[Effects of Monitoring "Out-of-Area" Vaccinated Children on Data Quality, San Pedro Health District, Côte D'ivoire in 2019]. / Effets du Suivi des Enfants « Hors Zone ¼ Vaccinés sur la Qualité des Données, District Sanitaire de San Pedro, Côte D'ivoire, 2019.

In order to improve the quality of vaccination data from the health centers, we carried out the follow-up of "out-of-area" children, vaccinated in the district of San Pedro. The objective of this work was to measure the effects of taking into account the "out-of-area" vaccinated children on the quality of the data and the immunization performance of the health centers. This monitoring, which was carried out between March and August 2019, consisted of four steps: the vaccination of "out-of-area" children by the health center, the monthly update in the register of the status of vaccinated "out-of-area" children, the accounting of these children, and the re-evaluation of the health center's vaccine performance. A total of 37 of the 40 district centers had 980 "out-of-area" vaccinated children, representing 5.7% of the immunization target. The quarter of these children resided outside the district. The vaccination of "out-of-area" children included all EPI vaccines, but especially BCG, DTP-HepB-Hib and Pneumococcus_13. The number of "outside the extra-district area" vaccinated children had not changed the district's immunization coverage. On the other hand, in the health centers concerned, the accuracy of the data had been improved in 65% of the centers for DTP-HepB-Hib_1, in 70% of the centers for RR and in 65% of the centers for the overall immunization dropout rate. The approach used had made it possible to improve the quality of immunization data from health centers at no additional cost.

[Performance of the Strategy to Catch Up with Drop Out and Unvaccinated Children in Côte d'Ivoire in 2018]. / Performance de la stratégie de rattrapage des enfants perdus de vue et non vaccinés en Côte d'Ivoire en 2018.

To improve the performance of Côte-d'Ivoire's immunization program, we have implemented a strategy to catch up with drop out children (DOC) and unvaccinated children (UVC) in 14 Health Districts (HDs) with the lowest measles vaccination coverage. This article presents the effectiveness and cost of this strategy. We selected the areas with the highest numbers of DOC: 5 health areas (HAs) per HD and 5 villages/neighborhoods per HA. The strategy, which was implemented by civil society organizations, health centre managers (HCMs) and community health workers (CHWs), combined sensitization of community leaders and groups, home visits (HV) and referral of children to the HCs for immunization. Out of the 17,912 reported DOC, 9,425 found (52.6%) and 8,245 were vaccinated (46% of declared, 87.5% of found). The HCMs reported 484 UVC while the home visits identified 1,315 of which 1,087 were vaccinated (82.7%). Out of a total declared number of 18,396 children to be caught up, 10,740 found (58.4%) and 9,332 vaccinated, i.e. 50.8% (9,332/18,396) of children to be caught up and 86.9% (9,332/10,740) of children found. The total specific recurrent cost of the strategy was XOF 22,375,008, with XOF 2,083 (22,375,008/10,740) per child found and XOF 2,398 (22,375,009/9,332) per child found and vaccinated. In view of these results, this strategy should be implemented in all of the country's low-performing HDs.

Pour améliorer la performance du programme élargi de vaccination de Côte d'Ivoire, nous avons mis en place une stratégie de rattrapage des enfants perdus de vue (EPDV) et des enfants non vaccinés (ENV) dans les 14 districts sanitaires (DS) ayant les plus faibles couvertures vaccinales antirougeoleuses. Cet article présente l'efficacité et le coût de cette stratégie. Nous avons retenu les localités ayant les plus grands nombres d'EPDV : cinq aires de santé (AS) par DS et cinq villages/quartiers par AS. La stratégie qui a été mise en oeuvre par les organisations de la société civile, les responsables des centres de santé (RCS) et les agents de santé communautaire a combiné la sensibilisation des leaders et groupes communautaires, les visites à domicile (VAD) et la référence des enfants aux CS pour la vaccination. Sur les 17 912 EPDV déclarés, 9 425 ont été retrouvés (52,6 %) et 8 245 vaccinés (46 % des déclarés et 87,5 % des retrouvés). Les RCS ont déclaré 484 ENValors que les VAD ont permis d'en identifier 1 315 dont 1 087 ont été vaccinés (82,7 %). Sur un nombre total déclaré de 18 396 enfants à rattraper, 10 740 ont été retrouvés (58,4 %) et 9 332 vaccinés, soit 50,8 % (9 332/18 396) d'enfants à rattraper et 86,9 % (9 332/10 740) d'enfants retrouvés. Le coût récurrent spécifique total de la stratégie était de 22 375 008 FCFA, soit 2 083 FCFA (22 375 008/10 740) par enfant retrouvé et 2 398 FCFA (22 375 008/9 332) par enfant retrouvé et vacciné. Au vu de ces résultats, cette stratégie devrait être mise en oeuvre dans tous les DS à faible performance du pays.

