Journal Article > ResearchFull Text
Ann Trop Med Parasitol. 1 January 2008; Volume 102 (Issue 1); DOI:10.1179/136485908X252142
Mueller YK, Nguimfack A, Cavailler P, Couffignal S, Rwakimari JB, et al.
Ann Trop Med Parasitol. 1 January 2008; Volume 102 (Issue 1); DOI:10.1179/136485908X252142
Between September 2003 and April 2004, the supply of antimonial drugs to Amudat Hospital, in north-eastern Uganda, was interrupted and all cases of visceral leishmaniasis presenting at the hospital could only be treated with amphotericin B deoxycholate (AmB). This allowed the safety and effectiveness of the AmB to be evaluated, in comparison with an historical cohort of patients treated, at the same hospital, with meglumine antimoniate (Sb(V)). Demographic and clinical data were collected before and after treatment. Adverse effects were recorded passively in all the subjects, and actively, using a standardized questionnaire, in a sub-group of the patients given AmB. The in hospital case-fatality 'rates' were 4.8% [95% confidence interval (CI) = 2.4%-8.8%] among the 210 patients treated with AmB and 3.7% (CI = 1.4%-7.9%) among the 161 patients treated with Sb(V) (P>0.20). Adverse effects requiring treatment interruption were rare in both cohorts. Treatment failures (i.e. non-responses or relapses) were observed in 2.9% (CI = 1.2%-6.4%) of the patients treated with AmB and 1.2% (CI = 0.1%-4.4%) of the patients treated with Sb(V) (P>0.20). For the treatment of visceral leishmaniasis in Uganda, AmB therefore had a similar effectiveness and safety profile to that of meglumine antimoniate.
Journal Article > ResearchFull Text
Vaccine. 29 May 2006; Volume 24 (Issue 22); 4890-4895.; DOI:10.1016/j.vaccine.2005.10.006
Cavailler P, Perroud V, Mcchesney M, Ampuero S, Guerin PJ, et al.
Vaccine. 29 May 2006; Volume 24 (Issue 22); 4890-4895.; DOI:10.1016/j.vaccine.2005.10.006
We conducted a study to assess the feasibility and the potential vaccine coverage of a mass vaccination campaign using a two-dose oral cholera vaccine in an urban endemic neighbourhood of Beira, Mozambique. The campaign was conducted from December 2003 to January 2004. Overall 98,152 doses were administered, and vaccine coverage of the target population was 58.6% and 53.6% for the first and second rounds, respectively. The direct cost of the campaign, which excludes the price of the vaccine, amounted to slightly over 90,000 dollars, resulting in the cost per fully vaccinated person of 2.09 dollars, which is relatively high. However, in endemic settings where outbreaks are likely to occur, integrating cholera vaccination into the routine activities of the public health system could reduce such costs.
Conference Material > Slide Presentation
Malou N, Al Asmar M, Fakhri RM, Badaro N, Kanapathipillai R, et al.
MSF Scientific Days International 2021: Innovation. 20 May 2021
Journal Article > ResearchFull Text
Trop Med Int Health. 1 September 2004; Volume 9 (Issue 9); DOI:10.1111/j.1365-3156.2004.01290.x
Stivanello E, Cavailler P, Cassano F, Omar SV, Kariuki D, et al.
Trop Med Int Health. 1 September 2004; Volume 9 (Issue 9); DOI:10.1111/j.1365-3156.2004.01290.x
To provide advice on the rational use of antimalarial drugs, Médecins Sans Frontières conducted a randomized, an open label efficacy study in Kajo Keji, an area of high transmission of malaria in southern Sudan. The efficacy of chloroquine (CQ), sulphadoxine-pyrimethamine (SP) and amodiaquine (AQ) were measured in a 28-day in vivo study, with results corrected by PCR genotyping. Of 2010 children screened, 115 children aged 6-59 months with uncomplicated Plasmodium falciparum malaria were randomized into each group to receive a supervised course of treatment. Of these, 114, 103 and 111 were analysed in the CQ, SP and AQ groups, respectively. The overall parasitological failure rates at day 28 were 93.9% [95% confidence interval (CI) 87.3-97.3] for CQ, 69.9% (95% CI 60.0-78.3) for SP, and 25.2% (95% CI 17.7-34.5) for AQ. These results provide important missing data on antimalarial drug efficacy in southern Sudan. They indicate that none of the drugs could be used in monotherapy and suggest that even in combination with artemisinin, cure rates might not be efficacious enough. We recommend a combination of artemether and lumefantrine as first-line treatment for uncomplicated P. falciparum malaria cases in Kajo Keji county.
