Conference Material > Abstract
Hopkins S, Hazel A, Pourtois J, Chamberlin A, Gajewski Z, et al.
MSF Scientific Days International 2023. 2023 June 7; DOI:10.57740/vj1f-v594
INTRODUCTION
An undervalued role of rural healthcare provision is its impact on forests and carbon balance. In addition to the effects of healthcare provision and livelihood programmes on improved human health, these programmes can also reduce forest degradation and prevent deforestation-related carbon emissions, since unaffordable healthcare drives logging as a source of rescue income. Shocks such as the Covid-19 pandemic may exacerbate this dynamic. Health In Harmony and Planet Indonesia are two planetary health non-governmental organisations (NGO’s) that work together with communities living in and around tropical rainforests in West Kalimantan, Indonesia.
METHODS
We used a cross-sectional mixed-methods survey in November-December 2021 to evaluate healthcare access and livelihoods in 1,016 households across six NGO-affiliated villages and four unaffiliated control villages. Additionally, satellite-generated imagery retrieved between January 2018 and December 2021 was used to contrast relative deforestation rates in 28 NGO-affiliated and 1,421 unaffiliated control villages bordering protected rainforests across Kalimantan.
ETHICS
This study was approved by the Stanford University Institutional Review Board and by the Institut Pertanian Bogor Ethical Review Board.
RESULTS
After accounting for environmental variables that affect deforestation, satellite analysis suggested that prior to the Covid-19 pandemic, average weekly deforestation rates in NGO-affiliated villages (0.018%; 95% confidence interval (CI), 0.012-0.026%) were 70% lower than in unaffiliated villages (0.062%; 95%CI, 0.045-0.078%; p<0.0001). Following the WHO pandemic declaration, deforestation rates dropped and then gradually rebounded in both NGO-affiliated and unaffiliated villages, with NGO-affiliated villages maintaining significantly lower average deforestation rates (0.008%; 95%CI, 0.005-0.011%) during the pandemic than unaffiliated villages (0.026%; 95%CI, 0.019-0.032%; p<0.01). Survey results indicated that clinic visits, out-of-pocket healthcare spending, and the proportion of households unable to access healthcare increased across all villages during the pandemic. The main reasons given for access problems were around fears of contracting Covid-19, unaffordability, or clinic closure. Throughout the pandemic, households affiliated with Health In Harmony, which runs a health clinic, were less likely to report barriers to affordable clinic access than households in unaffiliated villages (14% vs. 29%; odds ratio (OR); 0.41,95%CI, 0.2-0.69). Households in NGO-affiliated villages were more likely to do jobs with low environmental impact (e.g., small-scale farming, conservation; OR 1.61,95%CI, 1.15-2.24). Half of households in both groups reported income loss from at least one source during the pandemic, but households in NGO-affiliated villages were more likely to gain alternative income from multiple job types, especially resource-neutral jobs (e.g., public servant, sales, services). Additionally, households in NGO-affiliated villages had more sources of economic support, such as government programmes, co-operatives, family and NGO’s (OR 1.36, 95%CI, 1.11-1.69).
CONCLUSION
Communities with better access to healthcare and livelihood support were associated with significantly lower deforestation rates prior to the Covid-19 pandemic, and this lower reliance on forest-degrading income was resilient to the pandemic shock.
CONFLICTS OF INTEREST
None declared.
An undervalued role of rural healthcare provision is its impact on forests and carbon balance. In addition to the effects of healthcare provision and livelihood programmes on improved human health, these programmes can also reduce forest degradation and prevent deforestation-related carbon emissions, since unaffordable healthcare drives logging as a source of rescue income. Shocks such as the Covid-19 pandemic may exacerbate this dynamic. Health In Harmony and Planet Indonesia are two planetary health non-governmental organisations (NGO’s) that work together with communities living in and around tropical rainforests in West Kalimantan, Indonesia.
METHODS
We used a cross-sectional mixed-methods survey in November-December 2021 to evaluate healthcare access and livelihoods in 1,016 households across six NGO-affiliated villages and four unaffiliated control villages. Additionally, satellite-generated imagery retrieved between January 2018 and December 2021 was used to contrast relative deforestation rates in 28 NGO-affiliated and 1,421 unaffiliated control villages bordering protected rainforests across Kalimantan.
ETHICS
This study was approved by the Stanford University Institutional Review Board and by the Institut Pertanian Bogor Ethical Review Board.
RESULTS
After accounting for environmental variables that affect deforestation, satellite analysis suggested that prior to the Covid-19 pandemic, average weekly deforestation rates in NGO-affiliated villages (0.018%; 95% confidence interval (CI), 0.012-0.026%) were 70% lower than in unaffiliated villages (0.062%; 95%CI, 0.045-0.078%; p<0.0001). Following the WHO pandemic declaration, deforestation rates dropped and then gradually rebounded in both NGO-affiliated and unaffiliated villages, with NGO-affiliated villages maintaining significantly lower average deforestation rates (0.008%; 95%CI, 0.005-0.011%) during the pandemic than unaffiliated villages (0.026%; 95%CI, 0.019-0.032%; p<0.01). Survey results indicated that clinic visits, out-of-pocket healthcare spending, and the proportion of households unable to access healthcare increased across all villages during the pandemic. The main reasons given for access problems were around fears of contracting Covid-19, unaffordability, or clinic closure. Throughout the pandemic, households affiliated with Health In Harmony, which runs a health clinic, were less likely to report barriers to affordable clinic access than households in unaffiliated villages (14% vs. 29%; odds ratio (OR); 0.41,95%CI, 0.2-0.69). Households in NGO-affiliated villages were more likely to do jobs with low environmental impact (e.g., small-scale farming, conservation; OR 1.61,95%CI, 1.15-2.24). Half of households in both groups reported income loss from at least one source during the pandemic, but households in NGO-affiliated villages were more likely to gain alternative income from multiple job types, especially resource-neutral jobs (e.g., public servant, sales, services). Additionally, households in NGO-affiliated villages had more sources of economic support, such as government programmes, co-operatives, family and NGO’s (OR 1.36, 95%CI, 1.11-1.69).
CONCLUSION
Communities with better access to healthcare and livelihood support were associated with significantly lower deforestation rates prior to the Covid-19 pandemic, and this lower reliance on forest-degrading income was resilient to the pandemic shock.
CONFLICTS OF INTEREST
None declared.
Conference Material > Abstract
Idrissa AA, Atti S, Wasaulua RK, Kazadi S, Guindo O, et al.
MSF Scientific Days International 2023. 2023 June 7; DOI:10.57740/wg9g-dq47
INTRODUCTION
MSF supported Niger’s Ministry of Health (MoH) in responding to a serogroup C meningococcal meningitis epidemic in Magaria and Dungass Districts in 2022. WHO’s global roadmap for defeating meningitis by 2030 emphasises appropriate care for meningitis sequelae, but this is not yet part of standard epidemic response. Meningitis sequelae in the African meningitis belt are poorly described, hampering access to rehabilitation services. To better orient future care for sequelae, we performed a follow-up survey of survivors 9 months after the 2022 epidemic.
METHODS
WHO case definitions were used during the epidemic. Patient-level line-lists detailing village of origin were obtained from authorities, and results of polymerase chain reaction testing on cerebrospinal fluid were integrated. Guided by village leaders, study nurses attempted to visit cases at home to assess for sequelae. Nurses administered questionnaires asking about history including seizures and subjective vision and hearing loss; and carried out physical examinations assessing anosmia, weakness, and paralysis. Data were collected tablets using REDCap software. Prevalence of sequelae among survivors was calculated.
