Study protocol of a cluster randomized controlled trial of strategies to increase antenatal iron and folic acid supplementation and malaria prophylaxis in rural south-central Côte d'Ivoire.

BACKGROUND: Coverage of antenatal iron and folic acid supplementation (IFAS) and intermittent preventive treatment of malaria in pregnancy (IPTp) remains low in many countries. Evidence on the most effective ways to increase both IFASIPTp is mixed overall, with only few studies directly identifying cost-effective ways to increase coverage of both interventions. The proposed study aims to assess the cost, impact and relative cost-effectiveness of two complementary strategies of increasing IFAS and malaria chemoprophylaxis coverage among pregnant women relative to the current default system in a rural low-income setting of sub-Saharan Africa. METHODS/DESIGN: This study will be carried out in the Taabo health and demographic surveillance system (HDSS) in south-central Côte d'Ivoire. This is a cluster-randomized trial targeting 720 consenting pregnant women aged ≥15 years. The 118 clusters constituting the Taabo HDSS monitoring area will be randomly allocated to one of the following three groups with equal probability: a control group, an information only group, and an information plus home delivery group. To assess the relative effectiveness of each strategy, we will conduct an endline survey within the first 2 weeks after delivery. The primary outcomes of the trial will be maternal post-partum anaemia and malaria infection. Anaemia will be assessed using HEMOCUE devices; malaria infections will be assessed using standard rapid diagnostic tests named CareStart™ Malaria Pf (HRP2) Ag RDT (Multi Kit with capped lancet and inverted cup specimen transfer device). Other outcomes will include self-reported adherence to supplementation and malaria chemoprophylaxis, as well as miscarriages, stillbirths and low birth weight deliveries. DISCUSSION: This study will assess the cost-effectiveness of two alternative strategies to increase antenatal IFAS and malaria chemoprophylaxis coverage among pregnant women in rural Côte d'Ivoire and similar settings. TRIAL REGISTRATION: ClinicalTrials.gov NCT04250428 ; Registered 31 January 2020.

Heckman-type selection models to obtain unbiased estimates with missing measures outcome: theoretical considerations and an application to missing birth weight data.

BACKGROUND: In low-income settings, key outcomes such as biomarkers or clinical assessments are often missing for a substantial proportion of the study population. The aim of this study was to assess the extent to which Heckman-type selection models can create unbiased estimates in such settings. METHODS: We introduce the basic Heckman model in a first stage, and then use simulation models to compare the performance of the model to alternative approaches used in the literature for missing outcome data, including complete case analysis (CCA), multiple imputations by chained equations (MICE) and pattern imputation with delta adjustment (PIDA). Last, we use a large population-representative data set on antenatal supplementation (AS) and birth outcomes from Côte d'Ivoire to illustrate the empirical relevance of this method. RESULTS: All models performed well when data were missing at random. When missingness in the outcome data was related to unobserved determinants of the outcome, large and systematic biases were found for CCA and MICE, while Heckman-style selection models yielded unbiased estimates. Using Heckman-type selection models to correct for missingness in our empirical application, we found supplementation effect sizes that were very close to those reported in the most recent systematic review of clinical AS trials. CONCLUSION: Missingness in health outcome can lead to substantial bias. Heckman-selection models can correct for this selection bias and yield unbiased estimates, even when the proportion of missing data is substantial.

Pregnancy-related morbidity and risk factors for fatal foetal outcomes in the Taabo health and demographic surveillance system, Côte d'Ivoire.

BACKGROUND: Reliable, population-based data on pregnancy-related morbidity and mortality, and risk factors for fatal foetal outcomes are scarce for low- and middle-income countries. Yet, such data are essential for understanding and improving maternal and neonatal health and wellbeing. METHODS: Within the 4-monthly surveillance rounds of the Taabo health and demographic surveillance system (HDSS) in south-central Côte d'Ivoire, all women of reproductive age identified to be pregnant between 2011 and 2014 were followed-up. A questionnaire pertaining to antenatal care, pregnancy-related morbidities, delivery circumstances, and birth outcome was administered to eligible women. Along with sociodemographic information retrieved from the Taabo HDSS repository, these data were subjected to penalized maximum likelihood logistic regression analysis, to determine risk factors for fatal foetal outcomes. RESULTS: A total of 2976 pregnancies were monitored of which 118 (4.0%) resulted in a fatal outcome. Risk factors identified by multivariable logistic regression analysis included sociodemographic factors of the expectant mother, such as residency in a rural area (adjusted odds ratio (aOR) = 2.87; 95% confidence interval (CI) 1.31-6.29) and poorest wealth tertile (aOR = 1.79; 95% CI 1.02-3.14), a history of miscarriage (aOR = 23.19; 95% CI 14.71-36.55), non-receipt of preventive treatment such as iron/folic acid supplementation (aOR = 3.15; 95% CI 1.71-5.80), only two doses of tetanus vaccination (aOR = 2.59; 95% CI 1.56-4.30), malaria during pregnancy (aOR = 1.94; 95% CI 1.21-3.11), preterm birth (aOR = 4.45; 95% CI 2.82-7.01), and delivery by caesarean section (aOR = 13.03; 95% CI 4.24-40.08) or by instrumental delivery (aOR = 5.05; 95% CI 1.50-16.96). Women who paid for delivery were at a significantly lower odds of a fatal foetal outcome (aOR = 0.39; 95% CI 0.25-0.74). CONCLUSIONS: We identified risk factors for fatal foetal outcomes in a mainly rural HDSS site of Côte d'Ivoire. Our findings call for public health action to improve access to, and use of, quality services of ante- and perinatal care.