Journal Article > ResearchFull Text
Confl Health. 24 October 2018; Volume 12 (Issue 1); 42.; DOI:10.1186/s13031-018-0177-6
El-Khatib, Shah M, Zallappa SN, Nabeth P, Guerra J, et al.
Confl Health. 24 October 2018; Volume 12 (Issue 1); 42.; DOI:10.1186/s13031-018-0177-6
BACKGROUND
It is a challenge in low-resource settings to ensure the availability of complete, timely disease surveillance information. Smartphone applications (apps) have the potential to enhance surveillance data transmission.
METHODS
The Central African Republic (CAR) Ministry of Health and Médecins Sans Frontières (MSF) conducted a 15-week pilot project to test a disease surveillance app, Argus, for 20 conditions in 21 health centers in Mambéré Kadéi district (MK 2016). Results were compared to the usual paper-based surveillance in MK the year prior (MK 2015) and simultaneously in an adjacent health district, Nana-Mambére (NM 2016). Wilcoxon rank sum and Kaplan-Meier analyses compared report completeness and timeliness; the cost of the app, and users' perceptions of its usability were assessed.
RESULTS
Two hundred seventy-one weekly reports sent by app identified 3403 cases and 63 deaths; 15 alerts identified 28 cases and 4 deaths. Median completeness (IQR) for MK 2016, 81% (81-86%), was significantly higher than in MK 2015 (31% (24-36%)), and NM 2016 (52% (48-57)) (p < 0.01). Median timeliness (IQR) for MK 2016, 50% (39-57%) was also higher than in MK 2015, 19% (19-24%), and NM 2016 29% (24-36%) (p < 0.01). Kaplan-Meier Survival Analysis showed a significant progressive reduction in the time taken to transmit reports over the 15-week period (p < 0.01). Users ranked the app's usability as greater than 4/5 on all dimensions. The total cost of the 15-week pilot project was US$40,575. It is estimated that to maintain the app in the 21 health facilities of MK will cost approximately US$18,800 in communication fees per year.
CONCLUSIONS
The app-based data transmission system more than doubled the completeness and timeliness of disease surveillance reports. This simple, low-cost intervention may permit the early detection of disease outbreaks in similar low-resource settings elsewhere.
It is a challenge in low-resource settings to ensure the availability of complete, timely disease surveillance information. Smartphone applications (apps) have the potential to enhance surveillance data transmission.
METHODS
The Central African Republic (CAR) Ministry of Health and Médecins Sans Frontières (MSF) conducted a 15-week pilot project to test a disease surveillance app, Argus, for 20 conditions in 21 health centers in Mambéré Kadéi district (MK 2016). Results were compared to the usual paper-based surveillance in MK the year prior (MK 2015) and simultaneously in an adjacent health district, Nana-Mambére (NM 2016). Wilcoxon rank sum and Kaplan-Meier analyses compared report completeness and timeliness; the cost of the app, and users' perceptions of its usability were assessed.
RESULTS
Two hundred seventy-one weekly reports sent by app identified 3403 cases and 63 deaths; 15 alerts identified 28 cases and 4 deaths. Median completeness (IQR) for MK 2016, 81% (81-86%), was significantly higher than in MK 2015 (31% (24-36%)), and NM 2016 (52% (48-57)) (p < 0.01). Median timeliness (IQR) for MK 2016, 50% (39-57%) was also higher than in MK 2015, 19% (19-24%), and NM 2016 29% (24-36%) (p < 0.01). Kaplan-Meier Survival Analysis showed a significant progressive reduction in the time taken to transmit reports over the 15-week period (p < 0.01). Users ranked the app's usability as greater than 4/5 on all dimensions. The total cost of the 15-week pilot project was US$40,575. It is estimated that to maintain the app in the 21 health facilities of MK will cost approximately US$18,800 in communication fees per year.
CONCLUSIONS
The app-based data transmission system more than doubled the completeness and timeliness of disease surveillance reports. This simple, low-cost intervention may permit the early detection of disease outbreaks in similar low-resource settings elsewhere.