[Cost Analysis of the Immunization Program Supportive Supervision in Côte-d'Ivoire]. / Analyse des coûts de supervision formative du programme de vaccination en Côte-d'Ivoire.

One of the major obstacles to improve the performance of immunization programs is the lack of competent health personnel. To increase the availability of qualified health personnel, the Agence de Médecine Préventive (Agency of Preventive Medicine) has set up a technical assistance focused on supportive supervision. The objective of this study is to analyze the cost of this supportive supervision in 10 health districts of Côte-d'Ivoire. The data extracted from the financial and technical reports of the supportive supervisions included personnel costs (salary, per diem), transportation, communication, office supplies, vehicle maintenance and depreciation. The analysis consisted of estimating the total cost of the supportive supervision, the total cost per item and the average cost of a supervisory visit. The conduct of 40 supportive supervision visits amounted to 44,675.12 USD. Of this amount, recurring costs were 40,112.12 USD (89.79%) and non-recurring costs were 4,563 USD (10.21%). The unit cost per supervisory visit was 1,116.88 USD. The cost of personnel was the largest cost. The total cost of the formative supervision would be reduced by 58.68% through the resort to local facilities' staff for the supervision, and the review of the useful life of the vehicles. The costs for implementing supportive supervision were acceptable in comparison to the benefits. Mastering personnel costs, optimizing the scheduling of supervision tours and frequency of visits focused on districts with the lowest EPI indicators could lead to cost savings.

Un des obstacles à l'amélioration des performances des programmes de vaccination est l'insuffisance de ressources humaines compétentes. Pour accroître la disponibilité de personnel de santé qualifié, l'Agence de médecine préventive a mis en place une assistance technique centrée sur la supervision formative. L'objectif de cette étude est d'analyser les coûts de cette supervision formative dans dix districts sanitaires de Côte-d'Ivoire à partir des données extraites des rapports techniques et financiers de supervision. L'analyse a consisté en l'estimation du coût total des supervisions, du coût total par poste et du coût moyen par visite de supervision. Les 40 visites de supervision réalisées ont coûté 44 675,12 USD dont 40 112,12 USD de coûts récurrents (89,78 %) et 4 563 USD de coûts non récurrents. Le coût par visite de supervision était de 1 116,87 USD. Le coût du personnel était le poste de coûts le plus important. Le coût total et le coût unitaire de la supervision seraient réduits de 58,68 % par l'utilisation des superviseurs locaux et des recommandations de l'OMS sur la durée de vie utile des véhicules. Les coûts de la supervision formative étaient acceptables au regard des bénéfices obtenus. La maîtrise des coûts du personnel, une programmation optimale des tournées de supervision et une fréquence des visites centrée davantage sur les districts présentant les plus faibles indicateurs du PEV pourraient favoriser des économies.

[Impact of a targeted technical assistance to improve vaccine coverage in Cameroon, Côte d'Ivoire, and Mauritania in 2014]. / Effets d'une assistance technique ciblée pour l'amélioration de la couverture vaccinale au Cameroun, en Côte d'Ivoire et en Mauritanie en 2014.

