Conference Material > Abstract
Robinson E, van Braak F, Rose L, Yadenzi MS
MSF Scientific Days International 2021: Research. 2021 May 19
INTRODUCTION
Protracted conflict in CAR has led to widespread political unrest and fragile health systems. Hyperendemic malaria is the main cause of morbidity. Alongside global calls to prioritise malaria prevention during the COVID-19 pandemic, MSF initiated mass drug administration (MDA) for children aged between three months and 15 years within three communes of the Bossangoa health district between 17 August and 24 November 2020. The MDA comprised three cycles of dihydroartemisin-piperaquine (DHA-PQ), given at four-week intervals. We evaluated coverage and clinical impact of the MDA, and describe community perspectives.
METHODS
We conducted a two-stage cluster household survey between 22 November and 9 December 2020. We undertook structured interviews with the heads of households and with eligible children, focusing on participation in the MDA. Participation was verified against the MDA card, if available. Using routine MSF surveillance data, we compared the following indicators during the MDA intervention to the same periods of time during 2018 and 2019: consultations, confirmed malaria cases, and positivity rates of malaria rapid diagnostic tests (mRDT’s) in MSF facilities in the intervention area, overall and by age group (≥5; <5 years); hospital admissions and in-hospital deaths with a primary diagnosis of severe malaria among children <15 years from the MDA intervention area. Following each cycle we conducted nine focus groups discussions (FGD’s) with caregivers, community leaders, and community health workers (CHW’s) Participants were selected using purposive sampling. The topic guide inluded the key themes of reasons for participation, difficulties encountered, satisfaction, and experiences throughout the MDA.
ETHICS
This study was approved by the MSF Ethics Review Board (ERB) and by the national ERB of CAR.
RESULTS
In total, we distributed 134,117 DHA-PQ courses. Among eligible children, 93.1% (95% confidence interval, CI, 85.6-96.8) received all three cycles. We estimated significant reductions only for confirmed outpatient malaria cases overall (9.2%; 95% CI 5.6-12.8), and among those aged <5 years (20.5%; 95% CI 15.3-25.8). Following the first MDA cycle, FGD participants described positive perceptions and high adherence with regard to MDA, linked with the involvement of community leaders. Participants reported reductions in childhood malaria, as well as reduced household expenditure on healthcare. Rumours about ‘drug trials’ and concerns about side effects were initial reasons for refusal, however these concerns were overcome after seeing the positive impact on participating children. Participants’ recommendations included continuing the programme and expanding eligibility.
CONCLUSION
This is one of the first such MDA’s in CAR; our experience demonstrates MDA is feasible in complex emergencies. Although preliminary analysis of routine surveillance data suggested a limited impact on malaria diagnoses, community acceptance was high. Of note, outpatient surveillance data was limited to three structures in only one commune, and not available for the specific target ages of the MDA. Participants noted positive perceptions of impact, with a desire for repeated MDA’s. Further analysis will help to further elucidate the potential impact, and inform recommendations.
Protracted conflict in CAR has led to widespread political unrest and fragile health systems. Hyperendemic malaria is the main cause of morbidity. Alongside global calls to prioritise malaria prevention during the COVID-19 pandemic, MSF initiated mass drug administration (MDA) for children aged between three months and 15 years within three communes of the Bossangoa health district between 17 August and 24 November 2020. The MDA comprised three cycles of dihydroartemisin-piperaquine (DHA-PQ), given at four-week intervals. We evaluated coverage and clinical impact of the MDA, and describe community perspectives.
METHODS
We conducted a two-stage cluster household survey between 22 November and 9 December 2020. We undertook structured interviews with the heads of households and with eligible children, focusing on participation in the MDA. Participation was verified against the MDA card, if available. Using routine MSF surveillance data, we compared the following indicators during the MDA intervention to the same periods of time during 2018 and 2019: consultations, confirmed malaria cases, and positivity rates of malaria rapid diagnostic tests (mRDT’s) in MSF facilities in the intervention area, overall and by age group (≥5; <5 years); hospital admissions and in-hospital deaths with a primary diagnosis of severe malaria among children <15 years from the MDA intervention area. Following each cycle we conducted nine focus groups discussions (FGD’s) with caregivers, community leaders, and community health workers (CHW’s) Participants were selected using purposive sampling. The topic guide inluded the key themes of reasons for participation, difficulties encountered, satisfaction, and experiences throughout the MDA.
