Effects of Seasonal Conditions on Abundance of Malaria Vector Anopheles stephensi Mosquitoes, Djibouti, 2018-2021.

We describe the influence of seasonal meteorologic variations and rainfall events on Anopheles stephensi mosquito populations during a 40-month surveillance study at a US military base in Djibouti. Focusing surveillance and risk mitigation for An. stephensi mosquitoes when climatic conditions are optimal presents an opportunity for malaria prevention and control in eastern Africa.

Chikungunya Outbreak in Country with Multiple Vectorborne Diseases, Djibouti, 2019-2020.

During 2019-2020, a chikungunya outbreak occurred in Djibouti City, Djibouti, while dengue virus and malaria parasites were cocirculating. We used blotting paper to detect arbovirus emergence and confirm that it is a robust method for detecting and monitoring arbovirus outbreaks remotely.

Molecular investigation of malaria-infected patients in Djibouti city (2018-2021).

BACKGROUND: The Republic of Djibouti is a malaria endemic country that was in pre-elimination phase in 2006-2012. From 2013, however, malaria has re-emerged in the country, and its prevalence has been increasing every year. Given the co-circulation of several infectious agents in the country, the assessment of malaria infection based on microscopy or histidine-rich protein 2 (HRP2)-based rapid diagnostic tests (RDT) has shown its limitations. This study, therefore, aimed to assess the prevalence of malaria among febrile patients in Djibouti city using more robust molecular tools. METHODS: All suspected malaria cases reported to be microscopy-positive were randomly sampled (n = 1113) and included in four health structures in Djibouti city over a 4-year period (2018-2021), mainly during the malaria transmission season (January-May). Socio-demographic information was collected, and RDT was performed in most of the included patients. The diagnosis was confirmed by species-specific nested polymerase chain reaction (PCR). Data were analysed using Fisher's exact test and kappa statistics. RESULTS: In total, 1113 patients with suspected malaria and available blood samples were included. PCR confirmed that 788/1113 (70.8%) were positive for malaria. Among PCR-positive samples, 656 (83.2%) were due to Plasmodium falciparum, 88 (11.2%) Plasmodium vivax, and 44 (5.6%) P. falciparum/P. vivax mixed infections. In 2020, P. falciparum infections were confirmed by PCR in 50% (144/288) of negative RDTs. After the change of RDT in 2021, this percentage decreased to 17%. False negative RDT results were found more frequently (P < 0.05) in four districts of Djibouti city (Balbala, Quartier 7, Quartier 6, and Arhiba). Malaria occurred less frequently in regular bed net users than in non-users (odds ratio [OR]: 0.62, 95% confidence interval [CI]: 0.42-0.92). CONCLUSIONS: The present study confirmed the high prevalence of falciparum malaria and, to a lesser extent, vivax malaria. Nevertheless, 29% of suspected malaria cases were misdiagnosed by microscopy and/or RDT. There is a need to strengthen the capacity for diagnosis by microscopy and to evaluate the possible role of P. falciparum hrp2 gene deletion, which leads to false negative cases of P. falciparum.

Plasmodium falciparum pfhrp2 and pfhrp3 Gene Deletions and Relatedness to Other Global Isolates, Djibouti, 2019-2020.

Deletions of pfhrp2 and paralogue pfhrp3 (pfhrp2/3) genes threaten Plasmodium falciparum diagnosis by rapid diagnostic test. We examined 1,002 samples from suspected malaria patients in Djibouti City, Djibouti, to investigate pfhrp2/3 deletions. We performed assays for Plasmodium antigen carriage, pfhrp2/3 genotyping, and sequencing for 7 neutral microsatellites to assess relatedness. By PCR assay, 311 (31.0%) samples tested positive for P. falciparum infection, and 296 (95.2%) were successfully genotyped; 37 (12.5%) samples were pfhrp2+/pfhrp3+, 51 (17.2%) were pfhrp2+/pfhrp3-, 5 (1.7%) were pfhrp2-/pfhrp3+, and 203 (68.6%) were pfhrp2-/pfhrp3-. Histidine-rich protein 2/3 antigen concentrations were reduced with corresponding gene deletions. Djibouti P. falciparum is closely related to Ethiopia and Eritrea parasites (pairwise GST 0.68 [Ethiopia] and 0.77 [Eritrea]). P. falciparum with deletions in pfhrp2/3 genes were highly prevalent in Djibouti City in 2019-2020; they appear to have arisen de novo within the Horn of Africa and have not been imported.

