Randomized Trial of Vaccines for Zaire Ebola Virus Disease.

BACKGROUND: Questions remain concerning the rapidity of immune responses and the durability and safety of vaccines used to prevent Zaire Ebola virus disease. METHODS: We conducted two randomized, placebo-controlled trials - one involving adults and one involving children - to evaluate the safety and immune responses of three vaccine regimens against Zaire Ebola virus disease: Ad26.ZEBOV followed by MVA-BN-Filo 56 days later (the Ad26-MVA group), rVSVΔG-ZEBOV-GP followed by placebo 56 days later (the rVSV group), and rVSVΔG-ZEBOV-GP followed by rVSVΔG-ZEBOV-GP 56 days later (the rVSV-booster group). The primary end point was antibody response at 12 months, defined as having both a 12-month antibody concentration of at least 200 enzyme-linked immunosorbent assay units (EU) per milliliter and an increase from baseline in the antibody concentration by at least a factor of 4. RESULTS: A total of 1400 adults and 1401 children underwent randomization. Among both adults and children, the incidence of injection-site reactions and symptoms (e.g., feverishness and headache) was higher in the week after receipt of the primary and second or booster vaccinations than after receipt of placebo but not at later time points. These events were largely low-grade. At month 12, a total of 41% of adults (titer, 401 EU per milliliter) and 78% of children (titer, 828 EU per milliliter) had a response in the Ad26-MVA group; 76% (titer, 992 EU per milliliter) and 87% (titer, 1415 EU per milliliter), respectively, had a response in the rVSV group; 81% (titer, 1037 EU per milliliter) and 93% (titer, 1745 EU per milliliter), respectively, had a response in the rVSV-booster group; and 3% (titer, 93 EU per milliliter) and 4% (titer, 67 EU per milliliter), respectively, had a response in the placebo group (P<0.001 for all comparisons of vaccine with placebo). In both adults and children, antibody responses with vaccine differed from those with placebo beginning on day 14. CONCLUSIONS: No safety concerns were identified in this trial. With all three vaccine regimens, immune responses were seen from day 14 through month 12. (Funded by the National Institutes of Health and others; PREVAC ClinicalTrials.gov number, NCT02876328; EudraCT numbers, 2017-001798-18 and 2017-001798-18/3rd; and Pan African Clinical Trials Registry number, PACTR201712002760250.).

Field testing of user-friendly perennial malaria chemoprevention packaging in Benin, Côte d'Ivoire and Mozambique.

BACKGROUND: Perennial malaria chemoprevention (PMC) aims to protect children at risk from severe malaria by the administration of anti-malarial drugs to children of defined ages throughout the year. Sulfadoxine-pyrimethamine (SP) has been widely used for chemoprevention in Africa and a child-friendly dispersible tablet formulation has recently become available. METHODS: This qualitative non-interventional observational study was conducted in Benin, Côte d'Ivoire, and Mozambique between February and June 2022. Prototype blister packs, dispensing boxes and job aids designed to support dispersible SP deployment for PMC were evaluated using focus group discussions (FGD) and semi-structured in-depth individual interviews (IDI) with health authorities, health personnel, community health workers (CHWs) and caregivers. The aim was to evaluate knowledge and perceptions of malaria and chemoprevention, test understanding of the tools and identify gaps in understanding, satisfaction, user-friendliness and acceptability, and assess the potential role of CHWs in PMC implementation. Interviews were transcribed and imported to ATLAS.ti for encoding and categorization. Thematic content analysis used deductive and inductive coding with cross-referencing of findings between countries and participants to enrich data interpretation. Continuous comparison across the IDI and FGD permitted iterative, collaborative development of materials. RESULTS: Overall, 106 participants completed IDIs and 70 contributed to FGDs. Malaria was widely recognised as the most common disease affecting children, and PMC was viewed as a positive intervention to support child health. The role of CHWs was perceived differently by the target groups, with caregivers appreciating their trusted status in the community, whereas health authorities preferred clinic-based deployment of PMC by health professionals. Empirical testing of the prototype blister packs, dispensing boxes and job aids highlighted the context-specific expectations of respondents, such as familiar situations and equipment, and identified areas of confusion or low acceptance. A key finding was the need for a clear product identity reflecting malaria. CONCLUSION: Simple modifications profoundly affected the perception of PMC and influenced acceptability. Iterative quantitative investigation resulted in PMC-specific materials suited to the local context and socio-cultural norms of the target population with the aim of increasing access to chemoprevention in children most at risk of severe malaria.

