[Evaluation of the lifetime of nail markings during polio vaccinations in Chad]. / Évaluation de la durée de vie des marquages sur l'ongle pendant les vaccinations polio au Tchad.

BACKGROUND: SID (Supplemental Immunization Days) is a special strategy intended to accelerate eradication of poliomyelitis in countries where it is still endemic (India, Afghanistan, and Pakistan in Asia, and Nigeria in Africa). This strategy is also applied in Nigeria's neighbours (Cameroon, Chad, Niger and Benin). Since the poliomyelitis virus was imported from Nigeria in 2001, Chad has reported cases of poliomyelitis every year. After 30 SIDs in Chad and the inaccurate or false attribution of side-effects to polio vaccines, some groups persistently refuse polio vaccination. To ascertain the true coverage of SID, the Ministry of Health and several partners (WHO, UNICEF and Rotary) conduct external coverage evaluations, to identify the under-vaccinated areas where population may be refusing immunization. The nails of the children receiving vaccinations are marked with indelible ink and those markings are the best indicator of the area's actual SID coverage. When coverage investigators arrive and propose vaccination to all children not immunized during SID, mothers who wish to refuse vaccination may claim that the children's markings disappeared after a few days, due to bathing. WHO experts have found that markings applied to their own nails with the WHO-recommended markers persist a few weeks, but others suggested that the markings may disappear much faster among children living in a traditional tropical environment. Until now, the lifetime of these markings has not been tested among children in Africa. OBJECTIVES: To determine the lifetime of the fingernail markings after SID and factors that influence this lifetime in children young than 5 years old in Chad. MATERIALS AND METHODS: This prospective cohort study of 200 children (aged 0 to 59 months) took place from March to May 2009 in Milezi, a health zone north of Ndjamena, the capital of Chad, in central Africa. These children received nail markings on their left little finger with an indelible marker pen provided by WHO. The finger was monitored for 35 days, visually and by photographs, to determine the factors associated with the lifetime of the markings. Kaplan-Meier and log-rank methods were applied to estimate their survival curve and the variables significant for their lifetime; the Cox proportional hazard model was used to determine multivariable-adjusted hazard ratios. RESULTS: Of the 184 children surveyed through the end of the study, the markings disappeared after 35 days of follow-up for 35% of them. The average lifetime of markings on these children was 28 days (SD: 4.95) and was associated, according to the Cox model, with 3 variables: the quality of the marking (RR = 0.335, 95% CI: 0.182-0.617, p < 0.001), playing with soil or mud (RR = 0.38, 95% CI: 0.208-0.697, p = 0.002), and living in different blocks, after stratification for the variable of application of chemical products on the nail. The latter could not be included in the Cox model because it made the markings disappear instantly. CONCLUSION: WHO experts were right in stating that the lifetime of the markings was sufficient to estimate coverage accurately when external evaluation takes place one or two weeks after SID. The only action found to make markings disappear rapidly was the application of chemical products. Mothers who tell SID attendance evaluation teams that the marking disappeared with bathing are expressing a tacit refusal of vaccination. These evaluations, which take place well before the disappearance of markings, help to determine the precise coverage of SID.

Management of severely ill children at first-level health facilities in sub-Saharan Africa when referral is difficult.

OBJECTIVES: To quantify the main reasons for referral of infants and children from first-level health facilities to referral hospitals in sub-Saharan Africa and to determine what further supplies, equipment, and legal empowerment might be needed to manage such children when referral is difficult. METHODS: In an observational study at first-level health facilities in Uganda, the United Republic of Tanzania, and Niger, over 3-5 months, we prospectively documented the diagnoses and severity of diseases in children using the standardized Integrated Management of Childhood Illness (IMCI) guidelines. We reviewed the facilities for supplies and equipment and examined the legal constraints of health personnel working at these facilities. FINDINGS: We studied 7195 children aged 2-59 months, of whom 691 (9.6%) were classified under a severe IMCI classification that required urgent referral to a hospital. Overall, 226 children had general danger signs, 292 had severe pneumonia or very severe disease, 104 were severely dehydrated, 31 had severe persistent diarrhoea, 207 were severely malnourished, and 98 had severe anaemia. Considerably more ill were 415 young infants aged one week to two months: nearly three-quarters of these required referral. Legal constraints and a lack of simple equipment (suction pumps, nebulizers, and oxygen concentrators) and supplies (nasogastric tubes and 50% glucose) could prevent health workers from dealing more appropriately with sick children when referral was not possible. CONCLUSION: When referral is difficult or impossible, some additional supplies and equipment, as well as provision of simple guidelines, may improve management of seriously ill infants and children.