ETHICS
This study was approved by the MSF Ethics Review Board and by the National Ethics Committee for Health Research of Niger.
RESULTS
1001 suspected cases and 50 deaths (case fatality rate, CFR, 5.0%) originating in 230 villages were recorded on the line-lists. 469 cases (47%) had lumbar puncture, and 220 (47%) had a causative agent identified, including 192 cases of Neisseria meningitidis serogroup C (NmC) and 22 Streptococcus pneumoniae. After excluding 82 cases living in villages difficult to access, we attempted to trace 919 cases, of whom 570 (62%) were found and consented to interview. Among these cases, 49 had died (CFR 8.6%). Among the cases visited, 151 had confirmed NmC and 10 S. pneumoniae. Among the 521 surviving cases evaluated, 62 (12%) had sequelae; the most common were hearing loss (29), paralysis (16), epilepsy (9), and developmental regression (6). Among the 138 surviving confirmed cases of NmC, 25 (18%) had one or more sequelae.
CONCLUSION
We documented a higher CFR than reported during the epidemic, and a high burden of sequelae among survivors, particularly among those with confirmed NmC infection. To our knowledge, this is the second time that meningitis sequelae have been documented in Niger; these findings help identify priorities for integrating meningitis after-care into epidemic responses. MSF and the MoH should work to ensure linkages to long-term care and support for meningitis survivors and their caregivers. We were unable to find all cases, so the true prevalence of sequelae among survivors may differ. This follow-up survey used simple methods adapted for in-home evaluation, and formal audiometry may have led to detection of more subtle hearing loss.
CONFLICTS OF INTEREST
None declared
MSF supported Niger’s Ministry of Health (MoH) in responding to a serogroup C meningococcal meningitis epidemic in Magaria and Dungass Districts in 2022. WHO’s global roadmap for defeating meningitis by 2030 emphasises appropriate care for meningitis sequelae, but this is not yet part of standard epidemic response. Meningitis sequelae in the African meningitis belt are poorly described, hampering access to rehabilitation services. To better orient future care for sequelae, we performed a follow-up survey of survivors 9 months after the 2022 epidemic.
METHODS
WHO case definitions were used during the epidemic. Patient-level line-lists detailing village of origin were obtained from authorities, and results of polymerase chain reaction testing on cerebrospinal fluid were integrated. Guided by village leaders, study nurses attempted to visit cases at home to assess for sequelae. Nurses administered questionnaires asking about history including seizures and subjective vision and hearing loss; and carried out physical examinations assessing anosmia, weakness, and paralysis. Data were collected tablets using REDCap software. Prevalence of sequelae among survivors was calculated.
ETHICS
This study was approved by the MSF Ethics Review Board and by the National Ethics Committee for Health Research of Niger.
RESULTS
1001 suspected cases and 50 deaths (case fatality rate, CFR, 5.0%) originating in 230 villages were recorded on the line-lists. 469 cases (47%) had lumbar puncture, and 220 (47%) had a causative agent identified, including 192 cases of Neisseria meningitidis serogroup C (NmC) and 22 Streptococcus pneumoniae. After excluding 82 cases living in villages difficult to access, we attempted to trace 919 cases, of whom 570 (62%) were found and consented to interview. Among these cases, 49 had died (CFR 8.6%). Among the cases visited, 151 had confirmed NmC and 10 S. pneumoniae. Among the 521 surviving cases evaluated, 62 (12%) had sequelae; the most common were hearing loss (29), paralysis (16), epilepsy (9), and developmental regression (6). Among the 138 surviving confirmed cases of NmC, 25 (18%) had one or more sequelae.
CONCLUSION
We documented a higher CFR than reported during the epidemic, and a high burden of sequelae among survivors, particularly among those with confirmed NmC infection. To our knowledge, this is the second time that meningitis sequelae have been documented in Niger; these findings help identify priorities for integrating meningitis after-care into epidemic responses. MSF and the MoH should work to ensure linkages to long-term care and support for meningitis survivors and their caregivers. We were unable to find all cases, so the true prevalence of sequelae among survivors may differ. This follow-up survey used simple methods adapted for in-home evaluation, and formal audiometry may have led to detection of more subtle hearing loss.
CONFLICTS OF INTEREST
None declared
Conference Material > Abstract
Al Kady C, Moussally K, Caluwaerts S, Chreif W, Dibiasi J, et al.
MSF Scientific Days International 2023. 2023 June 7; DOI:10.57740/73jr-dg45
INTRODUCTION
Inappropriate use of antibiotics is widespread, and one of the main drivers for antimicrobial resistance (AMR). In pregnant women with suspected urinary tract infection (UTI), studies have suggested antibiotic over-use in up to 96%; use may be particularly high in settings with limited diagnostic resources and where reliant on symptomatic approaches. In south Beirut, specifically within camps where refugees settle and living conditions are poor, MSF has been operational since 2014 as the main provider of free primary healthcare services as well as sexual and reproductive health (SRH) care. Current MSF protocols operational in this setting recommend the use of urine dipsticks for UTI screening in pregnant women, followed by empirical antibiotic treatment for those with a positive result (positive for nitrites and/or leucocytes).
METHODS
In 2021, around 6,300 (24%) of the total 26,300 antenatal care (ANC) consultations conducted had a suspected UTI, based on urine dipstick results, and all those suspected with UTI were prescribed antibiotics. A prospective study was conducted between April and July 2022, to determine if adding urine
culture, following positive urine dipstick, to the protocol would reduce the use of unnecessary antibiotics. We used descriptive statistics to describe the population and compare positive and negative urine cultures. We calculated the proportion of patients receiving appropriate or inappropriate antibiotics.
ETHICS
This study was approved by the MSF Ethics Review Board, and by the ethics committee of the Lebanese American University.
RESULTS
A total of 449 pregnant women with suspected UTI were included in this study; all received urine culture. 81 (18%) were culture-positive. Under usual practice, 368 women (82%) would have been overprescribed antibiotics, based solely on urine dipstick results. 197 (44%) of the cohort were symptomatic, and were given empirical antibiotic treatment, with cefixime administered to 42 (21%) women and fosfomycin to 155 (79%). Escherichia coli (79%) was the most common bacterial species isolated, followed by Proteus (11%). In addition, among the 81 positive cultures, 4 (5%) were found resistant to fosfomycin and 39 (48%) to cefixim
CONCLUSION
These study findings reinforce concern around potential over prescription of unnecessary antibiotics in such populations, which could contribute to a potential rise in AMR. In addition, resistance to cefixime, one of the recommended antibiotics to treat UTI’s, is relatively high in this community. In contexts where urine culture is feasible, not costly, accessible, and results rapidly available, particularly with large cohorts of patients, urine culture should be the main method used to diagnose UTI; treatment should be based on microbiology/antibiotic sensitivity results.
CONFLICTS OF INTEREST
None declared.
Inappropriate use of antibiotics is widespread, and one of the main drivers for antimicrobial resistance (AMR). In pregnant women with suspected urinary tract infection (UTI), studies have suggested antibiotic over-use in up to 96%; use may be particularly high in settings with limited diagnostic resources and where reliant on symptomatic approaches. In south Beirut, specifically within camps where refugees settle and living conditions are poor, MSF has been operational since 2014 as the main provider of free primary healthcare services as well as sexual and reproductive health (SRH) care. Current MSF protocols operational in this setting recommend the use of urine dipsticks for UTI screening in pregnant women, followed by empirical antibiotic treatment for those with a positive result (positive for nitrites and/or leucocytes).
