Journal Article > ResearchFull Text
BMJ Glob Health. 1 December 2022; Volume 7 (Issue 12); e009674.; DOI:10.1136/bmjgh-2022-009674
Van Bortel W, Mariën J, Jacobs BKM, Sinzinkayo D, Sinarinzi P, et al.
BMJ Glob Health. 1 December 2022; Volume 7 (Issue 12); e009674.; DOI:10.1136/bmjgh-2022-009674
BACKGROUND
Long-lasting insecticidal nets (LLINs) are one of the key interventions in the global fight against malaria. Since 2014, mass distribution campaigns of LLINs aim for universal access by all citizens of Burundi. In this context, we assess the impact of LLINs mass distribution campaigns on malaria incidence, focusing on the endemic highland health districts. We also explored the possible correlation between observed trends in malaria incidence with any variations in climate conditions.
METHODS
Malaria cases for 2011—2019 were obtained from the National Health Information System. We developed a generalised additive model based on a time series of routinely collected data with malaria incidence as the response variable and timing of LLIN distribution as an explanatory variable to investigate the duration and magnitude of the LLIN effect on malaria incidence. We added a seasonal and continuous-time component as further explanatory variables, and health district as a random effect to account for random natural variation in malaria cases between districts.
RESULTS
Malaria transmission in Burundian highlands was clearly seasonal and increased non-linearly over the study period. Further, a fast and steep decline of malaria incidence was noted during the first year after mass LLIN distribution (p<0.0001). In years 2 and 3 after distribution, malaria cases started to rise again to levels higher than before the control intervention.
CONCLUSION
This study highlights that LLINs did reduce the incidence in the first year after a mass distribution campaign, but in the context of Burundi, LLINs lost their impact after only 1 year.
Long-lasting insecticidal nets (LLINs) are one of the key interventions in the global fight against malaria. Since 2014, mass distribution campaigns of LLINs aim for universal access by all citizens of Burundi. In this context, we assess the impact of LLINs mass distribution campaigns on malaria incidence, focusing on the endemic highland health districts. We also explored the possible correlation between observed trends in malaria incidence with any variations in climate conditions.
METHODS
Malaria cases for 2011—2019 were obtained from the National Health Information System. We developed a generalised additive model based on a time series of routinely collected data with malaria incidence as the response variable and timing of LLIN distribution as an explanatory variable to investigate the duration and magnitude of the LLIN effect on malaria incidence. We added a seasonal and continuous-time component as further explanatory variables, and health district as a random effect to account for random natural variation in malaria cases between districts.
RESULTS
Malaria transmission in Burundian highlands was clearly seasonal and increased non-linearly over the study period. Further, a fast and steep decline of malaria incidence was noted during the first year after mass LLIN distribution (p<0.0001). In years 2 and 3 after distribution, malaria cases started to rise again to levels higher than before the control intervention.
CONCLUSION
This study highlights that LLINs did reduce the incidence in the first year after a mass distribution campaign, but in the context of Burundi, LLINs lost their impact after only 1 year.
Conference Material > Slide Presentation
Schittecatte G, Pellechia U, Meudec M, Vanlerberghe V
MSF Scientific Days International 2022. 12 May 2022; DOI:10.57740/79m2-8h12
Conference Material > Abstract
Schittecatte G, Pellechia U, Meudec M, Vanlerberghe V
MSF Scientific Days International 2022. 12 May 2022; DOI:10.57740/w55h-9b93
INTRODUCTION
Community engagement (CE) rose to prominence with the Alma Ata Declaration in 1978, and remains a concept lauded by global health actors, including MSF. CE is often described as being linked with accountability, ownership, and sustainability of health programmes. It is also linked with social determinants of health through its empowering principles. Despite the recognition of its importance, challenges remain in incorporating
CE into programmes.
METHODS
We used a qualitative, case-based approach to explore how community engagement is defined, perceived, and evaluated in MSF contexts. Our aim was to identify challenges and opportunities in truly integrating communities into humanitarian health interventions. Three projects were purposively selected, in Democratic Republic of the Congo, Lebanon, and Venezuela, aiming to represent a variety of health programmes, as well as societal diversity. Document review and 55 semi-structured interviews were conducted. Participants represented different institutional levels and positions, as well as national and international staff. Interviews were transcribed and coded iteratively, as were the operational and technical documents, institutional policies, and reports included in the document reviews. The themes that emerged in the iterative coding were
then analysed.
ETHICS
This study was approved by the MSF Ethics Review Board, and by the Institutional Review Board at the Institute of Tropical Medicine, Antwerp, Belgium.
