A retrospective evaluation of the quality of malaria case management at twelve health facilities in four districts in Zambia

Objective:To establish the appropriateness of malaria case management at health facility level in four districts in Zambia.Methods:This study was a retrospective evaluation of the quality of malaria case management at health facilities in four districts conveniently sampled to represent both urban and rural settings in different epidemiological zones and health facility coverage.The review period was from January to December 2008.The sample included twelve lower level health facilities from four districts.The Pearson Chi-square test was used to identify characteristics which affected the quality of case management.Results:Out of 4891 suspected malaria cases recorded at the 12 health facilities,more than 80%of the patients had a temperature taken to establish their fever status.About 67%(CI_(95)66.1-68.7)were tested for parasitemia by either rapid diagnostic test or microscopy,whereas the remaining22.5%(CI_(95)213.1-23.7)were not subjected to any malaria test.Of the 2247 malaria cases reported(complicated and uncomplicated),71%were parasitologicaily confirmed while 29%were clinically diagnosed(unconfirmed).About 56%.(CI_(95)53.9-58.1)of the malaria cases reported were treated with artemether-lumefantrine(AL),35%(CI_(95)33.1-37.0)with sulphadoxine-pyrimethamine,8%(CI_(95)6.9-9.2)with quinine and 1%did not receive any anti-malarial.Approximately 30%of patients WHO were found negative for malaria parasites were still prescribed an anti-malarial,contrary to the guidelines.There were marked inter-district variations in the proportion of patients in WHOm a diagnostic tool was used,and in the choice of anti-malarials for the treatment of malaria confirmed cases.Association between health worker characteristics and quality of case malaria management showed that nurses performed better than environmental health technicians and clinical officers on the decision whether to use the rapid diagnostic test or not.Gender,in service training on malaria,years of residence in the district and length of service of the health worker at the facility were not associated with diagnostic and treatment choices.Conclusions:Malaria case management was characterised by poor adherence to treatment guidelines.The non-adherence was mainly in leans of:inconsistent use of confirmatory tests(rapid diagnostic test or microscopy)for malaria;prescribing anti-malarials which are not recommended(e.g.sulphadoxine-pyrimethamine)and prescribing anti-malarials to cases testing negative.Innovative approaches are required to improve health worker adherence to diagnosis and treatment guidelines.

Accessibility and availability of health care services to internally displaced persons, in Kitgum and Pader districts, northern Uganda

Introduction: During 1986-2009, an estimated 1.6 million persons were internally displaced from northern and eastern regions of Uganda due to civil war. We investigated accessibility to and availability of health care services for the internally displaced persons in Kitgum and Pader districts, northern Uganda. Methods: This was a cross-sectional study conducted in Kitgum and Pader districts, northern Uganda. We interviewed a total of 1383 respondents comprising 968 (70%) adults and 415 (30%) adolescents;60% were females and 40% males, randomly selected from 35 of 67 (52.2%) internally displaced persons (IDP) camps. We held 27 key informant interviews and 52 focus group discussions. Data were entered in EPI data version 3.02 and analysed using SPSS version 12.00 statistical packages. Findings: Two thirds of the respondents 67.5% lived within 5 km distance of a health facility. The majority 62.9% of respondents mentioned that health related information was readily provided. 43.5% of health providers were always available in a health facility. A quarter 25.1% of health facilities always had drugs available, while 56.9% of the drugs prescribed were always available. Two thirds of the respondents 65.9% were satisfied with the health care services provided. The main reasons for the choice of a health facility were proximity 29.6%, provision of free treatment 24.7% and availability of drugs 17.2%. Main barriers to health care access were due to the lack of financial resources, trained personnel, and inadequate drugs and supplies in the health facilities. Conclusions and Recommendations: The majority of IDPs lived in close proximity to health facilities and obtained health care services from public health facilities. Access to health care was determined mainly by proximity and availability of free services and drugs. Although geographic accessibility to health services was high, lack of finances, information and decision power hindered access to health care services.