METHODS
In 2021, around 6,300 (24%) of the total 26,300 antenatal care (ANC) consultations conducted had a suspected UTI, based on urine dipstick results, and all those suspected with UTI were prescribed antibiotics. A prospective study was conducted between April and July 2022, to determine if adding urine
culture, following positive urine dipstick, to the protocol would reduce the use of unnecessary antibiotics. We used descriptive statistics to describe the population and compare positive and negative urine cultures. We calculated the proportion of patients receiving appropriate or inappropriate antibiotics.
ETHICS
This study was approved by the MSF Ethics Review Board, and by the ethics committee of the Lebanese American University.
RESULTS
A total of 449 pregnant women with suspected UTI were included in this study; all received urine culture. 81 (18%) were culture-positive. Under usual practice, 368 women (82%) would have been overprescribed antibiotics, based solely on urine dipstick results. 197 (44%) of the cohort were symptomatic, and were given empirical antibiotic treatment, with cefixime administered to 42 (21%) women and fosfomycin to 155 (79%). Escherichia coli (79%) was the most common bacterial species isolated, followed by Proteus (11%). In addition, among the 81 positive cultures, 4 (5%) were found resistant to fosfomycin and 39 (48%) to cefixim
CONCLUSION
These study findings reinforce concern around potential over prescription of unnecessary antibiotics in such populations, which could contribute to a potential rise in AMR. In addition, resistance to cefixime, one of the recommended antibiotics to treat UTI’s, is relatively high in this community. In contexts where urine culture is feasible, not costly, accessible, and results rapidly available, particularly with large cohorts of patients, urine culture should be the main method used to diagnose UTI; treatment should be based on microbiology/antibiotic sensitivity results.
CONFLICTS OF INTEREST
None declared.
Conference Material > Abstract
Pasquier E, Lissouba P, Moore AM, Owolabi OO, Chen H, et al.
MSF Scientific Days International 2023. 2023 June 7; DOI:10.57740/pq3n-my95
INTRODUCTION
Abortion-related complications are one of the five main causes of maternal mortality. However, research about abortion is very limited in fragile and conflict-affected settings. We aimed to describe the severity of abortion-related complications and contributing factors in two MSF-supported referral hospitals; one in a rural setting, northern Nigeria, and one in the capital city, Bangui, in the Central African Republic (CAR).
METHODS
This cross-sectional mixed-methods study included four components: 1) a clinical study using prospective review of medical records for women presenting with abortion-related complications between November 2019 and July 2021; 2) a quantitative survey among hospitalized women, to identify contributing factors for severe complications; 3) a qualitative study to understand the care pathways of women with severe complications; and 4) a knowledge, attitude, and practice (KAP) survey among health professionals providing post-abortion care in the two hospitals. The clinical study and the quantitative survey used the methodology of the WHO multi-country study on abortion led in 11 sub-Saharan African countries in stable contexts.
ETHICS
This study was approved by the MSF Ethics Review Board, the Central African Republic’s Comité Scientifique Chargé de la Validation des Protocoles d’Etude et des Résultats de Recherche en Santé, and by the Guttmacher Institute International Review Board.
RESULTS
520 and 548 women comprised the clinical study enrollees for the Nigerian and CAR settings, respectively; of these, 360 and 362, respectively, participated in the quantitative survey. Of these women, 66 in Nigeria and 18 in CAR were interviewed for the qualitative study. Lasty, 140 and 84 health providers in Nigeria and CAR, respectively, participated in the KAP survey. The severity of abortion complications was high: 348 (67%) and 278 (50,7%) of women had a severe complication (potentially life-threatening, near-miss, or death) respectively in Nigerian and CAR hospitals. The KAP survey showed that almost 60% and 91% of health providers in Nigerian and CAR hospitals respectively, personally knew a woman who had died from abortion complications. Among women who did not have severe bleeding (146 in Nigeria and 231 in CAR), anemia was nonetheless frequent, affecting 66.7% of women in Nigeria and 37.6% in CAR. Among women participating in the quantitative survey, 23% in Nigeria and 45% in CAR reported having induced their abortion. Among them, 97% in Nigeria and almost 80% in CAR used unsafe methods. In CAR, qualitative data indicated that these included unsafe instrumental evacuations performed by unskilled individuals, and self-administered decoctions of traditional ingredients such as herbs, roots, or vegetables, ingested either alone or in combination with pharmaceutical drugs. In Nigeria, 50% did not want to be pregnant but fewer than 3% reported using contraception at the start of the index pregnancy. In CAR, 56% did not want the pregnancy, but 37% of women reported using contraception at its start. Women faced long delays accessing care, with 50% of hospitalized women in both settings taking two or more days to reach adequate post-abortion care after the onset of symptoms. Nevertheless, delays were worse in Nigeria where 27% took six days or more to access those care, versus 16% in CAR. Qualitative data indicated that factors implicated in longer delays included delayed recognition of danger signs necessitating medical care, unsuccessful attempts to self-manage symptoms, internalized stigma causing fear of disclosure among women reporting induced abortion, and in Nigeria, requiring permission to seek care. In both settings, structural barriers associated with lack of capacity and low quality of care in local health care structures, and transport difficulties to access adequate care also increased delays. Lastly, despite restrictive legal environments in both contexts, the KAP survey revealed that most health providers (74% in Nigeria and 67% in CAR) considered that access to safe abortion care was the right of every woman.
CONCLUSION
Our data suggests a higher severity of abortion-related complications, as compared to WHO data from African hospitals in more stable settings. Factors that could contribute to such high severity include greater delays in accessing post-abortion care, decreased access to contraception and safe abortion care, resulting in unsafe abortions; and food insecurity leading to iron deficiencies and chronic anaemia. The results highlight the need for better access to safe abortion care, contraception, and high-quality post-abortion care, to prevent and manage complications of abortions in fragile and conflict-affected settings.
CONFLICTS OF INTEREST
None declared
Abortion-related complications are one of the five main causes of maternal mortality. However, research about abortion is very limited in fragile and conflict-affected settings. We aimed to describe the severity of abortion-related complications and contributing factors in two MSF-supported referral hospitals; one in a rural setting, northern Nigeria, and one in the capital city, Bangui, in the Central African Republic (CAR).
METHODS
This cross-sectional mixed-methods study included four components: 1) a clinical study using prospective review of medical records for women presenting with abortion-related complications between November 2019 and July 2021; 2) a quantitative survey among hospitalized women, to identify contributing factors for severe complications; 3) a qualitative study to understand the care pathways of women with severe complications; and 4) a knowledge, attitude, and practice (KAP) survey among health professionals providing post-abortion care in the two hospitals. The clinical study and the quantitative survey used the methodology of the WHO multi-country study on abortion led in 11 sub-Saharan African countries in stable contexts.
ETHICS
This study was approved by the MSF Ethics Review Board, the Central African Republic’s Comité Scientifique Chargé de la Validation des Protocoles d’Etude et des Résultats de Recherche en Santé, and by the Guttmacher Institute International Review Board.
