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Nasopharyngeal carriage of aerobic Gram-negative bacilli (GNB) may precede the development of invasive respiratory infections. We assessed the prevalence of nasopharyngeal carriage of aerobic GNB and their antimicrobial resistance patterns among healthy under-five children attending seven selected day-care centres in the Accra metropolis of the Greater Accra region of Ghana from September to December 2016. This cross-sectional study analysed a total of 410 frozen nasopharyngeal samples for GNB and antimicrobial drug resistance. The GNB prevalence was 13.9% (95% CI: 10.8–17.6%). The most common GNB were Escherichia coli (26.3%), Klebsiella pneumoniae (24.6%), and Enterobacter cloacae (17.5%). Resistance was most frequent for cefuroxime (73.7%), ampicillin (64.9%), and amoxicillin/clavulanic acid (59.6%). The organisms were least resistant to gentamicin (7.0%), amikacin (8.8%), and meropenem (8.8%). Multidrug resistance (MDR, being resistant to ≥3 classes of antibiotics) was observed in 66.7% (95% CI: 53.3–77.8%). Extended-spectrum beta-lactamase (ESBL)-producing bacteria constituted 17.5% (95% CI: 9.5–29.9%), AmpC-producing bacteria constituted 42.1% (95% CI: 29.8–55.5%), and carbapenemase-producing bacteria constituted 10.5% (95% CI: 4.7–21.8%) of isolates. The high levels of MDR are of great concern. These findings are useful in informing the choice of antibiotics in empiric treatment of GNB infections and call for improved infection control in day-care centres to prevent further transmission.

Introduction: In 2017, Ethiopia included scabies management within the responsibility of health extension workers. In Kamba (the intervention district) workers were trained on scabies management. Whereas, in Arba Minch Zuria (the control district) there was no such training. This study assesses whether decentralization of scabies management to communities would reduce the load on health facilities and allow earlier scabies treatment access. Methodology: All individuals presenting with scabies before (January – June 2018) and after (August 2018-January 2019) the introduction of training (July 2018) in Kamba district and the Arba Minch Zuria district were included. We compared between the two districts in the period before and after training, the numbers of scabies cases presenting to health facilities, their demography, clinical characteristics and treatment. Results: There were 1,891 scabies cases in the intervention district and 809 in the control district. Scabies cases declined in the intervention district from 7.6 to 1.6 per 1,000 population (a 4.8-fold reduction). In the control district, scabies cases increased from 1.3 to 2.4 per 1,000 population (a 1.8-fold increase). In intervention district, the proportion of scabies patients with secondary skin infections reduced from 1,227 (78%, n = 1,565) to 156 (48%, n = 326, P < 0.001). In the control district the difference was insignificant 39 (14%, n = 288) to 86 (17%, n = 521, P = 0.2). Conclusions: Introducing trained health extension workers at community level were associated with reductions in health facility load for scabies and secondary infections. This is a wider community health benefit.

Introduction: In 2018, the Ethiopian Ministry of Health embarked on a Mass Drug Administration (MDA) campaign that involved over 9 million people in Ethiopia – the largest scabies MDA campaign ever conducted on a global level. We describe its implementation and report on a) numbers screened and identified with scabies, b) treatment category and drug type and c) human resources used, duration, and cost of the campaign. Methodology: The MDA campaign was conducted according to national guidelines and activities including: planning and organization, engagement of local leaders, community mobilisation and advocacy, awareness-raising among health workers, field implementation, and monitoring and evaluation. The campaign was conducted between July and August 2018. Results: The MDA campaign was implemented by about 15,000 people, mostly from the community, over an average of 6 days and reached 9, 057, 427 people. A total of 875,890 (9.7%) scabies cases were detected and 995,471 (11.0%) contacts received treatment. (Contact-to-case ratio = 1.3). Scabies prevalence varied, the highest prevalence was seen in Central Gondar (39.2%), South Gondar (16.7%) and North Gondar (15.0%), these neighbouring zones contributing more than two third of all scabies cases in the region. Of 1,738,304 (93%) who received treatment, 94% received ivermectin, the rest topical permethrin and sulfur. The average coverage capacity of an MDA campaign staff member was 84 people per day. The total cost was 11,696,333 United States Dollars (USD). Cost per 100,000 population = 129,135 USD. Conclusions: This experience of rapid-large scale implementation would be useful to scale up similar interventions and “stop the itch” in other regions of Ethiopia.

A study of 4 partner notification approaches in Côte d'Ivoire found that the provider approach is a successful and acceptable strategy for bringing in sex partners for human immunodeficiency virus testing., Background Four partner notification approaches were introduced in health facilities in Côte d'Ivoire to increase human immunodeficiency virus (HIV) testing uptake among the type of contacts (sex partners and biological children younger than 15 years). The study assessed the 4 approaches: client referral (index cases refer the contacts for HIV testing), provider referral (health care providers refer the contacts), contract referral (index case-provider hybrid approach), and dual referral (both the index and their partner are tested simultaneously). Methods Program data were collected at 4 facilities from October 2018 to March 2019 from index case files and HIV testing register. We compared uptake of the approaches, uptake of HIV testing, and HIV positivity percentages, stratified by contact type and gender. Results There were 1089 sex partners and 469 children from 1089 newly diagnosed index cases. About 90% of children were contacted through client referral: 85.2% of those were tested and 1.4% was positive. Ninety percent of the children came from female index cases. The provider referral brought in 56.3% of sex partners, of whom 97.2% were HIV-tested. The client referral brought in 30% of sex partners, of whom only 81.5% were HIV-tested. The HIV positivity percentages were 75.5% and 72.7%, respectively, for the 2 approaches. Male index cases helped to reach twice as many HIV-positive sexual contacts outside the household (115) than female index cases (53). The contract and dual referrals were not preferred by index cases. Conclusions Provider referral is a successful and acceptable strategy for bringing in sex partners for testing. Client referral is preferred for children.

Surgical site infections (SSIs) are common postoperative complications. Surgical antibiotic prophylaxis (SAP) can prevent the occurrence of SSIs if administered appropriately. We carried out a retrospective cohort study to determine the incidence of SSIs and assess whether SAP were administered according to WHO guidelines for Caesarean section (CS) and herniorrhaphy patients in Bo regional government hospital from November 2019 to October 2020. The analysis included 681 patients (599 CSs and 82 herniorrhaphies). Overall, the SSI rate was 6.7% among all patients, and 7.5% and 1.2% among CS patients and herniorrhaphy patients, respectively. SAP was administered preoperatively in 85% of CS and 70% of herniorrhaphy patients. Postoperative antibiotics were prescribed to 85% of CS and 100% of herniorrhaphy patients. Ampicillin, metronidazole, and amoxicillin were the most commonly used antibiotics. The relatively low rate of SSIs observed in this study is probably due to improved infection prevention and control (IPC) measures following the Ebola outbreak and the current COVID-19 pandemic. A good compliance rate with WHO guidelines for preoperative SAP was observed. However, there was a high use of postoperative antibiotics, which is not in line with WHO guidelines. Recommendations were made to ensure the appropriate administration of SAP and reduce unnecessary use of antibiotics.

Background Large numbers of tuberculosis (TB) patients seek care from private for-profit providers. This study aimed to assess and compare TB control activities in the private for-profit and public sectors in Kenya between 2013 and 2017. Methods We conducted a retrospective cross-sectional study using routinely collected data from the National Tuberculosis, Leprosy and Lung Disease Program. Results Of 421 409 patients registered and treated between 2013 and 2017, 86 894 (21%) were from the private sector. Data collection was less complete in the private sector for nutritional assessment and follow-up sputum smear examinations (p95% and >90%, respectively, in both sectors, but more patients were HIV positive in the private sector (39.6% vs 31.6%; p Conclusions The private sector is performing well in Kenya although there are programmatic challenges that need to be addressed.

