Partner Notification Approaches for Sex Partners and Children of Human Immunodeficiency Virus Index Cases in Côte d'Ivoire.

BACKGROUND: Four partner notification approaches were introduced in health facilities in Côte d'Ivoire to increase human immunodeficiency virus (HIV) testing uptake among the type of contacts (sex partners and biological children younger than 15 years). The study assessed the 4 approaches: client referral (index cases refer the contacts for HIV testing), provider referral (health care providers refer the contacts), contract referral (index case-provider hybrid approach), and dual referral (both the index and their partner are tested simultaneously). METHODS: Program data were collected at 4 facilities from October 2018 to March 2019 from index case files and HIV testing register. We compared uptake of the approaches, uptake of HIV testing, and HIV positivity percentages, stratified by contact type and gender. RESULTS: There were 1089 sex partners and 469 children from 1089 newly diagnosed index cases. About 90% of children were contacted through client referral: 85.2% of those were tested and 1.4% was positive. Ninety percent of the children came from female index cases. The provider referral brought in 56.3% of sex partners, of whom 97.2% were HIV-tested. The client referral brought in 30% of sex partners, of whom only 81.5% were HIV-tested. The HIV positivity percentages were 75.5% and 72.7%, respectively, for the 2 approaches. Male index cases helped to reach twice as many HIV-positive sexual contacts outside the household (115) than female index cases (53). The contract and dual referrals were not preferred by index cases. CONCLUSIONS: Provider referral is a successful and acceptable strategy for bringing in sex partners for testing. Client referral is preferred for children.

Frequency, characteristics and hospital outcomes of road traffic accidents and their victims in Guinea: a three-year retrospective study from 2015 to 2017.

BACKGROUND: Road traffic accidents (RTA) remain a global public health concern in developing countries. The aim of the study was to document the frequency, characteristics and hospital outcomes of road traffic accidents in Guinea from 2015 to 2017. METHODS: We conducted a retrospective cohort study using medical records of RTA victims from 20 hospitals and a cross-sectional study of RTA cases from eight police stations in eight districts in Guinea, West Africa. Data analysis included descriptive statistics, trends of RTA, a sequence of interrupted time-series models and a segmented ordinary least-squares (OLS) regression. RESULTS: Police stations recorded 3,140 RTA over 3 years with an overall annual increase in RTA rates from 14.0 per 100,000 population in 2015, to 19.2 per 100,000 population in 2016 (37.1% annual increase), to 28.7 per 100,000 population in 2017 (49.5% annual increase). Overall, the injury rates in 2016 and 2017 were .05 per 100,000 population higher on average per month (95% CI: .03-.07). Deaths from RTA showed no statistical differences over the 3 years and no association of RTA trends with season was found. Overall, 27,751 RTA victims were admitted to emergency units, representing 22% of all hospitals admissions. Most victims were males (71%) and young (33%). Deaths represented 1.4% of all RTA victims. 90% of deaths occurred before or within 24 h of hospital admission. Factors associated with death were being male (p = .04), being a child under 15 years (p = .045) or an elderly person aged ≥65 years (p < .001), and having head injury or coma (p < .001). CONCLUSIONS: RTA rates in Guinea are increasing. There is a need for implementing multisectoral RTA prevention measures in Guinea.

Compliance with follow-up and adherence to medication in hypertensive patients in an urban informal settlement in Kenya: comparison of three models of care.

OBJECTIVE: To determine and compare, among three models of care, compliance with scheduled clinic appointments and adherence to antihypertensive medication of patients in an informal settlement of Kibera, Kenya. METHODS: Routinely collected patient data were used from three health facilities, six walkway clinics and one weekend/church clinic. Patients were eligible if they had received hypertension care for more than 6 months. Compliance with clinic appointments and self-reported adherence to medication were determined from clinic records and compared using the chi-square test. Univariate and multivariate logistic regression models estimated the odds of overall adherence to medication. RESULTS: A total of 785 patients received hypertension treatment eligible for analysis, of whom two-thirds were women. Between them, there were 5879 clinic visits with an overall compliance with appointments of 63%. Compliance was high in the health facilities and walkway clinics, but men were more likely to attend the weekend/church clinics. Self-reported adherence to medication by those complying with scheduled clinic visits was 94%. Patients in the walkway clinics were two times more likely to adhere to antihypertensive medication than patients at the health facility (OR 1.97, 95% CI 1.25-3.10). CONCLUSION: Walkway clinics outperformed health facilities and weekend clinics. The use of multiple sites for the management of hypertensive patients led to good compliance with scheduled clinic visits and very good self-reported adherence to medication in a low-resource setting.