Epidemiology of malaria in the Taabo health and demographic surveillance system, south-central Côte d'Ivoire.

BACKGROUND: A deep understanding of the local epidemiology of malaria is essential for the design and implementation of setting-specific control and elimination efforts. In Côte d'Ivoire, new initiatives are underway to reduce the burden of malaria, which requires high-quality longitudinal data. The epidemiology of malaria was studied in the Taabo health and demographic surveillance system (HDSS) in south-central Côte d'Ivoire and implications for control are discussed. METHODS: Two cross-sectional surveys were carried out in the rainy season of June/July in 2010 and 2011. Inhabitants of approximately 7% of randomly selected households in the Taabo HDSS were invited to participate. People were clinically examined, ear temperature was measured and spleen size determined. Finger-prick blood samples were collected and subjected to a rapid diagnostic test (RDT). Additionally, thick and thin blood films were prepared on microscope slides and diagnosed under a microscope for Plasmodium infection and parasitaemia. Haemoglobin (Hb) level was determined using a HemoCue device. RESULTS: A total of 1187 and 1264 people in 2010 and 2011, respectively, had complete data records. The prevalence of Plasmodium infection was 46.0% in 2010 and 56.6% in 2011, owing to a statistically significant difference (p < 0.05). Males showed a higher Plasmodium infection prevalence than females (49.6 and 62.8% versus 42.6 and 51.2%; respectively, in 2010 and 2011; both p < 0.05). The highest malaria prevalence was observed among infants and young children (aged ≤9 years). The risk of Plasmodium infection was significantly higher in villages compared to small hamlets and urban settings (p < 0.05). Fever, Hb level and splenomegaly were associated with parasitaemia. CONCLUSION: Malaria is highly endemic in the Taabo HDSS in south-central Côte d'Ivoire with considerable spatial heterogeneity of Plasmodium infection. There is a pressing need to scale-up control interventions against malaria.

[Hepatitis B knowledge among secondary school students in Côte d'Ivoire]. / Connaissance de l'hépatite virale B par les élèves des écoles secondaires en Côte d'Ivoire.

AIM: The purpose of this study was to assess hepatitis B knowledge among secondary school students' in Côte d'Ivoire in order to promote the inclusion of hepatitis B education in school curricula. MATERIAL AND METHODS: a single cross-sectional survey involving six schools (7,376 students) was conducted. Data were collected using a self-administered questionnaire. RESULTS: All students present on the day of the survey agreed to participate in the study (100%, n = 3,352). The mean age of the participants was 17.9 years (10-26 years), with a male-to-female sex ratio of 1.68. Among them, 2,552 (76.6%) had heard of the HVB. School was the main source of information (12%), after the mass media (62%). The causative agent of the disease was known by 74.1% of students (n = 2,484), sexual transmission by 39.3% (n = 1316), and blood-borne transmission by 57.2% (n = 1919). Respectively 29%, 40% and 41% of the students were aware that acupuncture, body piercing and tattooing are high-risk practices. Only 35.7% of the students knew that there was an effective vaccine. The factors associated with hepatitis B knowledge were: being aged 16 to 20 years (OR = 1.73 [95% CI 1.198 to 2.49]), living in a permanent house or apartment (OR = 1.58 [95% CI 1.234 to 2.02]) or in a house or apartment with no more than 2 persons per room (OR = 1.41 [95% CI 1.15 to 1.74]), being in terminale (final year of high school) (OR = 2.54 [2.01 to 3, 20IC95%]), and having two working parents (OR =1.54 [95% CI 1.25 to 1.88]). CONCLUSION: The students' knowledge of the hepatitis B virus was found to be inadequate and superficial. Early awareness programs provided as part of the official curriculum and measures to improve the social conditions of students should help to improve knowledge in this area.

Improving coverage of antenatal iron and folic acid supplementation and malaria prophylaxis through targeted information and home deliveries in Côte d'Ivoire: a cluster randomised controlled trial.