Antimicrobial resistant (AMR) bacteria in effluents from seafood processing facilities can contribute to the spread of AMR in the natural environment. In this study conducted in Tema, Ghana, a total of 38 effluent samples from two seafood processing facilities were collected during 2021 and 2022, as part of a pilot surveillance project to ascertain the bacterial load, bacterial species and their resistance to 15 antibiotics belonging to the WHO AWaRe group of antibiotics. The bacterial load in the effluent samples ranged from 13–1800 most probable number (MPN)/100 mL. We identified the following bacterial species: E. coli in 31 (82%) samples, K. pneumoniae in 15 (39%) samples, Proteus spp. in 6 (16%) samples, P. aeruginosa in 2 (5%) samples and A. baumannii in 2 (5%) samples. The highest levels of antibiotic resistance (100%) were recorded for ampicillin and cefuroxime among Enterobacteriaceae. The WHO priority pathogens—E. coli (resistant to cefotaxime, ceftazidime and carbapenem) and K.pneumoniae (resistant to ceftriaxone)—were found in 5 (13%) effluent samples. These findings highlight the need for enhanced surveillance to identify the source of AMR and multi-drug resistant bacteria and an adoption of best practices to eliminate these bacteria in the ecosystem of the seafood processing facilities.

Hypertension, diabetes mellitus and asthma are on the rise in developing countries, including Rwanda; there is thus a need to ensure uninterrupted drug availability.To assess 1) the frequency and duration of drug stock-outs; 2) lead time duration 3) monthly stock levels; and 4) drug quantities requested vs. quantity delivered for captopril, metformin and inhaled salbutamol between January and December 2018 Kirehe District, Rwanda.This was a cross-sectional study using secondary programme data.The median annual stock-outs for captopril, metformin and inhaled salbutamol were respectively 4 (IQR 3-4), 3 (IQR 2-3) and 4 (IQR 4-5) at rural health facilities (RHCs); no stock-outs occurred at the district hospital. For all three drugs, the median lead time was 7.5 days (IQR 5.5-11.5) at the hospital vs. 5 days (IQR 3-6) in RHCs. Stock status for captopril was below the 4-week minimum stock level for 2/12 months at the hospital vs. 7/12 months at the RHCs, while metformin and inhaled salbutamol were below the 4-week minimum stock levels for respectively 1/12 and 4/12 months at both hospital and RHCs. Total drug quantities delivered were less than the combined total quantities requested in respectively 8/12, 5/12 and 8/12 months for captopril, metformin and inhaled salbutamol.There is a need to regularly and effectively monitor drug stock levels and ensure timely and sufficient stock replenishment to avert stock-outs.L’hypertension, le diabète sucré et l’asthme augmentent progressivement dans les pays en développement, y compris le Rwanda ; il est donc nécessaire d’assurer une disponibilité ininterrompue des médicaments.Évaluer 1) la fréquence et la durée des ruptures de stock de médicaments ; 2) durée du délai d’approvisionnement ; 3) niveaux de stock mensuels ; et 4) quantités de médicaments demandées par rapport aux quantités livrées pour le captopril, la metformine et le salbutamol inhalé ; entre janvier et décembre 2018 dans le district rural de Kirehe, au Rwanda.Il s’agissait d’une étude transversale utilisant des données secondaires de programme.Les ruptures de stock annuelles médianes pour le captopril, la metformine et le salbutamol inhalé étaient respectivement de 4 (intervalle interquartile [IQR] 3–4), 3 (IQR 2–3) et 4 (IQR 4–5) dans les Centre de Santé ruraux et aucune rupture de stock n’est survenue à l’hôpital de district. Pour les trois médicaments, le délai d’approvisionnement médian était de 7,5 jours (IQR 5,5–11,5) à l’hôpital contre 5 jours (IQR 3–6) dans les services sanitaires ruraux. L’état des stocks de captopril était inférieur au niveau de stock minimum de 4 semaines pendant 2/12 mois à l’hôpital contre 7/12 mois aux services sanitaires ruraux, tandis que pour la metformine et le salbutamol inhalé ils étaient inférieurs aux niveaux de stock minimum de 4 semaines pour 1/12 et 4/12 mois à l’hôpital et dans les Centre de Santé ruraux, respectivement. Les quantités totales de médicaments livrées étaient inférieures aux quantités totales combinées et demandées en 8/12, 5/12 et 8/12 mois pour le captopril, la metformine et le salbutamol inhalé, respectivement.Il est indispensable de surveiller régulièrement et convenablement les niveaux des stocks de médicaments et d’assurer un réapprovisionnement en temps propice et en quantité appropriée pour éviter les ruptures de stock.

Implementing and monitoring infection prevention and control (IPC) measures at immigration points of entry (PoEs) is key to preventing infections, reducing excessive use of antimicrobials, and tackling antimicrobial resistance (AMR). Sierra Leone has been implementing IPC measures at four PoEs (Queen Elizabeth II Quay port, Lungi International Airport, and the Jendema and Gbalamuya ground crossings) since the last Ebola outbreak in 2014–2015. We adapted the World Health Organization IPC Assessment Framework tool to assess these measures and identify any gaps in their components at each PoE through a cross-sectional study in May 2021. IPC measures were Inadequate (0–25%) at Queen Elizabeth II Quay port (21%; 11/53) and Jendema (25%; 13/53) and Basic (26–50%) at Lungi International Airport (40%; 21/53) and Gbalamuya (49%; 26/53). IPC components with the highest scores were: having a referral system (85%; 17/20), cleaning and sanitation (63%; 15/24), and having a screening station (59%; 19/32). The lowest scores (0% each) were reported for the availability of IPC guidelines and monitoring of IPC practices. This was the first study in Sierra Leone highlighting significant gaps in the implementation of IPC measures at PoEs. We call on the AMR multisectoral coordinating committee to enhance IPC measures at all PoEs.

Introduction: In three health care facilities in the Oromia region, the aim of this study is to report on 1) the number of VL cases registered over time (2013-2018) and 2) the clinical profile, type of treatment used and response to treatment. Methodology: A retrospective cohort study was conducted among all VL cases admitted with a diagnosis of VL. Results: A total of 434 VL cases were registered at the three health facilities, but patient files were available for only 188. Most (51.6%) were children and only three presented with VL relapse. 78 (41.5%) of the 188 patients presented within one month of symptom onset. Concurrent severe acute malnutrition (27.1%), tuberculosis (6.4%) and malaria (6.4%) were common. There were only two cases with HIV coinfection. Fourty-three percent were treated with antimonials, 34% with antimonials combined with paromomycin and 23% with AmBisome. Amongst the 188 patients with patient files there were no deaths and one treatment failure. Six months outcome data were however missing for all. Aggregated data from the 434 VL cases reported three deaths, two treatment failures and one relapse. Conclusions: Children were most commonly affected, suggesting long-term endemicity. While short-term outcomes are encouraging, long-term follow-up data are required.

Background: Malaria elimination requires infection detection using quality assured diagnostics and appropriate treatment regimens. Although Botswana is moving towards malaria elimination, reports of unconfirmed cases may jeopardise this effort. This study aimed to determine the proportion of cases treated for malaria that were confirmed by rapid diagnostic testing (RDT) and/or microscopy. Methods: This was a retrospective descriptive study using routine national data from the integrated disease surveillance and case-based surveillance systems from 2008 to 2014. The data were categorised into clinical and confirmed cases each year. An analysis of the data on cases registered in three districts that reported approximately 70% of all malaria cases was performed, stratified by year, type of reporting health facilities and diagnostic method. Results: During 2008-2014, 50 487 cases of malaria were reported in Botswana, and the proportion of RDT and/or blood microscopy confirmed cases improved from 6% in 2008 to 89% in 2013. The total number of malaria cases decreased by 97% in the same period, then increased by 41% in 2013. Conclusion: This study shows that malaria diagnostic tests dramatically improved malaria diagnosis and consequently reduced the malaria burden in Botswana. The study identified a need to build capacity on microscopy for species identification, parasite quantification and guiding treatment choices.