RESULTS
520 and 548 women comprised the clinical study enrollees for the Nigerian and CAR settings, respectively; of these, 360 and 362, respectively, participated in the quantitative survey. Of these women, 66 in Nigeria and 18 in CAR were interviewed for the qualitative study. Lasty, 140 and 84 health providers in Nigeria and CAR, respectively, participated in the KAP survey. The severity of abortion complications was high: 348 (67%) and 278 (50,7%) of women had a severe complication (potentially life-threatening, near-miss, or death) respectively in Nigerian and CAR hospitals. The KAP survey showed that almost 60% and 91% of health providers in Nigerian and CAR hospitals respectively, personally knew a woman who had died from abortion complications. Among women who did not have severe bleeding (146 in Nigeria and 231 in CAR), anemia was nonetheless frequent, affecting 66.7% of women in Nigeria and 37.6% in CAR. Among women participating in the quantitative survey, 23% in Nigeria and 45% in CAR reported having induced their abortion. Among them, 97% in Nigeria and almost 80% in CAR used unsafe methods. In CAR, qualitative data indicated that these included unsafe instrumental evacuations performed by unskilled individuals, and self-administered decoctions of traditional ingredients such as herbs, roots, or vegetables, ingested either alone or in combination with pharmaceutical drugs. In Nigeria, 50% did not want to be pregnant but fewer than 3% reported using contraception at the start of the index pregnancy. In CAR, 56% did not want the pregnancy, but 37% of women reported using contraception at its start. Women faced long delays accessing care, with 50% of hospitalized women in both settings taking two or more days to reach adequate post-abortion care after the onset of symptoms. Nevertheless, delays were worse in Nigeria where 27% took six days or more to access those care, versus 16% in CAR. Qualitative data indicated that factors implicated in longer delays included delayed recognition of danger signs necessitating medical care, unsuccessful attempts to self-manage symptoms, internalized stigma causing fear of disclosure among women reporting induced abortion, and in Nigeria, requiring permission to seek care. In both settings, structural barriers associated with lack of capacity and low quality of care in local health care structures, and transport difficulties to access adequate care also increased delays. Lastly, despite restrictive legal environments in both contexts, the KAP survey revealed that most health providers (74% in Nigeria and 67% in CAR) considered that access to safe abortion care was the right of every woman.
CONCLUSION
Our data suggests a higher severity of abortion-related complications, as compared to WHO data from African hospitals in more stable settings. Factors that could contribute to such high severity include greater delays in accessing post-abortion care, decreased access to contraception and safe abortion care, resulting in unsafe abortions; and food insecurity leading to iron deficiencies and chronic anaemia. The results highlight the need for better access to safe abortion care, contraception, and high-quality post-abortion care, to prevent and manage complications of abortions in fragile and conflict-affected settings.
CONFLICTS OF INTEREST
None declared
Conference Material > Abstract
Stringer B, Lowton K, Cusinato M, Fielding K, Liverko I, et al.
MSF Scientific Days International 2023. 2023 June 7; DOI:10.57740/0589-cg13
INTRODUCTION
The TB-PRACTECAL study trialed a shorter, more tolerable regimen of oral drugs than standard of care (SoC) – which can last for up to 20 months and involve both injectables and up to 20 tablets a day. In this sub-study, PRACTECAL-PRO, we measured and explored trial participant quality of life, experiences, and perspectives on treatment, to understand outcomes more fully. Both studies were conducted in Uzbekistan, South Africa, and Belarus.
METHODS
We conducted a mixed-methods evaluation using quality of life (QoL) surveys and in-depth interviews. Participants in investigational and SoC arms completed the Short Form 12 (SF-12) and St George’s Respiratory Questionnaire (SGRQ) at four timepoints (baseline, 12, 24, and 48 weeks). Healthy age- and sex-matched volunteers were surveyed at a single timepoint to establish locally relevant controls. Participants from investigational arms were purposively sampled for in-depth interviews to describe qualitatively patient satisfaction and experience with the investigational arm trial, including factors enabling toleration or rejection of a novel treatment by patients.
ETHICS
This study was approved by the MSF Ethics Review Board and by the ethics review committees of the Ministry of Health of the Republic of Uzbekistan; the Republican Scientific and Practical Centre for Pulmonology and Tuberculosis, Belarus; the regulatory authority of the Ministry of Health of the Republic of Belarus and Pharma Ethics Independent Ethics Committee, South Africa.
RESULTS
Overall, of 137 trial participants 28.5% (39) and 71.5% (98) were randomised to the SoC arm and one of three investigational arms, respectively. Statistically significant univariate scores by arm were observed at week 48 for SGRQ Impact domain (median -3.8, 95% confidence interval (CI), -5.7 to 0.0) and at week 24 for SF-12 physical component score (median 3.1, 95%CI 0.2 to 6.7). Longitudinal analysis showed that the proportional reduction in SGRQ scores per month was higher in the investigational group compared to the SoC for all domains and the total score. For both the SGRQ and SF-12, baseline scores indicated worse quality of life for the trial participant group (that is, investigational arms and SoC together) than for the healthy control group. Qualitative analysis showed early treatment satisfaction was a useful predictor of better adherence. Treatment acceptability was linked to participants’ support networks and their experience of counselling and clinical advice. Tolerability of the regimen helped reassure patients and household members on efficacy and value of the treatment. Participants reported that early improvement helped them return to productive lives sooner, with the potential to address social determinants with financial protection schemes for a shorter investment period. Patient perspectives around residual burden of disease can help inform clinicians about ongoing care.
CONCLUSION
All PRACTECAL-PRO participants reported worse generic and disease-specific QoL at baseline, compared to an age and sex-matched healthy control group. Participants taking a novel shortened oral regimens demonstrated both a quicker improvement in their respiratory disease-specific QoL over 48 weeks than those receiving SoC, and an improvement that exceeded the SGRQ’s minimum clinically important difference. In-depth interviews give insights suggesting investment toward patient-sensitive and socially responsive treatment and care. For interviewees, the supportive care experienced was as important as their satisfaction and tolerability of the novel drug regimen. Patient perspectives are an essential component of assessing clinical trial outcomes.
CONFLCITS OF INTEREST
None declared.
The TB-PRACTECAL study trialed a shorter, more tolerable regimen of oral drugs than standard of care (SoC) – which can last for up to 20 months and involve both injectables and up to 20 tablets a day. In this sub-study, PRACTECAL-PRO, we measured and explored trial participant quality of life, experiences, and perspectives on treatment, to understand outcomes more fully. Both studies were conducted in Uzbekistan, South Africa, and Belarus.
METHODS
We conducted a mixed-methods evaluation using quality of life (QoL) surveys and in-depth interviews. Participants in investigational and SoC arms completed the Short Form 12 (SF-12) and St George’s Respiratory Questionnaire (SGRQ) at four timepoints (baseline, 12, 24, and 48 weeks). Healthy age- and sex-matched volunteers were surveyed at a single timepoint to establish locally relevant controls. Participants from investigational arms were purposively sampled for in-depth interviews to describe qualitatively patient satisfaction and experience with the investigational arm trial, including factors enabling toleration or rejection of a novel treatment by patients.
ETHICS
This study was approved by the MSF Ethics Review Board and by the ethics review committees of the Ministry of Health of the Republic of Uzbekistan; the Republican Scientific and Practical Centre for Pulmonology and Tuberculosis, Belarus; the regulatory authority of the Ministry of Health of the Republic of Belarus and Pharma Ethics Independent Ethics Committee, South Africa.