Offering general pediatric care during the hard times of the 2014 Ebola outbreak: looking back at how many came and how well they fared at a Médecins Sans Frontières referral hospital in rural Sierra Leone.

BACKGROUND: In Bo district, rural Sierra Leone, we assessed the burden of the 2014 Ebola outbreak on under-five consultations at a primary health center and the quality of care for under-15 children at a Médecins Sans Frontières (MSF) referral hospital. METHODS: Retrospective cohort study, comparing a period before (May-October 2013) and during the same period of the Ebola outbreak (2014). Health worker infections occurred at the outbreak peak (October 2014), resulting in hospital closure due to fear of occupational-risk of contracting Ebola. Standardized hospital exit outcomes and case fatality were used to assess quality of care until closure. RESULTS: A total of 13,658 children under-five, were seen at the primary health center during 2013 compared to 8761 in 2014; a consultation decline of 36%. Of 6497 children seen in the hospital emergency room, during the outbreak, patients coming from within hospital catchment area declined with 38% and there were significantly more self-referrals (80% vs. 61%, P < 0.001). During Ebola, 23 children were dead on arrival and the proportion of children in severe clinical status (requiring urgent attention) was higher (74% during Ebola vs. 65% before, P < 0.001). Of 5,223 children with available hospital outcomes, unfavorable outcomes (combination of deaths and abandoned) were less than 15% during both periods, which is within the maximum acceptable in-house threshold set by MSF. Case fatality for severe malaria and lower respiratory tract infections (n = 3752) were similar (≤15%). CONCLUSIONS: Valuable and good quality pediatric care was being provided in the pediatric hospital during the 2014 Ebola outbreak, but could not be sustained because of hospital closure. Health facility and health worker safety should be tackled as a universal requirement to try to avoid a déjà-vu.

Peanut-based ready-to-use therapeutic food: how acceptable and tolerated is it among malnourished pregnant and lactating women in Bangladesh?

Within a Medecins Sans Frontieres's nutrition programme in Kamrangirchar slum, Dhaka, Bangladesh this study was conducted to assess the acceptability of a peanut-based ready-to-use therapeutic food (RUTF) - Plumpy'nut(®) (PPN) among malnourished pregnant and lactating women (PLW). This was a cross-sectional survey using semi-structure questionnaire that included all PLW admitted in the nutrition programme, who were either malnourished or at risk of malnutrition and who had received PPN for at least 4 weeks. A total of 248 women were interviewed of whom 99.6% were at risk of malnutrition. Overall, 212 (85%) perceived a therapeutic benefit. Despite this finding, 193 (78%) women found PPN unacceptable, of whom 12 (5%) completely rejected it after 4 weeks of intake. Reasons for unacceptability included undesirable taste (60%) and unwelcome smell (43%) - more than half of the latter was due to the peanut-based smell. Overall, 39% attributed side effects to PPN intake including nausea, vomiting, diarrhoea, abdominal distension and pain. Nearly 80% of women felt a need to improve PPN - 82% desiring a change in taste and 48% desiring a change in smell. Overall, only 146 (59%) understood the illustrated instructions on the package. Despite a perceived beneficial therapeutic effect, only two in 10 women found PPN acceptable for nutritional rehabilitation. We urge nutritional agencies and manufacturers to intensify their efforts towards developing more RUTF alternatives that have improved palatability and smell for adults and that have adequate therapeutic contents for treating malnourished PLW in Bangladesh.

Liposomal amphotericin B for complicated visceral leishmaniasis (kala-azar) in eastern Sudan: how effective is treatment for this neglected disease?

