• Between War and Peace: Humanitarian Assistance in Violent Urban Settings

      Lucchi, E; Médecins Sans Frontières, Spain (2010-06-07)
      Cities are fast becoming new territories of violence. The humanitarian consequences of many criminally violent urban settings are comparable to those of more traditional wars, yet despite the intensity of the needs, humanitarian aid to such settings is limited. The way in which humanitarian needs are typically defined, fails to address the problems of these contexts, the suffering they produce and the populations affected. Distinctions between formal armed conflicts, regulated by international humanitarian law, and other violent settings, as well as those between emergency and developmental assistance, can lead to the neglect of populations in distress. It can take a lot of time and effort to access vulnerable communities and implement programmes in urban settings, but experience shows that it is possible to provide humanitarian assistance with a significant focus on the direct and indirect health consequences of violence outside a traditional conflict setting. This paper considers the situation of Port-au-Prince (Haiti), Rio de Janeiro (Brazil) and Guatemala City (Guatemala).
    • Bleach sedimentation: an opportunity to optimize smear microscopy for tuberculosis diagnosis in settings of high prevalence of HIV

      Bonnet, M; Ramsay, A; Githui, W; Gagnidze, L; Varaine, F; Guerin, P J; Epicentre, Paris, France; Médecins Sans Frontières, Paris, France; Liverpool School of Tropical Medicine, Liverpool, United Kingdom; Centre for Respiratory Diseases Research, Kenya Medical Research Institute, Nairobi, Kenya (Infectious Diseases Society of America, 2008-06-01)
      BACKGROUND: The purpose of the study was to evaluate the performance and feasibility of tuberculosis diagnosis by sputum microscopy after bleach sedimentation, compared with by conventional direct smear microscopy, in a setting of high prevalence of HIV. METHODS: In a community-based study in Kenya (a population in which 50% of individuals with tuberculosis are infected with HIV), individuals with suspected pulmonary tuberculosis submitted 3 sputum specimens during 2 consecutive days, which were examined by blind evaluation. Ziehl-Neelsen-stained smears were made of fresh specimens and of specimens that were processed with 3.5% household bleach followed by overnight sedimentation. Two different cutoffs for acid-fast bacilli (AFB) per 100 high-power fields (HPF) were used to define a positive smear: >10 AFB/100 HPF and 1 AFB/100 HPF. Four smear-positive case definitions, based on 1 or 2 positive smears with the 1 AFB or 10 AFB cutoff, were used. RESULTS: Of 1879 specimens from 644 patients, 363 (19.3%) and 460 (24.5%) were positive by bleach sedimentation microscopy, compared with 301 (16.0%) and 374 (19.9%) by direct smear microscopy, with use of the 10 AFB/100 HPF (P < .001) and 1 AFB/100 HPF (P < .001) cutoffs, respectively. Regardless of the case definition used, bleach sedimentation microscopy detected significantly more positive cases than did direct smear microscopy: 26.7% (172 of 644) versus 21.7% (140 of 644), respectively, with the case definition of 1 positive smear and the 1 AFB/100 HPF cutoff (P < .001), and 21.4% (138 of 644) versus 18.6% (120 of 644), respectively, with the case definition of 1 positive smear and the 10 AFB/100 HPF cutoff (P < .001). Inter- and intrareader reproducibility were favorable, with kappa coefficients of 0.83 and 0.91, respectively. Bleach sedimentation was relatively inexpensive and was not time consuming. CONCLUSIONS: Bleach sedimentation microscopy is an effective, simple method to improve the yield of smear microscopy in a setting of high prevalence of HIV. Further evaluation of this method, under operational conditions, is urgently needed to determine its potential as a tool for tuberculosis control.
    • Effect of HIV-1 infection on T-Cell-based and skin test detection of tuberculosis infection

