Serologic features of cohorts with variable genetic risk for systemic lupus erythematosus.

BACKGROUND: Systemic lupus erythematosus (SLE) is an autoimmune disease with genetic, hormonal, and environmental influences. In Western Europe and North America, individuals of West African descent have a 3-4 fold greater incidence of SLE than Caucasians. Paradoxically, West Africans in sub-Saharan Africa appear to have a low incidence of SLE, and some studies suggest a milder disease with less nephritis. In this study, we analyzed sera from African American female SLE patients and four other cohorts, one with SLE and others with varying degrees of risk for SLE in order to identify serologic factors that might correlate with risk of or protection against SLE. METHODS: Our cohorts included West African women with previous malaria infection assumed to be protected from development of SLE, clinically unaffected sisters of SLE patients with high risk of developing SLE, healthy African American women with intermediate risk, healthy Caucasian women with low risk of developing SLE, and women with a diagnosis of SLE. We developed a lupus risk index (LRI) based on titers of IgM and IgG anti-double stranded DNA antibodies and levels of C1q. RESULTS: The risk index was highest in SLE patients; second highest in unaffected sisters of SLE patients; third highest in healthy African-American women and lowest in healthy Caucasian women and malaria-exposed West African women. CONCLUSION: This risk index may be useful in early interventions to prevent SLE. In addition, it suggests new therapeutic approaches for the treatment of SLE.

E-Health, another mechanism to recruit and retain healthcare professionals in remote areas: lessons learned from EQUI-ResHuS project in Mali.

BACKGROUND: The aim of this study was to evaluate the perceived influence of telehealth on recruitment and retention of healthcare professionals in remote areas in Mali. METHODS: After 15 months of diagnosis imaging training and telehealth activities at four project sites in remote Mali, between May 2011 and August 2012, a 75-item questionnaire was administered to healthcare professionals to assess the various factors related to Information and Communication Technologies (ICT), especially telehealth, and their influence on health personnel recruitment and retention. Questions assessing perceived impact of telehealth on recruitment and retention of healthcare professionals were rated on a five-point Likert scale. Dependent variables were perceived influence of ICT on recruitment and retention and independent variables were access to ICT, ICT training, ICT use, perceived benefits and drawbacks of telehealth, and perceived barriers to recruitment and retention. A multiple linear regression was performed to identify variables explaining the respondents' perceptions regarding telehealth influence on recruitment and retention. RESULTS: Data analysis showed that professionals in remote areas have very positive perceptions of telehealth in general. Many benefits of telehealth for recruitment and retention were highlighted, with perceived benefits of ICT (p = 0.0478), perceived effects of telehealth on recruitment (p = 0.0018), telehealth training (0.0338) and information on telehealth (0.0073) being the strongest motivators for recruitment, while the perceived effects of telehealth on retention (p = 0.0018) was the only factor significantly associated with retention. CONCLUSIONS: Based on our study results, telehealth could represent a mechanism for recruiting and retaining health professionals in remote areas and could reduce the isolation of these professionals through networking opportunities.

Effect on school attendance and performance of iron and multiple micronutrients as adjunct to drug treatment of Schistosoma-infected anemic schoolchildren.

BACKGROUND: Relationships among Schistosoma haematobium, anemia, and iron deficiency have been documented, and all have been found to be associated with a decline in school attendance and lower performance. OBJECTIVE: To assess the effect of single or combined iron and multiple micronutrients and/or praziquantel on school attendance and achievement in randomly selected 7- to 12-year-old anemic children with documented S. haematobium infection (n = 406) in Mali over a 3-month period. METHODS: Schistosomiasis infection was diagnosed by the presence of schistosome eggs in the urine. Venous blood samples (5 mL) were drawn from an antecubital vein for hemoglobin assessment. Children were randomly assigned to one of four treatment groups: praziquantel alone, praziquantel + iron, praziquantel + multiple micronutrients, and praziquantel + multiple micronutrients + iron. School attendance was defined by the number of days the child was absent from class. Achievement was defined by the child's overall school grades. RESULTS: Changes within treatment groups from baseline to the end of study were found for attendance (p < .001) but not for achievement (p > .05). Significant supplement treatments by age group interactions were found in 7- to 9-year-old children for attendance. Further exploration of treatment effects in this age group showed that only iron treatment's main effect was significant on attendance (p = .049) and was of borderline significance on school grades (p = .08). CONCLUSIONS: Combined praziquantel and iron treatment improved children's school attendance and performance better than praziquantel alone, particularly among younger children.

