This section contains articles written by MSF staff and MSF partners published in peer-reviewed journals. It contains research articles, reviews, editorials and letters. In all cases, the full text is available for free. Some articles are listed under more than one topic. The box on the right lists all the topics.

Collections in this community

Recent Submissions

  • The duration of chemoprophylaxis against malaria after treatment with artesunate-amodiaquine and artemether-lumefantrine and the effects of pfmdr1 86Y and pfcrt 76T: a meta-analysis of individual patient data

    Bretscher, M; Dahal, P; Griffin, J; Bassat, Q; Baudin, E; D'Alessandro, U; Djimde, AA; Dorsey, G; Espié, E; Fofana, B; et al. (BioMed Central, 2020-02-25)
    BACKGROUND: The majority of Plasmodium falciparum malaria cases in Africa are treated with the artemisinin combination therapies artemether-lumefantrine (AL) and artesunate-amodiaquine (AS-AQ), with amodiaquine being also widely used as part of seasonal malaria chemoprevention programs combined with sulfadoxine-pyrimethamine. While artemisinin derivatives have a short half-life, lumefantrine and amodiaquine may give rise to differing durations of post-treatment prophylaxis, an important additional benefit to patients in higher transmission areas. METHODS: We analyzed individual patient data from 8 clinical trials of AL versus AS-AQ in 12 sites in Africa (n = 4214 individuals). The time to PCR-confirmed reinfection after treatment was used to estimate the duration of post-treatment protection, accounting for variation in transmission intensity between settings using hidden semi-Markov models. Accelerated failure-time models were used to identify potential effects of covariates on the time to reinfection. The estimated duration of chemoprophylaxis was then used in a mathematical model of malaria transmission to determine the potential public health impact of each drug when used for first-line treatment. RESULTS: We estimated a mean duration of post-treatment protection of 13.0 days (95% CI 10.7-15.7) for AL and 15.2 days (95% CI 12.8-18.4) for AS-AQ overall. However, the duration varied significantly between trial sites, from 8.7-18.6 days for AL and 10.2-18.7 days for AS-AQ. Significant predictors of time to reinfection in multivariable models were transmission intensity, age, drug, and parasite genotype. Where wild type pfmdr1 and pfcrt parasite genotypes predominated (<=20% 86Y and 76T mutants, respectively), AS-AQ provided ~ 2-fold longer protection than AL. Conversely, at a higher prevalence of 86Y and 76T mutant parasites (> 80%), AL provided up to 1.5-fold longer protection than AS-AQ. Our simulations found that these differences in the duration of protection could alter population-level clinical incidence of malaria by up to 14% in under-5-year-old children when the drugs were used as first-line treatments in areas with high, seasonal transmission. CONCLUSION: Choosing a first-line treatment which provides optimal post-treatment prophylaxis given the local prevalence of resistance-associated markers could make a significant contribution to reducing malaria morbidity.
  • Field challenges to measles elimination in the Democratic Republic of the Congo

