• Vaccination Against Cholera in Juba - Authors' Reply

      Ciglenecki, I; Azman, AS; Rumunu, J; Cabrol, JC; Luquero, FJ (Elsevier, 2017-05-01)
    • Vaccination in emergencies.

      Paquet, C; Epicentre and Médecins Sans Frontières, 8 rue Saint Sabin, 75011, Paris, France. cpaquet@epicentre.msf.org (1999-10-29)
      Nongovernmental organisations (NGOs) are the main actors of vaccine delivery during complex humanitarian emergencies such as large population displacements. This paper discusses the use of vaccinations against measles, cholera and meningitis in this context. The role of NGOs in the advocacy for making new and more effective vaccines available to the most vulnerable populations is also emphasised.
    • Vaccination in humanitarian crises: satisficing should no longer suffice

      Grais, R; Juan-Giner, A (Oxford University Press, 2014-08-04)
      There are more possible vaccination interventions to mitigate the adverse health consequences of populations in crises than ever before, but recent reviews suggest delivering these vaccines has been fraught with difficulty. The decision to implement vaccination interventions in crises remains, more often than not, an exercise in satisficing. The sparse credible epidemiologic and effectiveness data in populations affected by crises contributes greatly to decision-making difficulty, as do the limits of vaccine presentations, formulations and storage. Political considerations and lack of decision-making guidance contribute further. Moving forward requires sound effectiveness studies to help ensure that decision-making is based to the degree possible on substance.
    • Vaccine testing. Ebola and beyond

      Lipsitch, Marc; Eyal, Nir; Halloran, M Elizabeth; Hernán, Miguel A; Longini, Ira M; Perencevich, Eli N; Grais, Rebecca F (High Wire Press, 2015-04-03)
    • Validation of mental health screening instruments in the Kashmir Valley, India

      Housen, T; Lenglet, A; Ariti, C; Ara, S; Shah, S; Dar, M; Hussain, A; Paul, A; Wagay, Z; Viney, K; et al. (SAGE Publications, 2018-03-19)
      The present study aimed to culturally adapt, translate, and validate the Hopkins Symptom Checklist-25 (HSCL-25) and the Harvard Trauma Questionnaire-Posttraumatic Stress Symptoms Checklist (HTQ-16) prior to use in a cross-sectional mental health population survey in the Kashmir Valley. Cultural adaptation and translation of the HSCL-25 and the HTQ-16 employed multiple forms of transcultural validity check. The HSCL-25 and HTQ-16 were compared against a "gold standard" structured psychiatric interview, the Mini International Neuropsychiatric Interview (MINI). Interviews were conducted with 290 respondents recruited using consecutive sampling from general medical outpatient departments in five districts of the Kashmir Valley. Receiver operating characteristics (ROC) analysis was used to estimate the cut point with optimal discriminatory power based on sensitivity and specificity. Internal reliability of the HSCL-25 was high, Cronbach's alpha (α) = .92, intraclass correlation coefficient (ICC) = 0.75, with an estimated optimal cut point of 1.50, lower than the conventional cut point of 1.75. Separation of the instruments into subscales demonstrated a difference in the estimated cut point for the anxiety subscale and the depression subscale, 1.75 and 1.57, respectively. Too few respondents were diagnosed with posttraumatic stress disorder (PTSD) during structured psychiatric interview, and therefore the HTQ-16 could not be validated despite the fact that high internal reliability was demonstrated (α = .90). This study verified the importance of culturally adapting and validating screening instruments in particular contexts. The use of the conventional cut point of 1.75 would likely have misclassified depression in our survey, leading to an underestimate of this condition.
    • Validation of Two Rapid Diagnostic Tests for Visceral Leishmaniasis in Kenya

      Mbui, Jane; Wasunna, Monique; Balasegaram, Manica; Laussermayer, Adrian; Juma, Rashid; Njenga, Simon Njoroge; Kirigi, George; Riongoita, Mark; de la Tour, Roberto; van Peteghem, Joke; et al. (Public Library of Science, 2013-09-26)
    • Validity, reliability and ease of use in the field of five rapid tests for the diagnosis of Plasmodium falciparum malaria in Uganda.

