Population Enumeration and Household Utilization Survey Methods in the Enterics for Global Health (EFGH): Shigella Surveillance Study.

Background: Accurate estimation of diarrhea incidence from facility-based surveillance requires estimating the population at risk and accounting for case patients who do not seek care. The Enterics for Global Health (EFGH) Shigella surveillance study will characterize population denominators and healthcare-seeking behavior proportions to calculate incidence rates of Shigella diarrhea in children aged 6-35 months across 7 sites in Africa, Asia, and Latin America. Methods: The Enterics for Global Health (EFGH) Shigella surveillance study will use a hybrid surveillance design, supplementing facility-based surveillance with population-based surveys to estimate population size and the proportion of children with diarrhea brought for care at EFGH health facilities. Continuous data collection over a 24 month period captures seasonality and ensures representative sampling of the population at risk during the period of facility-based enrollments. Study catchment areas are broken into randomized clusters, each sized to be feasibly enumerated by individual field teams. Conclusions: The methods presented herein aim to minimize the challenges associated with hybrid surveillance, such as poor parity between survey area coverage and facility coverage, population fluctuations, seasonal variability, and adjustments to care-seeking behavior.

Data Management in Multicountry Consortium Studies: The Enterics For Global Health (EFGH) Shigella Surveillance Study Example.

Background: Rigorous data management systems and planning are essential to successful research projects, especially for large, multicountry consortium studies involving partnerships across multiple institutions. Here we describe the development and implementation of data management systems and procedures for the Enterics For Global Health (EFGH) Shigella surveillance study-a 7-country diarrhea surveillance study that will conduct facility-based surveillance concurrent with population-based enumeration and a health care utilization survey to estimate the incidence of Shigella--associated diarrhea in children 6 to 35 months old. Methods: The goals of EFGH data management are to utilize the knowledge and experience of consortium members to collect high-quality data and ensure equity in access and decision-making. During the planning phase before study initiation, a working group of representatives from each EFGH country site, the coordination team, and other partners met regularly to develop the data management systems for the study. Results: This resulted in the Data Management Plan, which included selecting REDCap and SurveyCTO as the primary database systems. Consequently, we laid out procedures for data processing and storage, study monitoring and reporting, data quality control and assurance activities, and data access. The data management system and associated real-time visualizations allow for rapid data cleaning activities and progress monitoring and will enable quicker time to analysis. Conclusions: Experiences from this study will contribute toward enriching the sparse landscape of data management methods publications and serve as a case study for future studies seeking to collect and manage data consistently and rigorously while maintaining equitable access to and control of data.

Assessing capacities and resilience of health services during the COVID-19 pandemic: Lessons learned from use of rapid key informant surveys.

This article is part of the Research Topic: 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict.' Problem: Many countries lacked rapid and nimble data systems to track health service capacities to respond to COVID-19. They struggled to assess and monitor rapidly evolving service disruptions, health workforce capacities, health products availability, community needs and perspectives, and mitigation responses to maintain essential health services. Method: Building on established methodologies, the World Health Organization developed a suite of methods and tools to support countries to rapidly fill data gaps and guide decision-making during COVID-19. The tools included: (1) a national "pulse" survey on service disruptions and bottlenecks; (2) a phone-based facility survey on frontline service capacities; and (3) a phone-based community survey on demand-side challenges and health needs. Use: Three national pulse surveys revealed persisting service disruptions throughout 2020-2021 (97 countries responded to all three rounds). Results guided mitigation strategies and operational plans at country level, and informed investments and delivery of essential supplies at global level. Facility and community surveys in 22 countries found similar disruptions and limited frontline service capacities at a more granular level. Findings informed key actions to improve service delivery and responsiveness from local to national levels. Lessons learned: The rapid key informant surveys provided a low-resource way to collect action-oriented health services data to inform response and recovery from local to global levels. The approach fostered country ownership, stronger data capacities, and integration into operational planning. The surveys are being evaluated to inform integration into country data systems to bolster routine health services monitoring and serve as health services alert functions for the future.

Acquisition of antibodies that block Plasmodium falciparum adhesion to placental receptor chondroitin sulfate A with increasing gravidity in Malian women.