    Coulborn, RM; Nackers, F; Bachy, C; Porten, K; Vochten, H; Ndele, E; Van Herp, M; Bibala-Faray, E; Cohuet, S; Panunzi, I (Elsevier, 2020-02-25)
    BACKGROUND: During a measles epidemic, the Ministry of Public Health (MOH) of the Democratic Republic of the Congo conducted supplementary immunization activities (2016-SIA) from August 28-September 3, 2016 throughout Maniema Province. From October 29-November 4, 2016, Médecins Sans Frontières and the MOH conducted a reactive measles vaccination campaign (2016-RVC) targeting children six months to 14 years old in seven health areas with heavy ongoing transmission despite inclusion in the 2016-SIA, and a post-vaccination survey. We report the measles vaccine coverage (VC) and effectiveness (VE) of the 2016-SIA and VC of the 2016-RVC. METHODS: A cross-sectional VC cluster survey stratified by semi-urban/rural health area and age was conducted. A retrospective cohort analysis of measles reported by the parent/guardian allowed calculation of the cumulative measles incidence according to vaccination status after the 2016-SIA for an estimation of crude and adjusted VE. RESULTS: In November 2016, 1145 children (6-59 months old) in the semi-urban and 1158 in the rural areas were surveyed. Post-2016-SIA VC (documentation/declaration) was 81.6% (95%CI: 76.5-85.7) in the semi-urban and 91.0% (95%CI: 84.9-94.7) in the rural areas. The reported measles incidence in October among children less than 5 years old was 5.0% for 2016-SIA-vaccinated and 11.2% for 2016-SIA-non-vaccinated in the semi-urban area, and 0.7% for 2016-SIA-vaccinated and 4.0% for 2016-SIA-non-vaccinated in the rural area. Post-2016-SIA VE (adjusted for age, sex) was 53.9% (95%CI: 2.9-78.8) in the semi-urban and 78.7% (95%CI: 0-97.1) in the rural areas. Post 2016-RVC VC (documentation/declaration) was 99.1% (95%CI: 98.2-99.6) in the semi-urban and 98.8% (95%CI: 96.5-99.6) in the rural areas. CONCLUSIONS: Although our VE estimates could be underestimated due to misclassification of measles status, the VC and VE point estimates of the 2016-SIA in the semi-urban area appear suboptimal, and in combination, could not limit the epidemic. Further research is needed on vaccination strategies adapted to urban contexts.
  • Behind the Scenes of South Africa’s Asylum Procedure: A Qualitative Study on Long-term Asylum-Seekers from the Democratic Republic of Congo

    Schockaert, L; Venables, E; Gil-Bazo, MT; Barnwell, G; Gerstenhaber, R; Whitehouse, K (Oxford University Press, 2020-02-20)
    Despite the difficulties experienced by asylum-seekers in South Africa, little research has explored long-term asylum applicants. This exploratory qualitative study describes how protracted asylum procedures and associated conditions are experienced by Congolese asylum-seekers in Tshwane, South Africa. Eighteen asylum-seekers and eight key informants participated in the study. All asylum-seekers had arrived in South Africa between 2003 and 2013, applied for asylum within a year of arrival in Tshwane, and were still in the asylum procedure at the time of the interview, with an average of 9 years since their application. Thematic analysis was used to analyse the data. The findings presented focus on the process of leaving the Democratic Republic of Congo, applying for asylum and aspirations of positive outcomes for one’s life. Subsequently, it describes the reality of prolonged periods of unfulfilled expectations and how protracted asylum procedures contribute to poor mental health. Furthermore, coping mechanisms to mitigate these negative effects are described. The findings suggest that protracted asylum procedures in South Africa cause undue psychological distress. Thus, there is both a need for adapted provision of mental health services to support asylum-seekers on arrival and during the asylum process, and systemic remediation of the implementation of asylum procedures.
  • Emerging priorities for HIV service delivery

    Ford, N; Geng, E; Ellman, T; Orrell, C; Ehrenkranz, P; Sikazwe, I; Jahn, A; Rabkin, M; Ayisi Addo, S; Grimsrud, A; et al. (Public Library of Science, 2020-02-14)
    Nathan Ford and co-authors discuss global priorities in the provision of HIV prevention and treatment services.
  • Prevention of child wasting: Results of a Child Health & Nutrition Research Initiative (CHNRI) prioritisation exercise

    Frison, S; Angood, C; Khara, T; Bahwere, P; Black, R; Briend, A; Connell, N; Fenn, B; Isanaka, S; James, P; et al. (Public Library of Science, 2020-02-12)
    BACKGROUND: An estimated 49.5 million children under five years of age are wasted. There is a lack of robust studies on effective interventions to prevent wasting. The aim of this study was to identify and prioritise the main outstanding research questions in relation to wasting prevention to inform future research agendas. METHOD: A research prioritisation exercise was conducted following the Child Health and Nutrition Research Initiative method. Identified research gaps were compiled from multiple sources, categorised into themes and streamlined into forty research questions by an expert group. A survey was then widely circulated to assess research questions according to four criteria. An overall research priority score was calculated to rank questions. FINDINGS: The prioritised questions have a strong focus on interventions. The importance of the early stages of life in determining later experiences of wasting was highlighted. Other important themes included the identification of at-risk infants and young children early in the progression of wasting and the roles of existing interventions and the health system in prevention. DISCUSSION: These results indicate consensus to support more research on the pathways to wasting encompassing the in-utero environment, on the early period of infancy and on the process of wasting and its early identification. They also reinforce how little is known about impactful interventions for the prevention of wasting. CONCLUSION: This exercise provides a five-year investment case for research that could most effectively improve on-the-ground programmes to prevent child wasting and inform supportive policy change.
  • Prioritising pathogens for the management of severe febrile patients to improve clinical care in low- and middle-income countries