      Guthmann, J P; Ruiz, A; Priotto, G; Kiguli, J; Bonte, L; Legros, D; Epicentre, 4 rue Saint Sabin, 75011 Paris, France. jguthmann@epicentre.msf.org (Elsevier, 2008-02-14)
      A study was conducted to measure the overall performance of several rapid diagnostic tests for Plasmodium falciparum infection, in order to select the most appropriate test to be used in the field. A total of 742 patients attending the out-patient department of Mbarara Hospital with a clinical suspicion of malaria were included in the study. For each patient, a thick/thin film and 5 rapid tests based on the detection of histidine-rich protein II (HRP-II) (Paracheck Pf dipstick and device, ParaHIT f, Malaria Rapid and BIO P.F.) were performed. Outcomes were validity, inter-reader reliability and 'ease of use in the field', measured by both the general characteristics of the test and by the opinion of the readers. About half (57%) of the patients were positive for P. falciparum. The Paracheck Pf (dipstick and device) was considered as the most appropriate for the use in the field, being sensitive (97%), moderately specific (88%), reliable (kappa coefficient = 0.97), easy to use and cheap (about US$ 0.5/test). The ParaHIT f represented a good alternative.
    • The value of and challenges for cholera vaccines in Africa.

      von Seidlein, L; Jiddawi, M; Grais, R; Luquero, F J; Lucas, M; Deen, J; Menzies School of Health Research, Casuarina, Australia. (2013-11)
      The 21st century saw a shift in the cholera burden from Asia to Africa. The risk factors for cholera outbreaks in Africa are incompletely understood, and the traditional emphasis on providing safe drinking water and improving sanitation and hygiene has proven remarkably insufficient to contain outbreaks. Current killed whole-cell oral cholera vaccines (OCVs) are safe and guarantee a high level of protection for several years. OCVs have been licensed for >20 years, but their potential for preventing and control cholera outbreaks in Africa has not been realized. Although each item in the long list of technical reasons why cholera vaccination campaigns have been deferred is plausible, we believe that the biggest barrier is that populations affected by cholera outbreaks are underprivileged and lack a strong political voice. The evaluation and use of OCVs as a tool for cholera control will require a new, more compassionate, less risk-averse generation of decision makers.
    • Variability of Growth in Children Starting Antiretroviral Treatment in Southern Africa

      Gsponer, Thomas; Weigel, Ralf; Davies, Mary-Ann; Bolton, Carolyn; Moultrie, Harry; Vaz, Paula; Rabie, Helena; Technau, Karl; Ndirangu, James; Eley, Brian; et al. (American Academy of Pediatrics, 2012-10)
      Poor growth is an indication for antiretroviral therapy (ART) and a criterion for treatment failure. We examined variability in growth response to ART in 12 programs in Malawi, Zambia, Zimbabwe, Mozambique, and South Africa.
    • Variation in Specificity of HIV Rapid Diagnostic Tests over Place and Time: An Analysis of Discordancy Data Using a Bayesian Approach

      Klarkowski, Derryck; Glass, Kathryn; O'Brien, Daniel; Lokuge, Kamalini; Piriou, Erwan; Shanks, Leslie; Médecins sans Frontières, Operational Centre Amsterdam, Amsterdam, The Netherlands (Public Library of Science, 2013-11)
      Recent trends to earlier access to anti-retroviral treatment underline the importance of accurate HIV diagnosis. The WHO HIV testing strategy recommends the use of two or three rapid diagnostic tests (RDTs) combined in an algorithm and assume a population is serologically stable over time. Yet RDTs are prone to cross reactivity which can lead to false positive or discordant results. This paper uses discordancy data from Médecins Sans Frontières (MSF) programmes to test the hypothesis that the specificity of RDTs change over place and time.
    • Varying efficacy of artesunate+amodiaquine and artesunate+sulphadoxine-pyrimethamine for the treatment of uncomplicated falciparum malaria in the Democratic Republic of Congo: a report of two in-vivo studies

