Challenges in reducing maternal and neonatal mortality in Niger: an in-depth case study.

INTRODUCTION: Recent modelled estimates suggest that Niger made progress in maternal mortality since 2000. However, neonatal mortality has not declined since 2012 and maternal mortality estimates were based on limited data. We researched the drivers of progress and challenges. METHODS: We reviewed two decades of health policies, analysed mortality trends from United Nations data and six national household surveys between 1998 and 2021 and assessed coverage and inequalities of maternal and newborn health indicators. Quality of care was evaluated from health facility surveys in 2015 and 2019 and emergency obstetric assessments in 2011 and 2017. We determined the impact of intervention coverage on maternal and neonatal lives saved between 2000 and 2020. We interviewed 31 key informants to understand the factors underpinning policy implementation. RESULTS: Empirical maternal mortality ratio declined from 709 to 520 per 100 000 live births during 2000-2011, while neonatal mortality rate declined from 46 to 23 per 1000 live births during 2000-2012 then increased to 43 in 2018. Inequalities in neonatal mortality were reduced across socioeconomic and demographic strata. Key maternal and newborn health indicators improved over 2000-2012, except for caesarean sections, although the overall levels were low. Interventions delivered during childbirth saved most maternal and newborn lives. Progress came from health centre expansion, emergency care and the 2006 fee exemptions policy. During the past decade, challenges included expansion of emergency care, continued high fertility, security issues, financing and health workforce. Social determinants saw minimal change. CONCLUSIONS: Niger reduced maternal and neonatal mortality during 2000-2012, but progress has stalled. Further reductions require strategies targeting comprehensive care, referrals, quality of care, fertility reduction, social determinants and improved security nationwide.

Prolonged mass azithromycin distributions and macrolide resistance determinants among preschool children in Niger: A sub-study of a cluster-randomized trial (MORDOR).

BACKGROUND: Randomized controlled trials found that twice-yearly mass azithromycin administration (MDA) reduces childhood mortality, presumably by reducing infection burden. World Health Organization (WHO) issued conditional guidelines for mass azithromycin administration in high-mortality settings in sub-Saharan Africa given concerns for antibiotic resistance. While prolonged twice-yearly MDA has been shown to increase antibiotic resistance in small randomized controlled trials, the objective of this study was to determine if macrolide and non-macrolide resistance in the gut increases with the duration of azithromycin MDA in a larger setting. METHODS AND FINDINGS: The Macrolide Oraux pour Réduire les Décès avec un Oeil sur la Résistance (MORDOR) study was conducted in Niger from December 2014 to June 2020. It was a cluster-randomized trial of azithromycin (A) versus placebo (P) aimed at evaluating childhood mortality. This is a sub-study in the MORDOR trial to track changes in antibiotic resistance after prolonged azithromycin MDA. A total of 594 communities were eligible. Children 1 to 59 months in 163 randomly chosen communities were eligible to receive treatment and included in resistance monitoring. Participants, staff, and investigators were masked to treatment allocation. At the conclusion of MORDOR Phase I, by design, all communities received an additional year of twice-yearly azithromycin treatments (Phase II). Thus, at the conclusion of Phase II, the treatment history (1 letter per 6-month period) for the participating communities was either (PP-PP-AA) or (AA-AA-AA). In Phase III, participating communities were then re-randomized to receive either another 3 rounds of azithromycin or placebo, thus resulting in 4 treatment histories: Group 1 (AA-AA-AA-AA-A, N = 51), Group 2 (PP-PP-AA-AA-A, N = 40), Group 3 (AA-AA-AA-PP-P, N = 27), and Group 4 (PP-PP-AA-PP-P, N = 32). Rectal swabs from each child (N = 5,340) were obtained 6 months after the last treatment. Each child contributed 1 rectal swab and these were pooled at the community level, processed for DNA-seq, and analyzed for genetic resistance determinants. The primary prespecified outcome was macrolide resistance determinants in the gut. Secondary outcomes were resistance to beta-lactams and other antibiotic classes. Communities recently randomized to azithromycin (groups 1 and 2) had significantly more macrolide resistance determinants than those recently randomized to placebo (groups 3 and 4) (fold change 2.18, 95% CI 1.5 to 3.51, Punadj < 0.001). However, there was no significant increase in macrolide resistance in communities treated 4.5 years (group 1) compared to just the most recent 2.5 years (group 2) (fold change 0.80, 95% CI 0.50 to 1.00, Padj = 0.010), or between communities that had been treated for 3 years in the past (group 3) versus just 1 year in the past (group 4) (fold change 1.00, 95% CI 0.78 to 2.35, Padj = 0.52). We also found no significant differences for beta-lactams or other antibiotic classes. The main limitations of our study were the absence of phenotypic characterization of resistance, no complete placebo arm, and no monitoring outside of Niger limiting generalizability. CONCLUSIONS: In this study, we observed that mass azithromycin distribution for childhood mortality among preschool children in Niger increased macrolide resistance determinants in the gut but that resistance may plateau after 2 to 3 years of treatment. Co-selection to other classes needs to be monitored. TRIAL REGISTRATION: NCT02047981 https://classic.clinicaltrials.gov/ct2/show/NCT02047981.