Journal Article > CommentaryFull Text
Bull World Health Organ. 1 June 2018; Volume 96 (Issue 6); 428-435.; DOI:10.2471/BLT.17.207175
Mbangombe M, Pezzoli L, Reeder B, Kabuluzi S, Msyamboza K, et al.
Bull World Health Organ. 1 June 2018; Volume 96 (Issue 6); 428-435.; DOI:10.2471/BLT.17.207175
PROBLEM
With limited global supplies of oral cholera vaccine, countries need to identify priority areas for vaccination while longer-term solutions, such as water and sanitation infrastructure, are being developed.
APPROACH
In 2017, Malawi integrated oral cholera vaccine into its national cholera control plan. The process started with a desk review and analysis of previous surveillance and risk factor data. At a consultative meeting, researchers, national health and water officials and representatives from nongovernmental and international organizations reviewed the data and local epidemiological knowledge to determine priority districts for oral cholera vaccination. The final stage was preparation of an application to the global oral cholera vaccine stockpile for non-emergency use.
LOCAL SETTING
Malawi collects annual data on cholera and most districts have reported cases at least once since the 1970s.
RELEVANT CHANGES
The government’s application for 3.2 million doses of vaccine to be provided over 20 months in 12 districts was accepted in April 2017. By April 2018, over 1 million doses had been administered in five districts. Continuing surveillance in districts showed that cholera outbreaks were notably absent in vaccinated high-risk areas, despite a national outbreak in 2017–2018.
LESSONS LEARNT
Augmenting advanced mapping techniques with local information helped us extend priority areas beyond those identified as high-risk based on cholera incidence reported at the district level. Involvement of the water, sanitation and hygiene sectors is key to ensuring that short-term gains from cholera vaccine are backed by longer-term progress in reducing cholera transmission.
With limited global supplies of oral cholera vaccine, countries need to identify priority areas for vaccination while longer-term solutions, such as water and sanitation infrastructure, are being developed.
APPROACH
In 2017, Malawi integrated oral cholera vaccine into its national cholera control plan. The process started with a desk review and analysis of previous surveillance and risk factor data. At a consultative meeting, researchers, national health and water officials and representatives from nongovernmental and international organizations reviewed the data and local epidemiological knowledge to determine priority districts for oral cholera vaccination. The final stage was preparation of an application to the global oral cholera vaccine stockpile for non-emergency use.
LOCAL SETTING
Malawi collects annual data on cholera and most districts have reported cases at least once since the 1970s.
RELEVANT CHANGES
The government’s application for 3.2 million doses of vaccine to be provided over 20 months in 12 districts was accepted in April 2017. By April 2018, over 1 million doses had been administered in five districts. Continuing surveillance in districts showed that cholera outbreaks were notably absent in vaccinated high-risk areas, despite a national outbreak in 2017–2018.
LESSONS LEARNT
Augmenting advanced mapping techniques with local information helped us extend priority areas beyond those identified as high-risk based on cholera incidence reported at the district level. Involvement of the water, sanitation and hygiene sectors is key to ensuring that short-term gains from cholera vaccine are backed by longer-term progress in reducing cholera transmission.
Conference Material > Abstract
Malou N, Al Asmar M, Fakhri RM, Badaro N, Kanapathipillai R, et al.
MSF Scientific Days International 2021: Innovation. 20 May 2021
INTRODUCTION
Timely and accurate identification of microorganisms and assessment of antimicrobial susceptibility in clinical specimens help clinicians in selecting the most appropriate treatment for their patients. In low-to-middle income countries (LMIC), bacteriological testing is generally not performed routinely due to technological challenges. This contributes to treatment delays and consequent clinical complications, extended hospital stays, and the global spread of multidrug resistance (MDR). The MSF Foundation has developed Antibiogo, an offline smartphone-based application that allows non-microbiologists to carry out antimicrobial susceptibility testing (AST) and interpret the results. We are presenting the preliminary results of the Antibiogo performance evaluation.