RESULTS
Overall, of 137 trial participants 28.5% (39) and 71.5% (98) were randomised to the SoC arm and one of three investigational arms, respectively. Statistically significant univariate scores by arm were observed at week 48 for SGRQ Impact domain (median -3.8, 95% confidence interval (CI), -5.7 to 0.0) and at week 24 for SF-12 physical component score (median 3.1, 95%CI 0.2 to 6.7). Longitudinal analysis showed that the proportional reduction in SGRQ scores per month was higher in the investigational group compared to the SoC for all domains and the total score. For both the SGRQ and SF-12, baseline scores indicated worse quality of life for the trial participant group (that is, investigational arms and SoC together) than for the healthy control group. Qualitative analysis showed early treatment satisfaction was a useful predictor of better adherence. Treatment acceptability was linked to participants’ support networks and their experience of counselling and clinical advice. Tolerability of the regimen helped reassure patients and household members on efficacy and value of the treatment. Participants reported that early improvement helped them return to productive lives sooner, with the potential to address social determinants with financial protection schemes for a shorter investment period. Patient perspectives around residual burden of disease can help inform clinicians about ongoing care.
CONCLUSION
All PRACTECAL-PRO participants reported worse generic and disease-specific QoL at baseline, compared to an age and sex-matched healthy control group. Participants taking a novel shortened oral regimens demonstrated both a quicker improvement in their respiratory disease-specific QoL over 48 weeks than those receiving SoC, and an improvement that exceeded the SGRQ’s minimum clinically important difference. In-depth interviews give insights suggesting investment toward patient-sensitive and socially responsive treatment and care. For interviewees, the supportive care experienced was as important as their satisfaction and tolerability of the novel drug regimen. Patient perspectives are an essential component of assessing clinical trial outcomes.
CONFLCITS OF INTEREST
None declared.
Conference Material > Abstract
Solomos A, Musa AM, Mbui J, Mohammed R, Olobo J, et al.
MSF Scientific Days International 2023. 2023 June 7; DOI:10.57740/y4z2-pq54
INTRODUCTION
The parasitic disease visceral leishmaniasis (VL) is most commonly caused by Leishmania donovani in eastern Africa, currently the region with highest burden worldwide. Current treatment for VL comprises the combination of sodium stibogluconate and paromomycin, SSG/PM; this is toxic, painful, and requires hospitalisation and daily injections. Treatments are urgently needed that are safe, effective, and appropriate for use in remote areas.
METHODS
We conducted a phase III open-label randomised non-inferiority trial in Ethiopia, Kenya, Sudan, and Uganda. The trial used a parallel-arm design with two arms, comparing the combination regimen of 20 mg/kg/day paromomycin and allometric miltefosine (MF) for 14 days with the current 17-day standard of care, 20 mg/kg/day SSG and 15 mg/kg/day PM. We enrolled adults and children aged 4-50 years with primary VL, without HIV or severe concomitant disease co-infection. The primary endpoint was definitive cure at 6 months’ follow-up.
ETHICS
This study was approved by the MSF Ethics Review Board and by ethics committees at the Institute of Endemic Diseases, Khartoum, Sudan; Kenya Medical Research Institute, Nairobi, Kenya; Makerere University, Uganda; and the University of Gondar, Ethiopia. Clinicaltrials.gov registry number, NCT03129646.
RESULTS
439 predominantly male (80%) patients aged 4 to 50 years were recruited over a period of 29 months. A similar proportion of patients in the PM/MF and the SSG/PM arms achieved definitive cure at 6-month follow-up in primary efficacy analysis using modified intention-to-treat; mITT; 91.2% cure for PM/MF (97.5% confidence interval, CI, 85-98.6) and 91.8% for SSG/PM (97.5% CI, 85.6-99.2). Non-inferiority was not demonstrated in the mITT population, with the upper limit of the 97.5% CI, 7.4%, slightly exceeding the non-inferiority margin of 7%. However, the per protocol analysis did show non-inferiority, with 92% (97.5% CI, 85-98.5) cure in the PM/MF arm, as compared to 91.7% (97.5% CI, 84.7-98.2) in the SSG/PM arm. Most adverse drug reactions (ADR’s) were mild to moderate. The most common expected ADR’s were MF-related vomiting, and PM-related injection site pain and hypoacusis. ADR’s suggesting SSG-related cardiac toxicity were reported in 6.5% (11/170) of patients in the SSG/PM arm. Eighteen serious adverse events were reported in 13 patients, four of which were considered related to study drugs. Fatality rate in the trial was 0.9% (4/439), with one death judged due to SSG-related cardiotoxicity.
CONCLUSION
The results of this study demonstrate that the 14-day PM/MF regimen achieved a clinically meaningful rate of cure with very similar efficacy to the standard of care, SSG/PM. It was generally well tolerated, with ADR’s as expected, based on the known safety profiles of study drugs. The PM/MF regimen has one fewer painful injection per day, a 3-day shorter treatment duration, and with no risk of SSG-associated life threating cardiotoxicity, as compared to SSG/PM. This regimen may therefore provide a more patient-friendly alternative for adults and children with VL in eastern Africa.
CONFLICTS OF INTEREST
None declared
The parasitic disease visceral leishmaniasis (VL) is most commonly caused by Leishmania donovani in eastern Africa, currently the region with highest burden worldwide. Current treatment for VL comprises the combination of sodium stibogluconate and paromomycin, SSG/PM; this is toxic, painful, and requires hospitalisation and daily injections. Treatments are urgently needed that are safe, effective, and appropriate for use in remote areas.
METHODS
We conducted a phase III open-label randomised non-inferiority trial in Ethiopia, Kenya, Sudan, and Uganda. The trial used a parallel-arm design with two arms, comparing the combination regimen of 20 mg/kg/day paromomycin and allometric miltefosine (MF) for 14 days with the current 17-day standard of care, 20 mg/kg/day SSG and 15 mg/kg/day PM. We enrolled adults and children aged 4-50 years with primary VL, without HIV or severe concomitant disease co-infection. The primary endpoint was definitive cure at 6 months’ follow-up.
ETHICS
This study was approved by the MSF Ethics Review Board and by ethics committees at the Institute of Endemic Diseases, Khartoum, Sudan; Kenya Medical Research Institute, Nairobi, Kenya; Makerere University, Uganda; and the University of Gondar, Ethiopia. Clinicaltrials.gov registry number, NCT03129646.
RESULTS
439 predominantly male (80%) patients aged 4 to 50 years were recruited over a period of 29 months. A similar proportion of patients in the PM/MF and the SSG/PM arms achieved definitive cure at 6-month follow-up in primary efficacy analysis using modified intention-to-treat; mITT; 91.2% cure for PM/MF (97.5% confidence interval, CI, 85-98.6) and 91.8% for SSG/PM (97.5% CI, 85.6-99.2). Non-inferiority was not demonstrated in the mITT population, with the upper limit of the 97.5% CI, 7.4%, slightly exceeding the non-inferiority margin of 7%. However, the per protocol analysis did show non-inferiority, with 92% (97.5% CI, 85-98.5) cure in the PM/MF arm, as compared to 91.7% (97.5% CI, 84.7-98.2) in the SSG/PM arm. Most adverse drug reactions (ADR’s) were mild to moderate. The most common expected ADR’s were MF-related vomiting, and PM-related injection site pain and hypoacusis. ADR’s suggesting SSG-related cardiac toxicity were reported in 6.5% (11/170) of patients in the SSG/PM arm. Eighteen serious adverse events were reported in 13 patients, four of which were considered related to study drugs. Fatality rate in the trial was 0.9% (4/439), with one death judged due to SSG-related cardiotoxicity.
