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Description of suspected rickets cases among children under 5, Al-Salam Hospital, Khamier, Yemen Saïf Eldin Abdallah, Alfatih Suleiman, Matthew Coldiron, Klaudia Porten

Epicentre, France; Médecins Sans Frontières INTRODUCTION

RESULTS

• Rickets: refers to deficient mineralization and architectural disruption of the growth plates of bones • Osteomalacia: impaired mineralization of the bone matrix. – Rickets and osteomalacia usually occur together when growth plates are open (children); only osteomalacia occurs after growth plates have fused (adults)

• Mineralization defects are classified according to the predominant mineral deficiency. – Calcipenic rickets is caused by calcium deficiency, which usually is due to insufficient intake or metabolism of vitamin D, and in some cases insufficient intake or absorption of calcium in the setting of normal vitamin D levels. – Phosphopenic rickets is usually caused by renal phosphate wasting.

Figure Figure 1. Common bone abnormalities in childhood rickets

2.

Radiological findings in childhood rickets. Note the cupping of the metacarpals, osteopenia and enlarged metaphyses leading to widening of the wrist. Source: radiopaedia.org

Table 1: Demographic, nutritional and laboratory characteristics of suspected rickets cases among under children under 5, Al Salam Hospital, Khamier, Yemen (N=566). Characteristic Sex* Female Male Age (months)* 0-11 12-23 24-59 ≥60 Origin Khamer Bani Sureym Huth Gafla Aoozar Al-Alashah Other Nutritional Status Severe Acute Malnutrition Moderate Acute Malnutrition Global Acute Malnutrition Serum Calcium, mg/dl† <8 8-13 History of premature birth * Sex

Frequency

Percent

301 264

53.3 46.7

238 231 84 7

42.5 41.3 15.0 1.2

394 60 30 20 16 46

69.6 10.6 5.3 3.5 2.8 8.2

160 177 337

28.3 31.3 59.6

20 240 8

3.5 42.4 1.4

missing for one child and age missing for six children range 8-13 mg/dl

† Normal

MSF in Khamier • MSF-OCP has provided support to emergency department and inpatient pediatrics department of Al-Salam hospital since 2010

Table 2. Clinical signs and symptoms present at admission, suspected rickets cases, Al Salam Hospital, Khamier, Yemen (N=566). Sign or symptom Skull bossing Open fontanelles Rachitic rosary Pigeon chest Bowed legs Wide wrist Soft skull Dental enamel (hypoplasia) Pathological fracture Seizure Tetany

Frequency 474 454 364 352 325 209 75 70 6 6 1

Percent 83.7 80.2 64.3 62.2 57.4 36.9 13.3 12.4 1.1 1.1 0.2

Table 3. Radiographic tests and treatment at initial visit, suspected rickets cases, Al-Salam Hospital, Khamier, Yemen (N=566).

Figure 3. Yemen (Khamier noted in red circle).

RATIONALE • In March 2013, the MSF team in Khamier began screening for clinical rickets among children under 5 years of age presenting to the Emergency Department. • A clinical management program was put in place.

Skeletal X-ray performed Calcium prescribed Vitamin D loading dose 100000 IU 250000 IU 500000 IU Info not available

Frequency 387 525

Percent 68.4 92.8

134 83 3 346

23.7 14.7 0.5 61.1

DISCUSSION

OBJECTIVES • Primary objective: – Describe the clinical cases of suspected rickets in children under 5 years treated in Khamier Hospital, Yemen.

• Secondary objectives: – Collect standardized clinical information on children under 5 years old suspected of Vitamin D metabolism alteration. – Develop a data collection tool to follow treatment of patients and describe their outcomes.

METHODS • Retrospective chart review – 566 patients admitted to MSF rickets program between May 2012 and August 2013. – Clinical data (based on standardized data collection tool) – Laboratory data (Calcium, Vitamin D) – Radiographic data (x-rays and their reports)

• Data entry and analysis in Epi Info 7

 The suspected cases described here are based on clinical criteria. Laboratory data (vitamin D levels) and radiographic reports have not yet been analyzed. When this data is added to the database, it is possible that some suspected cases may be reclassified.  Suspected rickets cases are evenly distributed among boys and girls.  Most cases (69.6%) come from Khamier district.  The prevalence of malnutrition among suspected rickets cases is high (GAM= 60.2% and SAM=28.6%).  The most common findings on physical exam were skull bossing (83.7%), open fontanelles (80.2%) and rachitic rosary (64.3%).  Only 1.4% of cases were reported to have been born prematurely.  Follow up data were not available at the time of analysis but will be added to the databases. This information will allow for a better understanding of clinical progression over time.

HORIZONS  Follow-up data and radiographic reports will be added to the database.  Spatial analysis of cases would allow targeting further study and intervention areas.  Investigate the link between rickets and malnutrition in this population for evidence of causality.  Once the database is completed, the current clinical and lab diagnosis algorithms can be evaluated.


New definition of MDR TB treatment failure: Change in treatment outcomes Mathieu Bastard1, Maryline Bonnet1, Philipp du Cros2, Alex Telnov3, Cathy Hewison4, Francis Varaine4 1Epicentre,

Paris, France; 2Manson Unit, Médecins Sans Frontières, London, UK; 3Médecins Sans Frontières, Geneva, Switzerland; 4Médecins Sans Frontières, Paris, France

INTRODUCTION With the intention of simplifying the monitoring of programs treating multidrug resistant tuberculosis (MDR TB) patients, the World Health Organization (WHO) revised the definition of treatment failure in 2013.

WHO 2008 definition of failure for MDR TB

WHO 2013 definition of failure for MDR TB

Treatment will be considered to have failed if • Two or more of the five cultures recorded in the final 12 months of therapy are positive, or • If any one of the final three cultures is positive, and/or • If a clinical decision has been made to terminate treatment early because of poor clinical or radiological response or adverse events. These latter failures can be indicated separately in order to do sub analysis

Treatment terminated or need for permanent treatment change of at least 2 classes of anti TB drugs because of one or more of the following • Lack of culture negativation by 6 months for MDR TB (3 month for PDR TB), and/or • Resistance amplification, and/or • Bacteriological reversion (at least two positive smears or cultures at least 30 days apart) after conversion to negative, and/or • If a clinical decision has been made to terminate treatment early due to poor response or adverse events. These latter failures can be indicated separately in order to do sub analysis.

Treatment outcomes reporting for MDR TB If a case is assigned an outcome of Treatment failure and the patient is restarted on a revised regimen within the same year then, the case is not assigned another outcome. In other words, only the first outcome met is recorded for outcome monitoring.

METHODS • Retrospective analysis on routinely collected data in 5 Médecins Sans Frontières DRTB programs in Armenia, Abkhazia, Kenya, Swaziland and Uzbekistan. • MDR TB confirmed patients were enrolled between 2001 and 2009 and treatment regimens were based on 2008 WHO recommendations. • As the treatment was individualized and no maximum duration for the intensive phase was defined, we chose a 6 month cut off for culture negativation. • We report the proportion of patient meeting the new definition of treatment failure. • Treatment failures using the 2013 revised definition were presented compared to the patients’ outcomes using 2008 WHO outcome definitions.

OBJECTIVE • To assess the proportion of MDR TB treatment failures using the revised WHO 2013 definition

RESULTS 1455 MDR TB patients included Characteristics at inclusion Male, n(%) Age, median [IQR]

Outcomes of MDR TB patients (N=1455) WHO 2008 definition

Outcomes of MDR TB patients (N=1455) WHO 2013 definition

828 (56.9) 32 [24 – 43]

Body mass index, median [IQR]

18.6 [16.6 – 20.9]

DST at inclusion, n(%) MDR (resistance 1st line only) Pre XDR (injectables) Pre XDR (Fluoroquinolones) XDR MDR 2nd line not tested

822 (56.5) 357 (24.5) 37 (2.5) 37 (2.5) 202 (13.9)

Sputum smear microscopy, n(%) Negative 127 (8.7) Positive 1139 (78.3) Unknown 189 (13.0) Previous TB treatment, n(%) New cases 245 (16.8) Previously treated with 1st line 1014 (69.7) Previously treated with 2nd line 157 (10.8) Unknown 39 (2.7)

Success

808 (55.5%)

Success

Death

127 (8.7%)

Death

60 (4.1%)

Failure

165 (11.3%)

Failure

551 (37.9%)

Defaulter

333 (22.9%)

Defaulter

211 (14.5%)

Still on treatment or transfer out

22 (1.6%)

Using WHO 2013 definition

Still on treatment or transfer out

617 (42.4%)

16 (1.1%)

Patients newly classified as treatment failure with WHO 2013 definition Failure with WHO 2013 definition 191/808 (23.6%) 67/127 (52.8%)

551 (37.9%) patients were retrospectively classified as treatment failure

WHO 2008 outcome

• 290 (52.6%) had no culture negativation by 6 months

Success Death Failure Defaulter 122/333 (36.6%) Still on treatment or transfer out 6/22 (27.3%)

• 82 (14.9%) amplified resistance • 126 (22.9%) experienced bacteriological reversion • 10 (1.8%) never achieved culture conversion

DISCUSSION • The new definition of treatment failure will have a significant impact on the reporting of MDR TB treatment outcomes. • It may dramatically increase the proportion of failures and decrease the proportion of defaulters, probably better reflecting the reality of the treatment effectiveness. • With the new definitions, patients failing treatment will be registered under a new MDR TB regimen and will have another treatment outcome, however this final outcome will not be used for programme monitoring, only the first outcome met is recorded for outcome monitoring. Correspondence: Mathieu Bastard, Epicentre, 8 rue Saint Sabin, 75011 Paris; email: mathieu.bastard@geneva.msf.org


Risk factors of mortality and lost to follow up before antiretroviral therapy: a multicentric retrospective cohort study of 48 Médecins sans Frontières HIV programmes Mathieu Bastard1, Daniel O’Brien2, Esther Casas2, Jane Greig3, Suna Balkan4, Jean François Etard1,5 1

Epicentre, Paris, France; 2 Médecins Sans Frontières, Amsterdam, The Netherlands; 3 Manson Unit, Médecins Sans Frontières, London, United Kingdom; 4 Médecins Sans Frontières, Paris, France; 5 UMI 233 TransVIHMI, Institut de Recherche pour le Développement, Université Montpellier 1, Montpellier, France

INTRODUCTION • Access to antiretroviral treatment (ART) has greatly increased in resource limited settings in the past decade. • Most research related to HIV programs and patients have focused on the evaluation of treatment outcomes after the start of therapy. Nevertheless, improvement of the quality and effectiveness of HIV care requires monitoring and evaluation of patient outcomes before and after the start of ART. • Gaining understanding of pre ART is needed to improve strategies of care and maximize long term patient outcomes. • In Médecins Sans Frontières (MSF) supported HIV programs, 20 to 35% of the patients who are currently receiving HIV care have not yet started ART. • This study describes patients’ characteristics, initial and acquired eligibility, and delays in starting ART. It reports also rates of mortality and lost to follow up (LTFU) and associated risk factors during the pre ART period.

METHODS Study design and population

Statistical analysis

Design: • Retrospective longitudinal study of electronic health records.

Population: • • • •

HIV positive patients aged 15 years old in 48 HIV programs. ART naive Inclusion between January 1st 2005 and December 31st 2011. 1 year between inclusion and administrative censoring date.

Pre ART follow up in the HIV programs: • Follow up visits every 3 or 6 months . • CD4 count testing every 6 months but no viral load testing.

Descriptive statistics:

Survival analysis:

• Access to HIV care: time between HIV testing and program inclusion. • Pre ART follow up visits: frequency and time between visits. • ART eligibility at enrolment and delay in ART start. • Interruptions in follow up: not attending a visit for at least 60 days after appointment date. • Acquired eligibility during pre ART follow up and delay in ART start.

• LFU definition: missed appointment for 6 months. • Cumulative Kaplan Meier estimates of mortality and LFU. • Risk factors of mortality explored with Cox proportional hazards model. • Risk factors of LFU explored with competing risk regression model (treating death as a competing event)

RESULTS Study population

Timeline of Pre ART cascade of patients

173,779 patients eligible for the study. 1,473,704 person months of follow up. Number of inclusions stable over the study period.

Characteristics of patients at program enrolment Characteristics Sex Men Women

65,773 (37.9) 107,951 (62.1)

Age, years Median [IQR] 15 – 29 30 – 49 50

33 [27 – 40] 58,957 (33.9) 99,683 (57.4) 15,139 (8.7)

BMI, kg/m2 Median [IQR] < 18.5 18.5 Missing

19.8 [17.8 – 22.1] 48,636 (33.1) 98,366 (66.9) 26,777

WHO clinical Stage 1 2 3 4 Missing

47,883 (29.6) 31,879 (19.7) 63,686 (39.4) 18,270 (11.3) 12,061

CD4 count, cells/µL Median [IQR] < 50 50 – 199 200 – 349 350 – 499 500 Missing

222 [96 – 404] 19,165 (14.7) 40,908 (31.3) 30,124 (23.0) 18,796 (14.4) 21,703 (16.6) 43,083

Diagnosis of tuberculosis

21,905 (12.6)

Program location Urban Rural Prison

72,575 (41.8) 100,789 (58.0) 415 (0.2)

Project context Stable Unstable

166,262 (95.7) 7,517 (4.3)

Study follow up and care interruptions Patients enrolled in median 4 days [IQR 0 22] after being tested positive for HIV. Median number of 3 Pre ART visits [IQR 2 – 7] Median number of 1 Pre ART CD4 measures [IQR 1 – 1] 20,068 (11.6%) interrupted at least once HIV care for a median duration of 126 days [IQR 84 – 244].