Tropicalisation of epidemiological models in Africa: A mixed and hybrid approach to better predict COVID-19 indicators.

CONTEXT: Since the outbreak of the SARS-COV2 epidemic turned into a COVID-19 pandemic, international bodies such as the WHO as well as governments have announced projections for morbidity and mortality indicators related to COVID-19. Most of them indicated that the health situation would be worrying. Although using artificial intelligence with mathematical algorithms and/or neural networks, the results of the SIR models were poorly performing and not very accurate in relation to the observed reality in the African states in general and in Senegal in particular. Hence the imperative need to configure the modelling process and approach considering local contexts. METHOD: The model implemented is a mixed prediction model based on the Bucky model developed by OCHA and adapted to the context. The construction of the mixed model was done in two steps (basic model with publicly available data, such as those from United Nations-like organisations such as OCHA or WHO for Senegal), (adding more specific data collected through the mixed epidemiological survey). This survey was conducted in Senegal in six localities (Dakar, Thies, Diourbel, Kedougou, Saint-Louis and Ziguinchor) chosen according to the number of confirmed cases of COVID-19. In total, 1000 individuals distributed in proportion to the size of the regions were interviewed in April 2021. RESULTS: The projected cases in the baseline model were already considerably higher than the cases reported in April. This may be plausible, given the low detection rates throughout Senegal during this period. However, the hybrid model predicted an even higher infection rate than the baseline, perhaps mainly due to vulnerability related to food insecurity and solid cooking fuels. This may mean that there would be more unreported cases than reported. Overall, the mortality rate of both models would be considerably lower than the government-reported mortality rate, even though the number of confirmed cases remains high. This may be an underestimate of the death rate. CONCLUSION: An accurate and reliable prediction in times of epidemics and/or pandemics, such as COVID-19, should be based on mixed or hybrid data integrating a quantitative and qualitative approach to enable better policymaking. The projections resulting from this approach would still be effective and would take better account of local realities and contexts, especially for developing countries.

Participatory research for the development of information, education and communication tools to promote intermittent preventive treatment of malaria in pregnancy in the Democratic Republic of the Congo, Nigeria and Mozambique.

BACKGROUND: To improve the coverage of intermittent preventive treatment of malaria in pregnancy (IPTp) in Africa, Medicines for Malaria Venture (MMV) developed, tested and validated a new packaging of sulfadoxine-pyrimethamine (SP), as well as specific communications tools designed to improve knowledge of IPTp and the motivation of women to adhere to it, particularly if it is distributed by community health workers (CHW). METHODS: This article describes and analyses the results of an empirical research carried out in the Democratic Republic of the Congo (DRC), Nigeria and Mozambique, to evaluate the perception and social acceptability of SP for healthcare providers, CHW and pregnant women, and to assess the ability of the new SP packaging and the communications tools to change their perception of SP and improve their attitudes towards IPTp. RESULTS: The results indicate that SP's new individual packaging was perceived by pregnant women and healthcare providers as a "hygienic" and "safe", with a specific identity. The graphics used in IPTp communications tools were modified according to the respondents' feedback to make them more culturally and socially sensitive, and then validated. However, although the new blister packaging and IPTp communications tools generated greater confidence and motivation, SP side effects as well as preconceived ideas, particularly regarding its efficacy, remain a challenge that must be addressed to improve IPTp acceptance and compliance by healthcare providers and pregnant women. CONCLUSION: This participatory approach to social research based on ongoing feedback to the graphic designer provided more empirical evidence to improve and adapt the textual and visual content of communication tools (SP blister packaging, leaflet, user guide) to local contexts and user preferences. Tested and validated in different socio-cultural and socio-political contexts, these tools provide a good basis for the promotion of IPTp in Africa.

Effectiveness of Seasonal Malaria Chemoprevention in Children under Ten Years of Age in Senegal: A Stepped-Wedge Cluster-Randomised Trial.