CONCLUSION
The results of this study demonstrate that the 14-day PM/MF regimen achieved a clinically meaningful rate of cure with very similar efficacy to the standard of care, SSG/PM. It was generally well tolerated, with ADR’s as expected, based on the known safety profiles of study drugs. The PM/MF regimen has one fewer painful injection per day, a 3-day shorter treatment duration, and with no risk of SSG-associated life threating cardiotoxicity, as compared to SSG/PM. This regimen may therefore provide a more patient-friendly alternative for adults and children with VL in eastern Africa.
CONFLICTS OF INTEREST
None declared
Conference Material > Abstract
Nesbitt RC, Rumunu J, Asilaza VK, Gitahi P, Nkemenang P, et al.
MSF Scientific Days International 2023. 2023 June 7; DOI:10.57740/qdmj-8n51
INTRODUCTION
A three-dose recombinant vaccine against hepatitis E, Hecolin, has been licensed for use in China since 2011. While not recommended for routine use due to lack of evidence on burden in the general population, in 2015 WHO recommended the vaccine be considered in outbreaks. As of early 2022 however, the vaccine had not been used in outbreak settings. A reduced-dose vaccination schedule, if effective, could make the vaccine an important outbreak response tool. In response to an increase in hepatitis E cases in a camp for internally displaced people in Bentiu, South Sudan in late 2021, MSF and South Sudan’s MoH implemented the first ever mass reactive vaccination campaign against hepatitis E virus (HEV). Three vaccination rounds took place in March, April, and October 2022, targeting 26,848 individuals aged 16-40 years, including pregnant women. We set up enhanced surveillance and conducted a case-control study to estimate two-dose vaccine effectiveness (VE).
METHODS
All suspected cases presenting to the MSF hospital who were eligible for vaccination and provided consent were enrolled in the study, comprising a questionnaire, laboratory examinations and a follow-up visit after 2-4 weeks. Vaccine-eligible suspect cases were matched to community controls. We estimated twodose VE against probable (anti-HEV IgM positive with elevated alanine transaminase, or a four-fold rise in IgG in paired samples) and confirmed (HEV RNA positive) hepatitis E using conditional logistic regression models.
ETHICS
This study was approved by the MSF and South Sudan Ethics Review Boards.
RESULTS
Considering the period two weeks after the second vaccination round between 11 May and 30 December 2022, 287 vaccine-eligible suspect hepatitis E cases were enrolled, including one probable and 16 confirmed cases. Among probable and confirmed cases, two (11.8%) were vaccinated with two or more doses compared to 40 (40%) of their 100 matched controls. We estimated a VE of 86.5% (95% confidence interval, CI, 36.3–97.1) for one/two doses and 83.9% (95% CI, -33.1–98.1%) for two doses. In addition to this direct protection, we observed a 5.5-fold decrease in the incidence rate of probable/confirmed cases hepatitis E cases before and after the second dose campaign (including those not eligible for vaccination). Laboratory confirmation of hepatitis E infection is ongoing, and we expect to revise VE estimates and incidence based on these results.
CONCLUSION
Following the first mass reactive vaccination campaign against hepatitis E, incidence has declined. Preliminary VE estimates suggest that the short-term protection provided by this reduced dose regimen may be high and potentially sufficient for outbreak response.
CONFLICTS OF INTEREST
None declared
A three-dose recombinant vaccine against hepatitis E, Hecolin, has been licensed for use in China since 2011. While not recommended for routine use due to lack of evidence on burden in the general population, in 2015 WHO recommended the vaccine be considered in outbreaks. As of early 2022 however, the vaccine had not been used in outbreak settings. A reduced-dose vaccination schedule, if effective, could make the vaccine an important outbreak response tool. In response to an increase in hepatitis E cases in a camp for internally displaced people in Bentiu, South Sudan in late 2021, MSF and South Sudan’s MoH implemented the first ever mass reactive vaccination campaign against hepatitis E virus (HEV). Three vaccination rounds took place in March, April, and October 2022, targeting 26,848 individuals aged 16-40 years, including pregnant women. We set up enhanced surveillance and conducted a case-control study to estimate two-dose vaccine effectiveness (VE).
METHODS
All suspected cases presenting to the MSF hospital who were eligible for vaccination and provided consent were enrolled in the study, comprising a questionnaire, laboratory examinations and a follow-up visit after 2-4 weeks. Vaccine-eligible suspect cases were matched to community controls. We estimated twodose VE against probable (anti-HEV IgM positive with elevated alanine transaminase, or a four-fold rise in IgG in paired samples) and confirmed (HEV RNA positive) hepatitis E using conditional logistic regression models.
ETHICS
This study was approved by the MSF and South Sudan Ethics Review Boards.
RESULTS
Considering the period two weeks after the second vaccination round between 11 May and 30 December 2022, 287 vaccine-eligible suspect hepatitis E cases were enrolled, including one probable and 16 confirmed cases. Among probable and confirmed cases, two (11.8%) were vaccinated with two or more doses compared to 40 (40%) of their 100 matched controls. We estimated a VE of 86.5% (95% confidence interval, CI, 36.3–97.1) for one/two doses and 83.9% (95% CI, -33.1–98.1%) for two doses. In addition to this direct protection, we observed a 5.5-fold decrease in the incidence rate of probable/confirmed cases hepatitis E cases before and after the second dose campaign (including those not eligible for vaccination). Laboratory confirmation of hepatitis E infection is ongoing, and we expect to revise VE estimates and incidence based on these results.
CONCLUSION
Following the first mass reactive vaccination campaign against hepatitis E, incidence has declined. Preliminary VE estimates suggest that the short-term protection provided by this reduced dose regimen may be high and potentially sufficient for outbreak response.
CONFLICTS OF INTEREST
None declared
Conference Material > Abstract
van Zandvoort K, Bobe M, Buqul A, Ismail M, Saed M, et al.
MSF Scientific Days International 2023. 2023 June 7; DOI:10.57740/cxek-yg24
INTRODUCTION
Despite a likely high burden of disease caused by Streptococcus pneumoniae in humanitarian crises, pneumococcal conjugate vaccines (PCV’s) are rarely used in such settings. Routine immunisation is rarely feasible in crises, and there is little evidence on alternative delivery strategies for PCV. We used modelling to evaluate the effects of different vaccination strategies within humanitarian crisis settings, aiming to identify those which could quickly reduce and sustain low transmission of vaccine serotypes.
METHODS
We conducted a nested carriage and contact survey in a camp for internally displaced people (IDP) in Somaliland to parameterise a transmission model and used it to assess the potential impact and optimal age targeting of PCV campaigns. We extrapolated this model to other representative humanitarian crisis settings: an acute-phase IDP camp, a protracted crisis in a rural setting, and an urban setting with mixed IDP and host communities. For each we explored the impact and efficiency of campaigns with different target age groups and dosing strategies.
ETHICS
This study was approved by the Ethics Review Boards of the London School of Hygiene and Tropical Medicine and the Republic of Somaliland Ministry of Health Development.
