systems and address the broader needs of communities deprived of basic services in addition to the polio vaccine, as part of our collective effort to support polio-affected countries in moving towards a universal health coverage” [The ability to drive and directly manage the work of the programme staff is credited for the rapid advance and programme effectiveness of the GPEI, although the unexpectedly long course of this eradication programme has resulted in late stage work to re-integrate the effort into health systems for sustainability and maximum leverage. The recently launched Polio Endgame Strategy 2019–2023 calls for “overage” .The shift towards increased integration of activities has been fostered by recognition of best practices throughout the implementation of the GPEI. The most praised approaches to polio eradication in Africa include links with other child survival strategies and support to coordination and communication that benefited both polio and other diseases control programmes, as well as strengthening of other elements of the health systems, such as surveillance systems at all levels, epidemic preparedness and outbreak response, public health laboratories, expanded partnerships with all sectors of the community, and innovative public health approaches, such as data management for immunization .As recently as July 2020, the GPEI included the concept of integration among the priority issues to be improved when considering the initiative structure and decision making processes, based on the results of a stakeholder survey. The survey report identified the need for increased clarity on the decision making processes and accountability of different governance bodies, increased country ownership—including financial and programmatic responsibility, and better capacity to incorporate new evidence into financial and programmatic decisions, as well as to incorporate more countries and donors into the SC and POB, and assessing the possibility of creating a secretariat to strengthen the coordination function of the SC . AlthougAlthough some truly game-changing innovations became available only late in the polio eradication programme, research and innovation have been actively promoted by the GPEI at different stages and acknowledged for critical contributions to the progress against polio.In 1996, the Global Technical Consultative Group was convened as the first body to deal with the need for innovative approaches to polio eradication and taking on the risk of epidemics due to vaccine-derived poliovirus. Reflecting the intention of providing a more robust framework for relevant polio research, this group was replaced in 2008 by the Polio Research Committee (PRC), primarily supported by Rotary International and BMGF, and coordinated by the WHO. The role of the PRC is to identify knowledge gaps and determine research priorities through a group of experts committed to reviewing research proposals, prioritizing, and presenting them to the GPEI partners for funding. Such an approach has proven useful, particularly facilitated by the independence of funding lines between the research and programme activities, so that these were not perceived in competition [Every review of lessons learned from polio eradication points toward the critical importance of building and maintaining a capacity for research, innovation and epidemiological studies in order to generate evidence to establish—and redirect-tools and strategies. Contributions of research and development (R&D) to the programme range from the development of vaccines that constitute the very core strategy of GPEI, to most recent genetic tools to support strategic changes in immunization strategy, better interpretation of genetic surveillance data and identification of outbreaks associated with vaccine derived poliovirus , 36.In the early days of the GPEI, research projects were designed to solve problems and operational gaps faced by the programme. Solutions improved logistics and supply , diagnostics, tools for monitoring & evaluation, laboratory methodology and surveillance techniques for AFP. In the years that followed, research has been critical to address different and varied issues: the effectiveness of vaccines was assessed in the context of persistent wild polioviruses despite intense vaccination campaigns, driving the need for new tools other than trivalent OPV; and chronic excretion of infective vaccine virus by immunocompromized individuals that can act as hidden reservoirs was identified, highlighting the need for improved diagnostic tools to identify asymptomatic infected individuals. The fields of mathematical modelling for decision-making, new vaccine delivery strategies, and refined protocols for viral culture to reduce the time for case classification and outbreak response, all were the result of research investments. Following the eradication of type 2 poliovirus, monovalent and bivalent vaccines were developed, which resulted in a more robust immune response to the remaining components. At a time in which success of the GPEI depends largely of controlling vaccine derived outbreaks, the R&D community focused on developing a new oral vaccine using attenuated viruses with higher genetic stability and, therefore, reduced risk for mutation, which was listed under WHO emergency use in late 2020 , 36, 39.One of most useful innovations supporting GPEI, particularly in highest risk countries, has been environmental surveillance (ES) that detects wild poliovirus in sewage samples, indicating the presence of virus-shedding individuals in the community and allowing rapid outbreak response. In the future, and with the support of genetic tools, ES may play a role in the certification process for global eradication and provide relevant information on the elimination of attenuated viruses once OPV is discontinued , 40, 41.Robust surveillance systems to identify circulating viruses, monitoring progress, facilitate the search for the last cases, detect reintroductions and support documentation of interruption of transmission has been one of the pillars of the GPEI.Following the launch of GPEI, WHO established guidelines for the development of sensitive systems of epidemiologic and laboratory surveillance at all country levels, focusing on detection and evaluation of AFP and data management. The GPEI directly funds a vertical, polio specific surveillance infrastructure that has helped frame effective, coordinated multi-country synchronized campaigns which target contiguous epidemiological blocks crossing national borders, defined by population dynamics, ethnography, and migration.Surveillance data have been critical to the ability redirect strategies and adapt them to changing circumstances, identify transmission routes in populations crossing borders and contribute to the development of vaccination strategies for migrant and mobile populations and other hard to reach target groups.As the eradication goal approaches, this laboratory network has also been at the center of debates on how to transition these skills and assets to a platform for an integrated disease surveillance system, since in some countries the polio surveillance network is so much better than the routine national systems that it has been used to detect and tackle other epidemics of infectious diseases, such as yellow fever, cholera, meningitis, ebola, dengue, zika, chikungunya and most recently, COVID-19 , 42–45.As noted by the IMB in 2012, polio vaccinators are the very foundation of the GPEI. They go into individual houses and inoculate children with a vaccine unknown to the parents, sometimes up to 10 times to the same child. Trust is, therefore, a critical element for the success of vaccination campaigns, but it has not been achieved everywhere .GPEI has faced some major crises in terms of trust and community engagement. In 2011, the fake hepatitis B vaccination campaign organized by the US Central Intelligence Agency to track down Osama bin Laden gave a basis for suspicion that vaccinators may actually be spies. Some years before, in 2003, vaccination in Nigeria stopped following rumours that polio vaccine was contaminated with HIV and/or hormones to sterilize Muslim populations, with catastrophic results: one year after the interruption of vaccination in Nigeria, the number of cases doubled, re-infecting around 20 previously polio-free countries, including those affected by conflict, such as Sudan and Somalia, where organizing vaccination campaigns was already challenging. It took a site visit of a Nigerian team to a vaccine manufacturer in Indonesia (a Muslim country) along with unprecedented support from religious leaders, to restart the Nigerian vaccination programme the following year.because we weren’t doing the right thing in the first place” [The events in Nigeria shed light on the critical role of community engagement in eradication efforts and the need to understand the local factors that favour or impede trust in health interventions. In the case of Nigeria, key opinion leaders in the North questioned the focus on polio as a public health priority and saw GPEI as ‘stealing’ resources and undermining primary health care and routine immunization. Debates engaging religious leaders and health experts may have reinforced the idea that there was no consensus about the safety of the polio vaccine. Overall, the community’s hesitancy to accept polio was fueled by genuine fear, internal rivalries and unattended health problems, such as malnutrition and malaria considered by the population and local leadership as more urgent than polio (and treated for a fee), that fueled the perception of polio eradication