In malaria-endemic areas, pregnant women are more susceptible to Plasmodium falciparum infection, especially primigravidae. During pregnancy, parasites sequester in the placenta and bind to the receptor chondroitin sulfate (CSA). This unique adhesion is mediated by the parasite protein VAR2CSA expressed on the surface of infected erythrocytes (IE). Placental malaria is associated with poor pregnancy outcomes including perinatal mortality, preterm delivery, small for gestational age (SGA) and low birthweight deliveries. Over successive pregnancies, women acquire functional antibodies that inhibit IE adhesion to CSA. Here, we examine the development of anti-adhesion activity and the breadth of anti-adhesion activity as a function of number of previous pregnancies, using samples collected from pregnant women living in an area with high seasonal malaria transmission. Women reached plateau levels of anti-adhesion activity and breadth of anti-adhesion activity after 5 pregnancies. We related the level of anti-adhesion activity and reactivity with surface IE to SGA 19/232 pregnancies resulted in SGA, and report that an increase of 10% in median anti-adhesion activity reduced the odds of SGA by 13% and this relationship approached significance. Further, at an anti-adhesion activity level of 43.7%, an increase of 10% in the breadth of activity significantly reduced the odds of SGA by 21.5%. Antibodies that recognize IE surface increased over successive pregnancies, but were not associated with a reduction in SGA. These results can serve as a guideline for assessing vaccine candidates aiming to reduce poor pregnancy outcomes associated with placental malaria.

Pregnancy outcomes in a malaria-exposed Malian cohort of women of child-bearing age.

In Sub-Saharan Africa, malaria continues to be associated with adverse pregnancy outcomes including stillbirth, early neonatal death, preterm delivery, and low birth weight. Current preventive measures are insufficient and new interventions are urgently needed. However, before such interventions can be tested in pregnant women, background information on pregnancy outcomes in this target population must be collected. We conducted an observational study in Ouélessébougou, Mali, a malaria-endemic area where first antenatal visit commonly occurs during the second trimester of pregnancy, hindering calculation of miscarriage rate in the population. To accurately determine the rate of miscarriage, 799 non-pregnant women of child-bearing age were enrolled and surveyed via monthly follow up visits that included pregnancy tests. Out of 505 women that completed the study, 364 became pregnant and 358 pregnancies were analyzed: 43 (12%) resulted in miscarriage, 28 (65.1%) occurred during the first trimester of pregnancy. We also determined rates of stillbirth, neonatal death, preterm delivery, and small for gestational age. The results showed high rate of miscarriage during the first trimester and established a basis to evaluate new interventions to prevent pregnancy malaria. This survey design enabled identification of first trimester miscarriages that are often missed by studies conducted in antenatal clinics. Clinical trial registration: [https://clinicaltrials.gov/], identifier [NCT0297 4608].

eHealth or e-Chaos: The use of Digital Health Interventions for Health Systems Strengthening in sub-Saharan Africa over the last 10 years: A scoping review.

Background: Digital health solutions are a potent and complementary intervention in health system strengthening to accelerate universal access to health services. Implementing scalable, sustainable, and integrated digital solutions in a coordinated manner is necessary to experience the benefits of digital interventions in health systems. We sought to establish the breadth and scope of available digital health interventions (DHIs) and their functions in sub-Saharan Africa. Methods: We conducted a scoping review according to the Joanne Briggs Institute's reviewers manual and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - Extension for Scoping Reviews (PRISMA-ScR) checklist and explanation. We retrieved data from the WHO Digital Health Atlas (DHA), the WHO e-Health country profiles report of 2015, and electronic databases. The protocol has been deposited in an open-source platform - the Open Science Framework at https://osf.io/5kzq7. Results: The researchers retrieved 983 digital tools used to strengthen health systems in sub-Saharan Africa over the past 10 years. We included 738 DHIs in the analysis while 245 were excluded for not meeting the inclusion criteria. We observed a disproportionate distribution of DHIs towards service delivery (81.7%, n = 603), health care providers (91.8%, n = 678), and access and use of information (84.1%, n = 621). Fifty-three percent (53.4%, n = 394) of the solutions are established and 47.5% (n = 582) were aligned to 20% (n = 5) of the system categories. Conclusions: Sub-Saharan Africa is endowed with digital health solutions in both numbers and distinct functions. It is lacking in coordination, integration, scalability, sustainability, and equitable distribution of investments in digital health. Digital health policymakers in sub-Saharan Africa need to urgently institute coordination mechanisms to terminate unending duplication and disjointed vertical implementations and manage solutions for scale. Central to this would be to build digital health leadership in countries within SSA, adopt standards and interoperability frameworks; advocate for more investments into lagging components, and promote multi-purpose solutions to halt the seeming "e-chaos" and progress to sustainable e-health solutions.