ETHICS
This study was approved by the MSF Ethics Review Board (ERB) and by the national ERB of CAR.
RESULTS
In total, we distributed 134,117 DHA-PQ courses. Among eligible children, 93.1% (95% confidence interval, CI, 85.6-96.8) received all three cycles. We estimated significant reductions only for confirmed outpatient malaria cases overall (9.2%; 95% CI 5.6-12.8), and among those aged <5 years (20.5%; 95% CI 15.3-25.8). Following the first MDA cycle, FGD participants described positive perceptions and high adherence with regard to MDA, linked with the involvement of community leaders. Participants reported reductions in childhood malaria, as well as reduced household expenditure on healthcare. Rumours about ‘drug trials’ and concerns about side effects were initial reasons for refusal, however these concerns were overcome after seeing the positive impact on participating children. Participants’ recommendations included continuing the programme and expanding eligibility.
CONCLUSION
This is one of the first such MDA’s in CAR; our experience demonstrates MDA is feasible in complex emergencies. Although preliminary analysis of routine surveillance data suggested a limited impact on malaria diagnoses, community acceptance was high. Of note, outpatient surveillance data was limited to three structures in only one commune, and not available for the specific target ages of the MDA. Participants noted positive perceptions of impact, with a desire for repeated MDA’s. Further analysis will help to further elucidate the potential impact, and inform recommendations.
Conference Material > Slide Presentation
Robinson E, van Braak F, Rose L, Yadenzi MS
MSF Scientific Days International 2021: Research. 2021 May 19
Journal Article > Meta-AnalysisFull Text
Confl Health. 2019 November 21; Volume 13 (Issue 1); DOI:10.1186/s13031-019-0232-y
Robinson E, Crispino V, Ouabo A, Iballa F, Kremer R, et al.
Confl Health. 2019 November 21; Volume 13 (Issue 1); DOI:10.1186/s13031-019-0232-y
BACKGROUND
During humanitarian crises, health information systems are often lacking and surveys are a valuable tool to assess the health needs of affected populations. In 2013, a mortality and health survey undertaken by Médecins Sans Frontières (MSF) in the conflict affected Walikale territory of North Kivu, Democratic Republic of the Congo (DRC), indicated mortality rates exceeding humanitarian crisis thresholds and a high burden of mortality and morbidity due to malaria. In late 2017, after a period of relative stability, MSF reassessed the health status of the population through a second survey to guide ongoing operations.
METHODS
A two-stage cluster survey, selecting villages using probability proportional to size and households using random walk procedures, was conducted. Household members were interviewed on morbidity and mortality, healthcare use, vaccination status, and bednet availability.
RESULTS
The sample included 5711 persons in 794 households. The crude mortality rate (CMR) and under-five mortality rate (U5MR) were 0.98 per 10,000 persons/day (95% confidence interval (CI) 0.78–1.2) and 1.3 per 10,000 persons/day (95% CI): 0.82–2.0), respectively. The most frequently reported causes of death were fever/malaria (31%), diarrhoea (15%) and respiratory infections (8%). In 89% of households at least one person was reported as falling ill in the previous 2 weeks, and 58% sought healthcare. Cost was the main barrier amongst 58% of those who did not seek healthcare. Coverage of measles-containing-vaccine was 62% in under-fives. Sufficient bednet coverage (1 bednet/2 people) was reported from 17% of households.
CONCLUSION
The second survey illustrates that although mortality is now just below crisis thresholds, the area still experiences excess mortality and has substantial health needs. The study results have supported the further expansion of integrated community case management to improve access to care for malaria, diarrhoea and respiratory infections. Such surveys are important to orient operations to the health needs of the population being served and also highlight the ongoing vulnerability of populations after humanitarian crises.
During humanitarian crises, health information systems are often lacking and surveys are a valuable tool to assess the health needs of affected populations. In 2013, a mortality and health survey undertaken by Médecins Sans Frontières (MSF) in the conflict affected Walikale territory of North Kivu, Democratic Republic of the Congo (DRC), indicated mortality rates exceeding humanitarian crisis thresholds and a high burden of mortality and morbidity due to malaria. In late 2017, after a period of relative stability, MSF reassessed the health status of the population through a second survey to guide ongoing operations.