as an imposed, foreign agenda. According to a Nigerian professor, religious bias succeeded “t place” , 46, 47.Effective components of the strategy to overcome vaccine hesitancy included the formation of an Islamic Advisory Group for Polio Eradication, mass communication campaigns and Fatwas in support to polio vaccination by leading Islamic leaders. More generally, the IMB has recognized that, while the GPEI focuses on polio, parents in endemic countries have other perspectives and, therefore, the programme needs to be integrated with other health care interventions. Properly acknowledging and addressing different health requests by the population  increased the acceptability of the polio vaccine , 48.Research in the fields of social sciences, anthropology and communications have been key to understanding factors that contributed or challenged acceptance of vaccination and to develop strategies for mobile and migratory populations that play an important role in sustaining poliovirus transmission in some areas. In war and conflict zones, access is the key challenge to vaccination, making high-level political negotiations to facilitate immunization campaigns necessary. By incorporating these topics into the research agenda, GPEI developed a robust capacity for identifying communities with vaccine hesitancy and those not accessing immunization services due to logistics, culture, politics, ethnicity, gender, marginalization or security, developed context-specific communications strategies and social mobilization methods, and forged local partnerships with traditional, religious, and community leaders , 42.A review of lessons from the GPEI that are useful for the malaria field is best considered in the current and future context for the global malaria effort, taking into consideration that the programmes are in drastically different phases, and facing different challenges.the platform from which a successful and time-limited eradication effort can be launched” [The SAGme recommended that global malaria efforts focus on achieving the targets set by the GTS as the first step towards establishing “aunched” . This meUnderstanding what has worked and what has not in previous eradication efforts, such as polio, is one contribution to the intellectual landscape to prepare the global health community for when the moment comes to launch the final phase on malaria. Based on this review, conclusions can be drawn in the areas of implementation, surveillance, community engagement, governance, access to essential services and commodities, and innovation.As the history of the GPEI and the GMEP show, reaching complete consensus on launching an eradication campaign is an aspiration almost impossible to fulfill. The GPEI experience should remind the malaria community that, notwithstanding how pressing the burden of a disease is, its relative priority, as well as the assessment on the feasibility and appropriateness of a global campaign to eradicate it, varies from context to context and from different perspectives.Perhaps the most important lesson is that in global health, as in any other human task, decision making is not only an issue of following scientific evidence, but it also depends also on the capacity to make one’s voice heard, raise funds and mobilize support. In the case of polio, the power of influential epidemiologists committed to the eradication agenda and the funds made available for the cause, were instrumental in tipping the balance towards the approval of the eradication initiative, despite opposition mostly within the WHO, and the weak engagement of most countries represented at the WHA.In the future, in order to foster a richer debate, it may be useful to remember that those that oppose the launch of eradication efforts may not disagree on the gains that would be achieved, but rather on the appreciation of the feasibility of the task and the implications of such campaigns to the broader health scenario.Clearly, the case for polio eradication was based on feasibility of elimination in countries and regions with conditions for success. As shown by GPEI, certification of elimination in countries and regions can be a leverage and acceleration force for the global eradication approach, but starting where the task is likely to be easier may have harmful consequences and keep the world at risk of re-establishment of transmission for too long.In the case of polio, early focus leading to elimination in India and Nigeria—which have been among the hardest places—could have prevented serious setbacks, and successfully tackling the challenges of high burden countries or subnational regions within the global strategy might have resulted in an overall shorter timeline. For malaria, the proof of concept that targeted programmes can eliminate it has been successful, as countries in Asia, Latin America and Algeria in Northern Africa have continued to be certified and the WHO European Region was declared malaria-free in 2016 , 50. HowAnother lesson from polio is that challenges may come from a variety of sources, including mobile and migrant communities which are likely to be key in sustaining transmission and require targeted strategies, including cross-border collaboration and data sharing, and specific surveillance systems capable of providing data for real time decision-making. Insecurity is also a fundamental factor affecting the capacity to reach target populations, as demonstrated in Nigeria, Afghanistan and Pakistan. GPEI points to the need for specific strategies to address the ‘last mile’—the hardest to reach territories and populations within countries. While the last mile may be uniquely defined in each area, and require different approaches, it should be captured in the programmatic risk management strategy and with readiness to adapt as the scenario changes.Moreover, particular emphasis needs to be put on the risk of re-importation to disease-free certified countries. Experience from GPEI advises on the need for parallel focus on completing elimination and addressing the risk of periodic outbreaks that follow importations from still endemic countries, suggesting that hardest places and known “persistent sanctuaries” should be addressed early and that eliminated countries need to sustain surveillance and response to avoid infection and re-importation .The GPEI has been praised for its extraordinary resilience and for its capacity to keep interest in the eradication goal despite the long duration of the initiative. After three decades of intense work and investment, not only have the original partners not withdrawn their support, but new funders have been added to the initiative.However, the extended duration of the global eradication effort has led to reemergence of controversies, with calls to re-focus on effective polio control and to reallocate resources to health systems strengthening and other more urgent health needs. In this context, a key lesson is the strategic importance of presenting and planning for a time-defined eradication campaign, as sustaining enthusiasm for a long implementation programme can prove challenging. Programme delays generate new funding gaps, and can also results in ‘recipient fatigue’, given the efforts that eradication programmes require in endemic countries, particularly for those with competing, unfunded health priorities and weaker health systems.Limiting the eradication efforts to a relatively short period should be a strategic goal for any disease eradication programme, and is particularly challenging for malaria at this point of time, given the estimated 229 million cases in 2019 and the plateau in progress observed since 2017, and this without considering the effects of the COVID-19 pandemic. Although the reported COVID-19 numbers from Africa are relatively low, the impact on malaria in 2020 will only be known by the end of 2021 .Although concerns were raised that adaptations to GPEI governance took too long to be implemented, the modification of the governance structure over the polio programme lifetime demonstrates the critical need to adapt to the changing realities, engage new relevant stakeholders, and broaden the locus of control, even for a highly verticalized programme, such as GPEI. The opportunity for malaria is to consider how the governance structure for a potential eradication effort can evolve to meet future needs, rather than responding to crises.On the other hand, different voices have emphasized the value of country-led governance, making coordination even more relevant. Expert groups completely independent from power balances within the eradication effort can have a major impact in assessing both challenges and advances, and suggest reorientation of strategies, if needed. Such independent bodies with a coordination role may be useful at the regional, national and even sub-national levels (particularly to support implementation and community engagement), but may also create new challenges if not strongly linked to technical and management standards.versus faster wins that can result from vertical programmes are critically needed. The polio programme is based on vaccination and surveillance; for malaria, the effort includes not only prevention with vector control tools, and surveillance for disease and perhaps infection, but also the need for identification and treatment of malaria infections, requiring integration into other systems, such as national treatment programmes and implementation through Integrated Community Case Management and health extension workers.In terms of how to link a potential eradication programme with the existing health systems, comprehensive analysis regarding