BACKGROUND: Seasonal Malaria Chemoprevention (SMC) with sulfadoxine-pyrimethamine (SP) plus amodiaquine (AQ), given each month during the transmission season, is recommended for children living in areas of the Sahel where malaria transmission is highly seasonal. The recommendation for SMC is currently limited to children under five years of age, but, in many areas of seasonal transmission, the burden in older children may justify extending this age limit. This study was done to determine the effectiveness of SMC in Senegalese children up to ten years of age. METHODS AND FINDINGS: SMC was introduced into three districts over three years in central Senegal using a stepped-wedge cluster-randomised design. A census of the population was undertaken and a surveillance system was established to record all deaths and to record all cases of malaria seen at health facilities. A pharmacovigilance system was put in place to detect adverse drug reactions. Fifty-four health posts were randomised. Nine started implementation of SMC in 2008, 18 in 2009, and a further 18 in 2010, with 9 remaining as controls. In the first year of implementation, SMC was delivered to children aged 3-59 months; the age range was then extended for the latter two years of the study to include children up to 10 years of age. Cluster sample surveys at the end of each transmission season were done to measure coverage of SMC and the prevalence of parasitaemia and anaemia, to monitor molecular markers of drug resistance, and to measure insecticide-treated net (ITN) use. Entomological monitoring and assessment of costs of delivery in each health post and of community attitudes to SMC were also undertaken. About 780,000 treatments were administered over three years. Coverage exceeded 80% each month. Mortality, the primary endpoint, was similar in SMC and control areas (4.6 and 4.5 per 1000 respectively in children under 5 years and 1.3 and 1.2 per 1000 in children 5-9 years of age; the overall mortality rate ratio [SMC: no SMC] was 0.90, 95% CI 0.68-1.2, p = 0.496). A reduction of 60% (95% CI 54%-64%, p < 0.001) in the incidence of malaria cases confirmed by a rapid diagnostic test (RDT) and a reduction of 69% (95% CI 65%-72%, p < 0.001) in the number of treatments for malaria (confirmed and unconfirmed) was observed in children. In areas where SMC was implemented, incidence of confirmed malaria in adults and in children too old to receive SMC was reduced by 26% (95% CI 18%-33%, p < 0.001) and the total number of treatments for malaria (confirmed and unconfirmed) in these older age groups was reduced by 29% (95% CI 21%-35%, p < 0.001). One hundred and twenty-three children were admitted to hospital with a diagnosis of severe malaria, with 64 in control areas and 59 in SMC areas, showing a reduction in the incidence rate of severe disease of 45% (95% CI 5%-68%, p = 0.031). Estimates of the reduction in the prevalence of parasitaemia at the end of the transmission season in SMC areas were 68% (95% CI 35%-85%) p = 0.002 in 2008, 84% (95% CI 58%-94%, p < 0.001) in 2009, and 30% (95% CI -130%-79%, p = 0.56) in 2010. SMC was well tolerated with no serious adverse reactions attributable to SMC drugs. Vomiting was the most commonly reported mild adverse event but was reported in less than 1% of treatments. The average cost of delivery was US$0.50 per child per month, but varied widely depending on the size of the health post. Limitations included the low rate of mortality, which limited our ability to detect an effect on this endpoint. CONCLUSIONS: SMC substantially reduced the incidence of outpatient cases of malaria and of severe malaria in children, but no difference in all-cause mortality was observed. Introduction of SMC was associated with an overall reduction in malaria incidence in untreated age groups. In many areas of Africa with seasonal malaria, there is a substantial burden in older children that could be prevented by SMC. SMC in older children is well tolerated and effective and can contribute to reducing malaria transmission. TRIAL REGISTRATION: ClinicalTrials.gov NCT00712374.

"When I sleep under the net, nothing bothers me; I sleep well and I'm happy": Senegal's culture of net use and how inconveniences to net use do not translate to net abandonment.

