Journal Article > ResearchFull Text
PLOS One. 4 June 2021; Volume 16 (Issue 6); e0252460.; DOI:10.1371/journal.pone.0252460
Kuehne A, Van Boetzelaer E, Alfani P, Fotso A, Elhammali H, et al.
PLOS One. 4 June 2021; Volume 16 (Issue 6); e0252460.; DOI:10.1371/journal.pone.0252460
Libya is a major transit and destination country for international migration. UN agencies estimates 571,464 migrants, refugees and asylum seekers in Libya in 2021; among these, 3,934 people are held in detention. We aimed to describe morbidities and water, hygiene, and sanitation (WHS) conditions in detention in Tripoli, Libya. We conducted a retrospective analysis of data collected between July 2018 and December 2019, as part of routine monitoring within an Médecins Sans Frontières (MSF) project providing healthcare and WHS support for migrants, refugees and asylum seekers in some of the official detention centres (DC) in Tripoli. MSF had access to 1,630 detainees in eight different DCs on average per month. Only one DC was accessible to MSF every single month. The size of wall openings permitting cell ventilation failed to meet minimum standards in all DCs. Minimum standards for floor space, availability of water, toilets and showers were frequently not met. The most frequent diseases were acute respiratory tract infections (26.9%; 6,775/25,135), musculoskeletal diseases (24.1%; 6,058/25,135), skin diseases (14.1%; 3,538/25,135) and heartburn and reflux (10.0%; 2,502/25,135). Additionally, MSF recorded 190 cases of violence-induced wounds and 55 cases of sexual and gender-based violence. During an exhaustive nutrition screening in one DC, linear regression showed a reduction in mid-upper arm circumference (MUAC) of 2.5mm per month in detention (95%-CI 1.3-3.7, p<0.001). Detention of men, women and children continues to take place in Tripoli. Living conditions failed to meet minimum requirements. Health problems diagnosed at MSF consultations reflect the living conditions and consist largely of diseases related to overcrowding, lack of water and ventilation, and poor diet. Furthermore, every month that people stay in detention increases their risk of malnutrition. The documented living conditions and health problems call for an end of detention and better protection of migrants, refugees and asylum seekers in Libya.
Protocol > Research Protocol
Verdecchia M
1 July 2018
Objectives
Primary:
To describe outcomes of all patients started on the national MDR-TB treatment protocol in Matsapha & Mankayane by the MSF Manzini Project, Swaziland since its inception in 2011.
Secondary:
To identify any difference in outcomes between HIV-co-infected and non-co-infected MDR-TB patients.
To identify risk factors associated with poor outcomes (loss to follow up, treatment failure and death).
To evaluate time to culture conversion.
To evaluate time to poor outcomes (loss to follow up, treatment failure and death).
Primary:
To describe outcomes of all patients started on the national MDR-TB treatment protocol in Matsapha & Mankayane by the MSF Manzini Project, Swaziland since its inception in 2011.
Secondary:
To identify any difference in outcomes between HIV-co-infected and non-co-infected MDR-TB patients.
To identify risk factors associated with poor outcomes (loss to follow up, treatment failure and death).
To evaluate time to culture conversion.
To evaluate time to poor outcomes (loss to follow up, treatment failure and death).
Conference Material > Abstract
Verputten M, Gray NSB, Siddiqui R, Mohan H, Borgundvaag E, et al.
MSF Scientific Days International 2020: Research. 20 May 2020
INTRODUCTION
An estimated one in three women globally experience sexual violence (SV) and intimate partner violence. MSF has provided comprehensive medical and psychosocial care for SV and IPV survivors in Port-au-Prince, Haiti, and Delhi, India, since 2015. We aimed to understand the knowledge, attitudes, and practices (KAP) surrounding SV and care-seeking pathways, to improve access to and uptake of services.
METHODS
We conducted two sequential mixed-methods studies between March and October 2018. Quantitative data were collected using a KAP survey in randomly selected households. Qualitative data were collected using in-depth interviews (IDI’s) with key stakeholders and focus group discussions (FGD’s) with community members; in Haiti FGD’s with young people and IDI’s with survivors of SV were also done.
ETHICS
These studies were approved by the ethics committee of the Dr. B.R. Ambedkar Medical College in India (for Delhi), the Comité National de Bioéthique in Haiti (for Port-au-Prince), and the MSF Ethics Review Board (for both).
