Identifying and Characterizing the Poorest Urban Population Using National Household Surveys in 38 Cities in Sub-Saharan Africa.

Identifying and classifying poor and rich groups in cities depends on several factors. Using data from available nationally representative surveys from 38 sub-Saharan African countries, we aimed to identify, through different poverty classifications, the best classification in urban and large city contexts. Additionally, we characterized the poor and rich groups in terms of living standards and schooling. We relied on absolute and relative measures in the identification process. For absolute ones, we selected people living below the poverty line, socioeconomic deprivation status and the UN-Habitat slum definition. We used different cut-off points for relative measures based on wealth distribution: 30%, 40%, 50%, and 60%. We analyzed all these measures according to the absence of electricity, improved drinking water and sanitation facilities, the proportion of children out-of-school, and any household member aged 10 or more with less than 6 years of education. We used the sample size, the gap between the poorest and richest groups, and the observed agreement between absolute and relative measures to identify the best measure. The best classification was based on 40% of the wealth since it has good discriminatory power between groups and median observed agreement higher than 60% in all selected cities. Using this measure, the median prevalence of absence of improved sanitation facilities was 82% among the poorer, and this indicator presented the highest inequalities. Educational indicators presented the lower prevalence and inequalities. Luanda, Ouagadougou, and N'Djaména were considered the worst performers, while Lagos, Douala, and Nairobi were the best performers. The higher the human development index, the lower the observed inequalities. When analyzing cities using nationally representative surveys, we recommend using the relative measure of 40% of wealth to characterize the poorest group. This classification presented large gaps in the selected outcomes and good agreement with absolute measures.

The impact of the COVID-19 pandemic on trends in stillbirths, under-5 and maternal mortality in Brazil: Excess deaths and regional inequalities.

Background: Despite the proliferation of studies on the impact of the coronavirus disease 2019 (COVID-19) pandemic, there is less evidence on the indirect death toll compared to the health system and service provision disruptions. We assessed the impact of the COVID-19 pandemic on national and regional trends and differences in stillbirths, under-5 and maternal deaths in Brazil. Methods: We used the nationwide routine health information system data from January 2017 to December 2021, to which we applied descriptive and advanced mixed effects ordinary least squared regression models to measure the percent change in mortality levels during the COVID-19 pandemic (March 2020 to December 2021). We carried out counterfactual analyses comparing the observed and expected mortality levels for each type of mortality at national and regional levels. Results: Stillbirths increased 4.8% (3.1% in 2020 and 6.2% in 2021) and most noticeably maternal deaths increased 71.6% (35.3% in 2020 and 103.3% in 2021) over the COVID-19 period. An opposite pattern was observed in under-5 mortality, which dropped -10.2% (-12.5% in 2020 and -8.1% in 2021). We identified regional disparities, with a higher percent increase in stillbirths observed in the Central-West region and in maternal deaths in the South region. Discussion: Based on pre-pandemic trends and expected number of deaths in the absence of the COVID-19, we observed increases in stillbirths and maternal deaths and reductions in under-5 deaths during the pandemic. The months with the highest number of deaths (stillbirths and maternal deaths) coincided with the months with the highest mortality from COVID-19. The increase in deaths may also have resulted from indirect effects of the pandemic, such as unavailability of health services or even reluctance to go to the hospital when necessary due to fear of contagion. Conclusions: In Brazil, the COVID-19 outbreak and subsequent restrictions had a detrimental impact on stillbirths and maternal deaths. Even before the pandemic, mortality trends highlighted pre-existing regional inequalities in the country's health care system. Although there were some variations, increases were observed in all regions, indicating potential weaknesses in the health system and inadequate management during the pandemic, particularly concerning pregnant and postpartum women.

Prioritizing Variables for Evaluating the Efficacy and Effectiveness of Brief Interventions for Reducing Alcohol Consumption: A Latin American Perspective.