METHODS
Antibiogo comprises several components: the Image Analysis Program (IAP) that detects and measures inhibition zone diameters (IZDs); the Expert System (ES) that adjusts AST results based on the application of expert rules and identifies resistance mechanisms; and the Selective Reporting Program. For the evaluation of the IAP, we used collection isolates (n=8) and compared the automatic measurement of IZDs using Antibiogo with the readings made by eight laboratory technicians who inspected the plates manually. For evaluation of the ES, we used Antibiogo to assess 60 pathogens isolated from bone and tissues from patients admitted to MSF’s Reconstructive Surgical Project in Amman, Jordan, between February and September 2020. In parallel, pictures of AST were shared with an external clinical microbiologist who performed an independent and blinded interpretation. Results of the two parallel interpretations were compared and the discordances categorised (minor, major, very major).
RESULTS
Evaluation of the IAP showed good concordance of measurements between technicians and Antibiogo (Krippendorff’s alpha value of 0.957, 95% confidence interval [CI] 0.94-0.97; p<0.001). These results indicate excellent inter-rater agreement between human raters and the Antibiogo platform for these pathogen-antibiotic pairs. For evaluation of the ES, 509 paired samples were read in parallel, and agreement of the measured diameters was excellent (R2=0.95). The ES correctly classified 474 (95.2%) of 498 interpretable samples (95% CI 92.9- 97.4), corresponding to a Krippendorff’s alpha value of 90.6% (95% CI 87%-94%). This indicates excellent to near-perfect agreement. Further investigation of the samples showing non-agreement is underway.
CONCLUSIONS
Preliminary results suggest that Antibiogo is a very promising tool that can be used for the interpretation of antibiograms. This could improve access to microbiology diagnostic tests and the rational use of antibiotics in LMIC. The application currently undergoing further evaluation using a diverse set of pathogens isolated from multiple sites.
ETHICS
This study was approved by the MSF Ethics Review Board and the Hospital Director of Al Mowasah Hospital, Amman, Jordan.
Timely and accurate identification of microorganisms and assessment of antimicrobial susceptibility in clinical specimens help clinicians in selecting the most appropriate treatment for their patients. In low-to-middle income countries (LMIC), bacteriological testing is generally not performed routinely due to technological challenges. This contributes to treatment delays and consequent clinical complications, extended hospital stays, and the global spread of multidrug resistance (MDR). The MSF Foundation has developed Antibiogo, an offline smartphone-based application that allows non-microbiologists to carry out antimicrobial susceptibility testing (AST) and interpret the results. We are presenting the preliminary results of the Antibiogo performance evaluation.
METHODS
Antibiogo comprises several components: the Image Analysis Program (IAP) that detects and measures inhibition zone diameters (IZDs); the Expert System (ES) that adjusts AST results based on the application of expert rules and identifies resistance mechanisms; and the Selective Reporting Program. For the evaluation of the IAP, we used collection isolates (n=8) and compared the automatic measurement of IZDs using Antibiogo with the readings made by eight laboratory technicians who inspected the plates manually. For evaluation of the ES, we used Antibiogo to assess 60 pathogens isolated from bone and tissues from patients admitted to MSF’s Reconstructive Surgical Project in Amman, Jordan, between February and September 2020. In parallel, pictures of AST were shared with an external clinical microbiologist who performed an independent and blinded interpretation. Results of the two parallel interpretations were compared and the discordances categorised (minor, major, very major).
RESULTS
Evaluation of the IAP showed good concordance of measurements between technicians and Antibiogo (Krippendorff’s alpha value of 0.957, 95% confidence interval [CI] 0.94-0.97; p<0.001). These results indicate excellent inter-rater agreement between human raters and the Antibiogo platform for these pathogen-antibiotic pairs. For evaluation of the ES, 509 paired samples were read in parallel, and agreement of the measured diameters was excellent (R2=0.95). The ES correctly classified 474 (95.2%) of 498 interpretable samples (95% CI 92.9- 97.4), corresponding to a Krippendorff’s alpha value of 90.6% (95% CI 87%-94%). This indicates excellent to near-perfect agreement. Further investigation of the samples showing non-agreement is underway.
CONCLUSIONS
Preliminary results suggest that Antibiogo is a very promising tool that can be used for the interpretation of antibiograms. This could improve access to microbiology diagnostic tests and the rational use of antibiotics in LMIC. The application currently undergoing further evaluation using a diverse set of pathogens isolated from multiple sites.
ETHICS
This study was approved by the MSF Ethics Review Board and the Hospital Director of Al Mowasah Hospital, Amman, Jordan.