OBJECTIVES: The aim of this study was to report the patient profile and treatment outcomes, including relapses, of patients with visceral leishmaniasis (VL) treated with liposomal amphotericin B (AmBisome) in Gedaref, Sudan. METHODS: AmBisome was offered to two groups of patients: primary VL patients with specific criteria (age ≤2 or ≥45 years, advanced clinical disease, pregnancy, HIV co-infection and contraindications for antimonials) and VL relapses. AmBisome was given at a total dose of 30 mg/kg, over 10 days. Slow responders received up to 50 mg/kg. Treatment failure was confirmed parasitologically. Standardised treatment outcomes were assessed. RESULTS: Between March 2010 and June 2012, a total of 281 (74%) patients with primary VL and 98 (26%) patients with VL relapses received AmBisome (54% male, median age = 11 years, interquartile range 2-30). End-of-treatment outcomes for primary VL were 260 (92%) initial cure including three (1%) slow responders, three (1%) treatment failures, 14 (5%) deaths and four (1%) unknown outcomes. Outcomes for VL relapses were 92 (94%) initial cure with five (5%) slow responders, four (4%) treatment failures, one (1%) death and one (1%) unknown outcome. At 6 months, there were 19 (7%) relapses amongst primary VL and 10 (10%) VL relapses had a new relapse. Loss to follow-up in both groups was 38%. None of the deaths that occurred during the study period was attributed to AmBisome. CONCLUSION: AmBisome appears to be effective for initial cure of VL and the drug seems safe, but is expensive (400 USD/treatment). Sustained mechanisms to allow improved access of this expensive drug particularly in East Africa are urgently needed. Relapses and losses to follow-up require specific investigation.

Research to policy and practice change: is capacity building in operational research delivering the goods?

OBJECTIVES: Between 2009 and 2012, eight operational research capacity building courses were completed in Paris (3), Luxembourg (1), India (1), Nepal (1), Kenya (1) and Fiji (1). Courses had strict milestones that were subsequently adopted by the Structured Operational Research and Training InitiaTive (SORT IT) of the World Health Organization. We report on the numbers of enrolled participants who successfully completed courses, the number of papers published and their reported effect on policy and/or practice. DESIGN: Retrospective cohort study including a survey. METHODS: Participant selection criteria ensured that only those proposing specific programme-related and relevant operational research questions were selected. Effects on policy and/or practice were assessed in a standardised manner by two independent reviewers. RESULTS: Of 93 enrolled participants from 31 countries (14 in Africa, 13 in Asia, two in Latin America and two in South Pacific), 83 (89%) completed their courses. A total of 96 papers were submitted to scientific journals of which 89 (93%) were published and 88 assessed for effect on policy and practice. There was a reported effect in 65 (74%) studies including changes to programme implementation (27), adaptation of monitoring tools (24) and changes to existing guidelines (20). CONCLUSION: Three quarters of published operational research studies from these structured courses had reported effects on policy and/or practice. It is important that this type of tracking becomes a standard component of operational research and research in general.

Obstetric fistula in Burundi: a comprehensive approach to managing women with this neglected disease.

BACKGROUND: In Burundi, the annual incidence of obstetric fistula is estimated to be 0.2-0.5% of all deliveries, with 1000-2000 new cases per year. Despite this relatively high incidence, national capacity for identifying and managing obstetric fistula is very limited. Thus, in July 2010, Medecins Sans Frontieres (MSF) set up a specialised Obstetric Fistula Centre in Gitega (Gitega Fistula Centre, GFC), the only permanent referral centre for obstetric fistula in Burundi. A comprehensive model of care is offered including psychosocial support, conservative and surgical management, post-operative care and follow-up. We describe this model of care, patient outcomes and the operational challenges. METHODS: Descriptive study using routine programme data. RESULTS: Between July 2010 and December 2011, 470 women with obstetric fistula presented for the first time at GFC, of whom 458 (98%) received treatment. Early urinary catheterization (conservative management) was successful in four out of 35 (11%) women. Of 454 (99%) women requiring surgical management, 394 (87%) were discharged with a closed fistula, of whom 301 (76%) were continent of urine and/or faeces, while 93 (24%) remained incontinent of urine and/or faeces. In 59 (13%) cases, the fistula was complex and could not be closed. Outcome status was unknown for one woman. Median duration of stay at GFC was 39 days (Interquartile range IQR, 31-51 days). CONCLUSION: In a rural African setting, it is feasible to implement a comprehensive package of fistula care using a dedicated fistula facility, and satisfactory surgical repair outcomes can be achieved. Several operational challenges are discussed.

Hand Hygiene Practices and Promotion in Public Hospitals in Western Sierra Leone: Changes Following Operational Research in 2021.