Setting: Larviciding has potential as a component of integrated vector management for the reduction of malaria transmission in Botswana by complementing long-lasting insecticide nets and indoor residual sprays. Objective: To evaluate the susceptibility of local Anopheles to commonly used larvicides. Design: This field test of the efficacy of Bacillus thuringiensis subsp. israliensis vs. Anopheles was performed by measuring larval density before treatment and 24 h and 48 h after treatment in seven sites of Bobirwa district, eastern Botswana, in 2012 and 2013. Vector density and malaria cases were compared between Bobirwa and Ngami (northwestern Botswana), with no larviciding in the control arm. Results: Larviciding reduced larval density by 95% in Bobirwa in 2012, with two cases of malaria, while in 2013 larval density reduction was 81%, with 11 cases. Adult mosquito density was zero for both years in Robelela village (Bobirwa), compared to respectively four and 26 adult mosquitoes per room in Shorobe village (Ngami) in 2012 and 2013. There were no cases of malaria in Robelela in either year, but in Shorobe there were 20 and 70 cases, respectively, in 2012 and 2013. Conclusion: Larviciding can reduce the larval density of mosquitoes and reduce malaria transmission in Botswana. Large-scale, targeted implementation of larviciding in districts at high risk for malaria is recommended.

In 1995, a rapid response project for humanitarian and medical emergencies, including outbreak responses, named 'To assess the outcomes of cholera and measles outbreak alerts that were received in the PUC surveillance system between 2016 and 2018.This was a retrospective cross-sectional study.Overall, 459 outbreak alerts were detected, respectively 69% and 31% for cholera and measles. Of these, 32% were actively detected and 68% passively detected. Most alerts (90%) required no intervention and 10% of alerts had an intervention. There were 25% investigations that were not carried out despite thresholds being met; 17% interventions were not performed, the main reported reason being PUC operational capacity was exceeded. Confirmed cholera and measles outbreaks that met an investigation threshold comprised respectively 90% and 76% of alerts; 59% of measles investigations were followed by a delayed outbreak response of ⩾14 days (Some alerts for cholera and measles outbreaks that were detected in the PUC system did not lead to a response even when required; the main reported reason was limited operational capacity to respond to all of them.En République Démocratique du Congo, un projet appelé « Pool d’Urgence Congo » (PUC) a été mis en œuvre depuis 1995 par Médecins Sans Frontières pour une réponse rapide aux urgences humanitaires et médicales, notamment les réponses aux flambées épidémiques.Evaluer les résultats d’alertes épidémiques choléra et rougeole qui ont été reçues par le système de surveillance PUC entre 2016 et 2018.Ceci est étude rétrospective transversale.Au total, 459 alertes épidémiques ont été détectées, 69% et 31% pour le choléra et la rougeole, respectivement. Parmi elles, 32% ont été activement détectées et 68% détectées passivement ; 90% des alertes n’ont pas nécessité d’intervention et 10% ont été suivies d’intervention. Il y a eu 25% d’investigations qui n’ont pas été réalisées alors que les seuils étaient atteints, et 17% des interventions n’ont pas été réalisées ; la principale raison invoquée était que la capacité opérationnelle du PUC était dépassée. Les flambées de choléra et de rougeole qui ont atteint le seuil d’investigation et ont été confirmées étaient de 90% et 76%, respectivement. Ont été suivies 59% des investigations relatives à la rougeole d’une réponse à la flambée retardée de ⩾14 jours (Dans le système PUC, certaines alertes relatives à des flambées de choléra et de rougeole qui ont été détectées n’ont pas abouti à une réponse qui était pourtant requise ; la raison principale invoquée était la capacité opérationnelle limitée pour répondre à toutes les alertes.En la República Democrática del Congo, Médecins Sans Frontières introdujo desde 1995 un proyecto denominado ‘Evaluar los resultados de las alertas de brotes de cólera y sarampión que recibió el sistema de vigilancia del PUC del 2016 al 2018.Fue un estudio transversal retrospectivo.En general, se detectaron 459 alertas de brotes, 69% por cólera y 31% por sarampión, de los cuales 32% por detección activa y 68% por detección pasiva; 90% de las alertas no precisaron ninguna intervención y en 10% se realizó una intervención. No se llevó a cabo un 25% de las investigaciones, pese a que se habían alcanzado los umbrales y 17% de las intervenciones no se realizaron; la principal causa referida fue la sobrecarga de la capacidad operativa del PUC. De las alertas confirmadas, alcanzaron el umbral de investigación el 90% de cólera y el 76% de sarampión. En 59% de las investigaciones de sarampión, una respuesta tardía al brote comenzó 14 días o más después de finalizar la investigación (En el sistema PUC, algunas alertas por brotes de cólera y sarampión que se detectaron no dieron lugar a una respuesta, aunque esta era necesaria; la principal razón invocada, fue la limitación de la capacidad operativa para responder a todas las alertas.

Introduction: Endemic non-filarial elephantiasis also known as podoconiosis often affects bare footed farmers and is endemic in Ethiopia. The disease is prevented by wearing shoes. We recently observed several patients presenting to a dermatology clinic with skin depigmentation after wearing plastic shoes (“shoe-contact vitiligo”) which may deter shoe-wearing. We report on their sociodemographic and clinical characteristics. Methodology: This is a retrospective study of 17 months at tertiary level Hospital in Ethiopia. Patient data was retrieved from medical record department. We compared sociodemographic and clinical characteristics of patients presenting with idiopathic and shoe-contact vitiligo. Data was presented descriptively. Results: Of 460 vitiligo cases, 190 (41%) were shoe-contact vitiligo and the rest, idiopathic. The former was more common in females (Odds Ratio, OR = 2.5, P < 0.001) and those in rural areas (OR = 4.8, P < 0.001). Fifty-five percent with shoe-contact vitiligo had itching and/or burning sensation, compared to just 2% with idiopathic vitiligo (P < 0.001) and some had ulcerations (8%). Idiopathic vitiligo had no such findings. Skin discoloration occurred within three weeks (on average) after wearing plastic shoes, 91% of lesions were symmetrical and involved areas of the feet covered with plastic shoes. Symmetric lesions were observed in only 11% of idiopathic vitiligo (OR = 81, P < 0.001). Conclusions: Shoe-contact vitiligo was significantly associated with wearing cheap plastic shoes. The exact chemical culprit(s) needs to be identified. This will allow introducing quality control regulations and rigorous monitoring of shoe production sites.

Burundi has one of the highest maternal mortality ratios (MMR) in the world, estimated at 740 maternal deaths per 100 000 live births.1 The United Nations Millennium Development Goal 5 (MDG 5) aimed to reduce the MMR by 75% between 1990 and 2015.2 This has now been replaced by Sustainable Development Goal 3 (SDG 3), which aims to reduce the global MMR to less than 70 per 100 000 live births by 2030.3 Most sub-Saharan African countries, including Burundi, are lagging far behind in achieving these desired targets.4 Two previous studies from Burundi showed that offering dedicated emergency obstetric and neonatal care (EmONC), coupled with an efficient ambulance referral network, can rapidly reduce maternal mortality in a rural district setting. This was cited as a possible way forward for achieving and sustaining MDG 5 in sub-Saharan Africa.5,6 Tayler-Smith et al. reported that over 30% of all women transferred from health centres with severe acute maternal morbidity and requiring EmONC underwent a caesarean section (C-section).5 Although a C-section is an immediate and lifesaving surgical intervention, it increases the risk of uterine rupture in future pregnancies.7–9 This risk is accentuated if the inter-pregnancy interval (IPI) is less than 24 months.10 Burundi is known to have high fertility rates of 6.2 per woman compared to 1.8/woman in a country like Belgium.11 Burundi also has very low uptakes of family planning and limited general access to EmONC services.12 These factors further contribute to the risk of uterine rupture and maternal death in a pregnancy that follows a C-section.9 While there are studies from high-income countries on maternal outcomes after a C-section,13 no study from rural Africa has prospectively assessed the status of mothers at household level and as long as 2 years after a C-section. Similarly, no studies have collectively reported on the uptake of family planning, incident pregnancies and the IPI at household-level. Existing knowledge on these issues has been limited to cohorts of women who return to hospital, and is thus subject to selection bias. As these parameters are important determinants of uterine rupture and maternal death in rural Africa, better knowledge of these would help guide maternal health strategies to reduce maternal mortality among vulnerable mothers on the African continent. We aimed to determine the maternal status of women 2 years following a C-section in a district hospital in rural Burundi. Specific objectives were to determine 1) whether complications and/or death had occurred during the post-natal phase, 2) uptake of and compliance with family planning, 3) subsequent pregnancies, 4) the IPI and 5) maternal and neonatal outcomes of subsequent pregnancies.