Journal Article > ResearchFull Text
PLOS One. 3 February 2021; Volume 16 (Issue 2); e0245372.; DOI:10.1371/journal.pone.0245372
Kaufmann B, Boulle P, Berthou F, Fournier M, Beran D, et al.
PLOS One. 3 February 2021; Volume 16 (Issue 2); e0245372.; DOI:10.1371/journal.pone.0245372
Strict storage recommendations for insulin are difficult to follow in hot tropical regions and even more challenging in conflict and humanitarian emergency settings, adding an extra burden to the management of people with diabetes. According to pharmacopeia unopened insulin vials must be stored in a refrigerator (2-8°C), while storage at ambient temperature (25-30°C) is usually permitted for the 4-week usage period during treatment. In the present work we address a critical question towards improving diabetes care in resource poor settings, namely whether insulin is stable and retains biological activity in tropical temperatures during a 4-week treatment period. To answer this question, temperature fluctuations were measured in Dagahaley refugee camp (Northern Kenya) using log tag recorders. Oscillating temperatures between 25 and 37°C were observed. Insulin heat stability was assessed under these specific temperatures which were precisely reproduced in the laboratory. Different commercialized formulations of insulin were quantified weekly by high performance liquid chromatography and the results showed perfect conformity to pharmacopeia guidelines, thus confirming stability over the assessment period (four weeks). Monitoring the 3D-structure of the tested insulin by circular dichroism confirmed that insulin monomer conformation did not undergo significant modifications. The measure of insulin efficiency on insulin receptor (IR) and Akt phosphorylation in hepatic cells indicated that insulin bioactivity of the samples stored at oscillating temperature during the usage period is identical to that of the samples maintained at 2-8°C. Taken together, these results indicate that insulin can be stored at such oscillating ambient temperatures for the usual four-week period of use. This enables the barrier of cold storage during use to be removed, thereby opening up the perspective for easier management of diabetes in humanitarian contexts and resource poor settings.
Journal Article > ResearchFull Text
Bull World Health Organ. 27 September 2018; Volume 96 (Issue 12); 817-825.; DOI:10.2471/BLT.17.206417
Grandesso F, Rafael F, Chipeta S, Alley I, Saussier C, et al.
Bull World Health Organ. 27 September 2018; Volume 96 (Issue 12); 817-825.; DOI:10.2471/BLT.17.206417
OBJECTIVE
To evaluate vaccination coverage, identify reasons for non-vaccination and assess satisfaction with two innovative strategies for distributing second doses in an oral cholera vaccine campaign in 2016 in Lake Chilwa, Malawi, in response to a cholera outbreak.
METHODS
We performed a two-stage cluster survey. The population interviewed was divided in three strata according to the second-dose vaccine distribution strategy: (i) a standard strategy in 1477 individuals (68 clusters of 5 households) on the lake shores; (ii) a simplified cold-chain strategy in 1153 individuals (59 clusters of 5 households) on islands in the lake; and (iii) an out-of-cold-chain strategy in 295 fishermen (46 clusters of 5 to 15 fishermen) in floating homes, called zimboweras.
FINDING
Vaccination coverage with at least one dose was 79.5% (1153/1451) on the lake shores, 99.3% (1098/1106) on the islands and 84.7% (200/236) on zimboweras. Coverage with two doses was 53.0% (769/1451), 91.1% (1010/1106) and 78.8% (186/236), in the three strata, respectively. The most common reason for non-vaccination was absence from home during the campaign. Most interviewees liked the novel distribution strategies.
CONCLUSION
Vaccination coverage on the shores of Lake Chilwa was moderately high and the innovative distribution strategies tailored to people living on the lake provided adequate coverage, even among hard-to-reach communities. Community engagement and simplified delivery procedures were critical for success. Off-label, out-of-cold-chain administration of oral cholera vaccine should be considered as an effective strategy for achieving high coverage in hard-to-reach communities. Nevertheless, coverage and effectiveness must be monitored over the short and long term.
To evaluate vaccination coverage, identify reasons for non-vaccination and assess satisfaction with two innovative strategies for distributing second doses in an oral cholera vaccine campaign in 2016 in Lake Chilwa, Malawi, in response to a cholera outbreak.
