Patient-led active tuberculosis case-finding in the Democratic Republic of the Congo.

OBJECTIVE: To investigate the effect of using volunteer screeners in active tuberculosis case-finding in South Kivu, the Democratic Republic of the Congo, especially among groups at high risk of tuberculosis infection. METHODS: To identify and screen high-risk groups in remote communities, we trained volunteer screeners, mainly those who had themselves received treatment for tuberculosis or had a family history of the disease. A non-profit organization was created and screeners received training on the disease and its transmission at 3-day workshops. Screeners recorded the number of people screened, reporting a prolonged cough and who attended a clinic for testing, as well as test results. Data were evaluated every quarter during the 3-year period of the intervention (2014-2016). FINDINGS: Acceptability of the intervention was high. Volunteers screened 650 434 individuals in their communities, 73 418 of whom reported a prolonged cough; 50 368 subsequently attended a clinic for tuberculosis testing. Tuberculosis was diagnosed in 1 in 151 people screened, costing 0.29 United States dollars (US$) per person screened and US$ 44 per person diagnosed. Although members of high-risk groups with poorer access to health care represented only 5.1% (33 002/650 434) of those screened, they contributed 19.7% (845/4300) of tuberculosis diagnoses (1 diagnosis per 39 screened). The intervention resulted in an additional 4300 sputum-smear-positive pulmonary tuberculosis diagnoses, 42% (4 300/10 247) of the provincial total for that period. CONCLUSION: Patient-led active tuberculosis case-finding represents a valuable complement to traditional case-finding, and should be used to assist health systems in the elimination of tuberculosis.

Implementation and Operational Research: Programmatic Feasibility of Dried Blood Spots for the Virological Follow-up of Patients on Antiretroviral Treatment in Nord Kivu, Democratic Republic of the Congo.

BACKGROUND: As part of its policy to shift monitoring of antiretroviral therapy (ART) to primary health care (PHC) workers, the Ministry of Health of the Democratic Republic of Congo (DRC) tested the feasibility of using dried blood spots (DBS) for viral load (VL) quantification and genotypic drug resistance testing in off-site high-throughput laboratories. METHODS: DBS samples from adults on ART were collected in 13 decentralized PHC facilities in the Nord-Kivu province and shipped during program quarterly supervision to a reference laboratory 2000 km away, where VL was quantified with a commercial assay (m2000rt, Abbott). A second DBS was sent to a World Health Organization (WHO)-accredited laboratory for repeat VL quantification on a subset of samples with a generic assay (Biocentric) and genotypic drug resistance testing when VL >1000 copies per milliliter. FINDINGS: Constraints arose because of an interruption in national laboratory funding rather than to technical or logistic problems. All samples were assessed by both VL assays to allow ART adjustment. Median DBS turnaround time was 37 days (interquartile range: 9-59). Assays performed unequally with DBS, impacting clinical decisions, quality assurance, and overall cost-effectiveness. Based on m2000rt or generic assay, 31.3% of patients were on virological failure (VF) and 14.8% presented resistance mutations versus 50.3% and 15.4%, respectively. CONCLUSION: This study confirms that current technologies involving DBS make virological monitoring of ART possible at PHC level, including in challenging environments, provided organizational issues are addressed. Adequate core funding of HIV laboratories and adapted choice of VL assays require urgent attention to control resistance to ART as coverage expands.

High completion of isoniazid preventive therapy among HIV-infected children and adults in Kinshasa, Democratic Republic of Congo.

We assessed isoniazid preventive therapy (IPT) completion and predictors among HIV-infected children and adults in two HIV clinics in Kinshasa, Democratic Republic of Congo. Between 1 September 2012 and 15 June 2013, 546 children (1-15 years) and 1532 adults (>15 years) were initiated on IPT; 86.6% (408/470) of the children and 88.2% (1129/1280) of the adults with an IPT outcome completed their therapy. Patients on antiretroviral therapy at IPT initiation were more likely to complete IPT.

Factors contributing to outbreaks of wild poliovirus type 1 infection involving persons aged ≥15 years in the Democratic Republic of the Congo, 2010-2011, informed by a pre-outbreak poliovirus immunity assessment.