Hand hygiene is the most important intervention for preventing healthcare-associated infections and can reduce preventable morbidity and mortality. We described the changes in hand hygiene practices and promotion in 13 public hospitals (six secondary and seven tertiary) in the Western Area of Sierra Leone following the implementation of recommendations from an operational research study. This was a "before and after" observational study involving two routine cross-sectional assessments using the WHO hand hygiene self-assessment framework (HHSAF) tool. The overall mean HHSAF score changed from 273 in May 2021 to 278 in April 2023; it decreased from 278 to 250 for secondary hospitals but increased from 263 to 303 for tertiary hospitals. The overall mean HHSAF score and that of the tertiary hospitals remained at the "intermediate" level, while secondary hospitals declined from "intermediate" to "basic" level. The mean score increased for the "system change" and "institutional safety climate" domains, decreased for "training and education" and "reminders in the workplace" domains, and remained the same for the "evaluation and feedback" domain. Limited resources for hand hygiene promotion, lack of budgetary support, and formalized patient engagement programs are the persistent gaps that should be addressed to improve hand hygiene practices and promotion.

Assessing Changes in Surgical Site Infections and Antibiotic Use among Caesarean Section and Herniorrhaphy Patients at a Regional Hospital in Sierra Leone Following Operational Research in 2021.

Surgical site infections (SSIs) are a major public health threat to the success of surgery. This study assessed changes in SSIs and use of antibiotics among caesarean section (CS) and herniorrhaphy patients at a regional hospital in Sierra Leone following operational research. This was a comparative before and after study using routine hospital data. The study included all the CS and herniorrhaphy patients who underwent surgery between two time periods. Of the seven recommendations made in the first study, only one concerning improving the hospital's records and information system was fully implemented. Three were partially implemented and three were not implemented. The study population in both studies showed similar socio-demographic characteristics. The use of postoperative antibiotics for herniorrhaphy in both studies remained the same, although a significant increase was found for both pre- and postoperative antibiotic use in the CS patients, 589/596 (98.8%) in 2023 and 417/599 (69.6%) in 2021 (p < 0.001). However, a significant decrease was observed in the overall incidence of SSIs, 22/777 (2.8%) in 2023 and 46/681 (6.7%) in 2021 (p < 0.001), and the incidence of SSIs among the CS patients, 15/596 (2.5%) in 2023 and 45/599 (7.5%) in 2021 (p < 0.001). The second study highlights the potential value of timely assessment of the implementation of recommendations following operational research.

Short and long term retention in antiretroviral care in health facilities in rural Malawi and Zimbabwe.

BACKGROUND: Despite the successful scale-up of ART services over the past years, long term retention in ART care remains a major challenge, especially in high HIV prevalence and resource-limited settings. This study analysed the short (<12 months) and long (>12 months) term retention on ART in two ART programmes in Malawi (Thyolo district) and Zimbabwe (Buhera district). METHODS: Retention rates at six-month intervals are reported separately among (1) patients since ART initiation and (2) patients who had been on ART for at least 12 months, according to the site of ART initiation and follow-up, using the Kaplan Meier method. 'Retention' was defined as being alive on ART or transferred out, while 'attrition' was defined as dead, lost to follow-up or stopped ART. RESULTS: In Thyolo and Buhera, a total of 12,004 and 9,721 patients respectively were included in the analysis. The overall retention among the patients since ART initiation was 84%, 80% and 77% in Thyolo and 88%, 84% and 82% in Buhera at 6, 12 and 18 months, respectively. In both programmes the largest drop in ART retention was found during the initial 12 months on ART, mainly related to a high mortality rate in the health centres in Thyolo and a high loss to follow-up rate in the hospital in Buhera. Among the patients who had been on ART for at least 12 months, the retention rates leveled out, with 97%, 95% and 94% in both Thyolo and Buhera, at 18, 24 and 30 months respectively. Loss to follow-up was identified as the main contributor to attrition after 12 months on treatment in both programmes. CONCLUSIONS: To better understand the reasons of attrition and adapt the ART delivery care models accordingly, it is advisable to analyse short and long term retention separately, in order to adapt intervention strategies accordingly. During the initial months on ART more medical follow-up, especially for symptomatic patients, is required to reduce mortality. Once stable on ART, however, the ART care delivery should focus on regular drug refill and adherence support to reduce loss to follow up. Hence, innovative life-long retention strategies, including use of new communication technologies, community based interventions and drug refill outside the health facilities are required.

Incidence of Surgical Site Infection and Use of Antibiotics among Patients Who Underwent Caesarean Section and Herniorrhaphy at a Regional Referral Hospital, Sierra Leone.