RESULTS
We found disparity between MSF institutional policy, operational documents, and incorporation of CE at programme level. While there is policy acceptance of CE as essential, interviews show that MSF barely engages with communities in a participatory process. There is little prioritisation of CE, and lack of guidance on the processes needed to involve communities in decision making. Our results also show that despite shared claims of the importance of CE, definitions, objectives, and evaluation all vary significantly. Tensions emerge between seeing communities as active participants or as passive beneficiaries. Additional tensions appeared around whether CE was perceived as an approach for promotion of quality of care and accountability of operations, or purely as an activity to reach the organisation’s goals. Finally, while field projects may establish links with communities, MSF remains the sole decision-maker on the overall medical-humanitarian strategy. Interviewees questioned the capability of MSF to work within this community engagement approach, due to inherent power asymmetries and the predominant use of western-centred biomedical approaches. Inequalities and misconceptions between international and national staff created an additional barrier to bridging with
local communities.
CONCLUSION
If MSF is interested in improving its approach to CE, there should be a concerted effort to change the way communities are viewed with respect to the organisation‘s interventions. While a single model of CE is not possible, MSF needs to set up training on CE approaches and develop frameworks and clear objectives for CE, through dedicated resources at headquarters and field levels.
CONFLICTS OF INTEREST
None declared.
Community engagement (CE) rose to prominence with the Alma Ata Declaration in 1978, and remains a concept lauded by global health actors, including MSF. CE is often described as being linked with accountability, ownership, and sustainability of health programmes. It is also linked with social determinants of health through its empowering principles. Despite the recognition of its importance, challenges remain in incorporating
CE into programmes.
METHODS
We used a qualitative, case-based approach to explore how community engagement is defined, perceived, and evaluated in MSF contexts. Our aim was to identify challenges and opportunities in truly integrating communities into humanitarian health interventions. Three projects were purposively selected, in Democratic Republic of the Congo, Lebanon, and Venezuela, aiming to represent a variety of health programmes, as well as societal diversity. Document review and 55 semi-structured interviews were conducted. Participants represented different institutional levels and positions, as well as national and international staff. Interviews were transcribed and coded iteratively, as were the operational and technical documents, institutional policies, and reports included in the document reviews. The themes that emerged in the iterative coding were
then analysed.
ETHICS
This study was approved by the MSF Ethics Review Board, and by the Institutional Review Board at the Institute of Tropical Medicine, Antwerp, Belgium.
RESULTS
We found disparity between MSF institutional policy, operational documents, and incorporation of CE at programme level. While there is policy acceptance of CE as essential, interviews show that MSF barely engages with communities in a participatory process. There is little prioritisation of CE, and lack of guidance on the processes needed to involve communities in decision making. Our results also show that despite shared claims of the importance of CE, definitions, objectives, and evaluation all vary significantly. Tensions emerge between seeing communities as active participants or as passive beneficiaries. Additional tensions appeared around whether CE was perceived as an approach for promotion of quality of care and accountability of operations, or purely as an activity to reach the organisation’s goals. Finally, while field projects may establish links with communities, MSF remains the sole decision-maker on the overall medical-humanitarian strategy. Interviewees questioned the capability of MSF to work within this community engagement approach, due to inherent power asymmetries and the predominant use of western-centred biomedical approaches. Inequalities and misconceptions between international and national staff created an additional barrier to bridging with
local communities.
CONCLUSION
If MSF is interested in improving its approach to CE, there should be a concerted effort to change the way communities are viewed with respect to the organisation‘s interventions. While a single model of CE is not possible, MSF needs to set up training on CE approaches and develop frameworks and clear objectives for CE, through dedicated resources at headquarters and field levels.
CONFLICTS OF INTEREST
None declared.
Journal Article > ResearchFull Text
Trop Med Int Health. 1 February 2007; Volume 12 (Issue 2); DOI:10.1111/j.1365-3156.2006.01782.x
Vanlerberghe V, Diap G, Guerin PJ, Meheus F, Gerstl S, et al.
