[Malaria infection and nutritional status: results from a cohort survey of children from 6-59 months old in the Kivu province, Democratic Republic of the Congo]. / Infection palustre et état nutritionnel: résultats d'une cohorte d'enfants âgés de 6 à 59 mois au Kivu en République démocratique du Congo.

BACKGROUND: Despite a reduction in the magnitude of endemic malaria reported in recent years, malaria and protein-energy malnutrition (PEM) still remain major causes of morbidity and mortality in sub-Saharan Africa among children under five. The relationship between malaria and malnutrition remains a topic of controversy. We aimed to investigate malaria infection according to nutritional status in a community-based survey. METHODS: A cohort of 790 children aged 6 to 59 months and residing in eastern Democratic Republic of the Congo was followed-up from April 2009 to March 2010 with monthly visits. Data on nutritional status, morbidity between visits, use of insecticide-treated nets and malaria parasitemia were collected at each visit. The Z scores height for age, weight for age and weight for height were computed using the reference population defined by the WHO in 2006. Thresholds for Z scores were defined at -3 and -2. A binary logistic model of the generalized estimating equation (GEE) was used to quantify the association between PEM indicators and malaria parasitemia. Odds ratio (OR) and their 95% confidence interval (95% CI) were computed. RESULTS: After adjustment for season, children with severe stunting (height for age Z score<-3) were at lower risk of malaria parasitemia greater or equal to 5000 trophozoits/µL of blood as compared to those in with a better nutritional status (height for age Z score≥-2) (OR=0.48, 95% CI: 0.25-0.91). CONCLUSION: Severely stunted children are at a lower risk of high-level malaria parasitemia.

[Impact of mid-level management and support on the performance of a district health system in the Democratic Republic of the Congo]. / Gouvernance et soutien provincial au district de santé en RD-Congo.

INTRODUCTION: The aim of this study was to assess the contribution of mid-level management and support practices to the overall performance of a district healthcare system. METHODS: This case study was carried out in the North Kivu Province of the Democratic Republic of the Congo. It was based on analysis of (i) preventive and curative healthcare services and (ii) management and support practices provided from 2000 to 2008. RESULTS: In response to recurring sociopolitical unrest since 1992, the mid-level health system (provincial level) in North Kivu has strengthened management and support practices. The main goals have been to optimize allocation of interventions by external emergency organizations and integration of specialized program activities, to harmonize intervention techniques implemented by external partners, to standardize supervision of sanitary districts with regard to care provider skills, and to adapt strategic options defined by the Ministry of Health to the provincial level. Using this comprehensive approach, the performance of the North Kivu Province in terms of curative and preventive care has exceeded the national average since 2001. Between 2001 and 2008, use of curative services progressed from 0.36 to 0.50 new cases/capita/year. Positive results have also been recorded for infrastructure coverage, essential medicine stock, health information system, and emergency preparedness. CONCLUSION: Stronger mid-level management and support practices have improved care activities in the health district while protecting the population from unstructured interventions by emergency organizations or specialized programs. A comprehensive management approach has also improved the resilience of the district and increased its contribution to Millennium Development Goals.

Linking programmes and systems: lessons from the GAVI Health Systems Strengthening window.

OBJECTIVES: To analyse the first four rounds of country applications to the GAVI Alliance Health Systems Strengthening (GAVI-HSS) funding window; to provide valuable insight into how countries prioritize, articulate and propose solutions for health system constraints through the GAVI-HSS application process and to examine the extent to which this process embodies alignment and harmonization, Principles of the Paris Declaration. METHODS: The study applied multiple criteria to analyse 48 funding applications from 40 countries, submitted in the first four rounds, focusing on the country analysis of health systems constraints, coordination mechanisms, alignment with national and sector planning processes, inclusiveness of the planning processes and stakeholder engagement. RESULTS: The applications showed diversity in the health systems constraints identified and the activities proposed. Requirements of GAVI for sector oversight and coordination, and the management of the application process through the Ministry of Health's Planning Department, resulted in strong alignment with government policy and planning processes and good levels of stakeholder inclusion and local technical support (TS). CONCLUSION: Health Systems Strengthening initiatives for global health partnerships (GHPs) can provide a link between the programmatic and the systemic, influencing policy alignment and harmonization of processes. The applications strengthened in-country coordination and planning, with countries using existing health sector assessments to identify system constraints, and to propose. Analyses also produced evidence of broad stakeholder inclusiveness, a good degree of proposal alignment with national health plans and policy documents, and engagement of a largely domestic TS network. While the effectiveness of the proposed interventions cannot be determined from this data, the findings provide support for the GAVI-HSS initiative as implementation continues and evaluation begins.

