Postneonatal mortality impacts following grants from the Gavi Vaccine Alliance: an econometric analysis from 2000 to 2014.

We completed a retrospective multivariate panel study to evaluate the effect of Gavi Vaccine Alliance grants on vaccine-preventable disease (VPD) postneonatal mortality. We separately tested a composite VPD mortality rate and five vaccine-preventable mortality rates: pertussis, meningitis, measles, diarrhea, and pneumonia (lower-respiratory infection) as dependent variables. All 77 countries eligible for Gavi assistance from 2000 to 2014 were included in the study. To isolate the effect of Gavi funding in our primary model, we controlled for known and likely predictors of child mortality. We found evidence that, among other factors, Gavi investment, antenatal care access, and girls' primary education are important elements to reduce vaccine-preventable mortality rates. For every $1 per capita invested by the Gavi Vaccine Alliance, there are statistically significant effects decreasing the VPD postneonatal mortality rate by 1.848 per 1000 live births. We also found Gavi investments to be significantly associated with reductions in three VPD-specific rates: pertussis, meningitis, and pneumonia. We conclude that Gavi investments in developing country immunization programs have measurably contributed to reductions in postneonatal VPD mortality rates.

Is introducing rapid culture into the diagnostic algorithm of smear-negative tuberculosis cost-effective?

SETTING: In 2007, the World Health Organization recommended introducing rapid Mycobacterium tuberculosis culture into the diagnostic algorithm of smear-negative pulmonary tuberculosis (TB). OBJECTIVE: To assess the cost-effectiveness of introducing a rapid non-commercial culture method (thin-layer agar), together with Löwenstein-Jensen culture to diagnose smear-negative TB at a district hospital in Kenya. DESIGN: Outcomes (number of true TB cases treated) were obtained from a prospective study evaluating the effectiveness of a clinical and radiological algorithm (conventional) against the alternative algorithm (conventional plus M. tuberculosis culture) in 380 smear-negative TB suspects. The costs of implementing each algorithm were calculated using a 'micro-costing' or 'ingredient-based' method. We then compared the cost and effectiveness of conventional vs. culture-based algorithms and estimated the incremental cost-effectiveness ratio. RESULTS: The costs of conventional and culture-based algorithms per smear-negative TB suspect were respectively €39.5 and €144. The costs per confirmed and treated TB case were respectively €452 and €913. The culture-based algorithm led to diagnosis and treatment of 27 more cases for an additional cost of €1477 per case. CONCLUSION: Despite the increase in patients started on treatment thanks to culture, the relatively high cost of a culture-based algorithm will make it difficult for resource-limited countries to afford.

[Evaluation of vector control techniques: an economic approach]. / Evaluation de la lutte anti-vectorielle: approche économique.

Programs of disease control must be evaluated. Evaluation of these programs in terms of public health is straightforward but should be carried out in conjunction with economic evaluation to measure the cost effectiveness and cost-benefit ratio. The purpose of this report is to clarify the importance of economic evaluation by explaining why it is necessary, when it should be carried out, and what methods should be used. Program evaluation is a process with several steps. Each step is associated with specific indicators. Determining these indicators is a prerequisite for construction of the database needed for evaluation. Two methods are proposed for data analysis, i.e., a simple one for cost-effectiveness and cost-benefit analysis and a more sophisticated one for impact analysis that must take into consideration treated and non-treated groups. Economic evaluation of disease control programs is as important as epidemiologic evaluation. However this evaluation cannot be carried out as a standalone procedure but only within a multidisciplinary framework.

Impact of mass chemotherapy with praziquantel on Schistosoma haematobium and Schistosoma mansoni infections in Office du Niger, Mali.

Aims This study was carried up to assess the impact of mass chemotherapy with praziquantel on the prevalence and intensity of Schistosoma haematobium and Schistosoma mansoni in Office du Niger. Materials and Methods It was a cross sectional study with two passages about which we compared a test group of 7 villages (n=2342) treated in 1989 to a control group of 7 villages (n=2263). Results One year after mass chemotherapy, baseline prevalence rates of Schistoosma haematobium, Schistoaoma mansoni and those of the double infection decreased by 50%, 54% and 62,9% respectively. The geometric mean egg counts of Schistosma haematobium (GMECSh) was reduced by 66.6% and that of Schistosoma mansoni (GMECSm) by 43.4%. However, in spite of mass treatment, the overall prevalence rates of Schistosoma haematobium and mansoni were always higher than 20% in young people aged of 6-19 years. Conclusion These data show that in irrigated area, efficacy of praziquantel is strongly affected by age. This persistance of infection in population raises up several questions according to host immunity, parasite biology and praziquantel efficacy.

