• Dangerous Crossing: Demographic and Clinical Features of Rescued Sea Migrants Seen in 2014 at an Outpatient Clinic at Augusta Harbor, Italy

      Trovato, A; Reid, A; Takarinda, K C; Montaldo, C; Decroo, T; Owiti, P; Bongiorno, F; Di Carlo, S (BioMed Central, 2016-06-15)
      In recent years Europe has received an increasing influx of migrants, many of whom risked their lives crossing the Mediterranean Sea. In October 2013, Italy launched a search and rescue operation at sea in response to migrant deaths during the sea crossing. In August 2014, Médecins sans Frontières and the local Ministry of Health established an outpatient clinic at Augusta harbor, in Sicily, which received 26 % of total sea migrants arrived in Italy in 2014, to provide immediate medical assessment and care.
    • Data Sharing in a Humanitarian Organization: The Experience of Médecins Sans Frontières

      Karunakara, Unni (Public Library of Science, 2013-12-10)
      Open data and data sharing are essential for maximizing the benefits that can be obtained from institutional and research datasets [1]. In 2012, the medical humanitarian organization Me´decins Sans Frontieres (MSF) decided to adopt a data sharing policy for routinely collected clinical and research data (http://www.msf.org.uk/msf-data-sharing). Here we describe the policy’s principles, practicalities,and development process. We hope this paper will encourage and help other humanitarian and nongovernmental organizations to share their data with public health researchers for the benefit of the populations with which they work.
    • Death rates from malaria epidemics, Burundi and Ethiopia.

      Guthmann, J P; Bonnet, M; Ahoua, L; Dantoine, F; Balkan, S; Van Herp, M; Tamrat, A; Legros, D; Brown, V; Checchi, F; et al. (2007-01)
      Death rates exceeded emergency thresholds at 4 sites during epidemics of Plasmodium falciparum malaria in Burundi (2000-2001) and in Ethiopia (2003-2004). Deaths likely from malaria ranged from 1,000 to 8,900, depending on site, and accounted for 52% to 78% of total deaths. Earlier detection of malaria and better case management are needed.
    • Decentralisation of multidrug-resistant-tuberculosis care and management [letter]

      Cox, H; Ford, N; Médecins Sans Frontières, Cape Town, South Africa; Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa. (Elsevier, 2013-06-03)
    • Decline in national tuberculosis notifications with national scale-up of antiretroviral therapy in Malawi

      Kanyerere, H; Mganga, A; Harries, A D; Tayler-Smith, K; Jahn, A; Chimbwandira, F M; Mpunga, J (International Union Against Tuberculosis and Lung Disease, 2014-06-21)
    • Declining blood lead levels among small-scale miners participating in a safer mining pilot programme in Nigeria

      Gottesfeld, P; Meltzer, G; Costello, S; Greig, J; Thurtle, N; Bil, K; Mwangombe, BJ; Nota, MM (The BMJ, 2019-09-05)
      Objectives Our objective was to monitor blood lead levels (BLLs) of miners and ore processors participating in a pilot programme to reduce lead poisoning and take-home exposures from artisanal small-scale gold mining. A medical surveillance programme was established to assess exposures as new methods aimed at reducing lead exposures from ore were introduced in a community in Nigeria where children experienced substantial lead-related morbidity and mortality. Methods Extensive outreach and education were offered to miners, and investments were made to adopt wet methods to reduce exposures during mining and processing. We conducted medical surveillance, including a physical exam and repeated blood lead testing, for 61 miners selected from among several hundred who participated in the safer mining pilot programme and consented to testing. Venous blood lead concentrations were analysed using the LeadCare II device at approximately 3-month intervals over a period of 19 months. Results Overall geometric mean (GM) BLLs decreased by 32% from 31.6 to 21.5 µg/dL during the 19-month project. Women had a somewhat lower reduction in GM BLLs (23%) compared with men (36%). There was a statistically significant reduction in log BLLs from baseline to the final test taken by each participant (p<0.001). Conclusions The observed reductions in GM BLLs during the pilot intervention among this representative group of miners and ore processors demonstrated the effectiveness of the safer mining programme in this community. Such measures are feasible, cost-effective and can greatly improve health outcomes in mining communities.
    • Decontamination methods for samples preserved in cetylpyridinium chloride and cultured on thin-layer agar.