INTRODUCTION: Coverage of antenatal iron and folic acid (IFA) supplementation and malaria chemoprophylaxis remains low in many low-income and middle-income settings. We assessed the effectiveness of personal information (INFO) sessions and personal information session plus home deliveries (INFO+DELIV) to increase coverage of IFA supplementation and intermittent preventive treatment in pregnancy (IPTp), and their effectiveness on postpartum anaemia and malaria infection. METHODS: We included 118 clusters randomised to a control (39), INFO (39) and INFO+DELIV (40) arm, in a trial conducted between 2020 and 2021 with pregnant women (age ≥15 years) in their first or second trimester of pregnancy in Taabo, Côte d'Ivoire. We used generalised linear regression models to assess intervention impact in postpartum anaemia and malaria parasitaemia, and displayed resulting estimates as prevalence ratios. RESULTS: Overall, 767 pregnant women were enrolled and 716 (93.3%) were followed up after delivery. Neither intervention had an impact on postpartum anaemia, with estimated adjusted prevalence ratios (aPRs) of 0.97 (95% CI 0.79 to 1.19, p=0.770) for INFO and 0.87 (95% CI 0.70 to 1.09, p=0.235) for INFO+DELIV. While INFO had no effect on malaria parasitaemia (aPR=0.95, 95% CI 0.39 to 2.31, p=0.915), INFO+DELIV reduced malaria parasitaemia by 83% (aPR=0.17, 95% CI 0.04 to 0.75, p=0.019). No improvements in antenatal care (ANC) coverage (aPR=1.05, 95% CI 0.81 to 1.36, p=0.692), IFA (aPR=2.00, 95% CI 0.89 to 4.46, p=0.093) and IPTp (aPR=1.03, 95% CI 0.87 to 1.21, p=0.728) compliance were found for INFO. INFO+DELIV increased ANC attendance (aPR=1.35, 95% CI 1.02 to 1.78, p=0.037) and compliance with IPTp (aPR=1.60, 95% CI 1.41 to 1.80, p<0.001) and IFA recommendations (aPR=7.06, 95% CI 3.68 to 13.51, p<0.001). CONCLUSIONS: INFO+DELIV can substantially increase compliance with IFA supplementation and improve malaria prevention. However, the increases in IFA supplementation are likely insufficient to address the prevalence of often severe anaemia in this population. TRIAL REGISTRATION NUMBER: NCT04250428.

Successful grafting elite cocoa clones (Theobroma cacao L.) as a function of the age of rootstock.

Côte d'Ivoire, the world's largest cocoa producer, faces numerous challenges because the yield of orchards is low due to several factors including the non-use of improved plant materials. This work is part of ICRAF's Vision for Change (V4C) project, which aimed at contributing to the regeneration of cocoa farms by making effective plant materials available to small cocoa producers. It essentially consisted in evaluating the effect of the age of the rootstock on the success of grafting to obtain a satisfactory quantity of improved plants in the nursery. The study was carried out in Adiopodoumé at the National Agronomic Research Center (CNRA). Ten elite cocoa clones from the "Vision for Change" project were used as scions. Top grafting was performed on seedlings of 2, 3- and 4-months used as rootstocks. The experimental design was a randomized complete block design with 3 replications. Data collection was focused on the grafting success rate and morphological parameters. The results showed that the grafting success rate is proportional to the rootstock age. Two months after grafting, the success rate was low. This indicates that grafting should eventually start at 3 months. This period could therefore represent a good stage to successfully graft and replant cocoa seedlings.

Impact of newly constructed primary healthcare centres on antenatal care attendance, facility delivery and all-cause mortality: quasi-experimental evidence from Taabo health and demographic surveillance system, Côte d'Ivoire.

OBJECTIVES: Access to quality care remains limited, particularly in low-income and middle-income countries. Although better health outcomes for families living in close proximity to healthcare facilities have been documented in cross-sectional studies, evidence on the extent to which additional health facilities can contribute to improved population health remains scanty. We aimed to estimate the causal impact of newly constructed primary healthcare facilities within a health and demographic surveillance (HDSS) site in Côte d'Ivoire. DESIGN: We conducted a quasi-experimental study. Logistic and Cox proportional hazards regression models were used to estimate the impact of new healthcare facilities on healthcare-seeking behaviour and all-cause mortality. SETTING: Data were collected prospectively through the Taabo HDSS located in south-central Côte d'Ivoire between 2010 and 2018. PARTICIPANTS: We analysed 2957 deaths across 440 973 person-year observations as well as 14 132 live births. PRIMARY OUTCOME MEASURES: The primary outcomes were antenatal care (ANC) attendance, facility delivery and mortality. Logistic and Cox proportional hazards models were employed to estimate the impact of the new health facilities on ANC attendance, facility delivery and child as well as adult mortality. RESULTS: Average distance to the nearest healthcare facility declined from 5.5 km before to 2.8 km after opening of four new healthcare facilities in targeted villages. No improvement was observed for ANC attendance, institutional deliveries and adult mortality. New facilities reduced the risk of post-neonatal infant mortality by 46% (HR 0.54, 95% CI 0.31 to 0.94, p<0.05), suggesting a mortality gradient of 2 deaths per 1000 for each additional km (Coef=0.002, 95% CI 0.000 to 0.004, p<0.05). CONCLUSIONS: Our results suggest that new facilities do not necessarily improve healthcare utilisation and health outcomes. Further research is needed to identify the best ways to ensure access to quality care in resource-constrained settings.

Prevalence of Schistosoma mono- and co-infections with multiple common parasites and associated risk factors and morbidity profile among adults in the Taabo health and demographic surveillance system, South-Central Côte d'Ivoire.