      Rangaka, M X; Wilkinson, K A; Seldon, R; Van Cutsem, G; Meintjes, G A; Morroni, C; Mouton, P; Diwakar, L; Connell, T G; Maartens, G; et al. (2007-12-07)
      RATIONALE: Two forms of the IFN-gamma release assay (IFNGRA) to detect tuberculosis infection are available, but neither has been evaluated in comparable HIV-infected and uninfected persons in a high tuberculosis incidence environment. OBJECTIVE: To compare the ability of the T-SPOT.TB (Oxford Immunotec, Abingdon, UK), QuantiFERON-TB Gold (Cellestis, Melbourne, Australia), and Mantoux tests to identify latent tuberculosis in HIV-infected and uninfected persons. METHODS: A cross-sectional study of 160 healthy adults without active tuberculosis attending a voluntary counseling and testing center for HIV infection in Khayelitsha, a deprived urban South African community with an HIV antenatal seroprevalence of 33% and a tuberculosis incidence of 1,612 per 100,000. MEASUREMENTS AND MAIN RESULTS: One hundred and sixty (74 HIV(+) and 86 HIV(-)) persons were enrolled. A lower proportion of Mantoux results was positive in HIV-infected subjects compared with HIV-uninfected subjects (p < 0.01). By contrast, the proportion of positive IFNGRAs was not significantly different in HIV-infected persons for the T-SPOT.TB test (52 vs. 59%; p = 0.41) or the QuantiFERON-TB Gold test (43 and 46%; p = 0.89). Fair agreement between the Mantoux test (5- and 10-mm cutoffs) and the IFNGRA was seen in HIV-infected people (kappa = 0.52-0.6). By contrast, poor agreement between the Mantoux and QuantiFERON-TB Gold tests was observed in the HIV-uninfected group (kappa = 0.07-0.30, depending on the Mantoux cutoff). The pattern was similar for T-SPOT.TB (kappa = 0.18-0.24). Interpretation: IFNGRA sensitivity appears relatively unimpaired by moderately advanced HIV infection. However, agreement between the tests and with the Mantoux test varied from poor to fair. This highlights the need for prospective studies to determine which test may predict the subsequent risk of tuberculosis.
    • Efficacy of chloroquine, sulfadoxine-pyrimethamine and amodiaquine for treatment of uncomplicated Plasmodium falciparum malaria among children under five in Bongor and Koumra, Chad.

      Grandesso, F; Bachy, C; Donam, I; Ntambi, J; Habimana, J; D'Alessandro, U; Maikere, J; Vanlerberghe, V; Kerah, C H; Guthmann, J P; et al. (Elsevier, 2006-05)
      We report two 28-day in-vivo antimalarial efficacy studies carried out in the urban centres of Bongor and Koumra, southern Chad. We assess chloroquine (CQ), sulfadoxine-pyrimethamine (SP) and amodiaquine (AQ) to treat Plasmodium falciparum uncomplicated malaria. Methods and outcome classification complied with latest WHO guidelines. Out of the 301 and 318 children aged 6-59 months included in Bongor and Koumra, respectively, 246 (81.7%) and 257 (80.8%) were eligible for analysis. In Bongor and Koumra, the 28-day PCR-adjusted failure rates for CQ were 23.7% (95% CI 14.7-34.8%) and 32.9% (95% CI 22.1-45.1%), respectively, and those for SP were 16.3% (95% CI 9.4-25.5%) and 4.3% (95% CI 1.2-10.5%). AQ failure rates were 6.4% (95% CI 2.1-14.3%) and 2.2% (95% CI 0.3-7.6%). The current use of CQ in Bongor and Koumra is questionable, and a more efficacious treatment is needed. Considering the reduced efficacy of SP in Bongor, AQ seems to be the best option for the time being. Following WHO recommendations that prioritize the use of artemisinin-based combinations, artesunate plus amodiaquine could be a potential first-line treatment. Nevertheless, the efficacy of this combination should be evaluated and the change carefully prepared, implemented and monitored.
    • Epidemiology of Cholera Outbreak in Kampala, Uganda.