Contributions of the Measles Follow-Up Vaccination Campaign to Improving the Vaccination Coverage of Children Aged 6 - 59 Months in the Democratic Republic of the Congo in 2019

Background: In accordance with its measles elimination strategic plan 2012-2020, the Democratic Republic of the Congo (DRC) organized a follow-up vaccination campaign against measles from October to December 2019 in 26 provinces. This study aims to establish the contribution of this supplementary vaccination campaign to protecting children against measles. Methods: The survey was carried out in November 2020 among households of the DRC, according to the 2018 revised version of the World Health Organization’s stratified cluster sampling method, using multiple stage sampling. It targeted 280 children aged 6 - 59 months per stratum or province, with 10 children in each of the 28 selected clusters. Data collection using tablets with centralized and real-time data processing was preceded by enumeration to refine the household sampling frame. Clusters and households were selected by random draw. Data collected with CS Pro 7 software were analyzed with SPSS, Epi info 7 and Excel software to determine indicators and make before-after comparisons using the McNemar test, at a precision threshold of 5%. Results: Of the 8535 surveyed children, 89.5% were vaccinatedduring the follow-up campaign and 81.6% were vaccinated before. Only 3.7% had correctly completed campaign vaccination cards. Estimated vaccination coverage increased from 80.8% before the campaign to 92.6% after the campaign (p 0.001). Vaccination coverage after campaign against measles improved in all provinces (p < 0.001) except Bas-Uele and Maniema. Thirteen provinces reached the national coverage target of 95%, compared to five before the campaign. The proportion of zero-dose children dropped significantly after this campaign from 19.2% to 7.4% (p 0.001), and even fell below 1% in six provinces. Conclusion: This measles vaccination campaign improved overall vaccination coverage by 10% and reached more unvaccinated children. Efforts must continue to improve the retention of vaccination card, the adherence of unvaccinated children and the effectiveness of routine vaccination.

发展中国家筛查结核病接触者合适吗?1996-1998年尼泊尔东部地区的经验

背景:此项结核病研究是由一家非政府组织在尼泊尔东部8个丘陵及山区地区实施的。目的:评价筛查接触者对病例发现的作用。设计:对1996—1998年诊断并登记的"首登病例"(index cases),即涂片阳性、涂片阴性和肺外结核病例的接触者进行回顾性队列研究。首登病例的家庭成员为接触者,接触者经疫检筛查,2份痰涂片阳性者确定为涂阳肺结核病例。结果:大约从50%(668)的登记病人中确定接触者;在确定的接触者中75%(2298)送检1个或以上的痰标本。从接触者中共筛查出14例(0.61%)涂阳肺结核病例,除1例外,13例涂阳肺结核病人都是从涂阳肺结核首登病例的接触者中检出的。从涂阳菌量≥2+的首登病例接触者中检出的涂阳肺结核病人是涂阳菌量1+者的7.2倍(P=0.04)。讨论:在这样的背景下,从涂阴肺结核或肺外结核病人的家庭接触者中用痰检筛查是不合适的。为了评价筛查没有症状的涂阳肺结核病例接触者的实用性以及通过筛查痰菌量大(>24)病例的接触者是否可以改善费用效益,有必要进一步的评估。

Characteristics of Acute Flaccid Paralysis Reported by the Surveillance System and Verified by WHO Officer in Akwa Ibom State-Nigeria, 2006-2012

Background: Acute Flaccid Paralysis (AFP) was adopted by World Health Organization (WHO) in 1988 as a key pillar used in monitoring progress towards the global polio eradication initiative. High quality AFP surveillance is essential to support this global initiative. We applied recently developed case verification methods for the quantitative evaluation of AFP cases reported to the surveillance systems to evaluate the quality of AFP reports in Akwa Ibom State, Nigeria. Objectives: The aim of this study is to identify the demographic, clinical and epidemiological attributes and quality of acute flaccid paralysis surveillance. Methods: All AFP cases reported in children 0 - 14 years during January 2006 to December 2012 were investigated and verified by WHO surveillance officers, using standard questionnaire. Two stool samples 24 - 48 hours apart from a total of 1184 AFP cases were collected within 14 days of onset of paralysis with the prior oral/verbal informed consent and transported to the national polio laboratory under reverse cold chain. Result: In all, 885/1184 representing 75% of the AFP cases reported were verified by WHO officers in the period under review. Overall, 534/885 (60.3%) of AFP cases had more than >3 doses of Oral Polio Vaccine (OPV), while 196/885 (22.2%) received 3 dose of OPV and 128/885 (14.5%) received between 1 - 2 doses of OPV. It was interesting that 27/885 (3%) never received OPV before. Overall, 743/885 (84.0%) were reported within ≤14 days of paralysis onset, while 142/885 (16%) were reported after ≥14 days of paralysis onset. In total, 797/885 (90.1%) of cases were found to have fever at the onset of paralysis;paralysis was found to be asymmetric in 805/885 (91%). Wasting or diminished muscle tone was observed in 34.0% of cases verified, while deep tendon reflexes were good (normal) in 79% of cases. Gullain-Barre syndrome was observed in 50.9% of the reported cases followed by injection neuritis (25.0%) and transverse myelitis (2.0%). However, other causes recorded 22.1%. The legs (90.2%) are the parts of the body mostly affected, while arm recorded 9.8% of the AFP cases reported and verified. Conclusions: The result of this study indicates that the characterization of AFP cases reported to the surveillance network could provide better understanding of age, and sex distribution, common clinical causes of AFP and impact of distance to health facilities on the health seeking behaviours of AFP cases.