OBJECTIVE: The purpose of this study was to identify priority variables to evaluate alcohol brief interventions from the perspective of experts in the field in Latin America. METHOD: A two-round Delphi procedure was carried out through online surveys of 465 individuals from 18 Latin American countries, including core outcome set developers, researchers, health professionals, users of healthcare services, journal editors, members of nongovernmental organizations, and policymakers. The questionnaire, in Spanish and Portuguese, rated 101 variables according to their relevance to the efficacy and effectiveness of brief interventions. RESULTS: Round 1 yielded 47 variables that met the consensus criterion of at least 70% of participants; Round 2 yielded 63 variables. To reduce the possible effect of varying levels of expertise, data were analyzed by subgroup, with consensus defined as 70% of each subgroup rating a variable as critical. Seventeen outcome variables met this criterion, 14 from the initial set and 3 suggested by the participants in Round 1. CONCLUSIONS: Only four outcomes coincide with the findings of a similar international Delphi study that underrepresented Latin American countries. The findings point to the importance of including a wider variety of professionals and cultural backgrounds in international consensus panels to minimize the risk of predominance of a single perspective.

Limited specificity of commercially available SARS-CoV-2 IgG ELISAs in serum samples of African origin.

OBJECTIVES: Specific serological tests are mandatory for reliable SARS-CoV-2 diagnostics and seroprevalence studies. Here, we assess the specificities of four commercially available SARS-CoV-2 IgG ELISAs in serum/plasma panels originating from Africa, South America, and Europe. METHODS: 882 serum/plasma samples collected from symptom-free donors before the COVID-19 pandemic in three African countries (Ghana, Madagascar, Nigeria), Colombia, and Germany were analysed with three nucleocapsid-based ELISAs (Euroimmun Anti-SARS-CoV-2-NCP IgG, EDI™ Novel Coronavirus COVID-19 IgG, Mikrogen recomWell SARS-CoV-2 IgG), one spike/S1-based ELISA (Euroimmun Anti-SARS-CoV-2 IgG), and in-house common cold CoV ELISAs. RESULTS: High specificity was confirmed for all SARS-CoV-2 IgG ELISAs for Madagascan (93.4-99.4%), Colombian (97.8-100.0%), and German (95.9-100.0%) samples. In contrast, specificity was much lower for the Ghanaian and Nigerian serum panels (Ghana: NCP-based assays 77.7-89.7%, spike/S1-based assay 94.3%; Nigeria: NCP-based assays 39.3-82.7%, spike/S1-based assay 90.7%). 15 of 600 African sera were concordantly classified as positive in both the NCP-based and the spike/S1-based Euroimmun ELISA, but did not inhibit spike/ACE2 binding in a surrogate virus neutralisation test. IgG antibodies elicited by previous infections with common cold CoVs were found in all sample panels, including those from Madagascar, Colombia, and Germany and thus do not inevitably hamper assay specificity. Nevertheless, high levels of IgG antibodies interacting with OC43 NCP were found in all 15 SARS-CoV-2 NCP/spike/S1 ELISA positive sera. CONCLUSIONS: Depending on the chosen antigen and assay protocol, SARS-CoV-2 IgG ELISA specificity may be significantly reduced in certain populations probably due to interference of immune responses to endemic pathogens like other viruses or parasites.

Correlates of diabetic polyneuropathy of the elderly in Sub-Saharan Africa.

BACKGROUND: Diabetic polyneuropathy is associated with significant physical disability among older adults. However, their frequency and correlates are not well known in the older adults in Sub-Saharan-Africa. The objectives were to evaluate the hospital-based prevalence of diabetic polyneuropathy and identify its correlates in older adults. METHODS: Over a period of 5 months, a cross-sectional survey was carried out at Douala Laquintinie Hospital (DLH), a main reference hospital in Douala, the economic capital of Cameroon. Participants in our study group comprised all patients with type 2 diabetes, whatever the reason for their reporting to the hospital. Diabetic Polyneuropathy was defined according to a Diabetic Neuropathy Examination score > 3/16. RESULTS: A total of 159 older adults with diabetes were examined during this recruitment period, among whom 106 (66.7%) were women. The mean age was 68.3 ± 6.5 years. Diabetes median duration was 108 months. For all patients assessed using the Diabetic Neuropathy Examination score, polyneuropathy was reported in 31.4%; among them, polyneuropathy proved symptomatic in 78% of them. Correlates of polyneuropathy were glycated hemoglobin (p = 0.049), HIV infection (p = 0.031) and albuminuria (p< 0.001), even after adjustment for age, gender and duration of diabetes. CONCLUSION: A third of older adults with diabetes who visited our hospital were diagnosed with prevalent diabetes-related polyneuropathy. It shows that early detection is required through routine screening and regular follow-up examinations in order to reduce the risk of disability and improve the quality of life in elderly diabetics.

