Journal Article > CommentaryFull Text
PLOS Med. 2013 November 5; Volume 10 (Issue 11); DOI:10.1371/journal.pmed.1001544
Minetti A, Bopp C, Fermon F, Francois G, Grais RF, et al.
PLOS Med. 2013 November 5; Volume 10 (Issue 11); DOI:10.1371/journal.pmed.1001544
Andrea Minetti and colleagues compare measles outbreak responses from the Democratic Republic of the Congo and Malawi and argue that outbreak response strategies should be tailored to local measles epidemiology. Please see later in the article for the Editors' Summary.
Journal Article > ResearchFull Text
Trop Med Int Health. 2009 September 14; Volume 14 (Issue 10); 1210-1214.; DOI:10.1111/j.1365-3156.2009.02366.x
Minetti A, Shams Eldin M, Defourny I, Harczi G
Trop Med Int Health. 2009 September 14; Volume 14 (Issue 10); 1210-1214.; DOI:10.1111/j.1365-3156.2009.02366.x
OBJECTIVES
To describe the implementation of the WHO(2006) growth standards in a therapeutic feeding programme.
METHODS
Using programme monitoring data from 21,769 children 6-59 months admitted to the Médecins Sans Frontières therapeutic feeding programme during 2007, we compared characteristics at admission, type of care and outcomes for children admitted before and after the shift to the WHO(2006) standards. Admission criteria were bipedal oedema, MUAC <110 mm, or weight-for-height (WFH) of <-70% of the median (NCHS) before mid-May 2007, and WFH <-3 z score (WHO(2006)) after mid-May 2007.
RESULTS
Children admitted with the WHO(2006) standards were more likely to be younger, with a higher proportion of males, and less malnourished (mean WFH -3.6 z score vs. mean WFH -4.6 z score). They were less likely to require hospitalization or intensive care (28.4%vs. 77%; 12.8%vs. 36.5%) and more likely to be treated exclusively on an outpatient basis (71.6%vs. 23%). Finally, they experienced better outcomes (cure rate: 89%vs. 71.7%, death rate: 2.7%vs. 6.4%, default rate: 6.7%vs. 12.3%).
CONCLUSIONS
In this programme, the WHO(2006) standards identify a larger number of malnourished children at an earlier stage of disease facilitating their treatment success.
To describe the implementation of the WHO(2006) growth standards in a therapeutic feeding programme.
METHODS
Using programme monitoring data from 21,769 children 6-59 months admitted to the Médecins Sans Frontières therapeutic feeding programme during 2007, we compared characteristics at admission, type of care and outcomes for children admitted before and after the shift to the WHO(2006) standards. Admission criteria were bipedal oedema, MUAC <110 mm, or weight-for-height (WFH) of <-70% of the median (NCHS) before mid-May 2007, and WFH <-3 z score (WHO(2006)) after mid-May 2007.
RESULTS
Children admitted with the WHO(2006) standards were more likely to be younger, with a higher proportion of males, and less malnourished (mean WFH -3.6 z score vs. mean WFH -4.6 z score). They were less likely to require hospitalization or intensive care (28.4%vs. 77%; 12.8%vs. 36.5%) and more likely to be treated exclusively on an outpatient basis (71.6%vs. 23%). Finally, they experienced better outcomes (cure rate: 89%vs. 71.7%, death rate: 2.7%vs. 6.4%, default rate: 6.7%vs. 12.3%).
CONCLUSIONS
In this programme, the WHO(2006) standards identify a larger number of malnourished children at an earlier stage of disease facilitating their treatment success.
Journal Article > ResearchFull Text
Emerg Infect Dis. 2013 February 1; Volume 19 (Issue 2); DOI:10.3201/eid1902.120301
Minetti A, Kagoli M, Katsulukuta A, Huerga H, Featherstone A, et al.
Emerg Infect Dis. 2013 February 1; Volume 19 (Issue 2); DOI:10.3201/eid1902.120301
Despite high reported coverage for routine and supplementary immunization, in 2010 in Malawi, a large measles outbreak occurred that comprised 134,000 cases and 304 deaths. Although the highest attack rates were for young children (2.3%, 7.6%, and 4.5% for children <6, 6-8, and 9-11 months, respectively), persons >15 years of age were highly affected (1.0% and 0.4% for persons 15-19 and >19 years, respectively; 28% of all cases). A survey in 8 districts showed routine coverage of 95.0% for children 12-23 months; 57.9% for children 9-11 months; and 60.7% for children covered during the last supplementary immunization activities in 2008. Vaccine effectiveness was 83.9% for 1 dose and 90.5% for 2 doses. A continuous accumulation of susceptible persons during the past decade probably accounts for this outbreak. Countries en route to measles elimination, such as Malawi, should improve outbreak preparedness. Timeliness and the population chosen are crucial elements for reactive campaigns.