Strategic Engagement of Private Facilities to Increase Public-Private Mix (PPM) Contribution to Nigeria Tuberculosis Case Notification

Introduction: Finding the missing Tuberculosis (TB) cases remains the single most important priority for TB control in Nigeria. Between 66% - 92% of all cases of respiratory diseases including those with symptoms suggestive of TB are first seen byprivate health providers. Dependable, quality surveillance systems and notification are key roles in health services delivery, particularly as it is related to TB control. However, poor notification has been a challenge. This study was to assess the contribution of the public private mix (PPM) to Nigeria Tuberculosis national case notification. Methods: It was a national cross-sectional study. Data were extracted from the National database and reviewed. Private facilities were engaged in 2017 and assessed over 2018-2020. Interventions included: enrolling private practitioners (Private-For-Profit, Faith Based Organization, Private Medicine Vendors and Community Pharmacists), engaging a private standalone Laboratory for Gene Xpert testing within the network of private facilities, use of Mobile App for easy screening and reporting, instituting a HUB and spoke, and incentives to private providers for participating. Each private provider had a customized approach. Trend analysis was performed using Cochran-Armitage χ2 test for linear trends. Level of significance was at a p value of Results: Total case notification increased from 104,904 cases in 2017 to 138,591 in 2020. There were 2.0% increase in 2018, 13.0% in 2019 and 15.0% in 2020 (p < 0.001). PPM contribution to case notification increased from 10,699 cases in 2017 to 12,625 in 2018, then 17,250 in 2019 and 38,865 in 2020. There were 18.0% increase in 2018, 36.6% in 2019 and 125.3% increase in 2020 (p ). Conclusion: Effective engagement of the private sector in TB control efforts in Nigeria using a variety of approaches resulting in improved TB notification is possible. The National TB Programme should engage all private practitioners such that each practitioner will practice at least one TB service model.

Scaling up of trachoma mapping in Salima District, Central Malawi

Background: A number of suspected endemic districts with Trachoma have not been mapped in Malawi, and this contributes to delays for scaling up trachoma control activities. Objectives: To determine the prevalence of trachoma and associated risk factors in one of the suspected endemic districts (Salima District) in central Malawi and to generate information to guide policy decisions. Methods: A population-based survey conducted in randomly selected clusters in Salima District (population 418,672), centralMalawi. Children aged 1-9 years and adults aged 15 and above were assessed for clinical signs of trachoma. Results: In total, 884 households were enumerated within 36 clusters. A total of 2765 persons were examined for ocular signs of trachoma. The prevalence of trachomatous inflammation, follicular (TF) among children aged 1-9 years was 17.1% (95% CI 14.9-19.4). The prevalence of trachoma trichiasis (TT) in women aged 15 years and above was 1.3% (CI 0.7-2.3), while the prevalence in men was zero. The presence of a dirty face and lack of sanitation were significantly associated with trachoma follicular (P < 0.001). Conclusion: Prevalence rate of trachoma follicles (TF) in Central Malawi exceeds the WHO guidelines for the intervention with mass antibiotic distribution (TF > 10%), and warrants the trachoma SAFE (Surgery, Antibiotics, Face washing and Environmental hygiene) control strategy to be undertaken in Salima District.