      Legros, D; McCormick, M; Mugero, C; Skinnider, M; Bek'Obita, D D; Okware, S I; Epicentre, P.O. Box 2362, Kampala, Uganda. (2000-07)
      OBJECTIVE: To provide epidemiological description of the cholera outbreak which occurred in Kampala between December 1997 and March 1998. DESIGN: A four-month cross-sectional survey. SETTING: Kampala city, Uganda. MAIN OUTCOME MEASURES: Number of cases reported per day, attack rate per age group and per parish, case fatality ratio. RESULTS: The cholera outbreak was due to Vibrio cholerae O1 El Tor, serotype Ogawa. Between December 1997 and March 1998, 6228 cases of cholera were reported, of which 1091 (17.5%) were children under five years of age. The overall attack rate was 0.62%, similar in the under-fives and five and above age groups. The case fatality ratio among hospitalised patients was 2.5%. The peak of the outbreak was observed three weeks after the report of the first case, and by the end of January 1998 (less than two months after the first case), 88.4% of the cases had already been reported. The occurrence of cases concentrated in the slums where the overcrowding and the environmental conditions resembled a refugee camp situation. CONCLUSION: The explosive development of the cholera outbreak in Kampala, followed by a rapid decrease of the number of cases reported is unusual in a large urban setting. It appeared that each of the affected slums developed a distinct outbreak in a non immune population, which did not spread to contiguous areas. Therefore, we believe that, a decentralised strategy, that would focus the interventions on each heavily affected area, should be considered in these circumstances.
    • Factors associated with Condom Use Problems during Vaginal Sex with main and non-main partners

      DʼAnna, L H; Korosteleva, O; Warner, L; Douglas, J; Paul, S; Metcalf, C; McIlvaine, E; Malotte, C K; California State University, Long Beach, Center for Health Care Innovation, and Department of Math and Statistics, LongBeach, CA 90840, USA. laura.d’anna@csulb.edu (2012-09-01)
      Incorrect condom use is a common problem that can undermine their prevention impact. We assessed the prevalence of 2 condom use problems, breakage/slippage and partial use, compared problems by partnership type, and examined associations with respondent, partner, and partnership characteristics.
    • Heterogeneous decrease in malaria prevalence in children over a six-year period in south-western Uganda.

      De Beaudrap, Pierre; Nabasumba, Carolyn; Grandesso, Francesco; Turyakira, Eleanor; Schramm, Birgit; Boum, Yap; Etard, Jean-François; Epicentre Mbarara Research Base, Mbarara, Uganda. pierre.debeaudrap@epicentre.msf.org (2011-05-18)
      Malaria is a major public health problem, especially for children. However, recent reports suggest a decline in the malaria burden. The aim of this study was to assess the change in the prevalence of malaria infection among children below five years of age between 2004 and 2010 in a mesoendemic area of Uganda and to analyse the risk factors of malaria infection.
    • Localised transmission hotspots of a typhoid fever outbreak in the Democratic Republic of Congo

      Ali, E; Bergh, RVD; D'hondt, R; Kuma-Kuma, D; Weggheleire, AD; Baudot, Y; Lambert, V; Hunter, P; Zachariah, R; Maes, P (PAMJ-Center for Public Health Research and Information, 2017)
      In a semi-urban setting in the Democratic Republic of Congo, this study aims to understand the dynamic of a typhoid fever (TF) outbreak and to assess: a) the existence of hot spots for TF transmission and b) the difference between typhoid cases identified within those hot spots and the general population in relation to socio-demographic characteristics, sanitation practice, and sources of drinking water.
    • Measles epidemic in the urban community of Niamey: transmission patterns, vaccine efficacy and immunization strategies, Niger, 1990 to 1991.

      Malfait, P; Jataou, I M; Jollet, M C; Margot, A; De Benoist, A C; Moren, A; Epicentre, Paris, France. (1994-01)
      From October 1, 1990, until April 28, 1991, 13,578 cases of measles were reported in the urban community of Niamey, Niger. Vaccine coverages (one dose of Schwarz vaccine given after 9 months) in urban community of Niamey were, respectively, 63% at the age of 12 months and 73% at 24 months before the epidemic. Incidence rates were the highest among children ages 6 to 8 months and 9 to 11 months and 22% of the cases were less than 1 year old. Vaccine efficacy estimates ranged from 86 to 94% according to age groups and the method used (screening method, case control study, retrospective cohort study). The risk of transmission of illness increased with the intensity of contact with a case. Contact with a health facility 7 to 22 days before onset of rash was not a risk factor. Seasonal migrants in Niamey were more likely to develop measles. Recommendations included implementation of an early two dose schedule of measles immunization during the outbreak, vaccination offered at each contact with a health facility, radio and television advertising for measles immunization and distribution of vitamin A to all measles cases.
    • Measles hotspots and epidemiological connectivity