Women's involvement in decision-making and association with reproductive health behaviors: findings from a cross-sectional survey in Niger.

BACKGROUND: Though women in Niger are largely responsible for the familial health and caretaking, prior research shows limited female autonomy in healthcare decisions. This study extends current understanding of women's participation in decision-making and its influence on reproductive health behaviors. METHODS: Cross-sectional survey with married women (15-49 years, N = 2,672) in Maradi and Zinder Niger assessed women's participation in household decision-making in health and non-health issues. Analyses examined [1] if participation in household decision-making was associated with modern contraceptive use, antenatal care (ANC) attendance, and skilled birth attendance at last delivery and [2] what individual, interpersonal, and community-level factors were associated with women's participation in decision-making. RESULTS: Only 16% of the respondents were involved-either autonomously or jointly with their spouse-in all three types of household decisions: (1) large purchase, (2) visiting family/parents, and (3) decisions about own healthcare. Involvement in decision making was significantly associated with increased odds of current modern contraceptive use [aOR:1.36 (95% CI: 1.06-1.75)] and four or more ANC visits during their recent pregnancy [aOR:1.34 (95% CI: 1.00-1.79)], when adjusting for socio-demographic characteristics. There was no significant association between involvement in decision-making and skilled birth attendance at recent delivery. Odds of involvement in decision-making was significantly associated with increasing age and household wealth status, listening to radio, and involvement in decision-making about their own marriage. CONCLUSION: Women's engagement in decision-making positively influences their reproductive health. Social and behavior change strategies to shift social norms and increase opportunities for women's involvement in household decision making are needed. For example, radio programs can be used to inform specific target groups on how women's decision-making can positively influence reproductive health while also providing specific actions to achieve change. Opportunities exist to enhance women's voice either before women enter marital partnerships or after (for instance, using health and social programming).

Therapeutic efficacy and tolerability of artemether-lumefantrine for uncomplicated Plasmodium falciparum malaria in Niger, 2020.

BACKGROUND: Monitoring therapeutic efficacy is important to ensure the efficacy of artemisinin-based combination therapy (ACT) for malaria. The current first-line treatment for uncomplicated malaria recommended by the National Malaria Control Program in Niger is artemether-lumefantrine (AL). In 2020, an in vivo study was carried out to evaluate clinical and parasitological responses to AL as well as the molecular resistance to the drug in three sentinel sites: Agadez, Tessaoua and Gaya, in Niger. METHODS: A multi-center, single-arm trial was conducted according to the 28-day World Health Organization (WHO) 2009 therapeutic efficacy study protocol. Children between 6 months and 15 years with confirmed uncomplicated Plasmodium falciparum infection and 1000-200,000 asexual parasites/µL of blood were enrolled and followed up for 28 days. Uncorrected and PCR-corrected efficacy results at day 28 were calculated, and molecular correction was performed by genotyping the msp1, msp2, and glurp genes. The pfk13, pfdhfr, pfdhps, pfcrt and pfmdr genes were analyzed by PCR and Sanger sequencing. The Kaplan-Meier curve assessed parasite clearance. RESULTS: A total of 255 patients were enrolled in the study. The adequate clinical and parasitological response after PCR correction was 98.9% (95% CI 96.4-101.0%), 92.2% (85.0-98.5%) and 97.1% (93.1-101.0%) in Gaya, Tessaoua and Agadez, respectively. No adverse events were observed. Ten mutations (SNP) were found, including 7 synonyms (K248K, G690G, E691E, E612E, C469C, G496G, P718P) and 3 non-synonyms (N594K, R255K, V714S). Two mutations emerged: N594K and V714S. The R255K mutation detected in Southeast Asia was also detected. The pfdhpsK540E and pfdhfrI164L mutations associated with high levels of resistance are absent. There is a reversal of chloroquine resistance. CONCLUSION: The study findings indicate that AL is effective and well tolerated for the treatment of uncomplicated malaria in three sites in Niger. The emergence of a pfk13 mutation requires additional testing such as the Ring Stage Assay and CRISPR/Cas9 to confirm the role of these emerging mutations. Trial registration NCT05070520, October 7, 2021.

