Etramp5 as a useful serological marker in children to assess the immediate effects of mass drug campaigns for malaria.

INTRODUCTION: Serological methods provide useful metrics to estimate age-specific period prevalence in settings of low malaria transmission; however, evidence on the use of seropositivity as an endpoint remains scarce in studies to evaluate combinations of malaria control measures, especially in children. This study aims to evaluate the immediate effects of a targeted mass drug administration campaign (tMDA) in Haiti by using serological markers. METHODS: The tMDA was implemented in September-October 2018 using sulfadoxine-pyrimethamine and single low-dose primaquine. A natural quasi-experimental study was designed, using a pretest and posttest in a cohort of 754 randomly selected school children, among which 23% reported having received tMDA. Five antigens were selected as outcomes (MSP1-19, AMA-1, Etramp5 antigen 1, HSP40, and GLURP-R0). Posttest was conducted 2-6 weeks after the intervention. RESULTS: At baseline, there was no statistical difference in seroprevalence between the groups of children that were or were not exposed during the posttest. A lower seroprevalence was observed for markers informative of recent exposure (Etramp5 antigen 1, HSP40, and GLURP-R0). Exposure to tMDA was significantly associated with a 50% reduction in the odds of seropositivity for Etramp5 antigen 1 and a 21% reduction in the odds of seropositivity for MSP119. CONCLUSION: Serological markers can be used to evaluate the effects of interventions against malaria on the risk of infection in settings of low transmission. Antibody responses against Etramp5 antigen 1 in Haitian children were reduced in the 2-6 weeks following a tMDA campaign, confirming its usefulness as a short-term marker in child populations.

Success factors for implementing and sustaining a mature electronic medical record in a low-resource setting: a case study of iSanté in Haiti.

Electronic health information systems, including electronic medical records (EMRs), have the potential to improve access to information and quality of care, among other things. Success factors and challenges for novel EMR implementations in low-resource settings have increasingly been studied, although less is known about maturing systems and sustainability. One systematic review identified seven categories of implementation success factors: ethical, financial, functionality, organizational, political, technical and training. This case study applies this framework to iSanté, Haiti's national EMR in use in more than 100 sites and housing records for more than 750 000 patients. The author group, consisting of representatives of different agencies within the Haitian Ministry of Health (MSPP), funding partner the Centers for Disease Control and Prevention (CDC) Haiti, and implementing partner the International Training and Education Center for Health (I-TECH), identify successes and lessons learned according to the seven identified categories, and propose an additional cross-cutting category, sustainability. Factors important for long-term implementation success of complex information systems are balancing investments in hardware and software infrastructure upkeep, user capacity and data quality control; designing and building a system within the context of the greater eHealth ecosystem with a plan for interoperability and data exchange; establishing system governance and strong leadership to support local system ownership and planning for system financing to ensure sustainability. Lessons learned from 10 years of implementation of the iSanté EMR system are relevant to sustainability of a full range of increasingly interrelated information systems (e.g. for laboratory, supply chain, pharmacy and human resources) in the health sector in low-resource settings.

[Simplified Protocols for Cholera Diagnosis in the National Public Health Laboratory, Port-au-Prince, Haiti]. / Protocoles simplifiés de diagnostic du choléra au Laboratoire national de santé publique, Port-au-Prince, Haïti.

While the incidence of cholera is decreasing in Haiti, the time required to render stool culture results with antibiogram using the standard method practiced at the National Public Health Laboratory (LNSP) remains at an average of 80 hours. This delay can be further lengthened by the process of rendering the analysis reports to the sites of care which significantly delays the community responses to cholera. Through this study, we have aimed to assess the reliability of partial results. We have studied 250 stool samples that were analyzed between January and September 2017 at the LNSP by determining the specificity, positive predictive value and positive likelihood ratio of i) the identification of yellowish colonies and ii) the identification of yellowish colonies with a positive oxidase assay in comparison to the stool culture. Compared to the entire process, the identification of yellowish colonies showed a specificity of 56%, a positive predictive value of 69% and a positive likelihood ratio of 2.27. The identification of yellowish colonies with a positive oxidase assay showed a specificity of 77%, a positive predictive value of 81% and a positive likelihood ratio of 4.31. The communication of partial results at these steps would likely guide community interventions despite a relative decrease in reliability of the results.

