Active Surveillance for Adverse Events After a Mass Vaccination Campaign With a Group A Meningococcal Conjugate Vaccine (PsA-TT) in Mali.

BACKGROUND: The monovalent meningococcal A conjugate vaccine (PsA-TT, MenAfriVac) was developed for use in the "meningitis belt" of sub-Saharan Africa. Mali was 1 of 3 countries selected for early introduction. As this is a new vaccine, postlicensure surveillance is particularly important to identify and characterize possible safety issues. METHODS: The national vaccination campaign was phased from September 2010 to November 2011. We conducted postlicensure safety surveillance for PsA-TT in 40 government clinics from southern Mali serving approximately 400 000 people 1-29 years of age. We conducted analyses with individual-level data and population-level data, and we calculated rates of adverse events using the conditional exact test, a modified vaccine cohort risk interval method, and a modified self-controlled case series method for each outcome of interest, including 18 prespecified adverse events and 18 syndromic categories. RESULTS: An increased rate of clinic visits for fever within 3 days after vaccination was found using multiple methods for all age groups. Although other signals were found with some methods, complete assessment of all other prespecified outcomes and syndromic categories did not reveal that PsA-TT was consistently associated with any other health problem. CONCLUSIONS: No new safety concerns were identified in this study. These results are consistent with prelicensure data and other studies indicating that PsA-TT is safe. The approach presented could serve as a model for future active postlicensure vaccine safety monitoring associated with large-scale immunization campaigns in low-income countries.

Conflict, displacement and sexual and reproductive health services in Mali: analysis of 2013 health resources availability mapping system (HeRAMS) survey.

OBJECTIVE: Little is known specifically about the effects of conflict and displacement on provision of sexual and reproductive health (SRH) services. We aimed to understand the association between levels of conflict and displacement and the availability of SRH services in post-conflict Mali. METHODS: A national assessment was conducted between April and May 2013 employing Health Systems Availability Mapping System (HeRAMS). Data from 1581 primary care facilities were analysed, focusing on SRH services. Descriptive analyses and multivariable logistic regression models were used to examine the availability of SRH services by different levels of conflict and displacement. FINDINGS: Of 1581 facilities, 1551 had data available to identify the details of service provision. The majority of the facilities were part of the public sector (79.1 %), identified as basic community primary care facilities (71.9 %). Overall 15.7 % of the facilities were in the zones under occupation, 40.3 % in the areas with high concentration of displaced population and 44 % in areas with low concentration of displaced populations. Between zones of low concentration of displaced populations and under occupation the likelihood of service availability varied between OR: 2.9 (95 % CI 2.0-4.4) for basic emergency obstetric care and OR: 41.7 (95 % CI 20.4-85.3) for family planning. All of the services within the three domains of SRH were more likely to be available in the low and high concentration displaced population areas compared to the facilities in the under occupation zones, after adjusting for other facility-related variables. CONCLUSION: Areas with high concentration of displaced population had less service availability, and areas formerly under occupation had the least service availability. This suggests that those living in conflict areas, and many of those who are internally displaced, have poor access to essential SRH interventions. The systematic measurement of the availability of health services, including SRH, is feasible and can contribute to recovery planning in post-conflict and humanitarian settings.

[Cholera epidemics in Mali between 1995 and 2004]. / Les epidémies de choléra au Mali de 1995 & 2004.

INTRODUCTION: Cholera represents a public health problem in developing countries like Mali. AIM: This work aims to describe the characteristics of the cholera epidemics which occurred in Mali between 1995 and 2004. METHOD: A retrospective survey was conducted within the Division of the fight against the diseases of epidemic potential and the Institute of Public Health and Research of the Ministry of Health of Mali. Individual medical records tracking the follow-up of patients as well as the registers of these structures were used as sources to collect data for the study. RESULTS: There were 12,176 cases of cholera recorded, including 1,406 deaths, from 1995 to 2004. Cholera outbreaks in Mali have been a regular occurrence every year since 2001. The regions of Mopti and Segou seem to be the most impacted by these epidemics. The lethal rates were higher than 1% at the time of each of these epidemics during this period. Vibrio cholerae O: 1, biotype El Tor were responsible for the epidemics, and the serotype Ogawa was prevalent. CONCLUSION: Cholera epidemics have been constant in Mali since the beginning of the 21st century in spite of the efforts which have been made to prevent and control them. A rigorous analysis of the factors which support this persistence and appropriate measures are essential to reverse cholera in this country.