      Bonnet, Maryline; Broek, Ingrid van den; van Herp, Michel; Urrutia, Pedro Pablo Palma; van Overmeir, Chantal; Kyomuhendo, Juliet; Ndosimao, Célestin Nsibu; Ashley, Elizabeth; Guthmann, Jean-Paul; Epicentre, Geneva, Switzerland; Epicentre, Paris, France; Center for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands; Médecins Sans Frontières, Brussels, Belgium; Médecins Sans Frontières, Barcelona, Spain; Prince Leopold Institute of Tropical Medicine, Department of Parasitology, Antwerp, Belgium; Mbarara University of Science and Technology, Mbarara, Uganda; National Malaria Control Programme, Kinshasa, Democratic Republic of Congo; Unité des Maladies à Prévention Vaccinale, Département des Maladies Infectieuses, Institut de Veille Sanitaire, Saint-Maurice cedex, France (2009-10-08)
      BACKGROUND: Very few data on anti-malarial efficacy are available from the Democratic Republic of Congo (DRC). DRC changed its anti-malarial treatment policy to amodiaquine (AQ) and artesunate (AS) in 2005. METHODS: The results of two in vivo efficacy studies, which tested AQ and sulphadoxine-pyrimethamine (SP) monotherapies and AS+SP and AS+AQ combinations in Boende (Equatorial province), and AS+SP, AS+AQ and SP in Kabalo (Katanga province), between 2003 and 2004 are presented. The methodology followed the WHO 2003 protocol for assessing the efficacy of anti-malarials in areas of high transmission. RESULTS: Out of 394 included patients in Boende, the failure rates on day 28 after PCR-genotyping adjustment of AS+SP and AS+AQ were estimated as 24.6% [95% CI: 16.6-35.5] and 15.1% [95% CI: 8.6-25.7], respectively. For the monotherapies, failure rates were 35.9% [95% CI: 27.0-46.7] for SP and 18.3% [95% CI: 11.6-28.1] for AQ. Out of 207 patients enrolled in Kabalo, the failure rate on day 28 after PCR-genotyping adjustment was 0 [1-sided 95% CI: 5.8] for AS+SP and AS+AQ [1-sided 95% CI: 6.2]. It was 19.6% [95% CI: 11.4-32.7] for SP monotherapy. CONCLUSION: The finding of varying efficacy of the same combinations at two sites in one country highlights one difficulty of implementing a uniform national treatment policy in a large country. The poor efficacy of AS+AQ in Boende should alert the national programme to foci of resistance and emphasizes the need for systems for the prospective monitoring of treatment efficacy at sentinel sites in the country.
    • Vector control in a malaria epidemic occurring within a complex emergency situation in Burundi: a case study.

      Protopopoff, N; Van Herp, M; Maes, P; Reid, T; Baza, D; D'Alessandro, U; Van Bortel, W; Coosemans, M; Department of Parasitology, Prince Leopold Institute of Tropical Medicine, Antwerp, Belgium. nprotopopoff@itg.be (BMC, 2007)
      BACKGROUND: African highlands often suffer of devastating malaria epidemics, sometimes in conjunction with complex emergencies, making their control even more difficult. In 2000, Burundian highlands experienced a large malaria outbreak at a time of civil unrest, constant insecurity and nutritional emergency. Because of suspected high resistance to the first and second line treatments, the provincial health authority and Médecins Sans Frontières (Belgium) decided to implement vector control activities in an attempt to curtail the epidemic. There are few reported interventions of this type to control malaria epidemics in complex emergency contexts. Here, decisions and actions taken to control this epidemic, their impact and the lessons learned from this experience are reported. CASE DESCRIPTION: Twenty nine hills (administrative areas) were selected in collaboration with the provincial health authorities for the vector control interventions combining indoor residual spraying with deltamethrin and insecticide-treated nets. Impact was evaluated by entomological and parasitological surveys. Almost all houses (99%) were sprayed and nets use varied between 48% and 63%. Anopheles indoor resting density was significantly lower in treated as compared to untreated hills, the latter taken as controls. Despite this impact on the vector, malaria prevalence was not significantly lower in treated hills except for people sleeping under a net. DISCUSSION: Indoor spraying was feasible and resulted in high coverage despite being a logistically complex intervention in the Burundian context (scattered houses and emergency situation). However, it had little impact on the prevalence of malaria infection, possibly because it was implemented after the epidemic's peak. Nevertheless, after this outbreak the Ministry of Health improved the surveillance system, changed its policy with introduction of effective drugs and implementation of vector control to prevent new malaria epidemics. CONCLUSION: In the absence of effective drugs and sufficient preparedness, present study failed to demonstrate any impact of vector control activities upon the course of a short-duration malaria epidemic. However, the experience gained lead to increased preparedness and demonstrated the feasibility of vector control measures in this specific context.
    • Very early anthropometric changes after antiretroviral therapy predict subsequent survival, in karonga, Malawi.