      Ardizzoni, E; Mulders, W; Sanchez-Padilla, E; Varaine, F; de Jong, B C; Rigouts, L (2014-08-01)
      Long transportation times of samples to culture laboratories can lead to higher contamination rates and significant loss of viability, resulting in lower culture positivity rates. Thin-layer agar (TLA) is a sensitive culture method for the isolation of Mycobacterium tuberculosis that has been optimised with N-acetyl-L-cysteine-sodium hydroxide (NALC-NaOH) decontaminated samples. The combination of the TLA culture method and other decontamination procedures has not been extensively validated.
    • Decreased peripheral health service utilisation during an outbreak of Marburg haemorrhagic fever, Uíge, Angola, 2005.

      Roddy, P; Marchiol, A; Jeffs, B; Palma, P P; Bernal, O; de la Rosa, O; Borchert, M; Médecins Sans Frontières-Spain, Barcelona, Spain. (2008-10-04)
      In 2005, a Marburg haemorrhagic fever (MHF) outbreak occurred in Uíge province, Angola, which had its epicentre in Uíge municipality. Concurrently, a health facility located a considerable distance from the outbreak's epicentre reported a drastic reduction in attendance, possibly due to a remote effect of the ongoing MHF outbreak. Health officials should devise strategies to ensure that communities far from a filovirus haemorrhagic fever epicentre are not adversely affected by interventions at the epicentre and, to the greatest extent possible, ensure that these peripheral communities receive essential medical care during an epidemic.
    • Decreased risk of HIV-associated TB during antiretroviral therapy expansion in rural Eswatini from 2009 to 2016: a cohort and population-based analysis

      Kerschberger, B; Schomaker, M; Telnov, A; Vambe, D; Kisyeri, N; Sikhondze, W; Pasipamire, L; Ngwenya, SM; Rusch, B; Ciglenecki, I; et al. (John Wiley & Sons, 2019-07-16)
      This paper assesses patient- and population-level trends in TB notifications during rapid expansion of antiretroviral therapy in Eswatini which has an extremely high incidence of both TB and HIV. METHODS: Patient- and population-level predictors and rates of HIV-associated TB were examined in the Shiselweni region in Eswatini from 2009 to 2016. Annual population-level denominators obtained from projected census data and prevalence estimates obtained from population-based surveys were combined with individual-level TB treatment data. Patient- and population-level predictors of HIV-associated TB were assessed with multivariate logistic and multivariate negative binomial regression models. RESULTS: Of 11 328 TB cases, 71.4% were HIV co-infected and 51.8% were women. TB notifications decreased fivefold between 2009 and 2016, from 1341 to 269 cases per 100 000 person-years. The decline was sixfold in PLHIV vs. threefold in the HIV-negative population. Main patient-level predictors of HIV-associated TB were recurrent TB treatment (adjusted odds ratio [aOR] 1.40, 95% confidence interval [CI]: 1.19-1.65), negative (aOR 1.31, 1.15-1.49) and missing (aOR 1.30, 1.11-1.53) bacteriological status and diagnosis at secondary healthcare level (aOR 1.18, 1.06-1.33). Compared with 2009, the probability of TB decreased for all years from 2011 (aOR 0.69, 0.58-0.83) to 2016 (aOR 0.54, 0.43-0.69). The most pronounced population-level predictor of TB was HIV-positive status (adjusted incidence risk ratio 19.47, 14.89-25.46). CONCLUSIONS: This high HIV-TB prevalence setting experienced a rapid decline in TB notifications, most pronounced in PLHIV. Achievements in HIV-TB programming were likely contributing factors.
    • Deep Sequencing of RNA from Blood and Oral Swab Samples Reveals the Presence of Nucleic Acid from a Number of Pathogens in Patients with Acute Ebola Virus Disease and Is Consistent with Bacterial Translocation across the Gut