A typology of subseasonal rainfall evolution during the southern Niger monsoon.

Niger is highly vulnerable to rainfall variability, often with adverse socioeconomic consequences. This study examined observed subseasonal rainfall variability during Niger's monsoon season (May to September). Using k-means clustering of dekadal (ten-day) rainfall, a typology was developed for the annual evolution of the monsoon season. Year-to-year rainfall variability for each of the first few dekads of the season is modest, but the middle, or peak of the rainy season demonstrates large interannual variability. Clustering analysis of annual timeseries for each dekad of the season revealed two types of monsoon progression. The distinction between the two types is strongly dependent on differences during the latter half of the season. For the first and third ten-day periods in August, and the first ten days in September, the two groups of years are more distinct. These results imply that while reliable prediction of the timing of anomalous onsets will be challenging, due to the relatively narrow range of uncertainty historically, there are opportunities for further exploration of dynamic and or statistical predictors or precursors using this typology that could potentially provide better information for decision-makers, especially with respect to agriculture.

Application of the integrated gateway model on child nutrition behaviors in Niger: An exploratory analysis.

OBJECTIVE: To identify potential gateway factors and behaviors that are associated with infant and young child feeding (IYCF) practices in the Maradi and Zinder regions of Niger through application of the Integrated Gateway Model. METHODS: We analyzed data from 2,727 married women of reproductive age including details on child feeding practices for their 2,551 children between the ages of 0 to 23 months. We assessed the association of three gateway behaviors (i.e., any antenatal care, facility delivery, and communication on nutrition practices) and gateway factors (i.e., behavioral determinants, exposure to information, decision-making agency, and woman's group participation) on four IYCF practices (i.e., early initiation of breastfeeding, exclusive breastfeeding, minimum meal frequency, and minimum dietary diversity) while controlling for age, parity, educational attainment, and household wealth. RESULTS: We found antenatal care was associated with exclusive breastfeeding of children 0-5 months [adjusted odds ratio (aOR): 1.17 (95% confidence interval (CI): 1.03-1.33)], and minimum meal frequency of children 6-23 months [aOR: 1.10 (95% CI: 1.03-1.17)], and facility delivery was associated with early initiation of breastfeeding among children 0-5 months [aOR: 2.08 (95% CI: 1.39-3.12)]. We found negative associations with exclusive breastfeeding and communication on nutrition practices with husbands, family/friends, and health workers. Exposure to nutrition messages through radio, women's groups participation, and with health workers was positively associated with minimum dietary diversity. Self-efficacy was positively associated with both early initiation of breastfeeding, exclusive breastfeeding among children 0-5 months and minimum dietary diversity among children 6-23 months. Women's agency was positively associated with early initiation of breastfeeding. CONCLUSION: The association of antenatal care and facility delivery with child nutrition outcomes suggest intervening before a woman becomes pregnant or early in her pregnancy could improve nutrition outcomes. Programs strengthening the continuum of care should identify gateway behaviors to maximize adoption of priority health behaviors.

Risk factors associated with congenital central nervous system abnormalities in the National Hospital of Zinder, Niger.

INTRODUCTION: Congenital malformations of the central nervous system (CNS) are morphological abnormalities of the brain and spinal cord that occur during fetal development. They constitute the second most common congenital disability, after congenital cardiac defects. Many risk factors have been identified; however, these studies included various types of congenital abnormality. Furthermore, there is a lack of information on risk factors for congenital CNS malformation, and notably in the Zinder region of Niger. OBJECTIVE: This study aimed to identify the risk factors associated with congenital CNS malformations in the Zinder region. METHODS: In a case-control design, patients with congenital CNS malformation were enrolled between June 2022 and April 2023 in the Department of Neurosurgery of the National Hospital of Zinder. RESULTS: Family history of malformation (aOR:3.31, 95% CI:1.25-8.78) and consanguine marriage (aOR:2.28, 95% CI:1.23-4.20) were significantly associated with congenital CNS malformation. In contrast, folic acid supplementation (aOR:0.34, 95% CI:0.13, 0.89), multiparity (aOR:0.34, 95% CI:0.13, 0.89), and grand multiparity (aOR, 0.47; 95% CI:0.23, 0.97) had a protective effect. CONCLUSION: Risk factors such as family malformation history and consanguine marriage increased the risk of developing congenital malformations of the central nervous system. In contrast, folic acid supplementation in the index period and multiparity had a significant protective effect.