Kaplan Meier estimates of Pre ART mortality and LFU Mortality

LFU

At 1 month

1.6 (1.5 – 1.7)

13.4 (13.3 – 13.6)

At 6 months

4.7 (4.6 – 4.8)

23.9 (23.6 – 24.1)

At 12 months

5.8 (5.6 – 5.9)

31.1 (30.7 – 31.3)

At 24 months

7.1 (6.9 – 7.3)

40.2 (39.8 – 40.6)

Risk factors of Pre ART mortality and LFU Characteristics Sex Men Women Age, years 15 – 29 30 – 49 50 BMI, kg/m2 < 18.5 18.5 CD4 count, cells/µL < 50 50 – 199 200 – 349 350 – 499 500

Mortality aHR (95% CI)

LFU aSHR (95% CI)

1.33 (1.26 – 1.40) 1

1.25 (1.23 – 1.28) 1

1 1.20 (1.13 – 1.27) 1.50 (1.37 – 1.64)

1.36 (1.31 – 1.41) 1.06 (1.02 – 1.10) 1

2.14 (2.01 – 2.28) 1

1.13 (1.10 – 1.15) 1

6.78 (5.92 – 7.77) 3.26 (2.85 – 3.73) 1.46 (1.26 – 1.69) 1.25 (1.07 – 1.46) 1

1 0.90 (0.85 – 0.95) 1.14 (1.08 – 1.20) 1.39 (1.32 – 1.46) 1.57 (1.49 – 1.65)

Note: aHR: adjusted hazard ratios , aSHR: adjusted subhazard ratio; Ajustment on clinical stage, diagnosis of TB, program location and context, year of enrolment

DISCUSSION •This study shows an important proportion of patients eligible at enrolment reflecting that most patients presented with advanced stage of HIV disease highlighting the need to increase access to HIV program at an earlier stage of the disease. • Pre ART mortality remains higher among patients with advanced stage of disease , low BMI and among men (similar to known risk factors of on ART mortality). • Pre ART LFU was high, especially during the first months after inclusion, stressing the need to also improve pre ART care to maximize program retention, particularly among patients with high level of CD4 counts at enrollment, men and younger patients. • Better understanding of both, the barriers in accessing, and the factors facilitating long term retention in HIV care among men would be important to design appropriate innovative interventions specifically designed for this high risk group. Strategies of decentralization of HIV testing and care services to the work place might be effective in some contexts. Correspondence: Mathieu Bastard, Epicentre, 8 rue Saint Sabin, 75011 Paris; email: mathieu.bastard@geneva.msf.org


32515 adolescents and young adults in the study HIV programs 3937 (12.1%) with only 1 medical visit 28578 (87.9%) included in analysis 15059 (52.7%) started on ART

13519 (47.3%) never started on ART

We would like to thank the ministries of health of the countries and the MSF field teams for their daily work and effort to provide care to the patients and for data collection; the other members of the Epicentre FUCHIA team working in Paris (Elisabeth Poulet, Serge Balandine, Sarala Nicholas and Loretxu Pinoges) and in Africa (Laurence Ahoua and Megan McGuire) for their support in data collection and data quality maintenance.


4272 children initiated ART between Dec 2001 and Dec 2011

238 starting ART <1 year before closing database. 85 with only one recorded visit

3949 children included

We would like to thank the ministries of health of the countries and the MSF field teams for their daily work and effort to provide care to the patients and for data collection; the other members of the Epicentre FUCHIA team working in Paris (Serge Balandine, Sarala Nicholas and Loretxu Pinoges) and in Africa (Laurence Ahoua and Megan McGuire) for their support in data collection and data quality maintenance.


Comparison of MUAC and percent weight gain as discharge criterion in a large TFP program in Burkina Faso - 2007-2011 Cohuet S1, Goossens S2, Koudika MH2 , Shepherd S2, Martinez D2, Munger A2 , Porten K1. 1Epicentre, Paris, France 2Médecins sans Frontières, Paris, France Background

Results

• Community-based management of acute malnutrition (CMAM) is recommended as the standard of treatment for severe acute malnutrition (SAM) since 2007.

• During the total period, 50,841 children were admitted in the TFP: children during period A - 26,049 children during period B

• Simple diagnostic tools for SAM are needed for recruitment within the community, particularly where human resources are difficult to supervise.

• Median age was 13 months [IQR: 10-20] and sex ratio M:F was 0.9 at admission.

• Compared to WHZ, Mid Upper Arm Circumference (MUAC) is : – simple, rapid, less prone to errors, – facilitates coverage of therapeutic feeding programs (TFP), – identifies younger children at higher risk of mortality. • MUAC can be used: in community-based nutritional programs in emergencies, when close supervision is often not possible. • The World Health Organization (WHO) endorsed MUAC as an independent admission criterion to TFP for children 6-59 months old with acute malnutrition since 2008. • As of 2009, WHO recommends 15% weight gain to define nutritional recovery and discharge from program due to lack of evidence.

Period

MSF in Burkina Faso, Titao -Yako • Médecins Sans Frontières (MSF) and the Ministry of Health implemented a CMAM program using MUAC for both, screening and admission criterion to TFP in Burkina Faso. • Stunting and wasting prevalence are high in Titao and Yako, in North Region of Burkina Faso (see map). • Malnourished children were admitted if MUAC <120mm • From Sept 2007 to Mar 2009, percent weight gain, relative to admission weight, determined recovery • From Apr 2009 to Dec 2011, absolute value of MUAC, with a minimum stay of 4 weeks, was used as discharge criterion

- 24,792

Table 1: MUAC categories at admission, MSF program Titao-Yako, Sept 2007 – Dec 2011 MUAC categories at admission <100mm n(%)

100-110mm n(%)

112-114mm n(%)

116-118mm n(%)

Period A

1,306 (5.3)

6,618 (24.3)

5,378 (21.7)

12,090 (48.8)

Period B

949 (3.7)

4,480 (17.2)

5,840 (22.4)

14,780 (56.7)

11,098 (13.2)

11,218 (21.0)

26,870 (52.8)

Total period

2,255 (4.2)

Program outcomes and treatment response • 90.4% of all admissions recovered: 22,094 (89.1%) during period A and 23,865 (91.6%) during period B (Table 2). Table 2: Outcomes of children admitted to TFP, MSF program Titao-Yako, Sept 2007 – Dec 2011

Period Cured

Outcomes Non responders n(%) 384 (1.5)

Defaulters n(%)

Referred n(%)

n(%)

Death n(%)

Period A

22,094 (89.1)

260 (1.0)

1961 (7.9)

93 (0.4)

Period B

23,865 (91.6)

279 (1.1)

515 (2.0)

1248 (4.8)

140 (0.5)

Total period

45959 (90.4)

539 (1.1)

899 (1.8)

3209 (6.3)

233 (0.4)

• Average length of stay [ALS] in the program for children recovered during period A was 53.9 days compared to 37.0 days for those recovered over period B. - During period A, ALS was shorter for the most malnourished -During period B, ALS was longer for the most malnourished (Figure 1).

Anthropometry status of upon discharge by MUAC categories at admission • During period A, mean MUAC and WHZ at discharge were respectively < 120 mm and < -2 zscore among recovered children whose MUAC upon admission was < 100 mm. • During period B, MUAC and WHZ at discharge were respectively > 125 mm and > -2 z scores whatever MUAC categories at admission (Figure 2-3).

Objective • To compare program outcomes and nutritional recovery as assessed by both discharge criteria, 15% weight gain and MUAC 124 mm

Methods • Routinely collected data of children admitted in a TFP in Burkina Faso between 2007 and 2011 were analysed • Period A (September 2007 – March 2009) - defined recovery at discharge by 15% weight gain, based on admission weight, and absence of any pathology. • Period B (April 2009 – December 2011) - recovery at discharge was achieved at MUAC 124 mm, with a 4 week minimum stay and absence of any pathology. • Total period (September 2007 – December 2011) children were classified as: - defaulters if they missed weekly appointments for 3 consecutive weeks in ambulatory therapeutic center (A-TFC) or were absent 3 consecutive days in intensive therapeutic center (I-TFC). - non-responders if they failed to achieve discharge criteria after 6 weeks in ATFC without any associated pathology or chronic disease.

Conclusions • The MSF TFP in Burkina Faso is an innovative community-based nutritional program using MUAC as admission and discharge criterion since April 2009. • 15% weight gain as a discharge criterion led to the paradox of more malnourished children receiving shorter treatment and being discharged while still fulfilling admission criteria • The change in discharge criterion resulted in redirection of resources to the most malnourished while improving overall program coherency and efficiency. • MUAC >124 mm as TFP discharge criteria is superior to 15% weight gain when admission is based on MUAC. Percent weight gain as a discharge criterion should be abandoned.


Etude qualitative sur la santé maternelle en groupes focaux de discussion, Région du Hambol, Côte d’Ivoire Matthew Coldiron1, Isabelle Mouniaman Nara2, Jade Pena2, Anne Cugier3, Valérie Pierre3, Laurent Kouamé3, Klaudia Porten1 1

Epicentre, Paris Médecins Sans Frontières Centre Opérationnel Paris, France 3 Médecins Sans Frontières Centre Opérationnel Paris, Abidjan, Côte d’Ivoire 2

INTRODUCTION Santé maternelle en Côte d’Ivoire • Taux de mortalité maternelle:

–614 par 100 000 naissances vivantes (EDS 2012)

• Accouchements assistés par personnel de santé: –82% en milieu urbain –43% en milieu rural

• Consultations prénatales:

• Commencée directement après chaque séance avec un débriefing de 30 60 minutes avec l’équipe • Relecture systématique des transcriptions • Encodage par thème, ex: « transport » ou « relations homme femme » • Rédaction de 30 documents thématiques constitutés à partir des transcriptions –Relecture systématique des documents thématiques –Regroupement des thèmes similaires pour présentation

–91% avec 1 –45% avec 4

Politique sanitaire de la Côte d’Ivoire • Depuis début 2012: « gratuité ciblée » pour certains groupes –Toute pathologie chez les <5 ans –Soins prénataux / obstétriques • Y compris matériaux, médicaments et procédures

• Réalité: Fonctionnement partiel –Ruptures de stock approvisionnement des matériaux et des médicaments du secteur privé –Coûts à la charge des patients finalement importants, restreignant l’accès aux soins

La région du Hambol • 450 000 habitants, dont 150 000 à Katiola, le chef lieu • MSF OCP ouvre un projet de santé maternelle

RÉSULTATS • L’accès aux soins est limité pour des raisons financières: –Les femmes enceintes sont parfois obligées de payer pour les médicaments, les procédures, et le matériel médical nécessaire. • « Pour moi, la gratuité ciblée, on se rend compte que c’est un slogan. C’est gratuit si tu as 7000 CFA ! »

• L’accès aux soins est limité pour des raisons de transport, en particulier pendant la nuit et en cas d’urgence –Chercher un transport ou chercher de l’argent pour payer le transport contribue à des délais importants pendant les urgences obstétriques

• Les consultations prénatales ne sont pas toujours bien suivies –La première visite prénatale est souvent tardive est liée à des aspects administratives: le carnet mère enfant est nécessaire pour la déclaration de naissance.

Figure 1: La région du Hambol en Côte d’Ivoire

OBJECTIFS Décrire les expériences des femmes en âge de procréer pendant la grossesse, le travail et la période post natale, avec une attention particulière sur les aspects suivants : –Accès aux soins et qualité des soins –Leurs interactions avec les professionnels de santé –La médecine traditionnelle –Décisions de recours aux soins dans leurs familles (pendant la grossesse et à l’accouchement)

MÉTHODE Groupes focaux de discussion • 8 participants par groupe –Sélectionnés afin d’assurer homogénéité dans le groupe (âge, milieu, etc.) pour faciliter des échanges libres

• 90 minutes de discussion menée par une modératrice –Guide de discussion (thèmes à aborder, etc.) –En dioula ou français selon le groupe

• Transcription à la main (4 transcripteurs) puis transfert en format électronique Tableau 1. Groupes focaux de discussion faisant partie de l’étude Groupe 1 2 3 4 5 6 7 8

Analyse des données

Population cible Femmes 30 45 ans de Katiola Matrones du milieu rural Sages femmes et infirmiers Femmes 20 29 ans de Katiola Femmes 30 45 ans de Katiola et du milieu rural Chefs de village et de quartier Femmes 15 19 ans de Katiola et du milieu rural Femmes 20 29 ans de Katiola

• « La plupart des femmes, elles viennent juste pour prendre leur carnet une seule fois, puis elles accouchent à la maison. »

• Les décisions pour l’accouchement sont souvent prises à la dernière minute –Disponibilité de l’argent au moment où le travail commence • « C’est le monsieur qui guide. S’il a de l’argent, il peut décider que sa femme parte en ville pour accoucher. Dans le cas contraire, la femme est obligée de se fâcher pour venir en ville par force. »

–Rôle important de l’homme (souvent absent pour raisons culturelles ou pour travailler) dans la prise de décisions • « Souvent le mari et la femme ne préparent rien. Le mari reste éloigné avec son gris gris et revient une semaine après pour voir l’enfant et la femme. Souvent, c’est la sœur de la femme ou la maman qui accompagnent la femme pendant le travail. Le mari, il s’en fout. »

• L’utilisation des soins traditionnels est omniprésente dans la zone –En raison de croyances traditionnelles –En cas d’urgence et si pas de moyens financiers suffisant pour aller à l’hôpital –Traitements traditionnels souvent associés aux traitements reçus dans les centres de santé –Matrones considérées comme personnes de confiance et souvent présentes pendant les urgences obstétriques à domicile, particulièrement en cas de problèmes de référence/transport • « A mon avis, pour les femmes au village, c’est comme il n’y a pas d’hôpital. Si la femme a mal au ventre, elle va chez la vieille femme qui va l’aider à accoucher. Elle ne peut pas venir à l’hôpital si elle n’a pas d’argent. Elle est obligée de voir la vieille. »

DISCUSSION AND CONCLUSION • L’accès aux soins obstétriques est limité, particulièrement pour les femmes en milieu rural et en cas d’urgence • Le système sanitaire pourrait mieux fonctionner • Les matrones sont considérées des personnes de confiance • Les soins traditionnels jouent un rôle important dans la zone HORIZONS

Figure 2: Les participants d’un groupe focal

• Le projet de MSF OCP est maintenant ouvert • On s’attend à une amélioration importante de l’accès aux soins grâce à l’application de la gratuité et un meilleur accès logistique • Une enquête rétrospective de mortalité maternelle dans la région est prévue pour 2014


Taux d'attaque de la rougeole exceptionnel. Estimation et analyse du taux d’attaque et de la létalité rougeole dans l’aire de santé D’Aketi, RDC. 1

GIGNOUX Etienne1 , POLONSKY Jonathan1, THUAMBE LWIYO Enoch 2, PORTEN Klaudia1 EPICENTRE, 8 rue Saint Sabin, 75011 Paris, France, 2 Médecins Sans Frontières, 78 rue de Lausanne1211 Genève

En 2012, une épidémie a atteint la Province Orientale de la République Démocratique du Congo.