BACKGROUND: Despite recent advances in the fight against the disease, malaria remains a serious threat to the health and well-being of populations in endemic countries. The use of long-lasting insecticidal nets (LLIN) reduces contact between the vector and humans, thereby reducing transmission of the disease. LLINs have become an essential component of malaria control programmes worldwide. METHODS: The Culture of Net Use study used qualitative and quantitative methods in a longitudinal and iterative design over two phases, in order to capture changes in net use over a year and a half period and covering both dry and rainy seasons. Data were collected from a total of 56 households in eight regions to understand variations due to geographical, cultural, and universal coverage differences. At the time of the data collection, the universal coverage campaign had been completed in six of the eight regions (Dakar and Thies excluded). RESULTS: Perceived barriers to use were primarily related to the characteristics of the net itself, include shape, insecticide, and a variety of minority responses, such as perceived lack of mosquito density and being unaccustomed to using nets. Insecticide-related complaints found that insecticide did not present a significant barrier to use, but was cited as a nuisance. Feelings of suffocation continued to be the most commonly cited nuisance. Respondents who favoured the use of insecticide on nets appeared to be more aware of the health and malaria prevention benefits of the insecticide than those who perceived it negatively. CONCLUSION: Despite prior evidence that barriers such as heat, shape, insecticide and perceived mosquito density contribute to non-use of LLINs in other countries, this study has shown that these factors are considered more as nuisances and that they do not consistently prevent the use of nets among respondents in Senegal. Of those who cited inconveniences with their nets, few were moved to stop using a net. Respondents from this study overcame these barriers and continue to value the importance of nets.

"You need to take care of it like you take care of your soul": perceptions and behaviours related to mosquito net damage, care, and repair in Senegal.

BACKGROUND: Net care and repair behaviours are essential for prolonging the durability of long-lasting insecticidal nets. Increased net durability has implications for protection against malaria as well as cost savings from less frequent net distributions. This study investigated behaviours and motivations for net care and repair behaviours in Senegal with the aim of informing social and behaviour change communication (SBCC) programmes, using the Health Belief Model as a framework. METHODS: Data were collected from 114 participants in eight regions of Senegal. Participants were eligible for the study if they were at least 18 years old and if their household owned at least one net. These respondents included 56 in-depth interview respondents and eight focus groups with 58 participants. In addition, the qualitative data were supplemented with observational questionnaire data from a total of 556 sleeping spaces. Of these spaces, 394 had an associated net. RESULTS: Reported net care and repair behaviours and motivations varied substantially within this sample. Children and improper handling were seen as major sources of net damage and respondents often tried to prevent damage by storing nets when not in use. Washing was seen as an additional method of care, but practices for washing varied and may have been damaging to nets in some cases. Participants mentioned a sense of pride of having a net in good condition and the uncertainty around when they could expect another net distribution as motivations for net care. Net repair appeared to be a less common behaviour and was limited by the perspective that net degradation was inevitable and that repairs themselves could weaken nets. CONCLUSION: These findings can be understood using the Health Belief Model framework of perceived severity, perceived susceptibility, perceived barriers, perceived benefits, self-efficacy, and cues to action. This model can guide SBCC messages surrounding net care and repair to promote practices associated with net longevity. Such messages should promote the benefits of intact nets and provide tools for overcoming barriers to care and repair.

User-determined end of net life in Senegal: a qualitative assessment of decision-making related to the retirement of expired nets.

BACKGROUND: Procurement and distribution of long-lasting insecticidal nets (LLINs) in the African region has decreased from 145 million in 2010 to 66 million nets in 2012. As resources for LLIN distribution appear to stagnate, it is important to understand the users' perception of the life span of a net and at what point and why they stop using it. In order to get the most value out of distributed nets and to ensure that they are used for as long as possible, programmes must communicate to users about how to assess useful net life and how to extend it. METHODS: Data were collected from 114 respondents who participated in 56 in-depth interviews (IDIs) and eight focus group discussions (FGDs) in August 2012 in eight regions in Senegal. Households were eligible for the study if they owned at least one net and had an available household member over the age of 18. Data were coded by a team of four coders in ATLAS.ti using a primarily deductive approach. RESULTS: Respondents reported assessing useful net life using the following criteria: the age of net, the number and size of holes and the presence of mosquitoes in the net at night. If they had the means to do so, many respondents preferred the acquisition of a new net rather than the continued use of a very torn net. However, respondents would preferentially use newer nets, saving older, but useable nets for the future or sharing them with family or friends. Participants reported observing alternative uses of nets, primarily for nets that were considered expired. CONCLUSIONS: The results indicate that decisions regarding the end of net life vary among community members in Senegal, but are primarily related to net integrity. Additional research is needed into user-determined end of net life as well as care and repair behaviours, which could extend useful net life. The results from this study and from future research on this topic should be used to understand current behaviours and develop communication programmes to prolong the useful life of nets.