Trop Med Int Health. 1 February 2007; Volume 12 (Issue 2); DOI:10.1111/j.1365-3156.2006.01782.x
OBJECTIVE: To facilitate the choice of the best visceral leishmaniasis (VL) treatment strategy for first-line health services in (VL)-endemic areas, we compared in a formal decision analysis the cost and the cost-effectiveness of the different available options. METHODS: We selected four drug regimens for VL on the basis of frequency of use, feasibility and reported efficacy studies. The point estimates and the range of plausible values of effectiveness and cost were retrieved from a literature review. A decision tree was constructed and the strategy minimizing the cost per death averted was selected. RESULTS: Treatment with amphotericin B deoxycholate was the most effective approach in the baseline analysis and averted 87.2% of all deaths attributable to VL. The least expensive and the most cost-effective treatment was the miltefosine regimen, and the most expensive and the least cost-effective was AmBisome treatment. The cost of drug and medical care are the main determinants of the cost-effectiveness ranking of the alternative schemes. Sensitivity analysis showed that antimonial was competitive with miltefosine in the low-resistance regions. CONCLUSION: In areas with >94% response rates to antimonials, generic sodium stibogluconate remains the most cost-effective option for VL treatment, mainly due to low drug cost. In other regions, miltefosine is the most cost-effective option of treatment, but its use as a first-line drug is limited by its teratogenicity and rapid resistance development. AmBisome in mono- or combination therapy is too expensive to compete in cost-effectiveness with the other regimens.
Conference Material > Slide Presentation
Leclair C, Marien J, Sinzinkayo D, Abdelrahman A, Lampaert E, et al.
MSF Scientific Days International 2021: Research. 19 May 2021
Journal Article > ResearchFull Text
Trans R Soc Trop Med Hyg. 1 May 2006; Volume 100 (Issue 5); DOI:10.1016/j.trstmh.2005.07.017
Grandesso F, Bachy C, Donam I, Ntambi J, Habimana J, et al.
Trans R Soc Trop Med Hyg. 1 May 2006; Volume 100 (Issue 5); DOI:10.1016/j.trstmh.2005.07.017
We report two 28-day in-vivo antimalarial efficacy studies carried out in the urban centres of Bongor and Koumra, southern Chad. We assess chloroquine (CQ), sulfadoxine-pyrimethamine (SP) and amodiaquine (AQ) to treat Plasmodium falciparum uncomplicated malaria. Methods and outcome classification complied with latest WHO guidelines. Out of the 301 and 318 children aged 6-59 months included in Bongor and Koumra, respectively, 246 (81.7%) and 257 (80.8%) were eligible for analysis. In Bongor and Koumra, the 28-day PCR-adjusted failure rates for CQ were 23.7% (95% CI 14.7-34.8%) and 32.9% (95% CI 22.1-45.1%), respectively, and those for SP were 16.3% (95% CI 9.4-25.5%) and 4.3% (95% CI 1.2-10.5%). AQ failure rates were 6.4% (95% CI 2.1-14.3%) and 2.2% (95% CI 0.3-7.6%). The current use of CQ in Bongor and Koumra is questionable, and a more efficacious treatment is needed. Considering the reduced efficacy of SP in Bongor, AQ seems to be the best option for the time being. Following WHO recommendations that prioritize the use of artemisinin-based combinations, artesunate plus amodiaquine could be a potential first-line treatment. Nevertheless, the efficacy of this combination should be evaluated and the change carefully prepared, implemented and monitored.
Conference Material > Abstract
Leclair C, Marien J, Sinzinkayo D, Abdelrahman A, Lampaert E, et al.
MSF Scientific Days International 2021: Research. 19 May 2021
INTRODUCTION
In Burundi, malaria continues to be a major public health issue as the leading cause of health facility attendance, high levels of mortality and devastating malaria epidemics in highland areas. Since 2004, Burundi’s National Malaria Control Programme (PNILP) has developed an integrated malaria control strategy. Since 2016, Médecins Sans Frontières (MSF), in collaboration with the PNILP, has implemented integrated malaria control interventions within two malaria endemic health districts located in the central highlands and eastern border regions.
METHODS
We re-assessed epidemiological trends for malaria in Burundi to: (1) evaluate spatial heterogeneity and seasonality; (2) longitudinally describe trends in disease incidence for three epidemiological strata; and (3) assess the association between long-lasting insecticidal net (LLIN) mass distribution campaigns (MDC) and disease incidence. Analysis used malaria case data, routinely collected and reported weekly by PNILP from 2011- 2019. Malaria cases were converted into incidence rates, using existing population data, and expressed per 1000 population at risk. Health districts (n=47) were categorized into three different strata based upon geographic elevation and endemic channels, using the quartile method. A generalized additive mixed model (GAMM) was implemented in R to analyze time-series data.
ETHICS
This work met the requirements for exemption from MSF Ethics Review Board review, and was conducted with permission from Sebastian Spencer, Medical Director, Operational Centre Brussels, MSF.