Objectifs spécifiques: Entre novembre 2012 et juillet 2013, MSF OCG – Centre Opérationnel de Genève – est intervenu sur un volet curatif et un volet préventif dans six zones de santé.

Données des structures sanitaires: Taux d’attaque :10,7% Létalité <0.5%. Cas simples Nb de cas

• Facteurs associés à la létalité rougeole ; • Facteurs associés à l’infection par la rougeole ; • Couverture vaccinale contre la rougeole (PEV, AVS) ; • Efficacité vaccinale des vaccinations PEV et AVS.

Cas compliqués Vaccination

1000

600 400

1

2

3

4

5

6

7

8

Chez les moins de cinq ans: 7,1 % [IC à 95 % 4,6 9,6]

Analyse en régression linéaire généralisée.

0,98 décès/10 000 pers.jour

Analyse Géospatiale sur deux périodes: Avant la riposte curative, pendant la riposte curative

9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Létalité : 4,2 % [IC à 95 % 2,8 5,7]

Taux de mortalité spécifique rougeole pour les enfants de moins de cinq

200

Figure 1: Cas incidents hebdomadaires de rougeole ZS d’Aketi, RDC, 2013 (Source MSF OCG et MSP)

Chez les moins de cinq ans: 35 % [IC à 95 % 31,2 38,7]

Enquête transversale avec sondage aléatoire en grappe à deux degrés.

800

0

Taux d’attaque: 14,0% [IC à 95 % 12,2 15,8]

Objectifs secondaires

La Zone de Santé d’Aketi a été la plus touchée

1200

Résultats de l’enquête:

• Taux brut de mortalité • Létalité rougeole • Taux d’attaque de la rougeole

ans de janvier à septembre 2013: [IC à 95 % 0,63 1,32] Interpolation sur la Zone de Santé: 798 décès dus à la rougeole [IC à 95 % 520 1080] 18 004 cas [IC à 95 % 15664 20343]

Facteurs associés • L’ âge • Avoir été traité médicalement (risque relatif : 0.4 IC à 95% 0.2 0.7) • Ménage de plus de huit personnes (risque relatif : 1.8 IC à 95% 1.1 3.0) Avant la riposte curative : Distance à l’hôpital: risque relatif 4.09 par 100 km (IC à 95 % 2.4 7.0).

Avant la riposte curative (25 décembre / 28 février 2013) Pendant la riposte curative (1er Mars /9 octobre 2013) La croix représente l’hôpital général d’Aketi. Une unité d’échelle correspond à une personne étant décédée de la rougeole parmi 100 personnes ayant contractéla maladie durant cette période

Létalité dans la communauté largement supérieure à la létalité dans les structures sanitaires La stratégie de la riposte curative : • renforcement de l’hospitalisation + support au centre de santé et gratuité + recherche active des cas + référencement efficace et gratuit =>forte diminution de la létalité en périphérie Facteurs associés : Age, Sexe masculin (risque relatif : 0.9 IC à 95% 0.8 1.0) ; Né pendant la période de rappel (risque relatif : 0.3 IC à 95% 0.2 0.5); Au moins une autre personne malade dans le ménage (risque relatif : 2.8 IC à 95% 2.4 3.4); Être a distance de l’hôpital (risque relatif : 1.2 par 100 km de distance, IC à 95% 1.0 1.4).

Pas d’effet significatif trouvé du statut vaccinal AVS et PEV sur la tranche d’âge 2 ans à 4 ans

25 décembre 28 février 2013

1er Mars 9 Octobre 2013

La croix représente l’hôpital général d’Aketi. Une unité d’échelle correspond a une personne ayant contractée la rougeole parmi 100 personnes exposées durant cette période

Une épidémie qui touche toute la zone de santé pendant toute la période => La riposte doit cibler l’ensemble de la Zone de Santé • Notification des premiers cas en novembre 2013 • Déclaration de l’épidémie le 17 avril 2014 •Plus de quatre mois de délai Plus de 40 % des enfants de 2 a 4 ans ont contracté la rougeole. Cette tranche d’âge est censée avoir bénéficié du PEV et des AVS de 2011 . Les résultats de cette enquête doivent interroger les mesures mises en œuvre pour prévenir les épidémies et doivent inciter à une riposte vaccinale plus précoce


Violence généralisée à Bangui. Compilation des données des sections de Médecins Sans Frontières Bangui, République Centrafricaine Décembre 2013-Janvier 2014 GIGNOUX Etienne , RONSSE Axelle, PORTEN Klaudia

Activités MSF : • Prise en charges des blessés sur Bangui dès décembre 2013 • Quatre sections MSF sont intervenues • trois sections  ont  mis  en  place  des  salles  d’urgences.  

Ce poster présente les activités des salles d’urgences MSF  à  Bangui.

Compiler et fournir une Analyse dynamique des données médicales des services d’urgences des  sections  de   Médecins sans Frontières intervenant sur Bangui depuis décembre 2013.

100

100

80

80

60

60

40

40

20

20

0

Indeterminé

(2) Janvier 2014

Autre Accident Violence

0

01 03 05 07 09 11 13 15 17 19 21 23 25 27 29 31

•10 janvier 2014: Démission du président Michel Djotodia

120

Date

Date

Figure 1: Nombre de blessés admis par jour dans les services d'urgence de MSF à Bangui

1 400

M

F

1 200 Nombre de Cas

•5-6 décembre 2013: Début de l'opération militaire française "Sangaris“

140

(1) Décembre 2013

120

01 03 05 07 09 11 13 15 17 19 21 23 25 27 29 31

•5 décembre  2013:  Autorisation  de  l’ONU  du   déploiement de la Mission Internationale de Soutien à la Centrafrique sous conduite Africaine (MISCA)

140

Nombre de Cas

Chronologie: •5 décembre 2013 : Bangui, est attaquée par les antibalaka

1 000 800 600 400 200 0-4 ans

5-14 ans

14 et +

Tranche d'Age

Figure 2: Nombre de blessés par violence par âge et par sexe dans les services d'urgence de MSF à Bangui

Indéterminée, 12% Viol, 0%

Période concernée: Du 1er décembre 2013 au 31 janvier 2014 Données compilées: Pour chaque  patient  admis  en  salle  d’urgence:   •Jour  d’admission, •Age, •Sexe, •Blessure par accident ou par acte intentionnel (Violence), •Type    de  violence,  Type  d’accident, •Lieu  d’incident  (ou  par  défaut  lieu  de  résidence), •Gravité  de  l’état  de  santé  à  l’admission  , •Mode de sortie.

Bastonnade

Balle, 36%

Autre, 19 %

Machette, Arme Blanche, 22%

Balle Perdue, 3% Explosion, Grenade 7%

Figure 3: Nombre de blessés par cause de violence dans les services d'urgence de MSF à Bangui

Mode de saisie et de traitement des données: • Collectes depuis les registres • Saisies et analyse dans un Logiciel Excel conçu de manière ad hoc •Compilation des bases: • Chaque section avait sa propres base • Les bases étaient compilés mensuellement • Les patients  référés  vers  une  autre  structure  MSF  n’était  compté   qu’une  fois  afin  d’éliminer  les  doublons

Une violence élevée sur toute la période. La violence reste élevée sur toute la période. Des pics de violence sont concomitants à la démission de Michel Djotodia ainsi qu’  aux    convois  de  départ  de  Bangui.

Légende: Nombre de blessés par violence : 1 blessé 25 blessés 50 blessés

Aucun quartier  n’a  été  épargné Mais certains quartiers furent plus touchés. Les patients admis suite à des violences sont majoritairement des hommes de plus de quinze ans.

Hors de Bangui:

Plus de 50% des violences identifiées sont dues à des balles ou des grenades. Un suivi épidémiologique utile et possible en urgence. Cette expérience  a  montré  que  la  mise  en  place  d’un  tel  système  de  collecte   des  données  a  été  possible    en  urgences.  Cela  n’  a  pas  nécessité  des   ressources disproportionnées et cela permet une analyse dynamique de la situation.

Il s’agit  de  données  d’activités  qui  représentent   uniquement  l’incidence  mesurée  au  niveau  des   structures  MSF.    L’accès  et  les  capacité  de  prise  en   charge de MSF ont varié sur la période (la section bruxelloise  a  ouvert  sa  salle  d’urgence  en  Janvier) Dans  certain  registres,  le  lieu  de  l’incident  n’était  pas  explicitement   distingué du lieu de résidence du patient. Le détail de saisie des registres a évolué au cours du temps, ceci explique la diminution du nombre de trauma pour cause indéterminée.

Figure 4:  Distribution  géographique  par  lieux  d’incidents  des  blessés  pris  en  charge  par  MSF  à  Bangui


Impact de la chimiopr´ evention du paludisme saisonnier dans le district sanitaire de Mo¨ıssala au Tchad en 2012 Morgane Trouillet1,2, Francesco Grandesso1, Estrella Lasry3, Northan Hurtado3 et Klaudia Porten1 1

2

Epicentre, Paris, France Master en Sant´e Publique Paris XI et Sciences et Sant´e Paris XII 2 M´edecins Sans Fronti`eres, Paris, France

Introduction Contexte

projet ”Mo¨ıssala” : Population cible : 9.755 enfants de moins de 5 ans 4 distributions d’une dose th´erapeutique par mois (Juillet-Octobre) de la combinaison sulfadoxine-pyrim´ethamine (1 jour) plus amodiaquine (3 jours).

• la chimiopr´evention du paludisme saisonnier (CPS) consiste en la prise d’une dose th´erapeutique d’une combinaison m´edicamenteuse, une fois par mois, pendant la p´eriode de l’ann´ee o`u le risque d’infection est ´elev´e. • La CPS est une strat´egie de contrˆole du paludisme recommand´ee par l’OMS et mise en œvre dans les pays du Sahel. • M´edecins Sans Fronti`eres (MSF) a commenc´e un projet `a Mo¨ıssala en 2009 avec la mise en œvre d’un r´eseau d’agents palu dans huit aires de sant´e et d’une unit´e de soins des cas de paludisme s´ev`ere h´eberg´ee dans l’hˆopital du district sanitaire. • En 2012 MSF a ajout´e la mise en œvre la CPS dans deux des huit aires de sant´e du

Objectif • Estimer l’impact de la CPS en termes d’incidence du paludisme pendant la p´eriode de son impl´ementation. • Comparer l’incidence du paludisme entre la population ayant b´en´efici´e de la CPS et la population des aires de sant´e contigu¨es n’ayant pas re¸cu la CPS.

M´ ethode • Collecte des donn´ ees du nombre de cas de paludisme confirm´ es par un test de diagnostic rapide dans les ann´ ees 2008-2012 dans les aires de sant´ e suivantes, divis´ ees en trois strates : Aires de sant´ e suivies par MSF avec CPS : Bouna et Bara II. Aires de sant´ e suivies par MSF sans CPS : Beboro, Bengoro, Bourou, Kaba VIII, Ngalo, Takaoua. Aires de sant´ e non suivies par MSF et sans CPS : Bekamba, Bekourou, Dembo, Dilingala, Gabian, Gon, Gonhongon, Kaba VI, Koldaga, Mo¨ıssala Est, Mo¨ıssala Nord et Mo¨ıssala Sud.

• Mod` ele de pr´ ediction du nombre de cas attendus pour 2012 (ann´ ee de la CPS) ` a partir des donn´ ees 2008-2011, dans les trois strates. Mod`ele de r´egression cyclique de quasi-Poisson Logiciel R (R Foundation for Statistical Computing, Vienna, Austria) version 3.0. • Comparaison du nombre de cas attendus avec le nombre de cas observ´ es par tranche d’ˆ age (moins de 5 ans et 5-15 ans) dans les trois strates.

