Journal Article > ResearchFull Text
BMJ Glob Health. 2020 April 14; Volume 5 (Issue 4); e002141.; DOI:10.1136/bmjgh-2019-002141.
Farley ES, Oyemakinde MJ, Schuurmans J, Ariti C, Saleh F, et al.
BMJ Glob Health. 2020 April 14; Volume 5 (Issue 4); e002141.; DOI:10.1136/bmjgh-2019-002141.
BACKGROUND
Noma, a rapidly progressing infection of the oral cavity, mainly affects children. The true burden is unknown. This study reports estimated noma prevalence in children in northwest Nigeria.
METHODS
Oral screening was performed on all ≤15 year olds, with caretaker consent, in selected households during this cross-sectional survey. Noma stages were classified using WHO criteria and caretakers answered survey questions. The prevalence of noma was estimated stratified by age group (0–5 and 6–15 years). Factors associated with noma were estimated using logistic regression.
RESULTS
A total of 177 clusters, 3499 households and 7122 children were included. In this sample, 4239 (59.8%) were 0–5 years and 3692 (52.1%) were female. Simple gingivitis was identified in 3.1% (n=181; 95% CI 2.6 to 3.8), acute necrotising gingivitis in 0.1% (n=10; CI 0.1 to 0.3) and oedema in 0.05% (n=3; CI 0.02 to 0.2). No cases of late-stage noma were detected. Multivariable analysis in the group aged 0–5 years showed having a well as the drinking water source (adjusted odds ratio (aOR) 2.1; CI 1.2 to 3.6) and being aged 3–5 years (aOR 3.9; CI 2.1 to 7.8) was associated with being a noma case. In 6–15 year olds, being male (aOR 1.5; CI 1.0 to 2.2) was associated with being a noma case and preparing pap once or more per week (aOR 0.4; CI 0.2 to 0.8) was associated with not having noma. We estimated that 129120 (CI 105294 to 1 52 947) individuals <15 years of age would have any stage of noma at the time of the survey within the two states. Most of these cases (93%; n=120 082) would be children with simple gingivitis.
CONCLUSIONS
Our study identified a high prevalence of children at risk of developing advanced noma. This disease is important but neglected and therefore merits inclusion in the WHO neglected tropical diseases list.
Noma, a rapidly progressing infection of the oral cavity, mainly affects children. The true burden is unknown. This study reports estimated noma prevalence in children in northwest Nigeria.
METHODS
Oral screening was performed on all ≤15 year olds, with caretaker consent, in selected households during this cross-sectional survey. Noma stages were classified using WHO criteria and caretakers answered survey questions. The prevalence of noma was estimated stratified by age group (0–5 and 6–15 years). Factors associated with noma were estimated using logistic regression.
RESULTS
A total of 177 clusters, 3499 households and 7122 children were included. In this sample, 4239 (59.8%) were 0–5 years and 3692 (52.1%) were female. Simple gingivitis was identified in 3.1% (n=181; 95% CI 2.6 to 3.8), acute necrotising gingivitis in 0.1% (n=10; CI 0.1 to 0.3) and oedema in 0.05% (n=3; CI 0.02 to 0.2). No cases of late-stage noma were detected. Multivariable analysis in the group aged 0–5 years showed having a well as the drinking water source (adjusted odds ratio (aOR) 2.1; CI 1.2 to 3.6) and being aged 3–5 years (aOR 3.9; CI 2.1 to 7.8) was associated with being a noma case. In 6–15 year olds, being male (aOR 1.5; CI 1.0 to 2.2) was associated with being a noma case and preparing pap once or more per week (aOR 0.4; CI 0.2 to 0.8) was associated with not having noma. We estimated that 129120 (CI 105294 to 1 52 947) individuals <15 years of age would have any stage of noma at the time of the survey within the two states. Most of these cases (93%; n=120 082) would be children with simple gingivitis.
CONCLUSIONS
Our study identified a high prevalence of children at risk of developing advanced noma. This disease is important but neglected and therefore merits inclusion in the WHO neglected tropical diseases list.
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 > Poster
Post N, Boobier L, Vyncke J, Tremblay LL
MSF Scientific Day International 2023. 2023 June 7
Journal Article > ResearchFull Text
PLOS One. 2020 December 23; 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. 2020 December 23; 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 > 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.