BACKGROUND: Schistosomiasis remains an important public health problem, also among adults, and infected individuals not treated serve as a reservoir for continued transmission. Despite this fact, evidence on the epidemiology of schistosomiasis in adults in Côte d'Ivoire is scanty. This study aimed to determine the prevalence and risk factors of Schistosoma infection and co-infection with other helminth species and Plasmodium among adults in the Taabo region in the south-central part of Côte d'Ivoire. METHODS: A cross-sectional survey was carried out in April and May 2017 in the frame of the "Côte d'Ivoire Dual Burden of Disease Study" (CoDuBu). A total of 901 randomly selected individuals, aged 18-90 years, provided blood, stool and urine samples for the diagnosis of malaria and helminth infections. Stool samples were subjected to the Kato-Katz technique for detection of Schistosoma mansoni and soil-transmitted helminth eggs, while urine samples were examined for eggs of Schistosoma haematobium and circulating cathodic antigen of S. mansoni. Risk factors and morbidity profiles were assessed using health examination and questionnaires. Multinomial logistic regressions were employed to identify risk factors and morbidity patterns associated with S. mansoni mono- and co-infections. RESULTS: The prevalence of S. mansoni and S. haematobium was 23.2% and 1.0%, respectively. Most S. mansoni were mono-infections (81.3%). Independent determinants of S. mansoni infection were young age, low socioeconomic status (mono- and co-infection) and poor hygiene practices (co-infection) (P < 0.05). S. mansoni infection was independently associated with higher pain and symptom scores (mono-infection), poor self-rated health and low healthcare use (co-infection) (P < 0.05). CONCLUSIONS: This study showed that adults represent a substantial reservoir of S. mansoni. To sustain schistosomiasis control and improve people's wellbeing, it is important to expand preventive chemotherapy from school-aged children to adults, coupled with hygiene and health education.

Determinants of Modern Paediatric Healthcare Seeking in Rural Côte d'Ivoire.

Objectives: To determine factors that influence healthcare seeking among children with fatal and non-fatal health problems. Methods: Last disease episodes of surviving children and fatal outcomes of children under 5 years of age were investigated by means of an adapted social autopsy questionnaire administered to main caregivers. Descriptive analysis and logistic models were employed to identify key determinants of modern healthcare use. Results: Overall, 736 non-fatal and 82 fatal cases were assessed. Modern healthcare was sought for 63.9% of non-fatal and 76.8% of fatal cases, respectively. In non-fatal cases, young age, caregiver being a parent, secondary or higher education, living <5 km from a health facility, and certain clinical signs (i.e., fever, severe vomiting, inability to drink, convulsion, and inability to play) were positively associated with modern healthcare seeking. In fatal cases, only signs of lower respiratory disease were positively associated with modern healthcare seeking. A lack of awareness regarding clinical danger signs was identified in both groups. Conclusion: Interventions promoting prompt healthcare seeking and the recognition of danger signs may help improve treatment seeking in rural settings of Côte d'Ivoire and can potentially help further reduce under-five mortality.

Epidemiological links between malaria parasitaemia and hypertension: findings from a population-based survey in rural Côte d'Ivoire.

BACKGROUND: Although potential links between malaria parasitaemia and hypertension have been hypothesized, there is paucity of epidemiologic evidence on this link. We investigated in a population-based survey, the association between malaria parasitaemia and hypertension in Ivorian adults. METHODS: We estimated the adjusted odds ratios (OR) and 95% confidence intervals (CI) of hypertension in relation to malaria parasitaemia using multinomial regression, in 997 randomly selected adults in the 'Côte d'Ivoire Dual Burden of Disease Study' (CoDuBu), in south-central Côte d'Ivoire. We defined malaria parasitaemia as a positive rapid diagnostic test or identification of Plasmodium spp. on microscopy. Using the mean of the last two of three blood pressure (BP) measurements and questionnaire data, we defined hypertension as SBP at least 140 mmHg or DBP at least 90 mmHg or clinician-diagnosed hypertension. RESULTS: Prevalence of malaria parasitaemia and hypertension were 10 and 22%, respectively. Malaria parasitaemia was negatively associated with hypertension in participants with body temperature 36.5 °C or less [OR 0.23 (95% CI 0.06-0.84)]. Contrastingly, microscopic malaria parasitaemia showed positive associations with hypertension in participants with elevated body temperature [>36.5 °C; OR: 2.93 (95% CI 0.94-9.14)]. Participants having microscopic malaria parasitaemia with elevated body temperature had three-fold higher odds of hypertension [OR: 3.37 (95% CI 1.12-10.0)] than malaria parasitaemia-negatives with lower body temperature. CONCLUSION: Malaria parasitaemia and hypertension are prevalent and seemingly linked comorbidities in African settings. This link may depend on malaria parasitaemia symptomaticity/latency where individuals with more latent/asymptomatic malaria parasitaemia have lower risk of hypertension and those with more acute/symptomatic malaria parasitaemia have a tendency toward higher BP. The cross-sectional nature of the study limited the distinction of short-term BP elevation (interim pathophysiological stress) from hypertension development. Future longitudinal studies considering malaria/hypertension phenotypes and host molecular variations are needed to clarify involved biological mechanisms, toward comorbidity management.