RESULTS
We found high prevalence of nasopharyngeal carriage of Streptococcus pneumoniae; 37% (95% confidence interval (CI), 32-42) in all ages, and 76% (95% CI, 70-82) in children <5 years in the Somaliland IDP camp. 53% (95% CI, 45-61) of serotypes are included in the PCV13 vaccine. People had, on average, 9 (9-10) contacts per day, with high mixing rates between children and intergenerational contacts in older age groups. Our model projects that, for the Somaliland IDP camp, a single PCV campaign including children <5 years can temporarily establish substantial herd protection, averting 37% (95% credible interval (CrI) 24-48) of invasive pneumococcal disease cases in the 2 years following the campaign. Extending age eligibility to children up to 10 or 15 years old could further increase this impact by 49% (95% CrI, 39-50) and 53% (95% CrI, 40-64) respectively. Increased migration rates and close contact with unvaccinated host populations reduces the impact. These factors might require wider age targeting and more frequent repeat campaigns until routine services could be re-established.
CONCLUSION
We show that PCV campaigns could be an effective option to reduce the burden of pneumococcal disease in humanitarian crises until routine immunisation can be implemented. Our results are based on modelled estimates, intervention studies are needed to evaluate their feasibility and effectiveness in real settings.
CONFLICTS OF INTEREST
None declared
Despite a likely high burden of disease caused by Streptococcus pneumoniae in humanitarian crises, pneumococcal conjugate vaccines (PCV’s) are rarely used in such settings. Routine immunisation is rarely feasible in crises, and there is little evidence on alternative delivery strategies for PCV. We used modelling to evaluate the effects of different vaccination strategies within humanitarian crisis settings, aiming to identify those which could quickly reduce and sustain low transmission of vaccine serotypes.
METHODS
We conducted a nested carriage and contact survey in a camp for internally displaced people (IDP) in Somaliland to parameterise a transmission model and used it to assess the potential impact and optimal age targeting of PCV campaigns. We extrapolated this model to other representative humanitarian crisis settings: an acute-phase IDP camp, a protracted crisis in a rural setting, and an urban setting with mixed IDP and host communities. For each we explored the impact and efficiency of campaigns with different target age groups and dosing strategies.
ETHICS
This study was approved by the Ethics Review Boards of the London School of Hygiene and Tropical Medicine and the Republic of Somaliland Ministry of Health Development.
RESULTS
We found high prevalence of nasopharyngeal carriage of Streptococcus pneumoniae; 37% (95% confidence interval (CI), 32-42) in all ages, and 76% (95% CI, 70-82) in children <5 years in the Somaliland IDP camp. 53% (95% CI, 45-61) of serotypes are included in the PCV13 vaccine. People had, on average, 9 (9-10) contacts per day, with high mixing rates between children and intergenerational contacts in older age groups. Our model projects that, for the Somaliland IDP camp, a single PCV campaign including children <5 years can temporarily establish substantial herd protection, averting 37% (95% credible interval (CrI) 24-48) of invasive pneumococcal disease cases in the 2 years following the campaign. Extending age eligibility to children up to 10 or 15 years old could further increase this impact by 49% (95% CrI, 39-50) and 53% (95% CrI, 40-64) respectively. Increased migration rates and close contact with unvaccinated host populations reduces the impact. These factors might require wider age targeting and more frequent repeat campaigns until routine services could be re-established.
CONCLUSION
We show that PCV campaigns could be an effective option to reduce the burden of pneumococcal disease in humanitarian crises until routine immunisation can be implemented. Our results are based on modelled estimates, intervention studies are needed to evaluate their feasibility and effectiveness in real settings.
CONFLICTS OF INTEREST
None declared
Conference Material > Abstract
Sadique S, Beversluis D, Caleo GNC, Carter W, Chowdhury SM, et al.
MSF Scientific Days International 2023. 2023 June 7; DOI:10.57740/bzht-7p36
INTRODUCTION
Addressing occupational injury and disease has been declared a national priority in Bangladesh. However critical gaps remain in improving work safety in small-scale peri-urban factories. We aimed to assess the feasibility of collaborating with owners and workers to design and implement interventions to improve work safety in two metal factories in Kamrangirchar, Dhaka.
METHODS
We implemented a participatory mixed methods before-and-after study with four phases. Phase 1 explored the dynamics of injuries, hazards, and risks using hazard assessments, surveillance, in-depth interviews, and focus group discussions. Triangulation of phase 1 findings informed design and implementation of intervention packages implemented in phase 2. In phases 3 and 4, we repeated hazard assessments and used qualitative methods to document changes in hazards and perspectives at 6- and 12-months post-intervention. Observations captured by field notes complemented data generated throughout the study.
ETHICS
The study was approved by the MSF Ethical Review Board (ERB) and by the ERB of the Centre for Injury Prevention and Research, Bangladesh.
RESULTS
Overall 136 workers in two factories (A and B) participated in the study (with a turnover of 41.5%). Surveillance captured 129 injuries during phase 1 (from 10th March 2019 in factory A and 30th April 2019 in factory B, to 31st July 2019), and all workers aged under 18 years experienced incidents. Hazard assessments documented hazard risk scores (HRS) of 54% in factory A and 36% in factory B. Qualitative data indicated workers perceived their work as risky, but explained it was prioritised over their health due to financial necessity. Phase 2 intervention packages included engineering controls, personal protective equipment, infrastructure safety and training. Factory owners and workers actively participated in design and implementation. Phase 3 showed a two-fold reduction in HRS in factory A (24%) and a 1.5-fold reduction (21%) in factory B. Phase 4 hazard assessment revealed that improvement was sustained in one factory; the final HRS was 27% in factory A, but returned to the pre-intervention score of 36% in factory B. Workers explained they observed improvements in workplace safety but noted challenges in sustainability due to owner commitment and worker turnover. Observation and qualitative data revealed complex power dynamics in the factories, as well as power imbalances and risks faced by female and young workers.
CONCLUSION
It was feasible to collaborate with workers and owners to implement interventions aimed at improving work safety. However, sustainability was mixed, and long-standing structural inequities that contribute to poor safety remain. Findings indicate urgent action is needed to improve safety and build an inclusive model of occupational health, including social and protection components, with particular attention for female workers and workers aged under 18.
CONFLICTS OF INTEREST
None declared
Addressing occupational injury and disease has been declared a national priority in Bangladesh. However critical gaps remain in improving work safety in small-scale peri-urban factories. We aimed to assess the feasibility of collaborating with owners and workers to design and implement interventions to improve work safety in two metal factories in Kamrangirchar, Dhaka.
METHODS
We implemented a participatory mixed methods before-and-after study with four phases. Phase 1 explored the dynamics of injuries, hazards, and risks using hazard assessments, surveillance, in-depth interviews, and focus group discussions. Triangulation of phase 1 findings informed design and implementation of intervention packages implemented in phase 2. In phases 3 and 4, we repeated hazard assessments and used qualitative methods to document changes in hazards and perspectives at 6- and 12-months post-intervention. Observations captured by field notes complemented data generated throughout the study.
ETHICS
The study was approved by the MSF Ethical Review Board (ERB) and by the ERB of the Centre for Injury Prevention and Research, Bangladesh.