      Bharti, N; Djibo, A; Ferrari, M J; Grais, RF F; Tatem, A J; McCabe, C A; Bjornstad, O N; Grenfell, B T; Penn State University, Biology Department and Center for Infectious Disease Dynamics, University Park, PA, USA; Ministry of Health, Niamey, Niger; Epicentre, Paris, France; University of Florida, Emerging Pathogens Institute and Department of Geography, Gainesville, FL, USA; Penn State University, Department of Geography and GeoVISTA Center, University Park, PA, USA; Penn State University, Department of Entomology, University Park, PA, USA; Fogarty International Center, National Institutes of Health, Bethesda, MD, USA (2010-09-25)
      Though largely controlled in developed countries, measles remains a major global public health issue. Regional and local transmission patterns are rooted in human mixing behaviour across spatial scales. Identifying spatial interactions that contribute to recurring epidemics helps define and predict outbreak patterns. Using spatially explicit reported cases from measles outbreaks in Niger, we explored how regional variations in movement and contact patterns relate to patterns of measles incidence. Because we expected to see lower rates of re-introductions in small, compared to large, populations, we measured the population-size corrected proportion of weeks with zero cases across districts to understand relative rates of measles re-introductions. We found that critical elements of spatial disease dynamics in Niger are agricultural seasonality, transnational contact clusters, and roads networks that facilitate host movement and connectivity. These results highlight the need to understand local patterns of seasonality, demographic characteristics, and spatial heterogeneities to inform vaccination policy.
    • Moving from the 'Why' to the 'How': Reflections on Humanitarian Response in urban settings

      Lucchi, E; Médecins Sans Frontières, Operational Centre Barcelona-Athens, Barcelona, Spain. Elena.LUCCHI@barcelona.msf.org (2012-07-01)
      Given the rising numbers of crises in urban settings, Médecins Sans Frontières (MSF) is currently shifting its focus from 'why' it should intervene to 'how' it should intervene effectively in these contexts. Beyond communities affected by natural disasters and epidemics, MSF has chosen to target populations in urban settings that are affected by violence or by marginalisation and neglect: these groups appear to suffer the greatest number of severe threats to their health and well-being. Recent reflection within MSF has identified a number of key operational challenges to confront in order to respond efficiently to the needs of these populations. These include: appropriate assessments; measurable indicators of vulnerability and impact; pertinent operational approaches and medical strategies; adapted security management; and responsible closure of activities. This paper summarises the main lessons learned from working in urban settings with the principal aim of mutual sharing and understanding.
    • Physical and Sexual Violence, Mental Health indicators, and treatment seeking among street-based population groups in Tegucigalpa, Honduras

      Rio Navarro, J; Cohen, J; Rocillo Arechaga, E; Zuniga, E; Médecins Sans Frontières, México DF, México. javier.rio.navarro@geneva.msf.org (2012-05-01)
      To establish the prevalence of exposure to physical and sexual violence, mental health symptoms, and medical treatment-seeking behavior among three street-based subpopulation groups in Tegucigalpa, Honduras, and to assess the association between sociodemographic group, mental health indicators, and exposure to violence.
    • Reducing the Number of Sputum Samples Examined and Thresholds for Positivity: An Opportunity to Optimise Smear Microscopy.