Recent malaria does not substantially impact COVID-19 antibody response or rates of symptomatic illness in communities with high malaria and COVID-19 transmission in Mali, West Africa.

Malaria has been hypothesized as a factor that may have reduced the severity of the COVID-19 pandemic in sub-Saharan Africa. To evaluate the effect of recent malaria on COVID-19 we assessed a subgroup of individuals participating in a longitudinal cohort COVID-19 serosurvey that were also undergoing intensive malaria monitoring as part of antimalarial vaccine trials during the 2020 transmission season in Mali. These communities experienced a high incidence of primarily asymptomatic or mild COVID-19 during 2020 and 2021. In 1314 individuals, 711 were parasitemic during the 2020 malaria transmission season; 442 were symptomatic with clinical malaria and 269 had asymptomatic infection. Presence of parasitemia was not associated with new COVID-19 seroconversion (29.7% (211/711) vs. 30.0% (181/603), p=0.9038) or with rates of reported symptomatic seroconversion during the malaria transmission season. In the subsequent dry season, prior parasitemia was not associated with new COVID-19 seroconversion (30.2% (133/441) vs. 31.2% (108/346), p=0.7499), with symptomatic seroconversion, or with reversion from seropositive to seronegative (prior parasitemia: 36.2% (64/177) vs. no parasitemia: 30.1% (37/119), p=0.3842). After excluding participants with asymptomatic infection, clinical malaria was also not associated with COVID-19 serostatus or symptomatic seroconversion when compared to participants with no parasitemia during the monitoring period. In communities with intense seasonal malaria and a high incidence of asymptomatic or mild COVID-19, we did not demonstrate a relationship between recent malaria and subsequent response to COVID-19. Lifetime exposure, rather than recent infection, may be responsible for any effect of malaria on COVID-19 severity.

Allelic variants of full-length VAR2CSA, the placental malaria vaccine candidate, differ in antigenicity and receptor binding affinity.

Plasmodium falciparum-infected erythrocytes (IE) sequester in the placenta via surface protein VAR2CSA, which binds chondroitin sulfate A (CSA) expressed on the syncytiotrophoblast surface, causing placental malaria (PM) and severe adverse outcomes in mothers and their offspring. VAR2CSA belongs to the PfEMP1 variant surface antigen family; PfEMP1 proteins mediate IE adhesion and facilitate parasite immunoevasion through antigenic variation. Here we produced deglycosylated (native-like) and glycosylated versions of seven recombinant full-length VAR2CSA ectodomains and compared them for antigenicity and adhesiveness. All VAR2CSA recombinants bound CSA with nanomolar affinity, and plasma from Malian pregnant women demonstrated antigen-specific reactivity that increased with gravidity and trimester. However, allelic and glycosylation variants differed in their affinity to CSA and their serum reactivities. Deglycosylated proteins (native-like) showed higher CSA affinity than glycosylated proteins for all variants except NF54. Further, the gravidity-related increase in serum VAR2CSA reactivity (correlates with acquisition of protective immunity) was absent with the deglycosylated form of atypical M200101 VAR2CSA with an extended C-terminal region. Our findings indicate significant inter-allelic differences in adhesion and seroreactivity that may contribute to the heterogeneity of clinical presentations, which could have implications for vaccine design.

Malaria Infection Is Common and Associated With Perinatal Mortality and Preterm Delivery Despite Widespread Use of Chemoprevention in Mali: An Observational Study 2010 to 2014.