Cost analysis of an integrated disease surveillance and response system: case of Burkina Faso, Eritrea, and Mali.

BACKGROUND: Communicable diseases are the leading causes of illness, deaths, and disability in sub-Saharan Africa. To address these threats, countries within the World Health Organization (WHO) African region adopted a regional strategy called Integrated Disease Surveillance and Response (IDSR). This strategy calls for streamlining resources, tools, and approaches to better detect and respond to the region's priority communicable disease. The purpose of this study was to analyze the incremental costs of establishing and subsequently operating activities for detection and response to the priority diseases under the IDSR. METHODS: We collected cost data for IDSR activities at central, regional, district, and primary health care center levels from Burkina Faso, Eritrea, and Mali, countries where IDSR is being fully implemented. These cost data included personnel, transportation items, office consumable goods, media campaigns, laboratory and response materials and supplies, and annual depreciation of buildings, equipment, and vehicles. RESULTS: Over the period studied (2002-2005), the average cost to implement the IDSR program in Eritrea was $0.16 per capita, $0.04 in Burkina Faso and $0.02 in Mali. In each country, the mean annual cost of IDSR was dependent on the health structure level, ranging from $35,899 to $69,920 at the region level, $10,790 to $13,941 at the district level, and $1,181 to $1,240 at the primary health care center level. The proportions spent on each IDSR activity varied due to demand for special items (e.g., equipment, supplies, drugs and vaccines), service availability, distance, and the epidemiological profile of the country. CONCLUSION: This study demonstrates that the IDSR strategy can be considered a low cost public health system although the benefits have yet to be quantified. These data can also be used in future studies of the cost-effectiveness of IDSR.

Impact of intermittent preventive treatment with sulphadoxine-pyrimethamine targeting the transmission season on the incidence of clinical malaria in children in Mali.

BACKGROUND: Recent studies have shown that intermittent preventive malaria treatment (IPT) in infants in areas of stable malaria transmission reduces malaria and severe anaemia incidence. However in most areas malaria morbidity and mortality remain high in older children. METHODS: To evaluate the effect of seasonal IPT with sulphadoxine pyrimethamine (SP) on incidence of malaria disease in area of seasonal transmission, 262 children 6 months-10 years in Kambila, Mali were randomized to receive either IPT with SP twice at eight weeks interval or no IPT during the transmission season of 2002 and were followed up for 12 months. Subjects were also followed during the subsequent transmission season in 2003 to assess possible rebound effect. Clinical malaria cases were treated with SP and followed to assess the in vivo response during both periods. RESULTS: The incidence rate of malaria disease per 1,000 person-months during the first 12 months was 3.2 episodes in the treatment group vs. 5.8 episodes in the control group with age-adjusted Protective Efficacy (PE) of 42.5%; [95% CI 28.6%-53.8%]. When the first 16 weeks of follow up is considered age-adjusted PE was 67.5% [95% CI 55.3% - 76.6%]. During the subsequent transmission season, the incidence of clinical malaria per 1000 persons-days was similar between the two groups (23.0 vs 21.5 episodes, age-adjusted IRR = 1.07 [95% CI, 0.90-1.27]). No significant difference was detected in in vivo response between the groups during both periods. CONCLUSION: Two malaria intermittent treatments targeting the peak transmission season reduced the annual incidence rate of clinical malaria by 42.5% in an area with intense seasonal transmission. This simple strategy is likely to be one of the most effectives in reducing malaria burden in such areas. TRIAL REGISTRATION: Clinicaltrials.gov NCT00623155.

Acceptability and efficacy of intra-rectal quinine alkaloids as a pre-transfer treatment of non-per os malaria in peripheral health care facilities in Mopti, Mali.