      Carroll, M; Haldenby, S; Rickett, N; Pályi, B; Garcia-Dorival, I; Liu, X; Barker, G; Bore, J; Koundouno, F; Williamson, E; et al. (American Society for Microbiology, 2017-08-23)
      In this study, samples from the 2013-2016 West African Ebola virus outbreak from patients in Guinea with Ebola virus disease (EVD) were analyzed to discover and classify what other pathogens were present. Throat swabs were taken from deceased EVD patients, and peripheral blood samples were analyzed that had been taken from patients when they presented at the treatment center with acute illness. High-throughput RNA sequencing (RNA-seq) and bioinformatics were used to identify the potential microorganisms. This approach confirmed Ebola virus (EBOV) in all samples from patients diagnosed as acute positive for the virus by quantitative reverse transcription-PCR in deployed field laboratories. Nucleic acid mapping to Plasmodium was also used on the patient samples, confirming results obtained with an antigen-based rapid diagnostic test (RDT) conducted in the field laboratories. The data suggested that a high Plasmodium load, as determined by sequence read depth, was associated with mortality and influenced the host response, whereas a lower parasite load did not appear to affect outcome. The identifications of selected bacteria from throat swabs via RNA-seq were confirmed by culture. The data indicated that the potential pathogens identified in the blood samples were associated with translocation from the gut, suggesting the presence of bacteremia, which transcriptome data suggested may induce or aggravate the acute-phase response observed during EVD. Transcripts mapping to different viruses were also identified, including those indicative of lytic infections. The development of high-resolution analysis of samples from patients with EVD will help inform care pathways and the most appropriate general antimicrobial therapy to be used in a resource-poor setting. IMPORTANCE Our results highlight the identification of an array of pathogens in the blood of patients with Ebola virus disease (EVD). This has not been done before, and the data have important implications for the treatment of patients with EVD, particularly considering antibiotic stewardship. We show that EVD patients who were also infected with Plasmodium, particularly at higher loads, had more adverse outcomes than patients with lower levels of Plasmodium. However, the presence of Plasmodium did not influence the innate immune response, and it is likely that the presence of EBOV dominated this response. Several viruses other than EBOV were identified, and bacteria associated with sepsis were also identified. These findings were indicative of bacterial translocation across the gut during the acute phase of EVD.
    • Defective Interfering Genomes and Ebola Virus Persistence

      Calain, P; Roux, L; Kolakofsky, D (Elsevier, 2016-08-13)
    • Defining priority medical devices for cancer management: a WHO initiative

      Velazquez Berumen, A; Jimenez Moyao, G; Rodriguez, NM; Ilbawi, AM; Migliore, A; Shulman, LN (The Lancet, 2018-12)
    • Defining the Needs for Next Generation Assays for Tuberculosis

      Denkinger, C M; Kik, S V; Cirillo, D M; Casenghi, M; Shinnick, T; Weyer, K; Gilpin, C; Boehme, C C; Schito, M; Kimerling, M; et al. (Oxford University Press, 2015-04-01)
      To accelerate the fight against tuberculosis, major diagnostic challenges need to be addressed urgently. Post-2015 targets are unlikely to be met without the use of novel diagnostics that are more accurate and can be used closer to where patients first seek care in affordable diagnostic algorithms. This article describes the efforts by the stakeholder community that led to the identification of the high-priority diagnostic needs in tuberculosis. Subsequently target product profiles for the high-priority diagnostic needs were developed and reviewed in a World Health Organization (WHO)-led consensus meeting. The high-priority diagnostic needs included (1) a sputum-based replacement test for smear-microscopy; (2) a non-sputum-based biomarker test for all forms of tuberculosis, ideally suitable for use at levels below microscopy centers; (3) a simple, low cost triage test for use by first-contact care providers as a rule-out test, ideally suitable for use by community health workers; and (4) a rapid drug susceptibility test for use at the microscopy center level. The developed target product profiles, along with complimentary work presented in this supplement, will help to facilitate the interaction between the tuberculosis community and the diagnostics industry with the goal to lead the way toward the post-2015 global tuberculosis targets.
    • Delamanid for rifampicin-resistant tuberculosis: a retrospective study from South Africa.

      Mohr, E; Hughes, J; Reuter, A; Trivino Duran, L; Ferlazzo, G; Daniels, J; De Azevedo, V; Kock, Y; Steele, SJ; Shroufi, A; et al. (European Respiratory Society, 2018-06-14)
      Experience with delamanid (Dlm) is limited, particularly among HIV-positive individuals. We describe early efficacy and safety data from a programmatic setting in South Africa. This was a retrospective cohort study of patients receiving Dlm-containing treatment regimens between November 2015 and August 2017. We report 12-month interim outcomes, sputum culture conversion (SCC) by months 2 and 6, serious adverse events (SAEs) and QT intervals corrected using the Frederica formula (QTcF). Overall, 103 patients were initiated on Dlm; 79 (77%) were HIV positive. The main indication for Dlm was intolerance to second-line anti-tuberculosis (TB) drugs (n=58, 56%). There were 12 months of follow-up for 46 patients; 28 (61%) had a favourable outcome (cure, treatment completion or culture negativity). Positive cultures were found for 57 patients at Dlm initiation; 16 out of 31 (52%) had SCC within 2 months and 25 out of 31 (81%) within 6 months. There were 67 SAEs reported in 29 patients (28%). There were four instances of QTcF prolongation >500 ms in two patients (2%), leading to permanent discontinuation in one case; however, no cardiac arrhythmias occurred. This large cohort of difficult-to-treat patients receiving Dlm for rifampicin-resistant TB treatment in a programmatic setting with high HIV prevalence had favourable early treatment response and tolerated treatment well. Dlm should remain available, particularly for those who cannot be treated with conventional regimens or with limited treatment options.
    • Delayed access to emergency obstetrical care among preeclamptic and non-preeclamptic women in Port-Au-Prince, Haiti