Within the framework of its strategic goal of vaccine coverage (VC) improvement, GAVI, The Vaccine Alliance has entrusted the Agence de médecine préventive (agency for preventive medicine, AMP) with technical assistance services to Cameroon, Cote d'Ivoire (Ivory Coast), and Mauritania. This support was provided to selected priority districts (PDs) with the worst Penta3 coverage performances. In 2014, PDs benefited from technical and management capacities in vaccinology strengthening for district medical officers, supportive supervisions and technical assistance in health logistics, data management and quality. We analyzed the effects of the AMP technical assistance on the improvement of the cumulative Penta3 coverage, which is the key performance indicator of the expanded programme on immunization (EPI) performance. We compared Penta3 coverage between PDs and other non-priority districts (NPDs), Penta3 coverage evolution within each PD, and the distribution of PDs and NPDs according to Penta3 coverage category between January and December 2014. Technical assistance had a positive effect on the EPI performance. Indeed Penta3 coverage progression was higher in PDs than in NPDs throughout the period. Besides, between January and December 2014, the Penta3 VC increased in 70%, 100% and 86% of DPs in Cameroon, Côte d'Ivoire and Mauritania, respectively. Furthermore, the increase in the number of PDs with a Penta3 coverage over 80% was higher in DPs than in NPDs: 20% versus 8% for Cameroon, 58% versus 29% for Côte d'Ivoire and 17% versus 8% for Mauritania. Despite positive and encouraging results, this technical assistance service can be improved and efforts are needed to ensure that all health districts have a VC above 80% for all EPI vaccines. The current challenge is for African countries to mobilize resources for maintaining the knowledge and benefits and scaling such interventions in the public health area.

[Use of SMS to ask mothers to come to vaccination sessions in Bobo-Dioulasso]. / Recours aux SMS pour convoquer les mères aux séances de vaccination à Bobo-Dioulasso.

Even though the expanded programme for immunization (EPI) coverage at national level is high in Burkina (95% of fully vaccinated children), mothers of children following EPI in Health Centres (HC) would benefit from being reminded of EPI sessions by sending SMS (short message service) to their own mobile phone, or through mobile phone of a family member living in the same compound. SMS could be sent through Computerized Immunization Registers (CIR), hosted by HC computers. 210 mothers of children aged 0 to 5 years were chosen at random and questioned if they owned a mobile phone, if they could read a SMS, or, if not, what language they would understand if a voice SMS was sent. They were also asked if a family member could receive, read and transmit the message, if mothers did not own a mobile phone. They were also asked if they are willing to give their telephone number to HC. 94% of mothers could be reached through written or voice SMS, sent to their own or family member's mobile phone. 100% of mothers would be willing to give their telephone number to their HC to improve their ability to come at the right time for vaccination sessions. SMS reminders, delivered through CIR, should improve EPI attendance and management of sessions in HC, especially in epidemic context.

[Population's behaviour and expectations concerning malaria control in Ouidah, Benin, April 2006)]. / Comportements et attentes des populations en matière de lutte contre le paludisme dans la zone sanitaire de Ouidah, Bénin, avril 2006.

The aim of this study conducted in April 2006 in Ouidah (Benin), was to measure some results indicators of the implementation of "Roll Back Malaria" in Benin. Impregnated bed nets are available in 25.6% of the households and are used by 21.2% of children under five years old and 26.7% of pregnant women. The main reasons for this use are protection against harmful effect of mosquitoes (74%) and prevention of the malaria transmission (51%). The cost of impregnated bed net purchased is in average 2115 FCFA. Malaria morbidity in household is very high (48%) among children under five years old. The percentage of feverish children correctly treated in household according to the National Malaria Control Program's protocol is 1%. The major expectations of the households are supply of impregnated bed nets free of charge (33%), reduction of its delivery price (18%), its availability in health facilities (15%) and free treatment of malaria cases (12%).

[Experience with field epidemiology training programs in Africa: Cours IEIAA]. / Expérience d'une formation en épidémiologie de terrain en Afrique: le Cours IEIAA.

The International Course on Epidemiology and Applied Data Processing in Africa (Cours IEIAA) is a practical 4-week French-language training course for professional health care personnel working in Africa. The first course was organized in 1998 by the Association pour l'Aide à la Médecine Préventive (Association for the Promotion of Preventive Medicine). The course organizing committee includes a pedagogical director and a faculty of field epidemiology experts. Course activities are designed to give attendees competency in epidemiology, biostatistics, computer techniques and communication. Attendance is funded mainly through education grants from the French Foreign Affairs Ministry, WHO, UNICEF, Belgian Technical Cooperation, Swiss Technical Cooperation, and German GTZ. Based on 7 years of experience, consideration is now being given to transforming this course into a tutorial Field Epidemiology Training Program modeled after those now operating in Ghana and Uganda [TEPHINET members Programs located in Africa].

