Reaching hard-to-reach individuals: Nonselective versus targeted outbreak response vaccination for measles.

Current mass vaccination campaigns in measles outbreak response are nonselective with respect to the immune status of individuals. However, the heterogeneity in immunity, due to previous vaccination coverage or infection, may lead to potential bias of such campaigns toward those with previous high access to vaccination and may result in a lower-than-expected effective impact. During the 2010 measles outbreak in Malawi, only 3 of the 8 districts where vaccination occurred achieved a measureable effective campaign impact (i.e., a reduction in measles cases in the targeted age groups greater than that observed in nonvaccinated districts). Simulation models suggest that selective campaigns targeting hard-to-reach individuals are of greater benefit, particularly in highly vaccinated populations, even for low target coverage and with late implementation. However, the choice between targeted and nonselective campaigns should be context specific, achieving a reasonable balance of feasibility, cost, and expected impact. In addition, it is critical to develop operational strategies to identify and target hard-to-reach individuals.

Local discrepancies in measles vaccination opportunities: results of population-based surveys in Sub-Saharan Africa.

BACKGROUND: The World Health Organization recommends African children receive two doses of measles containing vaccine (MCV) through routine programs or supplemental immunization activities (SIA). Moreover, children have an additional opportunity to receive MCV through outbreak response immunization (ORI) mass campaigns in certain contexts. Here, we present the results of MCV coverage by dose estimated through surveys conducted after outbreak response in diverse settings in Sub-Saharan Africa. METHODS: We included 24 household-based surveys conducted in six countries after a non-selective mass vaccination campaign. In the majority (22/24), the survey sample was selected using probability proportional to size cluster-based sampling. Others used Lot Quality Assurance Sampling. RESULTS: In total, data were collected on 60,895 children from 2005 to 2011. Routine coverage varied between countries (>95% in Malawi and Kirundo province (Burundi) while <35% in N'Djamena (Chad) in 2005), within a country and over time. SIA coverage was <75% in most settings. ORI coverage ranged from >95% in Malawi to 71.4% [95% CI: 68.9-73.8] in N'Djamena (Chad) in 2005.In five sites, >5% of children remained unvaccinated after several opportunities. Conversely, in Malawi and DRC, over half of the children eligible for the last SIA received a third dose of MCV. CONCLUSIONS: Control pre-elimination targets were still not reached, contributing to the occurrence of repeated measles outbreak in the Sub-Saharan African countries reported here. Although children receiving a dose of MCV through outbreak response benefit from the intervention, ensuring that programs effectively target hard to reach children remains the cornerstone of measles control.

The dragonfly splint: a new disposable device designed to prevent both medial and lateral turbinate synechiae after sinonasal surgery.

Periturbinal adhesions are among the most frequent and challenging complications of sinonasal surgery. Endonasal paraseptal splints have proved to be very efficient in preventing "medial synechiae," that is, adhesions located between the medial faces of the middle/inferior turbinates and the septum. However, none of these devices for guiding mucosal healing can prevent "lateral synechiae" (adhesions between the lateral face of the middle turbinate and the lateral nasal wall) inside the middle meatal cleft, which is a very critical area for the physiology of the anterior sinus system. For this reason, if followed by the formation of lateral synechiae, the surgical maneuvers used to treat sinus diseases could paradoxically become a cause of persistent functional impairment and lead to iatrogenic sinusitis or mucocele.We describe our preliminary experience with a new endonasal splint called "Dragonfly" (because of its shape), which has been designed to prevent both medial and lateral postsurgical synechiae. This device has a long lateral wing designed to separate the mucosal surfaces of the middle meatal/ethmoid cavities and prevent adhesions during the postoperative process of healing. The device must be kept in situ for 3 to 4 weeks to permit the re-epithelialization of the internal nasal surfaces. Our experience shows that the splints are well tolerated and highly efficient, preventing both medial and lateral synechiae in 100% of cases. A randomized controlled study has now been started to confirm these positive preliminary findings in a larger patient population.

Lessons and challenges for measles control from unexpected large outbreak, Malawi.