BACKGROUND: The acceptability and efficacy of a new kit with a new formulation of quinine alkaloids designed for the intra-rectal administration in the treatment of non-per os malaria was assessed in the peripheral health care system of Mopti, Mali. METHODS: A single-arm trial was conducted from August 2003 to January 2004. An initial dose of diluted quinine alkaloids (20 mg/kg Quinimax) was administered by the intra-rectal route to children with presumptive non per-os malaria at six peripheral heath care centres. The children were then referred to two referral hospitals where standard inpatient care including intravenous route were routinely provided. A malaria thick smear was done at inclusion and a second malaria thick smear after arrival at the referral facility, where a more complete clinical examination and laboratory testing was done to confirm diagnosis. Confirmed cases of severe malaria or others diseases were treated according to national treatment guidelines. Cases of non per-os malaria received a second dose of intra rectal quinine alkaloids. Primary outcome was acceptability of the intra rectal route by children and their parents as well as the ease to handle the kit by health care workers. RESULTS: The study included 134 children with a median age of 33 months and 53.7% were male. Most of the children (67%) and 92% of parents or guardians readily accepted the intra-rectal route; 84% of health care workers found the kit easy to use. At the peripheral health care centres, 32% of children had a coma score < or = 3 and this was reduced to 10% at the referral hospital, following one dose of intra-rectal quinine alkaloids (IRQA). The mean time to availability of oral route treatment was 1.8 +/- 1.1 days. Overall, 73% of cases were confirmed severe malaria and for those the case fatality rate was 7.2%. CONCLUSION: IRQA was well accepted by children, their parents/guardians and by the health workers at peripheral health facilities in Mopti, Mali. There was also a quick recovery from deep coma and a reduced case fatality rate in severe malaria.

Efficacy of chloroquine and sulfadoxine/pyrimethamine for the treatment of uncomplicated falciparum malaria in Koumantou, Mali.

We report the results of an in vivo antimalarial efficacy study with chloroquine (CQ) and sulfadoxine/pyrimethamine (SP) conducted between 2003 and 2004 in Koumantou, southern Mali. A total of 244 children were included in the study; 210 children were followed-up for 28 days according to WHO recommendations, with PCR genotyping to distinguish late recrudescence from re-infection. Global failure proportions at Day 14, without taking into account re-infections, were 44.2% (95% CI 34.9-53.5%) in the CQ group and 2.0% (95% CI 0.0-4.8%) in the SP group. PCR-adjusted failure proportions at Day 28 were even higher in the CQ group (90.5% (95/105), 95% CI 84.8-96.2%) and relatively low in the SP group (7.0% (7/100), 95% CI 1.9-12.1%). These results show that CQ is no longer efficacious in Koumantou. The use of SP in monotherapy is likely to compromise its efficacy. We recommend the use of artemisinin-based combination therapy as first-line treatment for uncomplicated Plasmodium falciparum malaria in Koumantou.

Malaria treatment in remote areas of Mali: use of modern and traditional medicines, patient outcome.

Use of official health services often remains low despite great efforts to improve quality of care. Are informal treatments responsible for keeping a number of patients away from standard care, and if so, why? Through a questionnaire survey with proportional cluster samples, we studied the case histories of 952 children in Bandiagara and Sikasso areas of Mali. Most children with reported uncomplicated malaria were first treated at home (87%) with modern medicines alone (40%), a mixture of modern and traditional treatments (33%), or traditional treatment alone (27%). For severe episodes (224 cases), a traditional treatment alone was used in 50% of the cases. Clinical recovery after uncomplicated malaria was above 98% with any type of treatment. For presumed severe malaria, the global mortality rate was 17%; it was not correlated with the type of treatment used (traditional or modern, at home or elsewhere). In the study areas, informal treatments divert a high proportion of patients away from official health services. Patients' experience that outcome after standard therapeutic itineraries is not better than after alternative care may help to explain low use of official health services. We need to study whether some traditional treatments available in remote villages should be considered real, recommendable first aid.

[Breast cancer: factors influencing the therapeutic itinerary of patients in a medical oncology unit in Bamako (Mali)]. / Cancer du sein: facteurs influençant l'itinéraire thérapeutique des usagers d'un service d'oncologie médicale à Bamako (Mali).

Early therapy is a determining factor to the recovery in patients with breast cancer. The situation in Mali is characterized by the delayed diagnosis of this cancer which raises the hypothesis that medical itinerary of patients received in specialized oncology unit is particular. In order to verify this hypothesis, 44 patients including 43 women and one man aged 25 to 80 years (mean age 46.0 19.6 years), seen in medical oncology unit in Point G, were subjects of an interview about the motivation of their therapeutic itinerary. 22.7% was initially seen by a traditional physician and 77.3% by a health care professional. The request of care was influenced by the patient's representation of the disease and by their neighboring. The therapeutic itinerary: "from traditional medicine to conventional medicine" was the more frequently observed in our patients with a long delay between the first consultation and the specialized one. Very few patients have received information about their illness before their specialized consultation. We conclude that the medical itinerary of our patients is particular, that this itinerary is influenced by the patient's representation of the cancer and by difficulty in the relationship between patients and health professional. This raise questions about the quality of both the communication and the provided health care. So, health care for patients with breast cancer in Mali might widely consider the anthropological dimension of the disease.