RESULTS
From 2011-2016, seasonality and intensity of malaria transmission was heterogeneous across the three epidemiological strata. The median incidence (cases/1000 population) for health districts <1200m elevation was 6.0 (interquartile range, IQR, 4.3-8.5); for those 1200-1850m, incidence was 12.3 (IQR 8.0-17.6); and for those >1850m, incidence was 2.1 (IQR 1.1-6.3). In contrast to the observed incidence rates for health districts within the endemic channels at <1200m and >1850m, health districts within the endemic
channel at 1200-1850m showed marked seasonality, with a bimodal distribution. Health districts in these endemic channels, had peaks in median incidence of 17.6 cases/1000 and 15.1cases/1000 population in weeks 26 and 52, respectively. GAMM analysis suggested an increasing trend in malaria incidence over the period 2011—2019. The analysis further revealed that LLIN-MDC campaigns were associated with a rapid reduction in malaria incidence, but the epidemiological impact was attenuated after one year. Specifically, comparing malaria incidence in three health districts adjacent to MSF’s intervention area (1200-1850m channel), the 2017 LLIN-MCD was associated with a 44% reduction in clinical incidence one year post-distribution (RR 0.56, 95%CI 0.556-0.56), but no evidence for a reduction two years post-distribution was observed RR 1.10 (95%CI 1.092-1.099).
CONCLUSION
These findings highlight the effectiveness of LLIN as a malaria control intervention across different epidemiological strata in Burundi. However, the duration of functional effectiveness of LLIN is most definitely less than 3 years and may be shorter than one year in Burundi. The reasons underlying these finding are legion. Further operational research is needed to disentangle the dynamic interplay between operational, human behavioural, sociological, and entomological factors.
In Burundi, malaria continues to be a major public health issue as the leading cause of health facility attendance, high levels of mortality and devastating malaria epidemics in highland areas. Since 2004, Burundi’s National Malaria Control Programme (PNILP) has developed an integrated malaria control strategy. Since 2016, Médecins Sans Frontières (MSF), in collaboration with the PNILP, has implemented integrated malaria control interventions within two malaria endemic health districts located in the central highlands and eastern border regions.
METHODS
We re-assessed epidemiological trends for malaria in Burundi to: (1) evaluate spatial heterogeneity and seasonality; (2) longitudinally describe trends in disease incidence for three epidemiological strata; and (3) assess the association between long-lasting insecticidal net (LLIN) mass distribution campaigns (MDC) and disease incidence. Analysis used malaria case data, routinely collected and reported weekly by PNILP from 2011- 2019. Malaria cases were converted into incidence rates, using existing population data, and expressed per 1000 population at risk. Health districts (n=47) were categorized into three different strata based upon geographic elevation and endemic channels, using the quartile method. A generalized additive mixed model (GAMM) was implemented in R to analyze time-series data.
ETHICS
This work met the requirements for exemption from MSF Ethics Review Board review, and was conducted with permission from Sebastian Spencer, Medical Director, Operational Centre Brussels, MSF.
RESULTS
From 2011-2016, seasonality and intensity of malaria transmission was heterogeneous across the three epidemiological strata. The median incidence (cases/1000 population) for health districts <1200m elevation was 6.0 (interquartile range, IQR, 4.3-8.5); for those 1200-1850m, incidence was 12.3 (IQR 8.0-17.6); and for those >1850m, incidence was 2.1 (IQR 1.1-6.3). In contrast to the observed incidence rates for health districts within the endemic channels at <1200m and >1850m, health districts within the endemic
channel at 1200-1850m showed marked seasonality, with a bimodal distribution. Health districts in these endemic channels, had peaks in median incidence of 17.6 cases/1000 and 15.1cases/1000 population in weeks 26 and 52, respectively. GAMM analysis suggested an increasing trend in malaria incidence over the period 2011—2019. The analysis further revealed that LLIN-MDC campaigns were associated with a rapid reduction in malaria incidence, but the epidemiological impact was attenuated after one year. Specifically, comparing malaria incidence in three health districts adjacent to MSF’s intervention area (1200-1850m channel), the 2017 LLIN-MCD was associated with a 44% reduction in clinical incidence one year post-distribution (RR 0.56, 95%CI 0.556-0.56), but no evidence for a reduction two years post-distribution was observed RR 1.10 (95%CI 1.092-1.099).
CONCLUSION
These findings highlight the effectiveness of LLIN as a malaria control intervention across different epidemiological strata in Burundi. However, the duration of functional effectiveness of LLIN is most definitely less than 3 years and may be shorter than one year in Burundi. The reasons underlying these finding are legion. Further operational research is needed to disentangle the dynamic interplay between operational, human behavioural, sociological, and entomological factors.