Despite high reported coverage for routine and supplementary immunization, in 2010 in Malawi, a large measles outbreak occurred that comprised 134,000 cases and 304 deaths. Although the highest attack rates were for young children (2.3%, 7.6%, and 4.5% for children <6, 6-8, and 9-11 months, respectively), persons >15 years of age were highly affected (1.0% and 0.4% for persons 15-19 and >19 years, respectively; 28% of all cases). A survey in 8 districts showed routine coverage of 95.0% for children 12-23 months; 57.9% for children 9-11 months; and 60.7% for children covered during the last supplementary immunization activities in 2008. Vaccine effectiveness was 83.9% for 1 dose and 90.5% for 2 doses. A continuous accumulation of susceptible persons during the past decade probably accounts for this outbreak. Countries en route to measles elimination, such as Malawi, should improve outbreak preparedness. Timeliness and the population chosen are crucial elements for reactive campaigns.

Measles outbreak response immunization is context-specific: insight from the recent experience of Médecins Sans Frontières.

Andrea Minetti and colleagues compare measles outbreak responses from the Democratic Republic of the Congo and Malawi and argue that outbreak response strategies should be tailored to local measles epidemiology. Please see later in the article for the Editors' Summary.

A quantitative method for assessing the degree of axial proptosis in relation to orbital tissue involvement in Graves' orbitopathy.

PURPOSE: To define a method of quantifying axial proptosis in patients with Graves' orbitopathy (GO) and to validate a score that correlates with the orbital involvement and helps determine the degree of proptosis correction for elective orbital decompression. DESIGN: Retrospective, case series. PARTICIPANTS: The study included 50 patients (group A) and 29 control subjects who underwent orbital computed tomography (CT). The method was then validated in another group of 21 patients with GO (group B). METHODS: The orbital area (OA) was measured manually on the central axial section of the CT scan at a level where the lens is visualized. The OA intersects the projection of the globe and delimitates the chord of an arch (globe chord [OC]). The area of the circular sector under the chord (CA) represents the portion of the globe within the orbit. MAIN OUTCOME MEASURES: A CA-to-OA ratio was calculated to reduce the error due to variability of the measurements and to perform correlations with some of the clinical parameters of GO. RESULTS: Measurement error was low (<2%). We did not observe significant differences in the mean OA of patients with GO (783.6 ± 12.1 mm(2)) and controls (758.5 ± 20.4 mm(2); P = not significant). The OC value in patients with GO was 130.2 ± 11.5 mm(2), significantly lower than in controls (281.8 ± 9.7 mm(2); P<0.0001). The CA-to-OA ratio also was lower in patients with GO than in controls (0.16 ± 0.01 vs. 0.38 ± 0.01; P<0.0001). A significant correlation was found in patients with GO between the CA-to-OA ratio and proptosis (P<0.001), lid fissure (P = 0.004), and intraocular pressure (P<0.001). In group B, the CA-to-OA ratio was 0.18 ± 0.02, significantly different from that of controls (P<0.0001) and inversely correlated with proptosis (P<0.0001) and lid fissure (P<0.045). CONCLUSIONS: By measuring the CA-to-OA ratio, we were able to quantify the degree of axial proptosis in patients with GO. The significant correlation of CA/OA with some orbital parameters confirms that this parameter also may be used as a measure of orbital involvement in GO. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Measles in Democratic Republic of Congo: an outbreak description from Katanga, 2010-2011.

BACKGROUND: The Democratic Republic of Congo experiences regular measles outbreaks. From September 2010, the number of suspected measles cases increased, especially in Katanga province, where Medecins sans Frontieres supported the Ministry of Health in responding to the outbreak by providing free treatment, reinforcing surveillance and implementing non-selective mass vaccination campaigns. Here, we describe the measles outbreak in Katanga province in 2010-2011 and the results of vaccine coverage surveys conducted after the mass campaigns. METHODS: The surveillance system was strengthened in 28 of the 67 health zones of the province and we conducted seven vaccination coverage surveys in 2011. RESULTS: The overall cumulative attack rate was 0.71% and the case fatality ratio was 1.40%. CONCLUSIONS: Early investigation of the age distribution of cases is a key to understanding the epidemic, and should guide the vaccination of priority age groups.

Performance of small cluster surveys and the clustered LQAS design to estimate local-level vaccination coverage in Mali.