Role of Anopheles stephensi Mosquitoes in Malaria Outbreak, Djibouti, 2019.

Anopheles stephensi mosquitoes share urban breeding sites with Aedes aegypti and Culex quinquefasciatus mosquitoes in the Republic of Djibouti. We present evidence that A. stephensi mosquitoes might be responsible for an increase in malaria incidence in this country. We also document resistance of Plasmodium falciparum to dihydroartemisinin/piperaquine.

Aloe djiboutiensis: Antioxidant Activity, Molecular Networking-Based Approach and In Vivo Toxicity of This Endemic Species in Djibouti.

For the first time, the study of the antioxidant activity, the characterization of the phytoconstituants, and the evaluation of in vitro and in vivo toxicity of A. djiboutiensis leave and latex are performed. The antioxidant activity of both latex (ADL) and the methanolic extract of leaves (ADM) is determined using 1-diphenyl-2-picrylhydrazyl (DPPH), 2,2'-azino-bis 3-ethylbenzothiazoline-6-sulphonic acid (ABTS) scavenging radical methods and ferric reducing/antioxidant power (FRAP) assay. The phytochemical study of latex is done using Liquid Chromatography-Mass Spectrometry (LC-MS/MS) and a molecular networking-based approach. The evaluation of in vivo toxicity is performed on mice by oral gavage with a suspension of ADL. Our results show that weak antioxidant activity of ADL and ADM in opposition to their high polyphenol, 83.01 mg and 46.4 mg expressed in gallic acid equivalent (GAE)/g of dry weight (DW), respectively, and flavonoid contents 13.12 mg and 4.25 mg expressed in quercetin equivalent (QE)/g dry weight (DW), respectively. Using the Global Natural Products Social Molecular Networking (GNPS) website, nine (9) anthraquinones derivatives, ten (10) chromones derivatives, two (2) flavonols/ chromones isomers are annotated in the molecular network. The treated mice do not display abnormalities in their general physical appearance and biochemistry parameters, compared to the controls. Only glucose and calcium levels are slightly higher in male treated mice compared to the vehicles.

First record of Theropithecus (Cercopithecidae) from the Republic of Djibouti.

We describe here several specimens of the genus Theropithecus from the southern shore of Lake Assal in the Republic of Djibouti; they are the first record of the genus from this country. We assign them to a derived stage of T. oswaldi. This identification has implications for the age of the informal 'Formation 1' from this area, which should probably be assigned to the Middle Pleistocene. In addition, the presence of T. oswaldi close to the Bab el Mandeb Strait strongly suggests that the species followed this route to India, rather than a more northern one.

Five years following first detection of Anopheles stephensi (Diptera: Culicidae) in Djibouti, Horn of Africa: populations established-malaria emerging.

The Asian malaria mosquito, Anopheles stephensi, is a well-known and important vector of Plasmodium falciparum and P. vivax. Until 2013, its geographical distribution was confined to central and southern Asia including the Arabian Peninsula. In the Horn of Africa (HoA) Region, An. stephensi was first recorded from Djibouti in 2012, when it was linked geographically and temporally with an unusual outbreak of urban P. falciparum malaria. In 2016, An. stephensi was detected in the neighbouring Somali Region of Ethiopia. In order to determine whether An. stephensi populations have become established in Djibouti and contributed to the unusual rise in local malaria cases there, we carried out continuous vector surveillance from January 2013 to December 2017, investigated seasonal changes in An. stephensi population densities and bionomics, analysed available literature describing malaria in Djibouti since 2013, and investigated whether An. stephensi may have contributed to local malaria transmission by detecting circumsporozoite antigen of P. falciparum and P. vivax in female anophelines. From 2013 to 2016, seasonal activity of An. stephensi in urban Djibouti City primarily occurred during the colder, wetter season between September and May, with either no or rare trap catches from June to August. Unlike past years, this species was detected year-round, including the extremely hot summer months of June to August 2017. This change in seasonal occurrence may indicate that An. stephensi populations are adapting to their new environment in sub-Saharan Africa, facilitating their spread within Djibouti City. Among the 96 female An. stephensi investigated for malaria infectivity, three (3.1%) were positive for P. falciparum circumsporozoite antigen, including one P. falciparum/P. vivax VK 210 double infection. Subsequent to the unusual resurgence of local malaria in 2013, with 1684 confirmed cased reported for that year, malaria case numbers increased continuously, peaking at 14,810 in 2017. Prior to 2016, only P. falciparum malaria cases had been reported, but in 2016, autochthonously acquired P. vivax malaria cases occurred for the first time at a rate of 16.7% among all malaria cases recorded that year. This number increased to 36.7% in 2017. Our data indicate that the dynamics of malaria species in Djibouti is currently changing rapidly, and that An. stephensi can be involved in the transmission of both P. falciparum and P. vivax, simultaneously. Considering the extremely high potential impact of urban malaria on public health, the timely deployment of optimal multinational vector surveillance and control programs against An. stephensi is strongly recommended, not only for the HoA Region, but for the entire African continent.