RESULTS
Overall 136 workers in two factories (A and B) participated in the study (with a turnover of 41.5%). Surveillance captured 129 injuries during phase 1 (from 10th March 2019 in factory A and 30th April 2019 in factory B, to 31st July 2019), and all workers aged under 18 years experienced incidents. Hazard assessments documented hazard risk scores (HRS) of 54% in factory A and 36% in factory B. Qualitative data indicated workers perceived their work as risky, but explained it was prioritised over their health due to financial necessity. Phase 2 intervention packages included engineering controls, personal protective equipment, infrastructure safety and training. Factory owners and workers actively participated in design and implementation. Phase 3 showed a two-fold reduction in HRS in factory A (24%) and a 1.5-fold reduction (21%) in factory B. Phase 4 hazard assessment revealed that improvement was sustained in one factory; the final HRS was 27% in factory A, but returned to the pre-intervention score of 36% in factory B. Workers explained they observed improvements in workplace safety but noted challenges in sustainability due to owner commitment and worker turnover. Observation and qualitative data revealed complex power dynamics in the factories, as well as power imbalances and risks faced by female and young workers.
CONCLUSION
It was feasible to collaborate with workers and owners to implement interventions aimed at improving work safety. However, sustainability was mixed, and long-standing structural inequities that contribute to poor safety remain. Findings indicate urgent action is needed to improve safety and build an inclusive model of occupational health, including social and protection components, with particular attention for female workers and workers aged under 18.
CONFLICTS OF INTEREST
None declared
Conference Material > Abstract
Kerschberger B, Ntshalintshali N, Mafomisa M, Mabhena E, Daka M, et al.
MSF Scientific Days International 2023. 2023 June 7; DOI:10.57740/4e0e-e138
INTRODUCTION
Sexually transmitted infections (STI’s) are a public health threat. Syndromic approaches based on clinical symptoms have been suggested as having poor diagnostic performance, particularly in the type of settings where MSF is operational. We assessed the burden of STI’s and the diagnostic performance of a syndromic approach within an MSF-supported HIV/STI project in Eswatini.
METHODS
We conducted a cross-sectional study, enrolling adults accessing routine HIV testing and antiretroviral care services in six clinics in Shiselweni, from July 2022 to January 2023. HIV testing counselors performed HIV testing and nurses assessed patients for STI’s. Laboratory investigations included antibody-based rapid diagnostic tests (RDT’s) for Treponema pallidum (TP), hepatitis B (HBV) and hepatitis C (HBC). The molecular platform Xpert was used to test urine samples for Chlamydia trachomatis (CT), Neisseria gonorrhoea (NG), Trichomonas vaginalis (TV), Mycoplasma genitalium (MG), vaginal/anal swabs for human papillomavirus (HPV), and plasma for HIV viraemia to test for acute HIV infection (HIV). We calculated the prevalence of STI’s, and assessed diagnostic performance of a syndromic approach to diagnose male urethritis (MUS) and vaginal discharge (VDS) syndromes, versus laboratory-based testing.
ETHICS
This study was approved by the Eswatini Health and Human Research Review Board and by the MSF Ethics Review Board.
RESULTS
Of 1,041 study participants, 682 were women (65.5%), and the median age was 30 (interquartile range, IQR, 24-38) years. Overall, 280 (26.9%) were known HIV-positive and of 755 with unknown HIV status, 30 (4.0%) were newly diagnosed with HIV, of whom seven (23.3%) had AHI. 308 (29.6%) patients had at least one of the following three pathogens identified: NG 121 (11.6%); CT 155 (14.9%); TV 109 (10.5%). MG was detected in 33/330 participants (10.0%). In addition, 105 (10.1%) had antibodies against TP, 49 (4.7%) against HBV, and three (0.3%) against HCV. HPV prevalence was higher in tested women (104/196; 53.1%) versus men (5/27; 18.5%; p=0.001). Prevalence of NG/CT/TP was highest in newly-diagnosed HIV cases (48.2%) versus known HIV-positive cases (26.8%, p=0.019). Based on the syndromic approach, 188/634 (29.7%) had a VDS, and 97/334 (29.0%) a MUS. Diagnostic performance of the syndromic approach was better in men (MUS: sensitivity: 66.7%, specificity 87.5%; positive predictive value, PPV, 70.1%, negative predictive value, NPV, 85.7%), versus women (VDS: sensitivity 35.9%, specificity 72.9%; PPV 35.1%, NPV 73.5%).
CONCLUSION
A high burden of STI’s in Eswatini and poor diagnostic ability of the syndromic approach in this setting, calls for new approaches for STI care in MSF-supported sexual and reproductive health programmes in resource-poor settings.
CONFLICTS OF INTEREST
None declared
Sexually transmitted infections (STI’s) are a public health threat. Syndromic approaches based on clinical symptoms have been suggested as having poor diagnostic performance, particularly in the type of settings where MSF is operational. We assessed the burden of STI’s and the diagnostic performance of a syndromic approach within an MSF-supported HIV/STI project in Eswatini.
METHODS
We conducted a cross-sectional study, enrolling adults accessing routine HIV testing and antiretroviral care services in six clinics in Shiselweni, from July 2022 to January 2023. HIV testing counselors performed HIV testing and nurses assessed patients for STI’s. Laboratory investigations included antibody-based rapid diagnostic tests (RDT’s) for Treponema pallidum (TP), hepatitis B (HBV) and hepatitis C (HBC). The molecular platform Xpert was used to test urine samples for Chlamydia trachomatis (CT), Neisseria gonorrhoea (NG), Trichomonas vaginalis (TV), Mycoplasma genitalium (MG), vaginal/anal swabs for human papillomavirus (HPV), and plasma for HIV viraemia to test for acute HIV infection (HIV). We calculated the prevalence of STI’s, and assessed diagnostic performance of a syndromic approach to diagnose male urethritis (MUS) and vaginal discharge (VDS) syndromes, versus laboratory-based testing.
ETHICS
This study was approved by the Eswatini Health and Human Research Review Board and by the MSF Ethics Review Board.
RESULTS
Of 1,041 study participants, 682 were women (65.5%), and the median age was 30 (interquartile range, IQR, 24-38) years. Overall, 280 (26.9%) were known HIV-positive and of 755 with unknown HIV status, 30 (4.0%) were newly diagnosed with HIV, of whom seven (23.3%) had AHI. 308 (29.6%) patients had at least one of the following three pathogens identified: NG 121 (11.6%); CT 155 (14.9%); TV 109 (10.5%). MG was detected in 33/330 participants (10.0%). In addition, 105 (10.1%) had antibodies against TP, 49 (4.7%) against HBV, and three (0.3%) against HCV. HPV prevalence was higher in tested women (104/196; 53.1%) versus men (5/27; 18.5%; p=0.001). Prevalence of NG/CT/TP was highest in newly-diagnosed HIV cases (48.2%) versus known HIV-positive cases (26.8%, p=0.019). Based on the syndromic approach, 188/634 (29.7%) had a VDS, and 97/334 (29.0%) a MUS. Diagnostic performance of the syndromic approach was better in men (MUS: sensitivity: 66.7%, specificity 87.5%; positive predictive value, PPV, 70.1%, negative predictive value, NPV, 85.7%), versus women (VDS: sensitivity 35.9%, specificity 72.9%; PPV 35.1%, NPV 73.5%).
CONCLUSION
A high burden of STI’s in Eswatini and poor diagnostic ability of the syndromic approach in this setting, calls for new approaches for STI care in MSF-supported sexual and reproductive health programmes in resource-poor settings.
CONFLICTS OF INTEREST
None declared