BACKGROUND: The Democratic Republic of the Congo (DRC) experienced atypical outbreaks of wild poliovirus type 1 (WPV1) infection during 2010-2011 in that they affected persons aged ≥15 years in 4 (Bandundu, Bas Congo, Kasaï Occidental, and Kinshasa provinces) of the 6 provinces with outbreaks. METHODS: Analyses of cases of WPV1 infection with onset during 2010-2011 by province, age, polio vaccination status, and sex were conducted. The prevalence of antibodies to poliovirus (PV) types 1, 2, and 3 was assessed in sera collected before the outbreaks from women attending antenatal clinics in 3 of the 4 above-mentioned provinces. RESULTS: Of 193 cases of WPV1 infection during 2010-2011, 32 (17%) occurred in individuals aged ≥15 years. Of these 32 cases, 31 (97%) occurred in individuals aged 16-29 years; 9 (28%) were notified in Bandundu, 17 (53%) were notified in Kinshasa, and 22 (69%) had an unknown polio vaccination status. In the seroprevalence assessment, PV type 1 and 3 seroprevalence was lower among women aged 15-29 years in Bandundu and Kinshasa, compared with those in Kasaï Occidental. Seropositivity to PVs was associated with increasing age, more pregnancies, and a younger age at first pregnancy. CONCLUSIONS: This spatiotemporal analysis strongly suggests that the 2010-2011 outbreaks of WPV1 infection affecting young adults were caused by a PV type 1 immunity gap in Kinshasa and Bandundu due to insufficient exposure to PV type 1 through natural infection or vaccination. Poliovirus immunity gaps in this age group likely persist in DRC.

Correlates of syphilis seropositivity and risk for syphilis-associated adverse pregnancy outcomes among women attending antenatal care clinics in the Democratic Republic of Congo.

Screening and treatment for syphilis among pregnant women is the primary means of prevention of congenital syphilis. Sentinel surveillance for syphilis can inform these prevention efforts. We reviewed antenatal syphilis screening results to assess trends and to identify correlates of seropositivity among women attending antenatal care clinics in the Democratic Republic of Congo during 2011. Syphilis seropositivity among the 17,669 women attending the antenatal care clinics during 2011 was 4.2% (range 0.4%-16.9%). Syphilis seropositivity was significantly higher among women attending rural clinics (5.0%) as compared to urban clinics (3.0%) and those tested in antenatal care clinics in the provinces of Equateur (7.6%) and Orientale (7.7%) as compared to other provinces (p < 0.001). Based on the antenatal care syphilis seroprevalence and national pregnancy estimates, we estimate that approximately 128,591 pregnant women countrywide would have tested seropositive for syphilis during 2011. Over 85,000 adverse pregnancy outcomes would have resulted from these maternal infections, assuming prenatal syphilis diagnosis and treatment were not available. The prevalence of syphilis was highest in rural areas, but exceeded 1% in every area, indicating a need to assure screening and treatment throughout Democratic Republic of Congo. These sentinel surveillance estimates can be used to guide national congenital syphilis prevention efforts.

[Perception of pain by patients receiving antiretroviral treatment in North Kivu, DR Congo]. / Perceptions des douleurs chez les patients traités par antirétroviraux au Nord-Kivu (RD Congo).

This operational research conducted among TB patients co-infected with HIV in North Kivu had three objectives: (i) to clarify the local perception of a certain type of pain (michi in the local language) in patients on antiretroviral treatment (ART); (ii) to identify the attitudes of health care personnel regarding the management of ART side effects; and (iii) to explore ways to improve the quality of life of patients on ART and provide them with pain relief. Twenty in-depth interviews were conducted with patients on ART and their medical care providers in district health centers of North-Kivu and at patients' homes. A semantic analysis of the term michi revealed a nosologic folk entity based on a naturalistic view of the body; the term michi is used to name: (i) the "roots" of plants or trees; (ii) channels (veins, arteries, but also nerves and tendons) in the body through which fluids (blood, water) and energy are conveyed; (iii) different types of acute pain, possibly located along these channels. The description (location, duration, and intensity) of the functional signs and the context of their occurrence (while taking Stavudine) confirmed the medical diagnosis of acute sensory neuropathies. Although a classic ART side effect, neuropathies are underdiagnosed by health workers who find it difficult to recognize signs of treatment toxicity in apparently trivial symptoms. Different reasons account for this: (i) healthcare staff have little time to spend with TB/HIV patients and thus provide inadequate management of functional symptoms; (ii) insufficient attention is paid to patients' acute pain, which is often perceived as "normal"; (iii) insufficient knowledge of ART side effects due to staff turnover higher than the frequency of training that programmes. The study was conducted as part of the DR Congo national programmes for TB and AIDS and led to the formulation of recommendations about improving, especially through training, the assessment of functional symptoms as expressed in the main cultural areas of the country, including increased awareness of their vernacular expressions. This study also stressed the need for early diagnosis and management of iatrogenic neuropathy. The integration of leprosy and TB programmes in DR Congo in principle offers a suitable framework to develop synergies for the management of peripheral neuropathy. Finally, providing increased attention to patients (empathy, listening and counselling) requires time and calls for a careful analysis of the care providers' workload, to facilitate the smooth integration of HIV care into general health services.