Adolescent-led marriage in Somaliland and Puntland: A surprising interaction of agency and social norms.

INTRODUCTION: Child marriage, formal and informal unions when one or both spouses are under 18, disproportionately affects adolescent girls over boys. It has serious consequences for girls' health, wellbeing, and development. Little is known about the ways in which girls' agency and contextual social norms - unwritten rules of (un)acceptable behaviour in a group - intersect to affect child marriage practices. This paper investigates norms and agency as facilitators and obstacles to adolescent girls' marriage in Somaliland and Puntland. METHODS: Participants (n = 156) were men and women living in Somaliland and Puntland. We conducted 36 qualitative semi-structured individual interviews (12 men and 24 women). We also held 15 focus group discussions (8 in Somaliland and 7 in Puntland) with 6-10 people each (n = 120). Mixed focus groups were conducted with men and women together, and were segregated by age. RESULTS: Technology and economic deprivation were important contextual factors in explaining the prevalence of child marriage. Participants reported that adolescent girls' and boys' increased agency contributed to, rather than decreased, child marriage. Access to technology expanded adolescents' freedom from their parents' control. Adolescents used that freedom within the existing system of social norms that rewarded early (as opposed to later) marriage. CONCLUSIONS: Effective interventions that aim to reduce marriage among adolescents living in Somalia (where marriage can be a protective strategy) should integrate a social norms perspective to avoid increasing adolescent-led marriage.

[Partnership experience between an international and local NGO in Djibouti]. / Partenariat entre une ONG locale et une ONG internationale à Djibouti.

INTRODUCTION: This article relates and analyzes a partnership between a local and an international organization settled both in Djibouti.Purpose of research: From the very beginning, ongoing observational and analytical assessment allowed for a complete study of the entire partnership process, from the initial replies to calls for projects to the completion of projects. RESULTS: Results are given from two angles. A factual narrative of the partnership first illustrates some behaviors, and then the whole partnership is analyzed. CONCLUSIONS: Authors conclude that structural, functional and ethical asymmetry between both structures, as they are not of equal weight. Although they may be willing to work together and are complementary, this asymmetry produces a force-ratio absolutely unsuitable for project enhancement. Moreover, it pleads for aid localization and for local structures dedicated to development.localization and for local structures dedicated to humane development.

Seroprevalence and risk factors for peste des petits ruminants in sheep and goats in Djibouti.

Despite the occurrence of peste des petits ruminants (PPR) in all other countries in the Horn of Africa, which engage in free animal movement, to date, PPR has not been reported in Djibouti. The objective of this study was to estimate the seroprevalence of PPR and its associated risk factors in sheep and goats in that country. A cross-sectional method was used with proportional sampling to allocate the number of small ruminants to be sampled from each of the country's regions (Ali Sabieh, Arta, Dikhil, Djibouti, Obock and Tadjourah). From a total of 1,516 serum samples tested, using a competitive enzyme-linked immunosorbent assay (cELISA), 91 were positive, with an overall 6% (95% confidence interval [CI] = 4.8-7.2) prevalence of antibodies to the PPR virus (PPRV). Antibodies to PPRV were detected in small ruminants from all the regions, excluding Obock. Seroprevalence was highest in the Tadjourah region (8.92%), whereas the lowest prevalence was observed in the Djibouti region (1.28%). The species, age and sex of the animals and the herd size were identified as risk factors for PPR seropositivity. The risk of goats testing positive for PPRV antibodies was2.95 (CI = 1.39-6.35) times that of sheep. Moreover, the risk of animals younger than two years testing positive for PPRV antibodies was 2.29 (CI = 1.47-3.56) times that of animals older than two years. Similarly, it was shown that female animals were more frequently infected (odds ratio [OR] = 3.82; CI = 1.51 to 9.67) than their male counterparts. In addition, small ruminants from small herds/flocks were more likely to be seropositive (OR = 2.06; CI = 1.10-3.83) than those from medium-sized herds/flocks. The present study revealed, for the first time, the widespread occurrence of PPRV antibodies in small ruminants in Djibouti with low prevalence.