    Osborn, J; Roberts, T; Guillen, E; Bernal, O; Roddy, P; Ongarello, S; Sprecher, A; Page, AL; Ribeiro, I; Piriou, E; et al. (BioMed Central, 2020-02-10)
    BACKGROUND: Severe febrile illness without a known source (SFWS) is a challenge for clinicians when deciding how to manage a patient, particularly given the wide spectrum of potential aetiologies that contribute to fever. These infections are difficult to distinguish clinically, and accurate diagnosis requires a plethora of diagnostics including blood cultures, imaging techniques, molecular or serological tests, and more. When laboratory services are available, a limited test menu hinders clinical decision-making and antimicrobial stewardship, leading to empiric treatment and suboptimal patient outcomes. To specifically address SFWS, this work aimed to identify priority pathogens for a globally applicable panel for fever causing pathogens. METHOD: A pragmatic two-pronged approach combining currently available scientific data in an analytical hierarchy process and systematically gathered expert input, was designed to address the lack of comprehensive global aetiology data. The expert re-ranked list was then further adapted for a specific use case to focus on community acquired infections in whole blood specimens. The resulting list was further analysed to address different geographical regions (Asia, Africa, and Latin America), and Cohen kappa scores of agreement were calculated. RESULTS: The expert ranked prioritized pathogen list generated as part of this two-pronged approach included typhoidal Salmonella, Plasmodium species and Mycobacterium tuberculosis as the top 3 pathogens. This pathogen list was then further adapted for the SFWS use case to develop a final pathogen list to inform product development. Subsequent analysis comparing the relevance of the SFWS pathogen list to multiple populations and geographical regions showed that the SFWS prioritized list had considerable utility across Africa and Asia, but less so for Latin America. In addition, the list showed high levels of agreement across different patient sub-populations, but lower relevance for neonates and symptomatic HIV patients. CONCLUSION: This work highlighted once again the challenges of prioritising in global health, but it also shows that taking a two-pronged approach, combining available prevalence data with expert input, can result in a broadly applicable priority list. This comprehensive utility is particularly important in the context of product development, where a sufficient market size is essential to achieve a sustainable commercialized diagnostic product to address SFWS.
  • Evaluation of the stability of measles vaccine out of the cold chain under extended controlled temperature conditions.

    Juan-Giner, A; Alsalhani, A; Panunzi, I; Lambert, V; Van Herp, M; Gairola, S (Elsevier, 2020-02-08)
    Measles outbreaks occur periodically in remote and difficult to reach areas in countries such as the Democratic Republic of Congo. The possibility to keep measles vaccines at temperatures outside the cold chain for a limited period prior to administration would be an advantage for organizations such as Médecins Sans Frontières, which repeatedly respond to measles outbreaks in difficult contexts. Using stability data at 37 °C and 40 °C provided by Serum Institute of India Private Limited we applied the product release model for Extended Controlled Temperature Conditions (ECTC) to evaluate the possibility of an out of the cold chain excursion. Measles vaccine in the lyophilized form remains above the minimum required potency at the end of the shelf-life for up to 6 days at 37 °C or for 2 days at 40 °C. This evaluation supports the use of a monodose presentation of measles vaccine in ECTC. This could be an advantage for outbreak response in isolated and difficult to reach areas. However the operational advantages of this approach need to be established.
  • MDR/XDR-TB management of patients and contacts: challenges facing the new decade. The 2020 clinical update by the Global Tuberculosis Network.