Accumulation of potentially toxic elements in fourfinger threadfin (Eleutheronema tetradactylum) and black pomfret (Parastromateus niger) from Selangor, Malaysia.

The accumulation of potentially toxic elements (PTEs) has raised public awareness due to harmful contamination to both human and marine creatures. This study was designed to determine the concentration of copper (Cu), zinc (Zn), cadmium (Cd), and nickel (Ni) in the intestine, kidney, muscle, gill, and liver tissues of local commercial edible fish, fourfinger threadfin (Eleutheronema tetradactylum), and black pomfret (Parastromateus niger) collected from Morib (M) and Kuala Selangor (KS). Among the studied PTEs, Cu and Zn were essential elements to regulate body metabolism with certain dosages required while Cd and Ni were considered as non-essential elements that posed chronic and carcinogenic risk. The concentration of PTEs in fish tissue samples was analyzed using flame atomic absorption spectrometry (F-AAS). By comparing the concentration of PTEs in fish tissues as a bioindicator, the environmental risk of Morib was more serious than Kuala Selangor because both fish species collected from Morib resulted in a higher PTEs concentration. For an average 62 kg adult with a fish ingestion rate (FIR) of 0.16 kg/person/day in Malaysia, the estimated weekly intake (EWI) of Cd from the consumption of E. tetradactylum (M: 0.0135 mg/kg; KS: 0.0134 mg/kg) and P. niger (M: 0.0140 mg/kg; KS: 0.0132 mg/kg) had exceeded the provisional tolerable weekly intake (Cd: 0.007 mg/kg) established by the Joint FAO/WHO Expert Committee on Food Additives (JECFA) and oral reference dose (ORD) values of Cd (0.001 mg/kg/day) as provided by the United States Environmental Protection Agency (USEPA) regional screening level, thus it posed chronic risks for daily basis consumption. Besides, the value of the carcinogenic risk of Cd (0.7-3 to 0.8-3) and Ni (0.5-3 to 0.6-3) were in between the acceptable range (10-6 to 10-4) of the health index that indicates a relatively low possibility cancer occurrence to the consumers in both Morib and Kuala Selangor. This study recommended FIR to be 0.80 kg/person/day to reduce the possibility of posing chronic and carcinogenic risks while at the same time obtaining the essential nutrients from the fish.

Cost-effectiveness of severe acute malnutrition treatment delivered by community health workers in the district of Mayahi, Niger.

BACKGROUND: A non-randomized controlled trial, conducted from June 2018 to March 2019 in two rural communes in the health district of Mayahi in Niger, showed that including community health workers (CHWs) in the treatment of severe acute malnutrition (SAM) resulted in a better recovery rate (77.2% vs. 72.1%) compared with the standard treatment provided solely at the health centers. The present study aims to assess the cost and cost-effectiveness of the CHWs led treatment of uncomplicated SAM in children 6-59 months compared to the standard national protocol. METHODS: To account for all relevant costs, the cost analysis included activity-based costing and bottom-up approaches from a societal perspective and on a within-trial time horizon. The cost-effectiveness analysis was conducted through a decision analysis network built with OpenMarkov and evaluated under two approaches: (1) with recovery rate and cost per child admitted for treatment as measures of effectiveness and cost, respectively; and (2) assessing the total number of children recovered and the total cost incurred. In addition, a multivariate probabilistic sensitivity analysis was carried out to evaluate the effect of uncertainty around the base case input data. RESULTS: For the base case data, the average cost per child recovered was 116.52 USD in the standard treatment and 107.22 USD in the CHWs-led treatment. Based on the first approach, the CHWs-led treatment was more cost-effective than the standard treatment with an average cost per child admitted for treatment of 82.81 USD vs. 84.01 USD. Based on the second approach, the incremental cost-effectiveness ratio of the transition from the standard to the CHWs-led treatment amounted to 98.01 USD per additional SAM case recovered. CONCLUSIONS: In the district of Mayahi in Niger, the CHWs-led SAM treatment was found to be cost-effective when compared to the standard protocol and provided additional advantages such as the reduction of costs for households. TRIAL REGISTRATION: ISRCTN with ID 31143316. https://doi.org/10.1186/ISRCTN31143316.