[The effectiveness of community volunteers in counting populations and assessing their nutritional vulnerability during armed conflict: district health in D.R. Congo, Central Africa]. / Efficacité des relais communautaires dans le dénombrement et la détermination des populations vulnérables dans un contexte de malnutrition endémique et de conflit armé: cas d'un district sanitaire en RD Congo.

The study assessed the ability of community volunteers, working with district health officials, to conduct a local census to count the population in their villages and assess their nutritional vulnerability. The study involved organizing community volunteers in village nutrition committee and assigning them to count the village population in a Kivu rural health district (D.R.Congo) and assess their vulnerability in terms of nutrition. The study took place in March and April 2003, during armed conflict in the region. Community volunteers supervised by district health officials collected data, presented here as median proportions (with their Max and Min), by age category. The results show that community volunteers were able to conduct this census with reliable results. The population distribution by age category was similar to the national model from a survey by experts. The community volunteers estimated a median of 22.2 % (6.2-100 %) of households in each village in the eastern DR Congo were vulnerable and required foreign aid. Community volunteers can contribute accurately to the collection of demographic data to be used in health programme planning, thus allowing these data to be followed even during instability and armed conflicts.

[Protein-energy malnutrition and malaria-related morbidity in children under 59 months in the Kivu region of the Democratic Republic of the Congo]. / Malnutrition protéino-énergétique et morbidité liée au paludisme t chez les enfants de 0-59 mois dans la région du Kivu, République Démocratique du Congo.

In the Kivu region located in east of the Democratic Republic of the Congo, malnutrition and malaria is a major cause of morbidity and mortality. The relationship between malaria and malnutrition is unclear and has never been studied in the Kivu region. This report presents an analysis of data from 5695 children aged 0 to 5 years, admitted to the paediatric ward of Lwiro hospital between November 1992 and February 2004. The weight/age (W/A) index and weight/height (W/H) index expressed with standard deviation in relation to the reference median were calculated (Z score). The association between protein-energetic malnutrition and malaria infection and nutritional indicators was measured based on prevalence ratios determined by univariate analysis and adjusted Odds Ratio (OR) derived using a multivariate model. The prevalence of malaria at the time of admission was 35.8 % (n=5695). The W/A and W/H indexes and serum albumin level were correlated with malaria-related morbidity. Logistic regression showed that high malaria OR was associated with both anthropometric nutritional indicators [WHZ > -2: OR (CI 95 %) 1.7 (1.4-2.2)] [WAZ > -2: OR (CI 95 %) 1.3 (1.1-1.6)] and biological nutritional indicators [serum albumin > or = 23 g/L: OR (CI 95 %) 1.6 (1.2-2.1)]. Our findings indicate that malnourished children at admission have a lower risk of malaria infection.

Malnutrition proteino-energetique et morbidite liee au paludisme chez les enfants de 0-59 mois dans la region du Kivu; Republique Democratique du Congo

Dans la region du Kivu a l'Est de la Republique Democratique du Congo; la malnutrition et le paludisme sont responsables d'une morbidite et mortalite importantes. La relation entre paludisme et malnutrition est controversee et cette association n'a; jusqu'a present; pas ete exploree dans cette region du Kivu. Nous avons analyse les donnees de 5695 enfants ages de zero a cinq ans recueillies a l'admission a l'hopital pediatrique de Lwiro entre novembre 1992 et fevrier 2004. Les indices poids pour age (PPA) et poids pour taille (PPT) exprimes en ecart type par rapport a la mediane de reference ont ete calcules (Z score). L'association entre les indicateurs de la malnutrition proteino- energetique et le paludisme a ete mesuree par les rapports de prevalence en analyse univariee et les OR ajustes derives d'un modele de regression logistique. La prevalence du paludisme a l'admission etait de 35;8(n=5695). Les indices PPT et PPA et l'albumine serique etaient associes a la morbidite liee au paludisme. En regression logistique; des OR eleves de paludisme ont ete observes pour des valeurs elevees des indicateurs anthropometriques [Z score PPT - 2: OR (IC a 95) 1;7 (1;4-2;2)] [Z score PPA - 2: OR (IC a 95) 1;3 (1;1-1;6)] et biologiques [albumine serique = 23g/L : OR (IC a 95) 1;6 (1;2-2;1)] de l'etat nutritionnel. Nos analyses mettent en evidence une association inverse entre la malnutrition et la prevalence de l'infection palustre