Le temps nécessaire au rendu des résultats de culture des selles avec antibiogramme par la méthode classique pratiquée au Laboratoire national de santé publique (LNSP) d'Haïti s'étale sur une durée de 80 heures en moyenne. Ce délai peut être encore allongé par le processus de rendu des rapports d'analyse aux sites de prise en charge, ce qui retarde de manière significative les réponses communautaires face au choléra. Cette étude vise à évaluer la fiabilité de résultats partiels par rapport au processus complet. Nous avons inclus 250 échantillons de selles analysés au LNSP de janvier à septembre 2017 en déterminant la spécificité, la valeur prédictive positive et le rapport de vraisemblance positif de l'identification des colonies jaunâtres et de l'identification des colonies jaunâtres oxydase positive. Par rapport au processus complet de culture des selles, l'identification des colonies jaunâtres a montré une spécificité de 56 %, une valeur prédictive positive de 69 % et un rapport de vraisemblance positif de 2,27. Quant à l'identification des colonies jaunâtres oxydase positive, la spécificité est de 77 %, la valeur prédictive positive de 81 % et le rapport de vraisemblance positif de 4,31. La communication de résultats partiels aux équipes de terrain à ces étapes serait utile pour guider les interventions en dépit d'une relative diminution de leur fiabilité par rapport au gold standard.

[Update of knowledge on Neglected Diseases in Haiti: Mansonelliasis, Tungiasis, Leprosy, and Anthrax]. / Mise à jour des connaissances concernant quatre maladies délaissées en Haïti : mansonellose, tungose, lèpre, charbon.

Haiti, like most limited-resources countries in the world, faces numerous neglected infectious diseases. They represent a real public health issue with lethal consequences especially in children. We are reviewing here the available literature on four neglected infectious diseases, mansonelliasis, tungiasis, leprosy and anthrax. Filariasis, due to Mansonella ozzardi, has been totally neglected since its discovery in 1920 in Haiti; it persists in coastal homes with a high prevalence in adults when an effective treatment is available. The skin lesions caused by Tunga penetrans have existed since the pre-Columbian period in Haiti. They persist in the most retreated and hard-to-reach areas where the population lives in precarious conditions and in extreme poverty. New available research data show the importance of the problem with very high prevalence rates in some rural communities far away from any healthcare center. Cases of leprosy are recently reemerging as no monitoring program has been in place since 2004. Finally, anthrax is still endemic; small epidemics resurfacing periodically in families in rural areas. Screening of people for these diseases and managing the cases are necessary to improve health and reduce morbidity and mortality in Haiti.

Comme dans la plupart des pays pauvres de la planète, les maladies infectieuses négligées sont nombreuses en Haïti où elles représentent un réel problème de santé publique avec des conséquences létales, surtout pour les enfants. Nous faisons le point des données accessibles pour quatre d'entre elles. Totalement délaissée depuis la découverte de sa présence en Haïti en 1920, la filariose due à Mansonella ozzardi persiste en foyers côtiers avec une prévalence élevée chez les adultes alors qu'un traitement efficace est disponible. Connues depuis la période précolombienne dans l'île d'Hispaniola, les lésions cutanées dues à Tunga penetrans persistent dans les régions les plus reculées et difficiles d'accès où la population vit dans des conditions précaires et dans une très grande pauvreté. Nous rapportons les données d'enquêtes récentes qui montrent l'importance de cette ectoparasitose en Haïti où les taux de prévalence sont très élevés dans certaines communautés rurales isolées. Des cas de lèpre resurgissent en Haïti alors qu'aucun programme de surveillance n'est effectif depuis 2004. Enfin, la maladie du charbon est endémique dans les régions d'élevage où des épidémies familiales resurgissent périodiquement en milieu rural. Le dépistage des personnes atteintes de ces maladies et leur prise en charge sont nécessaires pour une amélioration de la santé et une baisse de la mortalité en Haïti.