Assessing the impacts of oil contamination on microbial communities in a Niger Delta soil.

Oil spills are a global challenge, contaminating the environment with organics and metals known to elicit toxic effects. Ecosystems within Nigeria's Niger Delta have suffered from prolonged severe spills for many decades but the level of impact on the soil microbial community structure and the potential for contaminant bioremediation remains unclear. Here, we assessed the extent/impact of an oil spill in this area 6 months after the accident on both the soil microbial community/diversity and the distribution of polycyclic aromatic hydrocarbon ring-hydroxylating dioxygenase (PAH-RHDGNα) genes, responsible for encoding enzymes involved in the degradation of PAHs, across the impacted area. Analyses confirmed the presence of oil contamination, including metals such as Cr and Ni, across the whole impacted area and at depth. The contamination impacted on the microbial community composition, resulting in a lower diversity in all contaminated soils. Gamma-, Delta-, Alpha- proteobacteria and Acidobacteriia dominated 16S rRNA gene sequences across the contaminated area, while Ktedonobacteria dominated the non-contaminated soils. The PAH-RHDαGN genes were only detected in the contaminated area, highlighting a clear relationship with the oil contamination/hydrocarbon metabolism. Correlation analysis indicated significant positive relationships between the oil contaminants (organics, Cr and Ni), PAH-RHDαGN gene, and the presence of bacteria/archaea such as Anaerolinea, Spirochaetia Bacteroidia Thermoplasmata, Methanomicrobia, and Methanobacteria indicating that the oil contamination not only impacted the microbial community/diversity present, but that the microbes across the impacted area and at depth were potentially playing an important role in degrading the oil contamination present. These findings provide new insights on the level of oil contamination remaining 6 months after an oil spill, its impacts on indigenous soil microbial communities and their potential for in situ bioremediation within a Niger Delta's ecosystem. It highlights the strength of using a cross-disciplinary approach to assess the extent of oil pollution in a single study.

Socio-economic baseline for oil-impacted communities in Ogoniland: towards a restoration framework in Niger Delta, Nigeria.

This study documents the socio-economic baselines in selected oil-impacted communities prior to the commencement of the Ogoni clean-up and restoration project. Adopting mixed approach consisting of semi-structured interviews, focus group discussions (FGDs), key informant interviews (KIIs), and household surveys, we surveyed the pre-remediation socio-economic conditions in the Ogoniland communities between July 2018 and March 2019. Results indicated that almost all respondents (99.6%) agreed that the smell of petroleum products or crude oil was evident in the air they breathed even as there were visible black particles (soot) in the respondents' nostrils, on their clothes, and in water. The respondents described the ambient air as smoky and choked with an offensive smell. The household waters were smelly, brownish, or oily, and most respondents (76%) cannot afford to treat their water. Forty-two percent of the respondents who relied on fishing and farming for a living sought for alternative means of subsistence and acknowledged that oil pollution caused stunted growth and low crop yield. The majority of respondents (91%) reported falling fish catches, while the fish caught smell and taste of oil, lowering their market value and posing a potential health risk to consumers. It is evident that oil pollution has impacted the socio-ecological values and sustainable livelihood in Ogoniland. This study provides baseline data for monitoring post-remediation socio-economic improvements in Ogoniland. It also highlights areas of urgent intervention to improve livelihood, and access to basic amenities (e.g., potable drinking water), waste management infrastructure, and statutory policy changes for sustainable development in Ogoniland.

Using Total Cohort Fertility in Adolescence (TCFA) to analyse adolescent fertility trends and factors in Niger: Evidence from 1992 to 2012 demographic and health surveys.