Wealth-related inequalities in the coverage of reproductive, maternal, newborn and child health interventions in 36 countries in the African Region.

OBJECTIVE: To investigate whether sub-Saharan African countries have succeeded in reducing wealth-related inequalities in the coverage of reproductive, maternal, newborn and child health interventions. METHODS: We analysed survey data from 36 countries, grouped into Central, East, Southern and West Africa subregions, in which at least two surveys had been conducted since 1995. We calculated the composite coverage index, a function of essential maternal and child health intervention parameters. We adopted the wealth index, divided into quintiles from poorest to wealthiest, to investigate wealth-related inequalities in coverage. We quantified trends with time by calculating average annual change in index using a least-squares weighted regression. We calculated population attributable risk to measure the contribution of wealth to the coverage index. FINDINGS: We noted large differences between the four regions, with a median composite coverage index ranging from 50.8% for West Africa to 75.3% for Southern Africa. Wealth-related inequalities were prevalent in all subregions, and were highest for West Africa and lowest for Southern Africa. Absolute income was not a predictor of coverage, as we observed a higher coverage in Southern (around 70%) compared with Central and West (around 40%) subregions for the same income. Wealth-related inequalities in coverage were reduced by the greatest amount in Southern Africa, and we found no evidence of inequality reduction in Central Africa. CONCLUSION: Our data show that most countries in sub-Saharan Africa have succeeded in reducing wealth-related inequalities in the coverage of essential health services, even in the presence of conflict, economic hardship or political instability.

Rice bran supplementation modulates growth, microbiota and metabolome in weaning infants: a clinical trial in Nicaragua and Mali.

Rice bran supplementation provides nutrients, prebiotics and phytochemicals that enhance gut immunity, reduce enteric pathogens and diarrhea, and warrants attention for improvement of environmental enteric dysfunction (EED) in children. EED is a subclinical condition associated with stunting due to impaired nutrient absorption. This study investigated the effects of rice bran supplementation on weight for age and length for age z-scores (WAZ, LAZ), EED stool biomarkers, as well as microbiota and metabolome signatures in weaning infants from 6 to 12 months old that reside in Nicaragua and Mali. Healthy infants were randomized to a control (no intervention) or a rice bran group that received daily supplementation with increasing doses at each month (1-5 g/day). Stool microbiota were characterized using 16S rDNA amplicon sequencing. Stool metabolomes were analyzed using ultra-high-performance liquid-chromatography tandem mass-spectrometry. Statistical comparisons were completed at 6, 8, and 12 months of age. Daily consumption of rice bran was safe and feasible to support changes in LAZ from 6-8 and 8-12 months of age in Nicaragua and Mali infants when compared to control. WAZ was significantly improved only for Mali infants at 8 and 12 months. Mali and Nicaraguan infants showed major differences in the overall gut microbiota and metabolome composition and structure at baseline, and thus each country cohort demonstrated distinct microbial and metabolite profile responses to rice bran supplementation when compared to control. Rice bran is a practical dietary intervention strategy that merits development in rice-growing regions that have a high prevalence of growth stunting due to malnutrition and diarrheal diseases. Rice is grown as a staple food, and the bran is used as animal feed or wasted in many low- and middle-income countries where EED and stunting is prevalent.

Strengthening Primary Care Through Family Medicine Around the World Collaborating Toward Promising Practices.

BACKGROUND AND OBJECTIVES: There is a limited evidentiary base on the development of family medicine in different contexts and countries. The lack of evidence impedes our ability to compare and characterize family medicine models and identify areas of success that have led to the effective provision of care. This paper offers a comparative compilation and analysis of the development of family medicine training programs in seven countries: Brazil, Canada, Ethiopia, Haiti, Indonesia, Kenya, and Mali. METHODS: Using qualitative case studies, this paper examines the process of developing family medicine programs, including enabling strategies and barriers, and shared lessons. An appreciative inquiry framework and complex adaptive systems thinking inform our qualitative study. RESULTS: Committed partnerships, the contribution of champions, health policy, and adaptability were identified as key enablers in all seven case studies. The case studies further reveal that some enablers were more salient in certain contexts as compared to others, and that it is the interaction of enablers that is crucial for understanding how and why initiatives succeeded. The barriers that emerged across the seven case studies include: (1) resistance from other medical specialties, (2) lack of resources and capabilities, (3) difficulty in sustaining support of champions, and (4) challenges in brokering effective partnerships. CONCLUSIONS: A key insight from this study is that the implementation of family medicine is nonlinear, dynamic, and complex. The findings of this comparative analysis offer insights and strategies that can inform the design and development of family medicine programs elsewhere.