      Maman, David; Glynn, Judith R; Crampin, Amelia C; Kranzer, Katharina; Saul, Jacqueline; Jahn, Andreas; Mwinuka, Venance; Ngwira, Msenga Hc; Mvula, Hazzie; Munthali, Fipson; et al. (2012-06)
      Antiretroviral (ART) scale-up in Malawi has been achieved on a large scale based mainly on clinical criteria. Simple markers of prognosis are useful, and we investigated the value of very early anthropometric changes in predicting mortality.
    • Very early mortality in patients starting antiretroviral treatment at primary health centres in rural Malawi.

      Zachariah, Rony; Harries, Katie; Moses, Massaquoi; Manzi, Marcel; Line, Arnould; Mwagomba, Beatrice; Harries, Anthony D; Medecins Sans Frontieres, Medical Department, Brussels, Belgium. zachariah@internet.lu (2009-07-15)
      OBJECTIVES: To report on the cumulative proportion of deaths occurring within 3 months of starting antiretroviral treatment (ART) and to identify factors associated with such deaths, among adults at primary health centres in a rural district of Malawi. METHODS: Retrospective cohort study: from June 2006 to April 2008, deaths occurring over a 3-month period were determined and risk factors examined. RESULTS: A total of 2316 adults (706 men and 1610 women; median age 35 years) were included in the analysis and followed up for a total of 1588 person-years (PY); 277 (12%) people died, of whom 206 (74%) people died within 3 months of initiating ART (cumulative incidence: 13.0; 95% confidence interval: 11.3-14.8 per 100 PY of follow-up). Significant risk factors associated with early deaths included male sex, WHO stage 4 disease, oesophageal or persistent oral candidiasis and unexplained presumed or measured weight loss >10%. One in every 3 patients who either died or was lost to follow up had unexplained weight loss >10%, and survival in this group was significantly different from patients without this condition. CONCLUSIONS: Seven in 10 individuals initiating ART at primary health centres die early. Specific groups of patients are at higher risk of such mortality and should receive priority attention, care and support.
    • Vibrio cholerae O1 variant with reduced susceptibility to ciprofloxacin, Western Africa [letter]

      Quilici, Marie Laure; Massenet, Denis; Gake, Bouba; Bwalki, Barem; Olson, David M; Institut Pasteur, Paris, France; Centre Pasteur Cameroun, Garoua, Cameroon; State Epidemiologic Unit, Yola, Adamawa State, Nigeria; Doctors Without Borders/Médecins Sans Frontières, New York, New York (2010-10-22)
    • Viewpoint: filovirus haemorrhagic fever outbreaks: much ado about nothing?

      Borchert, M; Boelaert, M; Sleurs, H; Muyembe-Tamfum, J J; Pirard, P; Colebunders, R; Van der Stuyft, P; van der Groen, G; Institute of Tropical Medicine, Antwerp, Belgium. mborchert@itg.be (2000-05)
      The recent outbreak of Marburg haemorrhagic fever in the Democratic Republic of Congo has put the filovirus threat back on the international health agenda. This paper gives an overview of Marburg and Ebola outbreaks so far observed and puts them in a public health perspective. Damage on the local level has been devastating at times, but was marginal on the international level despite the considerable media attention these outbreaks received. The potential hazard of outbreaks, however, after export of filovirus from its natural environment into metropolitan areas, is argued to be considerable. Some avenues for future research and intervention are explored. Beyond the obvious need to find the reservoir and study the natural history, public health strategies for a more timely and efficient response are urgently needed.
    • Viewpoint: Why do we need a point-of-care CD4 test for low-income countries?