    Battista Migliori, G; Tiberi, S; Zumla, A; Petersen, E; Muhwa Chakaya, J; Wejse, C; Muñoz Torrico, M; Duarte, R; Alffenaar, JW; Schaaf, HS; et al. (Elsevier, 2020-02-04)
    The continuous flow of new research articles on MDR-TB diagnosis, treatment, prevention and rehabilitation requires frequent update of existing guidelines. This review is aimed at providing clinicians and public health staff with an updated and easy-to-consult document arising from consensus of Global Tuberculosis Network (GTN) experts. The core published documents and guidelines have been reviewed including the recently published MDR-TB WHO rapid advice and ATS/CDC/ERS/IDSA guidelines. After a rapid review of epidemiology and risk factors, the clinical priorities on MDR-TB diagnosis (including whole genome sequencing and drug-susceptibility testing interpretations) and treatment (treatment design and management, TB in children) are discussed. Furthermore, the review comprehensively describes the latest information on contact tracing and LTBI management in MDR-TB contacts, while providing guidance on post-treatment functional evaluation and rehabilitation of TB sequelae, infection control and other public health priorities.
  • Tailored HIV programmes and universal health coverage

    Holmes, CB; Rabkin, M; Ford, N; Preko, P; Rosen, S; Ellman, T; Ehrenkranz, P (World Health Organization, 2020-02-01)
    Improvements in geospatial health data and tailored human immunodeficiency virus (HIV) testing, prevention and treatment have led to greater microtargeting of the HIV response, based on location, risk, clinical status and disease burden. These approaches show promise for achieving control of the HIV epidemic. At the same time, United Nations Member States have committed to achieving broader health and development goals by 2030, including universal health coverage (UHC). HIV epidemic control will facilitate UHC by averting the need to commit ever-increasing resources to HIV services. Yet an overly targeted HIV response could also distort health systems, impede integration and potentially threaten broader health goals. We discuss current approaches to achieving both UHC and HIV epidemic control, noting potential areas of friction between disease-specific microtargeting and integrated health systems, and highlighting opportunities for convergence that could enhance both initiatives. Examples of these programmatic elements that could be better aligned include: improved information systems with unique identifiers to track and monitor individuals across health services and the life course; strengthened subnational data use; more accountable supply chains that supply a broad range of services; and strengthened community-based services and workforces. We argue that the response both to HIV and to broader health threats should use these areas of convergence to increase health systems efficiency and mitigate the harm of any potential decrease in health funding. Further investments in implementation and monitoring of these programme elements will be needed to make progress towards both UHC and HIV epidemic control.
  • High cholera vaccination coverage following emergency campaign in Haiti: Results from a cluster survey in three rural Communes in the South Department, 2017

    Sharp, A; Blake, A; Backx, J; Panunzi, I; Barrais, R; Nackers, F; Luquero, F; Deslouches, YG; Cohuet, S (Public Library of Science, 2020-01-31)
    Oral cholera vaccine (OCV) has increasingly been used as an outbreak control measure, but vaccine shortages limit its application. A two-dose OCV campaign targeting residents aged over 1 year was launched in three rural Communes of Southern Haiti during an outbreak following Hurricane Matthew in October 2016. Door-to-door and fixed-site strategies were employed and mobile teams delivered vaccines to hard-to-reach communities. This was the first campaign to use the recently pre-qualified OCV, Euvichol. The study objective was to estimate post-campaign vaccination coverage in order to evaluate the campaign and guide future outbreak control strategies. We conducted a cluster survey with sampling based on random GPS points. We identified clusters of five households and included all members eligible for vaccination. Local residents collected data through face-to-face interviews. Coverage was estimated, accounting for the clustered sampling, and 95% confidence intervals calculated. 435 clusters, 2,100 households and 9,086 people were included (99% response rate). Across the three communes respectively, coverage by recall was: 80.7% (95% CI:76.8-84.1), 82.6% (78.1-86.4), and 82.3% (79.0-85.2) for two doses and 94.2% (90.8-96.4), 91.8% (87-94.9), and 93.8% (90.8-95.9) for at least one dose. Coverage varied by less than 9% across age groups and was similar among males and females. Participants obtained vaccines from door-to-door vaccinators (53%) and fixed sites (47%). Most participants heard about the campaign through community 'criers' (58%). Despite hard-to-reach communities, high coverage was achieved in all areas through combining different vaccine delivery strategies and extensive community mobilisation. Emergency OCV campaigns are a viable option for outbreak control and where possible multiple strategies should be used in combination. Euvichol will help alleviate the OCV shortage but effectiveness studies in outbreaks should be done.
  • Access to health services for men who have sex with men and transgender women in Beira, Mozambique: A qualitative study