BACKGROUND: Estimation of vaccination coverage at the local level is essential to identify communities that may require additional support. Cluster surveys can be used in resource-poor settings, when population figures are inaccurate. To be feasible, cluster samples need to be small, without losing robustness of results. The clustered LQAS (CLQAS) approach has been proposed as an alternative, as smaller sample sizes are required. METHODS: We explored (i) the efficiency of cluster surveys of decreasing sample size through bootstrapping analysis and (ii) the performance of CLQAS under three alternative sampling plans to classify local VC, using data from a survey carried out in Mali after mass vaccination against meningococcal meningitis group A. RESULTS: VC estimates provided by a 10 × 15 cluster survey design were reasonably robust. We used them to classify health areas in three categories and guide mop-up activities: i) health areas not requiring supplemental activities; ii) health areas requiring additional vaccination; iii) health areas requiring further evaluation. As sample size decreased (from 10 × 15 to 10 × 3), standard error of VC and ICC estimates were increasingly unstable. Results of CLQAS simulations were not accurate for most health areas, with an overall risk of misclassification greater than 0.25 in one health area out of three. It was greater than 0.50 in one health area out of two under two of the three sampling plans. CONCLUSIONS: Small sample cluster surveys (10 × 15) are acceptably robust for classification of VC at local level. We do not recommend the CLQAS method as currently formulated for evaluating vaccination programmes.

Can sleeping position be correctly identified by OSAS studies?

OBJECTIVE: Positional Obstructive Sleep Apnoea Syndrome (POSAS) is a sub-type of Obstructive Sleep Apnoea Syndrome (OSAS) in which obstructive apnoeas occur mainly in the supine sleeping position. In clinical practice, information on sleep posture is generally gathered by polysomnographic exam (PSG). The current trend in positional therapies consists of position trainers which help to avoid the supine position. The aim of this study is to detect the reliability of different devices on assessing sleeping position, comparing the data with objective evaluation by an infra-red camera. METHODS: We compared the positional results of 4 healthy volunteers obtained from a type III PSG and with a neck-worn sleep position trainer (Night Shift - NS). RESULTS: Data showed that NS is a good tool to assess the position of the trunk, with high rate of agreement with PSG, but in some conditions there are limitations, especially in detecting the real head and neck position and low accordance between NS data and information recorded by infra-red camera. CONCLUSIONS: Our study confirmed that more information about body position during sleep is needed, underling the necessity of developing new technologies that are able to better identify reciprocal body positions.

Violence and mortality in West Darfur, Sudan (2003-04): epidemiological evidence from four surveys.

BACKGROUND: Violence in Darfur, Sudan, has rendered more than one million people internally displaced. An epidemiological study of the effect of armed incursions on mortality in Darfur was needed to provide a basis for appropriate assistance to internally displaced people. METHODS: Between April and June, 2004, we did retrospective cluster surveys among 215?400 internally displaced people in four sites of West Darfur (Zalingei, Murnei, Niertiti, El Geneina). Mortality recall periods covered both the pre-displacement and post-displacement periods in Zalingei, Murnei, and Niertiti, but not in El Geneina. Heads of households provided dates, causes, and places of deaths, and described the family structure. FINDINGS: Before arrival at displacement sites, mortality rates (expressed as deaths per 10?000 per day), were 5.9 (95% CI 2.2-14.9) in Zalingei, 9.5 (6.4-14.0) in Murnei, and 7.3 (3.2-15.7) in Niertiti. Violence caused 68-93% of these deaths. People who were killed were mostly adult men (relative risk 29.1-117.9 compared with children younger than 15 years), but included women and children. Most households fled because of direct village attacks. In camps, mortality rates fell but remained above the emergency benchmark, with a peak of 5.6 in El Geneina. Violence persisted even after displacement. Age and sex pyramids of surviving populations were skewed, with a deficit in men. INTERPRETATION: This study, which was done in a difficult setting, provides epidemiological evidence of this conflict's effect on civilians, confirming the serious nature of the crisis, and reinforcing findings from other war contexts.

Comparing postoperative quality of life in children after microdebrider intracapsular tonsillotomy and tonsillectomy.