[Use and evaluation of the Belgian 3BT thesaurus adapted for Rwanda]. / Utilisation et evaluation du thésaurus belge 3BT adapté au Rwanda.

The Kigali university medical centre (CHUK) lacks visibility on its activities for many years. Institution management as well understanding the institution as the corner stone of the Rwandese health system and reinforcement of its visibility are all health policy major issues. Nevertheless, to this point no such tool has been developed nor implemented. The objective is to assess the feasibility of the use of the thesaurus 3BT as data collection tool in a Rwandese health institution. In august 2005, the thesaurus 3BT (Belgian, bilingual, biclassified ICD-10/ICPC-2) adapted to the CHUK has been implemented. Main issues: encoding quality and thesaurus operationality. Qualitative analysis has been performed on 899 coding of which 16 empty. Low occurrences (< or = 0.2%) of about 25% of codings of clinical diagnosis show the need for using a thesaurus but also to upgrade it. Near 45% of the empty codings could be fulfilled with a quick look to the original medical record. Some diagnoses are missing in the thesaurus 3BT. 66% of which have similar concepts in the thesaurus although not identifiable by a lay person. Finally, a clinical data blind coding test by a doctor used to classifications and by a lay person used to code clinical diagnosis from medical records of the hospitalised patients shows an exact similarity in 70% of the coding and a loss of coding precision in 20%. No coding error has been identified at this time. In conclusion, operationality of the thesaurus is quite acceptable in this study. The thesaurus makes easy the coding of clinical diagnosis even by lay people. Quality of data is enough to be able to interpret the quantitative results of the coding process. This study has to be repeated on a wider basis.

[Referral and delivery outcomes in Kivu, Democratic Republic of Congo]. / Référence et issues à l'accouchement au Kivu, République Démocratique du Congo.

BACKGROUND: The process of referral between the first and the second level of the health system in the Democratic Republic of Congo is poorly understood. This report intends to study the association between the referral and the hospital perinatal outcomes. METHODS: Delivery outcomes in a retrospective cohort of 1162 women admitted between June 95 and May 96, in two referral hospitals in Kivu were analyzed according to the referral status and the women's characteristics. RESULTS: Forty-three percent (n=492)of women admitted, corresponding to 2.3% of expected pregnant women, were referred. Referred women had higher risks of obstetrical complications (OR=2.0; CI95%: 1.3-3.1) and intervention (OR=1.5; CI95%: 1.0-2.3) and similar risks of low birth weight and perinatal mortality. Women with complications during the antenatal period had a double risk of intervention and perinatal mortality. The risk of obstetrical intervention was lower when women had attended 2 visits (OR=0.5; CI95%: 0.3-0.8); the risk of low birth weight was lowest only for mothers who had attended one visit (OR=0.5; CI95%: 0.3-0.9). Distance > or =90 minutes walking from home to hospital raised the risk of obstetrical complication (OR=1.7; CI95%: 1.1-2.5), the risk of obstetrical intervention (OR=1.5; CI95%: 1.0-2.1), and the risk of perinatal mortality (OR=1.6; CI95%: 1.0-2.7). Late admission raised the risk of perinatal mortality (OR=1.8; CI95%: 1.2-2.9) and lowered the risk of obstetrical complication (OR=0.7; CI95%: 0.5-1.0). Part payment of care was associated with higher risks of low birth weight (OR=1.9; CI95%: 1.3-2.9), perinatal mortality (OR=2.2; CI95%: 1.4-3.5) and obstetrical intervention (OR=2.4; CI95%: 1.7-3.4). CONCLUSION: These results suggest a deficit of referred cases considering that 15% of pregnant women in the area covered by the referral hospitals should have been referred. They confirm the negative influence of economic and geographic constraints on the delivery outcomes. They point out the relevance of making reorganization of the referral system a priority.

