Jacob Maikere

Assessment of two malaria rapid diagnostic tests in children under five years of age, with follow-up of false-positive pLDH test results, in a hyperendemic falciparum malaria area, Sierra Leone

BackgroundMost malaria rapid diagnostic tests (RDTs) use HRP2 detection, including Paracheck-Pf®, but their utility is limited by persistent false positivity after treatment. PLDH-based tests become negative more quickly, but sensitivity has been reported below the recommended standard of 90%. A new pLDH test, CareStart™ three-line P.f/PAN-pLDH, claims better sensitivity with continued rapid conversion to negative. The study aims were to 1) compare sensitivity and specificity of CareStart™ to Paracheck-Pf® to diagnose falciparum malaria in children under five years of age, 2) assess how quickly false-positive CareStart™ tests become negative and 3) evaluate ease of use and inter-reader agreement of both tests.MethodsParticipants were included if they were aged between two and 59 months, presenting to a Médecins Sans Frontières community health centre in eastern Sierra Leone with suspected malaria defined as fever (axillary temperature > 37.5°C) and/or history of fever in the previous 72 hours and no signs of severe disease. The same capillary blood was used for the RDTs and the blood slide, the latter used as the gold standard reference. All positive participants were treated with supervised artesunate and amodiaquine treatment for three days. Participants with a persistent false-positive CareStart™, but a negative blood slide on Day 2, were followed with repeated CareStart™ and blood slide tests every seven days until CareStart™ became negative or a maximum of 28 days.ResultsSensitivity of CareStart™ was 99.4% (CI 96.8-100.0, 168/169) and of Paracheck-Pf®, 98.8% (95% CI 95.8-99.8, 167/169). Specificity of CareStart™ was 96.0% (CI 91.9-98.4, 167/174) and of Paracheck-Pf®, 74.7% (CI 67.6-81.0, 130/174) (p < 0.001). Neither test showed any change in sensitivity with decreasing parasitaemia. Of the 155 eligible follow-up CareStart™ participants, 63.9% (99/155) had a false-positive test on day 2, 21.3% (33/155) on day 7, 5.8% (9/155) on day 14, 1.9% (3/155) on day 21 and 0.6% (1/155) on day 28. The median time for test negativity was seven days. CareStart™ was as easy to use and interpret as Paracheck-Pf® with excellent inter-reader agreement.ConclusionsBoth RDTs were highly sensitive, met WHO standards for the detection of falciparum malaria monoinfections where parasitaemia was >100 parasites/μl and were easy to use. CareStart™ persistent false positivity decreased quickly after successful anti-malarial treatment, making it a good choice for a RDT for a hyperendemic falciparum malaria area.

Long-lasting insecticide-treated net usage in eastern Sierra Leone - the success of free distribution.

Objective  Médecins Sans Frontières (MSF) runs a malaria control project in Bo and Pujehun districts (population 158 000) that includes the mass distribution, routine delivery and demonstration of correct use of free, long‐lasting insecticide–treated nets (LLINs). In 2006/2007, around 65 000 LLINs were distributed. The aim of this follow‐up study was to measure LLIN usage and ownership in the project area.

Successful introduction of artesunate combination therapy is not enough to fight malaria: results from an adherence study in Sierra Leone.

A study to measure adherence to artesunate and amodiaquine (AS+AQ) therapy in patients treated for uncomplicated malaria in community health centres (CHC) was conducted in Sierra Leone. Patients/caretakers were interviewed and remaining AS+AQ tablets at home after the last treatment dose were counted. Persons leaving CHCs with an AS+AQ prescription were also interviewed (exit interviews). In total, 118 patients were visited at home: 27 (22.9%) had one or more tablets left and were classed as certainly non-adherent; 34 (28.8%) were probably non-adherent [reported incorrect (n=27) or incomplete (n=7) intake]; and 57 (48.3%) were probably adherent. The main reasons for incomplete intake were sickness after one dose of AS+AQ, no food available for drug intake and forgetting to take them. For incorrect intake, reasons were vomiting after drug intake and incorrect instructions given by the CHC. Eighty-one percent of probably adherent patients reported following instructions given to them. In exit interviews, 82% of patients or caretakers of patients were able to repeat AS+AQ intake instructions correctly. Adherence to antimalarial treatment should not be taken for granted. Instructions on correct AS+AQ use should include discussion of disease symptoms as well as possible treatment side effects and how to manage them. Other factors are more difficult to influence, such as patients forgetting to take the treatment.

Challenges in mass drug administration for treating lymphatic filariasis in Papua, Indonesia

BackgroundThe World Health Organization (WHO) Global Program to Eliminate Lymphatic Filariasis relies on mass drug administration (MDA) of two drugs annually for 4 to 6 years. The goal is to reduce the reservoir of microfilariae in the blood to a level insufficient to maintain transmission by the mosquito vector. In 2008, the international medical aid organization Médecins Sans Frontières (MSF) performed the first round of a MDA in the high-burden area of Asmat district, in Papua, Indonesia. We report the challenges faced in this MDA on a remote Indonesian island and propose solutions to overcome these hurdles in similar future contexts.ResultsDuring the MDA, we encountered difficult challenges in accessing as well as persuading the patient population to take the antifilarial drugs. Health promotion activities supporting treatment need to be adapted and repetitive, with adequate time and resources allocated for accessing and communicating with local, seminomadic populations. Distribution of bednets resulted in an increase in MDA coverage, but it was still below the 80-85% target.ConclusionsMDA for lymphatic filariasis is how the WHO has planned to eliminate the disease from endemic areas. Our programmatic experience will hopefully help inform future campaign planning in difficult-to-access, high-burden areas of the world to achieve target MDA coverage for elimination of lymphatic filariasis.