RESULTS
2340 people participated in household surveys: 1083 in Haiti and 1257 in India. Qualitative data were collated for 382 individuals: 289 in Haiti (24 adult FGD’s, eight youth FGD’s, 15 IDI’s with key stakeholders and eight IDI’s with SV survivors during their follow-up visit) and 93 in India (14 adult FGD’s and 12 IDI’s with health workers). We found an almost universal perceived need for medical care for SV survivors, mostly for injury treatment. However, in both contexts, participants described numerous issues perceived to hinder or prevent survivors seeking and accessing care. Shame, fear of stigma, and social consequences were the most significant barriers reported, compounded by major service-level barriers. There were also context-specific factors. In India, lower knowledge of health consequences and available treatment, combined with media-influenced perceptions of rape as a physically violent event and a 'police issue' were major barriers, compounded by mandatory police reporting and a lack of confidentiality in health facilities. In Haiti, knowledge of medical consequences and care needs was higher than in India, but perceived lack of services, their inaccessibility, and high costs impeded access to care. Participants in both studies explained that most survivors were likely to stay silent. Those who would seek medical help would do so only should physical consequences (eg injuries) arise. A key factor facilitating access to care was support from trusted confidants; improving access would require enhancing social support and facilitating community referral networks, combined with ensuring provision and awareness of quality, comprehensive, confidential care.
CONCLUSION
Sociocultural conceptualisations and structural responses to SV influence perceived and lived consequences for survivors, shaping engagement with support and available services. These findings inform MSF's SV response, supporting adaptation of modalities of care provision and augmenting local knowledge and networks to improve access. We propose a model for understanding context-specific factors affecting access to survivor-centred care in different settings, to better inform development of strategies and activities to improve access and service utilisation.
CONFLICTS OF INTEREST
None declared.
An estimated one in three women globally experience sexual violence (SV) and intimate partner violence. MSF has provided comprehensive medical and psychosocial care for SV and IPV survivors in Port-au-Prince, Haiti, and Delhi, India, since 2015. We aimed to understand the knowledge, attitudes, and practices (KAP) surrounding SV and care-seeking pathways, to improve access to and uptake of services.
METHODS
We conducted two sequential mixed-methods studies between March and October 2018. Quantitative data were collected using a KAP survey in randomly selected households. Qualitative data were collected using in-depth interviews (IDI’s) with key stakeholders and focus group discussions (FGD’s) with community members; in Haiti FGD’s with young people and IDI’s with survivors of SV were also done.
ETHICS
These studies were approved by the ethics committee of the Dr. B.R. Ambedkar Medical College in India (for Delhi), the Comité National de Bioéthique in Haiti (for Port-au-Prince), and the MSF Ethics Review Board (for both).
RESULTS
2340 people participated in household surveys: 1083 in Haiti and 1257 in India. Qualitative data were collated for 382 individuals: 289 in Haiti (24 adult FGD’s, eight youth FGD’s, 15 IDI’s with key stakeholders and eight IDI’s with SV survivors during their follow-up visit) and 93 in India (14 adult FGD’s and 12 IDI’s with health workers). We found an almost universal perceived need for medical care for SV survivors, mostly for injury treatment. However, in both contexts, participants described numerous issues perceived to hinder or prevent survivors seeking and accessing care. Shame, fear of stigma, and social consequences were the most significant barriers reported, compounded by major service-level barriers. There were also context-specific factors. In India, lower knowledge of health consequences and available treatment, combined with media-influenced perceptions of rape as a physically violent event and a 'police issue' were major barriers, compounded by mandatory police reporting and a lack of confidentiality in health facilities. In Haiti, knowledge of medical consequences and care needs was higher than in India, but perceived lack of services, their inaccessibility, and high costs impeded access to care. Participants in both studies explained that most survivors were likely to stay silent. Those who would seek medical help would do so only should physical consequences (eg injuries) arise. A key factor facilitating access to care was support from trusted confidants; improving access would require enhancing social support and facilitating community referral networks, combined with ensuring provision and awareness of quality, comprehensive, confidential care.
CONCLUSION
Sociocultural conceptualisations and structural responses to SV influence perceived and lived consequences for survivors, shaping engagement with support and available services. These findings inform MSF's SV response, supporting adaptation of modalities of care provision and augmenting local knowledge and networks to improve access. We propose a model for understanding context-specific factors affecting access to survivor-centred care in different settings, to better inform development of strategies and activities to improve access and service utilisation.
CONFLICTS OF INTEREST
None declared.
Journal Article > ResearchFull Text
PLOS One. 17 October 2018; Volume 13 (Issue 10); e0205601.; DOI:10.1371/journal.pone.0205601
Verdecchia M, Keus K, Blankley S, Vambe D, Ssonko C, et al.