    Gamariel, F; Isaakidis, P; Tarquino, IAP; Beirão, JC; O'Connell, L; Mulieca, N; Gatoma, HP; Cumbe, VFJ; Venables, E (Public Library of Science, 2020-01-30)
    OBJECTIVES: HIV prevalence and incidence are higher among key populations including Men who have Sex with Men (MSM) and transgender women in low and middle income countries, when compared to the general population. Despite World Health Organisation guidelines on the provision of services to key populations recommending an evidence-based, culturally relevant and rights-based approach, uptake of HIV services in many resource-limited and rights-constrained settings remains low. Médecins Sans Frontières (MSF) has been offering health services for MSM and transgender women in Beira, Mozambique since 2014 using a peer-educator driven model, but uptake of services has not been as high as expected. This qualitative study aimed to learn more about these key populations in Beira, their experiences of accessing MSM- and transgender-friendly services and their use of face-to-face and virtual networks, including social media, for engagement with health care. METHODS: In-depth interviews were carried out with MSM and transgender women who were 1) enrolled in, 2) disengaged from or 3) never engaged in MSF's programme. Purposive and snowball sampling were used to recruit the different groups of interviewees. Interviews were conducted in Portuguese, transcribed and translated into English before being coded and manually analysed using a thematic network framework. RESULTS: Nine transgender women and 18 cisgender MSM participated in the study. Interviewees ranged in age from 19 to 47 years, with a median age of 29. Three main themes emerged from the data: perceptions of stigma and discrimination, experiences of the peer-educator driven model and the use of face-to-face and virtual platforms for communication and engagement, including social media. Interviewees reported experiencing stigma and discrimination because of their gender or sexual identity. HIV-related stigma and health-care setting discrimination, including gossip and breach of confidentiality, were also reported. Although the presence of the peer-educators and their outreach activities were appreciated, they had limited visibility and an over-focus on health and HIV. The face-to-face networks of MSM and transgender women were small and fragmented. Virtual networks such as Facebook were mainly used for flirting, dating and informal communication. Most interviewees were at ease using social media and would consider it as a means of engaging with health messaging. CONCLUSIONS: MSM and transgender women have challenges in accessing health services due to being stigmatised because of their gender identity and their sexual behaviour, and often experience stigma at home, in health-care facilities and in their communities. Peer-driven models of engagement were appreciated but have limitations. There is an untapped potential for further expansion and engagement with face-to-face and virtual platforms to reach MSM and transgender women in settings with a high HIV burden, and to provide them with essential information about HIV and their health.
  • Cost-effectiveness of diagnostic algorithms including lateral-flow urine lipoarabinomannan for HIV-positive patients with symptoms of tuberculosis