      Hutchinson, K; Bryant, M; Bachman DeSilva, M; Price, D; Sabin, L; Bryson, L; Jean Charles, R; Declercq, E (BMC, 2018-08-20)
      The primary objective of this comparative, cross-sectional study was to identify factors affecting delays in accessing emergency obstetric care and clinical consequences of delays among preeclamptic and non-preeclamptic women in Port-au-Prince, Haiti.
    • Delayed second dose of oral cholera vaccine administered before high-risk period for cholera transmission: Cholera control strategy in Lusaka, 2016.

      Ferreras, E; Matapo, B; Chizema-Kawesha, E; Chewe, O; Mzyece, H; Blake, A; Moonde, L; Zulu, G; Poncin, M; Sinyange, N; et al. (The Public Library of Science, 2019-08-30)
      BACKGROUND: In April 2016, an emergency vaccination campaign using one dose of Oral Cholera Vaccine (OCV) was organized in response to a cholera outbreak that started in Lusaka in February 2016. In December 2016, a second round of vaccination was conducted, with the objective of increasing the duration of protection, before the high-risk period for cholera transmission. We assessed vaccination coverage for the first and second rounds of the OCV campaign. METHODS: Vaccination coverage was estimated after each round from a sample selected from targeted-areas for vaccination using a cross-sectional survey in to establish the vaccination status of the individuals recruited. The study population included all individuals older than 12 months residing in the areas targeted for vaccination. We interviewed 505 randomly selected individuals after the first round and 442 after the second round. Vaccination status was ascertained either by vaccination card or verbal reporting. Households were selected using spatial random sampling. RESULTS: The vaccination coverage with two doses was 58.1% (25/43; 95%CI: 42.1-72.9) in children 1-5 years old, 59.5% (69/116; 95%CI: 49.9-68.5) in children 5-15 years old and 19.9% (56/281; 95%CI: 15.4-25.1) in adults above 15 years old. The overall dropout rate was 10.9% (95%CI: 8.1-14.1). Overall, 69.9% (n = 309/442; 95%CI: 65.4-74.1) reported to have received at least one OCV dose. CONCLUSIONS: The areas at highest risk of suffering cholera outbreaks were targeted for vaccination obtaining relatively high vaccine coverage after each round. However, the long delay between doses in areas subject to considerable population movement resulted in many individuals receiving only one OCV dose. Additional vaccination campaigns may be required to sustain protection over time in case of persistence of risk. Further evidence is needed to establish a maximum optimal interval time of a delayed second dose and variations in different settings.
    • Delays in arrival and treatment in emergency departments: Women, children and non-trauma consultations the most at risk in humanitarian settings

      Guzman, IB; Cuesta, JG; Trelles, M; Jaweed, O; Cherestal, S; van Loenhout, JAF; Guha-Sapir, D (Public Library of Science, 2019-03-05)
      Introduction Delays in arrival and treatment at health facilities lead to negative health outcomes. Individual and external factors could be associated with these delays. This study aimed to assess common factors associated with arrival and treatment delays in the emergency departments (ED) of three hospitals in humanitarian settings. Methodology This was a cross-sectional study based on routine data collected from three MSF-supported hospitals in Afghanistan, Haiti and Sierra Leone. We calculated the proportion of consultations with delay in arrival (>24 hours) and in treatment (based on target time according to triage categories). We used a multinomial logistic regression model (MLR) to analyse the association between age, sex, hospital and diagnosis (trauma and non-trauma) with these delays. Results We included 95,025 consultations. Males represented 65.2%, Delay in arrival was present in 27.8% of cases and delay in treatment in 27.2%. The MLR showed higher risk of delay in arrival for females (OR 1.2, 95% CI 1.2–1.3), children <5 (OR 1.4, 95% CI 1.4–1.5), patients attending to Gondama (OR 30.0, 95% CI 25.6–35.3) and non-trauma cases (OR 4.7, 95% CI 4.4–4.8). A higher risk of delay in treatment was observed for females (OR 1.1, 95% CI 1.0–1.1), children <5 (OR 2.0, 95% CI 1.9–2.1), patients attending to Martissant (OR 14.6, 95% CI 13.9–15.4) and non-trauma cases (OR 1.6, 95% CI 1.5–1.7). Conclusions Women, children <5 and non-trauma cases suffered most from delays. These delays could relate to educational and cultural barriers, and severity perception of the disease. Treatment delay could be due to insufficient resources with consequent overcrowding, and severity perception from medical staff for non-trauma patients. Extended community outreach, health promotion and support to community health workers could improve emergency care in humanitarian settings.
    • Delivering a primary-level non-communicable disease programme for Syrian refugees and the host population in Jordan: a descriptive costing study