METHODS
A two-stage cluster survey, selecting villages using probability proportional to size and households using random walk procedures, was conducted. Household members were interviewed on morbidity and mortality, healthcare use, vaccination status, and bednet availability.
RESULTS
The sample included 5711 persons in 794 households. The crude mortality rate (CMR) and under-five mortality rate (U5MR) were 0.98 per 10,000 persons/day (95% confidence interval (CI) 0.78–1.2) and 1.3 per 10,000 persons/day (95% CI): 0.82–2.0), respectively. The most frequently reported causes of death were fever/malaria (31%), diarrhoea (15%) and respiratory infections (8%). In 89% of households at least one person was reported as falling ill in the previous 2 weeks, and 58% sought healthcare. Cost was the main barrier amongst 58% of those who did not seek healthcare. Coverage of measles-containing-vaccine was 62% in under-fives. Sufficient bednet coverage (1 bednet/2 people) was reported from 17% of households.
CONCLUSION
The second survey illustrates that although mortality is now just below crisis thresholds, the area still experiences excess mortality and has substantial health needs. The study results have supported the further expansion of integrated community case management to improve access to care for malaria, diarrhoea and respiratory infections. Such surveys are important to orient operations to the health needs of the population being served and also highlight the ongoing vulnerability of populations after humanitarian crises.
Journal Article > ResearchFull Text
Malar J. 2024 May 15; Volume 23 (Issue 1); 146.; DOI:10.1186/s12936-024-04968-1
Robinson E, Ouabo A, Rose L, van Braak F, Vyncke J, et al.
Malar J. 2024 May 15; Volume 23 (Issue 1); 146.; DOI:10.1186/s12936-024-04968-1
BACKGROUND
In 2020, during the COVID-19 pandemic, Médecins Sans Frontières (MSF) initiated three cycles of dihydroartemisin-piperaquine (DHA-PQ) mass drug administration (MDA) for children aged three months to 15 years within Bossangoa sub-prefecture, Central African Republic. Coverage, clinical impact, and community members perspectives were evaluated to inform the use of MDAs in humanitarian emergencies.
METHODS
A household survey was undertaken after the MDA focusing on participation, recent illness among eligible children, and household satisfaction. Using routine surveillance data, the reduction during the MDA period compared to the same period of preceding two years in consultations, malaria diagnoses, malaria rapid diagnostic test (RDT) positivity in three MSF community healthcare facilities (HFs), and the reduction in severe malaria admissions at the regional hospital were estimated. Twenty-seven focus groups discussions (FGDs) with community members were conducted.
RESULTS
Overall coverage based on the MDA card or verbal report was 94.3% (95% confidence interval (CI): 86.3–97.8%). Among participants of the household survey, 2.6% (95% CI 1.6–40.3%) of round 3 MDA participants experienced illness in the preceding four weeks compared to 30.6% (95% CI 22.1–40.8%) of MDA non-participants. One community HF experienced a 54.5% (95% CI 50.8–57.9) reduction in consultations, a 73.7% (95% CI 70.5–76.5) reduction in malaria diagnoses, and 42.9% (95% CI 36.0–49.0) reduction in the proportion of positive RDTs among children under five. A second community HF experienced an increase in consultations (+ 15.1% (− 23.3 to 7.5)) and stable malaria diagnoses (4.2% (3.9–11.6)). A third community HF experienced an increase in consultations (+ 41.1% (95% CI 51.2–31.8) and malaria diagnoses (+ 37.3% (95% CI 47.4–27.9)). There were a 25.2% (95% CI 2.0–42.8) reduction in hospital admissions with severe malaria among children under five from the MDA area. FGDs revealed community members perceived less illness among children because of the MDA, as well as fewer hospitalizations. Other indirect benefits such as reduced household expenditure on healthcare were also described.
CONCLUSION
The MDA achieved high coverage and community acceptance. While some positive health impact was observed, it was resource intensive, particularly in this rural context. The priority for malaria control in humanitarian contexts should remain diagnosis and treatment. MDA may be additional tool where the context supports its implementation.
In 2020, during the COVID-19 pandemic, Médecins Sans Frontières (MSF) initiated three cycles of dihydroartemisin-piperaquine (DHA-PQ) mass drug administration (MDA) for children aged three months to 15 years within Bossangoa sub-prefecture, Central African Republic. Coverage, clinical impact, and community members perspectives were evaluated to inform the use of MDAs in humanitarian emergencies.