    Yakhelef, N; Audibert, M; Ferlazzo, G; Sitienei, J; Wanjala, S; Varaine, F; Bonnet, M; Huerga, H (Public Library of Science, 2020-01-30)
    BACKGROUND: Tuberculosis (TB) is the leading cause of death among HIV-positive patients. We assessed the cost-effectiveness of including lateral-flow urine lipoarabinomannan (LF-LAM) in TB diagnostic algorithms for severely ill or immunosuppressed HIV-positive patients with symptoms of TB in Kenya. METHODS: From a decision-analysis tree, ten diagnostic algorithms were elaborated and compared. All algorithms included clinical exam. The costs of each algorithm were calculated using a 'micro-costing' method. The efficacy was estimated through a prospective study that included severely ill or immunosuppressed (CD4<200cells/μL) HIV-positive adults with symptoms of TB. The cost-effectiveness analysis was performed using the disability-adjusted life year (DALY) averted as effectiveness outcome. A 4% discount rate was applied. RESULTS: The algorithm that added LF-LAM alone to the clinical exam lead to the least average cost per TB case detected (€47) and was the most cost-effective with a cost/DALY averted of €4.6. The algorithms including LF-LAM, microscopy and X-ray, and LF-LAM and Xpert in sputum, detected a high number of TB cases with a cost/DALY averted of €6.1 for each of them. In the comparisons of the algorithms two by two, using LF-LAM instead of microscopy (clinic&LAM vs clinic&microscopy) and using LF-LAM along with GeneXpert in sputum instead of GeneXpert in urine along with GeneXpert in sputum, (clinic&LAM&Xpert_sputum vs clinic&Xpert_sputum&Xpert_urine) led to the highest increase in the cost-effectiveness ratios (ICERs): €-7.2 and €-12.6 respectively. In these two comparisons, using LF-LAM increased the number of TB patients detected while reducing costs. Adding LF-LAM to smear microscopy alone or to smear microscopy and Xray led to the highest increase in the additional number of TB cases detected (31 and 25 respectively) with an incremental efficiency estimated at 134 and 344 DALYs respectively. The ICERs were €22.0 and €8.6 respectively. CONCLUSION: Including LF-LAM in TB diagnostic algorithms is cost-effective for severely ill or immunosuppressed HIV-positive patients.
  • Evaluating lactate prognostic value in children suspected of acetaminophen-induced liver failure in Liberia

    Haidar, MK; Morton, N; Roederer, T; Mayronne, S; Bawo, L; Kerkula, J; Porten, K; Baud, FJ (Springer Nature, 2020-01-29)
    BACKGROUND: The prognostic significance of hyperlactatemia in young children with liver injury suspected to be attributed to repeated supratherapeutic doses of acetaminophen remain understudied. METHODS: We conducted a retrospective medical chart review including children aged <5 years admitted with hepatocellular injury. The study was conducted in Bardnesville Junction Hospital operated by Médecins Sans Frontières in Monrovia, Liberia. RESULTS: We analyzed 95 children with liver injury in whom a blood lactate measurement on admission was available. Eighty children (84%) were aged <2 years; 49 children (52%) died during hospitalization. The median acetaminophen concentration on admission was 20 mg/L with 60 (70%) children presenting concentrations exceeding 10 mg/L. Median lactate was significantly higher in children who died (10.7 mmol/L; interquartile range (IQR): 8.5-15.7) than those who survived (6.1 mmol/L; IQR: 4.1-8.5), P value < 0.001). The optimal threshold obtained was 7.2 mmol/L with a sensitivity of 84% and specificity 70% (area under curve = 0.80). The previously established thresholds of 3.5 and 4 mmol/L lactate had very low specificity identifying non-survival in children included in this study. CONCLUSION: In this setting, young children with ALF possibly attributed to acetaminophen toxicity were unlikely to survive if the venous blood lactate concentration exceeded 7.2 mmol/L.
  • Male predominance in reported Visceral Leishmaniasis cases: Nature or nurture? A comparison of population-based with health facility-reported data