the risks and benefits of integration—and the key elements that are best integrated—for sustainability and generalizability The balance between vertical and systems programming will not be resolved either retrospectively or by history. Perhaps the lesson is that this is a real tension, and the targeted operational research to define what can best be done by strengthening health systems and where targeted staff and/or efforts are needed can bring clarity early in the programme.The polio experience showsthat estimating the cost of eradicating a disease and the benefits derivingfrom reaching this goal is a complex endeavour, with huge variations fromcountry to country depending on the standard of health services andsocioeconomic conditions, as well as unexpectedchanging scenarios over the life span of an eradication programme.An eradication programme also needs to be prepared to change the implementation strategy when data points to the value of alternate approaches. In the case of polio, the replacement of OPV by IPV in order to eliminate the risk of vaccine-derived polio is a critical shift deeply affecting vaccine production and supply dynamics, the cost of vaccination, and implementation strategies. This transition in the prevention strategy at the end of the eradication campaign reflected data-driven changes in risk-benefit considerations.In the light of these experiences, setting targets with presumed budgets necessary should include an emergency fund for surge activities, and a method for funding relevant research, which is often not a programmatic priority. Costing exercises should also recognize the inherent value of in-kind contributions by countries, as well as the ‘opportunity costs’ they imply for lower income settings.Funding gaps remain a major threat and challenge throughout an eradication program, but particularly at the latest stage where disease levels are low and the disease is rarely a national priority. In the case of malaria, the need for increased direct country financing has been identified by the partners, and the global financing plateau recognized . The focover time, in successful elimination initiatives, the best researchers will see their ideas implemented and the best implementers will continue to ask what research could further improve operations” [When considering the role of research for malaria eradication, a group of experts stated in 2011 that, “rations” . The chaThroughout the polio eradication initiative, building and maintaining a capacity for research and innovation, as well as impact and epidemiological studies proved critical to establish the evidence base for change of strategies. Several years after the establishment of the GPEI, an independent committee was established to identify research priorities with the potential for direct impact on the programme, and these were presented to the donors for funding annually. This unique visibility and coordination of a linked “research” programme is identified as one successful element of the GPEI.Such a centralized infrastructure is challenging to apply to the malaria field at a stage in which it is still facing a diverse set of challenges, including submicroscopic infections added to more than 200 million symptomatic cases, and the drug, vector and diagnostic resistance, which require engagement of a more diverse set of actors—from basic research to epidemiology, from national institutes to civil society. At this point, malaria is much more complex than polio, both as a control and as a research target.What is relevant, however, is the need for research and innovation, and the long-term view as to the needs of tomorrow. For polio, if the world had successfully invested in the new polio vaccines needed for the end of the programme 20 years ago, they could have been available when ultimately needed. Investments in innovation, product development, translation into combination strategies as well as impact assessment—with the longer timeframe—is critical.The malaria community has already started a collective reflection on critical knowledge gaps and R&D needs. While the malERA refresh review published in 2017 defined key problems and identified areas of importance for investment and exploration, it deliberately avoided creation of a list of research priorities . PrioritFor a disease as complex as malaria, an eradication programme should plan on a process to identify and address critical problems that can be solved through a research platform as an inherent component of coordinated efforts. Second, appropriate governance to link but make independent recommendations should be developed. Third, commitment to problem solving and continuous improvement of program implementation over the long term are likely to be critical drivers for long-term success. While at the current stage of malaria it seems that the appropriate action is to ensure funding for research, but keep its management and funding separate from implementation programmes; at the end stage, where polio is now, the concept of a research committee may be viable and could be revisited, particularly for implementation science and operational research.On the other hand, the use of evidence for decision-making requires knowledgeable cadres in endemic countries capable of identifying problems, proposing solutions and evaluating their own data as these emerge. Relevant activities in this field include training and leadership programmes to enhance the capacity for evidence-based decision-making and to build bridges that allow different groups to listen to each other, engaging both the laboratory (defining what can be done) and the field (identifying the problem to be solved) as well as national policy bodies and implementers.With regards to the use of data for decision-making, in the case of polio, evidence-based decision-making was favoured by the availability of novel surveillance technologies that increased the granularity of information and speed of reporting. Most relevant in this point is that different types of data are needed at each stage of the eradication effort, from the quantification of the burden of disease to inform programme decisions and monitor progress, to stratification to optimize programme interventions, identify the sources of remaining cases at low levels of disease, and finally, document interruption of transmission.Acceptability and local ownership of the value of public health interventions are critical for the success of any eradication effort. Targeted research efforts are required to understand factors that contribute to or challenge acceptance of the relevant interventions, particularly those delivered as community campaigns, and to develop strategies to reach vulnerable and distant populations. The polio experience shows that sociocultural and political aspects need to be understood when designing strategies to overcome barriers to health campaigns, and provide important lessons on the role of community engagement and other social factors in eradication efforts.When planning for the future, it should be remembered that community engagement is not just a matter of explaining the advantages of the proposed interventions or to deliver them with other health services that the community is more willing to accept, but to authentically acknowledge health priorities of specific contexts, and responding to them through strategies and packages of interventions that the communities themselves have contributed to shape.More specifically, malaria communications and community ownership will need to address the power of community interventions that can both directly and indirectly affect the community and individual risk of malaria. Detailed communications are needed to explain the benefits of interventions, such as community chemoprevention programmes or transmission-blocking vaccines.Over the 32 years of the polio eradication effort, the polio community built incredible systems and achieved unprecedented advances in the burden reduction of this paralytic disease, even while encountering unforeseen challenges and coming up with innovative solutions. It also had significant setbacks, and faced fundamental critiques to its very structure and approach to global health. While malaria is at a very different stage in the continuum from control to eradication, and the GPEI trials, tribulations and programme strategies do not parallel those faced by malaria, polio eradication provides useful insights when designing governance and financing structures, strategies, and implementation plans. The need for parallel innovation, better use of data, inclusive governance, appropriate level of integration and, above all, flexibility and openness to change in all relevant areas, often not under the direct purview of the health community, are among the key lessons from GPEI to malaria.On the other hand, the COVID-19 pandemic has highlighted two key aspects of the polio/malaria challenges: the first is the enormous power of a prioritized, multi-country research effort; and the second is the critical importance of bringing the necessary resources to address diagnosis, treatment and prevention challenges when the target is truly a priority. However, the implementation of any of the emerging COVID-19 tools also is challenged in many countries by the same health system weaknesses that makes disease eradication difficult.Thus COVID-19 highlights the potential impact of innovative research, sharing of information, and concerted product development and systems that are similarly valuable for final impact on polio and the urgency that should be applied to malaria, which remains endemic in 87 countries, today.