Bien que présente dans tous les autres pays de la corne d'Afrique où la libre circulation des animaux est de mise, la peste des petits ruminants (PPR) n'a jamais été notifiée à Djibouti. Les auteurs présentent les résultats d'une étude visant à estimer la prévalence sérologique de la PPR ainsi que les facteurs de risque qui lui sont associés chez les ovins et les caprins du pays. Il a été fait appel à une méthodologie transversale afin de prélever un échantillon proportionnel représentatif des effectifs de petits ruminants de chaque région du pays (Ali Sabieh,Arta, Dikhil, Djibouti, Obock et Tadjourah). Au total, 91 des 1 516 prélèvements de sérum testés au moyen d'une épreuve immuno-enzymatique de compétition (ELISAc) ont donné des résultats positifs, soit une prévalence globale d'animaux possédant des anticorps dirigés contre le virus de la peste des petits ruminants(VPPR) de 6 % (intervalle de confiance [IC] à 95% de 4,8 à 16,2). La présence d'anticorps vis-à-vis du VPPR chez des petits ruminants a été détectée dans toutes les régions à l'exclusion d'Obock. La prévalence sérologique la plus élevée a été observée à Tadjourah (8,92 %) tandis que la plus faible concernait la région de Djibouti (1,28 %). Les facteurs de risque associés à la présence d'anticorps contre la PPR étaient l'espèce, l'âge et le sexe des animaux, ainsi que la taille du troupeau. La probabilité de détection d'anticorps vis-à-vis du PPRV était 2,95 fois plus élevée chez les chèvres que chez les moutons (IC de 1,39 à 6,35). De plus, la probabilité de trouver des anticorps contre le VPPR était 2,29 fois plus élevée chez les jeunes de moins de deux ans que chez les animaux âgés de plus de deux ans (IC de 1,47 à 3,56). De même, l'infection était plus fréquente chez les femelles que chez les mâles (rapport de cotes ou odds ratio [OR] de 3,82 ;IC compris entre 1,51 et 9,67). Enfin, la probabilité d'être porteur d'anticorps était plus élevée chez les petits ruminants élevés dans des troupeaux ou cheptels de petite taille (OR de 2,06 ; IC de 1,10 à 3,83) que chez ceux appartenant à des troupeaux ou cheptels de taille moyenne. Cette étude fait état pour la première fois de la présence sur une vaste partie du territoire de Djibouti de petits ruminants porteurs d'anticorps dirigés contre le VPPR, à une prévalence relativement faible.

Aunque la peste de pequeños rumiantes (PPR) está presente en todos los demás países del Cuerno de África que participan de la libre circulación de animales, a día de hoy no se ha notificado su presencia en Djibouti. Los autores describen un estudio destinado a estimar la seroprevalencia de la enfermedad y sus factores de riesgo en los ovinos y caprinos de este último país. Para ello se utilizó un método transversal, asignando a cada una de las regiones del país (Ali Sabieh, Arta, Dikhil, Djibouti, Obock y Tadjoura) un número proporcional de muestras que extraer de la población de pequeños rumiantes. De un total de 1516 muestras de suero analizadas con un ensayo inmunoenzimático de competición (ELISAc), 91 resultaron positivas, lo que supone una prevalencia global de anticuerpos contra el virus de la PPR del 6% (intervalo de confianza [IC] al 95% = 4,8­7,2). Se detectaron anticuerpos en pequeños rumiantes de todas las regiones con la salvedad de Obock. El máximo nivel de seroprevalencia se registró en la región de Tadjoura (un 8,92%), mientras que el nivel más bajo se observó en la de Djibouti (un 1,28%). Como factores de riesgo de seropositividad se encontraron la especie, la edad y el sexo del animal, así como el tamaño del rebaño. El riesgo de seropositividad, o presencia de anticuerpos contra el virus de la PPR, era 2,95 veces mayor en los caprinos (IC = 1,39­6,35) que en los ovinos. Por otra parte, el riesgo de que los ejemplares de menos de 2 años resultaran positivos era 2,29 veces superior (IC = 1,47­3,56) al de los animales de más edad. Análogamente, quedó demostrado que las hembras resultaban infectadas con más frecuencia (razón de posibilidades [odds ratio: OR] = 3,82; IC = 1,51 a 9,67) que los machos homólogos. Además, los pequeños rumiantes de rebaños de escaso tamaño tenían mayor probabilidad de resultar seropositivos (OR = 2,06; IC = 1,10­3,83) que los de rebaños de mediano tamaño. El estudio puso de manifiesto, por primera vez, la presencia extendida, pero con escasa prevalencia, de anticuerpos contra el virus de la PPR en los pequeños rumiantes de Djibouti.