    Cloots, K; Burza, S; Malaviya, P; Hasker, E; Kansal, S; Mollett, G; Chakravarty, J; Roy, N; Lal, BK; Rijal, S; et al. (Public Library of Science, 2020-01-29)
    BACKGROUND: Bangladesh, India, and Nepal aim for the elimination of Visceral Leishmaniasis (VL), a systemic parasitic infectious disease, as a public health problem by 2020. For decades, male patients have comprised the majority of reported VL cases in this region. By comparing this reported VL sex ratio to the one observed in population-based studies conducted in the Indian subcontinent, we tested the working hypothesis that mainly socio-cultural gender differences in healthcare-seeking behavior explain this gender imbalance. METHODOLOGY/PRINCIPAL FINDINGS: We compared the observed sex ratio of male versus female among all VL cases reported by the health system in Nepal and in the two most endemic states in India with that observed in population-based cohort studies in India and Nepal. Also, we assessed male sex as a potential risk factor for seroprevalence at baseline, seroconversion, and VL incidence in the same population-based data. The male/female ratio among VL cases reported by the health systems was 1.40 (95% CI 1.37-1.43). In the population cohort data, the age- and study site-adjusted male to female risk ratio was 1.27 (95% CI 1.08-1.51). Also, males had a 19% higher chance of being seropositive at baseline in the population surveys (RR 1.19; 95% CI 1.11-1.27), while we observed no significant difference in seroconversion rate between both sexes at the DAT cut-off titer defined as the primary endpoint. CONCLUSIONS/SIGNIFICANCE: Our population-based data show that male sex is a risk factor for VL, and not only as a socio-cultural determinant. Biological sex-related differences likely play an important role in the pathogenesis of this disease.
  • Outcomes of visceral leishmaniasis in pregnancy: A retrospective cohort study from South Sudan

    Pekelharing, JE; Gatluak, F; Harrison, T; Maldonado, F; Siddiqui, MR; Ritmeijer, K (Public Library of Science, 2020-01-24)
    INTRODUCTION: Visceral leishmaniasis (VL) is endemic in South Sudan, where outbreaks occur frequently. Because of changes in the immune system during pregnancy, pregnant women are considered particularly vulnerable for developing complications of VL disease, including opportunistic infections. There is limited evidence available about clinical aspects and treatment outcomes of VL in pregnancy. We describe characteristics, maternal and pregnancy outcomes from a cohort of pregnant women with VL. METHODS: We conducted a retrospective analysis using routine programme data from a MSF health facility in Lankien, Jonglei State, South Sudan, between Oct 2014 and April 2018. Records were extracted of women diagnosed with VL while pregnant, and those symptomatic during pregnancy but diagnosed during the first two weeks postpartum. Records were matched with a random sample of non-pregnant women of reproductive age (15-45 years) with VL from the same period. RESULTS: We included 113 women with VL in pregnancy, and 223 non-pregnant women with VL. Women with VL in pregnancy presented with more severe anaemia, were more likely to need blood transfusion (OR 9.3; 95%CI 2.5-34.2) and were more often prescribed antibiotics (OR 6.0; 95%CI 3.4-10.6), as compared to non-pregnant women with VL. Adverse pregnancy outcomes, including miscarriage and premature delivery, were reported in 20% (16/81) where VL was diagnosed in pregnancy, and 50% 13/26) where VL was diagnosed postpartum. Postpartum haemorrhage was common. Pregnant women were more likely to require extension of treatment to achieve cure (OR 10.0; 95%CI 4.8-20.9), as compared to non-pregnant women with VL. Nevertheless, overall initial cure rates were high (96.5%) and mortality was low (1.8%) in this cohort of pregnant women with VL. CONCLUSION: This is the largest cohort in the literature of VL in pregnancy. Our data suggest that good maternal survival rates are possible in resource-limited settings, despite the high incidence of complications.
  • Non-disclosure of tuberculosis diagnosis by patients to their household members in south western Uganda