Community case management in malaria: review and perspectives after four years of operational experience in Saraya district, south-east Senegal.

BACKGROUND: Despite recent advances in malaria diagnosis and treatment, many isolated communities in rural settings continue to lack access to these life-saving tools. Community-case management of malaria (CCMm), consisting of lay health workers (LHWs) using malaria rapid diagnostic tests (RDTs) and artemisinin-based combination therapy (ACT) in their villages, can address this disparity. METHODS: This study examined routine reporting data from a CCMm programme between 2008 and 2011 in Saraya, a rural district in Senegal, and assessed its impact on timely access to rapid diagnostic tests and ACT. RESULTS: There was a seven-fold increase in the number of LHWs providing care and in the number of patients seen. LHW engagement in the CCM programme varied seasonally, 24,3% of all patients prescribed an ACT had a negative RDT or were never administered an RDT, and less than half of patients with absolute indications for referral (severe symptoms, age under two months and pregnancy) were referred. There were few stock-outs. DISCUSSION: This CCMm programme successfully increased the number of patients with access to RDT and ACT, but further investigation is required to identify the cause for over-prescription, and low rates of referrals for patients with absolute indications. In contrast, previous widespread stock-outs in Saraya's CCMm programme have now been resolved. CONCLUSION: This study demonstrates the potential for CCMm programmes to substantially increase access to life-saving malarial diagnostics and treatment, but also highlights important challenges in ensuring quality.

Factors influencing hesitancy towards adult and child COVID-19 vaccines in rural and urban West Africa: a cross-sectional study.

OBJECTIVES: This study aims: (1) to identify and describe similarities and differences in both adult and child COVID-19 vaccine hesitancy, and (2) to examine sociodemographic, perception-related and behavioural factors influencing vaccine hesitancy across five West African countries. DESIGN: Cross-sectional survey carried out between 5 May and 5 June 2021. PARTICIPANTS AND SETTING: 4198 individuals from urban and rural settings in Burkina Faso, Guinea, Mali, Senegal and Sierra Leone participated in the survey. STUDY REGISTRATION: The general protocol is registered on clinicaltrial.gov. RESULTS: Findings show that in West Africa at the time only 53% of all study participants reported to be aware of COVID-19 vaccines, and television (60%, n=1345), radio (56%; n=1258), social media (34%; n=764) and family/friends/neighbours (28%; n=634) being the most important sources of information about COVID-19 vaccines. Adult COVID-19 vaccine acceptance ranges from 60% in Guinea and 50% in Sierra Leone to 11% in Senegal. This is largely congruent with acceptance levels of COVID-19 vaccinations for children. Multivariable regression analysis shows that perceived effectiveness and safety of COVID-19 vaccines increased the willingness to get vaccinated. However, sociodemographic factors, such as sex, rural/urban residence, educational attainment and household composition (living with children and/or elderly), and the other perception parameters were not associated with the willingness to get vaccinated in the multivariable regression model. CONCLUSIONS: Primary sources of information about COVID-19 vaccines include television, radio and social media. Communication strategies addressed at the adult population using mass and social media, which emphasise COVID-19 vaccine effectiveness and safety, could encourage greater acceptance also of COVID-19 child vaccinations in sub-Saharan countries. TRIAL REGISTRATION NUMBER: NCT04912284.

Critical insights on the demographic concept of "birth spacing": locating Nef in family well-being, bodies, and relationships in Senegal.

Birth spacing has emerged since the early 1980s as a key concept to improve maternal and child health, triggering interest in birth spacing practices in low-income countries, and drawing attention to prevailing norms in favour of long birth intervals in West Africa. In Senegal, the Wolof concept of Nef, which means having children too closely spaced in time, is morally condemned and connotes a resulting series of negative implications for family well-being. While Nef and "birth spacing" intersect in key ways, including acknowledging the health benefits of longer birth intervals, they are not translations of each other, for each is embedded in distinct broader cultural and political assumptions about social relations. Most notably, proponents of the demographic concept of birth spacing assume that the practice of using contraception after childbearing to postpone births could contribute to "empowering" women socially. In Senegal, by contrast, preventing Nef (or short birth intervals) is also viewed as strengthening family well-being by allowing women to care more fully for their family. This paper draws on policy documents and interviews to explore women's and men's understanding of Nef, and in turn critically reflect on the demographic concept of birth spacing. Our findings reinforce the relevance of the concept of birth spacing to engage with women and men around family planning services in Senegal. Accounts of the Nef taboo in Senegal also show that social norms stigmatising short birth intervals can legitimise constraints faced by women on control of their body.