Asymptomatic Plasmodium infection and glycemic control in adults: Results from a population-based survey in south-central Côte d'Ivoire.

AIMS: We investigated the cross-sectional associations of Plasmodium infection (PI) with fasting glucose (FG) and glycated hemoglobin (HbA1c) in malaria-endemic south-central Côte d'Ivoire. METHODS: We studied 979 participants (non-pregnant; no treated diabetes; 51% males; 18-87 years) of the Côte d'Ivoire Dual Burden of Disease study. Fasting venous blood was obtained for PI, FG, and HbA1c assessment. We defined PI as a positive malaria rapid diagnostic test (RDT) or microscopic identification of Plasmodium species. We applied multivariable linear regressions to assess beta coefficients (ß) and 95% confidence intervals (CIs) of PI positivity for FG and HbA1c independent of diabetes risk factors. RESULTS: Prevalence of PI was 10.1% (5.5% microscopy; 9.7% RDT) without clinical fever. Prevalence of FG-based prediabetes (45.8%) and diabetes (3.6%) were considerably higher than HbA1c-based values (2.7% and 0.7%, respectively). PI was independently associated with FG among participants with higher body temperature (ß 0.34, 95% CI 0.06-0.63, pheterogeneity = 0.028), or family history of diabetes (ß 0.88, 95% CI 0.28-1.47, pheterogeneity = 0.009). Similar patterns observed with HbA1c were obliterated on accounting for FG. We also observed consistent associations with parasite density. CONCLUSIONS: FG-based diabetes diagnosis in the presence of asymptomatic PI may misclassify or overestimate diabetes burden in malaria-endemic settings. Longitudinal studies are needed to confirm these findings and determine the risk for diabetes.

Effect of an integrated intervention package of preventive chemotherapy, community-led total sanitation and health education on the prevalence of helminth and intestinal protozoa infections in Côte d'Ivoire.

BACKGROUND: Preventive chemotherapy with donated anthelminthic drugs is the cornerstone for the control of helminthiases. However, reinfection can occur rapidly in the absence of clean water and sanitation coupled with unhygienic behaviour. The purpose of this study was to assess the effect of an integrated package of interventions, consisting of preventive chemotherapy, community-led total sanitation (CLTS) and health education, on the prevalence of helminth and intestinal protozoa infections and on participants' knowledge, attitude, practice and beliefs (KAPB) towards these diseases including water, sanitation and hygiene (WASH). METHODS: A cross-sectional survey was carried out in nine communities of south-central Côte d'Ivoire to assess people's infection with helminths and intestinal protozoa and KAPB. Subsequently, interventions were targeted to five communities, while the remaining communities served as control. The intervention encouraged latrine construction and an evaluation was done 6-7 months later to determine open defecation status of the respective communities. Anthelminthic treatment was provided to all community members. A follow-up cross-sectional survey was conducted approximately one year later, using the same procedures. RESULTS: Overall, 810 people had complete baseline and follow-up data and were given anthelminthic treatment. The baseline prevalence of hookworm, Schistosoma haematobium, Trichuris trichiura, Schistosoma mansoni and Ascaris lumbricoides was 31.1%, 7.0%, 2.0%, 1.0% and 0.3%, respectively. Four of the five intervention communities were classified open-defecation free. For hookworm infection, we observed higher negative changes in terms of proportion of decrease (-0.10; 95% confidence interval (CI): - 0.16, -0.04) and higher egg reduction rate (64.9 vs 15.2%) when comparing intervention with control communities. For intestinal protozoa, prevalence reduction was higher in intervention compared to control communities (8.2 vs 2.6%) and WASH indicators and intervention outcomes associated with lower odds for infection at follow-up. The intervention significantly impacted on reported latrine use (before: 15.5%, after: 94.6%), open defecation in the community surroundings (before: 75.0%, after: 16.7%) and awareness for environmental contamination through open defecation (before: 20.4%, after: 52.2%). CONCLUSIONS: An integrated package of interventions consisting of preventive chemotherapy, health education and CLTS reduces the prevalence of helminth and intestinal protozoa infection. Additional studies in other social-ecological settings are warranted to confirm our findings.

An Integrated Approach to Control Soil-Transmitted Helminthiasis, Schistosomiasis, Intestinal Protozoa Infection, and Diarrhea: Protocol for a Cluster Randomized Trial.