R´ esultats

Nombre de cas

1000

1500

2000

4000 3000

Nombre de cas

2000

2000

Nombre de cas observés Nombre de cas prédits Intervalle de prédiction

2500

Nombre de cas observés Nombre de cas prédits Intervalle de prédiction

1−2008

7−2008

1−2009

7−2009

1−2010

7−2010

1−2011

7−2011

1−2012

7−2012

0

0

500

1000

1000 0

Nombre de cas

3000

Nombre de cas observés Nombre de cas prédits Intervalle de prédiction CPS

Nombre d’´ episodes pr´ edits et observ´ es de paludisme chez les enfants de moins de 5 ans dans les aires de sant´ e non suivies par MSF et sans CPS 3000

Nombre d’´ episodes pr´ edits et observ´ es de paludisme chez les enfants de moins de 5 ans dans les aires de sant´ e suivies par MSF sans CPS 5000

Nombre d’´ episodes pr´ edits et observ´ es de paludisme chez les enfants de moins de 5 ans dans les aires de sant´ e suivies par MSF avec CPS

1−2008

7−2008

1−2009

7−2009

1−2010

Mois/Année

7−2010

1−2011

7−2011

1−2012

7−2012

1−2008

Mois/Année

7−2008

1−2009

7−2009

1−2010

7−2010

1−2011

7−2011

1−2012

7−2012

Mois/Année

R´ eduction absolue et relative du nombre d’´ episodes de paludisme chez les enfants de moins de 5 ans pendant le quatre mois suivant la CPS (Aoˆ ut - Novembre 2012) Nombre d’´ episodes R´ eduction d’´ episodes/1000 ` a risque R´ eduction relative pr´ edits observ´ es Nombre [IP 95%*] % [IP 95%*] Aires de sant´e suivies par MSF avec CPS 6416 630 1007 [69 ; 1321] 89.4 [85.2 ; 91,7] Aires de sant´e suivies par MSF sans CPS 11278 7716 321 [110 ; 533] 31,6 [13,7 ; 43,4] Aires de sant´e non suivies par MSF et sans CPS 5891 5516 16 [-27 ; 59] 6,4 [-13,9 ; 20,5] *IP 95% : Intervalles de pr´ediction `a 95% • Chez les enfant de 5 `a 15 ans, une r´eduction relative de 42,5% [IP 95% -11,2% ; 61,2%] dans les aires de sant´e avec CPS et de 50,5% [IP 95% 24,5% ; 63,1%] dans les aires de sant´e suivies par MSF sans CPS a ´et´e aussi observ´ee. La r´eduction ´etait non significative dans la mˆeme tranche d’ˆage dans les aires des sant´e non suivies par MSF et sans CPS.

• La comparaison du nombre d’´episodes de paludisme grave suit la mˆeme ´evolution du nombre total d’´episodes d´ecrits ci-dessus, avec une r´eduction significative chez les enfants de moins de 5 ans, dans les aires de sant´e avec CPS.

Discussion • En comparant les cas pr´edits et observ´es entre aires de sant´e avec ou sans CPS, nous avons constat´e une r´eduction importante du nombre d’´episodes de paludisme dans les aires de sant´e ayant b´en´efici´e de la CPS. • Mˆeme si des facteurs climatiques non mesur´es dans cette analyse (i.e. la pluviom´etrie et la temp´erature) ont pu contribuer `a la r´eduction observ´ee, on peut conclure avec une certaine confiance qu’une grande part de la r´eduction dans la zone CPS est bien due `a cette intervention. • Les enfants ˆag´es de 5 `a 15 ans n’´etaient pas inclus dans la population cibl´ee par l’intervention. La r´eduction observ´ee dans cette tranche d’ˆage, dans les aires de sant´e avec CPS, peut ˆetre corrobor´ee par deux hypoth`eses : Des enfants de plus de 5 ans (probablement les plus jeunes dans cette tranche d’ˆage) ont pu quand mˆeme b´en´eficier de la CPS.

La CPS, bien que cibl´ee sur les enfants de moins de 5 ans, a pu produire une r´epercussion sur la transmission du parasite en r´eduisant le risque d’infection sur l’ensemble de la population. • Les aires de sant´e suivies par MSF mais sans CPS ont elle aussi enregistr´e une r´eduction significative, bien que limit´ee, du nombre de cas. Ces aires de sant´e ´etant limitrophes `a celles de la CPS, il est possible qu’un certain nombre d’enfants des ces aires de sant´e aient b´en´efici´e de l’intervention. • La CPS est une nouvelle strat´egie pr´eventive qui a une efficacit´e certaine. Cependant, comme tout traitement de masse, cette strat´egie peut acc´el´erer une r´esistance aux traitements utilis´es, r´eduisant au fil du temps ses avantages. La CPS doit donc ˆetre accompagn´ee par un monitorage de l’efficacit´e des traitements utilis´es et de leur impact.

Correspondence : Francesco Grandesso (francesco.grandesso@epicentre.msf.org, Epicentre, 8 rue Saint Sabin, 75011 Paris, France)


Time required to become negative after parasite clearance as factor influencing performance of malaria rapid diagnostic tests in field conditions Francesco Grandesso1, Carolyn Nabasumba2, Dan Nyehangane2, Anne-Laure Page1, Mathieu Bastard1, Martin de Smet3 , Yap Boum2 and Jean-Fran¸cois Etard1 1

Epicentre, Paris, France Epicentre Mbarara Research Centre, Uganda 3 M´edecins Sans Fronti`eres, Brussels, Belgium

2

Study sponsored by MSF’s International Innovation Fund and MSF Operational Centre Paris

Introduction Background

Objectives

• Rapid Diagnostic Tests (RDTs) are more and more popular due to their ease of use and good performance for biological confirmation of malaria. • The WHO Product Testing Programme, that evaluates malaria RDTs on a panel of pre-characterised specimens, is an extremely valuable tool to compare RDTs currently in the market. • However, field performance of RDTs may di↵er significantly from the WHO in vitro evaluation.

• To evaluate RDTs in two settings characterised by high and low malaria transmission: To estimate performance in field conditions To estimate the median time required to become negative after treatment • To answer the questions: Do RDTs perform di↵erently in high and low transmission settings? How many days after an e↵ective treatment can a RDT positive result reliably be considered a new malaria infection?

Methods and materials • Study sites in Greater Mbarara district, Uganda Kakiika health centre in Mbarara municipality (malaria prevalence 3-4%) Kazo health centre in Kazo sub-county (malaria prevalence 40-60%)

• Recruitment for performance Children attending the health centres with fever or reported fever in the previous 48 hours Parent’s or tutor’s written consent was required.

• RDTs evaluated SD Bioline Malaria Antigen P.f (Standard Diagnostics Inc.), catalogue number: 05FK50-02-4 CareStart Malaria HRP2 (Pf) (Access Bio Inc.), catalogue number: G0141 CareStart Malaria pLDH (PAN) (Access Bio Inc.), catalogue number: G0111

• Recruitment and follow-up for time to become negative In each study site, 212 children positive for both RDTs and microscopy were followed-up for 6 weeks Three-days antimalarial treatment intake was supervised RDTs and microscopy were repeated at fixed visit schedule: days 2, 3, 5, 7, 14, 21, 28, 35 and 42 Exclusion of patients with incomplete antimalarial intake or recurrent parasitaemia.

• Gold standard Thick/thin blood smear slide stained with Giemsa 10% Microscopy double reading of all slides 200 fields to be read before declaring a slide negative.

• Analysis for performance Sensitivity, specificity, likelihood ratios, positive and negative predictive values • Analysis for time to become negative Time to become negative = the first day when RDT was reported negative during follow-up Estimates were computed as the probability for the test to become negative using Kaplan-Meier survival function.

Results Performance of RDTs in Mbarara municipality study site (low transmission setting) N = 4946 Sensitivity Specificity Likelihood ratio (+) Likelihood ratio (-) Positive predictive value Negative predictive value

SD Bioline HRP2 % 95%CI 98.4 96.0-99.6 98.9 98.5-99.2 87.8 66.8-115 0.016 0.006-0.042 83.2 78.5-87.2 99.9 99.8-100.0

CareStart HRP2 % 95%CI 98.9 96.7-99.8 98.8 98.4-99.1 80.8 62.4-105 0.011 0.004-0.035 82.2 77.5-86.2 99.9 99.8-100.0

CareStart pLDH % 95%CI 96.2 93.3-98.2 99.7 99.6-99.9 374 212-658 0.038 0.021-0.069 95.5 92.3-97.7 99.8 99.6-99.9

Time to become negative for RDTs in Mbarara study site (low tranmsission setting) (N = 198)

Performance of RDTs in Kazo study site (high transmission setting) N = 503 Sensitivity Specificity Likelihood ratio (+) Likelihood ratio (-) Positive predictive value Negative predictive value

SD Bioline HRP2 % 95%CI 99.2 97.3-99.9 79.7 73.4-85.1 4.89 3.71-6.45 0.010 0.002-0.038 86.7 82.3-90.3 98.7 95.5-99.8

CareStart HRP2 % 95%CI 98.9 96.7-99.8 80.7 74.5-86.0 5.12 3.85-6.82 0.014 0.005-0.044 87.2 82.9-90.8 98.1 94.7-99.6

CareStart pLDH % 95%CI 94.7 91.2-97.1 93.9 89.6-96.8 15.5 8.98-26.9 0.057 0.034-0.095 95.4 92.1-97.6 93.0 88.5-96.1

Time to become negative for RDTs in Kazo study site (high tranmsission setting) (N = 114)

• 8 patients (3.8%) in Mbarara municipality and 89 patients (42%) in Kazo had recurrent parasitaemia during 42-day follow-up.

Summary and Discussion • The median time to become negative was very long (42 days or more) for the HRP2 tests and very short (2 days) for the pLDH test. • The two HPR2 tests were highly sensitive, but there was a remarkable di↵erence in specificity between high and low transmission settings. • The specificity of the pLDH test was higher, but sensitivity was lower than HRP2 tests in both settings, raising concern on the risk of missing some malaria cases. • In the high transmission setting, the long time required to become negative of HPR2 tests and the high frequency of malaria infections may lead children to be positive to

the HPR2 tests for a large proportion of the malaria season. Nevertheless, we cannot exclude that part of the false positive results could be explained by a sub-microscopic parasitaemia. • We still do not have a test that is highly sensitive and highly specific in all epidemiological conditions. A choice is to be made between using an HPR2 test with the consequence of over-treating patients and the risk of overlooking other possible reasons for fever, and using a pLDH test with risk of missing malaria cases.

Correspondence : Francesco Grandesso (francesco.grandesso@epicentre.msf.org, Epicentre, 8 rue Saint Sabin, 75011 Paris, France) and Dan Nyehangane (dan.nyehangane@epicentre.msf.org, Epicentre Mbarara Research Centre, Mbarara, Uganda)


COUVERTURE VACCINALE CONTRE LA ROUGEOLE ET LA POLIOMYÉLITE APRÈS LA CAMPAGNE DE VACCINATION DE DÉCEMBRE 2013 PROVINCES DU NORD ET SUD KIVU, RÉPUBLIQUE DÉMOCRATIQUE DU CONGO Emmanuel Grellety1, Andrea Bernasconi2, Klaudia Porten1 1Epicentre,

Paris, France; 2Epicentre, Barcelone, Espagne

CV du VAR reçu avant ou lors de la CVM; enfants de 6 mois - 9 ans

CONTEXTE En République Démocratique du Congo, les Activités de Vaccination Supplémentaires (ou AVS) anti-rougeoleuses du Programme Elargi de Vaccination (PEV) existent depuis l’an 2000. Cependant, la couverture vaccinale (CV) nationale est restée inférieure aux 95% recommandés par l’OMS, provoquant des épidémies de rougeole dans toutes les provinces du pays en 2011.

Avant Nord Kivu Garçons Filles Sud Kivu Garçons Filles Pendant Nord Kivu Garçons Filles Sud Kivu Garçons Filles

Avec carte IC95%

N

n(%)

2698 1343 1355 3035 1537 1498

391 (16,7) 195 (16,9) 196 (16,5) 193 (6,3) 90 (5,8) 103 (6,8)

2796 1379 1417 3168 1602 1566

1472 (52,9) 714 (51,9) 758 (53,8) 1393 (44,0) 724 (45,2) 669 (42,7)

Avec ou sans carte IC95% Deff

Deff

n(%)

10,9 - 22,5 10,5 - 23,3 11,1 - 21,9 2,5 - 13,5 0 - 13,3 0 - 14,9

16,6 10,5 7,5 32,7 34,3 31,4

2478 (91,8) 1239 (92,2) 1239 (91,5) 2773 (91,4) 1422(92,5) 1351 (90,2)

89,5 - 94,1 90,0 - 94,5 88,8 - 94,0 88,1 - 94,6 88,5 - 96,6 85,1 - 95,3

4,9 2,5 3,1 10,0 9,0 10,8

45,4 - 60,4 44,1 - 59,7 46,1 - 61,4 38,5 - 49,5 37,3 - 53,0 35,0 - 50,4

16,3 8,7 8,7 9,8 10,0 9,6

2614 (93,6) 1283 (93,2) 1331 (94,0) 2994 (94,5) 1526 (95,5) 1468 (93,7)

91,4 - 95,8 90,7 - 95,8 91,8 - 96,2 93,1 - 95,8 93,6 - 96,8 91,6 - 95,9

5,9 3,6 3,2 2,8 2,3 3,2

Les CV du VAR reçu avant ou lors de la CVM par tranche d'âge sont présentés ci-dessous.