Implementation of a triage score system in an emergency room in Timergara, Pakistan.

Following implementation of the South African Triage Scale (SATS) system in the emergency department (ED) at the District Headquarter Hospital in Timergara, Pakistan, we 1) describe the implementation process, and 2) report on how accurately emergency staff used the system. Of the 370 triage forms evaluated, 320 (86%) were completed without errors, resulting in the correct triage priority being assigned. Fifty completed forms displayed errors, but only 16 (4%) resulted in an incorrect triage priority being assigned. This experience shows that the SATS can be implemented successfully and used accurately by nurses in an ED in Pakistan.

Unregulated usage of labour-inducing medication in a region of Pakistan with poor drug regulatory control: characteristics and risk patterns

Background In developing countries such as Pakistan, poor training of mid-level cadres of health providers, combined with unregulated availability of labour-inducing medication can carry considerable risk for mother and child during labour. Here, we describe the exposure to labour-inducing medication and its possible risks in a vulnerable population in a conflict-affected region of Pakistan. Methods A retrospective cohort study using programme data, compared the outcomes of obstetric risk groups of women treated with unregulated oxytocin, with those of women with regulated treatment. Results Of the 6379 women included in the study, 607 (9.5%) received labour-inducing medication prior to reaching the hospital; of these, 528 (87.0%) received unregulated medication. Out of 528 labour-inducing medication administrators, 197 (37.3%) traditional birth attendants (also known as dai) and 157 (29.7%) lady health workers provided unregulated treatment most frequently. Women given unregulated medication who were diagnosed with obstructed/prolonged labour were at risk for uterine rupture (RR 4.1, 95% CI: 1.7–9.9) and severe birth asphyxia (RR 3.9, 95% CI: 2.5–6.1), and those with antepartum haemorrhage were at risk for stillbirth (RR 1.8, 95% CI: 1.0–3.1). Conclusions In a conflict-affected region of Pakistan, exposure to unregulated treatment with labour-inducing medication is common, and carries great risk for mother and child. Tighter regulatory control of labour-inducing drugs is needed, and enhanced training of the mid-level cadres of healthcare workers is required.

Offering Mental Health Services in a Conflict Affected Region of Pakistan: Who Comes, and Why?

Background North West Pakistan is an area ravaged by conflict and population displacement for over three decades. Recently, drone attacks and military operations have aggravated underlying mental disorders, while access to care is limited. Among patients attending a mental health clinic integrated in district hospital conducted by psychologists; we describe service utilization, patient characteristics, presenting complaints, morbidity patterns, and follow-up details. Methodology/Principal Findings A retrospective study using routinely collected programme data was conducted from February to December 2012. A total of 1545 consultations were conducted for 928 patients (86% females). There were 71(8%) children and adolescents. An increase was observed from February to July, followed by a decline. 163 new patients (18%) were on psychotropic medication at presentation. The most common morbidity in females (36%) were symptoms of adjustment disorders and acute reactions. Depression and anxiety were common in both genders while post traumatic disorder was frequent in males (21%). Out of the 928 new patients, 639(69%) had a follow up visit planned with their psychologist, but only 220(34%) new patients returned for a follow up visit. Conclusion In a district hospital, mental health services managed by psychologists were well attended. There is a need to consider widening the current package of care to cater to the diversity of mental health disorders, gender difference, children and adolescents. Standardized diagnostic and monitoring tools would also need to be adapted accordingly and to assess patient progress. Innovative approaches to tackle the problem of the low return rate are needed.

Offering general pediatric care during the hard times of the 2014 Ebola outbreak: looking back at how many came and how well they fared at a Médecins Sans Frontières referral hospital in rural Sierra Leone.

BackgroundIn Bo district, rural Sierra Leone, we assessed the burden of the 2014 Ebola outbreak on under-five consultations at a primary health center and the quality of care for under-15 children at a Médecins Sans Frontières (MSF) referral hospital.MethodsRetrospective cohort study, comparing a period before (May-October 2013) and during the same period of the Ebola outbreak (2014). Health worker infections occurred at the outbreak peak (October 2014), resulting in hospital closure due to fear of occupational-risk of contracting Ebola. Standardized hospital exit outcomes and case fatality were used to assess quality of care until closure.ResultsA total of 13,658 children under-five, were seen at the primary health center during 2013 compared to 8761 in 2014; a consultation decline of 36%. Of 6497 children seen in the hospital emergency room, during the outbreak, patients coming from within hospital catchment area declined with 38% and there were significantly more self-referrals (80% vs. 61%, P < 0.001). During Ebola, 23 children were dead on arrival and the proportion of children in severe clinical status (requiring urgent attention) was higher (74% during Ebola vs. 65% before, P < 0.001). Of 5,223 children with available hospital outcomes, unfavorable outcomes (combination of deaths and abandoned) were less than 15% during both periods, which is within the maximum acceptable in-house threshold set by MSF. Case fatality for severe malaria and lower respiratory tract infections (n = 3752) were similar (≤15%).ConclusionsValuable and good quality pediatric care was being provided in the pediatric hospital during the 2014 Ebola outbreak, but could not be sustained because of hospital closure. Health facility and health worker safety should be tackled as a universal requirement to try to avoid a déjà-vu.