METHODS
A household survey was undertaken after the MDA focusing on participation, recent illness among eligible children, and household satisfaction. Using routine surveillance data, the reduction during the MDA period compared to the same period of preceding two years in consultations, malaria diagnoses, malaria rapid diagnostic test (RDT) positivity in three MSF community healthcare facilities (HFs), and the reduction in severe malaria admissions at the regional hospital were estimated. Twenty-seven focus groups discussions (FGDs) with community members were conducted.
RESULTS
Overall coverage based on the MDA card or verbal report was 94.3% (95% confidence interval (CI): 86.3–97.8%). Among participants of the household survey, 2.6% (95% CI 1.6–40.3%) of round 3 MDA participants experienced illness in the preceding four weeks compared to 30.6% (95% CI 22.1–40.8%) of MDA non-participants. One community HF experienced a 54.5% (95% CI 50.8–57.9) reduction in consultations, a 73.7% (95% CI 70.5–76.5) reduction in malaria diagnoses, and 42.9% (95% CI 36.0–49.0) reduction in the proportion of positive RDTs among children under five. A second community HF experienced an increase in consultations (+ 15.1% (− 23.3 to 7.5)) and stable malaria diagnoses (4.2% (3.9–11.6)). A third community HF experienced an increase in consultations (+ 41.1% (95% CI 51.2–31.8) and malaria diagnoses (+ 37.3% (95% CI 47.4–27.9)). There were a 25.2% (95% CI 2.0–42.8) reduction in hospital admissions with severe malaria among children under five from the MDA area. FGDs revealed community members perceived less illness among children because of the MDA, as well as fewer hospitalizations. Other indirect benefits such as reduced household expenditure on healthcare were also described.
CONCLUSION
The MDA achieved high coverage and community acceptance. While some positive health impact was observed, it was resource intensive, particularly in this rural context. The priority for malaria control in humanitarian contexts should remain diagnosis and treatment. MDA may be additional tool where the context supports its implementation.
Conference Material > Video
Robinson E
MSF Scientific Days International 2021: Innovation. 2021 May 20
Conference Material > Video
Robinson E, Chen H, Venables E
MSF Scientific Days International 2021: Research. 2021 May 18
Conference Material > Slide Presentation
Robinson E, Lee L, Roberts L, Poelhekke A, Charles X, et al.
MSF Scientific Days International 2021: Research. 2021 May 18
Conference Material > Abstract
Robinson E, Lee L, Roberts L, Poelhekke A, Charles X, et al.
MSF Scientific Days International 2021: Research. 2021 May 18
INTRODUCTION
The Central African Republic (CAR) has the second-lowest human development index globally and has long been described as being in a state of “silent crisis”. We planned a nationwide study to obtain reliable and comparable mortality data for CAR. Due to the COVID-19 pandemic, only the survey in Ouaka Prefecture proceeded.
METHODS
We conducted a two-stage cluster mortality survey between 9 March and 9 April 2020. We aimed to include 64 clusters of 12 households each, for a target sample size of 3,636 persons. We assigned clusters to communes proportional to population size and used systematic random sampling to identify cluster starting points from a dataset of buildings in each commune. We used a novel approach by: focusing on mortality only; adding an opening question about challenges experienced in the last year to build rapport and document general difficulties; and, for females aged 10-49 years, we included specific pregnancy-related questions to improve detection of neonatal and maternal deaths, and to estimate birth rate. The recall period ran from 26 May 2019 to the interview day (range 289-320 days). We coded reported challenges using a content analysis approach.
ETHICS
This study was approved by the MSF Ethics Review Board (ERB) and the national ERB of CAR.
RESULTS
We reached 50 clusters, including 591 participating households with a total of 4,272 individuals. We identified 160 deaths. Crude and under-five mortality rates (CMR, U5MR) were 1.33 (95% confidence interval, CI, 1.09-1.61) and 1.87 (95%CI 1.37-2.54) deaths/10,000 persons/day, respectively. The most common specified causes of death (COD) for individuals aged >5 years were violence (16.7%; n=20; 95%CI 7.7-32.5) and malaria/fever (9.9%; n=11; 95%CI 5.9-16.2). Amongst children aged <5 years, the most common causes were malaria/fever (30.5%;n=15; 95%CI 17.8-47.1), diarrhoea/vomiting (24.0%; n=11;95%CI 11.9-42.7), neonatal deaths (11.9%; n=6; 95%CI 5.3-24.7), and respiratory infections (6.8%; n=3; 95%CI 2.1-20.1).Amongst females aged 10-49 years, 29.1% (95%CI 26.4-31.9%) were pregnant during the recall period. The birth rate was 59/1,000 population (95%CI 51.7-67.4), and the maternal mortality ratio was 2,525/100,000 live births (95%CI 825-5,794). Reported challenges included concerns about specific illnesses, access to healthcare, bereavement, lack of safe drinking water, insufficient means of subsistence, food insecurity, and violence.