Oral Hygiene: Knowledge and Practices of Students in Three Quranic Schools in Koutiala, Mali

Objective: To evaluate the knowledge, attitudes, and practices on oral hygiene (OH) of students of three Quranic schools of Koutiala, Mali. Material and Methods: It was carried out a descriptive prospective study with 300 students in three Quranic schools in the city of Koutiala, Mali. The data analyzed with the Epi Info 3.5.4 software. Results: The male sex was the most represented with 57.7% and the sex ratio = 0.73. The most represented age group was 8-12 with 52% with an average age of 17 years and minimum and maximum age of was 8 and 26 years. It was observed that 98.3% of students had a notion of knowledge about oral hygiene and this information was given by parents / elders in 60% of cases. They claimed that people who do not brush their teeth properly are the most likely to get tooth decay in 93.3% of cases. Regarding dental caries, 61.3% of students said that caries is transmitted by lack of oral hygiene; 33.3% of students said that using toothbrushes and having good oral hygiene are ways to avoid oral diseases. It was thought in 93.3% of cases that a good oral hygiene prevents oral diseases. The students brushed their teeth every day (98%) and they had a consultation with the dental surgeon in 8.7% of the cases. Conclusion: This study shows that students had knowledge of oral hygiene and preventive measures. Efforts should be made to promote, prevent, screen and manage oral diseases in Quranic schools while involving parents in the processes.

Knowledge, Attitudes and Practices of Doctors and Dental Surgeons in Bamako on the Relationship Between Periodontal Diseases and Chronic Non-Communicable Diseases

Objective: To assess the level of knowledge, attitudes and practices of doctors and dentists in Bamako on the relationship between chronic non-communicable diseases and periodontal diseases. Material and Methods: A cross-sectional study of 420 physicians and dental surgeons was conducted from March to August 2016. Data analysis involved descriptive statistics (frequency distribution). All statistical analyses were performed using the Epi Info 3.5.4 Software. Results: The male sex was the most represented with 58% for a sex ratio of 1.3. The most represented age group was 30-40 years old (48.8%) with an average age of 33 ± 8.2 years. General practitioners were the most represented in 93.6% of cases. Physicians with no knowledge of periodontal disease accounted for 60% of all cases, and all dental surgeons reported knowledge of chronic noncommunicable conditions in 100% of cases. Physicians and dental surgeons rated their knowledge levels of periodontal disease and chronic disease as inadequate in 98% and 90% of cases, respectively. Examination of the oral cavity by the doctors was "sometimes" carried out in 66% of the cases and the non-demand of the clinical signs of the gingival bleeding (64%) and dental migration (80.5%). They did not make recommendations on oral hygiene in 61.7% of cases. Conclusion: This study shows shortcomings among doctors and dentists in Bamako on the relationship between periodontal diseases and chronic non-communicable diseases. Capacity building and multidisciplinary collaboration are needed to support people's health.

Manejo quirúrgico de los carcinomas diferenciados de tiroides Experiencia en un país de bajos ingresos / SURGICAL MANAGEMENT OF DIFFERENTIATED THYROID CARCINOMAS. EXPERIENCE IN A LOW INCOME COUNTRY