Fretting wear is a common phenomenon that happens between contact parts when there is an oscillatory relative movement. To investigate wear characteristics history in the fretting process, the finite element method (FEM) is commonly applied to simulate the fretting by considering the wear in the model. In most literature publications, the wear coefficient is considered as a constant, which is not a real case based on the experimental results. To consider the variation of wear coefficient, a double-linear model is applied in this paper, and the tribologically transformed structure (TTS) phase is considered in the study of the wear coefficient variation model. By using these models for variable wear coefficient for both flat and cylinder, the difference of wear characteristics, plastic strain, and stress between variable wear coefficient model (VWCM) and constant wear coefficient model (CWCM) are analyzed. The results show that the variable wear coefficient has no significant effect on the wear characteristic at the end of the process in the gross sliding regime. However, in the partial slip regime, the effect of variable wear coefficient on wear characteristics is significant. Due to the difference in contact geometry in the fretting process between VWCM and CWCM, the tangential and shear stress and equivalent plastic strain also show differences during the fretting process. Fretting is a common phenomenon that happens between contacting parts, which is caused by oscillatory relative movements under normal load. Fretting regimes can be classified into stick regime, mixed stick-slip regime, and gross slip regime based on relative slip amplitude, which was first analyzed by Vingsbo . FrettinMany parameters can affect the fretting wear characterization, among which the main effect comes from slip amplitude, normal load, material properties, coefficient of friction, and geometry of the contact parts ,7,8,9,10The vital and persistent goal for the engineers and designers in tribology is to have robust mathematical equations to calculate the wear rates and translate the microscopic experimental results into the macroscopic model in the fretting process . Both phIn this paper, the effect of variation of wear coefficient during the fretting process on wear characteristics and stress is analyzed in both partial slip regime and gross sliding regime. Moreover, equivalent plastic strain is considered in the whole fretting process. This paper is structured as follows: after the introduction of fretting wear, the wear models and problem description are given in FEM is commonly used to simulate the fretting wear process due to both efficiency and accuracy ,24,25. TMcColl et al. implemented Archard’s equation in their FE model and used a modified Archard’s model given by :(3)Δhi,jBy analyzing the relation between dissipated energy and wear volume, a dissipated energy wear model was proposed by Fouvry et al. . This mond Wahab .The wear coefficient in the above-mentioned two wear models is mostly considered as a constant in FE simulation, whereas the experimental results show the opposite. Zhou and Sauger proposed and analyzed TTS in the fretting process, which is the transition phase between the bulk material and debris ,32,33. TThe experimental results and setup are obtained from . The geoThe material properties are listed in The nonlinear FE model is designed in the commercial software ABAQUS by Python scripts, shown in The normal load and slip between the two contact parts are both relatives. To simplify the model, we apply the normal load and oscillatory displacement on the top center of the cylindrical pad. The loading history is shown in The variation of wear coefficient during the fretting process is an interesting topic. As shown in −9 MPa−1 in the 25,000 cycles for flat. To make the wear coefficient more accurate to be used in the FE model, a wear coefficient modification method is applied in this paper, as is shown in To obtain the wear coefficient for every cycle period of the flat and cylindrical pad, relative slip amplitude on the contact surface, −9 and 2.058 × 10−8 MPa−1 in the first 25,000 cycles, respectively.From 3 for flat and cylindrical pads by CWCM after 25,000 cycles, respectively. Compared with the experimental result, 0.0497 and 0.2026 mm3, we can see that the computational wear characteristics by CWCM show a good agreement with experimental results.Validation of the wear models is applied for both specimens. The cross-sections of both specimens are shown in In the FE model, the wear profile of the flat specimen can be obtained by export the coordinate of contact surface nodes after the fretting wear process directly. However, for the cylindrical pad, it is not the same case. The profiles of the cylinder before and after fretting wear are shown in Considering the above conditions, double linear models are used for both flat specimen and cylindrical pad in the first 25,000 cycles. The wear volume after 25,000 cycles is set to be the same as the experimental data for both specimens. CWCM and VWCM in the first 25,000 cycles for both specimens are shown in −9 and 9.98 × 10−9 for flat specimen and are 8.23 × 10−9 and 4.115 × 10−8 for the cylindrical pad. Because COF is 1.0 in the stable stage, the dissipated energy wear coefficient In Flowchart of the numerical implementation for the cylindrical pad and the flat specimen is shown in As described in , the staThe corresponding wear characteristics, plastic strains and stresses, for the gross sliding regime and partial slip regime are analyzed in detail in the following two sections, respectively.For flat specimens, a moderate-sharp VWCM and CWCM are used. The wear characteristics history can be found in From The shear stress and tangential stress history in the fretting process are shown in For the cylindrical pad, a sharp-moderate VWCM and CWCM are used. The wear characteristics in VWCM, wear width, wear depth, and wear volume are lower in the TTS period and then increase dramatically in the sharp increment period, after which wear characteristics in VWCM exceed that in CWCM at about the 5000th cycle. At the end of the 25,000th cycle, the wear characteristics of VWCM and CWCM show a good agreement with each other. The ripples on the left-hand side also happened to the cylindrical pad due to the plastic deformation. Based on The same trend is shown in The tangential and shear stress profiles and maximum value history are shown in The wear coefficient in the partial slip regime is assumed to be the same as that in the gross sliding regime. Therefore, the applied displacement The wear characteristic for the flat specimen in the partial slip regime is shown in From The tangential and shear stress profiles and maximum value history are shown in Wear characteristics for the cylindrical pad in partial slip regime are shown in From The history and profile of tangential and shear stress are shown in In a gross sliding regime, the characteristics of the wear profile have an opposite effect on the maximum tangential and shear stress for both flat specimen and cylindrical specimen. Lower maximum stress corresponds to the higher wear characteristics. The effect of wear volume on the plasticity accumulation is significant. The higher wear volume caused less plasticity accumulation. The effect of VWCM for flat and cylindrical specimens on the history of stress, wear characteristics and plasticity accumulation are significant.In a partial slip regime, the characteristics of the wear profile have an opposite effect on the maximum shear stress and a positive effect on the tangential for both flat specimen and cylindrical specimen. Lower maximum shear stress and higher maximum tangential stress corresponds to the higher wear characteristics. The effect of wear volume on the plasticity accumulation is not significant. Plasticity accumulation in CWCM tends to be higher than that in VCWM for both specimen and cylinder. The effect of VWCM for flat and cylindrical specimens on the history of stress, wear characteristics and plasticity accumulation are significant.The history of stress and strain in VWCM differs from that in CWCM. Stress and strain history can affect the crack initiation lifetime. Therefore, the effect of VWCM on crack initiation can be future investigated.