      Zachariah, R; Reid, S D; Chaillet, P; Massaquoi, M; Schouten, E J; Harries, A D; Médecins sans Frontières, Operational Centre Brussels; CD4 Initiative, Institute for Global Health, UK; Clinton Health Access Initiative, Liberia; Department of HIV/AIDS, Ministry of Health, Malawi; Management Sciences for Health, Malawi; International Union against Tuberculosis and Lung Disease, France; London School of Hygiene and Tropical Medicine, UK (2010-11-02)
      In this paper, we discuss the reasons why we urgently need a point-of-care (POC) CD4 test, elaborate the problems we have experienced with the current technology which hampers CD4-count coverage and highlight the ideal characteristics of a universal CD4 POC test. It is high-time that CD4 technology is simplified and adapted for wider use in low-income countries to change the current paradigm of restricted access once and for all.
    • Village registers for vital registration in rural Malawi

      Singogo, E; Kanike, E; van Lettow, M; Cataldo, F; Zachariah, R; Bissell, K; Harries, A D; Dignitas International, Zomba, Malawi. (John Wiley & Sons Ltd, 2013-08)
      Paper-based village registers were introduced 5 years ago in Malawi as a tool to measure vital statistics of births and deaths at the population level. However, usage, completeness and accuracy of their content have never been formally evaluated. In Traditional Authority Mwambo, Zomba district, Malawi, we assessed 280 of the 325 village registers with respect to (i) characteristics of village headmen who used village registers, (ii) use and content of village registers, and (iii) whether village registers provided accurate information on births and deaths. All village headpersons used registers. There were 185 (66%) registers that were regarded as 95% completed, and according to the registers, there were 115 840 people living in the villages in the catchment area. In 2011, there were 1753 births recorded in village registers, while 6397 births were recorded in health centre registers in the same catchment area. For the same year, 199 deaths were recorded in village registers, giving crude death rates per 100 000 population of 189 for males and 153 for females. These could not be compared with death rates in health centre registers due to poor and inconsistent recording in these registers, but they were compared with death rates obtained from the 2010 Malawi Demographic Health Survey that reported 880 and 840 per 100 000 for males and females, respectively. In conclusion, this study shows that village registers are a potential source for vital statistics. However, considerable inputs are needed to improve accuracy of births and deaths, and there are no functional systems for the collation and analysis of data at the traditional authority level. Innovative ways to address these challenges are discussed, including the use of solar-powered electronic village registers and mobile phones, connected with each other and the health facilities and the District Commissioner's office through the cellular network and wireless coverage.
    • Village-based AIDS prevention in a rural district in Uganda.

      Schopper, D; Doussantousse, S; Ayiga, N; Ezatirale, G; Idro, W J; Homsy, J; Médecins Sans Frontières, Geneva, Switzerland. (Oxford Journals, 1995-06)
      OBJECTIVE: To design, implement and evaluate a village-based AIDS prevention programme in a rural district in north-western Uganda. A baseline KAP survey of the general population was carried out to design a district-wide information campaign and condom promotion programme. Eighteen months later the impact achieved was measured through a second KAP survey, using the same methodology. METHODS: Anonymous structured interviews were conducted in March 1991 and October 1992 with 1486 and 1744 randomly selected individuals age 15-49, respectively. RESULTS: At 18 months, 60% of respondents had participated in an information session in the past year (47% women, 71% men) and 42% had received a pamphlet about AIDS (26% women, 58% men). Knowledge about AIDS, high initially (94%), reached 98%. More respondents knew that the incubation period is longer than one year (from 29% to 40%), and were willing to take care of a PWA (from 60% to 77%). Knowledge about condoms increased from 26 to 63% in women and 57 to 91% in men. Ever use of condoms among persons having engaged in casual sex in the past year increased from 6 to 33% in women, and 27 to 48% in men. Fifty per cent of condom users criticized lack of regular access to condoms. CONCLUSIONS: This is the first documented example of the impact a village-based AIDS prevention programme can achieve in a rural African community. Critical areas to be improved were identified, such as: women must be given better access to information, more attention must be paid to explain the asymptomatic state of HIV infection in appropriate terms, and condom social marketing must be developed.
    • Violence Against Civilians and Access to Health Care in North Kivu, Democratic Republic of Congo: Three Cross-Sectional Surveys

      Alberti, Kathryn P; Grellety, Emmanuel; Lin, Ya-Ching; Polonsky, Jonathan; Coppens, Katrien; Encinas, Luis; Rodrigue, Marie-Noëlle; Pedalino, Biagio; Mondonge, Vital; Epicentre, France; Médecins Sans Frontières, Amsterdam; Médecins Sans Frontières, Belgium; Médecins Sans Frontières, France; Ministry of Health, Democratic Republic of Congo (2010-11-08)
      ABSTRACT: