Evolution of the monitoring and evaluation strategies to support the World Health Organization's Global Programme to Eliminate Lymphatic Filariasis.

The Global Programme to Eliminate Lymphatic Filariasis (GPELF) was established with the ambitious goal of eliminating LF as a public health problem. The remarkable success of the GPELF over the past 2 decades in carrying out its principal strategy of scaling up and scaling down mass drug administration has relied first on the development of a rigorous monitoring and evaluation (M&E) framework and then the willingness of the World Health Organization and its community of partners to modify this framework in response to the practical experiences of national programmes. This flexibility was facilitated by the strong partnership that developed among researchers, LF programme managers and donors willing to support the necessary research agenda. This brief review summarizes the historical evolution of the GPELF M&E strategies and highlights current research needed to achieve the elimination goal.

Soil-transmitted helminthiasis in four districts in Bangladesh: household cluster surveys of prevalence and intervention status.

BACKGROUND: In 2016, after 8 years of twice-annual nationwide preventive chemotherapy (PC) administration to school-age children (SAC), the Bangladesh Ministry of Health & Family Welfare (MOHFW) sought improved impact and intervention monitoring data to assess progress toward the newly adopted goal of eliminating soil-transmitted helminthiasis (STH) as a public health problem. METHODS: We surveyed four Bangladeshi districts between August and October 2017. We conducted a multi-stage, cluster-sample, household survey which produced equal-probability samples for preschool-age children (PSAC; 1-4 years), SAC (5-14 years), and adults (≥ 15 years). Standardized questionnaires were administered, using Android-based smart phones running an Open Data Kit application. Stool samples were collected and testing for STH prevalence and infection intensity used the Kato-Katz technique. RESULTS: In all, 4318 stool samples were collected from 7164 participants. Estimates of STH prevalence by risk group in three of the four surveyed districts ranged from 3.4 to 5.0%, all with upper, 1-sided 95% confidence limits < 10%. However, STH prevalence estimates in Sirajganj District ranged from 23.4 to 29.1%. Infections in that district were spatially focal; four of the 30 survey clusters had > 50% prevalence in at least one risk group. Among all tested specimens, Ascaris lumbricoides was the most common STH parasite [8.2% (n = 352)], followed by Trichuris trichiura [0.9% (n = 37)], and hookworm [0.6% (n = 27)]. In each district, PC coverage among SAC was above the 75% program target but did not exceed 45% among PSAC in any district. Improved sanitation at home, school, or work was over 90% in all districts. CONCLUSIONS: In the three low-prevalence districts, the MOHFW is considering decreasing the frequency of mass drug administration, per World Health Organization (WHO) guidelines. Also, the MOHFW will focus programmatic resources and supervisory efforts on Sirajganj District. Despite considering WHO guidance, the MOHFW will not expand PC administration to women of reproductive age partly due to the low prevalence of hookworm and T. trichiura, the STH parasites that contribute most to morbidity in that risk group. Data collected from surveys such as ours would help effectively guide future STH control efforts in Bangladesh and elsewhere.

The rationale and cost-effectiveness of a confirmatory mapping tool for lymphatic filariasis: Examples from Ethiopia and Tanzania.

Endemicity mapping is required to determining whether a district requires mass drug administration (MDA). Current guidelines for mapping LF require that two sites be selected per district and within each site a convenience sample of 100 adults be tested for antigenemia or microfilaremia. One or more confirmed positive tests in either site is interpreted as an indicator of potential transmission, prompting MDA at the district-level. While this mapping strategy has worked well in high-prevalence settings, imperfect diagnostics and the transmission potential of a single positive adult have raised concerns about the strategy's use in low-prevalence settings. In response to these limitations, a statistically rigorous confirmatory mapping strategy was designed as a complement to the current strategy when LF endemicity is uncertain. Under the new strategy, schools are selected by either systematic or cluster sampling, depending on population size, and within each selected school, children 9-14 years are sampled systematically. All selected children are tested and the number of positive results is compared against a critical value to determine, with known probabilities of error, whether the average prevalence of LF infection is likely below a threshold of 2%. This confirmatory mapping strategy was applied to 45 districts in Ethiopia and 10 in Tanzania, where initial mapping results were considered uncertain. In 42 Ethiopian districts, and all 10 of the Tanzanian districts, the number of antigenemic children was below the critical cutoff, suggesting that these districts do not require MDA. Only three Ethiopian districts exceeded the critical cutoff of positive results. Whereas the current World Health Organization guidelines would have recommended MDA in all 55 districts, the present results suggest that only three of these districts requires MDA. By avoiding unnecessary MDA in 52 districts, the confirmatory mapping strategy is estimated to have saved a total of $9,293,219.

Tetanus Immunity among Women Aged 15 to 39 Years in Cambodia: a National Population-Based Serosurvey, 2012.

To monitor progress toward maternal and neonatal tetanus elimination (MNTE) in Cambodia, we conducted a nationwide serosurvey of tetanus immunity in 2012. Multistage cluster sampling was used to select 2,154 women aged 15 to 39 years. Tetanus toxoid antibodies in serum samples were measured by gold-standard double-antigen enzyme-linked immunosorbent assay (DAE) and a novel multiplex bead assay (MBA). Antibody concentrations of ≥0.01 IU/ml by DAE or the equivalent for MBA were considered seroprotective. Estimated tetanus seroprotection was 88% (95% confidence interval [CI], 86 to 89%); 64% (95% CI, 61 to 67%) of women had antibody levels of ≥1.0 IU/ml. Seroprotection was significantly lower (P < 0.001) among women aged 15 to 19 years (63%) and 20 to 24 years (87%) than among those aged ≥25 years (96%), among nulliparous women than among parous women (71 versus 97%), and among those living in the western region than among those living in other regions (82 versus 89%). The MBA showed high sensitivity (99% [95% CI, 98 to 99%]) and specificity (92% [95% CI, 88 to 95%]) compared with DAE. Findings were compatible with MNTE in Cambodia (≥80% protection). Tetanus immunity gaps should be addressed through strengthened routine immunization and targeted vaccination campaigns. Incorporating tetanus testing in national serosurveys using MBAs, which can measure immunity to multiple pathogens simultaneously, may be beneficial for monitoring MNTE.

Predictors of health worker performance after Integrated Management of Childhood Illness training in Benin: a cohort study.

BACKGROUND: Correct treatment of potentially life-threatening illnesses (PLTIs) in children under 5 years, such as malaria, pneumonia, and diarrhea, can substantially reduce mortality. The Integrated Management of Childhood Illness (IMCI) strategy has been shown to improve treatment of child illnesses, but multiple studies have shown that gaps in health worker performance remain after training. To better understand factors related to health worker performance, we analyzed 9,330 patient consultations in Benin from 2001-2002, after training one of the first cohorts of 32 health workers in IMCI. METHODS: With data abstracted from patient registers specially designed for IMCI-trained health workers, we examined associations between health facility-, health worker-, and patient-level factors and 10 case-management outcomes for PLTIs. RESULTS: Altogether, 63.6% of children received treatment for all their PLTIs in accordance with IMCI guidelines, and 77.8% received life-saving treatment (i.e., clinically effective treatment, even if not exactly in accordance with IMCI guidelines). Performance of individual health workers varied greatly, from 15-88% of patients treated correctly, on average. Multivariate regression analyses identified several factors that might have influenced case-management quality, many outside a manager's direct control. Younger health workers significantly outperformed older ones, and infants received better care than older children. Children with danger signs, those with more complex illnesses, and those with anemia received worse care. Health worker supervision was associated with improved performance for some outcomes. CONCLUSIONS: A variety of factors, some outside the direct control of program managers, can influence health worker practices. An understanding of these influences can help inform the development of strategies to improve performance.

Unprogrammed deworming in the Kibera slum, Nairobi: implications for control of soil-transmitted helminthiases.

BACKGROUND: Programs for control of soil-transmitted helminth (STH) infections are increasingly evaluating national mass drug administration (MDA) interventions. However, "unprogrammed deworming" (receipt of deworming drugs outside of nationally-run STH control programs) occurs frequently. Failure to account for these activities may compromise evaluations of MDA effectiveness. METHODS: We used a cross-sectional study design to evaluate STH infection and unprogrammed deworming among infants (aged 6-11 months), preschool-aged children (PSAC, aged 1-4 years), and school-aged children (SAC, aged 5-14 years) in Kibera, Kenya, an informal settlement not currently receiving nationally-run MDA for STH. STH infection was assessed by triplicate Kato-Katz. We asked heads of households with randomly-selected children about past-year receipt and source(s) of deworming drugs. Local non-governmental organizations (NGOs) and school staff participating in school-based deworming were interviewed to collect information on drug coverage. RESULTS: Of 679 children (18 infants, 184 PSAC, and 477 SAC) evaluated, 377 (55%) reported receiving at least one unprogrammed deworming treatment during the past year. PSAC primarily received treatments from chemists (48.3%) or healthcare centers (37.7%); SAC most commonly received treatments at school (55.0%). Four NGOs reported past-year deworming activities at 47 of >150 schools attended by children in our study area. Past-year deworming was negatively associated with any-STH infection (34.8% vs 45.4%, p = 0.005). SAC whose most recent deworming medication was sourced from a chemist were more often infected with Trichuris (38.0%) than those who received their most recent treatment from a health center (17.3%) or school (23.1%) (p = 0.05). CONCLUSION: Unprogrammed deworming was received by more than half of children in our study area, from multiple sources. Both individual-level treatment and unprogrammed preventive chemotherapy may serve an important public health function, particularly in the absence of programmed deworming; however, they may also lead to an overestimation of programmed MDA effectiveness. A standardized, validated tool is needed to assess unprogrammed deworming.

Evaluating health worker performance in Benin using the simulated client method with real children.

BACKGROUND: The simulated client (SC) method for evaluating health worker performance utilizes surveyors who pose as patients to make surreptitious observations during consultations. Compared to conspicuous observation (CO) by surveyors, which is commonly done in developing countries, SC data better reflect usual health worker practices. This information is important because CO can cause performance to be better than usual. Despite this advantage of SCs, the method's full potential has not been realized for evaluating performance for pediatric illnesses because real children have not been utilized as SCs. Previous SC studies used scenarios of ill children that were not actually brought to health workers. During a trial that evaluated a quality improvement intervention in Benin (the Integrated Management of Childhood Illness [IMCI] strategy), we conducted an SC survey with adult caretakers as surveyors and real children to evaluate the feasibility of this approach and used the results to assess the validity of CO. METHODS: We conducted an SC survey and a CO survey (one right after the other) of health workers in the same 55 health facilities. A detailed description of the SC survey process was produced. Results of the two surveys were compared for 27 performance indicators using logistic regression modeling. RESULTS: SC and CO surveyors observed 54 and 185 consultations, respectively. No serious problems occurred during the SC survey. Performance levels measured by CO were moderately higher than those measured by SCs (median CO - SC difference = 16.4 percentage-points). Survey differences were sometimes much greater for IMCI-trained health workers (median difference = 29.7 percentage-points) than for workers without IMCI training (median difference = 3.1 percentage-points). CONCLUSION: SC surveys can be done safely with real children if appropriate precautions are taken. CO can introduce moderately large positive biases, and these biases might be greater for health workers exposed to quality improvement interventions. TRIAL NUMBER: http://clinicaltrials.gov Identifier NCT00510679.

Trends in health worker performance after implementing the Integrated Management of Childhood Illness strategy in Benin.

OBJECTIVE: Training health workers to use Integrated Management of Childhood Illness (IMCI) guidelines can improve care for ill children in outpatient settings in developing countries. However, even after IMCI training, important performance gaps exist. One potential reason is that the effect of training can rapidly wane. Our aim was to determine if the performance of IMCI-trained health workers deteriorated over 3 years. METHODS: We studied two departments in Benin. First, we performed a record review of 32 IMCI-trained health workers during the first year of IMCI implementation (2001-2002). Second, we analysed data from cross-sectional health facility surveys from 2001 to 2004 that represented the entire study area. Primary outcomes were the proportion of children under 5 years old with potentially life-threatening illnesses who received either recommended or adequate treatment, and among all children, an index of overall guideline adherence. Secondary outcomes reflected the treatment of individual diseases. Outcomes were calculated monthly, and time trends were evaluated with regression modelling. RESULTS: The record review included 9393 consultations, and the surveys included 411 consultations performed by 105 health workers. For both data sources, performance trends were essentially flat for nearly all outcomes. Absolute levels of performance revealed substantial performance gaps. CONCLUSIONS: We found no evidence that performance declined over 3 years after IMCI training. However, important performance gaps found immediately after IMCI training persisted and should be addressed.

Impact of a malaria-control project in Benin that included the integrated management of childhood illness strategy.

OBJECTIVES: To estimate the impact of the Integrated Management of Childhood Illness (IMCI) strategy on early-childhood mortality, we evaluated a malaria-control project in Benin that implemented IMCI and promoted insecticide-treated nets (ITNs). METHODS: We conducted a before-and-after intervention study that included a nonrandomized comparison group. We used the preceding birth technique to measure early-childhood mortality (risk of dying before age 30 months), and we used health facility surveys and household surveys to measure process indicators. RESULTS: Most process indicators improved in the area covered by the intervention. Notably, because ITNs were also promoted in the comparison area children's ITN use increased by about 20 percentage points in both areas. Regarding early-childhood mortality, the trend from baseline (1999-2001) to follow-up (2002-2004) for the intervention area (13.0% decrease; P < .001) was 14.1% (P < .001) lower than was the trend for the comparison area (1.3% increase; P = .46). CONCLUSIONS: Mortality decreased in the intervention area after IMCI and ITN promotion. ITN use increased similarly in both study areas, so the mortality impact of ITNs in the 2 areas might have canceled each other out. Thus, the mortality reduction could have been primarily attributable to IMCI's effect on health care quality and care-seeking.

The rise and fall of supervision in a project designed to strengthen supervision of Integrated Management of Childhood Illness in Benin.

OBJECTIVE: In developing countries, supervision is a widely recognized strategy for improving health worker performance; and anecdotally, maintaining regular, high-quality supervision is difficult. However, remarkably little research has explored in depth why supervision is so challenging. METHODS: In the context of a trial to improve health worker adherence to Integrated Management of Childhood Illness (IMCI) guidelines and strengthen supervision in southeastern Benin, we used record reviews, focus group discussions, key informant interviews, and cross-sectional surveys to examine the supervision process. FINDINGS: Initially, little IMCI supervision occurred. The frequency increased substantially after implementing a series of workshops, but then deteriorated. Quantitative and qualitative data revealed obstacles to supervision at multiple levels of the health system. Based on supervisors' opinions, the main problems were: poor coordination; inadequate management skills and ineffective management teams; a lack of motivation; problems related to decentralization; health workers sometimes resisting IMCI implementation; and less priority given to IMCI supervision because of incentives for non-supervision activities, a lack of leadership, and an expectation of integrated supervision. To this list, based on our observations, we add: the increasing supervision workload, time required for non-supervision activities, project interventions not always being implemented as planned, and the loss of particularly effective supervisors. In terms of correctly completing steps of the supervision process, the quality of supervision was generally good. CONCLUSIONS: Managers should monitor supervision, understand the evolving influences on supervision, and use their resources and authority to both promote supervision and remove impediments to supervision. Support from leaders can be crucial, thus donors and politicians should help make supervision a true priority. As with front-line clinicians, supervisors are health workers who need support. We emphasize the importance of research to identify effective and affordable strategies for improving supervision frequency and quality. (ClinicalTrials.gov number NCT00510679).

Improving pneumonia case-management in Benin: a randomized trial of a multi-faceted intervention to support health worker adherence to Integrated Management of Childhood Illness guidelines.

BACKGROUND: Pneumonia is a leading cause of death among children under five years of age. The Integrated Management of Childhood Illness strategy can improve the quality of care for pneumonia and other common illnesses in developing countries, but adherence to these guidelines could be improved. We evaluated an intervention in Benin to support health worker adherence to the guidelines after training, focusing on pneumonia case management. METHODS: We conducted a randomized trial. After a health facility survey in 1999 to assess health care quality before Integrated Management of Childhood Illness training, health workers received training plus either study supports (job aids, non-financial incentives and supervision of workers and supervisors) or "usual" supports. Follow-up surveys were conducted in 2001, 2002 and 2004. Outcomes were indicators of health care quality for Integrated Management-defined pneumonia. Further analyses included a graphical pathway analysis and multivariable logistic regression modelling to identify factors influencing case-management quality. RESULTS: We observed 301 consultations of children with non-severe pneumonia that were performed by 128 health workers in 88 public and private health facilities. Although outcomes improved in both intervention and control groups, we found no statistically significant difference between groups. However, training proceeded slowly, and low-quality care from untrained health workers diluted intervention effects. Per-protocol analyses suggested that health workers with training plus study supports performed better than those with training plus usual supports (20.4 and 19.2 percentage-point improvements for recommended treatment [p=0.08] and "recommended or adequate" treatment [p=0.01], respectively). Both groups tended to perform better than untrained health workers. Analyses of treatment errors revealed that incomplete assessment and difficulties processing clinical findings led to missed pneumonia diagnoses, and missed diagnoses led to inadequate treatment. Increased supervision frequency was associated with better care (odds ratio for recommended treatment=2.1 [95% confidence interval: 1.13.9] per additional supervisory visit). CONCLUSION: Integrated Management of Childhood Illness training was useful, but insufficient, to achieve high-quality pneumonia case management. Our study supports led to additional improvements, although large gaps in performance still remained. A simple graphical pathway analysis can identify specific, common errors that health workers make in the case-management process; this information could be used to target quality improvement activities, such as supervision (ClinicalTrials.gov number NCT00510679).

A multifaceted intervention to improve health worker adherence to integrated management of childhood illness guidelines in Benin.

OBJECTIVES: We evaluated an intervention to support health workers after training in Integrated Management of Childhood Illness (IMCI), a strategy that can improve outcomes for children in developing countries by encouraging workers' use of evidence-based guidelines for managing the leading causes of child mortality. METHODS: We conducted a randomized trial in Benin. We administered a survey in 1999 to assess health care quality before IMCI training. Health workers then received training plus either study supports (job aids, nonfinancial incentives, and supervision of workers and supervisors) or usual supports. Follow-up surveys conducted in 2001 to 2004 assessed recommended treatment, recommended or adequate treatment, and an index of overall guideline adherence. RESULTS: We analyzed 1244 consultations. Performance improved in both intervention and control groups, with no significant differences between groups. However, training proceeded slowly, and low-quality care from health workers without IMCI training diluted intervention effects. Per-protocol analyses revealed that workers with IMCI training plus study supports provided better care than did those with training plus usual supports (27.3 percentage-point difference for recommended treatment; P < .05), and both groups outperformed untrained workers. CONCLUSIONS: IMCI training was useful but insufficient. Relatively inexpensive supports can lead to additional improvements.

Care takers' recall of Integrated Management of Childhood Illness counselling messages in Benin.

A key goal of the Integrated Management of Childhood Illness (IMCI) strategy is to improve the management of childhood illness at health facilities. IMCIguidelines contain many counselling messages, and as it is not known how well caretakers recall these messages, we studied caretakers' recall of IMCI messages when given under ideal conditions. At a clinic in Benin, a study clinician performed counselling and confirmed caretakers'comprehension of all messages. Caretakers were randomly assigned to be interviewed either immediately after the consultation or a day later. Recall was assessed with general and focused open-ended questions. Recall was assessed for 55 caretakers, 29.1% of whom were literate. Caretakers received 3-75 messages (mean = 38.7). The mean percentage of messages recalled was 89.7% immediately after the consultation and 81.9% one day later. These results support IMCI's recommendation that health workers should verify caretakers' comprehension by asking caretakers to repeat counselling messages during consultations.

Effect of multiple interventions on community health workers' adherence to clinical guidelines in Siaya district, Kenya.

Evaluation of a community health worker (CHW) programme in Siaya district, Kenya, showed CHWs commonly made errors in managing childhood illness. We assessed the effect of multiple interventions on CHW healthcare practices. A sample of 192 ill-child consultations performed by 114 CHWs in a hospital outpatient department between February and March 2001 were analysed. The mean percentage of assessment, classification and treatment procedures performed correctly for each child was 79.8% (range 13.3-100%). Of the 187 children who required at least one treatment or referral to a health facility, only 38.8% were prescribed all treatments (including referral) recommended by the guidelines. Multivariate analyses found no evidence that the intervention-related factors studied (refresher training, supervision, involvement of community women in the CHW selection process, adequacy of medicine supplies, and use of a guideline flipchart during consultations) were significantly associated with overall or treatment-specific guideline adherence. A multivariate linear regression analysis revealed that several non-intervention-related factors, such as patient characteristics, were significantly associated with overall guideline adherence. Given that our study was cross-sectional and our measurement of exposure to several interventions was based on CHW recall, the estimated effects of the interventions should be interpreted with caution. Despite these limitations, however, our results raise questions about the effectiveness, in the setting of Siaya district, of several interventions commonly used to improve the quality of care given by CHWs.

Risk and protective factors for two types of error in the treatment of children with fever at outpatient health facilities in Benin.

BACKGROUND: In developing countries, health workers often do not follow clinical practice guidelines. However, few studies have examined why different types of errors occur. METHODS: We analysed a sample of consultations of children with non-severe malaria (defined as fever without signs of severe illness) from a health facility survey conducted in Ouémé Département, Benin. Treatment was defined as correct (recommended antimalarial), a minor error (non-recommended antimalarial), or a major error (no antimalarial). RESULTS: In all, 85 health workers and 289 children were studied. In a multivariate logistic regression analysis, the following factors were significantly associated with major errors: treatment by a physician (adjusted odds ratio [aOR] = 13.57, 95% CI: 1.45-126.75), child's age <12 months (aOR = 3.41, 95% CI: 1.15-10.07), and child's temperature (aOR = 0.58 per degrees C, 95% CI: 0.34-0.97). Factors significantly associated with minor errors were: child's temperature (aOR = 1.43 per degrees C, 95% CI: 1.07-1.92), electricity at the health facility (aOR = 3.10, 95% CI: 1.05-9.17), >/=1 supervision visit in the past 6 months (aOR = 0.33, 95% CI: 0.14-0.77), fever treatment wall chart in the consultation room (aOR = 0.29, 95% CI: 0.12-0.73), and number of non-fever chief complaints (aOR = 0.67 per complaint, 95% CI: 0.48-0.93). In-service training in malaria treatment was not significantly associated with either error type. CONCLUSIONS: Many factors may influence health worker performance, and factors such as pre-service training may influence performance in unexpected ways. Identifying different errors and analysing them separately can help reveal potential causes that may be masked by combining errors into a single category.

Evaluation of the Integrated Management of Childhood Illness guidelines for treatment of intestinal helminth infections among sick children aged 2-4 years in western Kenya.

Anthelmintic treatment of sick preschool-age children at health facilities is a potentially effective strategy for intestinal helminth control in this age-group. We conducted a study from July 1998 to February 1999 in western Kenya to determine whether the Integrated Management of Childhood Illness (IMCI) guidelines' clinical assessment can be used to identify helminth-infected children, and to evaluate the nutritional benefit of treating sick children without pallor with an anthelmintic (mebendazole is already part of IMCI treatment for sick children aged 2-4 years with palmar pallor in areas where hookworm and Trichuris trichiura infections are endemic). Sick children aged 2-4 years seen at 3 rural health facilities were clinically evaluated and tested for haemoglobin concentration, malaria parasites, and intestinal helminths. Children without pallor were randomly assigned to receive a single dose of 500 mg of mebendazole or a placebo and re-examined 6 months later. Among the 574 children enrolled, 11% had one or more intestinal helminths. Most infections were of light intensity. Selected clinical signs and symptoms available from the IMCI assessment, including palmar pallor and low weight-for-age, were not associated with helminth infection. Six months after enrollment, no differences in growth of children without pallor were observed between the mebendazole (n = 166) and placebo (n = 181) groups. However, there was a significantly greater mean increase in weight, height, and weight-for-age Z score among the helminth-infected children in the mebendazole group (n = 22) as compared with helminth-infected children in the placebo group (n = 20). We conclude that even lightly infected preschool-age children without palmar pallor benefit from anthelmintic treatment; however, in this study setting of low helminth prevalence and intensity, helminth-infected children could not be identified using the IMCI guidelines. Cost-effectiveness studies are needed to help define helminth prevalence thresholds for routine anthelmintic treatment of sick preschool-age children seen at first-level health facilities.

Tetanus toxoid coverage as an indicator of serological protection against neonatal tetanus.

OBJECTIVE: A Multiple-Indicator Cluster Survey (MICS) was conducted at mid-decade in more than 60 developing countries to measure progress towards the year 2000 World Summit for Children goals. These goals included the protection of at least 90% of children against neonatal tetanus through the immunization of their mothers, as measured by tetanus toxoid (TT) coverage. In the Central African Republic (CAR), serological testing was added to the MICS to understand better the relationship between survey estimates of TT coverage and the prevalence of serological protection. METHODS: In the CAR MICS, mothers of children younger than one year of age gave verbal histories of the TT vaccinations they had received, using the MICS TT questionnaire. A subsample of mothers was tested for tetanus antitoxin, using a double-antigen enzyme-linked immunoadsorbent assay (ELISA). Seropositivity was defined as a titre of > or =0.01 IU/ml, and TT coverage was defined as the proportion of mothers protected at delivery, according to their history of TT vaccinations. FINDINGS: Among the 222 mothers in the subsample, weighted TT coverage was 74.4% (95% Confidence Interval (CI); 67.0% - 81.7%) and tetanus antitoxin seroprevalence was 88.7% (95% CI; 83.2% - 94.2%). The weighted median antitoxin titre was 0.35 IU/ml. CONCLUSIONS: Tetanus toxoid coverage in the CAR was lower than the prevalence of serological protection against neonatal tetanus. If this relationship holds for other countries, TT coverage estimates from the MICS may underestimate the extent to which the year 2000 goal for protecting children against neonatal tetanus was reached. We also showed that a high level of serological protection had been achieved in a country facing major public health challenges and resource constraints.

A pilot study of treatment of Buruli ulcer with rifampin and dapsone.

OBJECTIVE: Buruli ulcer disease (BU), caused by Mycobacterium ulcerans, is endemic in many regions of Africa and causes substantial physical disability. Surgical resection, currently the mainstay of clinical management of BU, is impractical in many endemic areas. Therefore, the study was undertaken to evaluate an antibiotic regimen for medical management of BU. METHODS: A randomized, placebo-controlled pilot study of dapsone plus rifampin versus placebo was conducted. RESULTS: Forty-one participants were recruited in a BU-endemic zone of Côte d'Ivoire. Thirty persons completed the 2-month trial: 15 were treated with placebo and 15 with dapsone and rifampin. On blinded evaluation of photographs of the ulcers, clinicians with experience examining BU judged that 82% of ulcers in the treatment group improved compared with 75% in the placebo group (P=0.51). The median change in ulcer size was a decrease of 14.0 cm2 in the treatment group and a decrease of 2.5 cm2 in the placebo group (P=0.02), but initial ulcer sizes were larger in the treatment group (median 26.2 cm2) compared with the placebo group (median 4.8 cm2) (P=0.04). CONCLUSIONS: Results of this study indicate that larger studies of antimycobacterial therapy of BU are warranted and can be successfully undertaken.