Tranche d’âge

Evolution des cas suspects de rougeole entre 2003 et 2013 en RDC, surveillance épidémiologique OMS Au Nord-Kivu et au Sud-Kivu, le nombre de cas de rougeole a plus que doublé de 2012 à 2013. Du 10 au 21 Décembre 2013, le Ministère de la Santé Publique (MSP) et l’OMS ont organisé une campagne de vaccination de masse (CVM) intégrée contre la rougeole et la poliomyélite. Les Directives pour l’évaluation des AVS contre la Rougeole de l’OMS recommandent que, dans le mois suivant la fin de la CVM, une équipe indépendante effectue une enquête de couverture pour valider les estimations de la CV administrative. C’est dans ce cadre que l’OMS a commandité à Epicentre une enquête de CV au Nord et au Sud Kivu.

OBJECTIF Estimer la CV de la CVM intégrée contre la rougeole et la poliomyélite menée par le MSP en décembre 2013 chez les enfants âgés respectivement de 6 mois à 9 ans et de 0 à 59 mois, dans les provinces du Nord et Sud Kivu.

Avant 6 -8 mois 9 -11 mois 12 - 59 mois 5 - 9 ans Pendant 6 -8 mois 9 -11 mois 12 - 59 mois 5 - 9 ans

N 2698 88 102 1676 832 2796 89 103 1721 883

Nord Kivu Avec carte Avec ou sans carte n(%) n(%) 0 (0,0) 16 (15,7) 286 (17,1) 89 (10,7)

23 (26,1) 68 (66,7) 1587 (94,7) 800 (96,2)

34 (38,2) 57 (55,3) 920 (53,5) 455 (51,5)

63 (70,8) 97 (94,2) 1632 (94,8) 822 (93,1)

Afin d’atteindre l’échantillon nécessaire pour les tranches d’âge-cible du vaccin anti-rougeole (VAR) et le vaccin oral contre la poliomyélite (VPO), 20 grappes de 70 individus ont été sélectionnées dans chaque antenne. Les enquêtes ont été réalisées en partenariat avec deux Organisations Non Gouvernementales Nationales en charge des ressources humaines et de la logistique, Network Response To

4 (2,7) 11 (15,7) 87 (5,6) 72 (10,7)

32 (21,9) 50 (66,7) 1368 (88,6) 1101 (87,6)

9 (6,3) 41 (42,3) 697 (44,1) 603 (44,6)

16 (11,3) 75 (77,3) 1545 (94,0) 1277 (94,5)

Au total, après la CVM 86% (Nord Kivu) et 91% (Sud Kivu) des enfants avaient reçu deux doses de VAR.

CV du VPO reçu avant ou lors de la CVM; enfants de moins de 5 ans

METHODOLOGIE Une méthode de sondage aléatoire en grappe à deux degrés a été utilisée pour évaluer la CV des populations ciblées par les deux antennes du PEV que comportent chacune des provinces du Nord et Sud Kivu. Pour des raisons logistiques ou de sécurité, 20% des aires de santé de l’antenne de Goma (Nord Kivu) et de celle de Bukavu (Sud Kivu) n’étaient pas accessibles.

N 3035 146 88 1544 1257 3168 141 97 1579 1351

Sud Kivu Avec carte Avec ou sans carte n(%) n(%)

Avant Nord Kivu Sud Kivu Pendant Nord Kivu Sud Kivu

N

n(%)

1996 2198

361 (19,1) 130 (5,9)

2049 2308

Avec carte IC95%

Avec ou sans carte IC95% Deff

Deff

n(%)

12,3 - 26,0 1,5 - 10,2

15,8 18,8

1932 (96,8) 2096 (95,3)

95,6 - 98,0 92,4 - 98,3

2,4 10,8

1024 (52,9) 45,6 - 60,3 949 (41,1) 35,7 - 46,5

11,5 7,0

1847 (90,1) 2141 (93,1)

87,9 - 92,3 91,3 - 94,8

2,9 2,8

Nous n’avons pas observé de différence significative par tranche d'âge ou par sexe concernant la CV VPO que cela soit avant ou après la CVM.

Emergencies « NETRESE » au Nord Kivu et le Groupe Engagé pour les Actions de

Limitations

Développement et droits des Bases Unies « GeadBu » au Sud Kivu. Dans chaque province, un épidémiologiste d’Epicentre a assuré la coordination de l’enquête. Onze (Nord Kivu) et 14 (Sud Kivu) équipes de deux personnes ont été sélectionnées après une formation standardisée de deux jours sur la méthodologie de l’enquête, le questionnaire utilisé, et une phase pilote permettant de tester les documents et les procédures sur le terrain.

RESULTATS L’enquête a été menée du 19 au 26 février (Nord Kivu) et du 27 février au 6 mars 2014 (Sud Kivu). Au total, 1207 (Nord Kivu) et 1122 (Sud Kivu) ménages ont été interrogés. Aucun n’a refusé de participer. Lors de l’enquête, 52 (Nord Kivu) et 114 (Sud Kivu) ménages étaient absents.

Description de  l’échantillon Nord Kivu Tranche d'âge

Sud Kivu

Garçons

Filles

Total

Garçons

Filles

Total

n (%)

n (%)

n (%)

n (%)

n (%)

n (%)

N

1446 (49,3) 1486 (50,7) 2932 (100,0) 1757 (50,6) 1719 (49,4) 3476 (100,0)

<9 mois

76 (5,3)

90 (6,1)

166 (5,7)

134 (7,6)

135 (7,9)

269 (7,7)

<6 mois

31 (2,1)

47 (3,2)

78 (2,7)

51 (2,9)

47 (2,7)

98 (2,8)

6-8 mois

45 (3,1)

43 (2,9)

88 (3,0)

83 (4,7)

88 (5,1)

171 (4,9)

808 (55,9)

817 (55,0)

1625 (55,4)

888 (50,5)

863 (50,2)

1751 (50,4)

44 (3,0)

9-59 mois 9-11 mois

43 (2,9)

87 (3,0)

58 (3,3)

49 (2,9)

107 (3,1)

12-23 mois 178 (12,3)

189 (12,7)

367 (12,5)

187 (10,6)

194 (11,3)

381 (11,0)

24-59 mois 586 (40,5)

585 (39,4)

1171 (39,9)

643 (36,6)

620 (36,1)

1263 (36,3)

579 (39,0)

1141 (38,9)

735 (41,8)

721 (41,9)

1456 (41,9)

>= 5ans

562 (38,9)

1) Représentativité limitée aux aires de santé investiguées (excluant 20% des aires de santé des antennes de Goma et de Bukavu); 2) La supervision des équipes sur le terrain qui n’a pu être réalisée qu’à distance. Néanmoins, aucun biais n’a été observé lors des sous analyses effectuées par équipe et selon la distribution par âge ou par sexe des sujets enquêtés; 3) Près de 40% des statuts vaccinaux ont été obtenus verbalement. La validité de cette information a déjà été rapportée (Valadez et al., 1992).

CONCLUSION Les résultats de ces enquêtes concordent. Comprises entre 90% et 97% selon la carte vaccinale et les déclarations des responsables du ménage, les CV contre la rougeole et la poliomyélite dans la province du Nord et du Sud Kivu étaient satisfaisantes, que cela soit avant ou pendant la CVM intégrée de décembre 2013. Néanmoins, ces CVs ne permettent pas d’exclure l’apparition de nouveaux cas de rougeole D’une part, nous n’avons pas d’information sur les possibles ruptures dans la chaîne du froid dues au manque d’accessibilité et aux défis logistiques que représentent les deux provinces du Kivu. D’autre part, la CV contre la rougeole reste faible au Sud Kivu parmi les enfants âgés de 9 à 11 mois (77,3%). L’efficacité du VAR est plus faible dans cette tranche d’âge et, en l’absence d’une seconde vaccination, l’accumulation de personnes susceptibles pourrait potentiellement mener à l’apparition de foyers épidémiques. L’apparition d’épidémies de rougeole malgré une couverture vaccinale élevée ont déjà été décrites, notamment au Malawi (Minetti et al,.2013). Cela souligne une fois de plus l’importance de continuer à renforcer le PEV de routine pour limiter au maximum les retards dans le calendrier vaccinal ainsi que de renforcer les AVS pour assurer une seconde opportunité de vaccination pour tous.


Is TST a barrier to implement the 36 months Isoniazid Preventive Therapy (IPT) strategy in HIV infected patients in a resource constraint setting? Huerga H1, Ferlazzo G2, Bevilacqua P1, Ouattara A3, Weyenga H4, Varaine F2, Bonnet M1 1 Epicentre,

Paris, France; 2 Médecins Sans Frontières, Paris, France; 3 Médecins Sans Frontières, Nairobi, Kenya, 4 National Tuberculosis Program, Nairobi, Kenya

Background

Patient flow after inclusion

IPT reduces by 70% risk of TB in TST positive HIV infected adults WHO recommend 2 strategies : – 6 months IPT for all HIV infected – 36 months IPT for TST positive TST based IPT for 36 months: – Avoids unnecessary exposure to INH – Ensure longer protection – Challenges of TST implementation

Included N=550 TST administered N=491 (89.3%)

Did not come for reading (n=72) Came late (n=5)

TST result read N=414 (84.3%)

75.3 % of included

TST positive N=206 (49.8%)

Objectifs

Medical contraindication (n=2)

To assess the feasibility of TST based screening for IPT initiation in HIV infected patients in programmatic conditions in a resource constraint setting.

IPT eligible N=204 (99.0%) IPT initiated N=196 (96.1%)

Methods • Design: Prospective cohort study • Population: HIV infected patients • Inclusion criteria: –Aged 15 years –Symptom screen negative for TB –No previous TST –No contraindications to IPT –Written informed consent

TST not accepted (n=4) Unable to come for reading (n=55)

Site: Mathare HIV/TB Clinic in Kenya • • • •

Urban slum 350,000 hab. MSF outpatient facility HIV & TB care and treatment Free of charge

I PT not accepted (n=8)

35.6 % of included

TST Results • Prevalence TST positive: 49.8% • Induration diameter [median, (IQR)]: 18mm (14 20) • Phlyctenular reaction: 7.5% Table 2: TST result according to CD4 count <200 (n=24) TST positive, n 7 TST positive, % 29.2

200 499 (n=131) 59 45.0

500 (n=259) 140 54.1

* Trend p: 0.028

Table 3: Multivariate analysis of the factors associated to TST positive OR (95% CI) Currently on ART 1.66 (1.001 2.74) CD4 200cell/ L 2.79 (1.13 6.93)

p 0.049 0.026

*Model includes age, male, previous TB treatment

TST reading agreement (% concordant): • TST positive/negative: 99.5% (kappa=0.99) • TST in mm: 61.5% (kappa=0.50) • Phlyctenular reaction: 91.3% (kappa=0.51)

Acceptability of TST and IPT

• Procedures – All patients coming to HIV consultation: • Symptom screen for TB • Checking if TST previously done • Assessment of IPT contraindications – Patients included in study: •Interview and TST administration •TST reading 3 days later •TST positive ( 5mm induration): started on 36 months IPT •TST negative: no IPT •No tracing done •Inter reader agreement assessed in a subgroup of patients

• Accepted TST: 89.3% (491/550) • Came for reading on time: 84.3% (414/491)

Practical implementation Human resources / Physical space: • No human resources or space added

IPT initiation [n, (% of 897 screened)] IPT unnecessarily started [n/N (%)] Cost per patient screened1

From June to October 2012: 550 included from 897 HIV infected patients assessed

• TST based IPT was feasible: –Very good acceptance of TST and IPT –No extra resources were required –Good inter reader agreement

Systematic IPT 585 (65%) 315/585 (54%) 0.48€

• Limitations: –Urban private clinic –Long term IPT adherence not evaluated

• Results in favor of TST based IPT strategy: –50% of TST positive among HIV infected –54% avoided unnecessary exposure to INH

Table 1: Clinical demographic characteristics of 550 patients included 372

(67.6)

39

(33 45)

ART initiation [n (%)]

460

(83.6)

CD4 count [median (IQR), cells/ L]

564

(427 749)

34

(6.2)

188

(34.2)

Previous TB treatment [n (%)]

TST based IPT 196 (22%) 0/196 (0%) 1.39€

Discussion

Study population

CD4 count < 200 cells/µL [n (%)]

• Space shared with other programs • TB symptom screening not systematically done in the clinic

1. Includes cost of human resources (clinicians and nurse), medical material and tuberculin

Reasons for non inclusion: – 18% symptom screened positive for TB – 10% previous TST – 8% IPT contraindications – 3% on secondary IPT after TB treatment – 1% did not consent

Age [median (IQR), years]

Challenges:

Table 4: TST based IPT versus systematic IPT

Results

Female [n, (%)]

• Accepted IPT: 96.1% (196/204)

Conclusions • TST was not a barrier to implement 36m IPT in an urban resource constraint setting • TST avoided unnecessary exposure to IPT for a high proportion of patients • TST allowed initiation of long term IPT to the eligible patients • Recommendations: – Implement TST based IPT in urban settings – Evaluate feasibility in rural settings


