The Effort to Attain Measles Pre-elimination Targets by 2012 and to Eliminate Measles in the African Region by 2020

Reduction in measles mortality contributes significantly towards attaining the Millennium Development Goal 4 (MDG 4); which aims to reduce overall under-five childhood deaths by two thirds by 2015; compared with 1990 levels. Routine measles immunization coverage is a key indicator for measuring progress towards attainment of this goal. Implementation of measles mortality reduction strategies in the African Region has led to major achievements; notably a reduction of estimated measles deaths by 92between 2000 and 2008. Despite the progress made; renewed commitment by countries is required to attain the pre-elimination targets and subsequently reach the ultimate goal of measles elimination by 2020. Countries will need to strengthen their immunization systems through ensuring that quality immunization services reach the hard-to-reach populations in addition to scaling up implementation of proven approaches and strategies such as the Reaching-Every-District approach. Gaps in the mobilization of resources have had a negative impact on the ability of countries to attain and sustain a high level of routine immunization and supplemental immunization activities coverage. Countries will also need to adopt a stepwise approach towards achieving the measles elimination goal by 2020; beginning with the attainment by 2012 of the proposed pre-elimination targets

Monitoring community-directed treatment programmes for sustainability: lessons from the African Programme for Onchocerciasis Control (APOC).

Community-directed treatment is a relatively new strategy that was adopted in 1997 by the African Programme for Onchocerciasis Control (APOC), for large-scale distribution of ivermectin (Mectizan). Participatory monitoring of 39 of the control projects based on community-directed treatment with ivermectin (CDTI) was undertaken from 1998-2000, with a focus on process implementation of the strategy and the predictors of sustainability. Data from 14,925 household interviews in 2314 villages, 183 complete treatment records, 382 focus-group discussions, and the results of interviews with 669 community leaders, 757 trained community-directed drug distributors (CDD) and 146 health personnel (in 26 projects in four countries) were analysed. The data show that CDD dispensed ivermectin to 65.4% of the total population (71.2% of the eligible population), with no significant gender differences in coverage (P > 0.05). Treatment coverage ranged from 60.2% of the eligible subjects in Cameroon to 76.9% in Uganda. There was no significant relationship between the provision of incentives to CDD and treatment coverage (P > 0.05). The frequency of treatment refusal was highest in Cameroon (29.2%). Although most (72.1%) of the communities investigated selected their CDD on the basis of a community decision at a village meeting, only 37.9% chose their distribution period in the same way. There is clearly a need to improve communication strategies, to address the issues of absentees and refusals, to emphasise community ownership and to de-emphasise incentives for CDD. The investigation of the 'predictor indicators' of sustainability should enable APOC to understand the determinants of project performance and to initiate any appropriate changes in the programme.

The use of spatial analysis in mapping the distribution of bancroftian filariasis in four West African countries.

The geographical distribution of human infection with Wuchereria bancrofti was investigated in four West African countries (Benin, Burkina Faso, Ghana and Togo), using a commercial immunochromatographic test for filarial antigen. Efforts were made to cover each health-system implementation unit and to ensure no sampling point was >50 km from another, but otherwise the 401 study communities were selected at random. The aim was to enable spatial analysis of the data, to provide a prediction of the overall spatial relationships of the infection. The results, which were subjected to an independent random validation in Burkina Faso and Ghana, revealed that prevalence in the adult population of some communities exceeded 70% and that, over large areas of Burkina Faso, community prevalences were between 30% and 50%. Most of Togo, southern Benin and much of southern Ghana appeared completely free of the infection. Although there were foci on the Ghanaian coast with prevalences of 10%-30%, such high prevalences did not extend into coastal Togo or costal Benin. The prevalence map produced should be useful in prioritizing areas for filariasis control, identifying potential overlap with ivermectin-distribution activities undertaken by onchocerciasis-control programmes, and enabling inter-country and sub-regional planning to be initiated. The results indicate that bancroftian filariasis is more widely distributed in arid areas of Burkina Faso than hitherto recognized and that the prevalences of infection have remained fairly stable for at least 30 years. The campaign to eliminate lymphatic filariasis as a public-health problem in Africa will require significantly more resources (human, financial, and logistic) than previously anticipated.

Strengthening patient education for ORT services in the Central African Republic.