The objective of the study was to assess knowledge of pregnant women in the third trimester of pregnancy on non-pharmacological techniques for pain relief during labor and childbirth.A cross-sectional study was conducted at a tertiary care facility of the University of Campinas, Brazil. The participants were 171 pregnant women, aged 18–35 years with 36 or more weeks of a singleton pregnancy. Participants responded to a questionnaire with data about sociodemographic and obstetric characteristics, knowledge on non-pharmacological techniques for pain relief during childbirth, the source of the information on these techniques, practice of physical activity and occurrence of pain during pregnancy. Parous women responded on the use of non-pharmacological techniques for pain relief during childbirth in previous deliveries. Multiple regression analysis with stepwise criteria of selection of variables was used to identify variables significantly associated with knowledge of non-pharmacological techniques for pain relief during childbirth.A total of 165 (96.5%) participants reported knowledge on at least one non-pharmacological technique; 87.1% on the use of a warm shower during labor for pain relief, 80.7% on the use of the birthing ball, and 74.8% on breathing techniques. There were no significant differences between nulliparous and parous women. The main source of information reported was the Internet. Multivariate analysis showed that pregnant women who had pain during pregnancy reported more knowledge on the use of warm showers during labor .Most women had knowledge of at least one non-pharmacological technique for pain relief during childbirth. Many factors influence women’s experience of pain associated with labor, including prior experience of delivery and sociocultural factors, such as years of schooling3. Fear of childbirth pain in many settings is frequent among women and has been described as one of the main reasons associated with the solicitation of elective caesarean delivery, increasing the possibilities of antepartum depression and anxiety levels4.Labor and childbirth pose a physiological and psychological challenge for women. Pain associated with labor and childbirth, described as a physiological condition and as one of the most unique and intense forms of pain that can be experienced, it is intense, expected, and considered a normal event. Each woman has a unique way to cope with childbirth pain. A better comprehension of pain during labor and childbirth is important for the development of strategies to help women during this experience to develop capacity to reduce the use of pharmacological interventions5 and the Ministry of Health of Brazil6 recommend, among other sources for pain relief and to improve laboring women’s well-being, the use of non-pharmacological techniques. Some of these techniques are non-invasive, help women to develop strategies to control pain during labor and childbirth, are safe for the woman and the newborn, do not present side effects, present benefits, and have no cost10. It has been reported that many women in labor and during childbirth would like to use non-pharmacological techniques of pain relief including massage and heat application, position changes, breathing exercises, bathing in labor, aromatherapy, acupressure and acupuncture, TENS, among others12.Non-pharmacological techniques can be used to relieve pain and improve women’s well-being during childbirth. The World Health Organisation13. It has been reported that in a group of pregnant women with superficial knowledge of the non-pharmacological techniques, the majority (83.3%) did not have clear information regarding what techniques can be used and are adequate for the different stages of labor and childbirth. The technique that pregnant women reported more frequently was breathing exercises (51.8%) followed by massage (36.7%), position changes (32.2%), and relaxation (26.5%)15. Furthermore, it was reported that women were interested in using these techniques; however, most of the participant women did not know how to use these techniques in a satisfactory manner15.The use of non-pharmacological techniques for pain relief is associated with previous knowledge and adequate guidance that enable women to use them correctly and efficiently for pain relief, anxiety, and to be in control of their labourIn general, there is scarce information and there are gaps regarding the knowledge on what pregnant women know about non-pharmacological techniques for pain relief during labor and childbirth as well as on the source of the information. Due to this paucity of data, our objectives were to assess the knowledge of pregnant women regarding non-pharmacological techniques for pain relief during labor and childbirth and the source of the information they reported.A cross-sectional study was conducted between April 2019 and March 2020 with pregnant women in the third trimester of pregnancy regarding knowledge of non-pharmacological techniques for pain relief during labor and childbirth, the source of that information, the practice of physical activity during pregnancy, and reported pain during pregnancy. The study was conducted in a teaching referral hospital for women, University of Campinas Faculty of Medical Sciences, Brazil.The inclusion criteria were: pregnant women aged 18–35 years (to have the possibility to include more primiparous women), with a singleton pregnancy, and with 36 or more weeks of pregnancy. We excluded pregnant women with medical pathologies such as human immunodeficiency virus infection, heart diseases, pregnancy-related pathologies , deaf-mute women, and women with two previous caesarean deliveries. All participants were selected according to the inclusion and exclusion criteria the day before their routine antenatal consultation through the medical record system of the hospital and all identified women were invited to participate. All the enrolled women responded to a questionnaire elaborated for this study, which included data about sociodemographic and obstetric characteristics, knowledge on the non-pharmacological techniques for pain relief during labor and childbirth , the source of information on these techniques, practice of physical activity, and the occurrence of pain during pregnancy. The questionnaire with closed-ended questions was pre-tested for content and comprehension, with 20 pregnant women of the same facility before the initiation of the study. The corrected version was pre-tested with 20 pregnant women at the same site and no further corrections were needed.For statistical analysis, we used frequency and percentage for categorical variables and mean and standard deviation (SD) for numerical variables. We compared knowledge of the techniques and practice of physical activities using the chi-squared or Fisher’s exact tests . Subsequently, we used the Mann-Whitney U test because the variables did not present a normal distribution. Among parous women, we also assessed the use of non-pharmacological techniques for pain relief during childbirth in previous deliveries. We performed bivariate and multivariate analyses to compare women’s knowledge of non-pharmacological methods for pain relief with reported pain during pregnancy. The variables included in the analysis regarding the non-pharmacological techniques performed during labor were as follows: maintaining an upright position, using a birthing ball, breathing exercises, relaxation technique, massage, use of water shower, aromatherapy, acupressure, TENS, and continuous support of a companion chosen by the laboring women. The level of significance was set at p<0.05.A total of 171 pregnant women were enrolled. The age of the participants (mean ± SD) was 27.7 (± 4.7) years. Moreover, 53 (30.9%) were nulliparous, 121 (70.6%) had 13 or more years of schooling, and 103 (60.2%) were working outside home . RegardiRegarding knowledge of non-pharmacological techniques for pain relief during labor and childbirth, 165 (96.5%) participants had some knowledge of at least one technique, and 87.1% had information on the use of a warm shower during labor for pain relief, 80.7% on the use of the birthing ball, and 74.8% on the use of breathing exercises , withoutWhen we compared the practice of physical activity and the desire for a vaginal or caesarean delivery with knowledge about non-pharmacological methods for pain relief during labor, we did not observe any significant differences. We also did not observe any significant differences in knowledge of non-pharmacological methods for pain relief between nulliparous and parous women. After multivariate analyses, we found that pregnant women with pain during pregnancy reported more knowledge on the use of warm showers during labor for pain relief  .Our results show that most of the pregnant women had some knowledge about non-pharmacological methods for pain relief during labor and childbirth, and the most mentioned techniques were the use of warm showers, the use of the birthing ball and breathing techniques; and the main source of information reported was the Internet. However, the women in our study did not mention the water birth or tub, probably because it is uncommon practice in Brazil and it is not part of the practices offered at our hospital.14, and a study in India reported that 22% of women did not have knowledge of these techniques13. However, knowledge on these techniques does not mean that women know how to use them. Considering this, it was reported by Anarado et al.14 that 80% of pregnant women were aware that pain during labor could be relieved using non-pharmacological methods, but only one-third was able to identify at least four of these methods, enumerate at least two advantages and disadvantages, and report the self-efficacy of use of these methods.Most of our results are consistent with studies conducted during the last decade. A study conducted in Nigeria has shown that 31% of pregnant women did not have knowledge of non-pharmacological methods for pain relief in labor and childbirth13; however, we found that previous childbirths were not a good indicator regarding the knowledge women had. This result indicates that previous experience without active guidance or support is not sufficient for women to acquire knowledge and to use non-pharmacological methods correctly in a subsequent childbirth. This may explain why our results did not show significant differences in knowledge among nulliparous and parous women.Previous childbirths have been associated with more knowledge of non-pharmacological techniques for pain relief. It has been reported that the level of knowledge is higher among women with two previous childbirths16.It can be supposed that women who desire vaginal delivery, a situation where women’s participation is more active during labor, were more prone to practice physical activities. However, we did not observe this association in our study. Our findings were different from the findings of a recent study that described an association between the practice of physical exercise during pregnancy for at least 6 months, one to three times a week for at least 30 min, and a lower chance of caesarean delivery17. Most of the published evidence on the benefits of using water for pain control comes from studies on the use of immersion in water12. However, our results even though similar regarding the use of warm water in alleviating pain, refer only to the use of warm showers. This is a relevant issue that deserves more study considering that in several low- and middle-income countries, it is more realistic to think that women have access to a warm shower rather than any form of immersion in water12.We found that women who experienced pain during pregnancy were those who had more knowledge regarding the use of warm showers during labor. It has been reported that this technique was used by pregnant women to alleviate Braxton-Hicks contractions and promote relaxation. It may be considered that women are familiar with this technique because it is frequent practice that non-pregnant women use this technique to alleviate dysmenorrhoea17 were described by pregnant women as techniques to alleviate discomfort and for pain relief during labour14. Our results showed that the recommendations from the Brazilian Ministry of Health6 about the use of non-pharmacological techniques, such as breathing exercises, massage and relaxation, and to incentivize women to adopt an upright position during labor to alleviate pain and improve well-being, are not always followed by healthcare providers and healthcare services. Although the recommendations from the Ministry of Health6 give much emphasis to these recommendations, it still has not been implemented in all obstetric services, and frequently it is only implemented as guidance and support in the labor ward and scarce information provided during antenatal visits.Previous studies have shown that pregnant women had scarce knowledge but were interested in some non-pharmacological techniques for pain relief during childbirth. The breathing technique, massage, and upright position18. We found that almost all the parous and 50% of the nulliparous women reported the Internet as the main source of knowledge, and less than one-fifth of the participants reported that they received the information at the hospital during antenatal consultations or when they were admitted to the hospital in a previous delivery. We need to consider that women who did not attend antenatal education programs and wanted to be prepared for childbirth and postpartum also used this resource to obtain information19.We found that the Internet was the main source of information about non-pharmacological techniques for pregnant women. This result was in agreement with previous study which reported that Internet was the main source that women used to improve knowledge regarding these techniques and YouTube videos were described as a resource for this kind of searchWe found that although our assessment was performed in the third trimester of pregnancy, which may indicate that the participants had already attended several antenatal consultations, our results do not indicate that the women had received guidance on the use of non-pharmacological techniques for pain relief.Our results show that healthcare professionals providing outpatient obstetric care must not only offer good quality of care for pregnancy control but also include strategies to include guidance on non-pharmacological techniques for pain relief. Considering that the participants identified the Internet as the main source of information about the non-pharmacological techniques for pain relief, it is important to conduct more studies that will contribute to the elaboration of adequate messages. The transmission of this type of information to pregnant women in an easy-to-understand manner is important and will help them become familiar with these methods. It would be interesting to include this kind of information on the website of healthcare facilities and create channels of interaction for the users with the healthcare professionals of the maternity hospitals were they receive antenatal care and receive attention during childbirth. It is desirable that maternity facilities offer some training on non-pharmacological techniques for pain relief to healthcare providers who provide assistance to pregnant women.The strength of our study was the number of participating women. However, a limitation is that the study was conducted in only one teaching referral hospital.Most of the interviewed women had some knowledge of at least one non-pharmacological technique for pain relief during labor and childbirth. The most mentioned techniques were use of a warm shower and use of birthing balls and breathing techniques. The main source of information was the Internet.