OBJECTIVE: To evaluate postoperative quality of life in patients undergoing microdebrider intracapsular tonsillotomy and adenoidectomy (PITA) in comparison with traditional adenotonsillectomy (AT) and to assess PITA's efficacy in solving upper-airway obstructive symptoms. METHODS: 29 children with adenotonsillar hyperplasia referred for AT were included. Patients were divided into two groups: Group 1 (underwent PITA) included 14 children (age 5.1±1.8 years) affected by night-time airway obstruction without a relevant history of recurrent tonsillitis; Group 2 (underwent AT) included 15 children (age 5.2±1.7 years) with a history of upper-airway obstruction during sleep and recurrent acute tonsillitis. Outcomes measures included the number of administered pain medications, time before returning to a full diet, Obstructive Sleep Apnea survey (OSA-18), parent's postoperative pain measure questionnaire (PPPM) and Wong-Baker Faces Pain Rating Scale (WBFPRS). RESULTS: Postoperative pain was significantly lower in the PITA group, as demonstrated by PPPM and WBFPRS scores and by a lower number of pain medications used. PITA group also resumed a regular diet earlier (P<0.001). OSA-18 scores proved that both PITA and AT were equally effective in curing upper-airway obstructive symptoms. CONCLUSION: PITA reduces post-tonsil ablation morbidity and can be a valid alternative to AT for treating upper-airway obstruction due to adenotonsillar hyperplasia.

Nutrition outcomes of HIV-infected malnourished adults treated with ready-to-use therapeutic food in sub-Saharan Africa: a longitudinal study.

BACKGROUND: Among people living with HIV/AIDS, nutritional support is increasingly recognized as a critical part of the essential package of care, especially for patients in sub-Saharan Africa. The objectives of the study were to evaluate the outcomes of HIV-positive malnourished adults treated with ready-to-use therapeutic food and to identify factors associated with nutrition programme failure. METHODS: We present results from a retrospective cohort analysis of patients aged 15 years or older with a body mass index of less than 17 kg/m² enrolled in three HIV/AIDS care programmes in Africa between March 2006 and August 2008. Factors associated with nutrition programme failure (patients discharged uncured after six or more months of nutritional care, defaulting from nutritional care, remaining in nutritional care for six or more months, or dead) were investigated using multiple logistic regression. RESULTS: Overall, 1340 of 8685 (15.4%) HIV-positive adults were enrolled in the nutrition programme. At admission, median body mass index was 15.8 kg/m² (IQR 14.9-16.4) and 12% received combination antiretroviral therapy (ART). After a median of four months of follow up (IQR 2.2-6.1), 524 of 1106 (47.4%) patients were considered cured. An overall total of 531 of 1106 (48.0%) patients failed nutrition therapy, 132 (11.9%) of whom died and 250 (22.6%) defaulted from care. Men (OR = 1.5, 95% CI 1.2-2.0), patients with severe malnutrition at nutrition programme enrolment (OR = 2.2, 95% CI 1.7-2.8), and those never started on ART (OR = 4.5, 95% CI 2.7-7.7 for those eligible; OR = 1.6, 95% CI 1.0-2.5 for those ineligible for ART at enrolment) were at increased risk of nutrition programme failure. Diagnosed tuberculosis at nutrition programme admission or during follow up, and presence of diarrhoeal disease or extensive candidiasis at admission, were unrelated to nutrition programme failure. CONCLUSIONS: Concomitant administration of ART and ready-to-use therapeutic food increases the chances of nutritional recovery in these high-risk patients. While adequate nutrition is necessary to treat malnourished HIV patients, development of improved strategies for the management of severely malnourished patients with HIV/AIDS are urgently needed.

Mortality risk among children admitted in a large-scale nutritional program in Niger, 2006.

BACKGROUND: In 2006, the Médecins sans Frontières nutritional program in the region of Maradi (Niger) included 68,001 children 6-59 months of age with either moderate or severe malnutrition, according to the NCHS reference (weight-for-height<80% of the NCHS median, and/or mid-upper arm circumference<110 mm for children taller than 65 cm and/or presence of bipedal edema). Our objective was to identify baseline risk factors for death among children diagnosed with severe malnutrition using the newly introduced WHO growth standards. As the release of WHO growth standards changed the definition of severe malnutrition, which now includes many children formerly identified as moderately malnourished with the NCHS reference, studying this new category of children is crucial. METHODOLOGY: Program monitoring data were collected from the medical records of all children admitted in the program. Data included age, sex, height, weight, MUAC, clinical signs on admission including edema, and type of discharge (recovery, death, and default/loss to follow up). Additional data included results of a malaria rapid diagnostic test due to Plasmodium falciparum (Paracheck) and whether the child was a resident of the region of Maradi or came from bordering Nigeria to seek treatment. Multivariate logistic regression was performed on a subset of 27,687 children meeting the new WHO growth standards criteria for severe malnutrition (weight-for-height<-3 Z score, mid-upper arm circumference<110 mm for children taller than 65 cm or presence of bipedal edema). We explored two different models: one with only basic anthropometric data and a second model that included perfunctory clinical signs. PRINCIPAL FINDINGS: In the first model including only weight, height, sex and presence of edema, the risk factors retained were the weight/height(1.84) ratio (OR: 5,774; 95% CI: [2,284; 14,594]) and presence of edema (7.51 [5.12; 11.0]). A second model, taking into account supplementary data from perfunctory clinical examination, identified other risk factors for death: apathy (9.71 [6.92; 13.6]), pallor (2.25 [1.25; 4.05]), anorexia (1.89 [1.35; 2.66]), fever>38.5 degrees C (1.83 [1.25; 2.69]), and age below 1 year (1.42 [1.01; 1.99]). CONCLUSIONS: Although clinicians will continue to perform screening using clinical signs and anthropometry, these risk indicators may provide additional criteria for the assessment of absolute and relative risk of death. Better appraisal of the child's risk of death may help orientate the child towards either hospitalization or ambulatory care. As the transition from the NCHS growth reference to the WHO standards will increase the number of children classified as severely malnourished, further studies should explore means to identify children at highest risk of death within this group using simple and standardized indicators.