ience in the management of differentiated thyroid carcinomas in a low- income country. Materials and Methods: We performed a retrospective study in our department where 21 cases of differentiated thyroid carcinomas were recorded from February 2001 to December 2010. Results: We performed 334 thyroidectomies for 326 patients. Of this group, 21 differentiated thyroid carcinomas were diagnosed. Differentiated thyroid carcinomas represented 6.4% of all thyroid neoplasm managed during the same period (n=326). Median age was 44 years (range 13 - 75 years). Male to female ratio was 1:20. Six (6) patients underwent primary hemithyroidectomy in other institutions while the fifteen left were entirely managed in our clinic. Of them, one patient was referred with positive fine needle aspiration cytology for papillary thyroid carcinoma (incidental detection by fine needle aspiration biopsy) and another had history of sinus pyriform fistula. Pathology of surgical specimens showed 13 cases of papillary thyroid carcinomas and 8 cases of follicular thyroid carcinomas with association to Hashimoto thyroiditis and Grave's disease in respectively in 1 case. Twenty cases were incidentally discovered by thyroid surgery and undergone completion thyroidectomy with prophylactic central neck dissection, completion thyroidectomy alone, modified lateral neck dissection alone and surveillance respectively in 13, 1, 1 and 6 cases. Complications of thyroid surgery were bilateral recurrent laryngeal nerve paralysis and hematoma respectively in 1 case. Median hospital stay was 5 days ranged from 3 to 15 days. During the follow-up period, most of our patients were lost of follow-up. Conclusion: Management guidelines of differentiated thyroid carcinomas are well established but not applicable to low- income country for several reasons. National guidelines, based on further researches, must then be implemented to improve our practice

Adaptive differentiation of Plasmodium falciparum populations inferred from single-nucleotide polymorphisms (SNPs) conferring drug resistance and from neutral SNPs.

BACKGROUND: Theoretical and experimental data support the geographic differentiation strategy as a valuable tool for detecting loci under selection. In the context of Plasmodium falciparum malaria, few populations have been studied, with limited genomic coverage. METHODS: We examined geographic differentiation in P. falciparum populations on the basis of 12 single-nucleotide polymorphisms (SNPs) in 4 genes encoding drug resistance determinants, 5 SNPs in 2 genes encoding antigens, and a set of 17 putatively neutral SNPs dispersed on 13 chromosomes. We sampled 326 parasite isolates representing 7 P. falciparum populations from regions with varied levels of malaria transmission (Gabon, Kenya, Madagascar, Mali, Mayotte, Haiti, and the Philippines). RESULTS: Frequencies of drug resistance alleles varied considerably among populations (mean F(ST), 0.52). In contrast, allele frequencies varied significantly less for antigenic and neutral SNPs (mean F(ST), 0.16 and 0.24, respectively). This contrasting pattern was more pronounced when only the African populations were considered. Signature of selection was detected for most of the resistant SNPs but not for the antigenic SNPs. CONCLUSION: These data further validate the utility of geographic differentiation for identifying loci under strong positive selection, such as drug resistance loci. This study also provides frequencies of molecular makers of resistance in some overlooked populations.

Aspectos ginecológicos e hormonais de pacientes nefropatas e transplantadas renais / Gynecologic and hormonal aspects of chronic kidney disease and transplantation

A prevalência de disfunção ovariana é alta em mulheres com doença renal crônica e parece resultar da disfunção em diversos níveis do eixo hipotálamo-hipófise-ovariano (HHO). Estas pacientes costumam apresentar ciclos irregulares, amenorréia, atraso no desenvolvimento puberal e baixa estatura. No entanto, em pacientes transplantadas renais, há uma melhora da função do eixo HHO, incluindo a melhora da fertilidade. Por isso, a contracepção após o transplante é importante e deve ter uma abordagem especializada. Ao prescrever um método contraceptivo, deve-se levar em conta a vulnerabilidade do órgão transplantado, os efeitos adversos, as interações medicamentosas, seus potenciais benefícios e malefícios e a condição clínica da paciente. O objetivo dessa revisão foi avaliar o eixo HHO das pacientes com doença renal crônica (DRC) ou transplante renal, bem como as peculiaridades da contracepção, uso de drogas e avaliação do colo uterino nessas pacientes.

The prevalence of ovarian dysfunction is high in women with CKD and seems to result from dysfunction at several levels along hypothalamic-pituitary-ovarian (HPO) axis. This situation results in menstrual disturbances or even amenorrhea, late puberty, and low stature. On the other hand, kidney transplantation can improve these abnormalities and also increase fertility. The contraception after transplantation is important and must have a specialized approach. When prescribing a contraceptive method, the vulnerability of the graft, side effects, drug interaction and clinical condition of the patient must be evaluated. The objective of this review was to evaluate the HPO axis of patients with chronic kidney disease (CKD) or kidney transplantation and the peculiarities of contraception, drug and cervical assessment in these patients.