Subarachnoid hemorrhage from rupture of an intracranial aneurysm  is a devastating subset of stroke. Since brain damage from the initial hemorrhage is a major cause for the poor outcome after aneurysmal subarachnoid hemorrhage, prevention of aneurysmal subarachnoid hemorrhage has the highest potential to prevent poor outcome from aneurysmal subarachnoid hemorrhage.In this review, we describe the groups at high risk of aneurysmal subarachnoid hemorrhage who may benefit from preventive screening for unruptured intracranial aneurysms followed by preventive treatment of unruptured intracranial aneurysms found. Furthermore, we describe the advantages and disadvantages of screening and advise how to perform counseling on screening.Modeling studies show that persons with two or more affected first-degree relatives with aneurysmal subarachnoid hemorrhage and patients with autosomal dominant polycystic kidney disease (ADPKD) are candidates for screening for unruptured intracranial aneurysms. One modeling study also suggests that persons with only one affected first-degree relative with aneurysmal subarachnoid hemorrhage are also likely candidates for screening. Another group who may benefit from screening are persons ≥35 years who smoke(d) and are hypertensive, given their high lifetime risk of aneurysmal subarachnoid hemorrhage of up to 7%, but the prevalence of unruptured intracranial aneurysms in such persons and the efficiency and cost-effectiveness of screening in this group are not yet known. The ultimate goal of screening is to increase the number of quality years of life of the screening candidates, and therefore the benefits but also many downsides of screening –such as risk of incidental findings, very small unruptured intracranial aneurysms that require regular follow-up, preventive treatment with inherent risk of complications and anxiety – should be discussed with the candidate so that an informed decision can be made before intracranial vessels are imaged.Several groups of persons who may benefit from screening have been identified, but since these constitute only a minority of all aneurysmal subarachnoid hemorrhage patients, additional high-risk groups still need to be identified. Further research is also needed to identify persons at low or high risk of aneurysmal development and rupture within the groups identified thus far to improve the efficiency of screening. Moreover, if new medical treatment strategies that can reduce the risk of rupture of unruptured intracranial aneurysm become available, the groups of persons who may benefit from screening could increase considerably. One third of the patients die in the initial days to weeks after ASAH. Of those who survive these initial weeks, a considerable proportion remains dependent on help from others, and even those who have a so-called good outcome, defined as being able to take care of own affairs, often have cognitive complaints or deficits that preclude resuming all pre-morbid activities. All in all, only 5% of patients can take up their pre-morbid life without any restrictions or complaints.Aneurysmal subarachnoid hemorrhage (ASAH) from rupture of an intracranial aneurysm (IA) is a devastating subset of stroke. The mean age at which it occurs is around 50 years, which is much lower than for the more common types of stroke. Another difference with more common types of stroke is that it occurs more often in women than in men. prevention of ASAH has the highest potential to prevent poor outcome from ASAH. IAs are hardly ever symptomatic before they rupture, and therefore screening is the only way to detect IAs before rupture, and to install preventive treatment. The purpose of screening is, however, not to detect IAs, or to prevent ASAH, but to improve the number of life years in good quality of life, and persons who seek advice on screening should be properly informed about the benefits, but also the risks of screening so that they can make an informed decision whether or not to undergo screening.Since brain damage from the initial hemorrhage is a major cause for the poor outcome after ASAH, For such a modeling approach, data are needed on chances of finding an unruptured intracranial aneurysm (UIA) and of rupture of the aneurysm in the particular subgroup of persons, and on life expectancy, risk of complications from preventive aneurysm treatment, and level of anxiety in both the screened and non-screened persons. Modeling studies can also inform on the cost-effectiveness of screening strategies, a factor to be considered since screening and preventive treatment of UIAs come with costs.For medical interventions, the best available evidence are randomized clinical trials, or meta-analyses thereof. Such trials have never been done for screening of high-risk groups of ASAH, and the chance that such trials will ever be performed is small given the large number of persons that should participate in such trials, the decades of follow-up needed for such a trial, and last but not least the unlikeliness that a sufficient number of potential participants will agree to participate. Persons with a familial preponderance of ASAH are an important group of potential screening candidates, or trial participants, but if someone already has seen close relatives dying or being impaired from ASAH, the likelihood that someone agrees in no screening but regular follow-up is probably small. In the absence of randomized trials, modeling studies are a good alternative and therefore evidence that screening is useful therefore comes only from such studies.In this review, we describe the high-risk groups for ASAH, the evidence for screening in these high-risk groups, the disadvantages of screening, and advise on how to counsel persons who seek advice on screening.7Persons with a positive family history for ASAH are the largest group of persons who may benefit from screening and preventive aneurysm treatment, since around 10% of all ASAH patients have a one or more relatives who also had an ASAH. depending on the type of relation and presence or absence of other risk factors  after screening and preventive treatment of UIAs.pulation .1 SecoMost studies thus far have focused on relatives with ASAH or have not discriminated between relatives with ASAH and relatives with UIAs. There are no good data on prevalence of UIA or risk of ASAH for persons who have one or more relatives with UIA, but no relatives with ASAH. Thus, for such persons the efficiency of screening is unknown, and we tend to discourage such persons from screening. For persons with one first-degree relative with ASAH and one or more relatives with UIA, we advise screening every five years, despite lacking evidence for this particular subset of persons. ADPKD patients have a high risk of hypertension and cardiovascular disease including UIA and ASAH.2426 The estimated prevalence of UIA is 10%, which is higher in case of a positive family history for hemorrhagic stroke  or UIA with a risk ratio of 2.3 (95% CI 1.6–3.4). ADPKD is most often caused by mutations in the genes PKD1 (in 78% of families) or PKD2 (in 15% of families). Up to 6% of ADPKD patients might die of ASAH. In a recent prospective series of 495 ADPKD patients, ASAH incidence was 2.0/1000 patient-years, thus 20 times higher than in the general population. Although ASAH is common in patients with ADPKD, only 1% of