Po L6.49 INTÉRÊT DU DÉPISTAGE TUBERCULINIQUE POUR UNE PROPHYLAXIE ANTITUBERCULEUSE DE 36 MOIS CHEZ LES PERSONNES VIVANT AVEC LE VIH DANS DEUX CLINIQUES RURALES AU SWAZILAND Yolanda Mueller1, Qhubekani Mpala2, Béatrice Vasquez2, Calorine Noël Mekiedje2, Charles Ikechi Azih3, Kiran Jobanputra2, Nelson Manana3, Gugu Mchunu3, Sithembile Dlamini Ngeketo3, Maryline Bonnet1 1Epicentre,

Paris, France; 2Médecins Sans Frontières OCG; 3Ministère de la Santé, Royaume du Swaziland

INTRODUCTION

RÉSULTATS (suite)

• L’OMS recommande le traitement préventif à l’isoniazide (IPT) 6 mois sans test tuberculinique (TST) préalable, ou 36 mois pour les patients avec TST positif ou inconnu (recommandation conditionnelle), OMS 2010 – Pas de recommandation claire en faveur du TST par crainte de freiner l’adoption de l’IPT en raison de problèmes de faisabilité (2 visites, chaine du froid, lecture…) • L’IPT 36 mois est plus efficace que 6 mois pour prévenir la tuberculose (TB) chez les personnes TST positif, Samandari, Lancet 2011 • Nous évaluons l’acceptabilité et la faisabilité du TST dans deux cliniques rurales du Swaziland – Prévalence du VIH chez les 15 à 49 ans: 25.9% – Incidence TB: 1287 par 100’000 par an en 2010

TB Screening – triage symptomatique • Parmi les 1021 dépistes, 152 avec au moins 1 symptôme TB (14.9%) – Seuls 28/152 (18.4%) investigués – 2 cas de tuberculose confirmée

• 54 inclus dans l’étude malgré un symptôme TB (dont 11 investigués)

Prévalence de TST positif • 33.2% (95%CI 29.6 – 36.8) avec premier TST positif (n=217/654) • 40.2% (95%CI 36.4 – 43.9) avec au moins un TST positif (264/654) – Après un deuxième test effectué chez 78% des négatifs au premier test

• Prédicteurs d’un TST positif

50%

– Niveau de CD4 (OR ajusté 1.2, 95%CI 1.1 1.3 par 100 CD4) – Antécédents de tuberculose (OR ajusté 1.9, 95%CI 1.3 2.8 par 100 CD4)

40%

• Cohorte observationnelle de tous les adultes suivis pour le VIH dans les deux cliniques de l’étude • En cas de TST positif (induration 5mm), IPT prescrit pour 36 mois • Les patients avec un TST négatif se voient proposer le protocole national d’IPT 6 mois, ainsi qu’un deuxième TST après 6 mois • Patients débutant les ARVs réévalués pour l’IPT après 3 mois d’ARV

45%

MÉTHODES

PVVIH Screening symptomatique TB (toux, sudations nocturnes, fièvre, perte de poids, douleur thoracique)

Investigations

TB

25%

Positif

30%

35%

Flux des patients

Négatif

TST 1

TST 1 et 2

95% confidence intervals

Pas de contreindication à l’isoniazide (INH) Coût pour 100 patients, en EUR Scénario 1: pas de TST, IPT 36 mois pour tous Médicaments Scénario 2: TST, avec 30% TST positif Coût du TST Patients TST pos sous IPT 36 mois (médicaments) Patients TST inconnu sous IPT 6 mois (médicaments) Total scénario 2 Scénario 3: pas de TST, IPT 6 mois pour tous Médicaments

Consentement TST

TST<5mm

TST>5mm

INH 6 mois

INH 36 mois

2è TST

RÉSULTATS OLOS

Population d’étude

New Haven

N=399 Age moyen (DS), 1 manquant 39.7 (12.2) Genre féminin, n (%) 272 (68.2) Sous antirétroviraux (ARV), n (%) 380 (95.2) Durée médiane des ARV, en années (EIQ) 2.3 (1.1 3.5) CD4 médian (EIQ) 390 (270 541) Antécédents de TB et IPT N=388 Traitement TB par le passé 116 (29.9) Traitement TB terminé <6 mois 17 (4.3) Traitement TB en cours 0 (0.0) IPT 6 mois par le passé 235 (60.7) IPT 6 mois en cours 15 (3.8)

N=321 38.1 (11.8) 218 (67.9) 266 (82.9) 2.4 (1.0 3.7) 490 (341 642) N=319 65 (20.4) 7 (2.2) 0 (0.0) 93 (29.1) 34 (10.6)

Valeur de p 0.070 0.941 <0.001 0.596

0.004 0.124 <0.001 <0.001

1021 dépistés 53 avec un critère d’exclusion INH 96 avec symptôme TB ou débutant les ARV 872 éligibles 152 refus (17%) 720 inclus 24 prophylaxie secondaire (pas de TST)

Coût, 100% des TST lus

Coût, 75% des TST lus

3561 209 1068 (n=30) 0 1277

209 801 (n=22.5) 149 1159

594

Eléments du calcul

Coût, en EUR

Ressources humaines TST, par test

0.98

Matériel TST, par test

1.12

Total TST, par test

2.09

Isonazid + vitamin B6, par patient par jour

0.04

Patient sous IPT, 6 mois

5.94

Patient sous IPT, 36 mois

35.91

Coût médian du transport payé par le patient pour la lecture du TST 1.04 EUR

DISCUSSION • La proportion de TST positif est plus basse qu’attendue vu la haute prévalence de TB et le haut niveau de CD4 des patients inclus • Le TST est facilement accepté par les PVVIH – Refus par 17% des éligibles, non lecture chez 6% – Meilleure acceptation si test reproposé à une visite ultérieure • Le TST a un coût faible comparé au coût de 36 mois d’isoniazide pour tous les patients • Difficultés liées au dépistage symptomatique de la TB – Pas d’investigation secondaire après le triage symptomatique – Nombreux patients exclus de l’IPT pour cause de symptôme TB au triage symptomatique

2 refus de TST 40 TST non lus 654 TST lu (75% éligibles) 437 TST<5mm

217 TST 5mm (33%)

340 deuxième TST 217 IPT 36 mois 293 TST<5mm

47 TST 5mm (13%) 264 IPT 36 mois (40%)

CONCLUSION • Le TST est accepté par les patients et peut être implémenté en zone rurale • La stratégie basée sur le TST est trois fois moins chère qu’un traitement de 36 mois systématique • Elle permet d’éviter de donner l’IPT aux 70% des patients qui n’en bénéficieraient pas (TST négatif), sans compter les problèmes de tolérabilité et d’adhérence • Le fort pourcentage de séroconversion du TST justifie une répétition du test (annuelle ou bisannuelle) • Le suivi de l’adhérence et de l’issue sous isoniazide 36 mois se poursuit dans les deux cliniques de l’étude


Risk factors for visceral leishmaniasis in Gedaref State, Sudan Fabienne Nackers1, Yolanda Müller1, Niven Salih², Mousab Siddig Elhag Ali³, Mubarak Ilnour4, Omer Hammam², Ann Mumina², Atia Abdalla Atia², Jean François Etard1,5, Koert Ritmeijer6, François Chappuis2,7 1

4

Epicentre, ² Médecins Sans Frontières, Operational Centre Geneva, ³ Federal ministry of Health, Sudan, State Ministry of Health, Gedaref, Sudan, 5 Institut de Recherche pour le Développement, Montpellier, France, 6 Médecins Sans Frontières, Operational Centre Amsterdam, 7 Geneva University Hospital

BACKGROUND

FINAL MULTIVARIATE LOGISTIC REGRESSION MODEL

Gedaref state is the main endemic foci of visceral leishmaniasis (VL), or kala azar, in Sudan. Yearly incidence varies between 6.6 and 8.4 cases per 1000 persons, with a large variation between villages. Since the end of 2009, MSF OCG supports the Tabarak Allah (TBK) hospital for the diagnosis and treatment of VL. In this area, VL is believed to be mainly anthroponotic. It is caused by Leishmania donovani, transmitted through the sandfly Phlebotomus orientalis. The P. orientalis sandfly populations peak at the late dry season and are concentrated in areas with high densitiy of Acacia Seyal and Balanites aegyptica trees that grow on black cotton soil. The proportion of post kala azar dermal leishmaniasis (PKDL) is affecting up to 50% of treated VL patients in Sudan and it is suspected to play a role in the transmission.

Gender, in <10 years Male Female Gender, 10 years and above Male Female

*

VL incidence per 100,000 inhabitants, Sudan, 2011 Source: Federal Ministry of Health, Sudan 15 / 100,000

0 5 / 100,000

10 15 / 100,000 5 10 / 100,000

Uncertain

*

Gedaref State (+/ 1,400,000 inhabitants)

There is currently insufficient knowledge on risk factors for VL in areas where P. orientalis is the main vector to clearly orient a control strategy. Consequently, we aimed to identify individual and household level determinants of primary VL in highly endemic villages of Tabarak Allah area. In particular, we investigated the role of suspected risk factors which could guide future control activities such as contact with the environment (vegetation, domestic animals, characteristics of the house, yard and surroundings), individual behaviours (travel, occupation, sleeping habits, evening activities, use of mosquito nets, insect repellents, spraying activities) and the presence of patients with VL or PKDL among relatives and neighbours.

METHODS • Design: Unmatched case control study • Target sample size: 270 cases / 810 controls • Time: September 2012 to July 2013 (Dry season) • Setting : 24 villages (46,564 population) with high VL incidence in TBK Hospital catchment area • Participants: Cases: successive patients treated in TBK Hospital for primary VL (probable: positive rk39 rapid test or direct agglutination test; confirmed: positive lymph node aspirate and/or clinical response to VL treatment) Controls : randomly selected in the villages using geographic spatial sampling; age, sex and village distribution proportionate to the distribution in the target population; no VL symptoms (fever of any duration and a history of recent weight loss or splenomegaly or lymphadenopathies); no previous VL treatment; negative rk39 rapid test. Both cases and controls: 6 months, resident in the same house in the study area for the past year. • Data collection: Interview by questionnaire at home (for cases : during the month after discharge); questions referred to the period preceding the onset of the case VL symptoms; where relevant, separate questions were asked for behaviours in rainy and dry season. • Statistics: Multivariate mixed logistic regression model (including village as a random effect). Stepwise approach: (1) Variables associated with VL in univariate analysis (p<0.20) were adjusted for age, sex and village; (2) Variables associated with VL (p<0.20) after adjustment were combined in multivariate models by thematic sections and by season (exit criteria p>0.20); (3) Variables from these models were combined in final multivariate logistic model (exit criteria p>0.05). Meaningful interactions tested (LR test). “VL or PKDL among relatives and neighbours” kept in separately because likely on causal pathway. • Ethical clearance: MSF ethical review board and Sudanese Research Ethics Review Committee.

RESULTS • 198 cases and 801 controls interviewed (3 refusals and 15 rK39 positive among controls) • VL incidence (passive detection) per village: from 0 to 16.4 per 1000 person years (lower than 2010 2011)

Age (years)

Village

Control (N=801)

n

%

n

%

Crude OR

146 136

51.8 48.2

69 35

66.4 33.7

1 0.54

%

n

%

p value

0 to 9

283

35.3

104

52.5

<0.001

10 to 19

196

24.5

52

26.3

20 to 39

187

23.4

24

12.1

40 or more

135

16.9

18

9.1

414

51.7

124

62.6

0.006

Berber Al Fugera

87

10.9

59

29.8

<0.001

Tabarak Allah

84

10.5

43

21.7

Khuor Zaraf

78

9.7

7

3.5

Jebel Ghana

63

7.9

24

12.1

Others

489

61.0

65

32.8

Ethnicity

Massalit

263

34.8

57

31.0

(60 missing)

Fallata/Hausa/Zabarma

198

26.2

24

13.0

Tama

52

6.9

37

20.1

Arnga/Gemir

63

8.3

19

10.3

Sudanese Arabs

81

10.7

14

7.6

Other Sudanese

52

6.9

22

12.0

Others

46

6.1

11

6.0

Univariate (N=998) 95%CI

0.34

0.87

per 10 years

267 251

51.5 48.5

55 39

58.5 41.5

1 0.75

1 0.38

95%CI

0.22

0.67

0.48

1.18

1 0.54

0.35

<0.001 <0.001

0.81

0.73 0.90

0.64 0.77

0.84 1.04

0.52 0.70

0.35 0.59

0.76 0.84

183 15 181

92.4 7.6 91.4

1 2.77 1.95

1.42 1.14

5.41 3.33

1 3.63 2.69

1.58 1.36

8.35 5.32

53 65 27 47 4 2

26.8 32.8 13.6 23.7 2.0 1.0

1 1.94 2.38 0.81 0.39 0.24

1.28 1.37 0.53 0.13 0.06

2.93 4.13 1.25 1.13 1.00

1 1.79 3.70 1.41 0.55 0.39

1.09 1.85 0.83 0.17 0.08

2.93 7.39 2.39 1.80 1.94

per increase in 1

8.4 (4.0)

p value

per 10 years

8 (6 14) 10 (6 24)

Mean (SD)

Mean household size 7.7 (3.3) Source of drinking water in the dry season Village water tank 162 20.3 River/surface water 342 42.8 Pump, well, water sellers 296 37 Distance to the closest house yard Share a common limit 591 73.9 Space in between (<10m) 119 14.9 More than 10 m 90 11.3 Forest at eye range 255 31.9 Acacia nilotica in surroundings 348 43.5 Ground nut oil as animal repellent 18 2.3 Animals in the yard at night 688 86 Dog in the yard at night 55 6.9