Surgical site infections (SSIs) are common postoperative complications. Surgical antibiotic prophylaxis (SAP) can prevent the occurrence of SSIs if administered appropriately. We carried out a retrospective cohort study to determine the incidence of SSIs and assess whether SAP were administered according to WHO guidelines for Caesarean section (CS) and herniorrhaphy patients in Bo regional government hospital from November 2019 to October 2020. The analysis included 681 patients (599 CSs and 82 herniorrhaphies). Overall, the SSI rate was 6.7% among all patients, and 7.5% and 1.2% among CS patients and herniorrhaphy patients, respectively. SAP was administered preoperatively in 85% of CS and 70% of herniorrhaphy patients. Postoperative antibiotics were prescribed to 85% of CS and 100% of herniorrhaphy patients. Ampicillin, metronidazole, and amoxicillin were the most commonly used antibiotics. The relatively low rate of SSIs observed in this study is probably due to improved infection prevention and control (IPC) measures following the Ebola outbreak and the current COVID-19 pandemic. A good compliance rate with WHO guidelines for preoperative SAP was observed. However, there was a high use of postoperative antibiotics, which is not in line with WHO guidelines. Recommendations were made to ensure the appropriate administration of SAP and reduce unnecessary use of antibiotics.

Alarming Levels of Multidrug Resistance in Aerobic Gram-Negative Bacilli Isolated from the Nasopharynx of Healthy Under-Five Children in Accra, Ghana.

Nasopharyngeal carriage of aerobic Gram-negative bacilli (GNB) may precede the development of invasive respiratory infections. We assessed the prevalence of nasopharyngeal carriage of aerobic GNB and their antimicrobial resistance patterns among healthy under-five children attending seven selected day-care centres in the Accra metropolis of the Greater Accra region of Ghana from September to December 2016. This cross-sectional study analysed a total of 410 frozen nasopharyngeal samples for GNB and antimicrobial drug resistance. The GNB prevalence was 13.9% (95% CI: 10.8-17.6%). The most common GNB were Escherichia coli (26.3%), Klebsiella pneumoniae (24.6%), and Enterobacter cloacae (17.5%). Resistance was most frequent for cefuroxime (73.7%), ampicillin (64.9%), and amoxicillin/clavulanic acid (59.6%). The organisms were least resistant to gentamicin (7.0%), amikacin (8.8%), and meropenem (8.8%). Multidrug resistance (MDR, being resistant to ≥3 classes of antibiotics) was observed in 66.7% (95% CI: 53.3-77.8%). Extended-spectrum beta-lactamase (ESBL)-producing bacteria constituted 17.5% (95% CI: 9.5-29.9%), AmpC-producing bacteria constituted 42.1% (95% CI: 29.8-55.5%), and carbapenemase-producing bacteria constituted 10.5% (95% CI: 4.7-21.8%) of isolates. The high levels of MDR are of great concern. These findings are useful in informing the choice of antibiotics in empiric treatment of GNB infections and call for improved infection control in day-care centres to prevent further transmission.

Assessment of Infection Prevention and Control Measures at Points of Entry in Sierra Leone in 2021: A Cross-Sectional Study.

Implementing and monitoring infection prevention and control (IPC) measures at immigration points of entry (PoEs) is key to preventing infections, reducing excessive use of antimicrobials, and tackling antimicrobial resistance (AMR). Sierra Leone has been implementing IPC measures at four PoEs (Queen Elizabeth II Quay port, Lungi International Airport, and the Jendema and Gbalamuya ground crossings) since the last Ebola outbreak in 2014-2015. We adapted the World Health Organization IPC Assessment Framework tool to assess these measures and identify any gaps in their components at each PoE through a cross-sectional study in May 2021. IPC measures were Inadequate (0-25%) at Queen Elizabeth II Quay port (21%; 11/53) and Jendema (25%; 13/53) and Basic (26-50%) at Lungi International Airport (40%; 21/53) and Gbalamuya (49%; 26/53). IPC components with the highest scores were: having a referral system (85%; 17/20), cleaning and sanitation (63%; 15/24), and having a screening station (59%; 19/32). The lowest scores (0% each) were reported for the availability of IPC guidelines and monitoring of IPC practices. This was the first study in Sierra Leone highlighting significant gaps in the implementation of IPC measures at PoEs. We call on the AMR multisectoral coordinating committee to enhance IPC measures at all PoEs.