Objective To determine and compare, among three models of care, compliance with scheduled clinic appointments and adherence to antihypertensive medication of patients in an informal settlement of Kibera, Kenya. Methods Routinely collected patient data were used from three health facilities, six walkway clinics and one weekend/church clinic. Patients were eligible if they had received hypertension care for more than 6 months. Compliance with clinic appointments and self-reported adherence to medication were determined from clinic records and compared using the chi-square test. Univariate and multivariate logistic regression models estimated the odds of overall adherence to medication. Results A total of 785 patients received hypertension treatment eligible for analysis, of whom two-thirds were women. Between them, there were 5879 clinic visits with an overall compliance with appointments of 63%. Compliance was high in the health facilities and walkway clinics, but men were more likely to attend the weekend/church clinics. Self-reported adherence to medication by those complying with scheduled clinic visits was 94%. Patients in the walkway clinics were two times more likely to adhere to antihypertensive medication than patients at the health facility (OR 1.97, 95% CI 1.25-3.10). Conclusion Walkway clinics outperformed health facilities and weekend clinics. The use of multiple sites for the management of hypertensive patients led to good compliance with scheduled clinic visits and very good self-reported adherence to medication in a low-resource setting.

Introduction:transmissible blood-borne infections are a serious threat to blood transfusion safety in West African countries; and yet blood remains a key therapeutic product in the clinical management of patients. Sierra Leone screens blood donors for blood-borne infections but has not implemented prevention of mother-to-child transmission for hepatitis B. This study aimed to describe the overall prevalence of hepatitis B and C, HIV and syphilis among blood donors in Sierra Leone in 2016 and to compare the differences between volunteer versus family replacement donors, as well as urban versus rural donors. Methods:retrospective, cross-sectional study from January-December 2016 in five blood bank laboratories across the country. Routinely-collected programme data were analyzed; blood donors were tested with rapid diagnostic tests-HBsAg for HBV, anti-HCV antibody for HCV, antibodies HIV1&2 for HIV and TPHA for syphilis. Results:there were 16807 blood samples analysed, with 80% from males; 2285 (13.6%) tested positive for at least one of the four pathogens. Overall prevalence was: 9.7% hepatitis B; 1.0% hepatitis C; 2.8% HIV; 0.8% syphilis. Prevalence was higher among samples from rural blood banks, the difference most marked for hepatitis C. The proportion of voluntary donors was 12%. Family replacement donors had a higher prevalence of hepatitis B, C and HIV than volunteers. Conclusion:a high prevalence of blood-borne pathogens, particularly hepatitis B, was revealed in Sierra Leone blood donors. The study suggests the country should implement the prevention of mother-to-child transmission of hepatitis B and push to recruit more volunteer, non-remunerated blood donors.

As neonatal care is being scaled up in economically poor settings, there is a need to know more on post-hospital discharge and longer-term outcomes. Of particular interest are mortality, prevalence of developmental impairments and malnutrition, all known to be worse in low-birthweight neonates (LBW

Objectives The aim of this study was to report the patient profile and treatment outcomes, including relapses, of patients with visceral leishmaniasis (VL) treated with liposomal amphotericin B (AmBisome) in Gedaref, Sudan. Methods AmBisome was offered to two groups of patients: primary VL patients with specific criteria (age ≤2 or ≥45 years, advanced clinical disease, pregnancy, HIV co-infection and contraindications for antimonials) and VL relapses. AmBisome was given at a total dose of 30 mg/kg, over 10 days. Slow responders received up to 50 mg/kg. Treatment failure was confirmed parasitologically. Standardised treatment outcomes were assessed. Results Between March 2010 and June 2012, a total of 281 (74%) patients with primary VL and 98 (26%) patients with VL relapses received AmBisome (54% male, median age = 11 years, interquartile range 2–30). End-of-treatment outcomes for primary VL were 260 (92%) initial cure including three (1%) slow responders, three (1%) treatment failures, 14 (5%) deaths and four (1%) unknown outcomes. Outcomes for VL relapses were 92 (94%) initial cure with five (5%) slow responders, four (4%) treatment failures, one (1%) death and one (1%) unknown outcome. At 6 months, there were 19 (7%) relapses amongst primary VL and 10 (10%) VL relapses had a new relapse. Loss to follow-up in both groups was 38%. None of the deaths that occurred during the study period was attributed to AmBisome. Conclusion AmBisome appears to be effective for initial cure of VL and the drug seems safe, but is expensive (400 USD/treatment). Sustained mechanisms to allow improved access of this expensive drug particularly in East Africa are urgently needed. Relapses and losses to follow-up require specific investigation.

A Médecins Sans Frontières emergency obstetric and neonatal care facility specialising as a referral centre for three districts for women with complications during pregnancy or delivery in rural Burundi.To describe the characteristics and in-facility mortality rates of neonates born in 2011.Descriptive study involving a retrospective review of routinely collected facility data.Of 2285 women who delivered, the main complications were prolonged labour 331 (14%), arrested labour 238 (10%), previous uterine intervention 203 (9%), breech 171 (8%) and multiple gestations 150 (7%). There were 175 stillbirths and 2110 live neonates, of whom 515 (24%) were of low birth weight, 963 (46%) were delivered through caesarean section and 267 (13%) required active birth resuscitation. Overall, there were 102 (5%) neonatal deaths. A total of 453 (21%) neonates were admitted to dedicated neonatal special services for sick and low birth weight babies. A high proportion of these neonates were delivered by caesarean section and needed active birth resuscitation. Of 67 (15%) neonatal deaths in special services, 85% were due to conditions linked to low birth weight and birth asphyxia.Among neonates born to women with complications during pregnancy or delivery, in-facility deaths due to low birth weight and birth asphyxia were considerable. Sustained attention is needed to reduce these mortality rates.Un service de soins d’urgence en obstétrique et soins néonatals de Médecins Sans Frontières dans le Burundi rural, spécialisé comme centre de référence pour trois districts à l’intention des femmes encourant des complications au cours de la grossesse et de l’accouchement.Décrire les caractéristiques et la mortalité lors de l’hospitalisation chez les nouveau-nés nés en 2011.Etude descriptive impliquant une revue rétrospective des données de routine du service.Parmi 2285 femmes qui ont accouché, les complications principales ont été les suivantes:prolongement du travail 331 (14%), arrêt du travail 238 (10%), intervention utérine antérieure 203 (9%), accouchement par le siège 171 (8%) et gestation multiple 150 (7%). On a noté 175 mort-nés et 2110 nouveau-nés en vie parmi lesquels un faible poids de naissance existait chez 515 (24%), un accouchement par césarienne chez 963 (46%) et la nécessité d’une réanimation néo-natale active chez 267 (13%). Au total, il y a eu 102 décès néonatals (5%) et 453 des nouveau-nés (21%) ont été admis dans les services néonatals spécialement axés sur les bébés malades ou à faible poids de naissance. Une proportion plus élevée de ces nouveau-nés étaient nés par césarienne et avaient nécessité une réanimation active à la naissance. On a noté 67 décès néonatals (15%) dans les services spéciaux, parmi lesquels 85% étaient dus à des affections liées au faible poids de naissance ou à l’asphyxie lors de la naissance.Parmi les nouveau-nés nés de femmes ayant encouru des complications au cours de la grossesse ou de l’accouchement, les décès hospitaliers liés à un faible poids de naissance et à une asphyxie à la naissance ont été nombreux. Une attention soutenue s’impose pour réduire ces décès.Un centro de urgencias obstétricas y neonatales dirigido por Médicos Sin Fronteras, especializado como centro de referencia de las mujeres con complicaciones durante el embarazo o el parto de tres distritos rurales de Burundi.Describir las características y la mortalidad intrahospitalaria de los recién nacidos atendidos en el 2011.Fue este un estudio descriptivo que consistió en el examen retrospectivo de los datos recogidos de manera sistemática en la institución.Se atendieron 2285 partos en el período del estudio. Las complicaciones que motivaron con mayor frecuencia la remisión consistieron en: el trabajo de parto prolongado en 331 casos (14%), la detención del trabajo de parto en 238 (10%), el antecedente de cirugía uterina en 203 (9%), presentación de nalgas en 171 (8%) y el embarazo múltiple en 150 mujeres (7%). Se recibieron 175 mortinatos y 2110 recién nacidos vivos, de los cuales 515 presentaron bajo peso al nacer (24%), 963 nacieron por cesárea (46%) y 267 neonatos precisaron reanimación activa al nacimiento (13%). En general, se presentaron 102 (5%) muertes neonatales. Se admitieron 453 neonatos en los servicios neonatales especiales que atienden a los recién nacidos enfermos o con bajo peso (21%). La mayoría de estos neonatos nació por cesárea y precisó reanimación activa al nacimiento. Se presentaron 67 casos de muerte neonatal en los servicios especiales (15%), de los cuales el 85% por complicaciones derivadas del bajo peso al nacer y la asfixia del nacimiento.En los neonatos que nacieron de mujeres que presentaron complicaciones durante el embarazo o el parto fue considerable la mortalidad intrahospitalaria asociada con el bajo peso al nacer y la asfixia del nacimiento. Es preciso reforzar la atención con el fin de evitar estas situaciones.