BACKGROUND: In malaria-endemic areas, pregnant women and especially first-time mothers are more susceptible to Plasmodium falciparum. Malaria diagnosis is often missed during pregnancy, because many women with placental malaria remain asymptomatic or have submicroscopic parasitemia, masking the association between malaria and pregnancy outcomes. Severe maternal anemia and low birthweight deliveries are well-established sequelae, but few studies have confirmed the relationship between malaria infection and severe outcomes like perinatal mortality in high transmission zones. METHODS: Pregnant women of any gestational age enrolled at antenatal clinic into a longitudinal cohort study in Ouelessebougou, Mali, an area of high seasonal malaria transmission. Follow-up visits included scheduled and unscheduled visits throughout pregnancy. Blood smear microscopy and polymerase chain reaction (PCR) analysis were employed to detect both microscopic and submicroscopic infections, respectively. Intermittent preventative treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) was documented and prompt treatment regardless of symptoms given upon malaria diagnosis. RESULTS: Of the 1850 women followed through delivery, 72.6% of women received 2 or more IPTp-SP doses, 67.2% of women experienced at least 1 infection between enrollment up to and including delivery. Malaria infection increased the risks of stillbirth (adjusted hazard ratio [aHR] 3.87, 95% confidence interval [CI]: 1.18-12.71) and preterm delivery (aHR 2.41, 95% CI: 1.35-4.29) in primigravidae, and early neonatal death (death within 7 days) in secundigravidae and multigravidae (aHR 6.30, 95% CI: 1.41-28.15). CONCLUSIONS: Malaria treatment after diagnosis, alongside IPTp-SP, is insufficient to prevent malaria-related stillbirth, early neonatal death and preterm delivery (PTD). Although IPTp-SP was beneficial in Mali during the study period, new tools are needed to improve pregnancy outcomes. CLINICAL TRIALS REGISTRATION: NCT01168271.

Adverse pregnancy outcomes among women presenting at antenatal clinics in Ouélessébougou, Mali.

BACKGROUND: In sub-Saharan Africa, malaria continues to scourge the population and is the primary cause of morbidity and mortality in young children and pregnant women. As current preventative measures such as intermittent preventive treatment and use of insecticide-treated nets provide incomplete protection, several malaria vaccines are currently under development, including one to specifically prevent pregnancy malaria. Prior to conducting vaccine trials, it is important to obtain background information on poor pregnancy outcomes in the target population to establish a baseline. METHODS: Pregnant women presenting at community health care centers for antenatal care were recruited to the study. Gestational age was determined by ultrasound examination following recruitment. Antenatal care and pregnancy outcome information were collected during a visit 4-8 weeks post-delivery. RESULTS: One thousand eight hundred fifty women completed the study, and analysis included 1814 women after excluding multiple gestations (n = 26) and missing/incomplete data (n = 10). The percentage (95% CI) of adverse pregnancy outcomes is as follows: miscarriage, 0.28% (0.04-0.52); stillbirth, 1.93% (1.30-2.56); early neonatal death, 1.65% (1.03-2.24); late neonatal death, 0.39%, (0.10-0.68); and preterm delivery (PTD), 4.74% (3.76-5.73). The percentages of early and late neonatal deaths and PTD were significantly higher (p < 0.01) in primigravid compared to multigravid women. In primigravidae, 3.1, 1.1 and 7.1% of pregnancies resulted in early neonatal death, late neonatal death and PTD, respectively, while these outcomes in multigravidae were 1.0, 0.1 and 2.7%, respectively. Major malformations were identified in 4 newborns. CONCLUSIONS: Low gravidity and young age predict perinatal death and PTD. The information collected here can be used as a baseline for adverse pregnancy outcomes in future vaccine trials in pregnant women.

Systemic Inflammatory Response to Malaria During Pregnancy Is Associated With Pregnancy Loss and Preterm Delivery.

BACKGROUND: Pregnancy malaria (PM) is associated with a proinflammatory immune response characterized by increased levels of cytokines and chemokines such as tumor necrosis factor-α, interferon-γ, interleukin 10 (IL-10), and CXCL9. These changes are associated with poor outcomes including low birthweight delivery and maternal anemia. However, it is unknown if inflammatory pathways during malaria are related to pregnancy loss and preterm delivery (PTD). METHODS: Cytokine and chemokine levels were measured in maternal peripheral blood at enrollment, gestational week 30-32, and delivery, and in placental blood, of 638 women during a longitudinal cohort study in Ouelessebougou, Mali. Plasmodium falciparum infection was assessed by blood smear microscopy at all visits. RESULTS: PM was associated with increased levels of cytokines and chemokines including IL-10 and CXCL9. In a competing risks model adjusted for known covariates, high CXCL9 levels measured in the peripheral blood during pregnancy were associated with increased risk of pregnancy loss and PTD. At delivery, high IL-10 levels in maternal blood were associated with an increase in pregnancy loss, and increased IL-1ß levels in placental blood were associated with pregnancy loss and PTD. CONCLUSIONS: PM is associated with increased proinflammatory cytokine and chemokine levels in placental and maternal peripheral blood. Systemic inflammatory responses to malaria during pregnancy predict increased risk of pregnancy loss and PTD. CLINICAL TRIALS REGISTRATION: NCT01168271.