Experience d'une formation en epidemiologie de terrain en Afrique: le cours IEIAA

The International Course on Epidemiology and Applied Data Processing in Africa (Cours IEIAA) is a practical 4-week Fre n ch - l a n g u age training course for professional health care personnel wo rking in A f rica. The fi rst course was organ i zed in 1998 by the A s s o c i ation pour l'Aide a la Medecine Preve n t ive (Association for the Promotion of Preve n t ive Medicine). The course organizing committee includes a pedagogical director and a faculty of field epidemiology experts. Course activities are designed to give attendees competency in epidemiology; biostatistics; computer techniques and communication. Attendance is funded mainly through education grants from the French Foreign Affairs Ministry; WHO; UNICEF; Belgian Te chnical Cooperat i o n ; Swiss Te chnical Cooperat i o n ; and German GTZ. Based on 7 ye a rs of ex p e ri e n c e; c o n s i d e ration is now being given to transforming this course into a tutorial Field Epidemiology Training Program modeled after those now operating in Ghana and Uganda [TEPHINET members Programs located in Africa]

Effectiveness of incidence thresholds for detection and control of meningococcal meningitis epidemics in northern Togo.

BACKGROUND: Early outbreak detection is necessary for control of meningococcal meningitis epidemics. A weekly incidence of 15 cases per 100 000 inhabitants averaged over 2 consecutive weeks is recommended by the World Health Organization (WHO) for detection of meningitis epidemics in Africa. This and other thresholds are tested for ability to predict outbreaks and timeliness for control measures. METHODS: Meningitis cases recorded for 1990-1997 in health centres of northern Togo were reviewed. Weekly and annual incidences were determined for each district. Ability of different weekly incidence thresholds to detect outbreaks was assessed according to sensitivity, specificity, and positive and negative predictive values. The number of cases potentially prevented by reactive vaccination in 1997 was calculated for each threshold. RESULTS: Outbreaks occurred in 1995-1996 and in 1996-1997. The WHO-recommended threshold had good specificity but low sensitivity. Thresholds of 10 and 7 cases per 100,000 inhabitants in one week had sensitivity and specificity of 100% and increased the time available for intervention by more than one or two weeks, respectively. A maximum of 65% of cases could have been prevented during the 1997 epidemic, with up to 8% fewer cases prevented for each week of delay in achieving vaccine coverage. CONCLUSIONS: In northern Togo, thresholds of 7 or 10 cases per 100,000 inhabitants per week were excellent predictors of meningitis epidemics and allowed more time for a reactive vaccination strategy than current recommendations.

Effect of daily iron supplementation on iron status, cell-mediated immunity, and incidence of infections in 6-36 month old Togolese children.

OBJECTIVE: To assess the impact of a daily oral iron supplementation on hematological status, cell-mediated immunity and susceptibility to infections in children living in an environment where iron deficiency, malaria and other infections are frequent. DESIGN: Randomized, double-blind iron supplementation including a placebo group. SETTING: A village in Togo, West Africa. SUBJECTS: Of the 229 6-36-month-old children of both sexes recruited, 197 with hemoglobin concentration >/=80 g/l were included and 163 completed the study. INTERVENTION: Children received daily a placebo (n=79) or a dose of 2-3 mg of elemental iron per kg of body weight (n=84) for 3 months. Hematological, nutritional and immune status were assessed at the beginning and at the end of the supplementation period, and 6 months later. Morbidity was recorded throughout the study. RESULTS: Iron supplementation had a significant and positive effect on iron status of children and no impact on the incidence of infections, especially malaria. Its probable effect on immune status was masked by interference of infections and their treatment, which contributed to improve hematological and immune status in both groups. CONCLUSION: According to the negative consequences of anemia and iron deficiency on global child development, control of iron deficiency by oral iron supplementation in young children has to be conducted, associated with prophylaxis and treatment of malaria and repeated deworming. SPONSORSHIP: Program supported by IRD. European Journal of Clinical Nutrition (2000) 54, 29-35

[An epidemic of meningococcal meningitis in the region of Savanes in Togo in 1997: research and control strategies]. / Une épidémie de méningite à méningocoque dans la région des Savanes au Togo en 1997: investigation et stratégies de contrôle.