[Financing healthcare in low-income countries: recurring questions, new challenges]. / Financement de la santé dans les pays à faible revenu: questions récurrentes, nouveaux défis.

Healthcare financing policies in low-income countries have gone through three successive phases. In the first phase the dominant approach was based on free access to healthcare and focused first on development of vertical programs and then on the necessity of providing primary care to all. While maintaining the emphasis on accessibility to primary care, the second policy phase introduced user fees and attempted to integrate healthcare programs into district-based healthcare structures. The third phase has been strongly influenced by the relationship between healthcare and development and the Millenium Objectives and places strong emphasis on necessity of developing insurance schemes. Recent studies on the relationship between healthcare spending and health status indicate that the efficiency and effectiveness of healthcare spending plays a more determinant role than the amount. At the same time an effort is being made to develop synergy between the different players in the health care systems and to clarify the role of each player by hinging financing decisions on operating criteria such as "public welfare", externalities, catastrophic costs, and equity. Although many countries have made significant progress, there are still several lagging areas, i.e., coverage for the poorest segment of the population (despite the rhetoric), follow-up of financing, and governance. Increasing external aid already initiated by several states may have a non-negligible impact on the macroeconomic balance. Since these changes could lead to adverse effects on health, there is a need to implement careful non-dogmatic policies.

Inland valley rice production systems and malaria infection and disease in the savannah of Côte d'Ivoire.

In sub-Saharan Africa, lowlands developed for rice cultivation favour the development of Anopheles gambiae s. l. populations. However, the epidemiological impact is not clearly determined. The importance of malaria was compared in terms of prevalence and parasite density of infections as well as in terms of disease incidence between three agroecosystems: (i) uncultivated lowlands, 'R0', (ii) lowlands with one annual rice cultivation in the rainy season, 'R1' and (iii) developed lowlands with two annual rice cultivation cycles, 'R2'. We clinically monitored 2000 people of all age groups, selected randomly in each agroecosystem, for 40 days (in eight periods of five consecutive days scheduled every 6 weeks for 1 year). During each survey, a systematic blood sample was taken from every sick and asymptomatic person. The three agroecosystems presented a high endemic situation with a malaria transmission rate of 139-158 infective bites per person per year. The age-standardized annual malaria incidence reached 0.9 malaria episodes per person in R0, 0.6 in R1 and 0.8 in R2. Children from 0 to 9-year-old in R0 and R2 had two malarial attacks annually, but this was less in R1 (1.4 malaria episodes per child per year). Malaria incidence varied with season and agroecosystem. In parallel with transmission, a high malaria risk occurs temporarily at the beginning of the dry season in R2, but not in R0 and R1. Development of areas for rice cultivation does not modify the annual incidence of malarial attacks despite their seasonal influence on malaria risk. However, the lower malaria morbidity rate in R1 could be explained by socio-economic and cultural factors.

Malaria and property accumulation in rice production systems in the savannah zone of Côte d'Ivoire.

Irrigation stabilizes agricultural production and hence improves farmers' living standards and conditions. The permanent presence of water may, however, increase the burden of water-related parasitic diseases and counter the economic benefits of irrigation by reducing farmers' health. The purpose of this study was to assess the impact of malaria on farm household property, beyond the health risk (studied elsewhere). The research question was: by weakening individuals, does malaria reduce productive capacities and income workers, and consequently limit their property accumulation? To test this hypothesis, we use data on property (farming equipment, livestock and durable consumer goods) and Plasmodium falciparum indicators generated by a study carried out in 1998 in the Ivorian savannah zone characterized by inland valley rice cultivation, with a sample of nearly 750 farming households. Property is influenced by many factors related to the size of the family, the area under cultivation and high parasite density infection rate of P. falciparum. A significant negative correlation between high-density infection rate and the property values confirms that by reducing the living standards of households, malaria is a limiting factor for property accumulation.

[Water contacts in dracunculiasis-infected patients in Mali: transmission risk activities]. / Contacts homme-eau chez des malades atteints de dracunculose au Mali: activités à risque de transmission.