Girls aged 10-19 currently represent 12% of Niger's population (2020). And this number continues to grow as the fertility rate is higher while mortality is declining faster. Using Niger's demographic and health surveys carried out between 1992 and 2012, the study investigated adolescent fertility, its trends and associated factors. It mobilised descriptive methods (Total cohort fertility in adolescence (TCFA) computation, distribution of the number of adolescent births, and computation of adolescent cohort childbearing mean age) and multivariate Logistic and Poisson models. The result shows the TCFA went from 1.29 in 1992 to 1.17 in 2012. Early sexual intercourse and marriage, infant mortality, the desire for a large family, and urbanisation are among the factors significantly associated with adolescent fertility in Niger. The study concludes that the high level of adolescent fertility in Niger does not seem to be changing.

Les adolescentes représentent 12 % de la population Nigerienne (2020). Ce chiffre continue de croître car la fécondité reste elevée alors que la mortalité diminue rapidement. Utilisant les enquêtes démographiques et de santé du Niger entre 1992 et 2012, cette étude s'est intéressée aux tendances et facteurs de la descendance finale à l'adolescence (DFA). Elle a mobilisé des méthodes descriptives (calcul de la DFA, distribution du nombre de naissances adolescentes, calcul de l'âge moyen à la maternité adolescente) et des modèles multivariés de régression logistique et de Poisson. Les résultats montrent que la DFA est passée de 1,29 en 1992 à 1,17 en 2012. Les rapports sexuels et le mariage précoces, la mortalité infantile, le désir d'une famille nombreuse et l'urbanisation sont parmi les facteurs significativement associés à la fécondité adolescente au Niger. L'étude conclut que le niveau élevé de la fécondité des adolescentes au Niger ne semble pas évoluer.

Health transformation toward universal healthcare coverage amidst conflict: examining the impact of international cooperation in Niger.

Background: Approximately 70% of Sub-Saharan African countries have experienced armed conflicts with significant battle-related fatalities in the past two decades. Niger has witnessed a substantial rise in conflict-affected populations in recent years. In response, international cooperation has aimed to support health transformation in Niger's conflict zones and other conflict-affected areas in Sub-Saharan Africa. This study seeks to review the available evidence on health interventions facilitated by international cooperation in conflict zones, with a focus on Niger. Methods: We conducted a systematic literature review (SLR) adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search was conducted from 2000 to 4 September 2022 using MeSH terms and keywords to identify relevant studies and reports in Sub-Saharan Africa and specifically in Niger. Databases such as PubMed (Medline), Google Scholar, Google, and gray literature were utilized. The findings were presented both narratively and through tables and a conceptual framework. Results: Overall, 24 records (10 studies and 14 reports) that highlighted the significant role of international cooperation in promoting health transformation in conflict zones across Sub-Saharan Africa, including Niger, were identified. Major multilateral donors identified were the World Health Organization (WHO), United Nations Children's Fund (UNICEF), United Nations Fund for Population Activities (UNFPA), World Bank, United States Agency for International Development (USAID), European Union, European Commission Humanitarian Aid (ECHO), Global Fund, and Global Alliance for Vaccines and Immunization (GAVI). Most supports targeted maternal, newborn, child, adolescent, and youth health, nutrition, and psycho-social services. Furthermore, interventions were in the form of public health initiatives, mobile clinic implementation, data management, human resource capacity building, health information systems, health logistics, and research funding in conflict zones. Conclusion: This literature review underscores the significant engagement of international cooperation in strengthening and transforming health services in conflict-affected areas across Sub-Saharan Africa, with a particular focus on Niger. However, to optimize the effectiveness of healthcare activities from short- and long-term perspectives, international partners and the Ministry of Public Health need to re-evaluate and reshape their approach to health intervention in conflict zones.

Efficacy of Single-Dose Azithromycin for Ocular Chlamydial Infection: A Longitudinal Study.

Millions of doses of azithromycin are distributed each year for trachoma, yet the treatment efficacy of a single dose of azithromycin for ocular Chlamydia infection has not been well characterized. In this study, four villages in Niger received a mass azithromycin distribution for trachoma. All 426 children aged 0-5 years residing in the study villages were offered conjunctival swabbing every 6 months to test for ocular Chlamydia trachomatis. Among the children infected with ocular Chlamydia before treatment, 6% (95% CI: 2-15%) tested positive for ocular Chlamydia infection 6 months later, and 15% (95% CI: 7-28%) tested positive 12 months later. The most important predictor of post-treatment ocular Chlamydia infection was pretreatment ocular Chlamydia infection (relative risk: 3.5, 95% CI: 1.3-9.4). Although the 6-monthly monitoring schedule was suboptimal for testing the treatment efficacy of an antibiotic, these findings are nonetheless consistent with high treatment efficacy of a single dose of azithromycin and suggest that additional interventions might be most effective if targeted to those children infected prior to treatment.