Increasing rabies data availability: The example of a One Health research project in Chad, Côte d'Ivoire and Mali.

Rabies is a fatal but preventable disease that remains notoriously underreported. Weak data availability hampers advocacy, constitutes a barrier to resource allocation and inhibits effective prevention and control. To gain better insight into the global rabies burden and human vaccine demand several studies were funded through the Vaccine Alliance (GAVI) learning agenda. With the help of this funding, Swiss TPH and local in country partner organizations implemented a One Health research project in Chad, Côte d'Ivoire and Mali to collect data at household, public health facility and veterinary level. This paper describes the implementation of this research project and evaluates its success on amount of information gained, achieved capacity building, impact on knowledge creation and influence on national and international policies. The project was based on the One Health concept and guided by the principles of transboundary research partnerships formulated by the Swiss Academy of Sciences. Data was collected on bite incidents and health seeking from over 24'000 households, on access to treatment of over 8'800 bite cases registered in public health facilities and on the status of over 1'800 rabies suspect animals. Selected country specific datasets have contributed to more than 10 scientific articles so far. On the international level, the multi-level data collection provided a unique set of indicators to inform, along with results from other studies, new WHO rabies immunization recommendations and a vaccine investment case scenario to prevent human rabies. New rabies burden estimates based on the data gathered are published for Mali and will be modelled for the whole West and Central African region. On the national level, the project facilitated communication between animal health and human health workers catalyzing creation of local and national committees and formulation of national action plans for Mali and Côte D'Ivoire. Major challenges arose from lack of data collection and documentation experience of human health and veterinary workers and weak infrastructural capacities of the veterinary and human health systems of the project countries. Through adherence to the principles of transboundary research partnerships, project team members acquired valuable research and networking skills despite language barriers, enabling them to play key roles in the future agenda towards national, regional and global canine rabies elimination. Project external collaborations with local public institutions was facilitated through long-term local partnerships. Both factors enabled success in project implementation and outcomes by identifying and mitigating risks in advance, resolving challenges amiably and enabling mutual knowledge creation as a fructuous ground for sustained commitment. Lack of immediate follow-up funding did not allow to maintain activities beyond the project timeframe. However, the national and international policy changes triggered, as well as the strengthened local disease control and research capacities provides sustainable basis for the elimination of dog transmitted human rabies.

Burden of rabies in Mali.

Rabies is the most dreaded neglected zoonosis worldwide. It affects mostly developing countries with limited access to post-exposure prophylaxis and a low coverage of dog vaccination. OBJECTIVE: This study estimates the burden of human rabies in Mali from the extrapolation of animal bite surveillance, mostly dogs, in the region of Sikasso and the District of Bamako in 2016 and 2017. MATERIAL AND METHODS: Monte Carlo simulations of a series of interconnected probabilities were used to estimate the burden of rabies. The data was collected from cross-sectional surveys of 8775 households of which 4172 were in the District of Bamako and 4603 in the region of Sikasso. Further data was collected in health centres and from the respective veterinary services. RESULTS: We estimate that in the year 2016 133 [95% Confidence Interval (95%CI) 87-186] people died and that 5'366 [95%CI 3'510-7'504] years of life (YLL) were lost and in 2017 et 136 [95%CI 96-181] people died and that 5530 [IC 95% 3'913-7'377] YLLs were lost. The loss of income was estimated at 3.2 million USD [95%CI 2,1-4,5] en 2016, and 3,3 million USD [95%CI 2,3-4,4] in 2017. This represents the highest financial loss from rabies, followed by the cost of postexposure prophylaxis (PEP) of 86'848 $USD and 89'371 $ USD respectively. From the whole cost of rabies in Mali, 92% of the cost in 2016 and 94% of those in 2017 were attributable to premature mortality and the cost of help seeking. The proportion of cost of PEP was 3% in 2016 and 2017 of the total cost of disease. The cost related to dog vaccination changed from 3% to 1% in the same time period. CONCLUSION: This study shows that despite the possibility of preventing human rabies by PEP, its burden remains important in Malian communities. Rabies control by mass vaccination of dogs is hardly done and access to PEP is difficult. However, Rabies elimination by mass vaccination of dogs has been demonstrated to be feasible. Hence a coordinated regional effort between countries by funding dog mass vaccination and full access to PEP can eliminate rabies in West Africa.