PLOS One. 17 October 2018; Volume 13 (Issue 10); e0205601.; DOI:10.1371/journal.pone.0205601
INTRODUCTION
Since 2011 Médecins sans Frontières together with the eSwatini Ministry of Health have been managing patients with multi-drug resistant tuberculosis (MDR-TB) at Matsapha and Mankayane in Manzini region. This analysis describes the model of care and outcomes of patients receiving a 20 months MDR-TB treatment regimen between 2011 and 2013.
METHOD
We conducted a retrospective observational cohort study of MDR-TB patients enrolled for treatment between May 2011 and December 2013. An extensive package of psychological care and socio-economic incentives were provided including psychological support, paid treatment supporters, transport fees and a monthly food package. Baseline demographic details and treatment outcomes were recorded and for HIV positive patient's univariate analysis as well as a cox regression hazard model were undertaken to assess risk factors for unfavorable outcomes.
RESULTS
From the 174 patients enrolled, 156 (89.7%) were HIV co-infected, 102 (58.6%) were female, median age 33 years old (IQR: 28-42), 55 (31.6%) had a BMI less than 18 and 86 (49.4%) had not been previously treated for any form of TB. Overall cohort outcomes revealed a 75.3% treatment success rate, 21.3% mortality rate, 0.6% failure and 0.6% lost to follow-up rate. In the adjusted multivariate analysis, low BMI and low CD4 count at treatment initiation were associated with an increased risk of unfavorable outcome.
CONCLUSIONS
A model of care that included psychosocial support and patient's enablers led to a high level of treatment success with a very low lost to follow up rate. Limiting the overall treatment success was a high mortality rate which was associated with advanced HIV and a low BMI at presentation. These factors will need to be addressed in order to improve upon the overall treatment success rate in future.
Since 2011 Médecins sans Frontières together with the eSwatini Ministry of Health have been managing patients with multi-drug resistant tuberculosis (MDR-TB) at Matsapha and Mankayane in Manzini region. This analysis describes the model of care and outcomes of patients receiving a 20 months MDR-TB treatment regimen between 2011 and 2013.
METHOD
We conducted a retrospective observational cohort study of MDR-TB patients enrolled for treatment between May 2011 and December 2013. An extensive package of psychological care and socio-economic incentives were provided including psychological support, paid treatment supporters, transport fees and a monthly food package. Baseline demographic details and treatment outcomes were recorded and for HIV positive patient's univariate analysis as well as a cox regression hazard model were undertaken to assess risk factors for unfavorable outcomes.
RESULTS
From the 174 patients enrolled, 156 (89.7%) were HIV co-infected, 102 (58.6%) were female, median age 33 years old (IQR: 28-42), 55 (31.6%) had a BMI less than 18 and 86 (49.4%) had not been previously treated for any form of TB. Overall cohort outcomes revealed a 75.3% treatment success rate, 21.3% mortality rate, 0.6% failure and 0.6% lost to follow-up rate. In the adjusted multivariate analysis, low BMI and low CD4 count at treatment initiation were associated with an increased risk of unfavorable outcome.
CONCLUSIONS
A model of care that included psychosocial support and patient's enablers led to a high level of treatment success with a very low lost to follow up rate. Limiting the overall treatment success was a high mortality rate which was associated with advanced HIV and a low BMI at presentation. These factors will need to be addressed in order to improve upon the overall treatment success rate in future.
Journal Article > ResearchFull Text
PLOS One. 23 December 2020; Volume 15 (Issue 12); e0244214.; DOI:10.1371/journal.pone.0244214
Van Boetzelaer E, Chowdhury SM, Etsay B, Faruque A, Lenglet AD, et al.
PLOS One. 23 December 2020; Volume 15 (Issue 12); e0244214.; DOI:10.1371/journal.pone.0244214
BACKGROUND
Following an influx of an estimated 742,000 Rohingya refugees in Bangladesh, Médecins sans Frontières (MSF) established an active indicator-based Community Based Surveillance (CBS) in 13 sub-camps in Cox’s Bazar in August 2017. Its objective was to detect epidemic prone diseases early for rapid response. We describe the surveillance, alert and response in place from epidemiological week 20 (12 May 2019) until 44 (2 November 2019).