CONCLUSION
Mortality indicators seen here exceed previous estimates, and the CMR is above the humanitarian emergency threshold. New methods used in this study may have improved data completeness and quality. Violence is a leading COD, while other causes highlight poor living conditions and difficulties accessing healthcare and preventive measures; these findings are consistent with reported challenges. The high MMR, despite its lack of precision, alongside the high neonatal death rate and birth rate, call for accessible reproductive healthcare. If our results are generalisable to other regions of CAR, national mortality rates would be among the highest globally. The planned nationwide study should proceed as soon as feasible.
CONFLICTS OF INTEREST
None declared.
The Central African Republic (CAR) has the second-lowest human development index globally and has long been described as being in a state of “silent crisis”. We planned a nationwide study to obtain reliable and comparable mortality data for CAR. Due to the COVID-19 pandemic, only the survey in Ouaka Prefecture proceeded.
METHODS
We conducted a two-stage cluster mortality survey between 9 March and 9 April 2020. We aimed to include 64 clusters of 12 households each, for a target sample size of 3,636 persons. We assigned clusters to communes proportional to population size and used systematic random sampling to identify cluster starting points from a dataset of buildings in each commune. We used a novel approach by: focusing on mortality only; adding an opening question about challenges experienced in the last year to build rapport and document general difficulties; and, for females aged 10-49 years, we included specific pregnancy-related questions to improve detection of neonatal and maternal deaths, and to estimate birth rate. The recall period ran from 26 May 2019 to the interview day (range 289-320 days). We coded reported challenges using a content analysis approach.
ETHICS
This study was approved by the MSF Ethics Review Board (ERB) and the national ERB of CAR.
RESULTS
We reached 50 clusters, including 591 participating households with a total of 4,272 individuals. We identified 160 deaths. Crude and under-five mortality rates (CMR, U5MR) were 1.33 (95% confidence interval, CI, 1.09-1.61) and 1.87 (95%CI 1.37-2.54) deaths/10,000 persons/day, respectively. The most common specified causes of death (COD) for individuals aged >5 years were violence (16.7%; n=20; 95%CI 7.7-32.5) and malaria/fever (9.9%; n=11; 95%CI 5.9-16.2). Amongst children aged <5 years, the most common causes were malaria/fever (30.5%;n=15; 95%CI 17.8-47.1), diarrhoea/vomiting (24.0%; n=11;95%CI 11.9-42.7), neonatal deaths (11.9%; n=6; 95%CI 5.3-24.7), and respiratory infections (6.8%; n=3; 95%CI 2.1-20.1).Amongst females aged 10-49 years, 29.1% (95%CI 26.4-31.9%) were pregnant during the recall period. The birth rate was 59/1,000 population (95%CI 51.7-67.4), and the maternal mortality ratio was 2,525/100,000 live births (95%CI 825-5,794). Reported challenges included concerns about specific illnesses, access to healthcare, bereavement, lack of safe drinking water, insufficient means of subsistence, food insecurity, and violence.
CONCLUSION
Mortality indicators seen here exceed previous estimates, and the CMR is above the humanitarian emergency threshold. New methods used in this study may have improved data completeness and quality. Violence is a leading COD, while other causes highlight poor living conditions and difficulties accessing healthcare and preventive measures; these findings are consistent with reported challenges. The high MMR, despite its lack of precision, alongside the high neonatal death rate and birth rate, call for accessible reproductive healthcare. If our results are generalisable to other regions of CAR, national mortality rates would be among the highest globally. The planned nationwide study should proceed as soon as feasible.
CONFLICTS OF INTEREST
None declared.
Conference Material > Video
Robinson E
MSF Scientific Days International 2021: Research. 2021 May 18