To assess the acceptability of a ready-to-use therapeutic food (Plumpy'nut(®) [PPN]) among 1) care givers of malnourished children and 2) community health workers (CHWs) at a nutrition rehabilitation centre in an urban slum in Dhaka, Bangladesh.This was a cross-sectional semi-structured questionnaire survey conducted between April and June 2011 as part of a nutritional programme run by Médecins Sans Frontières. The study population included care givers of malnourished children aged 6-59 months who received PPN for at least 3 weeks, and CHWs.Of the 149 care givers (93% female) interviewed, 60% expressed problems with PPN acceptability. Overall, 43% perceived the child's dissatisfaction with the taste, 31% with consistency and 64% attributed side effects to PPN (nausea, vomiting, loose motion, diarrhoea, abdominal distension and pain). It is to be noted that 47% of children needed encouragement or were forced to eat PPN, while 5% completely rejected it after 3 weeks. Of the 29 CHWs interviewed, 48% were dissatisfied with PPN's taste and consistency, and 55% with its smell. However, 91% of the care givers and all CHWs still perceived a therapeutic benefit of PPN for malnourished children.Despite a therapeutic benefit, only 4 in 10 care givers perceived PPN as being acceptable as a food product, which is of concern.Evaluer à Dacca, Bangladesh, au sein d’un centre de réhabilitation nutritionnelle d’un bidonville, l’acceptabilité d’une alimentation thérapeutique prête à l’emploi (Plumpy’nutIl s’agit d’une enquête transversale par questionnaire semi-structuré menée entre avril et juin 2011 dans un programme nutritionnel de Médecins Sans Frontières. La population de l’étude a comporté les soignants d’enfants en état de malnutrition âgés de 6 à 59 mois qui avaient reçu du PPN pendant au moins 3 semaines, ainsi que les CHW.Sur les 149 soignants (93% de femmes) interviewés, 60% ont exprimé des problèmes en ce qui concerne l’acceptabilité du PPN. Au total, 43% d’entre eux avaient perçu une non-satisfaction de l’enfant concernant le goût et 31% la consistance, et 64% avaient attribué des effets collatéraux au PPN (nausées, vomissements, selles liquides, diarrhée, distension abdominale et douleurs). Il faut noter que 47% des enfants devaient être encouragés ou forcés à manger le PPN alors que 5% d’entre eux l’ont rejeté complètement après 3 semaines. Sur les 29 CHW interviewés, 48% n’étaient pas satisfaits du goût et de la consistance du PPN et 55% n’étaient pas satisfaits de son odeur. Il est important de noter que 91% des soignants et l’ensemble des CHW percevaient néanmoins encore l’avantage thérapeutique du PPN pour les enfants en état de malnutrition.En dépit d’un avantage thérapeutique, seuls quatre soignants sur 10 ont perçu le PPN comme un aliment acceptable, ce qui constitue une préoccupation.Evaluar la aceptabilidad de un alimento terapéutico preparado (Plumpy’nutSe llevó a cabo una encuesta transversal con un cuestionario semi-estructurado entre abril y junio del 2011 en el marco de un programa nutricional de Médicos Sin Fronteras. La población del estudio consistió en las personas a cargo de niños desnutridos cuya edad oscilaba entre 6 y 59 meses y que habían recibido PPN como mínimo durante 3 semanas y los CHW.De los 149 cuidadores entrevistados (93% de mujeres), el 60% expresó problemas de aceptabilidad del PPN. En general, el 43% de los cuidadores percibía insatisfacción del niño por causa del sabor, el 31% por la consistencia y el 64% atribuía al PPN reacciones adversas (náuseas, vómito, heces blandas, diarrea y distensión o dolor abdominal). Cabe anotar que el 47% de los niños precisó estímulos para recibir el PNN o lo aceptó por la fuerza y el 5% de ellos lo rechazó totalmente después de 3 semanas de administración. De los 29 CHW que respondieron a la encuesta, el 48% se manifestó insatisfecho con el sabor y la consistencia del PPN y el 55% desaprobó su olor. Sin embargo, es importante anotar que el 91% de los cuidadores y todos los CHW percibieron una ventaja terapéutica con el uso del PPN en los niños desnutridos.Es fuente de preocupación el reconocer que pese a la aceptación de una ventaja terapéutica del PPN, solo cuatro de los 10 cuidadores de niños desnutridos lo consideraron como un producto alimentario aceptable.

1 Medical Department (Operational Research Unit), Medecins sans Frontieres, Operational Centre Brussels, MSF-Luxembourg, Luxembourg, Luxembourg 2 Department of Molecular and Cellular Interactions, Flemish Institute of Biotechnology, Brussels, Belgium 3 Department of Microbiology, Institute of Tropical Medicine, Antwerp, Belgium 4 Department of Obstetrics and Gynecology, University of Nairobi, Nairobi, Kenya 5 Centre for International Health, University of Bergen, Bergen, Norway 6 Center for Operational Research, International Union Against Tuberculosis and Lung Disease, Paris, France 7 International Union Against TB and Lung Disease, Kampala, Uganda 8 Medecins Sans Frontieres, Addis Ababa, Ethiopia 9 International Union Against Tuberculosis and Lung Disease, South East Asia office, New Delhi, India 10 Medecins Sans Frontieres, Somali Mission, Somalia 11 Medecins Sans Frontieres, Bujumbura, Burundi 12 National Institute for Medical Research, Dar Es Salaam, Tanzania 13 National Tuberculosis Control Programme, Harare, Zimbabwe 14 Medecins Sans Frontieres, Capetown, South Africa 15 Medecins Sans Frontieres, Nairobi, Kenya 16 Joint Center for Bioethics, University of Toronto, Toronto, Canada 17 London School of Hygiene and Tropical Medicine, London, UK

Within a Medecins Sans Frontieres's nutrition programme in Kamrangirchar slum, Dhaka, Bangladesh this study was conducted to assess the acceptability of a peanut-based ready-to-use therapeutic food (RUTF) - Plumpy'nut(®) (PPN) among malnourished pregnant and lactating women (PLW). This was a cross-sectional survey using semi-structure questionnaire that included all PLW admitted in the nutrition programme, who were either malnourished or at risk of malnutrition and who had received PPN for at least 4 weeks. A total of 248 women were interviewed of whom 99.6% were at risk of malnutrition. Overall, 212 (85%) perceived a therapeutic benefit. Despite this finding, 193 (78%) women found PPN unacceptable, of whom 12 (5%) completely rejected it after 4 weeks of intake. Reasons for unacceptability included undesirable taste (60%) and unwelcome smell (43%) - more than half of the latter was due to the peanut-based smell. Overall, 39% attributed side effects to PPN intake including nausea, vomiting, diarrhoea, abdominal distension and pain. Nearly 80% of women felt a need to improve PPN - 82% desiring a change in taste and 48% desiring a change in smell. Overall, only 146 (59%) understood the illustrated instructions on the package. Despite a perceived beneficial therapeutic effect, only two in 10 women found PPN acceptable for nutritional rehabilitation. We urge nutritional agencies and manufacturers to intensify their efforts towards developing more RUTF alternatives that have improved palatability and smell for adults and that have adequate therapeutic contents for treating malnourished PLW in Bangladesh.

