Challenges and opportunities for healthcare workers in a rural district of Chad.

BACKGROUND: Trained healthcare workers are an essential resource for effective health systems. However, healthcare workers' perspective on healthcare, the challenges they face to provide quality health services, and opportunities to improve motivation and providing adequate care are rarely investigated in resource-constrained settings of sub-Saharan Africa. METHODS: All reachable nurses of Abou Deia, a primarily rural district in the south-eastern part of Chad, were invited to participate. In-depth interviews were conducted to assess current challenges and opportunities faced in daily work, including factors that influence motivation and social wellbeing. Particular emphasis was placed on paediatric care. RESULTS: Eight nurses were interviewed. Main work challenges pertained to overall workload, a lack of training and support regarding a serious case mix to be managed on their own, adverse working conditions, issues related to the local communities, and the impact of postings on nurses' private life. Poor working conditions and perceived lack of recognition emerged as the main demotivating factors. Motivation to improve nurses' skills so that they can provide good care, coupled with small, suggested changes in working conditions and health care organisation provide opportunities worth exploring to improve health workers' satisfaction, motivation and the care they can provide. CONCLUSIONS: Health workers in a predominantly rural district in Chad face a wide variety of challenges, and hence their perspectives need to be taken into account to improve health services interventions that aim at enhancing quality of care. Nurses' willingness to further develop skills and knowledge, proactive search of solutions to remedy stock-outs of drugs and other medical devices, and motivational factors to improve the quality of care represent important opportunities for improving health services for all.

Vaccination of dogs in an African city interrupts rabies transmission and reduces human exposure.

Despite the existence of effective rabies vaccines for dogs, dog-transmitted human rabies persists and has reemerged in Africa. Two consecutive dog vaccination campaigns took place in Chad in 2012 and 2013 (coverage of 71% in both years) in the capital city of N'Djaména, as previously published. We developed a deterministic model of dog-human rabies transmission fitted to weekly incidence data of rabid dogs and exposed human cases in N'Djaména. Our analysis showed that the effective reproductive number, that is, the number of new dogs infected by a rabid dog, fell to below one through November 2014. The modeled incidence of human rabies exposure fell to less than one person per million people per year. A phylodynamic estimation of the effective reproductive number from 29 canine rabies virus genetic sequences of the viral N-protein confirmed the results of the deterministic transmission model, implying that rabies transmission between dogs was interrupted for 9 months. However, new dog rabies cases appeared earlier than the transmission and phylodynamic models predicted. This may have been due to the continuous movement of rabies-exposed dogs into N'Djaména from outside the city. Our results show that canine rabies transmission to humans can be interrupted in an African city with currently available dog rabies vaccines, provided that the vaccination area includes larger adjacent regions, and local communities are informed and engaged.

Community health outreach program of the Chad-Cameroon petroleum development and pipeline project.