[Gametocyte carriage in asymptomatic Plasmodium falciparum infections in Haiti (2010-2013)]. / Portage de gamétocytes de Plasmodium falciparum en Haïti en 2010-2013.

A survey conducted from May 2010 to October 2013 in five from ten departments of Haiti among 5,342 persons aged from 1 to 107 years showed a gametocytic rate = 3.2%. However, it varies greatly from one Department to another, ranging from 0.5% in Grande Anse Department to 5.9% in Southeast Department. Malaria is present in Haiti in heterogeneous coastal foci. Gametocytes occur at all ages, but two times most often in male under 20 years. Entomological studies in Haiti are needed to better characterize the relationships between man and the vector Anopheles albimanus, adapting the fight more effectively.

[Epidemiological characteristics of malaria in the village of Corail, Grand'Anse, Haiti]. / Caractéristiques épidémiologiques du paludisme dans la commune de Corail, Grande Anse, Haïti.

Malaria is considered to be a major problem of public health in Haiti. However the impact of Plasmodium falciparum on health is poorly known in this country. The objective of this study is to verify the incidence of malaria as the cause of hospital consultation and to evaluate the rate of P. falciparum gametocytes carriage among the population living in a municipality within the Department of Grand'Anse where the prevalence of malaria is considered one of the strongest in Haiti. Analysis of hospital statistics of Corail (Grand'Anse) showed that only 17.4% of consultations of patients presenting with fever are due to microscopically confirmed malaria. The fraction of the population most affected is that of adults aged 15-39 years (55% of cases). Children under five represent only 11% of the cases. A community survey showed the rarity of the carriage of gametocytes in asymptomatic persons (0.9%). In Haiti, the epidemiological characteristics of malaria must have specified and documented field studies in order to adapt a strategy for fighting against this parasitic disease with greater efficiency.

Stepwise implementation of a new diagnostic algorithm for multidrug-resistant tuberculosis in Haiti.

SETTING: The uptake of tests endorsed by the World Health Organization to detect and appropriately confirm multidrug-resistant tuberculosis (MDR-TB) in low-income countries remains insufficient. OBJECTIVE: To validate the implementation of line-probe assays (LPA) and liquid culture to develop an algorithm to detect MDR-TB in the challenging setting of Haiti. METHODS: Through an EXPAND-TB (Expanding Access to New Diagnostics for TB) partnership, proficiency testing and validation of 221 acid-fast bacilli positive specimens were performed. Sensitivity, cost and processing time were analysed. RESULTS: Using liquid vs. solid culture shortened the turnaround time from 54 to 19 days, with a sensitivity of 100% vs. 98.6% and a total cost reduction of 13%. LPA detected all TB and MDR-TB cases at a lower cost than culture, in a mean time of 7.5 days. CONCLUSION: The combined use of molecular and liquid culture techniques accelerates the accurate diagnosis of TB and susceptibility testing against first-line drugs in a significantly shorter time, and is less expensive. The implementation of this new algorithm could significantly and accurately improve the screening and treatment follow-up of patients affected with TB and MDR-TB.

Risk factors for cholera transmission in Haiti during inter-peak periods: insights to improve current control strategies from two case-control studies.