Adj* OR

per 10 years

per 10 years

Age, among males 14 (7 35) Age, among females 14 (7 30) Location of sleep In the house yard 777 97.1 Outside the house yard 23 2.9 Not sleeping in field/farm 676 84.5 Evening outdoor activities in the rainy season Stay indoor only 243 30.4 Playing 154 19.3 TV / radio 52 6.5 Discussing relaxing 265 33.1 Cooking/house activities 47 5.9 Other activities 39 4.9

Mulltivariate (N=998)

<0.001 <0.001 0.003 0.003 0.001

per increase in 1

1.06

1.01

1.10

1.06

1.00

1.13

73 41 84

36.9 20.7 42.4

1 0.27 0.63

0.17 0.44

0.41 0.91

1 0.37 0.64

0.18 0.41

0.74 1.00

169 14 15 80 125 12 158 21

85.4 7.1 7.6 40.4 63.1 6.1 79.8 10.6

1 0.41 0.58 1.45 2.22 2.80 0.64 1.61

0.23 0.33 1.05 1.61 1.33 0.43 0.95

0.73 1.03 2.00 3.07 5.92 0.96 2.73

1 0.34 0.50 1.70 1.71 4.22 0.56 2.47

0.18 0.25 1.14 1.16 1.68 0.34 1.28

0.67 0.98 2.54 2.51 10.6 0.91 4.79

0.032 0.018

0.001

0.009 0.007 0.003 0.021 0.009

*Adjusted for each others, age sex interaction and for village as a random effect (14% of variance, 95%CI 5 35%)

SEPARATE MULTIVARIATE MODEL FOR VL AND PKDL Age (median (IQR), per 10 years) Female Household member with VL in the past year (per increase in 1) Household member who developed a PKDL like rash in the past year

Case (N=198) 14 (7 32) 387 48.3

Control (N=800) 9 (6 15) 74 37.4

Crude OR 0.79 0.63

59

7.4

142

15

1.9

25

0.87 0.87

Adj* OR 0.73 0.65

0.71 0.46

0.64 0.42

0.85 1.01

<0.001 0.053

71.7

19.1

13.0

28.3

21.4

13.5

33.9

<0.001

12.7

7.61

3.93

14.73

0.38

0.15

0.94

0.036

95%CI

95%CI

p value

*Adjusted for each other and for village as a random effect

LIMITATIONS • Selection bias: patients with VL who did not present to TBK hospital, nomads or seasonal workers, and patients who died from VL at home were not included. Some eligible controls were absent at time of interview and not included. Also, some subclinical VL infections (rK39 negative) have probably been included as controls. However, these likely represent only a minor proportion of cases and controls. • Recall bias: patients with VL might have overestimated exposure to known determinants. • Reverse cause: patients with VL might have changed their behaviour because of the disease. • Observer bias: surveyors were not blinded of the participant VL status and this might have influenced their interpretation of the participant answers. This was limited by standardization of all procedures. • The multiple variables investigated might have lead to chance findings.

DISCUSSION AND CONCLUSION

Case (N=198)

n

Male

Case (N=198)

Median (IQR)

OBJECTIVES

DEMOGRAPHIC CHARACTERISTICS

Control (N=800)

<0.001

• Having a VL patient in the household in the past year was the strongest risk factor. Evening activities in the rainy season were also associated with VL, as were the location of sleep, the presence of Acacia nilotica in the surroundings of the yard, the distance to the nearest house yard and the use of ground nut oil as animal repellent. Keeping animals in the yard at night appeared protective (except for dogs). By contrast with previous studies, ethnicity, black cotton soil, Balanites aegyptica, Acacia seyal, Azadirachta indica, use of mosquito nets, housing factors did not appear independent VL determinants. • Although our results do not provide evidence of causality, they provide useful suggestions for the development of relevant VL preventive measures as well as for guiding further studies.

RECOMMENDATIONS • Target control efforts in and around households of patients diagnosed with VL • Promote early diagnosis and treatment through health education campaigns • Evaluate innovative targeted personal protection strategies: provide chemical repellent or insecticide impregnated clothing for household members of all VL cases and to all inhabitants of villages experiencing an increase in VL cases; develop health education campaign to promote their use • Discourage the use of ground nut oil as animal repellent • Because of the conflicting evidence on trees, systematic tree cutting should not be promoted • Avoid keeping dogs around the house • Additional research: Assess innovative targeted personal protection strategies on sandfly population and infection by L. donovani through an entomological assessment or randomised trial Entomological study done in house yards, including blood meal analysis Model of VL transmission across villages over time Role of possible zoonotic transmission (especially with dogs)


Two-year surveillance of meningitis in Moissala, Chad, during and after introduction of MenAfriVac Anne-Laure Page1, Matthew Coldiron1, Dionmaye Gustave Maimian², Kadidja Gamougam3, Florence Fermon², Dominique Caugant4, Klaudia Porten1 1

3

Epicentre, France; ² Médecins Sans Frontières – Operational Center Paris, France; Hôpital Général de Référence National, Chad; 4 Norwegian Institute for Public Health, Norway

RESULTS (continued)

INTRODUCTION  The African meningitis belt has been affected for many decades by large epidemics of meningitis mostly due to Neisseria meningitidis serogroup A (NmA).  Other serogroups of N. meningitidis and other bacteria, such as Streptococcus pneumoniae and Haemophilus influenzae type b (Hib), also cause meningitis.  An effective and long-lasting conjugate vaccine against NmA, MenAfriVac, is being introduced in the countries of the meningitis belt.  Introduction of MenAfriVac in some regions of Chad in 2011 drastically reduced the incidence of meningitis during the 2012 epidemic season, compared to non-vaccinated areas (Figure 1).  Moissala district in Southern Chad was not vaccinated in 2011 and had a meningitis outbreak in 2012. The district was vaccinated with MenAfriVac in response to the outbreak.  We report results from a case-based meningitis surveillance system during and after the 2012 outbreak, continuing through end 2013 in order to show the evolution of cases characteristic and germs identified after the introduction of MenAfriVac.

Weekly incidence/100,000

Vaccinated Non-vaccinated

7 6

epidemic and post-epidemic periods, Moissala district, Chad, 2012-2013 Epidemic Post-epidemic Characteristic N=329 N=102 Cases, n(%) Confirmed 95 (28.9) 43 (42.2) Probable 234 (71.1) 6 (5.9) Suspect 0 (0) 53 (52.0)

p-value <0.001

Sex M, n(%)

170 (51.8)

58 (56.9)

0.37

Age in years, median (IQR)

10 (5-20)

6 (0-12)

<0.001

Fatal cases (%)

13 (4.0)

14 (13.7)

<0.001

315 (95.7) 14 (4.3) 0

57 (57.6) 37 (37.4) 5 (5.1)

MenAfriVac status Not vaccinated Vaccinated Unknown

9 8

Table 1. Characteristics of suspect, probable and confirmed cases of meningitis in the

<0.001

5 MenAfriVac

4 3 1 0 2009

2010

2011

2012

Figure 1. Incidence of reported cases of meningitis cases in Chad, 2009-2012, in areas vaccinated (red) or non-vaccinated (blue) with MenAfriVac in 2011 From Daugla et al., Effect of a serogroup A meningococcal conjugate vaccine (PsA-TT) on serogroup A meningococcal meningitis and carriage in Chad: a community study. Lancet 2014;383:40-47.

METHODS Surveillance procedures  2012: Retrospective and prospective collection of demographic, clinical and biological data for all suspect cases of meningitis from clinical registers and files  2013: Case-based surveillance based on Chad national guidelines using case notification files

Age group distribution

2

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

≥45 years 30-44 years 15-29 years 5-14 years 1-4 years <1 year

All cases (N=329)

Confirmed cases (N=95)

Epidemic Period

All cases (N=102)

Confirmed cases (N=43)

Non-epidemic period

Figure 3. Age groups of all or confirmed meningitis cases in epidemic and post-epidemic

Laboratory analyses

periods, Moissala district, Chad, 2012-2013

 Cerebrospinal fluid (CSF) collected at district hospital in Moissala  Pastorex Meningitis assay performed at district laboratory in Moissala  Transisolate transport media inoculated and sent to General National Reference Hospital laboratory in N’Djamena and Supranational Reference Laboratory in Oslo, Norway for culture and PCR

Table 2. Distribution of organisms identified in the epidemic and post-epidemic periods,

Referrals  During the 2012 epidemic, some cases were only seen in peripheral health centers. Since the end of the 2012 epidemic, all suspect cases have been referred systematically from health centers to the district hospital in Moissala.

Definitions  Suspect case: fever with bulging fontanel or petechiae (or altered consciousness or other signs of meningeal involvement in 2013) in children <1 year and sudden onset of fever with neck stiffness or petechiae (or altered consciousness or other signs of meningeal involvement in 2013) in adults  Probable case: during the epidemic season, any suspect case. Outside of the epidemic season, suspect case with turbid or purulent CSF, or with Gram suggestive of bacterial meningitis, or with leucocyte count > 10 cells/mm3.  Confirmed case: any suspect case with identification of a bacterial pathogen from the CSF by latex test, culture or PCR.  Epidemic period: weeks 1 to 19, 2012

confirmed meningitis cases, Moissala district, Chad, 2012-2013 Epidemic Organism N=95 NmA 51 (53.7) NmW135 22 (23.2) NmB 1 (1.1) Nm - unspecifed 6 (6.3) S. pneumoniae 9 (9.5) Hib 4 (4.2) Group B streptococcus 2 (2.1) Salmonella paratyphi A 0

Post-epidemic N=43 2 (4.7) 8 (18.6) 0 1 (2.3) 27 (62.8) 2 (4.7) 2 (4.7) 1 (2.3)

SUMMARY  As described in the rest of Chad, the incidence of meningitis fell considerably after vaccination with MenAfriVac.  While NmA was the main causative agent during the epidemic period, S. pneumoniae was the most frequent causative organism in the post-epidemic period.

RESULTS

 The 2 cases of NmA in the post-epidemic period were not confirmed by culture or PCR, and neither reported prior vaccination with MenAfriVac

60

Vaccination 50

 Sporadic cases of NmW135 were reported during the epidemic and post-epidemic periods.

40

 Meningitis cases were slightly younger in the post-epidemic period, although older children (5-14 years) remain heavily affected.

30

DISCUSSION AND CONCLUSION  Although over a short period of time, these results confirm the impact of MenAfriVac in stopping meningitis outbreaks in the meningitis belt.

20

 To date, no serogroup replacement or emergence of new causes of large outbreaks has been reported in Chad.

10

0

1

3

5

7

9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 1

2012

3

5

7

9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51

Epidemiological week Suspect

Probable

2013

Confirmed

Figure 2. Suspect, probable and confirmed cases of meningitis by epidemiological week, Moissala district, Chad, 2012-2013

 Outside the epidemic setting, meningitis cases, mostly due to S. pneumoniae, carry a high burden (number of cases, high case fatality). Vaccination against S. pneumoniae is necessary to continue the fight against meningitis.  Case-based surveillance was feasible to implement in this setting, and is needed to continue following the epidemiology of meningitis after the introduction of MenAfriVac.


Treatment response of bleomycine combined with cART in HIV infected patients with advanced Kaposi sarcoma in Homa Bay, Kenya Elisabeth Poulet1, Jihane Ben Farhat1, Bennadette Mugita2, Suna Balkan3, Elisabeth Szumilin3, Mar Pujades-RodrĂ­guez1,4 1Epicentre,

France ; 2MSF, Kenya; 3MSF France; 4University College London, London, United Kingdom

Rationale

Results (II)

Objectives

Study setting

Methods

Results (I)

Conclusion

Acknowledgements


Antibiotic drug resistant bacteria isolated from Syrian war injured patients managed in a medical humanitarian surgical program Carrie LeeTeicher,1 Jean Baptiste Ronat,2 Rasheed M. Fakhri, 3 Mohamed Basel3, Amy S. Labar,4 Patrick Herard,2 Richard A. Murphy 5, 6 1

Epicentre, New York, New York, USA 2Médecins Sans Frontières/Doctors Without Borders, Paris, France 3 Médecins Sans Frontières/Doctors Without Borders, Amman, Jordan 4 Harvard School of Public Health, Boston, Massachusetts 5Médecins Sans Frontières/Doctors Without Borders, New York, NY, USA 6Albert Einstein College of Medicine, Bronx, NY, USA

BACKGROUND

DISCUSSION

Efforts to describe the epidemiology of infected war-related injuries are complicated by difficult access to patients, limited availability of high-quality laboratory support and the widespread empirical use of antibiotics. A surgical project of MSF in Amman, Jordan, provided an opportunity to describe the microbiology of war injury in Syrian civilian patients who were able to seek care in Amman.

This study demonstrates that in our cohort an important proportion of MDR organisms are found amongst war-injured patients from Syria. For a surgical project, MDR organisms lead to formidable diagnostic, treatment and infection control challenges. These include the need for ongoing access to high quality clinical microbiology for individual patient care, the need for late-generation antibiotics typically given parenterally for up to 6 weeks, the need for trained infection prevention personnel and the need for sufficient hospital space to allow for single-room or cohort isolation of patients highly-resistant strains.