A critical appraisal has been presented of the CHOP for a large-scale energy infrastructure development project that was implemented in two of the world's poorest countries. The project is under close scrutiny from various independent monitoring groups, civil society organizations, and human rights groups. Reviewing the achievements and shortcomings permits the extraction of important lessons that will be critical for the future adoption of the CHOP in the current setting and for the implementation of additional CHOPs elsewhere in the developing world. The authors believe that the design must be flexible, efficient, and innovative so that a CHOP promptly can address pressing public health issues as they arise (eg, epidemic outbreak) and include the needs and demands of the concerned communities. An innovative feature of the current project is the high degree and mix of public-private partnerships. The project's CHOP also relies on partnerships. As elaborated elsewhere, public-private partnerships should be seen as a social experiment--they reveal promise but are not the solution for every problem. For this CHOP, the focus is on partnerships between a multinational consortium, government agencies, and international organizations. The partnerships also include civil society organizations for monitoring and evaluation and local NGOs designated for the implementation of the selected public health interventions within the CHOP. The governments and their respective health policies often form the umbrella under which the partnerships operate. With the increase in globalization, however, the importance and capacities of governments have diminished, and there is growing private-sector involvement. Private enterprise is seen as an efficient, innovative, pragmatic, and powerful means to achieve environmental and social sustainability. Experiences with the partnership configurations in the current CHOP are of importance for tackling grand challenges in global health by applying a systemic approach. Other innovations of the project in general, and the CHOP in particular, are the strong emphases on institutional-capacity building, integration, and sustainability. In countries like Chad and Cameroon, there are serious shortages of well-qualified health personnel. The CHOP described in this article provides leverage for initiating better healthcare that will reduce the high burden of disease in the developing world. Reducing mortality rates for infants and children younger than 5 years in sub-Saharan Africa requires massive scaling-up of malaria-control interventions (eg, large-scale distribution of ITNs to protect millions of African children), thereby approaching the Abuja targets (see Armstrong Schellenberg et al). The local NGOs that took a lead within the framework of the CHOP in the distribution of ITNs and accompanying health education messages can extend these activities to communities living outside the vicinity of the project area. Serious shortcomings of the current CHOP, consistently identified by the external monitoring groups, include the lack of a regional health plan, cumulative impact assessment, and provision of clean water and sanitation outside the narrowly defined project area. This point is of central importance, particularly for Chad, where access to clean water and improved sanitation facilities is low. Another limitation of the current CHOP is the insufficient amount of significance addressed to tuberculosis and the apparent lack of concerted control efforts against HIV infection, AIDS, and tuberculosis. These criticisms, however, must be balanced against the lack of clarity in international discourse about the proper extent of responsibility of the corporate sector for dealing with the health problems of countries in which they do business. In an elegant analysis, the environmental risk factor "unsafe water, sanitation and hygiene" was shown to be one of the major contributors to loss of healthy life, particularly in the developing world. Provision of clean water and sanitation is a key factor for sustainable control of schistosomiasis and soil-transmitted helminths. Reduction of helminth infections might have a beneficial effect on the HIV and AIDS pandemic. The question still remains: What is, or should be, the scope and limits of responsibility of the corporate sector in solving these problems? There is a critical need for the monitoring and evaluation of the long-term impact of a CHOP that develops in parallel with a large development project, emphasizing the broadest possible determinants of health and well-being. To become operational, it requires the establishment and running of a longitudinal demographic surveillance system in the area and in adjacent areas that are unlikely to be affected by the project. This approach, coupled with regular household surveys for in-depth appraisal of health-seeking and asset indices, is the most promising source of data for impact measurement of health, poverty, and equity-related issues. It will facilitate subtle monitoring and surveillance activities, fostering a truly systemic approach by inclusion of all stake holders on the basis of the existing but constantly evolving system.

The spatial and seasonal distribution of Bulinus truncatus, Bulinus forskalii and Biomphalaria pfeifferi, the intermediate host snails of schistosomiasis, in N'Djamena, Chad.

There is a paucity of epidemiological and malacological data pertaining to schistosomiasis in Chad. In view of a recently articulated elimination agenda, a deeper understanding of the spatio-temporal distribution of schistosomiasis intermediate host snails is pivotal. We conducted cross-sectional malacological surveys during the dry season (April/May 2013) and after the short rainy season (October 2013) in N'Djamena, the capital of Chad. Snails were identified at the genus and species level using morphological keys and molecular DNA barcoding approaches. Those belonging to Bulinus and Biomphalaria were examined for cercarial shedding. Snail habitats were characterised and their predictive potential for the presence of schistosomiasis intermediate host snails explored. Seasonal patterns were studied using geographical information system and kriging in order to interpolate snail abundance data to make predictions at non-sampled locations across N'Djamena. Overall, 413 Bulinus truncatus, 369 Bulinus forskalii and 108 Biomphalaria pfeifferi snails were collected and subjected to cercarial shedding. During the dry season, one Bu. truncatus of 119 snails collected shed Schistosoma spp. cercariae (0.84%), while S. mansoni was shed by one of 108 Bi. pfeifferi snails (0.93%). None of the snails collected after the rainy season shed Schistosoma spp. cercariae. The abundance of Bu. truncatus and Bu. forskalii showed an inverse U-shape relationship with the square term of conductivity, i.e. low abundance at the lowest and highest levels of conductivity and high abundance at intermediate levels. Bi. pfeifferi showed a negative, linear association with pH in the dry seasons. It is planned to link these intermediate host snail data to infection data in human populations with the goal to draw a predictive risk map that can be utilised for control and elimination of schistosomiasis in N'Djamena.