BACKGROUND: The global strategy to control helminthiases (schistosomiasis and soil-transmitted helminthiasis) emphasizes preventive chemotherapy. However, in the absence of access to clean water, improved sanitation, and adequate hygiene, reinfection after treatment can occur rapidly. Integrated approaches might be necessary to sustain the benefits of preventive chemotherapy and make progress toward interruption of helminthiases transmission. OBJECTIVE: The aim of this study was to assess and quantify the effect of an integrated control package that consists of preventive chemotherapy, community-led total sanitation, and health education on soil-transmitted helminthiasis, schistosomiasis, intestinal protozoa infection, and diarrhea in rural Côte d'Ivoire. METHODS: In a first step, a community health education program was developed that includes an animated cartoon to promote improved hygiene and health targeting school-aged children, coupled with a health education theater for the entire community. In a second step, a cluster randomized trial was implemented in 56 communities of south-central Côte d'Ivoire with 4 intervention arms: (1) preventive chemotherapy; (2) preventive chemotherapy plus community-led total sanitation; (3) preventive chemotherapy plus health education; and (4) all 3 interventions combined. Before implementation of the aforementioned interventions, a baseline parasitologic, anthropometric, and hygiene-related knowledge, attitudes, practices, and beliefs survey was conducted. These surveys were repeated 18 and 39 months after the baseline cross-sectional survey to determine the effect of different interventions on helminth and intestinal protozoa infection, nutritional indicators, and knowledge, attitudes, practices, and beliefs. Monitoring of diarrhea was done over a 24-month period at 2-week intervals, starting right after the baseline survey. RESULTS: Key results from this cluster randomized trial will shed light on the effect of integrated approaches consisting of preventive chemotherapy, community-led total sanitation, and health education against infections with soil-transmitted helminths, schistosomes, an intestinal protozoa and prevention of diarrhea in a rural part of Côte d'Ivoire. CONCLUSIONS: The research provided new insights into the acceptability, strengths, and limitations of an integrated community-based control package targeting helminthiases, intestinal protozoa infections, and diarrhea in rural communities of Côte d'Ivoire. In the longer term, the study will allow determining the effect of the integrated control approach on infection patterns with parasitic worms and intestinal protozoa, diarrheal incidence, anthropometric measures, and hygiene-related knowledge, attitudes, practices, and beliefs. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN): 53102033; http://www.isrctn.com/ISRCTN53102033 (Archived by WebCite at http://www.webcitation.org/6wpnXEiHo). REGISTERED REPORT IDENTIFIER: RR1-10.2196/9166.

Côte d'Ivoire Dual Burden of Disease (CoDuBu): Study Protocol to Investigate the Co-occurrence of Chronic Infections and Noncommunicable Diseases in Rural Settings of Epidemiological Transition.

BACKGROUND: Individual-level concomitance of infectious diseases and noncommunicable diseases (NCDs) is poorly studied, despite the reality of this dual disease burden for many low- and middle-income countries (LMICs). OBJECTIVE: This study protocol describes the implementation of a cohort and biobank aiming for a better understanding of interrelation of helminth and Plasmodium infections with NCD phenotypes like metabolic syndrome, hypertension, and diabetes. METHODS: A baseline cross-sectional population-based survey was conducted over one year, in the Taabo health and demographic surveillance system (HDSS) in south-central Côte d'Ivoire. We randomly identified 1020 consenting participants aged ≥18 years in three communities (Taabo-Cité, Amani-Ménou, and Tokohiri) reflecting varying stages of epidemiological transition. Participants underwent health examinations consisting of NCD phenotyping (anthropometry, blood pressure, renal function, glycemia, and lipids) and infectious disease testing (infections with soil-transmitted helminths, schistosomes, and Plasmodium). Individuals identified to have elevated blood pressure, glucose, lipids, or with infections were referred to the central/national health center for diagnostic confirmation and treatment. Aliquots of urine, stool, and venous blood were stored in a biobank for future exposome/phenome research. In-person interviews on sociodemographic attributes, risk factors for infectious diseases and NCDs, medication, vaccinations, and health care were also conducted. Appropriate statistical techniques will be applied in exploring the concomitance of infectious diseases and NCDs and their determinants. Participants' consent for follow-up contact was obtained. RESULTS: Key results from this baseline study, which will be published in peer-reviewed literature, will provide information on the prevalence and co-occurrence of infectious diseases, NCDs, and their risk factors. The Taabo HDSS consists of rural and somewhat more urbanized areas, allowing for comparative studies at different levels of epidemiological transition. An HDSS setting is ideal as a basis for longitudinal studies since their sustainable field work teams hold close contact with the local population. CONCLUSIONS: The collaboration between research institutions, public health organizations, health care providers, and staff from the Taabo HDSS in this study assures that the synthesized evidence will feed into health policy towards integrated infectious disease-NCD management. The preparation of health systems for the dual burden of disease is pressing in low- and middle-income countries. The established biobank will strengthen the local research capacity and offer opportunities for biomarker studies to deepen the understanding of the cross-talk between infectious diseases and NCDs. TRIAL REGISTRATION: International Standard Randomized Controlled Trials Number (ISRCTN): 87099939; http://www.isrctn.com/ISRCTN87099939 (Archived by WebCite at http://www.webcitation.org/6uLEs1EsX).