Two community-based density case-control studies were performed to assess risk factors for cholera transmission during inter-peak periods of the ongoing epidemic in two Haitian urban settings, Gonaives and Carrefour. The strongest associations were: close contact with cholera patients (sharing latrines, visiting cholera patients, helping someone with diarrhoea), eating food from street vendors and washing dishes with untreated water. Protective factors were: drinking chlorinated water, receiving prevention messages via television, church or training sessions, and high household socioeconomic level. These findings suggest that, in addition to contaminated water, factors related to direct and indirect inter-human contact play an important role in cholera transmission during inter-peak periods. In order to reduce cholera transmission in Haiti intensive preventive measures such as hygiene promotion and awareness campaigns should be implemented during inter-peak lulls, when prevention activities are typically scaled back.

[Prevalence of Plasmodium falciparum during the rainy season (June-December) in the southeast district of Haiti]. / Prévalence de Plasmodium falciparum pendant la saison humide (juin-décembre) dans le département du Sud-Est, Haïti

This malaria prevalence survey was conducted in Haiti from June through November 2010. The Plasmodium falciparum rate was assessed in 16 municipalities and villages of the southeast district, by examination of thick films from a randomly drawn population sample. The study included 2,126 people aged one to 90 years. P. falciparum was detected among 201 non-febrile subjects. This district, with a P. falciparum rate of 9.5%, is in a low endemic area for malaria. Nonetheless, the infection rates varied considerably from one area to another. Along the coast, the P. falciparum rate ranged from 0 to 34.5%, in four separate categories: four highly infected (mean P. falciparum rate = 21.4% and mean gametocyte rate = 15.3%), four moderately infected (mean P. falciparum rate = 6.1% and gametocyte rate = 5.9%), five slightly infected (mean P. falciparum rate = 3.3% and gametocyte rate = 1.1%) and one uninfected in the interior. No cases of infection were detected in two areas located at an altitude above 600 m. The trophozoite and gametocyte rates varied little as a function of age and thus indicated a low level of protection within the population. This study shows the persistence of endemic malaria at highly variable prevalence levels in this district of Haiti. The development of this region that could be highly desirable to tourists requires the establishment of an appropriate disease control program.

Cross-sectional serological survey of human fascioliasis in haiti.

Fasciola hepatica, the aetiological agent of fascioliasis in the Caribbean region, occurs throughout the major islands of the Greater Antilles and in localised zones on two islands (Martinique and Saint Lucia) of the Lesser Antilles. However, apart from Puerto Rico, information regarding human fascioliasis in islands of the Caribbean is out of date or unavailable, or even nonexistent as in Haiti. The authors conducted a retrospective, cross-sectional serological survey in Port-au-Prince using a Western blotting test (LDBIO Diagnostics) on human fascioliasis in Haiti. A total of 216 serum samples obtained from apparently healthy adults were tested. The frequency of antibodies in serum samples of the study population was 6.5% (14/216). The immunodominant bands recognised in Western blots were 27-28 kDa (100%), 42 kDa (64%), 60 kDa, and 8-9 kDa (28%). This is the first survey to reveal a relatively low proportion of asymptomatic F. hepatica-infected humans in Haiti.

Seroprevalence of human Taenia solium cysticercosis in Haiti.

Human Taenia solium cysticercosis is common in developing countries due to poor sanitary conditions and economics based on breeding livestock, especially pigs, with low hygiene standards. Neurocysticercosis, caused by migration of the larvae of the tapeworm in the nervous system, is the leading cause of acquired epilepsy in adults in Central and South America, sub-Saharan Africa, and East and South Asia. This makes neurocysticercosis a large public health problem in developing countries. Two clinical cases of neurocysticercosis have been observed recently in Haiti. In order to evaluate the prevalence of human T. solium cysticercosis in this country, in 2007 we conducted a cross-sectional serological retrospective survey using a Western blotting test (LDBIO Diagnostics) in Port-au-Prince, where sewage systems are rare and swine usually roam freely throughout the area. A total of 216 serum samples, obtained from healthy adults seen in the work setting of periodical medical visits, were tested after storage at - 20 degrees C. The frequency of antibodies in serum samples of the study population was 2.8% (6/216). The immunodominant bands recognized in Western blots were 23-26 kDa (100%), 39 kDa (67%), 45 kDa and 6-8 kDa (50%), 50-55 kDa (33%). These results confirm for the first time an endemic situation of cysticercosis in humans in Haiti, with similar prevalence as that reported in other Latin American and African countries. It reinforces the urgent need for control and prevention measures to be taken by local public health services.