    Nyangoma, M; Bajunirwe, F; Atwine, D (Public Library of Science, 2020-01-24)
    BACKGROUND: Tuberculosis (TB) non-disclosure by adult patients to all household members is a setback to TB control efforts. It reduces the likelihood that household contacts will seek early TB screening, initiation on preventive or curative treatment, but also hinders the implementation of infection controls and home-based directly observed treatment. Therefore, the purpose of this study was to determine the level of TB non-disclosure, its predictors and the effects of disclosure among adult TB patients in Uganda. METHODS: We conducted a cross-sectional study at a large regional referral hospital in Mbarara, south-western Uganda. Questionnaires were administered to collect patients' sociodemographic and their TB disclosure data. Non-disclosure was considered if a patient did not reveal their TB diagnosis to all household members within 2 weeks post-treatment initiation. Univariate and multivariate logistic regression models were fitted for predictors of non-disclosure. RESULTS: We enrolled 62 patients, 74% males, mean age of 32 years, and median of five people per household. Non-disclosure rate was 30.6%. Post-disclosure experiences were positive in 98.3% of patients, while negative experiences suggestive of severe stigma occurred in 12.3% of patients. Being female (OR 6.5, 95% CI: 1.4-29.3) and belonging to Muslim faith (OR 12.4, 95% CI: 1.42-109.1) were significantly associated with TB non-disclosure to household members. CONCLUSIONS: There is a high rate of TB non-disclosure to all household members by adult patients in rural Uganda, particularly among women and muslim patients. Interventions enhancing TB disclosure at household level while minimizing negative effects of stigma should be developed and prioritized.
  • Language and beliefs in relation to noma: a qualitative study, northwest Nigeria

    Farley, E; Lenglet, A; Abubakar, A; Bil, K; Fotso, A; Oluyide, B; Tirima, S; Mehta, U; Stringer, B (PLoS, 2020-01-23)
    BACKGROUND: Noma is an orofacial gangrene that rapidly disintegrates the tissues of the face. Little is known about noma, as most patients live in underserved and inaccessible regions. We aimed to assess the descriptive language used and beliefs around noma, at the Noma Children's Hospital in Sokoto, Nigeria. Findings will be used to inform prevention programs. METHODS: Five focus group discussions (FGD) were held with caretakers of patients with noma who were admitted to the hospital at the time of interview, and 12 in-depth interviews (IDI) were held with staff at the hospital. Topic guides used for interviews were adapted to encourage the natural flow of conversation. Emergent codes, patterns and themes were deciphered from the data derived from IDI's and FGDs. RESULTS: Our study uncovered two main themes: names, descriptions and explanations for the disease, and risks and consequences of noma. Naming of the disease differed between caretakers and heath care workers. The general names used for noma illustrate the beliefs and social system used to explain the disease. Beliefs were varied; participant responses demonstrate a wide range of understanding of the disease and its causes. Difficulty in accessing care for patients with noma was evident and the findings suggest a variety of actions taking place before reaching a health center or health worker. Patient caretakers mentioned that barriers to care included a lack of knowledge regarding this medical condition, as well as a lack of trust in seeking medical care. Participants in our study spoke of the mental health strain the disease placed on them, particularly due to the stigma that is associated with noma. CONCLUSIONS: Caretaker and practitioner perspectives enhance our understanding of the disease in this context and can be usedto improve treatment and prevention programs, and to better understand barriers to accessing health care. Differences in disease naming illustrate the difference in beliefs about the disease. This has an impact on health seeking behaviours, which for noma cases has important ramifications on outcomes, due to the rapid progression of the disease.
  • Perceptions and Health-Seeking Behaviour for Mental Illness Among Syrian Refugees and Lebanese Community Members in Wadi Khaled, North Lebanon: A Qualitative Study

    Al Laham, D; Ali, E; Mousally, K; Nahas, N; Alameddine, A; Venables, E (Springer, 2020-01-21)
    This is a qualitative exploration of the perceptions of mental health (MH) and their influence on health-seeking behaviour among Syrian refugees and the Lebanese population in Wadi Khaled, a rural area of Lebanon bordering Syria. Eight focus group discussions and eight key informant interviews were conducted with male and female Syrian refugees and Lebanese community members from March to April 2018. MH illness was associated with stigma, shame and fear among both populations. Beliefs surrounding mental illness were strongly linked to religious beliefs, including Jinn. Religious healers were considered the first line of help for people with mental illnesses, and were perceived as culturally acceptable and less stigmatizing than MH professionals. It is essential for MH professionals to build trust with the communities in which they work. Collaboration with religious healers is key to identifying MH symptoms and creating referral pathways to MH professionals in this context.

View more