METHODS
We performed a two-stage cluster survey. The population interviewed was divided in three strata according to the second-dose vaccine distribution strategy: (i) a standard strategy in 1477 individuals (68 clusters of 5 households) on the lake shores; (ii) a simplified cold-chain strategy in 1153 individuals (59 clusters of 5 households) on islands in the lake; and (iii) an out-of-cold-chain strategy in 295 fishermen (46 clusters of 5 to 15 fishermen) in floating homes, called zimboweras.
FINDING
Vaccination coverage with at least one dose was 79.5% (1153/1451) on the lake shores, 99.3% (1098/1106) on the islands and 84.7% (200/236) on zimboweras. Coverage with two doses was 53.0% (769/1451), 91.1% (1010/1106) and 78.8% (186/236), in the three strata, respectively. The most common reason for non-vaccination was absence from home during the campaign. Most interviewees liked the novel distribution strategies.
CONCLUSION
Vaccination coverage on the shores of Lake Chilwa was moderately high and the innovative distribution strategies tailored to people living on the lake provided adequate coverage, even among hard-to-reach communities. Community engagement and simplified delivery procedures were critical for success. Off-label, out-of-cold-chain administration of oral cholera vaccine should be considered as an effective strategy for achieving high coverage in hard-to-reach communities. Nevertheless, coverage and effectiveness must be monitored over the short and long term.
Journal Article > ResearchFull Text
BMC Public Health. 28 June 2014; Volume 14 (Issue 1); DOI:10.1186/1471-2458-14-658
Lover AA, Buchy P, Rachline A, Moniboth D, Huy R, et al.
BMC Public Health. 28 June 2014; Volume 14 (Issue 1); DOI:10.1186/1471-2458-14-658
Background: Dengue is a major contributor to morbidity in children aged twelve and below throughout Cambodia; the 2012 epidemic season was the most severe in the country since 2007, with more than 42,000 reported (suspect or confirmed) cases.
Methods: We report basic epidemiological characteristics in a series of 701 patients at the National Paediatric Hospital in Cambodia, recruited during a prospective clinical study (2011-2012). To more fully explore this cohort, we examined climatic factors using multivariate negative binomial models and spatial clustering of cases using spatial scan statistics to place the clinical study within a larger epidemiological framework.
Results: We identify statistically significant spatial clusters at the urban village scale, and find that the key climatic predictors of increasing cases are weekly minimum temperature, median relative humidity, but find a negative association with rainfall maximum, all at lag times of 1-6 weeks, with significant effects extending to 10 weeks.
Conclusions: Our results identify clustering of infections at the neighbourhood scale, suggesting points for targeted interventions, and we find that the complex interactions of vectors and climatic conditions in this setting may be best captured by rising minimum temperature, and median (as opposed to mean) relative humidity, with complex and limited effects from rainfall. These results suggest that real-time cluster detection during epidemics should be considered in Cambodia, and that improvements in weather data reporting could benefit national control programs by allow greater prioritization of limited health resources to both vulnerable populations and time periods of greatest risk. Finally, these results add to the increasing body of knowledge suggesting complex interactions between climate and dengue cases that require further targeted research.
Methods: We report basic epidemiological characteristics in a series of 701 patients at the National Paediatric Hospital in Cambodia, recruited during a prospective clinical study (2011-2012). To more fully explore this cohort, we examined climatic factors using multivariate negative binomial models and spatial clustering of cases using spatial scan statistics to place the clinical study within a larger epidemiological framework.
Results: We identify statistically significant spatial clusters at the urban village scale, and find that the key climatic predictors of increasing cases are weekly minimum temperature, median relative humidity, but find a negative association with rainfall maximum, all at lag times of 1-6 weeks, with significant effects extending to 10 weeks.
Conclusions: Our results identify clustering of infections at the neighbourhood scale, suggesting points for targeted interventions, and we find that the complex interactions of vectors and climatic conditions in this setting may be best captured by rising minimum temperature, and median (as opposed to mean) relative humidity, with complex and limited effects from rainfall. These results suggest that real-time cluster detection during epidemics should be considered in Cambodia, and that improvements in weather data reporting could benefit national control programs by allow greater prioritization of limited health resources to both vulnerable populations and time periods of greatest risk. Finally, these results add to the increasing body of knowledge suggesting complex interactions between climate and dengue cases that require further targeted research.