The aim of this study lies in the identification of human activities responsible for the transmission of the Guinea worm in an endemic village in Diema Region in Mali. Human water contacts observations started after a census followed by the implementation of a bi-monthly notification system, carried out from May to November 1993. Water contacts were noticed and observed from the mid-July to the end of November of the same year. The first case of dracunculiasis observed was randomly drawn out of a list of the families with obvious cases. The patent case activities involving either surface water, traditional wells or bore-hole water were recorded for 10 consecutive days. During this observation period, contacts made by other patients with the same water sources were also recorded. After 14 days, the case list was updated and a new case selected out of families previously selected. This cycle was repeated until the end of the study period. A "contact at risk for transmission" was defined by a close correspondence between the location of the worm's emergence and the surface of the skin exposed to water, within two weeks following emergence. Contacts were described according to water sources, activities in relation to water, date, gender and age. Observations were made on 103 patients who had 2506 activities in relation with a water body: 1132 of these activities implied a skin contact with the water. Only 133 (9%) of these water contacts were at risk for transmission, 75% took place during the months of August and September, 80% were related to surface waters and 20% to traditional wells. Woman household activities and boys games were the major activities at risk, in contrast to economic activities (watering cattle). The low proportion of "at risk activities" evaluated in this study suggests that a small number of water contacts is sufficient to maintain the transmission. The case implications of the current eradication strategy might not be sufficient alone to break the transmission and should therefore be associated with a reinforcement of the use of filters for drinking water together with an health education.

Cost recovery in Mauritania: initial lessons.

Cost recovery was introduced in Mauritania in 1993. Analysis of the Mauritanian experience provides a number of key points to the discussion surrounding the contribution of user fees to health care systems. Initial results appear to be largely positive regarding the improvement of the quality of health care and the overall level of utilization of basic health establishments. They suggest that users are globally willing to pay when the quality of health care improves, and that, contrary to a frequently voiced concern, EPI activities have increased. Several elements tend to show that cost recovery accompanied by a fair supply of essential drugs and by a better motivated staff has contributed to improve the efficiency of the health system. But a coherent price structure is needed to guide patients more efficiently to the different levels of the health pyramid. It is therefore vital that user fees are extended, as the government intends, to the second and third levels of the health system. The analysis conducted here also suggests that cost recovery has probably had no major negative effects as far as equity is concerned, although further investigation is necessary before a more precise judgement can be made.

Age-acquired resistance and predisposition to reinfection with Schistosoma haematobium after treatment with praziquantel in Mali.

The effect of age, previous intensity of infection, and exposure on reinfection with Schistosoma haematobium after treatment was studied in a cohort of 468 subjects six years of age and over living in an irrigation scheme area in Mali. Prevalence and intensity of S. haematobium infection were measured each year between 1989 and 1991, but the reinfection study period was restricted to the last year of the follow-up. Observations were made at the principal water contact sites where the number of Bulinus truncatus shedding furcocercous cercariae was recorded. A cumulative index of exposure taking into account time, duration and type of contact, and malacologic data was calculated for each subject. Univariate analysis showed that the reinfection risk decreased with age and increased with exposure and pretreatment intensity. These results were confirmed by fitting a logistic model that showed that this risk was seven times lower among those 15 years of age and older than among the 6-14-year-old children, while linear trends with exposure to infection and pretreatment intensity were significant. This study supports the concept of an age-acquired resistance to reinfection and is in favor of a predisposition to infection that raises the question of a genetic factor controlling susceptibility/resistance to S. haematobium infection.

Social and epidemiological aspects of guinea worm control.

Dracunculiasis prevention should be simple: in a population at risk, everyone may be protected by the filtration of drinking water. The research described in this paper allowed the authors to follow the acceptance of new information by villagers in nine localities in Mali. Two strategies were studied: safe water supply (bore-hole or cement lined wells) plus health education on the one hand, and health education alone (based on filtration) on the other. Safe water supply is undoubtedly an effective strategy whereas the success of the health education intervention is uncertain. This experience showed that health education as the only means of control failed due to a lack of social cohesion or of coordinated group-action. Also, when dracunculiasis control is not a population's priority goal, the constraints on systematic filtration are too great and a tendency to discontinue the filtration process occurs. On the other hand, when dracunculiasis is considered to be a serious problem by the population, new information about systematic filtration is better assimilated and leads to behavioural changes. In order that the goal of eradicating dracunculiasis by 1995 should not be an utopic dream, it is necessary to prioritize the allocation of clean rural water supply projects only to those endemic villages where the conditions that allow for health education to be successful are met.

[Hematocolpometra and local estrogen therapy: an overdose of promestriene?]. / Hématocolpométrie et estrogénothérapie locale: surdosage au Promestriène?

We report a case of hyperestrogenisation which showed itself by the presence of a haematocolpometra in an elderly lady which could be attributed to prolonged and continuous treatment with Promestriene cream. Haematocolpometra is due to intra-uterine haemorrhage (itself due to hyperplastic endometrial polyps) with vaginal stenosis caused by vaginal atrophy that existed before local treatment was started. The Pomestriene is an estrogenic substance which works locally and does not seem to cause much in the way of general effects when used for short courses. If when it is used in large doses over a prolonged period of time, however, it is necessary to look for generalised hyperestrogenisation. Further studies are needed to confirm these finding.