Neisseria meningitidis is responsible for high levels of morbidity and mortality in the developing countries of the African meningitis belt. There are frequent meningococcal meningitis epidemics in this region affecting almost 1,000 people in every 100,000 (1%). Epidemics generally occur during the dry season but the interval between epidemics is variable (between 2 and 25 years). The reasons for these recurrent epidemics are unclear. There is a safe and effective polysaccharide vaccine against meningococci A and C. Unfortunately, the immunity it provides decreases with time, especially in young children (aged less than 5 years) and it is thus not included in the Expanded Program on Immunization (EPI). WHO recommends mass vaccination using a threshold approach. This control strategy is effective if vaccination begins very soon after the threshold is crossed. There was an outbreak of group A meningococcal meningitis in the Savanes region of northern Togo in December 1996. The national surveillance system put out an alert and control measures were implemented. These involved improvement of the surveillance system, and containment immunization in villages for early cases followed by a mass immunization campaign in the entire region, distribution of oily chloramphenicol and decentralized case management. The target population for mass vaccination included everyone older than 6 months of age living in the Savanes region. The aim was to vaccinate at least 80% of the target population. There were 2,992 cases of meningitis reported in the Savanes region between December 1996 and May 1997 (in a population of about 500,000). This gives a cumulative incidence rate of 581 per 100,000 population. The epidemic was bimodal, with the first peak in the number of cases occurring at the end of January and the second peak in March. There were 60,700 vaccinations in two of the four districts of the region in December and January, as part of the containment strategy and 346,469 vaccinations in the four districts of the region during February, as part of the mass vaccination campaign. By the end of the mass campaign, 67.3% of the target population in the region as a whole had been vaccinated, with 61% vaccinated in the Kpendjal district and 78% in the Oti district. There was an increase in the number of cases 2 weeks after the end of the mass vaccination campaign. This was attributed to the inadequate level of vaccination achieved. Only 52% of the urban population of Dapaong were vaccinated. The national surveillance system put out an alert early in the epidemic. The intervention was planned and adapted according to the progression of the epidemic, and national and international efforts were well coordinated. This emphasizes the importance of a rapid reaction from the surveillance system and of the choice of strategy for dealing with meningitis epidemics in sub-Sahelian Africa.

[Evaluation of the impact of iron treatment. Interference of malaria]. / Evaluation de l'impact d'un traitement martial. Interférence du paludisme.

In Togo, where malaria occurs all the year, 151 children, from 6 months to 3 years old, were distributed in 2 groups, one of which received an iron supplementation during three months, and the other a placebo during the same time. At the end of the trial, no significant difference was observed between the two groups. However, taking into account malaria infection at the end of the trial, children who received iron supplementation and who were free of malaria infection showed improvement of their haematological status when compared to children receiving placebo and also free of malaria infection. Authors presumed that iron supplementation was masked by malaria when they evaluated effect of iron supplementation on anaemia.

The integration of family planning and childhood immunization services in Togo.

Improvements in the constellation of services in the African context are largely addressed through attaining better measures of service integration, which can be achieved through improved referral across categories of health programs. The use of an unobtrusive referral message that linked family planning and the Expanded Program of Immunizations (EPI) services was tested in an operations research study in Togo. The introduction of the referral message was accompanied by an 18-percent increase in awareness of available family planning services and an increase in the average monthly number of new family planning clients of 54 percent. These positive results indicate that the use of referral can have a significant and dramatic impact on family planning services in a relatively short time. In Togo, no evidence existed of a negative impact on EPI services, and a majority of the EPI providers reported satisfaction with the effect of the referral message at the close of the study.