Comparison of the new World Health Organization growth standards and the National Center for Health Statistics growth reference regarding mortality of malnourished children treated in a 2006 nutrition program in Niger.

OBJECTIVE: To compare the National Centre for Health Statistics (NCHS) international growth reference with the new World Health Organization (WHO) growth standards for identification of the malnourished (wasted) children most at risk of death. DESIGN: Retrospective data analysis. SETTING: A Médecins Sans Frontières (Doctors Without Borders) nutrition program in Maradi, Niger, in 2006 that treated moderately and severely malnourished children. PARTICIPANTS: A total of 53 661 wasted children aged 6 months to 5 years (272 of whom died) in the program were included. INTERVENTIONS: EpiNut (Epi Info 6.0; Centers for Disease Control and Prevention, Atlanta, Georgia) software was used to calculate the percentage of the median for the NCHS reference group, and the WHO (igrowup macro; Geneva, Switzerland) software was used to calculate z scores for the WHO standards group of the 53 661 wasted children. OUTCOME MEASURES: The main outcome measures are the difference in classification of children as either moderate or severely malnourished according to the NCHS growth reference and the new WHO growth standards, specifically focusing on children who died during the program. RESULTS: Of the children classified as moderately wasted using the NCHS reference, 37% would have been classified as severely wasted according to the new WHO growth standards. These children were almost 3 times more likely to die than those classified as moderately wasted by both references, and deaths in this group constituted 47% of all deaths in the program. CONCLUSIONS: The new WHO growth standards identifies more children as severely wasted compared with the NCHS growth reference, including children at high mortality risk who would potentially otherwise be excluded from some therapeutic feeding programs.

A large-scale distribution of milk-based fortified spreads: evidence for a new approach in regions with high burden of acute malnutrition.

BACKGROUND: There are 146 million underweight children in the developing world, which contribute to up to half of the world's child deaths. In high burden regions for malnutrition, the treatment of individual children is limited by available resources. Here, we evaluate a large-scale distribution of a nutritional supplement on the prevention of wasting. METHODS AND FINDINGS: A new ready-to-use food (RUF) was developed as a diet supplement for children under three. The intervention consisted of six monthly distributions of RUF during the 2007 hunger gap in a district of Maradi region, Niger, for approximately 60,000 children (length: 60-85 cm). At each distribution, all children over 65 cm had their Mid-Upper Arm Circumference (MUAC) recorded. Admission trends for severe wasting (WFH<70% NCHS) in Maradi, 2002-2005 show an increase every year during the hunger gap. In contrast, in 2007, throughout the period of the distribution, the incidence of severe acute malnutrition (MUAC<110 mm) remained at extremely low levels. Comparison of year-over-year admissions to the therapeutic feeding program shows that the 2007 blanket distribution had essentially the same flattening effect on the seasonal rise in admissions as the 2006 individualized treatment of almost 60,000 children moderately wasted. CONCLUSIONS: These results demonstrate the potential for distribution of fortified spreads to reduce the incidence of severe wasting in large population of children 6-36 months of age. Although further information is needed on the cost-effectiveness of such distributions, these results highlight the importance of re-evaluating current nutritional strategies and international recommendations for high burden areas of childhood malnutrition.