Cyclospora infection in adults infected with HIV. Clinical manifestations, treatment, and prophylaxis.

OBJECTIVE: To determine the prevalence and clinical manifestations of Cyclospora in Haitians infected with human immunodeficiency virus (HIV) who have diarrhea and to evaluate therapy and prophylaxis. DESIGN: Cohort study. From 1990 to 1993, stool samples were collected from adults seropositive for HIV who had had diarrhea for at least 3 weeks. SETTING: A clinic in Haiti. INTERVENTIONS: Stool samples were examined for enteric protozoa after acid-fast staining. Patients with Cyclospora infection were treated with trimethoprimsulfamethoxazole (160 mg and 800 mg, respectively) given orally four times a day for 10 days. After completion of therapy, patients were evaluated weekly and re-treated if clinical and parasitologic recurrences occurred, followed by trimethoprim-sulfamethoxazole prophylaxis three times a week. RESULTS: 804 of 2400 patients (33%) seropositive for HIV had a history of chronic or intermittent diarrhea; 502 of these 804 patients (62%) currently had diarrhea, and 450 patients each provided two stool specimens for examination. Enteric protozoa identified included Cryptosporidium (30%), Isospora belli (12%), Cyclospora species (11%), Giardia lamblia (3%), and Entamoeba histolytica (1%). Forty-three patients with diarrhea and Cyclospora infection were studied; their symptoms were indistinguishable from those seen in patients with isosporiasis or cryptosporidiosis. In all patients, diarrhea ceased and results from stool examinations were negative within 2.5 days after beginning oral trimethoprim-sulfamethoxazole therapy. Recurrent symptomatic cyclosporiasis developed in 12 of 28 patients (43%) followed for 1 month or more, but it also responded promptly to trimethoprim-sulfamethoxazole therapy. These 12 patients received trimethoprim-sulfamethoxazole three times a week as secondary prophylaxis, with only a single recurrence after 7 months. CONCLUSION: Cyclospora infection is common in Haitian patients with HIV infection, responds to trimethoprim-sulfamethoxazole therapy, and has a high recurrence rate that can be largely prevented with long-term trimethoprim-sulfamethoxazole prophylaxis.

Clinical evaluation of Mansonella ozzardi in Haiti.

The clinical evaluation of 150 individuals in Bayeux, Haiti, revealed no significant morbidity that could be attributed to infection with Mansonella ozzardi. However, the distribution of patent infections and their microfilaria density were significantly affected by the age and sex of the individuals. Also, the eosinophilic response was associated with the intensity of the microfilaremia when age was considered as a co-variable. The microfilaria rate was significantly higher in certain occupations, but this was discounted as a risk factor for reasons that are explained.

Mansonella ozzardi in Haiti. IV. Evaluation of antibody reactivity to heterologous antigens.

Sera from individuals in an area of Haiti endemic for Mansonella ozzardi were analyzed for reactivity to antigens of Brugia pahangi, Dirofilaria immitis, Mansonella llewellyni or Ascaris lumbricoides using either an enzyme-linked immunosorbent assay or an indirect immunofluorescent antibody test. IgM and IgG reactivity to all antigens was observed with sera from both microfilaremic and amicrofilaremic individuals when compared to reactivity of sera from individuals from nonendemic areas. Antibody reactivity to B. pahangi was greater than that to other antigens. IgG reactivity of sera from endemic patients to filarial antigens was consistently greater than that of IgM. Antibody reactivity was not correlated with age or microfilarial density.

[Toxoplasma gondii in Haiti. Results of a sero-epidemiologic survey in a rural area]. / Toxoplasma gondii en Haiti. Résultats d'un sondage séro-épidémiologique en milieu rural.