Journal Article > ResearchFull Text
Int J Tuberc Lung Dis. 2010 December 1; Volume 14 (Issue 12); 1589-1595.
Minetti A, Camelique O, Hsa Thaw K, Thi SS, Swaddiwudhipong W, et al.
Int J Tuberc Lung Dis. 2010 December 1; Volume 14 (Issue 12); 1589-1595.
SETTING
Although tuberculosis (TB) is a curable disease, it remains a major global health problem and an important cause of morbidity and mortality among vulnerable populations, including refugees and migrants.
OBJECTIVE
To describe results and experiences over 20 years at a TB programme in refugee camps on the Thai-Burmese border in Tak Province, Thailand, and to identify risk factors associated with adverse outcomes (e.g., default, failure, death).
DESIGN
Retrospective review of routine records of 2425 patients admitted for TB treatment in the Mae La TB programme between May 1987 and December 2005.
RESULTS
TB cases notified among refugees decreased over 20 years. Among patients treated with a first-, second- or third-line regimen, 77.5% had a successful outcome, 13.5% defaulted, 7.6% died and 1.3% failed treatment. Multivariate analysis for new cases showed higher likelihood of adverse outcomes for patients who were Burmese migrants or Thai villagers, male, aged >15 years or with smear-negative pulmonary TB.
CONCLUSION
These findings suggest that treatment outcomes depend on the programme's capacity to respond to specific patients' constraints. High-risk groups, such as migrant populations, need a patient-centred approach, and specific, innovative strategies have to be developed based on the needs of the most vulnerable and marginalised populations.
Although tuberculosis (TB) is a curable disease, it remains a major global health problem and an important cause of morbidity and mortality among vulnerable populations, including refugees and migrants.
OBJECTIVE
To describe results and experiences over 20 years at a TB programme in refugee camps on the Thai-Burmese border in Tak Province, Thailand, and to identify risk factors associated with adverse outcomes (e.g., default, failure, death).
DESIGN
Retrospective review of routine records of 2425 patients admitted for TB treatment in the Mae La TB programme between May 1987 and December 2005.
RESULTS
TB cases notified among refugees decreased over 20 years. Among patients treated with a first-, second- or third-line regimen, 77.5% had a successful outcome, 13.5% defaulted, 7.6% died and 1.3% failed treatment. Multivariate analysis for new cases showed higher likelihood of adverse outcomes for patients who were Burmese migrants or Thai villagers, male, aged >15 years or with smear-negative pulmonary TB.
CONCLUSION
These findings suggest that treatment outcomes depend on the programme's capacity to respond to specific patients' constraints. High-risk groups, such as migrant populations, need a patient-centred approach, and specific, innovative strategies have to be developed based on the needs of the most vulnerable and marginalised populations.
Journal Article > ResearchFull Text
PLOS One. 2009 January 29; Volume 4 (Issue 1); e4313.; DOI:10.1371/journal.pone.0004313
Lapidus N, Minetti A, Djibo A, Guerin JP, Hustache S, et al.
PLOS One. 2009 January 29; Volume 4 (Issue 1); e4313.; DOI:10.1371/journal.pone.0004313
BACKGROUND
In 2006, the Médecins sans Frontières nutritional program in the region of Maradi (Niger) included 68,001 children 6-59 months of age with either moderate or severe malnutrition, according to the NCHS reference (weight-for-height<80% of the NCHS median, and/or mid-upper arm circumference<110 mm for children taller than 65 cm and/or presence of bipedal edema). Our objective was to identify baseline risk factors for death among children diagnosed with severe malnutrition using the newly introduced WHO growth standards. As the release of WHO growth standards changed the definition of severe malnutrition, which now includes many children formerly identified as moderately malnourished with the NCHS reference, studying this new category of children is crucial.
METHODOLOGY
Program monitoring data were collected from the medical records of all children admitted in the program. Data included age, sex, height, weight, MUAC, clinical signs on admission including edema, and type of discharge (recovery, death, and default/loss to follow up). Additional data included results of a malaria rapid diagnostic test due to Plasmodium falciparum (Paracheck) and whether the child was a resident of the region of Maradi or came from bordering Nigeria to seek treatment. Multivariate logistic regression was performed on a subset of 27,687 children meeting the new WHO growth standards criteria for severe malnutrition (weight-for-height<-3 Z score, mid-upper arm circumference<110 mm for children taller than 65 cm or presence of bipedal edema). We explored two different models: one with only basic anthropometric data and a second model that included perfunctory clinical signs.