Irrigation, schistosomiasis, and malaria in the Logone Valley, Cameroon.

Field studies of a rice irrigation project in Mayo-Danai, North Cameroon permitted a direct comparison between pre- and post-development data relating to schistosomiasis and malaria infection. A stratified sample of 4,000 inhabitants, representing 8% of the population living in 28 areas at the time of the first survey, was investigated 5 times between 1979 and 1985. Due to the significant population increase since 1982, 1,500 persons were added to the initial sample. The prevalence of schistosomiasis and malaria remained constant over the 6 years. No changes in the transmission sites were observed. Malacological investigations showed a decrease in the snail population in the project area. Sanitation activities (i.e., drain cleaning and well construction) and decreased rainfall contributed to this situation. The prevalence of infection among the migrants was low. High prevalence of schistosomiasis was found only in villages located along a previously contaminated temporary river.

[The primary consequences of a large agricultural project (SEMRY II) on the demographic situation in its area of influence]. / Les premieres consequences d'un grand projet agricole (SEMRY II) sur la situation demographique de son aire d'influence.

"This article describes to what extent a rice-growing development project, begun in 1979 in northern Cameroon, modified the demographic and migratory characteristics of the population within the zone of influence. A representative sample and a control group were followed from 1979 to 1981 using a multi-round survey technique. Data from the general population census (1976) were used to study the population's characteristics from 1976 to 1979." The study population is linked to 1976 census data, and various demographic estimates for the population are produced. An examination of migration patterns in the area indicates that "the project had not yet succeeded in attracting the populations living in the more distant zones two years after its installation." (SUMMARY IN ENG)

[Prevalence of Schistosoma haematobium schistosomiasis in Mayo Danaï (North Cameroon)]. / Prévalence de la schistosomiase à Schistosoma haematobium dans le Mayo Danaï (Nord Cameroun).

The state of the S. haematobium infection in North Cameroon seemed sufficiently well known to regard as negligible the risks involved in planning hydro-agricultural plants. However, a series of field-studies conducted by the authors in one of these sites (SEMRY II, North of Yagoua, in the Mayo Danaï area) has shown that the spread of this disease varies widely from village to village. It is sometimes absent, and on average, it rarely exceeds 15% of the sample (approximately 4,000 people, spread over 28 survey areas). This result is obtained using a representative sample of about 70,000 people, directly or indirectly affected by the hydro-agricultural project. The technique used was a simple centrifugation, and no egg count was made. Two malacological investigations performed in the same area complemented the parasitological inquiry. Comparison of these results with previous works shows that the latter used too few observations, the statistical representativity of which was never assured. On the other hand, recent evaluations, done independently of those reported in this paper, but which are limited to a few villages, confirm that the present infection rate for S. haematobium is appreciably lower than what is believed, and that it varies considerably from village to village. This re-evaluation of the problem leads us to conclude that the hydroagricultural plants, which are intended to develop irrigated rice-growing, might cause a considerable upsurge of the disease; and that this risk should be prevented by setting up specific control programs.

[Health statistics and health index in developing countries]. / Statistiques sanitaires et indicateur de santé dans les pays en voie de développement.

Having briefly criticized those health indexes which are currently used, the author suggests that the LDC'S should exploit the information contained in routine statistical reports of health services activities: utilization rate (number of patients divided by population served) and intensity of service rate (number of visits per patient). She shows that these rate depend not only on morbidity, but also on the characteristics of the supply of health services (distance . . .) and on the characteristics of the demand for those services (behavioral attitudes of the patients . . .). The author uses multiple regression techniques to isolate the influence of these factors on utilization rate and on service's intensity. She concludes that the residual may be considered as a health status indicator. The application of this method to data for the forty administrative areas of Cameroon (1970 and 1975), shows that the resulting health index is correlated with infant mortality rates and with sanitary conditions.

[Influence of various thermal processes and microwaves on the amino acid composition of food products: implications on their nutritional value]. / Influence de divers procédés thermiques et des micro-ondes sur la composition en acides aminés de produits alimentaires les implications sur la valeur nutritionnelle.

The cinetic study of free amino nitrogen and total soluble nitrogen of hard wheat semolina, when comparatively treated by thermal processings (convection and microwaves) shows a decrease conditioned by time and strength of heating. Aminograms show the same decrease, which is however different for each amino acid. After thermal treatment, appear ninhydrin-reactive substances, to be identified. In short, micro-wave heating seems to have the same effect as conventional heating, on free amino acids of these cereal products.