Multiple micronutrients including iron are not more effective than iron alone for improving hemoglobin and iron status of Malian school children.

Iron deficiency and anemia remain among the most important global public health problems facing school children. Helminth infections often peak at school age and aggravate nutritional risks. We conducted a 12-wk randomized controlled trial in 406 Malian anemic schoolchildren infected with Schistosoma hematobium to examine the effects of 2 doses of praziquantel (P) (40 mg/kg body weight), P + 60 mg/d iron (Fe), and/or a multiple micronutrient supplement (MM) that included 18 mg/d Fe. Supplements were administered to the children each school day (5 d/wk) throughout the study. Changes in hemoglobin (Hb), serum ferritin (SF), and serum transferrin receptors (s-TfR) were followed. We also examined interactions between Fe and MM supplements on Hb and SF concentrations and malaria incidence. The effects of Fe on Hb and SF concentrations were greater than the effects of P alone and MM with or without added Fe at 6 and 12 wk (P < 0.001). In all groups, s-TfR decreased at 6 and 12 wk compared with baseline. The decrease was most pronounced in the P + Fe group compared with the other 3 groups at wk 6 (P = 0.05). Fe and MM interacted negatively at wk 6 and 12 to affect Hb (beta = -0.43, 95% CI = -0.77, -0.09; P = 0.01 and beta = -0.47, 95% CI = -0.83, -0.11; P = 0.01, respectively) and SF (beta = -0.42, 95% CI = -25.60, 12.31; P < 0.001, and beta = -0.37, 95% CI = -0.63, -0.12; P = 0.004, respectively). Malaria incidence was higher in the groups treated with added Fe (relative risk: 1.66; 95% CI: 0.75, 3.67). In this context, MM with added iron were not more effective than Fe without MM. Fe supplementation of schoolchildren with 60 mg/d for anemia control should be considered carefully.

Malaria treatment in remote areas of Mali: use of modern and traditional medicines, patient outcome.

Use of official health services often remains low despite great efforts to improve quality of care. Are informal treatments responsible for keeping a number of patients away from standard care, and if so, why? Through a questionnaire survey with proportional cluster samples, we studied the case histories of 952 children in Bandiagara and Sikasso areas of Mali. Most children with reported uncomplicated malaria were first treated at home (87%) with modern medicines alone (40%), a mixture of modern and traditional treatments (33%), or traditional treatment alone (27%). For severe episodes (224 cases), a traditional treatment alone was used in 50% of the cases. Clinical recovery after uncomplicated malaria was above 98% with any type of treatment. For presumed severe malaria, the global mortality rate was 17%; it was not correlated with the type of treatment used (traditional or modern, at home or elsewhere). In the study areas, informal treatments divert a high proportion of patients away from official health services. Patients' experience that outcome after standard therapeutic itineraries is not better than after alternative care may help to explain low use of official health services. We need to study whether some traditional treatments available in remote villages should be considered real, recommendable first aid.

Determinants of anemia among pregnant women in Mali.