The Drivers of Low Vaccination Utilization in Niger.

Vaccination adherence involves the expected benefit of a vaccine and the perceived risk of the disease. To develop an evidence-based communication strategy aimed at improving vaccination coverage in Niger, we conducted a mixed socio-anthropological study of the perceptions among the population on the benefit and the risk of the childhood (Expanded Program on Immunization) and the COVID-19 vaccines. Our results show that negative rumors are not a significant driver of vaccine refusal. The insufficient level of fully vaccinated, compared with partially vaccinated, children might be explained by misunderstandings around the side effects of vaccines and the necessity for full vaccination. Approximately one-fourth of the population is vaccinated against COVID-19, whereas 73.3% think that vaccines against the disease are a "good thing," and 83% of those who have heard messages promoting the vaccination approve of them. This apparent contradiction is explained by a low perception of the risks of COVID-19. More than half of the population surveyed believe that the disease is not present in the country. A large majority believe that only ill people can transmit the disease, whereas only 12.8% think they know anybody who has ever been sick with COVID-19. Three-fourths of the interviewees have seen images from around the world of persons sick or deceased from COVID-19; the same proportion has not seen any such images of affected patients in Niger. Communication to improve COVID-19 uptake should focus on the reality of the disease presence and its transmission and not on rumors surrounding the vaccines.

How Outreach Training and Supportive Supervision (OTSS) Affect Health Facility Readiness and Health-Care Worker Competency to Prevent and Treat Malaria in Niger: A Secondary Analysis of OTSS Data.

The quality of health services is key to the goal of averting morbidity and mortality from malaria. From July 2020 to August 2021, PMI Impact Malaria supported the implementation of four rounds of Outreach Training and Supportive Supervision (OTSS) in 12 health districts in the two regions of Niger: Dosso and Tahoua. Through OTSS, trained supervisors conducted onsite visits to observe an average of 174 healthcare workers (HCWs) per round in 96 public primary health facilities, managing persons with fever or conducting antenatal care (ANC) consultations, and then provided instant and individualized feedback and onsite training. Data from health facility readiness, case management, and malaria in pregnancy (MiP) checklists across the four rounds were analyzed using Wilcoxon's and the χ2 tests. These analyses highlighted improved facility readiness, including an increased likelihood that HCWs had received classroom training, and facilities had increased availability of guidelines and algorithms by round 4 compared with round 1. Median HCW performance scores showed an improvement in the correct performance and interpretation of malaria rapid diagnostic tests, in classification of malaria as uncomplicated or severe, and in the management of uncomplicated malaria across the four rounds. For MiP services, malaria prevention and the management of pregnant women with malaria also improved from round 1 to round 4. These findings provide further evidence that OTSS can achieve rapid improvements in health facility readiness and HCW competency in managing outpatients and ANC clients.

Development of a macroinvertebrate-based biotic index to assess water quality of rivers in Niger State, North Central Ecoregion of Nigeria.

The increasing pollution of lotic ecosystems in sub-Saharan Africa, particularly in Nigeria, poses a threat to water quality, public health and biodiversity. It is therefore essential to develop appropriate tools and methods for monitoring these rivers, particularly in heavily affected areas, where these water resources are vital to the surrounding communities that are heavily dependent on them. To fill this gap, we propose to develop a multimetric index based on macroinvertebrates for the assessment of ecological quality of rivers in Niger State (NSRBI). Eighty-eight metrics were evaluated through a step-by-step statistical process (namely, range test and stability, redundancy test and relationship with abiotic variables), in which metrics that did not meet the conditions were excluded. At the end of this process, only four metrics (%Hemiptera, Diptera richness, Pielou equitability and % of very large individuals (size > 40 mm)) fulfilling all criteria were included in the index. These metrics were then scored on a continuous scale and divided into four water quality classes: "very poor", "poor", "fair" and "good". Evaluation of the performance of the index on test sites showed a correspondence of 90% between index result and environmental-based classification. Therefore, the NSRBI could be a valuable tool for monitoring and assessing the ecological conditions of rivers in Niger State and the North Central Nigeria ecoregion predominantly in urban and agricultural landscapes.