Clinical Research and the Training of Host Country Investigators: Essential Health Priorities for Disease-Endemic Regions.

The health-care needs and resources of disease-endemic regions such as west Africa have been a major focus during the recent Ebola outbreak. On the basis of that experience, we call attention to two priorities that have unfortunately been ignored thus far: 1) the development of clinical research facilities and 2) the training of host country investigators to ensure that the facilities and expertise necessary to evaluate candidate interventions are available on-site in endemic regions when and where they are needed. In their absence, as illustrated by the recent uncertainty about the use of antivirals and other interventions for Ebola virus disease, the only treatment available may be supportive care, case fatality rates may be unacceptably high and there may be long delays between the time potential interventions become available and it becomes clear whether those interventions are safe or effective. On the basis of our experience in Mali, we urge that the development of clinical research facilities and the training of host country investigators be prioritized in disease-endemic regions such as west Africa.

Does the survival motor neuron copy number variation play a role in the onset and severity of sporadic amyotrophic lateral sclerosis in Malians?

INTRODUCTION: Spinal muscular atrophy (SMA) and sporadic amyotrophic lateral sclerosis (SALS) are both motor neuron disorders. SMA results from the deletion of the survival motor neuron (SMN) 1 gene. High or low SMN1 copy number and the absence of SMN2 have been reported as risk factors for the development or severity of SALS. OBJECTIVE: To investigate the role of SMN gene copy number in the onset and severity of SALS in Malians. MATERIAL AND METHODS: We determined the SMN1 and SMN2 copy number in genomic DNA samples from 391 Malian adult volunteers, 120 Yoruba from Nigeria, 120 Luyha from Kenya and 74 U.S. Caucasians using a Taqman quantitative PCR assay. We evaluated the SALS risk based on the estimated SMA protein level using the Veldink formula (SMN1 copy number + 0.2 ∗ SMN2 copy number). We also characterized the disease natural history in 15 ALS patients at the teaching hospital of Point G, Bamako, Mali. RESULTS: We found that 131 of 391 (33.5%) had an estimated SMN protein expression of ≤ 2.2; 60 out of 391 (15.3%) had an estimated SMN protein expression < 2 and would be at risk of ALS and the disease onset was as early as 16 years old. All 15 patients were male and some were physically handicapped within 1-2 years in the disease course. CONCLUSION: Because of the short survival time of our patients, family histories and sample DNA for testing were not done. However, our results show that sporadic ALS is of earlier onset and shorter survival time as compared to patients elsewhere. We plan to establish a network of neurologists and researchers for early screening of ALS.

Non-motor signs in patients with Parkinson's disease at the University Hospital of Point "G", Mali.

INTRODUCTION: Despite significant progress in the field of scientific research on Parkinson's disease (PD), the prevalence and pathophysiology of its non-motor signs remains less understood than the classic motor signs of bradykinesia, rigidity, tremor and postural instability. Data covering this topic are rare in Africa, and almost non-existent in sub-Saharan Africa. Thus, this study aims to highlight the frequency of certain non-motor signs in PD patients followed in the Department of Neurology of the University Hospital Point "G", Bamako, Mali. METHODOLOGY: This is a retrospective and descriptive study from January 2012 to November 2013. We identified records of patients with dopamine-responsive idiopathic Parkinson's disease, and quantified associated non-motor symptoms. Data were analyzed with Epi-Info 2000 version 3.5.5. RESULT: During this period we reviewed 60 patient charts of which 68.3% were men. The average age of patients was 66.51 ranging from 25 to 94 years.Non-motor symptoms were present in 90% of cases, including sensitive disorders in 76.7%, dysautonomia in 73.3%, and psycho-behavioral disorders, including sleep disorders, in 81.7%. CONCLUSION: At the end of this study, we observed an important place for non-motor signs in the clinical manifestation of PD patients in general.

Socio-cultural adaptation and standardization of Dubois' five words testing in a population of normal subject in Mali, West Africa.