Table 1: Patient Demographics, n= 61 patients Median age yr, [IQR] Men, n (%) Origin within Syria, n (%) Aleppo Damascus Daraa Hama Homs

26 [22 34] 60 (98.36%) 1 (1.64%) 4 (6.56%) 51 (83.61%) 2 (3.28%) 3 (4.92%)

Total N of patient

61

Number patient with positive culture

45

mean different isolate per infected patient

METHODS

Number of patient with 2 isolates

We reviewed surgical biopsy results obtained from Syrian war-injured civilians between August 2011 and March 2013. Data were collected from programmatic databases and from individual chart reviews in Amman. Organism

Table 2: Patient characteristics Median months since injury [IQR] 5.06 [1.18 8.05] Months since injury, n (%) <1 mo 15 (24.59%) 1 <6 mo 19 (31.15%) 6 <12 mo 15 (24.59%) 12 <24 mo 9 (14.75%) 24+ mo 3 (4.92%) Injury location, n (%) Upper extremity 14 (22.95%) Lower extremity 47 (77.05%) Median prior surgery procedures [IQR] 2 [1 4] Mechanism of injury, n (%) Accident (other) 1 (1.64%) Traffic accident 5 (8.20%) Bombs 20 (32.79%) Gunshot 32 (52.46%) Torture 3 (4.92%) Efforts to at describe the epidemiology of infected war-related injuries are complicated by difficult Diagnosis admission*, number (%**) access toBone patients, loss limited availability of high-quality laboratory 9 (9.68%) support and the widespread empirical use of antibiotics. A surgical project of MSF in Amman, Jordan, provided an opportunity Mal union 24 (25.81%) to describe the microbiology of war injury in Syrian civilian patients who were able to seek care in Non union 39 (41.94%) Amman. Soft tissue loss 11 (11.83%) Union infected 7 (7.53%) Union non infected indicated for plate 1 (1.08%) removal Nerve 2 (2.15%) *for patients with multiple diagnoses, each diagnosis is counted separately. **The total number of diagnoses is 93 Surgical Specialty, n (%)

ALL (n=61)

Orthopedic Ortho plastic

59 (96.72%) 2 (3.28%)

POS ONLY (n=45) 44 (97.78%) 1 (2.22%)

RESULTS Between August 2011 and March 2013, 1586 Syrian patients were evaluated in the project representing 35% of total arrivals in both the inpatient and outpatient departments. Among 204 Syrian patients admitted to the surgical inpatient ward, 61 (18%) had a suspected infection at initial evaluation (98% male; median age 26); Among these 61 patients with a pathogen isolated, evacuation to Amman often involved significant delay; the median time from injury to culture was 5 months [IQR 1.2-8.1]. Injuries that resulted from gunshot wounds (52%) and bombs (33%) represented the main etiologies of trauma. Forty-five (74%) of them were found to have a sample positive for one or more bacterial isolates. Among Syrian surgical patients presenting with delayed definitive management of infected orthopedic and soft tissue war injuries, multidrug-resistant (MDR) organisms notably MDR gramnegative pathogens and methicillin-resistant Staphylococcus aureus were frequently recovered from deep surgical samples. PER PATIENT Injury Location Upper extremity (N = 14 patients)

Lower extremity (N = 47 patients)

Mechanism of Total Injury Accident 0 (other) Traffic accident 0 Bombs 7 Gunshot 6 Torture 1 Accident 1 (other) Traffic accident 5 Bombs 13 Gunshot 26 Torture 2

1.13

Patients With at Least 1 Pos With at least one MDR Isolate (% of total) isolate (% of total)

6 (85.71%) 2 (33.33%) 1 (100.00%)

6 (85.71%) 2 (33.33%) 0 (0.00%)

1 (100.00%)

1 (100.00%)

5 (100.00%) 8 (61.54%) 21 (80.77%) 1 (50.00%)

2 (40.00%) 5 (38.46%) 14 (53.85%) 1 (50.00%)

Staphylococcus aureus

6

Pseudomonas aeruginosa

Escherichia coli

Acinetobacter baumannii

N= 19

Resistant (%)

N= 10

Resistant (%)

N= 8

Resistant (%)

N=6

Resistant (%)

8 (19)

42

4 (10)

40

5 (8)

62

6

100

1 (9)

11

1(7)

14

6 (6)

100

Ampicillin

5 (5)

100

AmoxicillinClavulanate

6 (6)

100

Cefotaxime

6 (8)

75

Ceftriaxone

5 (8)

62

5 (8)

62

4 (4)

100

Cefepime

5 (8)

62

5 (5)

100

Cefixime

5 (8)

62

5 (5)

100

MDR Amikacin

Ceftazidime

3 (9)

33

Ciprofloxacin

5 (8)

62

2 (7)

28

5 (5)

100

Colistin

NA

NA

NA

NA

0 (5)

0

3 (5)

60

TMP/SMX Gentamicin

4 (9)

44

4 (8)

50

6 (6)

100

Piperacillin/ Tazobactam

2 (9)

22

3 (7)

42

NA

NA

Imipenem

0 (9)

0

1 (7)

14

4 (5)

80

Penicillin

9 (10)

90

Oxacillin

7 (17)

41

Clindamycin

9 (17)

52

Gentamicin

10 (18)

55

Rifampin

6 (15)

40

Fusidic acid

10 (15)

66

TMP SMX

3 (14)

21

Ciprofloxacin

7 (17)

41

Vancomycin

1(19)

5

Acknowledgments We would like to thank the MSF staff in Amman, Dubai and Paris for all their support. Additionally we would like to thank Emmanuel Baron for assistance with this poster.


Malaria-related morbidity and mortality in the Danga health area (Orientale Province, Democratic Republic of Congo) Brahima Toure1, Mathieu Bichet2, Ester Sterk2, Annick Antierrens2, Joris Losimba Likwela3, Klaudia Porten2 1Epicentre,

Paris, France;

2Médecins

sans Frontières, Suisse; 3Programme National de Lutte contre le Paludisme, RDC

CONTEXT Malaria is endemic in the Democratic Republic of Congo (DRC), where 97% of the population lives in a high transmission zone. With more than 9 million cases reported in 2011, malaria remains the leading cause of morbidity in the DRC. During the first half of 2012, the number of malaria-related cases and deaths in Orientale Province was higher than in previous years. In the face of this resurgence, Médecins Sans Frontières (MSF) implemented an emergency malaria management programme in some of the hardest-hit health areas (HA) in Orientale province’s Ganga and Pawa health zones. Together with these interventions, a crosssectional retrospective household survey was conducted in order to describe malaria-related mortality and the malaria prevalence in the Danga HA.

RESULTS (continued) 2. Rapid diagnostic test (RDT) The RDT was performed on 4,448 people The RDT was positive in 2,111 people (positivity rate = 47.5%) Table 1: Distribution of positive RDTs by age in Danga and Nemanzi localities

Age group 0-4 years (n=821) 5-9 years (n=670) 10-14 years (n=475) >14 years (2482)

Danga

Nemanzi

Total

171 (35.8%) 195 (51.5%) 158 (60.5%) 579 (42.6%)

149 (43.3%) 164 (56.1%) 130 (60.7%) 565 (50.2%)

320 (38.9%) 320 (53.5%) 288 (60.6%) 1144 (46.0%)

3. Thick and thin films Figure 1: Distribution of Orientale province health zones by malaria incidence and case fatality rate in 2012 (W1 – W38)

Thick and thin films were done on a sample of 579 people. The thick film was positive in 104 people (17.9%) Table 2: Results for thick and thin films

OBJECTIVES

Frequency

1. Primary objective: - To estimate the retrospective malaria-related mortality and the malaria prevalence in the Danga HA.

0 1 - 999 1000 - 9999

2. Secondary objectives: - To assess the retrospective mortality from 1 January 2012 to 25 September 2012 among Danga HA residents - To assess the malaria prevalence in the health area - To assess the population’s haemoglobin level in the Danga HA - To assess the insecticide-treated mosquito net coverage in the Danga HA.

475 70 29 7

Plasmodium species* (n=579) Plasmodium falciparum Plasmodium malariae Plasmodium ovale Presence of gametocytes Plasmodium falciparum Presence of schizonts Plasmodium falciparum Plasmodium malariae Presence of pigments

METHODS 1. Study location The Danga health area, located in the Ganga health zone, is divided into two localities (Danga and Nemanzi)

(%) (81.8%) (12.0%) (5.0%) (1.2%)

98 (16.9%) 4 (0.7%) 4 (0.7%) 6

(1.0%)

4 1 10

(0.7%) (0.1%) (1.7%)

*: Mixed infections found in two people Table 3: Breakdown of RDT and thick film results by age group RDT

AS DANGA

0-4 years (n=107) 5-9 years (n=86) 10-14 years (n=62) >14 years (n=324) Figure 2: The Danga health area

Positive (%) 42 (39.3%) 47 (54.7%) 43 (69.4%) 147 (45.1%)

Thick film Negative (%) 65 (60.7%) 39 (45.3%) 19 (30.6%) 177 (54.9%)

Positive (%) 17 (15.9%) 20 (23.1%) 19 (30.6%) 48 (14.8%)

4. Haemoglobin

2. Study type An exhaustive cross-sectional retrospective mortality and prevalence survey was conducted from 5 September to 25 September 2012 among 4,958 people (51.5% female) in 874 households in the Danga HA

The mean haemoglobin level (measured in 1,692 people) was 11.6 g/dl (standard deviation = 1.7). Anaemia was identified in 48 people (2.8%).

Table 4: Distribution of anaemia cases by age in the Danga HA (n=1,692).

20

Age group

400

200

0 Population

200

Masculin

400

Hb level < 8 g/dl (%)

0-4 years (n = 818)

31 (3.7%)

5-9 years (n = 481)

14 (2.9%)

10-14 years (n = 64)

2 (3.1%)

> 14 years (n = 329)

1 (0.3%)

Figure 6 : Haemoglobin level by age group in the Danga HA.

0

5

10

15

95-99 90-94 85-89 80-84 75-79 70-74 65-69 60-64 60-64 55-59 55-59 50-54 50-54 50-54 45-49 45-49 45-49 40-44 40-44 40-44 35-39 35-39 35-39 35-39 30-34 30-34 30-34 30-34 25-29 25-29 25-29 25-29 25-29 20-24 20-24 20-24 20-24 15-19 15-19 15-19 15-19 15-19 10-14 10-14 10-14 10-14 10-14 10-14 5-9 5-9 5-9 5-9 5-9 5-9 5-9 5-9 5-9 5-9 0-4 0-4 0-4 0-4 0-4 0-4 0-4 0-4 0-4 0-4 0-4 0-4 0-4

600

Negative (%) 90 (84.1%) 67 (77.9%) 43 (69.4%) 276 (85.2%)

600

Féminin

Figure 3 : Population distribution in the Danga health area

5. Mosquito net coverage

Recall period: 1 January 2012 to the day of the survey

Among the 874 households surveyed, there were 781 mosquito nets in 491 households, for a coverage of 56.2%. The mosquito net coverage was 53.9% in Danga and 59.6% in Nemanzi.

3. Sampling - Exhaustive sampling - Malaria rapid diagnostic test (RDT) done on all subjects surveyed - Thick film, thin film and haemoglobin measurement done on a random sample

Table 5: Characteristics of the mosquito nets found in the Danga HA

4. Laboratory Blood samples were collected by drawing capillary blood from the fingertip or from the heel, in infants. - RDT used: SD Bioline Malaria Ag Pf (HRP2) - Haemoglobin measurement: HemoCue Hb 301

5. Statistical analysis The data were analysed using Stata 11 software. Percentages and means were calculated with their standard deviations. 6. Ethical considerations

Mosquito net present (n=874) Mosquito net placement (n=780) Wrapped Loose Attached Mattress cover Mosquito net condition (n=776) Good condition

The protocol was submitted to the DRC Ministry of Health Ethics Committee and the MSF Ethics Committee. Written informed consent was obtained from each head of household. Everyone with a positive RDT was treated for malaria according to the national protocol (artesunate + amodiaquine)

RESULTS 1. Retrospective mortality 128 deaths reported: Crude death rate = 1.1 per 10,000 people/day.

10

Malaria-specific mortality rate = 0.8 per 10,000 people/day.

14

9 12

8

NEMANZI DANGA

7

10

NEMANZI DANGA

Fre q u en cy

Freq u en cy

6 8

6

7.7 9.4 56.8 26.2

394

50.8

Retrospective mortality Malaria-related mortality was high High prevalence of malaria The RDT and thick film were positive in 47.5% and 17.9%, respectively, of people surveyed. Plasmodium falciparum was the species found most frequently (94.2%). Treatment was administered to everyone with a positive RDT. Low prevalence of anaemia Anaemia was observed in 2.8% of people surveyed. Only 3.7% of children under 5 years were anaemic. Roughly half mosquito net coverage 56.2% of households had at least one mosquito net. Of the 780 mosquito nets reported, only 56.8% were attached.

4

CONCLUSION The high malaria-related mortality combined with high malaria prevalence and only about 50% mosquito net coverage suggest a worrisome malaria situation in the Danga HA; this should prompt a stepping-up of malaria

1 0

0

60 73 443 204

5

2 2

Percentage (%) 56.2

DISCUSSION

3

4

Number 491

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37

Week

Week

Figure 4: Weekly deaths in the Danga HA, 01/01/2012 to 25/09/2012.

Figure 5: Weekly malaria-related deaths in the Danga HA, 01/01/2012 to 25/09/2012

control measures. This survey also demonstrated the feasibility of a community malaria testing and treatment (Test & Treat) strategy in the DRC context

Epicentre/MSF Scientific Day - Journée Scientifique 2014  

Epicentre/MSF Scientific Day - Journée Scientifique 2014

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