Enrolling study personnel in Ebola vaccine trials: from guidelines to practice in a non-epidemic context.

BACKGROUND: Enrolling participants in clinical trials can be challenging, especially with respect to prophylactic vaccine trials. The vaccination of study personnel in Ebola vaccine trials during the 2014-2016 epidemic played a crucial role in inspiring trust and facilitating volunteer enrollment. We evaluated the ethical and methodological considerations as they applied to an ongoing phase 2 randomized prophylactic Ebola vaccine trial that enrolled healthy volunteers in Guinea, Liberia, Sierra Leone, and Mali in a non-epidemic context. METHODS: On the assumption that the personnel on site involved in executing the protocol, as well as community mobilizers (not involved in the on-site procedures), might also volunteer to enter the trial, we considered both ethical and methodological considerations to set clear rules that can be shared a priori with these persons. We reviewed the scientific and gray literature to identify relevant references and then conducted an analysis of the ethical and methodological considerations. RESULTS: There are currently no regulations preventing a clinical investigator or site staff from participating in a trial. However, the enrollment of personnel raises the risk of undue influence and challenges the basic ethical principle of voluntary participation. The confidentiality of personal medical information, such as HIV test results, may also be difficult to ensure among personnel. There is a risk of disruption of trial operations due to the potential absence of the personnel for their commitment as trial participants, and there is also a potential for introducing differential behavior of on-site staff as they obtain access to accumulating information during the trial (e.g., the incidence of adverse events). Blinding could be jeopardized, given knowledge of product-specific adverse event profiles and the proximity to unblinded site staff. These aspects were considered more relevant for on-site staff than for community mobilizers, who have limited contact with site staff. CONCLUSION: In a non-epidemic context, ethical and methodological considerations limit the collective benefit of enrolling site staff in a vaccine trial. These considerations do not apply to community mobilizers, whose potential enrollment should be considered as long as they meet the inclusion criteria and they are not exposed to any form of coercion.

[Becoming a mother in Senegal: the experience of motherhood in a setting of social injustice and health service failures]. / Devenir mère au Sénégal : des expériences de maternité entre inégalités sociales et défaillances des services de santé

We explain here the processes through which social injustice is created, the indicators that define social status, and the mechanism that express them in the field of health. Because we do not believe that they come out of any natural process, we seek to discover the extent to which they are socially produced. The data we use here come from a qualitative survey conducted in a rural community (Malicounda, Senegal) and targeting pregnant women and those giving birth. The results show that the individual environments, the policies of the maternal health services and women's social standing contribute jointly to the experience of motherhood and to access to health care. Taking into account the realties of health care facilities (places of mediation, personalization of health care relations), the social situation, defined as all the resources and all of the women's attributes, determines to a large extent the care or management she receives in those facilities. Three cases studies show how individual characteristics, social resources, relationships, and structural and political factors define social status and access to care. These attributes are so closely connected that it is hard to assign to any one of them an exclusive role in explaining social injustice. They also change throughout her lifetime, depending on social, occupational, emotional or relational successes or failures, which modify her social status and affect her life and health experiences.

Understanding 'missed appointments' for pills and injectables: a mixed methods study in Senegal.

INTRODUCTION: High discontinuation rates of contraceptive methods have been documented in sub-Saharan Africa. However, little is known about gaps within individual episodes of method use, despite their implications for unintended pregnancies. The objective of this mixed methods study was to examine the prevalence of, and explore the factors contributing to, delays in repeat appointments for pills and injectables in Senegal. METHODS: First, we constructed a longitudinal data set of women's contraceptive consultations using routine records from 67 facilities in Senegal. Consultations for pills and injectables were classified as on time, delayed or with unknown delay status based on time since previous appointment. We described the prevalence of delayed appointments and used backward stepwise regression to build a mixed-effects model to investigate risk factors for delay. Second, we conducted workshops with family planning (FP) providers, and indepth interviews and focus group discussions with women of reproductive age, to explore factors contributing to delays. RESULTS: Almost one-third (30%) of appointments for pills and injectables were delayed, resulting in risk of pregnancy. Previous delay, pill use, lower educational level, higher parity, third and subsequent visits, and Islamic faith were independently predictive of delays (p<0.04 for all). Although women's 'forgetfulness' was initially mentioned as the main reason for delays by women and providers, examining the routines around appointment attendance revealed broader contextual barriers to timely refills-particularly widespread covert use, illiteracy, financial cost of FP services and limited availability of FP services. CONCLUSION: Delays in obtaining repeat pills and injections are common among contraceptive users in Senegal, exposing women to unintended pregnancies. Strategies to reduce such delays should move beyond a narrow focus on individual women to consider contraceptive behaviour within the broader socioeconomic and health systems context. In particular, effective interventions addressing low acceptability of contraception and appointment reminder strategies in high illiteracy contexts are needed.