In Haiti, positive immunofluorescent tests are observed in 5.9% of the inhabitants of a rural area in the South of the country. The index of positive reactions is increasing with age. No difference between males and females is noticed. Seropositive cases are clustered within defined families for 60% of them. The antibodies titers are low: 8 I. U. for 88% of cases. The prevalence of toxoplasmosis varies from 0 to 15%, according to the village, without any clear relationship with rainfall, altitude, or prevalence of intestinal worm infections. Subjects harboring nematodes transmitted by skin penetration are more often serologically positive than others. Oocysts voided by cats seem to be mainly responsible for transmission to humans in this part of the world.

[Lymphatic filariasis in Haiti. Results of treatment with diethylcarbamazine in the town of Limbe]. / Filariose lymphatique en Haiti. Résultats du traitement par le diéthylcarbamazine dans la ville du Limbe.

In the town of Limbe, in Haiti, 16,8% of the inhabitants show W. bancrofti microfilariae in their blood taken by finger prick between 8.00 and 10.00 p.m. From those positive patients, 208 have received a cure of DEC at the dosage of 6 mg/kg/day during ten days. The control of the therapeutic efficacity among 190 patients, after three and a half months of this cure, shows a negativity of 72%. The positives patients show a very low parasitic charge (MfD50 = 1.9). If the secondary effects are frequent (83.7%), they are often benign and temporary.

[Absence of response of Mansonella ozzardi microfilaria in the diethylcarbamazine provocation test]. / Défaut de réponse des microfilaires Mansonella ozzardi au test de provocation par le diéthyl-carbamazine.

One hundred and twelve inhabitants of an area endemic for M. ozzardi received 20 cmm capillary blood samples by finger prick before and 30 minutes after the ingestion of 100 mg of diethylcarbamazine citrate. No significant variations in microfilaremia were detected. Thus, a provocative dose of DEC would not appear to be helpful in sampling for mansonellosis in Haiti.

Mansonella ozzardi in Haiti. III. A comparison of the sensitivity of four sampling methods in detecting infections.

A study to compare the sensitivity of four sampling methods in detecting Mansonella ozzardi among 133 inhabitants of Bayeux, Haiti, is reported. The Knott method proved the most sensitive with 40 microfilaria carriers detected. No additional infections were revealed by the other sampling methods. This was followed in order by 20 mm3 thick films of earlobe blood (34 cases), finger-prick blood (32 cases in the first sample), and skin biopsy (14 cases from paired samples). The combination of three finger-prick samples (60 mm3 of blood) detected 38 of 40 (95%) Knott-positive infections. The Knott method detected only one case not observed by at least one of the other three sampling methods. This sampling procedure did not detect more M. ozzardi in the 0-19-year age group than observed by the 20-mm3 finger prick method. Based on these results, a correction factor of 1.25 can be applied to our earlier Bayeux survey.

[Modulation of lymphocyte proliferation by serum factors and lipopolysaccharide]. / Modulation de la prolifération lymphocytaire par des facteurs sériques et le lipopolyoside

The in vitro proliferative response of rat lymphoctes culitivated in increasing concentrations of calf serm (LCS) was measured by the incorporation of 3H-thymidine. Results showed that in contrast to the response of PHA, the response to concanavlin A (conA) was greatly dependent on the concentration of serum in the medium. Kinetics of the response of ConA indicated that increasing concentrations of LCS unblocked the non-response to supraoptimal doses of the mitogen. The supportive effect of LCS was not due to an increase in cell viability and was abolished when serum was dialyzed. By contrast, lipopolysaccharide (LPS) exerted an adjuvant effect on the response to optimal and suboptimal concentrations of ConA without unblocking the non-response to high doses. LPS facilitated the response to ConA of a distinct subpopulation of T cell isolated by separation on nylon wool columns. This in vitro model allowed us to study some factors which may be implicated in tolerance and immunity.