Trial Evaluating Ambulatory Therapy of Travelers' Diarrhea (TrEAT TD) Study: A Randomized Controlled Trial Comparing 3 Single-Dose Antibiotic Regimens With Loperamide.

BACKGROUND: Recommended treatment for travelers' diarrhea includes the combination of an antibiotic, usually a fluoroquinolone or azithromycin, and loperamide for rapid resolution of symptoms. However, adverse events, postdose nausea with high-dose azithromycin, effectiveness of single-dose rifaximin, and emerging resistance to front-line agents are evidence gaps underlying current recommendations. METHODS: A randomized, double-blind trial was conducted in 4 countries (Afghanistan, Djibouti, Kenya, and Honduras) between September 2012 and July 2015. US and UK service members with acute watery diarrhea were randomized and received single-dose azithromycin (500 mg; 106 persons), levofloxacin (500 mg; 111 persons), or rifaximin (1650 mg; 107 persons), in combination with loperamide (labeled dosing). The efficacy outcomes included clinical cure at 24 hours and time to last unformed stool. RESULTS: Clinical cure at 24 hours occurred in 81.4%, 78.3%, and 74.8% of the levofloxacin, azithromycin, and rifaximin arms, respectively. Compared with levofloxacin, azithromycin was not inferior (P = .01). Noninferiority could not be shown with rifaximin (P = .07). At 48 and 72 hours, efficacy among regimens was equivalent (approximately 91% at 48 and 96% at 72 hours). The median time to last unformed stool did not differ between treatment arms (azithromycin, 3.8 hours; levofloxacin, 6.4 hours; rifaximin, 5.6 hours). Treatment failures were uncommon (3.8%, 4.4%, and 1.9% in azithromycin, levofloxacin, and rifaximin arms, respectively) (P = .55). There were no differences between treatment arms with postdose nausea, vomiting, or other adverse events. CONCLUSIONS: Single-dose azithromycin, levofloxacin, and rifaximin with loperamide were comparable for treatment of acute watery diarrhea. CLINICAL TRIAL REGISTRATION: NCT01618591.

Burden of musculoskeletal disorders in the Eastern Mediterranean Region, 1990-2013: findings from the Global Burden of Disease Study 2013.

OBJECTIVES: We used findings from the Global Burden of Disease Study 2013 to report the burden of musculoskeletal disorders in the Eastern Mediterranean Region (EMR). METHODS: The burden of musculoskeletal disorders was calculated for the EMR's 22 countries between 1990 and 2013. A systematic analysis was performed on mortality and morbidity data to estimate prevalence, death, years of live lost, years lived with disability and disability-adjusted life years (DALYs). RESULTS: For musculoskeletal disorders, the crude DALYs rate per 100 000 increased from 1297.1 (95% uncertainty interval (UI) 924.3-1703.4) in 1990 to 1606.0 (95% UI 1141.2-2130.4) in 2013. During 1990-2013, the total DALYs of musculoskeletal disorders increased by 105.2% in the EMR compared with a 58.0% increase in the rest of the world. The burden of musculoskeletal disorders as a proportion of total DALYs increased from 2.4% (95% UI 1.7-3.0) in 1990 to 4.7% (95% UI 3.6-5.8) in 2013. The range of point prevalence (per 1000) among the EMR countries was 28.2-136.0 for low back pain, 27.3-49.7 for neck pain, 9.7-37.3 for osteoarthritis (OA), 0.6-2.2 for rheumatoid arthritis and 0.1-0.8 for gout. Low back pain and neck pain had the highest burden in EMR countries. CONCLUSIONS: This study shows a high burden of musculoskeletal disorders, with a faster increase in EMR compared with the rest of the world. The reasons for this faster increase need to be explored. Our findings call for incorporating prevention and control programmes that should include improving health data, addressing risk factors, providing evidence-based care and community programmes to increase awareness.