Author Correction: Implementation, coverage and equity of large-scale door-to-door delivery of Seasonal Malaria Chemoprevention (SMC) to children under 10 in Senegal.

A correction to this article has been published and is linked from the HTML and PDF versions of this paper. The error has not been fixed in the paper.

Implementation, coverage and equity of large-scale door-to-door delivery of Seasonal Malaria Chemoprevention (SMC) to children under 10 in Senegal.

SMC has been introduced widely in the Sahel since its recommendation by WHO in 2012. This study, which provided evidence of feasibility that supported the recommendation, included school-age and pre-school children. School-age children were not included in the 2012 recommendation but bear an increasing proportion of cases. In 2006, consultations with health-staff were held to choose delivery methods. The preferred approach, door-to-door with the first daily-dose supervised by a community-health-worker (CHW), was piloted and subsequently evaluated on a large-scale in under-5's in 2008 and then in under-10's 2009-2010. Coverage was higher among school-age children (96%(95%CI 94%,98%) received three treatments in 2010) than among under 5's (90%(86%,94%)). SMC was more equitable than LLINs (odds-ratio for increase in coverage for a one-level rise in socioeconomic-ranking (a 5-point scale), was 1.1 (0.95,1.2) in 2009, compared with OR 1.3 (1.2,1.5) for sleeping under an LLIN. Effective communication was important in achieving high levels of uptake. Continued training and supervision were needed to ensure CHWs adhered to treatment guidelines. SMC door-to-door can, if carefully supervised, achieve high equitable coverage and high-quality delivery. SMC programmes can be adapted to include school-age children, a neglected group that bears a substantial burden of malaria.

Vaccination and blood sampling acceptability during Ramadan fasting month: A cross-sectional study in Conakry, Guinea.

INTRODUCTION: There are few data on the acceptability of vaccination or blood sampling during Ramadan fasting month in Muslim countries. This could impact vaccination campaigns, clinical trials or healthcare during Ramadan. METHODS: Using a semi-structured questionnaire, we conducted a cross-sectional study on 201 practising Muslims and 10 religious leaders in Conakry, Guinea in the wake of the recent epidemic Ebola epidemic. Acceptability of vaccination and blood sampling during Ramadan were investigated as well as reasons for refusal. RESULTS: Vaccination was judged acceptable during Ramadan by 46% (93/201, 95% CI 0.40-0.53) of practising Muslims versus 80% (8/10, 95% CI 0.49-0.94) of religious leaders (p=0.11). Blood sampling was judged acceptable during Ramadan by 54% (108/201, 95% CI 0.47-0.60) of practising Muslims versus 80% (8/10, 95% CI 0.49-0.94) of religious leaders (p=0.19). The percentage of participants that judged both blood sampling and vaccination acceptable during Ramadan was 40% (81/201, 95% CI 0.34-0.47) for practising Muslims versus 80% (8/10, 95% CI 0.49-0.94) for religious leaders (p=0.048). The most common reasons for refusal of vaccination or blood sampling were that nothing should enter or leave the body during Ramadan (43%), that adverse events could lead to breaking the fast (32%), that blood should not be seen during Ramadan (9%) and that the Quran explicitly forbids it (9%). DISCUSSION: Although most Muslims leaders and scientists consider that injections including immunization and blood sampling should be authorized during Ramadan, many Muslims in our study judged vaccination or blood sampling unacceptable when fasting. Widely available recommendations on healthcare during Ramadan would be useful to inform Muslims.