The unseen face of humanitarian crisis in eastern Democratic Republic of Congo: was nutritional relief properly targeted?

STUDY OBJECTIVE: Comparison of children's nutritional status in refugee populations with that of local host populations, one year after outbreak refugee crisis in the North Kivu region of Democratic Republic of Congo. DESIGN: Cross sectional surveys. SETTING: Temporary and other settlements, in the town of Goma and surrounding rural areas. SUBJECTS: Anthropometric indicators of nutritional status and presence or absence of oedema were measured among 5121 children aged 6 to 59 months recruited by cluster sampling with probability proportional to size, between June and August 1995. RESULTS: Children in all locations demonstrated a typical pattern of growth deficit relative to international reference. Prevalence of acute malnutrition (wt/ht < -2 Z score) was higher among children in the rural non-refugee populations (3.8 and 5.8%) than among those in the urban non-refugee populations (1.4%) or in the refugee population living in temporary settlements (1.7%). Presence of oedema was scarcely noticed in camps (0.4%) while it was a common observation at least in the most remote rural areas (10.1%). As compared with baseline data collected in 1989, there is evidence that nutritional status was worsening in rural non-refugee populations. CONCLUSIONS: Children living in the main town or in the refugee camps benefited the most from nutritional relief while those in the rural non-refugee areas were ignored. This is a worrying case of inequity in nutritional relief.

How robust are district health systems? Coping with crisis and disasters in Rutshuru, Democratic Republic of Congo.

BACKGROUND: Since the eighties, the North Kivu Province socio-economic environment has been deteriorating. This province also faced an influx of Rwandan refugees in July 1994. The objective of the paper is to show how a rural health district has been able to adjust and maintain its medical activities under unfavourable conditions. METHOD: Performances of the local health system were assessed through the analysis of routine medical data collected in the Rutshuru Health District (RHD) between 1985 and 1995. Specific data collected during the Rwandan refugee crisis measured the workload of RHD due to the refugees. RESULTS: For 11 years, health infrastructures have remained accessible and functional in RHD. The curative utilization and preventive coverage rates increased. Obstetrical activities were intensified from a quantitative as well as from a qualitative point of view. Between July and October 1994, the RHD treated 65000 cases of various pathological conditions in Rwandan refugees settled outside the camps. This corresponds to 9.3% of consultations for Rwandan refugees settled on RHD's territory and represents a 400% increase in the curative workload for the RHD health services. Human and financial resources remained at a very low level, especially when compared with those available in the camps through relief agencies. CONCLUSION: The RHD was severely affected by various stresses but its services managed to provide significant and efficient response to these crises. Health district systems may constitute an effective tool to provide health care under adverse conditions.

Prognostic indices for mortality of hospitalized children in central Africa.

A hospital-based follow-up study was conducted between 1986 and 1988 at Lwiro (South Kivu Province, Zaire). Of 1,129 children in the study, three of four were severely malnourished, and 17.4% died. This study analyzes the mortality in hospital; its objectives are to evaluate the prognostic power of edema and anthropometric and biologic indicators and to seek indices that perform better. Receiver operating characteristic curves were established for each parameter under study and for each index constructed. Areas under receiver operating characteristic curves were highest for biologic indicators, and simple indices, obtained by counting the number of risk factors present, performed best. In the absence of biologic parameters, the authors suggest classifying children as at risk of dying when they present with edema and/or with arm circumference of less than 115 mm. When biologic measurements are possible, in addition to edema and arm circumference, the authors suggest taking serum albumin and transthyretin into account. For serum albumin and transthyretin, mortality risk is defined in terms of values of less than 16 g/liter and 6.5 mg/dl, respectively. Children will be classified as at risk of dying when they present with at least two of the four risk factors. The resulting diagnostic test has a high sensitivity (91.2%) and positive and negative predictive values of 40.8% and 97.9%, respectively.

The role of the Zairian Health Services in the Rwandan refugee crisis.

In July 1994, a stream of Rwandan refugees entered the southern part of North Kivu Region, Zaire. The public health consequences of this crisis for the host population and health services have not been analysed up to now. The lack of human and financial resources did not prevent Zairian health structures and personnel from taking care of the many refugees settled outside the camps, following their arrival. The public health consequences of the crisis for the local population should be considered an integral part of the disaster.