Strengthening close to community provision of maternal health services in fragile settings: an exploration of the changing roles of TBAs in Sierra Leone and Somaliland.

BACKGROUND: Efforts to take forward universal health coverage require innovative approaches in fragile settings, which experience particularly acute human resource shortages and poor health indicators. For maternal and newborn health, it is important to innovate with new partnerships and roles for Traditional Birth Attendants (TBAs) to promote maternal health. We explore perspectives on programmes in Somaliland and Sierra Leone which link TBAs to health centres as part of a pathway to maternal health care. Our study aims to understand the perceptions of communities, stakeholder and TBAs themselves who have been trained in new roles to generate insights on strategies to engage with TBAs and to promote skilled birth attendance in fragile affected settings. METHODS: A qualitative study was carried out in two chiefdoms in Bombali district in Sierra Leone and the Maroodi Jeex region of Somaliland. Purposively sampled participants consisted of key players from the Ministries of Health, programme implementers, trained TBAs and women who benefitted from the services of trained TBAs. Data was collected through key informants and in-depth interviews and focus group discussions. Data was transcribed, translated and analyzed using the framework approach. For the purposes of this paper, a comparative analysis was undertaken reviewing similarities and differences across the two different contexts. RESULTS: Analysis of multiple viewpoints reveal that with appropriate training and support it is possible to change TBAs practices so they support pregnant women in new ways (support and referral rather than delivery). Participants perceived that trained TBAs can utilize their embedded and trusted community relationships to interact effectively with their communities, help overcome barriers to acceptability, utilization and contribute to effective demand for maternal and newborn services and ultimately enhance utilization of skilled birth attendants. Trained TBAs appreciated cordial relationship at the health centres and feeling as part of the health system. Key challenges that emerged included the distance women needed to travel to reach health centers, appropriate remuneration of trained TBAs and strategies to sustain their work. CONCLUSION: Our findings highlight the possible gains of the new roles and approaches for trained TBAs through further integrating them into the formal health system. Their potential is arguably critically important in promoting universal health coverage in fragile and conflict affected states (FCAS) where human resources are additionally constrained and maternal and newborn health care needs particularly acute.

Failure of dihydroartemisinin plus piperaquine treatment of falciparum malaria by under-dosing in an overweight patient.

BACKGROUND: Artemisinin-based combination therapy (ACT) introduced in the mid-1990s has been recommended since 2005 by the World Health Organization as first-line treatment against Plasmodium falciparum in all endemic countries. In 2010, the combination dihydroartemisinin-piperaquine (DP) was recommended for the treatment of uncomplicated P. falciparum malaria. DP is one of the first-line treatments used by the French army since 2013. CASE PRESENTATION: A case of P. falciparum clinical failure with DP at day 20 was described in a 104 kg French soldier deployed in Djibouti. He was admitted to hospital for supervision of oral treatment with DP [40 mg dihydroartemisinin (DHA) plus 320 mg piperaquine tetraphosphate (PPQ)]. This corresponded to a cumulative dose of 4.6 mg/kg DHA and 37 mg/kg PPQ in the present patient, which is far below the WHO recommended ranges. No mutation was found in the propeller domain of the Kelch 13 (k13) gene, which is associated with artemisinin resistance in Southeast Asia. Pfmdr1 N86, 184F, S1034 and N1042 polymorphisms and haplotype 72-76 CVIET for the pfcrt gene were found in the present case. There was no evidence of resistance to DP. CONCLUSION: This case confirms the risk of therapeutic failure with dihydroartemisinin-piperaquine by under-dosing in patients weighing more than 100 kg. This therapeutic failure with DP by under-dosing highlighted the importance of appropriate dosing guidelines and the need of research data (efficacy, pharmacokinetics and pharmacodynamics) in over-weight patient group.