Ripple effect, driving branch, and economic development: case of the agro-food industry in Côte d'Ivoire / Avaliação da eficácia dos efeitos puxadores da indústria agro-alimentar (IAA) na economia da Costa do Marfim

ABSTRACT: In Côte d'Ivoire, agricultural development has been made possible by the Government strategy to support it through an industrialization-based policy. However, the agricultural sector is still facing many difficulties, despite significant investment efforts undertaken to turn the country into a significant agricultural and agro-food industry (AFI) products exporter on the international market. This study evaluated the effectiveness of the driving role of AFI branches in the Ivorian economy. We used Leontief's model, coupled with Diamond's model and Rasmussen's indices, to assess the ripple effects, and identify the driving branch in the Ivorian economy. Data used are derived from the Input-Output Table (IOT) of the 2018 National Accounts produced by the Government and aggregated into 21 branches or subsectors. Our study showed that there is no outstanding driving branch in the economy. However, some branches are close to compliance with driving branch status. For a driving sector to emerge, the Government should invest in priority order in the following branches: Grain Processing and Starchy Product Manufacturing (GPSPM), Cocoa & Coffee Processing (CCP), Oilseed Industry (OI), Dairy Industry and Fruit & Vegetable Industry (DIFVI), Beverage Industry (BI), Tobacco Industry (TI). And currently, the country's development strategy should be based primarily on these branches, because they are able to improve the effectiveness and efficiency of production system in the Agro-Food Industry (AFI) and, by extension, the economy.

RESUMO: Na Costa do Marfim, o desenvolvimento agrícola tornou-se possível graças à estratégia de apoio do governo através de uma política de industrialização. Contudo, o setor agrícola continua a enfrentar muitas dificuldades, apesar dos grandes esforços de investimento empreendidos para transformar o país num grande exportador de produtos agrícolas e de indústria agro-alimentar (IAA) no mercado internacional. O objetivo do presente estudo é avaliar a eficácia do papel motor dos ramos da Indústria Agro-alimentar (IAA) na economia da Costa do Marfim. Utilizámos o modelo de Leontief, juntamente com o modelo de Diamond e os índices de Rasmussen, para avaliar os efeitos puxadores e identificar o ramo motor da economia marfinense. Os dados utilizados provêm da Tabela Entradas-Saídas (TES) da Contabilidade Nacional de 2018, produzida pelo governo e que foi agregada em 21 ramos ou sub-sectores. Tendo em conta o princípio de identificação do ramo motor, os nossos resultados mostram que não existe verdadeiramente um ramo motor na economia marfinense. Entretanto, alguns ramos estão a aproximar-se desta conformidade de identificação de ramo motor. São, por ordem de conformidade no setor agro-alimentar: Trabalho de Grãos e Fabricação de Produtos à base de Amido (TGFPA); Transformação do Cacau e do Café (TCC); Indústria de Oleaginosas (IO); Indústria de Lacticínios e Indústria de Frutas e Legumes (ILIFL); Indústria de Bebidas (IB); Indústria do Tabaco (IT). Isso significa que, atualmente, a estratégia de desenvolvimento do país deverá apoiar-se, em primeiro lugar, nestes ramos, pois, são eles que podem melhorar a eficácia e a eficiência do sistema de produção da Indústria Agro-alimentar (IAA) e, portanto, a economia da Costa do Marfim.

Causes of death in the Taabo health and demographic surveillance system, Côte d'Ivoire, from 2009 to 2011.

BACKGROUND: Current vital statistics from governmental institutions in Côte d'Ivoire are incomplete. This problem is particularly notable for remote rural areas that have limited access to the health system. OBJECTIVE: To record all deaths from 2009 to 2011 and to identify the leading causes of death in the Taabo health and demographic surveillance system (HDSS) in south-central Côte d'Ivoire. DESIGN: Deaths recorded in the first 3 years of operation of the Taabo HDSS were investigated by verbal autopsy (VA), using the InterVA-4 model. InterVA-4 is based on the World Health Organization 2012 VA tool in terms of input indicators and categories of causes of death. RESULTS: Overall, 948 deaths were recorded, of which 236 (24.9%) had incomplete VA data. Among the 712 deaths analyzed, communicable diseases represented the leading causes (58.9%), with most deaths attributed to malaria (n=129), acute respiratory tract infections (n=110), HIV/AIDS (n=80), and pulmonary tuberculosis (n=46). Non-communicable diseases accounted for 18.9% of the deaths and included mainly acute abdomen (n=38), unspecified cardiac diseases (n=15), and digestive neoplasms (n=13). Maternal and neonatal conditions accounted for 8.3% of deaths, primarily pneumonia (n=19) and birth asphyxia (n=16) in newborns. Among the 3.8% of deaths linked to trauma and injury, the main causes were assault (n=6), accidental drowning (n=4), contact with venomous plants/animals (n=4), and traffic-related accidents (n=4). No clear causes were determined in 10.0% of the analyzed deaths. CONCLUSIONS: Communicable diseases remain the predominant cause of death in rural Côte d'Ivoire. Based on these findings, measures are now being implemented in the Taabo HDSS. It will be interesting to monitor patterns of mortality and causes of death in the face of rapid demographic and epidemiological transitions in this part of West Africa.

Health & Demographic Surveillance System Profile: The Taabo Health and Demographic Surveillance System, Côte d'Ivoire.