INTRODUCTION: Dubois' five words testing (5WT) is a verbal memory test that depends on many parameters. The aim of this study is to adapt Dubois' 5WT to the Malian socio-cultural conditions to (i) determine performances of normal subjects to the 5WT and (ii) provide reference scores of the 5WT. METHODS: A sample of 276 normal subjects aged ≥ 50 years (154 males and 122 females; 144 literates and 132 illiterates) were enrolled from February 2008 to January 2009. Subjects with a history of symptoms likely to modify cognitive functions and those who were found disabled under Lawton's four simplified item test were excluded. RESULTS: The learning score in illiterates was 1.51 in Dubois' 5WT and 4.90 in the modified 5WT. The mean value of the modified 5WT total score was 9.71. Majority (90.22%) of the subjects scored the maximum (10). The modified 5WT reduced with both the age (p < 0.006) and education level (p < 0.04). CONCLUSION: Our results show that Dubois' 5WT is influenced by culture and the socio-educative level in French. Its adaptation to the socio-cultural context could prove useful and efficient in countries with a low literacy rate and a diverse cultural background.

Moving data off the shelf and into action: an intervention to improve data-informed decision making in Côte d'Ivoire.

BACKGROUND: Improving a health system requires data, but too often they are unused or under-used by decision makers. Without interventions to improve the use of data in decision making, health systems cannot meet the needs of the populations they serve. In 2008, in Côte d'Ivoire, data were largely unused in health decision-making processes. OBJECTIVE: To implement and evaluate an intervention to improve the use of data in decision making in Cote d'Ivoire. DESIGN: From 2008 to 2012, Cote d'Ivoire sought to improve the use of national health data through an intervention that broadens participation in and builds links between data collection and decision-making processes; identifies information needs; improves data quality; builds capacity to analyze, synthesize, and interpret data; and develops policies to support data use. To assess the results, a Performance of Routine Information System Management Assessment was conducted before and after the intervention using a combination of purposeful and random sampling. In 2008, the sample consisted of the central level, 12 districts, and 119 facilities, and in 2012, the sample consisted of the central level, 20 districts, and 190 health facilities. To assess data use, we developed dichotomous indicators: discussions of analysis findings, decisions taken based on the analysis, and decisions referred to upper management for action. We aggregated the indicators to generate a composite, continuous index of data use. RESULTS: From 2008 to 2012, the district data-use score increased from 40 to 70%; the facility score remained the same - 38%. The central score is not reported, because of a methodological difference in the two assessments. CONCLUSIONS: The intervention improved the use of data in decision making at the district level in Côte d'Ivoire. This study provides an example of, and guidance for, implementing a large-scale intervention to improve data-informed decision making.

Evaluation of the Mercy weight estimation method in Ouelessebougou, Mali.

BACKGROUND: This study evaluated the performance of a new weight estimation strategy (Mercy Method) with four existing weight-estimation methods (APLS, ARC, Broselow, and Nelson) in children from Ouelessebougou, Mali. METHODS: Otherwise healthy children, 2 mos to 16 yrs, were enrolled and weight, height, humeral length (HL) and mid-upper arm circumference (MUAC) obtained by trained raters. Weight estimation was performed as described for each method. Predicted weights were regressed against actual weights. Agreement between estimated and actual weight was determined using Bland-Altman plots with log-transformation. Predictive performance of each method was assessed using residual error (RE), percentage error (PE), root mean square error (RMSE), and percent predicted within 10, 20 and 30% of actual weight. RESULTS: 473 children (8.1±4.8 yr, 25.1±14.5 kg, 120.9±29.5 cm) participated in this study. The Mercy Method (MM) offered the best correlation between actual and estimated weight when compared with the other methods (r2=0.97 vs. 0.80-0.94). The MM also demonstrated the lowest ME (0.06 vs. 0.92-4.1 kg), MPE (1.6 vs. 7.8-19.8%) and RMSE (2.6 vs. 3.0-6.7). Finally, the MM estimated weight within 20% of actual for nearly all children (97%) as opposed to the other methods for which these values ranged from 50-69%. CONCLUSIONS: The MM performed extremely well in Malian children with performance characteristics comparable to those observed for U.S and India and could be used in sub-Saharan African children without modification extending the utility of this weight estimation strategy.