all ASAH cases is attributable to ADPKD because ADPKD is relatively rare with a prevalence of 1/1000 individuals. ASAH occurs at a younger age in patients with ADPKD (median age 42.8 years) than in patients without ADPKD (median age 52.8 years). In addition, ASAH occurs from smaller aneurysms in patients with ADPKD than in patients without ADPKD (6.00 vs 8.00 mm). Two recent modeling studies show that preventive screening for UIA in patients with ADPKD is cost-effective, regardless of the presence of a positive family history.30 Repeated screening every five years is advised after a negative initial study, because of the 10% risk of a new ASAH in the first decade after the initial episode.ADPKD is an autosomal dominant hereditary disorder in which patients develop cysts in kidneys and sometimes liver.3234 Marfan syndrome35 and Loeys-Dietz syndrome,37 but the series describing UIA and ASAH in these disorders are small. UIA and ASAH have also been associated with other (non-connective tissue) conditions fibromuscular dysplasia (FMD),39 coarctatio aortae, and bicuspid aortic valve, but also for these associations this evidence is weak because based on small patient series. Therefore, reliable estimates on occurrence of UIAs and ASAH cannot be made. Moreover, little is known about the rupture risk of aneurysms, or the complication risks of preventive treatment in patients with these specific conditions. This makes evidence-based advice not possible. Some experts from international consortia screening have, however, expressed the opinion that screening may be considered for type IV Ehlers-Danlos, Loeys-Dietz syndrome, and FMD.Other conditions associated with UIA and ASAH include the rare, genetic connective tissue disorders type IV Ehlers-Danlos syndrome (vascular subtype), Together with the group of patients with a positive family history, this high risk group constitutes 30% of all ASAH patients. Therefore, a third of all ASAH cases could potentially be prevented with an optimal preventive screening strategy in these two groups of high-risk individuals. However, the prevalence of UIAs in persons ≥35 years who smoke(d) and are hypertensive, and thus the efficiency and cost-effectiveness of screening in this group are not yet known.A group who may also benefit from screening are persons ≥35 years of age who smoke(d) and are hypertensive given their high lifetime risk of aSAH of up to 7%. CTA can be performed instead. The purpose of screening, i.e. preventing ASAH and consequently increasing the number of quality years of life in the future, should be discussed. Herewith it is important to realize that with repeated screening and preventive treatment of UIAs identified not all episodes of ASAH can be prevented. In rare instances, aneurysms can develop and rupture within the regular screening interval of five years. Moreover, the optimal age for screening, the chance of an ASAH and the yield of screening for the screening candidate need to be outlined. The need of repeated screening should also be mentioned. Possible disadvantages of screening should be discussed as well. These include the risk of complications in case of preventive treatment of an UIA found at screening and the risk of finding a small UIA that is still too small to be treated at that time and must be followed up for possible growth with follow-up imaging. If the screening candidate has children, he/she should be informed that if on screening an UIA is identified, his/her children also become eligible for screening. It should also be mentioned that there is a chance of incidental findings other than aneurysms, including an asymptomatic brain infarcts, meningioma, cavernoma or a hypophyseal adenoma. Last, the implications for driving and flying licenses and life insurance, which may differ by country, should be discussed. At the end of the consultation, it is up to the patient to make an informed decision whether or not to undergo screening. Sometimes, a follow-up consultation proves necessary to give a patient an opportunity to reflect on the decision or for further discussion or information. Finally, all patients, even those who decide not to be screened, should be advised to stop smoking and have their blood pressure checked regularly because also in persons with familial risk or ADPKD, smoking and hypertension increase the risks for both aneurysm development and ASAH.46The purpose of counseling is providing the screening candidate the information on benefits and risks of screening she/he needs to make an informed decision on whether or not to undergo screening. Important is that the person feels sufficiently informed to make a sound decision. As the ultimate goal of screening is to increase the number of quality years of life of the screening candidates, the risks and benefits of screening should be weighed, before intracranial vessels are imaged . First, Based on the data presented, persons with two or more affected first-degree relatives with ASAH and patients with ADPKD are candidates for screening for IA. Current data also suggest that screening increases the number of quality adjusted life years at acceptable costs in persons with only one first-degree relative with ASAH. We feel such persons should also be informed about the higher risk they have for ASAH and about the possibility of counseling for screening.Given the downsides there are with screening, persons should be counseled before imaging is ordered. The purpose of counseling is to present all relevant data to persons in such a way that they can make a truly informed decision on whether or not they want to undergo screening. For the physician who counsels the screening candidate, the ultimate interest of the encounter is not whether or not to have convinced the screening candidate for the most appropriate decision according to the statistical model, but a patient who feels to have been able to make an informed decision. become available, the groups of persons who may benefit from screening could increase considerably.Because the groups of persons who may benefit from screening constitute only a minority of all ASAH patients, additional high risk groups still need to be identified. Moreover, within the groups of persons identified to benefit from screening, the current screening strategies for these groups are still inefficient. Many persons undergo several cycles of screening without ever having an aneurysm, and some persons still have ASAH despite screening. Future research on genetics, including on rare genetic variants in familial aneurysms and genetic risk scores predicting UIA or ASAH, and on anatomical risk factors such as configuration of the circle of Willis, may identify persons at low or high risk of aneurysmal development and rupture within the groups identified thus far, which may render screening more efficient. Similarly, data on absolute risks of UIA or ASAH according to age, number of affected relatives, and environmental risk factors as smoking and hypertension may further discriminate low- from high-risk persons within the group of persons with a positive family history. Current treatment strategies for preventive aneurysm occlusion carry considerable risks, which reduce the benefit of screening. If new treatment strategies to reduce the risk of rupture of UIA, such as medical treatment with antihypertensive drugs and aspirin,