The Integrated Disease Surveillance and Response (IDSR) strategy is a pillar of the surveillance system of many low- and middle-income countries (LMICs).1 It focuses on the detection of and response to public health threats such as infectious disease outbreaks. A recent systematic review of the IDSR strategy in LMICs highlighted several fundamental constraints that still hamper integrated surveillance, such as complex logistics, lack of financial resources and poor professional skills, motivation and supervision.2 The Democratic Republic of Congo (DRC) has implemented the IDSR strategy through its national surveillance system since 2000.3,4 While it has achieved considerable success, such as controlling wild poliovirus, challenges remain in the most remote and deprived areas of the country.5 Unfortunately, no further evidence on the performance of the surveillance system in the DRC has been published to date. The medical humanitarian organisation Medecins Sans Frontieres (MSF) has a unique opportunity to access the most remote areas of the DRC through its emergency intervention project, the Pool d'Urgence Congo (PUC, Congo Emergency Team). For 20 years, the PUC has aimed at detecting epidemics and responding to medical emergencies occurring in man-made and natural disasters. The PUC intervenes in more than 10 emergencies per year, primarily providing curative and preventive care for vulnerable (mainly paediatric) and difficult to access (geographically) populations. Outbreak responses such as those of the PUC rely to an extent on the good functioning of the IDSR strategy. Although not the first objective in an outbreak response, the PUC uses the opportunity of such interventions to strengthen the national notifiable disease surveillance system (NNDSS) at service and community level in the affected health zone. It is unknown, however, to what extent such emergency, short-term interventions can positively affect the NNDSS and how sustained this putative effect is. This study aims to investigate whether this ancillary activity of strengthening the NNDSS during short-term PUC interventions results in a change in disease notification in the areas of intervention.

Five hospitals in four conflict and post-conflict countries (Democratic Republic of Congo, Somaliland, Sierra Leone and Burundi).To report among hospital deliveries: 1) the proportion of severe acute maternal morbidity (SAMM), 2) the pattern of SAMM, and 3) maternal deaths according to type of SAMM.An audit of data from a standardised database implemented in all the sites in the study.Of the 18 675 deliveries, there were 6314 (34%) known SAMM cases with 63 associated deaths, implying that for every 100 SAMM cases there was one maternal death. In descending order, the death-to-SAMM ratios per 1000 deliveries were: 1:7 for sepsis, 6 for haemorrhage 1:70 for hypertensive disorder and 1:398 for obstructed labour. A substantial proportion of deaths (38%) that occurred in hospitals could not be categorised into the standardised SAMM conditions available in the database.As this is the first study using multi-centre data from conflict and post-conflict countries, these findings are relevant to improving maternal health in such settings. Findings, implications and possible ways forward in addressing various challenges are discussed.Cinq hôpitaux dans quatre pays en conflit ou après conflit (République Démocratique du Congo, Somalie, Sierra Leone et Burundi).Décrire parmi les accouchements hospitaliers : 1) la proportion à morbidité maternelle aigue élevée (SAMM) ; 2) le type de SAMM ; et 3) les décès maternels en fonction du type de SAMM.Examen des données provenant d’une base de données standardisée réalisée dans tous les sites de l’étude.Sur 18 675 accouchements, il y a eu 6314 cas de SAMM connus avec 63 décès associés, ce qui implique que pour chaque centaine de cas de SAMM, il y a eu un décès maternel. Par ordre décroissant, le rapport décès par SAMM pour 1000 accouchements a été de 1/7 par septicémies, de 1/46 par hémorragies, de 1/70 par maladies hypertensives et de 1/398 par un accouchement compliqué. Une proportion substantielle des décès (38%) survenus dans les hôpitaux n’a pas pu être classée dans les conditions standardisées SAMM disponibles dans la base de données.Il s’agit ici de la première étude utilisant les données multicentriques provenant de pays en guerre ou après-guerre ; les observations sont pertinentes pour améliorer la santé maternelle dans de tels contextes. Les implications de ces données et les moyens possibles d’amélioration visant à répondre aux défis font l’objet de discussions. Cinco hospitales en los siguientes países que se encuentran actualmente en situación de conflicto o que lo superaron en un período reciente: la República Democrática del Congo, Somalia, Sierra Leona y Burundi. Notificar, con respecto a los partos atendidos en medio hospitalario, la proporción de hospitales donde se observó: 1) una morbilidad materna aguda grave (SAMM); 2) las características de esta SAMM; y 3) la mortalidad materna según el tipo de SAMM. Tras analizar los datos de la base de datos normalizada que opera en todos los centros del estudio se redactó un informe. En los 18 675 partos atendidos se presentaron 6314 casos de SAMM (34%) que causaron 63 defunciones, lo cual corresponde a una defunción por cada 100 casos. En orden descendente, el cociente entre defunciones y casos de SAMM en 1000 partos fue por sepsis 1/7, por hemorragia 1/46, por trastorno hipertensivo 1/70 y por obstrucción del trabajo de parto 1/398. Una alta proporción de defunciones que ocurrió en los hospitales no se pudo categorizar en el marco de las condiciones normalizadas de la base de datos sobre la SAMM. El presente artículo representa el primer estudio con base en datos multicéntricos obtenidos en países en situación de conflicto actual o reciente y sus resultados son pertinentes para el mejoramiento de la salud materna en estos contextos. Se analizan las repercusiones de estos resultados en las posibles respuestas que se pueden aportar al problema.

Objectives To estimate the reduction in maternal mortality associated with the emergency obstetric care provided by Medecins Sans Frontieres (MSF) and to compare this to the fifth Millennium Development Goal of reducing maternal mortality. Methods The impact of MSF's intervention was approximated by estimating how many deaths were averted among women transferred to and treated at MSF's emergency obstetric care facility in Kabezi, Burundi, with a severe acute maternal morbidity. Using this estimate, the resulting theoretical maternal mortality ratio in Kabezi was calculated and compared to the Millennium Development Goal for Burundi. Results In 2011, 1385 women from Kabezi were transferred to the MSF facility, of whom 55% had a severe acute maternal morbidity. We estimated that the MSF intervention averted 74% (range 55–99%) of maternal deaths in Kabezi district, equating to a district maternal mortality rate of 208 (range 8–360) deaths/100 000 live births. This lies very near to the 2015 MDG 5 target for Burundi (285 deaths/100 000 live births). Conclusion Provision of quality emergency obstetric care combined with a functional patient transfer system can be associated with a rapid and substantial reduction in maternal mortality, and may thus be a possible way to achieve Millennium Development Goal 5 in rural Africa. Objectifs Estimer la reduction de la mortalite maternelle associee a la prise en charge des soins obstetricaux d'urgence fournie par Medecins Sans Frontieres (MSF) et comparer cela au 5eme Objectif du Millenaire pour le Developpement dans la reduction de la mortalite maternelle. Methodes L'impact de l'intervention de MSF a ete modelise en estimant le nombre de deces evites chez les femmes transferees et traitees dans les services pour les soins obstetricaux d'urgence de MSF a Kabezi, au Burundi avec une morbidite maternelle severe aigue. Sur base de cette estimation, le taux theorique resultant de la mortalite maternelle a Kabezi a ete calcule et compare au 5eme Objectif de Developpement du Millenaire pour le Burundi. Resultats En 2011, 1385 femmes de Kabezi ont ete transferees au centre de MSF, dont 55% avec des morbidites severes aigues. Nous avons estime que l'intervention de MSF a evite 74% (intervalle 55-99%) des deces maternels dans le district de Kabezi, ce qui equivaut a un taux de mortalite maternelle du district de 208 (intervalle 8-360) deces/100.000 naissances vivantes. Cela se rapproche assez de la cible 2015 de l’OMD5 pour le Burundi (285 deces pour 100.000 naissances vivantes). Conclusion La fourniture de soins obstetricaux d'urgence de qualite combinee avec un systeme de transfert des patients fonctionnel peut etre associee a une reduction rapide et substantielle de la mortalite maternelle, et peut donc etre une voie possible pour atteindre l'Objectif 5 du Millenaire pour le Developpement en Afrique rurale. Objetivos Calcular la reduccion en la mortalidad materna asociada con las urgencias obstetricas suministradas por Medicos Sin Fronteras (MSF), y comparar estos resultados con el quinto Objetivo de Desarrollo del Milenio (ODM) de reducir la mortalidad materna. Metodos El impacto de la intervencion de MSF se modelo calculando cuantas muertes pudieron evitarse entre mujeres transferidas a y tratadas en las instalaciones para cuidados obstetricos de emergencia de MSF en Kabezi, Burundi con una gran morbilidad materna aguda. Utilizando esta estimacion, se calculo la tasa de mortalidad materna teorica en Kabezi y se comparo al ODM para Burundi. Resultados En el 2011, 1385 mujeres de Kabezi fueron transferidas a la instalacion de la MSF, y de ellas un 55% tenian una morbilidad materna aguda severa. Calculamos que la intervencion de MSF evito un 74% (rango 55-99%) de las muertes maternas en el distrito de Kabezi, igualandolas a un distrito con una tasa de mortalidad materna de 208 (rango 8–360) muertes/100,000 nacidos vivos. Esto esta muy cerca del objetivo del ODM de 2015 para Burundi (285 muertes/100,000 nacidos vivos). Conclusion La prestacion de servicios obstetricos de emergencia, combinados con un sistema funcional de transferencia de pacientes puede asociarse con una reduccion rapida y sustancial en la mortalidad materna, y puede por lo tanto ser una forma posible de alcanzar el Quinto Objetivo de Desarrollo del Milenio en Africa rural.