METHODS
Suspected cases were identified through passive health facility surveillance and active indicator-based CBS. CBS-teams conducted active case finding for suspected cases of acute watery diarrhea (AWD), acute jaundice syndrome (AJS), acute flaccid paralysis (AFP), dengue, diphtheria, measles and meningitis. We evaluate the following surveillance system attributes: usefulness, Positive Predictive Value (PPV), timeliness, simplicity, flexibility, acceptability, representativeness and stability.
RESULTS
Between epidemiological weeks 20 and 44, an average of 97,340 households were included in the CBS per surveillance cycle. Household coverage reached over 85%. Twenty-one RDT positive cholera cases and two clusters of AWD were identified by the CBS and health facility surveillance that triggered the response mechanism within 12 hours. The PPV of the CBS varied per disease between 41.7%-100%. The CBS required 354 full-time staff in 10 different roles. The CBS was sufficiently flexible to integrate dengue surveillance. The CBS was representative of the population in the catchment area due to its exhaustive character and high household coverage. All households consented to CBS participation, showing acceptability.
DISCUSSION
The CBS allowed for timely response but was resource intensive. Disease trends identified by the health facility surveillance and suspected diseases trends identified by CBS were similar, which might indicate limited additional value of the CBS in a dense and stable setting such as Cox’s Bazar. Instead, a passive community-event-based surveillance mechanism combined with health facility-based surveillance could be more appropriate.
Following an influx of an estimated 742,000 Rohingya refugees in Bangladesh, Médecins sans Frontières (MSF) established an active indicator-based Community Based Surveillance (CBS) in 13 sub-camps in Cox’s Bazar in August 2017. Its objective was to detect epidemic prone diseases early for rapid response. We describe the surveillance, alert and response in place from epidemiological week 20 (12 May 2019) until 44 (2 November 2019).
METHODS
Suspected cases were identified through passive health facility surveillance and active indicator-based CBS. CBS-teams conducted active case finding for suspected cases of acute watery diarrhea (AWD), acute jaundice syndrome (AJS), acute flaccid paralysis (AFP), dengue, diphtheria, measles and meningitis. We evaluate the following surveillance system attributes: usefulness, Positive Predictive Value (PPV), timeliness, simplicity, flexibility, acceptability, representativeness and stability.
RESULTS
Between epidemiological weeks 20 and 44, an average of 97,340 households were included in the CBS per surveillance cycle. Household coverage reached over 85%. Twenty-one RDT positive cholera cases and two clusters of AWD were identified by the CBS and health facility surveillance that triggered the response mechanism within 12 hours. The PPV of the CBS varied per disease between 41.7%-100%. The CBS required 354 full-time staff in 10 different roles. The CBS was sufficiently flexible to integrate dengue surveillance. The CBS was representative of the population in the catchment area due to its exhaustive character and high household coverage. All households consented to CBS participation, showing acceptability.
DISCUSSION
The CBS allowed for timely response but was resource intensive. Disease trends identified by the health facility surveillance and suspected diseases trends identified by CBS were similar, which might indicate limited additional value of the CBS in a dense and stable setting such as Cox’s Bazar. Instead, a passive community-event-based surveillance mechanism combined with health facility-based surveillance could be more appropriate.
Conference Material > Abstract
Genovese GOM, Woudenberg T, Kamau C, Beko P, Miaka EM, et al.
MSF Scientific Days International 2020: Research. 26 May 2020; DOI:10.7490/f1000research.1117908.1
INTRODUCTION
Human African trypanosomiasis (HAT) is a parasitic disease that can be fatal if left untreated. MSF conducted an active screening campaign for HAT, deploying mobile teams in remote areas of the Democratic Republic of Congo (DRC) between February 2018 and June 2019. We aimed to identify village-level risk factors associated with the presence of HAT cases, to better inform future targeted screening activities.
METHODS
Between Jan 2018 and June 2019, 170 villages were included in an exploratory phase of the study, with activities involving information, education and communication, population counts, collection of global positioning system coordinates, and assessment of risk factors. Risk factors were identified based on literature review and interviews with HAT experts, and included distances between village and water, presence of specific land types, tsetse flies, and hunting and fishing activities. 152 villages were included in the later active screening phase. Screening involved lymph node palpation, card agglutination test for trypanosomes (CATT) done on whole blood for all villagers, CATT dilutions, as well as parasitological testing and confirmation should patients test 1:16 CATT positive. Serological suspect cases were defined as those CATT 1:16 positive. Treatment with pentamidine was given to all suspect cases. Univariable and multivariable Poisson regression models were used to examine the association between at least one positive case in a village and risk factors.