PRINCIPAL FINDINGS
In the first model including only weight, height, sex and presence of edema, the risk factors retained were the weight/height(1.84) ratio (OR: 5,774; 95% CI: [2,284; 14,594]) and presence of edema (7.51 [5.12; 11.0]). A second model, taking into account supplementary data from perfunctory clinical examination, identified other risk factors for death: apathy (9.71 [6.92; 13.6]), pallor (2.25 [1.25; 4.05]), anorexia (1.89 [1.35; 2.66]), fever>38.5 degrees C (1.83 [1.25; 2.69]), and age below 1 year (1.42 [1.01; 1.99]).
CONCLUSIONS
Although clinicians will continue to perform screening using clinical signs and anthropometry, these risk indicators may provide additional criteria for the assessment of absolute and relative risk of death. Better appraisal of the child's risk of death may help orientate the child towards either hospitalization or ambulatory care. As the transition from the NCHS growth reference to the WHO standards will increase the number of children classified as severely malnourished, further studies should explore means to identify children at highest risk of death within this group using simple and standardized indicators.
In 2006, the Médecins sans Frontières nutritional program in the region of Maradi (Niger) included 68,001 children 6-59 months of age with either moderate or severe malnutrition, according to the NCHS reference (weight-for-height<80% of the NCHS median, and/or mid-upper arm circumference<110 mm for children taller than 65 cm and/or presence of bipedal edema). Our objective was to identify baseline risk factors for death among children diagnosed with severe malnutrition using the newly introduced WHO growth standards. As the release of WHO growth standards changed the definition of severe malnutrition, which now includes many children formerly identified as moderately malnourished with the NCHS reference, studying this new category of children is crucial.
METHODOLOGY
Program monitoring data were collected from the medical records of all children admitted in the program. Data included age, sex, height, weight, MUAC, clinical signs on admission including edema, and type of discharge (recovery, death, and default/loss to follow up). Additional data included results of a malaria rapid diagnostic test due to Plasmodium falciparum (Paracheck) and whether the child was a resident of the region of Maradi or came from bordering Nigeria to seek treatment. Multivariate logistic regression was performed on a subset of 27,687 children meeting the new WHO growth standards criteria for severe malnutrition (weight-for-height<-3 Z score, mid-upper arm circumference<110 mm for children taller than 65 cm or presence of bipedal edema). We explored two different models: one with only basic anthropometric data and a second model that included perfunctory clinical signs.
PRINCIPAL FINDINGS
In the first model including only weight, height, sex and presence of edema, the risk factors retained were the weight/height(1.84) ratio (OR: 5,774; 95% CI: [2,284; 14,594]) and presence of edema (7.51 [5.12; 11.0]). A second model, taking into account supplementary data from perfunctory clinical examination, identified other risk factors for death: apathy (9.71 [6.92; 13.6]), pallor (2.25 [1.25; 4.05]), anorexia (1.89 [1.35; 2.66]), fever>38.5 degrees C (1.83 [1.25; 2.69]), and age below 1 year (1.42 [1.01; 1.99]).
CONCLUSIONS
Although clinicians will continue to perform screening using clinical signs and anthropometry, these risk indicators may provide additional criteria for the assessment of absolute and relative risk of death. Better appraisal of the child's risk of death may help orientate the child towards either hospitalization or ambulatory care. As the transition from the NCHS growth reference to the WHO standards will increase the number of children classified as severely malnourished, further studies should explore means to identify children at highest risk of death within this group using simple and standardized indicators.
Journal Article > ResearchFull Text
BMC Public Health. 2014 February 21; Volume 14; DOI:10.1186/1471-2458-14-193
Grout L, Conan N, Giner AJ, Hurtado N, Fermon F, et al.
BMC Public Health. 2014 February 21; Volume 14; DOI:10.1186/1471-2458-14-193
Background: The World Health Organization recommends African children receive two doses of measles containing vaccine (MCV) through routine programs or supplemental immunization activities (SIA). Moreover, children have an additional opportunity to receive MCV through outbreak response immunization (ORI) mass campaigns in certain contexts. Here, we present the results of MCV coverage by dose estimated through surveys conducted after outbreak response in diverse settings in Sub-Saharan Africa.
Methods: We included 24 household-based surveys conducted in six countries after a non-selective mass vaccination campaign. In the majority (22/24), the survey sample was selected using probability proportional to size cluster-based sampling. Others used Lot Quality Assurance Sampling.