      Bonnet, M; Ramsay, A; Gagnidze, L; Githui, W; Guerin, P J J; Varaine, F; Epicentre, Paris, France. maryline.bonnet@geneva.msf.org (International Union Against TB and Lung Disease, 2007-09)
      SETTING: Urban health clinic, Nairobi. OBJECTIVE: To evaluate the impact on tuberculosis (TB) case detection and laboratory workload of reducing the number of sputum smears examined and thresholds for diagnosing positive smears and positive cases. DESIGN: In this prospective study, three Ziehl-Neelsen stained sputum smears from consecutive pulmonary TB suspects were examined blind. The standard approach (A), > or = 2 positive smears out of 3, using a cut-off of 10 acid-fast bacilli (AFB)/100 high-power fields (HPF), was compared with approaches B, > or = 2 positive smears (> or = 4 AFB/100 HPF) out of 3, one of which is > or = 10 AFB/100 HPF; C, > or = 2 positive smears (> or = 4 AFB/100 HPF) out of 3; D, > or = 1 positive smear (> or = 10 AFB/100 HPF) out of 2; and E, > or = 1 positive smear (> or = 4 AFB/100 HPF) out of 2. The microscopy gold standard was detection of at least one positive smear (> or = 4 AFB/100 HPF) out of 3. RESULTS: Among 644 TB suspects, the alternative approaches detected from 114 (17.7%) (approach B) to 123 cases (19.1%) (approach E) compared to 105 cases (16.3%) for approach A (P < 0.005). Sensitivity ranged between 82.0% (105/128) for A and 96.1% (123/128) for E. The single positive smear approaches reduced the number of smears by 36% compared to approach A. CONCLUSION: Reducing the number of specimens and the positivity threshold to define a positive case increased the sensitivity of microscopy and reduced laboratory workload.
    • The role of community-based organizations in household ability to pay for health care in Kilifi District, Kenya

      Molyneux, Catherine; Hutchison, Beryl; Chuma, Jane; Gilson, Lucy; Kenya Medical Research Institute (KEMRI)/Wellcome Trust Collaborative Research Programme, Centre for Geographic Medicine Research, Kilifi, Kenya; Medecins Sans Frontieres, Amsterdam, The Netherlands; Centre for Health Policy, University of Witwatersrand, Johannesburg, South Africa; London School of Hygiene and Tropical Medicine, London, UK; (2007-11-01)
      There is growing concern that health policies and programmes may be contributing to disparities in health and wealth between and within households in low-income settings. However, there is disagreement concerning which combination of health and non-health sector interventions might best protect the poor. Potentially promising interventions include those that build on the social resources that have been found to be particularly critical for the poor in preventing and coping with illness costs. In this paper we present data on the role of one form of social resource--community-based organizations (CBOs)--in household ability to pay for health care on the Kenyan coast. Data were gathered from a rural and an urban setting using individual interviews (n = 24), focus group discussions (n = 18 in each setting) and cross-sectional surveys (n = 294 rural and n = 576 urban households). We describe the complex hierarchy of CBOs operating at the strategic, intermediate and local level in both settings, and comment on the potential of working through these organizations to reach and protect the poor. We highlight the challenges around several interventions that are of particular international interest at present: community-based health insurance schemes; micro-finance initiatives; and the removal of primary care user fees. We argue the importance of identifying and building upon organizations with a strong trust base in efforts to assist households to meet treatment costs, and emphasize the necessity of reducing the costs of services themselves for the poorest households.
    • [Surveillance of the Nutritional Status of the Population in Kinshasa, Zaire (1991-1994)]

      Arbyn, M; Dedeurwaerder, M; Miakala, M; Bikangi, N; Boelaert, M; Médecins sans Frontières, Brussels, Belgium. (1995-06)
      Six anthropometric surveys using a random cluster sampling design have been organised in the capital of Zaire between November 1991 and March 1994. The prevalence of acute malnutrition fluctuated with the seasons and followed the cyclic movements of food prices on the market. The general tendency was rising. In March '94, 10.7% (95% confidence interval: 8.8-12.9%) of the children was suffering of acute malnutrition. Nevertheless, the standardised prevalence remained stable. This may suggest that the most disadvantaged living at certain poor zones of the city disconnected, while the rest of the population could still manage to maintain their nutritional status. The hypothesis of increasing heterogeneity is supported by the raising of the design-effect.