Surveillance of WHO Priority Gram-Negative Pathogenic Bacteria in Effluents from Two Seafood Processing Facilities in Tema, Ghana, 2021 and 2022: A Descriptive Study.

Antimicrobial resistant (AMR) bacteria in effluents from seafood processing facilities can contribute to the spread of AMR in the natural environment. In this study conducted in Tema, Ghana, a total of 38 effluent samples from two seafood processing facilities were collected during 2021 and 2022, as part of a pilot surveillance project to ascertain the bacterial load, bacterial species and their resistance to 15 antibiotics belonging to the WHO AWaRe group of antibiotics. The bacterial load in the effluent samples ranged from 13-1800 most probable number (MPN)/100 mL. We identified the following bacterial species: E. coli in 31 (82%) samples, K. pneumoniae in 15 (39%) samples, Proteus spp. in 6 (16%) samples, P. aeruginosa in 2 (5%) samples and A. baumannii in 2 (5%) samples. The highest levels of antibiotic resistance (100%) were recorded for ampicillin and cefuroxime among Enterobacteriaceae. The WHO priority pathogens-E. coli (resistant to cefotaxime, ceftazidime and carbapenem) and K.pneumoniae (resistant to ceftriaxone)-were found in 5 (13%) effluent samples. These findings highlight the need for enhanced surveillance to identify the source of AMR and multi-drug resistant bacteria and an adoption of best practices to eliminate these bacteria in the ecosystem of the seafood processing facilities.

Is vitiligo associated with wearing plastic shoes in a podoconiosis endemic region of Ethiopia?

INTRODUCTION: Endemic non-filarial elephantiasis also known as podoconiosis often affects bare footed farmers and is endemic in Ethiopia. The disease is prevented by wearing shoes. We recently observed several patients presenting to a dermatology clinic with skin depigmentation after wearing plastic shoes ("shoe-contact vitiligo") which may deter shoe-wearing. We report on their sociodemographic and clinical characteristics. METHODOLOGY: This is a retrospective study of 17 months at tertiary level Hospital in Ethiopia. Patient data was retrieved from medical record department. We compared sociodemographic and clinical characteristics of patients presenting with idiopathic and shoe-contact vitiligo. Data was presented descriptively. RESULTS: Of 460 vitiligo cases, 190 (41%) were shoe-contact vitiligo and the rest, idiopathic. The former was more common in females (Odds Ratio, OR = 2.5, P < 0.001) and those in rural areas (OR = 4.8, P < 0.001). Fifty-five percent with shoe-contact vitiligo had itching and/or burning sensation, compared to just 2% with idiopathic vitiligo (P < 0.001) and some had ulcerations (8%). Idiopathic vitiligo had no such findings. Skin discoloration occurred within three weeks (on average) after wearing plastic shoes, 91% of lesions were symmetrical and involved areas of the feet covered with plastic shoes. Symmetric lesions were observed in only 11% of idiopathic vitiligo (OR = 81, P < 0.001). CONCLUSIONS: Shoe-contact vitiligo was significantly associated with wearing cheap plastic shoes. The exact chemical culprit(s) needs to be identified. This will allow introducing quality control regulations and rigorous monitoring of shoe production sites.

Does training of Health Extension Workers reduce scabies load in district health facilities in rural Ethiopia?

INTRODUCTION: In 2017, Ethiopia included scabies management within the responsibility of health extension workers. In Kamba (the intervention district) workers were trained on scabies management. Whereas, in Arba Minch Zuria (the control district) there was no such training. This study assesses whether decentralization of scabies management to communities would reduce the load on health facilities and allow earlier scabies treatment access. METHODOLOGY: All individuals presenting with scabies before (January - June 2018) and after (August 2018-January 2019) the introduction of training (July 2018) in Kamba district and the Arba Minch Zuria district were included. We compared between the two districts in the period before and after training, the numbers of scabies cases presenting to health facilities, their demography, clinical characteristics and treatment. RESULTS: There were 1,891 scabies cases in the intervention district and 809 in the control district. Scabies cases declined in the intervention district from 7.6 to 1.6 per 1,000 population (a 4.8-fold reduction). In the control district, scabies cases increased from 1.3 to 2.4 per 1,000 population (a 1.8-fold increase). In intervention district, the proportion of scabies patients with secondary skin infections reduced from 1,227 (78%, n = 1,565) to 156 (48%, n = 326, P < 0.001). In the control district the difference was insignificant 39 (14%, n = 288) to 86 (17%, n = 521, P = 0.2). CONCLUSIONS: Introducing trained health extension workers at community level were associated with reductions in health facility load for scabies and secondary infections. This is a wider community health benefit.