      Ansbro, E; Garry, S; Karir, V; Reddy, A; Jobanputra, K; Fardous, T; Sadique, Z (Oxford University Press, 2020-07-04)
      The Syrian conflict has caused enormous displacement of a population with a high non-communicable disease (NCD) burden into surrounding countries, overwhelming health systems’ NCD care capacity. Médecins sans Frontières (MSF) developed a primary-level NCD programme, serving Syrian refugees and the host population in Irbid, Jordan, to assist the response. Cost data, which are currently lacking, may support programme adaptation and system scale up of such NCD services. This descriptive costing study from the provider perspective explored financial costs of the MSF NCD programme. We estimated annual total, per patient and per consultation costs for 2015–17 using a combined ingredients-based and step-down allocation approach. Data were collected via programme budgets, facility records, direct observation and informal interviews. Scenario analyses explored the impact of varying procurement processes, consultation frequency and task sharing. Total annual programme cost ranged from 4 to 6 million International Dollars (INT$), increasing annually from INT$4 206 481 (2015) to INT$6 739 438 (2017), with costs driven mainly by human resources and drugs. Per patient per year cost increased 23% from INT$1424 (2015) to 1751 (2016), and by 9% to 1904 (2017), while cost per consultation increased from INT$209 to 253 (2015–17). Annual cost increases reflected growing patient load and increasing service complexity throughout 2015–17. A scenario importing all medications cut total costs by 31%, while negotiating importation of high-cost items offered 13% savings. Leveraging pooled procurement for local purchasing could save 20%. Staff costs were more sensitive to reducing clinical review frequency than to task sharing review to nurses. Over 1000 extra patients could be enrolled without additional staffing cost if care delivery was restructured. Total costs significantly exceeded costs reported for NCD care in low-income humanitarian contexts. Efficiencies gained by revising procurement and/or restructuring consultation models could confer cost savings or facilitate cohort expansion. Cost effectiveness studies of adapted models are recommended.
    • Delivering HIV Care in Challenging Operating Environments: The MSF Experience Towards Differentiated Models of Care for Settings with Multiple Basic Health Care Needs

      Ssonko, C; Gonzalez, L; Mesic, A; da Fonseca, M; Achar, J; Safar, N; Martin, B; Wong, S; Casas, E (International AIDS Society, 2017-07-21)
      Introduction: Countries in the West and Central African regions struggle to offer quality HIV care at scale, despite HIV prevalence being relatively low. In these challenging operating environments, basic health care needs are multiple, systems are highly fragile and conflict disrupts health care. Médecins Sans Frontières (MSF) has been working to integrate HIV care in basic health services in such settings since 2000. We review the implementation of differentiated HIV care and treatment approaches in MSF-supported programmes in South Sudan (RoSS), Central African Republic (CAR) and Democratic Republic of Congo (DRC). Methods: A descriptive analysis from CAR, DRC and RoSS programmes reviewing methodology and strategies of HIV care integration between 2010 and 2015 was performed. We describe HIV care models integrated within the provision of general health care and highlight best practices and challenges. Results: Services included provision of general health care, with out-patient care (range between countries 43,343 and 287,163 consultations/year in 2015) and in-patient care (range 1076–16,595 in 2015). By the end of 2015 antiretroviral therapy (ART) initiations reached 12–255 patients/year. A total of 1101 and 1053 patients were on ART in CAR and DRC, respectively. In RoSS 186 patients were on ART when conflict recommenced late in 2013. While ART initiation and monitoring were mostly clinically driven in the early phase of the programmes, DRC implemented CD4 monitoring and progressively HIV viral load (VL) monitoring during study period. Attacks to health care facilities in CAR and RoSS disrupted service provision temporarily. Programmatic challenges include: competing health priorities influencing HIV care and need to integrate within general health services. Differentiated care approaches that support continuity of care in these programmes include simplification of medical protocols, multi-month ART prescriptions, and community strategies such as ART delivery groups, contingency plans and peer support activities. Conclusions: The principles of differentiated HIV care for high-quality ART delivery can successfully be applied in challenging operating environments. However, success heavily depends on specific adaptations to each setting.