ETHICS
This work fulfilled the exemption criteria set by the MSF Ethics Review Board (ERB) for a posteriori analyses of routinely collected clinical data, and thus did not require MSF ERB review. It was conducted with permission from Sidney Wong, Medical Director, Operational Centre Amsterdam, MSF.
RESULTS
Of 33,147 screened individuals, from a population of 41,764 (79%) in 152 villages, 46 suspect cases were diagnosed (1.4 cases per 1000). Suspect cases came from 33 villages (22%), of which nine villages (6%) had more than one suspect case. The highest incidence was in Otanga, with 5.6 suspect cases per 1000 screened population. Limited sample size prevented us from conducting a multivariable Poisson regression, and reduced power to find statistically significant effects. Incidence rate ratios (IRR) for relevant risk factors were: presence of hunters in a village (IRR 1.7; 95%CI 0.9-3.8), village screened more than 5 years ago (IRR 2.0; 95%CI 1.0–4.7), tsetse fly observed on visit (IRR 1.3; 95%CI 0.4 –3.3), and absence of forests within 1000m of village (IRR 0.2; 95%CI 0.0–1.0).
CONCLUSION
We detected small numbers of HAT suspect cases, preventing predictive algorithm development. However our data suggest that where HAT prevalence is low, active screening campaigns might not be effective; risk factors are not likely predictive enough to enable development of targeted screening programmes. Integrating passive screening into health posts and reactionary responses, when parasitological confirmed cases are detected, may be a better alternative. This will require training of medical staff, and reformed strategies within MSF.
CONFLICTS OF INTEREST
None declared.
Human African trypanosomiasis (HAT) is a parasitic disease that can be fatal if left untreated. MSF conducted an active screening campaign for HAT, deploying mobile teams in remote areas of the Democratic Republic of Congo (DRC) between February 2018 and June 2019. We aimed to identify village-level risk factors associated with the presence of HAT cases, to better inform future targeted screening activities.
METHODS
Between Jan 2018 and June 2019, 170 villages were included in an exploratory phase of the study, with activities involving information, education and communication, population counts, collection of global positioning system coordinates, and assessment of risk factors. Risk factors were identified based on literature review and interviews with HAT experts, and included distances between village and water, presence of specific land types, tsetse flies, and hunting and fishing activities. 152 villages were included in the later active screening phase. Screening involved lymph node palpation, card agglutination test for trypanosomes (CATT) done on whole blood for all villagers, CATT dilutions, as well as parasitological testing and confirmation should patients test 1:16 CATT positive. Serological suspect cases were defined as those CATT 1:16 positive. Treatment with pentamidine was given to all suspect cases. Univariable and multivariable Poisson regression models were used to examine the association between at least one positive case in a village and risk factors.
ETHICS
This work fulfilled the exemption criteria set by the MSF Ethics Review Board (ERB) for a posteriori analyses of routinely collected clinical data, and thus did not require MSF ERB review. It was conducted with permission from Sidney Wong, Medical Director, Operational Centre Amsterdam, MSF.
RESULTS
Of 33,147 screened individuals, from a population of 41,764 (79%) in 152 villages, 46 suspect cases were diagnosed (1.4 cases per 1000). Suspect cases came from 33 villages (22%), of which nine villages (6%) had more than one suspect case. The highest incidence was in Otanga, with 5.6 suspect cases per 1000 screened population. Limited sample size prevented us from conducting a multivariable Poisson regression, and reduced power to find statistically significant effects. Incidence rate ratios (IRR) for relevant risk factors were: presence of hunters in a village (IRR 1.7; 95%CI 0.9-3.8), village screened more than 5 years ago (IRR 2.0; 95%CI 1.0–4.7), tsetse fly observed on visit (IRR 1.3; 95%CI 0.4 –3.3), and absence of forests within 1000m of village (IRR 0.2; 95%CI 0.0–1.0).
CONCLUSION
We detected small numbers of HAT suspect cases, preventing predictive algorithm development. However our data suggest that where HAT prevalence is low, active screening campaigns might not be effective; risk factors are not likely predictive enough to enable development of targeted screening programmes. Integrating passive screening into health posts and reactionary responses, when parasitological confirmed cases are detected, may be a better alternative. This will require training of medical staff, and reformed strategies within MSF.
CONFLICTS OF INTEREST
None declared.
Conference Material > Poster
Borum Mølskov Bech M, Otieno Khisa A, Ndoca K, Ayuaya T, Kajuju P, et al.
MSF Scientific Days International 2022. 9 May 2022; DOI:10.57740/pk5z-0q14