The Taabo Health and Demographic Surveillance System (HDSS) is located in south-central Côte d'Ivoire, approximately 150 km north-west of Abidjan. The Taabo HDSS started surveillance activities in early 2009 and the man-made Lake Taabo is a key eco-epidemiological feature. Since inception, there has been a strong interest in research and integrated control of water-associated diseases such as schistosomiasis and malaria. The Taabo HDSS has generated setting-specific evidence on the impact of targeted interventions against malaria, schistosomiasis and other neglected tropical diseases. The Taabo HDSS consists of a small town, 13 villages and over 100 hamlets. At the end of 2013, a total population of 42 480 inhabitants drawn from 6707 households was under surveillance. Verbal autopsies have been conducted to determine causes of death. Repeated cross-sectional epidemiological surveys on approximately 5-7% of the population and specific, layered-on haematological, parasitological and questionnaire surveys have been conducted. The Taabo HDSS provides a database for surveys, facilitates interdisciplinary research, as well as surveillance, and provides a platform for the evaluation of health interventions. Requests to collaborate and to access data are welcome and should be addressed to the secretariat of the Centre Suisse de Recherches Scientifiques en Côte d'Ivoire: [secretariat@csrs.ci].

Scope and Limits of an anamnestic questionnaire in a control-induced low-endemicity helminthiasis setting in south-central Côte d'Ivoire.

BACKGROUND: Schistosomiasis and soil-transmitted helminthiasis are two high-burden neglected tropical diseases. In highly endemic areas, control efforts emphasize preventive chemotherapy. However, as morbidity, infection, and transmission begin to decrease, more targeted treatment is likely to become more cost-effective, provided that comparatively cheap diagnostic methods with reasonable accuracy are available. METHODOLOGY: Adults were administered an anamnestic questionnaire in mid-2010 during a cross-sectional epidemiological survey in the Taabo health demographic surveillance system in south-central Côte d'Ivoire. Questions pertaining to risk factors and signs and symptoms for schistosomiasis and soil-transmitted helminthiasis were included. The individuals' helminth infection status and their belonging to three different anthelmintic treatment groups were compared with the questionnaire results (i) to inform the local health authorities about the epidemiological and clinical footprint of locally prevailing helminthiases, and (ii) to explore the scope and limits of an anamnestic questionnaire as monitoring tool, which eventually could help guiding the control of neglected tropical diseases in control-induced low-endemicity settings. PRINCIPAL FINDINGS: Our study sample consisted of 195 adults (101 males, 94 females). We found prevalences of hookworm, Trichuris trichiura, Schistosoma haematobium, and Schistosoma mansoni of 39.0%, 2.7%, 2.1%, and 2.1%, respectively. No Ascaris lumbricoides infection was found. Helminth infection intensities were generally very low. Seven, 74 and 79 participants belonged to three different treatment groups. Multivariable logistic regression models revealed statistically significant (p<0.05) associations between some risk factors, signs, and symptoms, and the different helminth infections and treatment groups. However, the risk factors, signs, and symptoms showed weak diagnostic properties. CONCLUSIONS/SIGNIFICANCE: The generally low prevalence and intensity of helminth infection in this part of south-central Côte d'Ivoire indicates that recent control efforts have turned our study area into a low endemicity setting. Our anamnestic questionnaire had low sensitivity and specificity to identify infected individuals or treatment groups.

Adult non-communicable disease mortality in Africa and Asia: evidence from INDEPTH Health and Demographic Surveillance System sites.

BACKGROUND: Mortality from non-communicable diseases (NCDs) is a major global issue, as other categories of mortality have diminished and life expectancy has increased. The World Health Organization's Member States have called for a 25% reduction in premature NCD mortality by 2025, which can only be achieved by substantial reductions in risk factors and improvements in the management of chronic conditions. A high burden of NCD mortality among much older people, who have survived other hazards, is inevitable. The INDEPTH Network collects detailed individual data within defined Health and Demographic Surveillance sites. By registering deaths and carrying out verbal autopsies to determine cause of death across many such sites, using standardised methods, the Network seeks to generate population-based mortality statistics that are not otherwise available. OBJECTIVE: To describe patterns of adult NCD mortality from INDEPTH Network sites across Africa and Asia, according to the WHO 2012 verbal autopsy (VA) cause categories, with separate consideration of premature (15-64 years) and older (65+ years) NCD mortality. DESIGN: All adult deaths at INDEPTH sites are routinely registered and followed up with VA interviews. For this study, VA archives were transformed into the WHO 2012 VA standard format and processed using the InterVA-4 model to assign cause of death. Routine surveillance data also provide person-time denominators for mortality rates. RESULTS: A total of 80,726 adult (over 15 years) deaths were documented over 7,423,497 person-years of observation. NCDs were attributed as the cause for 35.6% of these deaths. Slightly less than half of adult NCD deaths occurred in the 15-64 age group. Detailed results are presented by age and sex for leading causes of NCD mortality. Per-site rates of NCD mortality were significantly correlated with rates of HIV/AIDS-related mortality. CONCLUSIONS: These findings present important evidence on the distribution of NCD mortality across a wide range of African and Asian settings. This comes against a background of global concern about the burden of NCD mortality, especially among adults aged under 70, and provides an important baseline for future work.