"Stopping the itch": mass drug administration for scabies outbreak control covered for over nine million people in Ethiopia.

INTRODUCTION: In 2018, the Ethiopian Ministry of Health embarked on a Mass Drug Administration (MDA) campaign that involved over 9 million people in Ethiopia - the largest scabies MDA campaign ever conducted on a global level. We describe its implementation and report on a) numbers screened and identified with scabies, b) treatment category and drug type and c) human resources used, duration, and cost of the campaign. METHODOLOGY: The MDA campaign was conducted according to national guidelines and activities including: planning and organization, engagement of local leaders, community mobilisation and advocacy, awareness-raising among health workers, field implementation, and monitoring and evaluation. The campaign was conducted between July and August 2018. RESULTS: The MDA campaign was implemented by about 15,000 people, mostly from the community, over an average of 6 days and reached 9, 057, 427 people. A total of 875,890 (9.7%) scabies cases were detected and 995,471 (11.0%) contacts received treatment. (Contact-to-case ratio = 1.3). Scabies prevalence varied, the highest prevalence was seen in Central Gondar (39.2%), South Gondar (16.7%) and North Gondar (15.0%), these neighbouring zones contributing more than two third of all scabies cases in the region. Of 1,738,304 (93%) who received treatment, 94% received ivermectin, the rest topical permethrin and sulfur. The average coverage capacity of an MDA campaign staff member was 84 people per day. The total cost was 11,696,333 United States Dollars (USD). Cost per 100,000 population = 129,135 USD. CONCLUSIONS: This experience of rapid-large scale implementation would be useful to scale up similar interventions and "stop the itch" in other regions of Ethiopia.

Clinical features and treatment outcomes of visceral leishmaniasis patients admitted to three centers in Oromia, Ethiopia.

INTRODUCTION: In three health care facilities in the Oromia region, the aim of this study is to report on 1) the number of VL cases registered over time (2013-2018) and 2) the clinical profile, type of treatment used and response to treatment. METHODOLOGY: A retrospective cohort study was conducted among all VL cases admitted with a diagnosis of VL. RESULTS: A total of 434 VL cases were registered at the three health facilities, but patient files were available for only 188. Most (51.6%) were children and only three presented with VL relapse. 78 (41.5%) of the 188 patients presented within one month of symptom onset. Concurrent severe acute malnutrition (27.1%), tuberculosis (6.4%) and malaria (6.4%) were common. There were only two cases with HIV coinfection. Fourty-three percent were treated with antimonials, 34% with antimonials combined with paromomycin and 23% with AmBisome. Amongst the 188 patients with patient files there were no deaths and one treatment failure. Six months outcome data were however missing for all. Aggregated data from the 434 VL cases reported three deaths, two treatment failures and one relapse. CONCLUSIONS: Children were most commonly affected, suggesting long-term endemicity. While short-term outcomes are encouraging, long-term follow-up data are required.

Very early mortality in patients starting antiretroviral treatment at primary health centres in rural Malawi.

OBJECTIVES: To report on the cumulative proportion of deaths occurring within 3 months of starting antiretroviral treatment (ART) and to identify factors associated with such deaths, among adults at primary health centres in a rural district of Malawi. METHODS: Retrospective cohort study: from June 2006 to April 2008, deaths occurring over a 3-month period were determined and risk factors examined. RESULTS: A total of 2316 adults (706 men and 1610 women; median age 35 years) were included in the analysis and followed up for a total of 1588 person-years (PY); 277 (12%) people died, of whom 206 (74%) people died within 3 months of initiating ART (cumulative incidence: 13.0; 95% confidence interval: 11.3-14.8 per 100 PY of follow-up). Significant risk factors associated with early deaths included male sex, WHO stage 4 disease, oesophageal or persistent oral candidiasis and unexplained presumed or measured weight loss >10%. One in every 3 patients who either died or was lost to follow up had unexplained weight loss >10%, and survival in this group was significantly different from patients without this condition. CONCLUSIONS: Seven in 10 individuals initiating ART at primary health centres die early. Specific groups of patients are at higher risk of such mortality and should receive priority attention, care and support.