Results: In total, data were collected on 60,895 children from 2005 to 2011. Routine coverage varied between countries (>95% in Malawi and Kirundo province (Burundi) while <35% in N'Djamena (Chad) in 2005), within a country and over time. SIA coverage was <75% in most settings. ORI coverage ranged from >95% in Malawi to 71.4% [95% CI: 68.9-73.8] in N'Djamena (Chad) in 2005.In five sites, >5% of children remained unvaccinated after several opportunities. Conversely, in Malawi and DRC, over half of the children eligible for the last SIA received a third dose of MCV.
Conclusions: Control pre-elimination targets were still not reached, contributing to the occurrence of repeated measles outbreak in the Sub-Saharan African countries reported here. Although children receiving a dose of MCV through outbreak response benefit from the intervention, ensuring that programs effectively target hard to reach children remains the cornerstone of measles control.
Methods: We included 24 household-based surveys conducted in six countries after a non-selective mass vaccination campaign. In the majority (22/24), the survey sample was selected using probability proportional to size cluster-based sampling. Others used Lot Quality Assurance Sampling.
Results: In total, data were collected on 60,895 children from 2005 to 2011. Routine coverage varied between countries (>95% in Malawi and Kirundo province (Burundi) while <35% in N'Djamena (Chad) in 2005), within a country and over time. SIA coverage was <75% in most settings. ORI coverage ranged from >95% in Malawi to 71.4% [95% CI: 68.9-73.8] in N'Djamena (Chad) in 2005.In five sites, >5% of children remained unvaccinated after several opportunities. Conversely, in Malawi and DRC, over half of the children eligible for the last SIA received a third dose of MCV.
Conclusions: Control pre-elimination targets were still not reached, contributing to the occurrence of repeated measles outbreak in the Sub-Saharan African countries reported here. Although children receiving a dose of MCV through outbreak response benefit from the intervention, ensuring that programs effectively target hard to reach children remains the cornerstone of measles control.
Journal Article > ResearchFull Text
JAMA Pediatr. 2009 February 2; Volume 163 (Issue 2); 126-130.; DOI:10.1001/archpediatrics.2008.540
Dale NM, Grais RF, Minetti A, Miettola J, Barengo NC
JAMA Pediatr. 2009 February 2; Volume 163 (Issue 2); 126-130.; DOI:10.1001/archpediatrics.2008.540
OBJECTIVE
To compare the National Centre for Health Statistics (NCHS) international growth reference with the new World Health Organization (WHO) growth standards for identification of the malnourished (wasted) children most at risk of death.
DESIGN
Retrospective data analysis.
SETTING
A Médecins Sans Frontières (Doctors Without Borders) nutrition program in Maradi, Niger, in 2006 that treated moderately and severely malnourished children.
PARTICIPANTS
A total of 53 661 wasted children aged 6 months to 5 years (272 of whom died) in the program were included.
INTERVENTIONS
EpiNut (Epi Info 6.0; Centers for Disease Control and Prevention, Atlanta, Georgia) software was used to calculate the percentage of the median for the NCHS reference group, and the WHO (igrowup macro; Geneva, Switzerland) software was used to calculate z scores for the WHO standards group of the 53 661 wasted children.
OUTCOME MEASURES
The main outcome measures are the difference in classification of children as either moderate or severely malnourished according to the NCHS growth reference and the new WHO growth standards, specifically focusing on children who died during the program.
RESULTS
Of the children classified as moderately wasted using the NCHS reference, 37% would have been classified as severely wasted according to the new WHO growth standards. These children were almost 3 times more likely to die than those classified as moderately wasted by both references, and deaths in this group constituted 47% of all deaths in the program.
CONCLUSIONS
The new WHO growth standards identifies more children as severely wasted compared with the NCHS growth reference, including children at high mortality risk who would potentially otherwise be excluded from some therapeutic feeding programs.
To compare the National Centre for Health Statistics (NCHS) international growth reference with the new World Health Organization (WHO) growth standards for identification of the malnourished (wasted) children most at risk of death.
DESIGN
Retrospective data analysis.
SETTING
A Médecins Sans Frontières (Doctors Without Borders) nutrition program in Maradi, Niger, in 2006 that treated moderately and severely malnourished children.
PARTICIPANTS
A total of 53 661 wasted children aged 6 months to 5 years (272 of whom died) in the program were included.
INTERVENTIONS
EpiNut (Epi Info 6.0; Centers for Disease Control and Prevention, Atlanta, Georgia) software was used to calculate the percentage of the median for the NCHS reference group, and the WHO (igrowup macro; Geneva, Switzerland) software was used to calculate z scores for the WHO standards group of the 53 661 wasted children.