Mass Distribution Campaign of Long-Lasting Insecticidal Nets in the Democratic Republic of Congo from 2018 to 2021 in the Context of the Emergence of COVID-19: Results and Lessons Learned

Introduction: The DRC had planned 23 mass distribution campaigns distribution of long-lasting insecticidal nets (LLIN) for the years 2018-2020, the implementation of which spanned from 2018 to July 2021. This article reviews the campaign’s planning process, the results, challenges, and lessons learned. Methods: A descriptive method was used to postpone the planning and implementation process according to the National Malaria Control Program (NMCP) standards adapted to the COVID-19 context. The changes and adaptations implemented as well as the challenges encountered are described. Results: Between January 2018 to June 2021, 23 LLIN mass distribution campaigns were organized in the DRC with the financial support of The Global Fund to Fight against Tuberculosis, AIDS and Malaria (GFTAM) and Against Malaria Foundation (AMF) allowing the distribution of 55,273,473 LLINs to 19,048,372 households at risk of malaria transmission with an average of 2.9 LLINs per household. The enumerated population (111,081,191) exceeded 7% of the micro plans projected population (102,790,391) while the number of households enumerated (19,311,629) was 3% lower compared to the micro planning projection households (19,862,417). Compared to a reported household coverage of 96% of households achieved over the expected households, the independent monitoring carried out revealed 91% of households served in the intervention areas. The main reasons for not reaching households mentioned by the respondents were absence at the time of distribution (26%) followed by the loss of vouchers (16%). Several communication channels were used among which, community workers were the most frequently mentioned (63.1%), followed by radios (18.5%) and churches (12.4%). Conclusion: Good planning, effective coordination of stakeholders, and revision of the implementing campaigns methods following the COVID-19 were factors in the success of this campaign. An effort to respect the schedules for renewing LLINs in households, coupled with good continuous distribution, is necessary to maintain the gains and hope for an impact in terms of morbidity and mortality reduction of malaria.

发展中国家筛查结核病接触者合适吗?1996-1998年尼泊尔东部地区的经验

背景:此项结核病研究是由一家非政府组织在尼泊尔东部8个丘陵及山区地区实施的。 目的:评价筛查接触者对病例发现的作用。 设计:对1996-1998年诊断并登记的“首登病例”(index cases),即涂片阳性、涂片阴性和肺外结核病例的接触者进行回顾性队列研究。首登病例的家庭成员为接触者,接触者经痰检筛查,2份痰涂片阳性者确定为涂阳肺结核病例。 结果:大约从50％(668)的登记病人中确定接触者;在确定的接触者中75％(2298)送检1个或以上的痰标本。从接触者中共筛查出14例(0.61％)涂阳肺结核病例,除1例外,13例涂阳肺结核病人都是从涂阳肺结核首登病例的接触者中检出的。从涂阳菌量≥2+的首登病例接触者中检出的涂阳肺结核病人是涂阳菌量1+者的7.2倍(P=0.04)。 讨论:在这样的背景下,从涂阴肺结核或肺外结核病人的家庭接触者中用痰检筛查是不合适的。为了评价筛查没有症状的涂阳肺结核病例接触者的实用性以及通过筛查痰菌量大(≥2+)病例的接触者是否可以改善费用效益,有必要进一步的评估。

Innate and adaptive T cells in influenza disease

Influenza is a major global health problem, causing infections of the respiratory tract, often leading to acute pneumonia, life-threatening complications and even deaths. Over the last seven decades, vaccination strategies have been utilized to protect people from complications of influenza, especially groups at high risk of severe disease. While current vaccination regimens elicit strain-specific antibody responses, they fail to generate cross-protection against seasonal, pandemic and avian viruses. Moreover, vaccines designed to generate influenza- specific T-cell responses are yet to be optimized. During natural infection, viral replication is initially controlled by innate immunity before adaptive immune responses （T cells and antibody-producing B cells） achieve viral clearance and host recovery. Adaptive T and B cells maintain immunological memory and provide protection against subsequent infections with related influenza viruses. Recent studies also shed light on the role of innate T- cells （MAIT cells, y~ T cells, and NKT cells） in controlling influenza and linking innate and adaptive immune mechanisms, thus making them attractive targets for vaccination strategies. We summarize the current knowledge on influenza-specific innate MAIT and γδ T cells as well as adaptive CD8＋ and CD4＋ T cells, and discuss how these responses can be harnessed by novel vaccine strategies to elicit cross-protective immunity against different influenza strains and subtypes.