Using routine data from three clinics offering care to survivors of sexual violence (SV) in Monrovia, Liberia, we describe the characteristics of SV survivors and the pattern of SV and discuss how the current approach could be better adapted to meet survivors’ needs. There were 1500 survivors seeking SV care between January 2008 and December 2009. Most survivors were women (98%) and median age was 13 years (Interquartile range: 9–17 years). Sexual aggression occurred during day-to-day activities in 822 (55%) cases and in the survivor’s home in 552 (37%) cases. The perpetrator was a known civilian in 1037 (69%) SV events. Only 619 (41%) survivors sought care within 72 h. The current approach could be improved by: effectively addressing the psychosocial needs of child survivors, reaching male survivors, targeting the perpetrators in awareness and advocacy campaigns and reducing delays in seeking care.

OBJECTIVES: In a district hospital in conflict-torn Somalia, we assessed (i) the impact of introducing telemedicine on the quality of paediatric care, and (ii) the added value as perceived by local clinicians. METHODS: A 'real-time' audio-visual exchange of information on paediatric cases (Audiosoft Technologies, Quebec, Canada) took place between clinicians in Somalia and a paediatrician in Nairobi. The study involved a retrospective analysis of programme data, and a perception study among the local clinicians. RESULTS: Of 3920 paediatric admissions, 346 (9%) were referred for telemedicine. In 222 (64%) children, a significant change was made to initial case management, while in 88 (25%), a life-threatening condition was detected that had been initially missed. There was a progressive improvement in the capacity of clinicians to manage complicated cases as demonstrated by a significant linear decrease in changes to initial case management for meningitis and convulsions (92-29%, P = 0.001), lower respiratory tract infection (75-45%, P = 0.02) and complicated malnutrition (86-40%, P = 0.002). Adverse outcomes (deaths and lost to follow-up) fell from 7.6% in 2010 (without telemedicine) to 5.4% in 2011 with telemedicine (30% reduction, odds ratio 0.70, 95% CI: 0.57-0.88, P = -0.001). The number needed to be treated through telemedicine to prevent one adverse outcome was 45. All seven clinicians involved with telemedicine rated it to be of high added value. CONCLUSION: The introduction of telemedicine significantly improved quality of paediatric care in a remote conflict setting and was of high added value to distant clinicians.

To describe the frequency, risk factors, and clinical signs and symptoms associated with hepatotoxicity (HT) in patients on nevirapine- or efavirenz-based antiretroviral therapy (ART), we conducted a retrospective cohort analysis of patients attending the ART clinic in Kibera, Kenya, from April 2003 to December 2006 and in Mavalane, Mozambique, from December 2002 to March 2007. Data were collected on 5832 HIV-positive individuals who had initiated nevirapine- or efavirenz-based ART. Median baseline CD4+ count was 125 cells/μL (interquartile range [IQR] 55–196). Over a median follow-up time of 426 (IQR 147–693) days, 124 (2.4%) patients developed HT. Forty-one (54.7%) of 75 patients with grade 3 HT compared with 21 (80.8%) of 26 with grade 4 had associated clinical signs or symptoms ( P = 0.018). Four (5.7%) of 124 patients with HT died in the first six months compared with 271 (5.3%) of 5159 patients who did not develop HT ( P = 0.315). The proportion of patients developing HT was low and HT was not associated with increased mortality. Clinical signs and symptoms identified 50% of grade 3 HT and most cases of grade 4 HT. This suggests that in settings where alanine aminotransferase measurement is not feasible, nevirapine- and efavirenz-based ART may be given safely without laboratory monitoring.

Using data of human immunodeficiency virus-positive patients with tuberculosis from three primary care clinics in Kibera slums, Nairobi, Kenya, we report on the proportion that started antiretroviral treatment (ART) and attrition (deaths, lost to follow-up and stopped treatment) before and while on ART. Of 427 ART eligible patients, enrolled between January 2004 and December 2008, 70% started ART, 19% were lost to attrition and 11% had not initiated ART. Of those who started ART, 14% were lost to attrition, making a cumulative pre-ART and ART attrition of 33%. ART uptake among patients with TB was relatively good, but programme attrition was high and needs urgent addressing.

Summary A study conducted among HIV-positive adults in WHO clinical stages 1 and 2 was followed up at Thyolo District Hospital (rural Malawi) to report on: (1) retention and attrition before and while on antiretroviral treatment (ART); and (2) the criteria used for initiating ART. Between June 2008 and January 2009, 1633 adults in WHO stages 1 and 2 were followed up for a total of 282 person-years. Retention in care at 1, 2, 3 and 6 months for those not on ART (n = 1078) was 25, 18, 11 and 4% vs. 99, 97, 95 and 90% for patients who started ART (n = 555, P = 0.001). Attrition rates were 31 times higher among patients not started on ART compared with those started on ART (adjusted hazard ratio, 31.0, 95% CI 22–44). Ninety-two patients in WHO stage 1 or 2 were started on ART without the guidance of a CD4 count, and 11 were incorrectly started on ART with CD4 count ≥250 cells/mm3. In a rural district hospital setting in Malawi, attrition of individuals in WHO stages 1 and 2 is unacceptably high, and specific operational strategies need to be considered to retain such patients in the health system.

Summary In an urban district hospital in Burkina Faso we investigated the relative proportions of HIV-1, HIV-2 and HIV-1/2 among those tested, the baseline sociodemographic and clinical characteristics, and the response to and outcome of antiretroviral therapy (ART). A total of 7368 individuals (male = 32%; median age = 34 years) were included in the analysis over a 6 year period (2002–2008). The proportions of HIV-1, HIV-2 and dual infection were 94%, 2.5% and 3.6%, respectively. HIV-1-infected individuals were younger, whereas HIV-2-infected individuals were more likely to be male, have higher CD4 counts and be asymptomatic on presentation. ART was started in 4255 adult patients who were followed up for a total of 8679 person-years, during which time 469 deaths occurred. Mortality differences by serotype were not statistically significant, but were generally worse for HIV-2 and HIV-1/2 after controlling for age, CD4 count and WHO stage. Among severely immune-deficient patients, mortality was higher for HIV-2 than HIV-1. CD4 count recovery was poorest for HIV-2. HIV-2 and dually infected patients appeared to do less well on ART than HIV-1 patients. Reasons may include differences in age at baseline, lower intrinsic immune recovery in HIV-2, use of ineffective ART regimens (inappropriate prescribing) by clinicians, and poor drug adherence.

Summary objectves To report on the cumulative proportion of deaths occurring within 3 months of starting antiretroviral treatment (ART) and to identify factors associated with such deaths, among adults at primary health centres in a rural district of Malawi. methods Retrospective cohort study: from June 2006 to April 2008, deaths occurring over a 3-month period were determined and risk factors examined. results A total of 2316 adults (706 men and 1610 women; median age 35 years) were included in the analysis and followed up for a total of 1588 person-years (PY); 277 (12%) people died, of whom 206 (74%) people died within 3 months of initiating ART (cumulative incidence: 13.0; 95% confidence interval: 11.3‐14.8 per 100 PY of follow-up). Significant risk factors associated with early deaths included male sex, WHO stage 4 disease, oesophageal or persistent oral candidiasis and unexplained presumed or measured weight loss >10%. One in every 3 patients who either died or was lost to follow up had unexplained weight loss >10%, and survival in this group was significantly different from patients without this condition. conclusions Seven of 10 patients who die after initiating ART at primary health centres die early. Specific groups of patients are at higher risk of such mortality and should receive priority attention, care and support.