BACKGROUND: Anemia in pregnancy remains a major problem in nearly all developing and many industrialized countries. In Mali, the subpopulation prevalence and etiology of anemia during pregnancy are largely unknown. OBJECTIVE: To examine the prevalence and likely etiologies of anemia in pregnancy in a poor urban population in Bamako, Mali. METHODS: Pregnant women (n = 190) were selected randomly. Hemoglobin, serum iron, and total iron-binding capacity were measured; blood smears were examined for Plasmodium falciparum malaria; and single stool and urine samples were examined for Schistosoma haematobium and hookworm. Gynecologic examinations were performed and interviews conducted to qualitatively assess food consumption and other socioeconomic characteristics. Associations among mild, moderate, and severe anemia; iron and parasite status; erythrocyte sedimentation rates; and the presence of abnormal vaginal discharge were evaluated. Differences in hemoglobin and serum iron concentrations, total iron-binding capacity, and anemia were compared according to trimester of pregnancy and between infected and noninfected women. The relative and attributable risks of anemia were calculated, and adjusted odds ratios for anemia and low serum iron were estimated by multivariate logistic regression. RESULTS: Of the 131 women for whom complete data were available, 47% had hemoglobin concentrations below 110 g/L; 13% had serum iron concentrations below 12 micromol/L; none had transferrin saturation values below 16%; 11%, 23%, and 8% harbored P. falciparum, S. haematobium, and hookworm, respectively; and 82% had an abnormal vaginal discharge. Food restrictions were reported by 45% of the women. Abnormal vaginal discharge correlated significantly with anemia (Pearson chi2 = 62.4; p < .01). Univariate and multivariate analyses found that infections were strongly associated with and predictive of anemia. CONCLUSIONS: Our data suggest that infections and food accessibility contribute to the high rates of anemia during pregnancy in Mali.

Wuchereria bancrofti transmission pattern in southern Mali prior to and following the institution of mass drug administration.

BACKGROUND: The Global Programme to Eliminate Lymphatic Filariasis (GPELF) was launched in 2000 with the goal of stopping transmission of lymphatic filariasis (LF) through yearly mass drug administration (MDA). Although preliminary surveys of the human population in Mali suggested that Wuchereria bancrofti infection was highly endemic in the Sikasso district, baseline entomological data were required to confirm high levels of transmission prior to the selection of villages in this region for a study of the impact of MDA on transmission of LF by anopheline vectors. METHODS: W. bancrofti transmission was assessed in 2001 (pre-MDA) and 2002 (post-MDA) in the Central District of Sikasso in southern Mali by dissection of Anopheles mosquitoes caught using the human landing catch (HLC) method. The relative frequencies and molecular forms of An. gambiae complex were determined. RESULTS: The majority (86%) of the anopheline vectors captured were identified as An. gambiae complex, and these accounted for >90% of the entomological inoculation rate (EIR) during both years of the study. There was a dramatic decrease in the number of An. gambiae complex mosquitoes captured and in the An. gambiae complex infectivity rates following MDA, accounting for the observed decrease in EIR in 2002 (from 12.55 to 3.79 infective bites per person during the transmission season). An. funestus complex mosquitoes were responsible for a low level of transmission, which was similar during both years of the study (1.2 infective bites per person during the transmission season in 2001 and 1.03 in 2002). CONCLUSIONS: Based on the entomological data from this study, the district of Sikasso was confirmed as an area of high W. bancrofti transmission. This led to the selection of this area for a multi-national study on the effects of MDA on LF transmission by anopheline vectors. Comparison of vector transmission parameters prior to and immediately following the first round of MDA demonstrated a significant decrease in overall transmission. Importantly, the dramatic variability in EIR over the transmission season suggests that the efficacy of MDA can be maximized by delivering drug at the beginning of the rainy season (just prior to the peak of transmission).

Integration of basic dermatological care into primary health care services in Mali.

OBJECTIVE: To evaluate, in a developing country, the effect of a short training programme for general health care workers on the management of common skin diseases--a neglected component of primary health care in such regions. METHODS: We provided a one-day training programme on the management of the skin diseases to 400 health care workers who worked in primary health care centres in the Bamako area. We evaluated their knowledge and practice before and after training. FINDINGS: Before training, knowledge about skin diseases often was poor and practice inadequate. We found a marked improvement in both parameters after training. We analysed the registers of primary health care centres and found that the proportion of patients who presented with skin diseases who benefited from a clear diagnosis and appropriate treatment increased from 42% before the training to 81% after; this was associated with a 25% reduction in prescription costs. Improved levels of knowledge and practice persisted for up to 18 months after training. CONCLUSIONS: The training programme markedly improved the basic dermatological abilities of the health care workers targeted. Specific training may be a reasonable solution to a neglected component of primary health care in many developing countries.