PIP: Quality of care is currently construed to mean matching population needs with service provision. Improvements in African services are valued when there is a constellation of multiple services provided in a fixed center. In Togo, a simple intervention was developed to link childhood immunization and family planning services. Before immunizing each child, the service provider would make 3 family planning statements to the child's mother. The statements were salient and easy to remember: "Madame, your child is still young, and you should be concerned about having another pregnancy too soon." "This clinic provides family planning services that can help you delay your next pregnancy." And, "You should visit the family planning services after the immunization today for more information." Clinic staff were trained in a day and a half orientation session. The referral message was evaluated with a quasi-experimental design. Impact was measured in terms of knowledge of family planning methods and availability of family planning in the clinic, intention to use a contraceptive method, and the history of contraceptive use. 16 urban and rural clinics were involved. The sample included 1000 randomly selected women who has just had their children immunized. The pretest was conducted in January, 1992, and the post test was conducted in August, 1992, 6 months after the intervention in the study. Service statistics were also collected from 9 months prior to the intervention until September, 1992. Pretest and post test women were similar demographically. Recall levels were also similar. The results indicated that control group persons did not show any change in their awareness of family service availability in the clinic. The increase in the study group was from 40% to 58%. Differences between awareness in the control and study groups was 8% before the intervention and 22% after. Women desiring a longer birth-spacing period were more likely to be aware of service availability. The mean number of acceptors in the study group increased significantly from 200 to 307; average monthly number of family planning users also increased significantly from 1035 to 1311, which was a significant difference from control group users. Both groups showed significant increases in number of vaccines administered monthly in the study period.

Anémie et état nutritionnel chez les jeunes enfants dans un centre hôspitalier régional (CHR) au Togo

Une etude transversale de six mois traitant de l'anemie et de l'etat nutritionnel a ete effectuee aupres de 495 enfants ages de 3 a 48 mois; admis dans le service de Pediatrie du CHR de Kara. Les auteurs ont constate que: 65;6 pour cent des cas sont atteints d'anemie a predominance hypochrome; dont le risque de survenue est accru au cours de la periode de sevrage (3 a 30 mois) et de l'utilisation d'une farine pharmaceutique de sevrage; les memes facteurs de risque seront retrouves dans la malnutrition proteino-energique (MPE) qui a touche 18 pour cent des cas; l'association MPE-anemie existe de facon stable faisant evoquer avec l'hypochromie surajoutee; une origine nutritionnelle (ferriprive) a cette anemie

[Effects od iron supplementation on malaria infection]. / Effets de la supplémentation en fer sur l'infection palustre.

An iron supplementation trial had been performed in a southern village of Togo during the rainy season when occurs malaria transmission. 241 infants from 6 to 36 months old were matched in two randomized groups. The first one (G1) received oral iron supplementation every day during three months. The second group (G2) received placebo. Tablet administration was double blind made. A third group (G3) had been created from two others with anaemic infants and received daily iron supplementation. Three biological and clinical surveys were done, i) before the trial (T0), ii) after supplementation (T3) and iii) six months later (T9). Several parameters were studied including malaria parasite density and titration of malaria antibodies. For each group the prevalence of Plasmodium falciparum was identical in the three surveys. Means of parasite density decreased during and after rainy season but variations were not significant. High parasitaemia frequency (i.e. greater than 10,000 parasitized red cells per mm3, considered as pyrogenic threshold) were identical in all groups and decreased after rainy season. Antibodies titers did not show any variation in the three groups. It seems that iron supplementation did not modify in 6 to 36 months infants the susceptibility to malaria nor the organism response.

[Digestive parasitic diseases in young children in a tropical outpatient setting]. / Parasitoses digestives chez le jeune enfant en milieu extra-hospitalier tropical.

Parasites were looked for in stools of infants aged 6 months to 3 years living in a village in the south of Togo. These children were enrolled in a nutritional surveillance program. 42.5% of children harboured at least one parasite and 12.1% had more than one parasite: The most common parasites found included Giardia (21%), Ancylostoma (13%), and Ascaris (12.5%). Infection with a single parasite and infection with several parasites were observed from the age of nine months and 18 months, respectively; the incidence of these infections increased with advancing age. The incidence of diarrheal stools decreased with advancing age and no particular parasite seemed to be directly and exclusively responsible for diarrhea. The distribution of parasites and diarrheal symptoms were not influenced by sex. No correlation was found between nutritional status and presence of a parasitic infection or diarrhea. After treatment, reinfection with Ancylostoma (65%), whipworm (50%), and Giardia (34.2%) were common.