We report on rates of patient retention and attrition in the context of scaling-up antiretroviral treatment (ART) within a district hospital and its primary health centres in rural Malawi. 'Retention' was defined as being alive and on ART or transferred out, whereas 'attrition' was defined as died, lost to follow-up or stopped treatment. A total of 4074 patients were followed-up for 1803 person-years: 2904 were at the hospital and 1170 at health centres. Approximately 85% of patients were retained in care, both at hospital and health centres, with a retention rate per 100 person-years of 185 and 211, respectively [adjusted hazard ratio (HR) 1.18, 95% CI 1.10-1.28, P=0.001). Attrition rates per 100 person-years were similar: 33 and 36, respectively (adjusted HR 1.17, 95% CI 0.97-1.4, P=0.1). At health centres the incidence of loss to follow-up was significantly lower than at the hospital (adjusted HR 0.24, P

Summary This retrospective analysis of routine programme data from Mbagathi District Hospital, Nairobi, Kenya shows the difference in rates of loss to follow-up between a cohort that paid 500 shillings/month (approximately US$7) for antiretroviral drugs (ART) and one that received medication free of charge. A total of 435 individuals (mean age 31.5 years, 65% female) was followed-up for 146 person-years: 265 were in the ‘payment’ cohort and 170 in the ‘free’ cohort. The incidence rate for loss to follow-up per 100 person-years was 47.2 and 20.5, respectively (adjusted hazard ratio 2.27, 95% CI 1.21–4.24, P = 0.01). Overall risk reduction attributed to offering ART free of charge was 56.6% (95% CI 20.0–76.5). Five patients diluted their ART regimen to one tablet (instead of two tablets) twice daily in order to reduce the monthly cost of medication by half. All these patients were from the payment cohort. Payment for ART is associated with a significantly higher rate of loss to follow-up, as some patients might be unable to sustain payment over time. In resource-limited settings, ART should be offered free of charge in order to promote treatment compliance and prevent the emergence of drug resistance.

Background Death among premature neonates contributes significantly to neonatal mortality which in turn represents approximately 40 % of paediatric mortality. Care for premature neonates is usually provided at the tertiary care level, and premature infants in rural areas often remain bereft of care. Here, we describe the characteristics and outcomes of premature neonates admitted to neonatal services in a district hospital in rural Burundi that also provided comprehensive emergency obstetric care. These services included a Neonatal Intensive Care Unit (NICU) and Kangaroo Mother Care (KMC) ward, and did not rely on high-tech interventions or specialist medical staff. Methods A retrospective descriptive study, using routine programme data of neonates (born at

In 2009, the International Union Against Tuberculosis and Lung Disease (The Union) and Médecins sans Frontières Brussels-Luxembourg (MSF) began developing an outcome-oriented model for operational research training. In January 2013, The Union and MSF joined with the Special Programme for Research and Training in Tropical Diseases (TDR) at the World Health Organization (WHO) to form an initiative called the Structured Operational Research and Training Initiative (SORT IT). This integrates the training of public health programme staff with the conduct of operational research prioritised by their programme. SORT IT programmes consist of three one-week workshops over 9 months, with clearly-defined milestones and expected output. This paper describes the vision, objectives and structure of SORT IT programmes, including selection criteria for applicants, the research projects that can be undertaken within the time frame, the programme structure and milestones, mentorship, the monitoring and evaluation of the programmes and what happens beyond the programme in terms of further research, publications and the setting up of additional training programmes. There is a growing national and international need for operational research and related capacity building in public health. SORT IT aims to meet this need by advocating for the output-based model of operational research training for public health programme staff described here. It also aims to secure sustainable funding to expand training at a global and national level. Finally, it could act as an observatory to monitor and evaluate operational research in public health. Criteria for prospective partners wishing to join SORT IT have been drawn up.En 2009, L'Union Internationale contre la Tuberculose et les Maladies pulmonaires (L'Union) et Médecins sans Frontières Bruxelles-Luxembourg (MSF) ont commencé à élaborer un modèle orienté par les résultats pour la formation en recherche opérationnelle. En janvier 2013, l'Union et MSF ont rejoint le Programme Spécial de Recherche et de Formation des Maladies Tropicales (TDR) à l'OMS pour former une initiative baptisée « The Structured Operational Research and Training Initiative (SORT IT) » [Initiative structurée de recherche opérationnelle et de formation]. Celle-ci intègre la formation du personnel des programmes de santé publique et la conduite de recherche opérationnelle en fonction des priorités de leur programme. Les programmes SORT IT consistent en trois ateliers d'une semaine, étalés sur 9 mois, avec des étapes bien définies et des résultats attendus. Cet article décrit la vision, les objectifs et la structure des programmes SORT IT, notamment les critères de sélection des candidats, les projets de recherche qui peuvent être entrepris dans le temps imparti, la structure et les étapes du programme, le tutorat, le suivi et l'évaluation des programmes et les suites du programme en termes de recherche ultérieure, de publications et de conception/mise en œuvre de programmes de formation supplémentaire. Il y a un besoin croissant, national et international, de recherche opérationnelle et de renforcement des capacités dans ce domaine en santé publique. SORT IT vise à répondre à ce besoin en plaidant pour un modèle de formation en recherche opérationnelle basé sur les résultats du personnel de santé publique décrit ici. Il vise également à sécuriser un financement pérenne pour la formation des experts au niveau mondial et national. Enfin, il pourrait servir d'observatoire de suivi et d'évaluation de la recherche opérationnelle en santé publique. Les critères de recrutement de nouveaux partenaires potentiels qui souhaitent rejoindre SORT IT ont été élaborés.En el 2009, La Unión contra la Tuberculosis y las Enfermedades Respiratorias (La Unión) y Médecins sans Frontières de Bruselas y Luxemburgo comenzaron a desarrollar un modelo de capacitación en investigación operativa orientada por los resultados. En enero del 2013, ambas organizaciones se unieron a un Programa Especial de Investigación y Capacitación en Enfermedades Tropicales de la Organización Mundial de la Salud (OMS), con el fin de poner en marcha una iniciativa denominada SORT IT (acrónimo por

Setting: Thyolo District Hospital rural Malawi. Objectives: In a prevention of mother-to-child HIV transmission (PMTCT) programme to determine: the acceptability of offering opt-out voluntary counselling and HIV-testing (VCT); the progressive loss to follow up of HIV-positive mothers during the antenatal period at delivery and to the 6-month postnatal visit; and the proportion of missed deliveries in the district. Design: Cohort study. Methods: Review of routine antenatal VCT and PMTCT registers. Of 3136 new antenatal mothers 2996 [96% 95% confidence interval (CI): 95-97] were pretest counselled 2965 (95% CI: 94-96) underwent HIV-testing all of whom were post-test counselled. Thirty-one (1%) mothers refused HIV-testing. A total of 646 (22%) individuals were HIV-positive and were included in the PMTCT programme. Two hundred and eighty-eight (45%) mothers and 222 (34%) babies received nevirapine. The cumulative loss to follow up (n = 646) was 358 (55% CI: 51-59) by the 36-week antenatal visit 440 (68% CI: 64-71) by delivery 450 (70% CI: 66-73) by the first postnatal visit and 524 (81% CI: 78-84) by the 6-month postnatal visit. This left just 122 (19% CI: 16-22) of the initial cohort still in the programme. The great majority (87%) of deliveries occurred at peripheral sites where PMTCT was not available. In a rural district hospital setting at least 9 out of every 10 mothers attending antenatal services accepted VCT of whom approximately one-quarter were HIV-positive and included in the PMTCT programme. The progressive loss to follow up of more than three-quarters of this cohort by the 6-month postnatal visit demands a different way of acting if PMTCT is to be scaled up in our setting. (authors)