OUTCOME MEASURES
The main outcome measures are the difference in classification of children as either moderate or severely malnourished according to the NCHS growth reference and the new WHO growth standards, specifically focusing on children who died during the program.
RESULTS
Of the children classified as moderately wasted using the NCHS reference, 37% would have been classified as severely wasted according to the new WHO growth standards. These children were almost 3 times more likely to die than those classified as moderately wasted by both references, and deaths in this group constituted 47% of all deaths in the program.
CONCLUSIONS
The new WHO growth standards identifies more children as severely wasted compared with the NCHS growth reference, including children at high mortality risk who would potentially otherwise be excluded from some therapeutic feeding programs.
Journal Article > ResearchFull Text
J Int AIDS Soc. 2011 January 10; Volume 14 (Issue 1); DOI:10.1186/1758-2652-14-2
Ahoua L, Umutoni C, Huerga H, Minetti A, Szumilin E, et al.
J Int AIDS Soc. 2011 January 10; Volume 14 (Issue 1); DOI:10.1186/1758-2652-14-2
Among people living with HIV/AIDS, nutritional support is increasingly recognized as a critical part of the essential package of care, especially for patients in sub-Saharan Africa. The objectives of the study were to evaluate the outcomes of HIV-positive malnourished adults treated with ready-to-use therapeutic food and to identify factors associated with nutrition programme failure.
Journal Article > ResearchFull Text
BMC Infect Dis. 2013 May 22; Volume 13 (Issue 1); DOI:10.1186/1471-2334-13-232
Grout L, Minetti A, Hurtado N, Francois G, Fermon F, et al.
BMC Infect Dis. 2013 May 22; Volume 13 (Issue 1); DOI:10.1186/1471-2334-13-232
BACKGROUND: The Democratic Republic of Congo experiences regular measles outbreaks. From September 2010, the number of suspected measles cases increased, especially in Katanga province, where Medecins sans Frontieres supported the Ministry of Health in responding to the outbreak by providing free treatment, reinforcing surveillance and implementing non-selective mass vaccination campaigns. Here, we describe the measles outbreak in Katanga province in 2010--2011 and the results of vaccine coverage surveys conducted after the mass campaigns. METHODS: The surveillance system was strengthened in 28 of the 67 health zones of the province and we conducted seven vaccination coverage surveys in 2011. RESULTS: The overall cumulative attack rate was 0.71% and the case fatality ratio was 1.40%.The attack rate was higher in children under 4 and decreased with age. This pattern was consistent across districts and time. The number of cases aged 10 years and older barely increased during the outbreak. CONCLUSIONS: Early investigation of the age distribution of cases is a key to understanding the epidemic, and should guide the vaccination of priority age groups.
Journal Article > ResearchFull Text
Lancet. 2004 October 14; Volume 364 (Issue 9442); DOI:10.1016/S0140-6736(04)17187-0
Depoortere E, Checchi F, Broillet F, Gerstl S, Minetti A, et al.
Lancet. 2004 October 14; Volume 364 (Issue 9442); DOI:10.1016/S0140-6736(04)17187-0
BACKGROUND: Violence in Darfur, Sudan, has rendered more than one million people internally displaced. An epidemiological study of the effect of armed incursions on mortality in Darfur was needed to provide a basis for appropriate assistance to internally displaced people. METHODS: Between April and June, 2004, we did retrospective cluster surveys among 215?400 internally displaced people in four sites of West Darfur (Zalingei, Murnei, Niertiti, El Geneina). Mortality recall periods covered both the pre-displacement and post-displacement periods in Zalingei, Murnei, and Niertiti, but not in El Geneina. Heads of households provided dates, causes, and places of deaths, and described the family structure. FINDINGS: Before arrival at displacement sites, mortality rates (expressed as deaths per 10?000 per day), were 5.9 (95% CI 2.2-14.9) in Zalingei, 9.5 (6.4-14.0) in Murnei, and 7.3 (3.2-15.7) in Niertiti. Violence caused 68-93% of these deaths. People who were killed were mostly adult men (relative risk 29.1-117.9 compared with children younger than 15 years), but included women and children. Most households fled because of direct village attacks. In camps, mortality rates fell but remained above the emergency benchmark, with a peak of 5.6 in El Geneina. Violence persisted even after displacement. Age and sex pyramids of surviving populations were skewed, with a deficit in men. INTERPRETATION: This study, which was done in a difficult setting, provides epidemiological evidence of this conflict's effect on civilians, confirming the serious nature of the crisis, and reinforcing findings from other war contexts.