Learning from Somaliland? Transferability of learning from volunteering to national health service practice in the UK.

BACKGROUND: Capacity building partnerships between healthcare institutions have the potential to benefit both partners particularly in staff development. Previous research suggests that volunteering can contribute to professional development but there is little evidence on how learning is acquired, the barriers and facilitators to learning in this context or the process of translation of learning to the home environment. RESULTS: Volunteers from a healthcare partnership between the UK and Somaliland reported learning in communication, interdisciplinary working, teaching, management, leadership and service development. This learning came from observing familiar practices in unfamiliar environments; alternative solutions to familiar problems; learning about Somali culture; opportunities to assume higher levels of responsibility and new professional relationships. There was variability in the extent of translation to NHS practice. Time and support available for reflection and mentoring were important facilitators of this process. CONCLUSIONS: The professional development outcomes documented in this study came directly from the experience of volunteering. Experiential learning theory suggests that this requires a complex process of critical reflection and new knowledge generation, testing and translation for use in new contexts. This process benefits from identification of learning as an important element of volunteering and support for reflection and the translation translation of learning to UK contexts. We suggest that missed opportunities for volunteer learning will remain until the volunteering process is overtly framed as part of continuing professional development.

Diagnostic Accuracy of Emergency Physician-Performed Ultrasound for Acute Appendicitis in a Remote Location.

BACKGROUND: Preoperative imaging for suspected acute appendicitis (AA), such as ultrasonography (US), was shown to improve diagnostic accuracy and patient outcomes. Criteria for diagnosis of AA by US are well established and reliable. In previous studies, US assessments were always performed by skilled radiologist physicians. However, a radiologist and computed tomography scanning equipment are not always available in the community hospitals or remote sites of developing countries. OBJECTIVE: Our aim was to assess a diagnostic pathway using clinical evaluation, routine US performed by an emergency physician, and clinical re-evaluation for patients suspected of having AA. METHODS: Patients suspected of having AA admitted to the emergency department in a developing country were prospectively enrolled between November 2010 and January 2011. Clinical and US data were studied. A noncompressible appendix with a diameter ≥6 mm was the main US diagnosis criterion. RESULTS: Among the 104 included patients, surgery was performed on 28. Of the 25 patients with positive US, 22 actually had AA, matching the surgical report. The remaining 76 patients without US appendicitis criteria underwent clinical follow-up and had medical conditions. Sensitivity of US was 88%, specificity was 96%, positive predictive value was 88%, and negative predictive value was 96%. The likelihood ratios for our US assessment highlight the need for a test with enhanced diagnostic accuracy. CONCLUSIONS: A diagnostic strategy using clinical evaluations, routine US performed by emergency physicians, and clinical re-evaluation of patients with acute abdominal pain is appropriate to provide positive results for the diagnosis and treatment of appendicitis in remote locations.

Prevalence of Primary HPV in Djibouti: Feasibility of Screening for Early Diagnosis of Squamous Intraepithelial Lesions.

OBJECTIVE: In many African Sub-Saharan countries, human papilloma virus (HPV) prevalence data are not available. The current study estimated the prevalence of HPV virus in the female population of Djibouti. METHODS: Approximately 1000 asymptomatic women 16 to 64 years old were enrolled from 3 of the main health structures of Djibouti in 2014 and 2015; 998 cervical samples were tested for HPV-DNA of high risk types, 499 during the first year, and 499 during the second. Positive samples were typed with an HPV genotyping kit. RESULTS: The women were an average age of 38.8 years (SD, 10.2); 54 women tested positive for HPV (prevalence rate, 5.4% [95% confidence interval, 4.0-6.8]). The highest prevalence was observed among the women younger than 35 years. HPV66 was the most prevalent (15.4% of the infections), followed by HPV31 and HPV52 (10.8% both) and HPV16 (9.2%). All 54 women who tested HPV-positive underwent a Pap test, which was positive in 8 cases (14.8%): 2 high-grade squamous intraepithelial lesion (HSIL) and 6 low-grade (LSIL). CONCLUSIONS: The HPV prevalence shows a curve by age similar to that of other African countries. The proportion of HPV16 is among the lowest ever seen in similar studies. The findings suggest to Djibouti the choice of a strategy of screening that includes forms of cytological triage, thus limiting recourse to colposcopy.