This paper describes the design and implementation of a health worker training program in diarrhea case management and its effect on patient education in health facilities in the Central African Republic (C.A.R.). In 1989, a facility-based assessment of health worker practices in managing diarrheal disease in children under 5 years of age documented serious deficiencies in patient education as performed by health workers. Based on these results, the Ministry of Health (MOH) designed an inservice training program that promoted education as an integral component of curative care. The training program was implemented in all five health regions of the country. An evaluation of the training's impact on the delivery of patient education indicated dramatic increases in the number of messages health workers communicated to mothers. This experience demonstrated that the patient education practices of health workers can be improved through inservice training that integrates the teaching of clinical and communication skills. Additional study in C.A.R. is needed to (1) further improve the quality of patient education for diarrhea and other childhood communicable diseases, (2) determine the impact of patient education on the care provided by mothers in the home following a clinic visit, and (3) assess how operational research can be conducted within the limitations of inservice training programs and routine clinical operations.

PIP: A 1989 facility-based assessment of health worker practices in managing diarrheal disease in children under age 5 years found that some health workers in the Central African Republic were not providing relevant quality information to patients. The Ministry of Health therefore designed an in-service training program to promote education as an integral component of curative care. The training program was implemented in all five health regions of the country and led to dramatic increases in the number of messages health workers communicated to mothers. The success of this training program shows that the patient education practices of health workers can be improved through in-service training which integrates the teaching of clinical and communication skills.

Avoiding missed opportunities for immunization in the Central African Republic: potential impact on vaccination coverage.

Quantified in the study are the extent of missed opportunities for immunization and the potential increases in vaccination coverage and timeliness that could be achieved by using all health centre visits to administer childhood vaccinations in the Central African Republic. The data were collected during a national vaccination coverage survey of 642 children aged 12-23 months from three areas: rural, urban, and the capital, Bangui. Dates of all vaccination visits and other health centre visits were obtained from combined vaccination/health cards. Nationwide, 70% of all opportunities for valid measles vaccination were missed. Of these, 28% occurred at visits when at least one vaccine was given, while 72% occurred at other health centre visits. If there had been no missed opportunities to administer all vaccinations due when at least one vaccine was given, the coverage would have increased from 53% to 67% for the diphtheria-pertussis-tetanus series, from 54% to 70% for measles, and from 34% to 59% for all antigens. If there had been no missed opportunities at any visit, the corresponding increases would have been to 70%, 76%, and 65%. For measles, 46% of the potential increase depends on recognizing that an earlier dose of the vaccine was invalid and on revaccinating. Days-at-risk for measles (after the age of 270 days) would have been reduced by a mean of 74 days per subject with a health card had no opportunities been missed. The method used serves as a valuable adjunct to evaluations of missed opportunities based on exit interviews at health facilities.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: The Central African Republic in 1986 initiated an accelerated immunization program which became fully operational in 1988. As part of the program, a policy of vaccinating eligible children at all health facility contacts was adopted. National surveys conducted in 1985 and 1989 indicated that there had been a substantial increase in vaccination coverage, but that immunizations were not being given at all visits on a widespread basis. The authors quantify the extent of these missed opportunities for immunization and the potential increases in vaccination coverage and timeliness which could be achieved if all health center visits were used to administer childhood vaccinations in the Central Africa Republic. Study data were collected during a national vaccination coverage survey of 642 children aged 12-23 months from rural and urban areas as well as Bangui, the capital. Dates of all vaccination and other health center visits were obtained from combined vaccination/health cards. Analysis found that 70% of all opportunities nationwide for valid measles vaccination were missed. Of these, 28% occurred at visits when at least one vaccine was given and 72% occurred at other health center visits. If there had been no missed opportunities to administer all vaccinations due when at least one vaccine was given, coverage would have increased from 53% to 67% for the diphtheria-pertussis-tetanus series, from 54% to 70% for measles, and from 34% to 59% for all antigens. If there had been no missed opportunities at any visit, the corresponding increases would have been 70%, 76%, and 65%, respectively. For measles, 46% of the potential increase depends on recognizing that an earlier dose of the vaccine was invalid and on revaccinating. Days at risk for measles after the age of 270 days would have been reduced by a mean of 74 days per subject with an health card had no opportunities been missed.

Propositions pour une stratégie alternative de lutte contre la trypanosomiase humaine africaine en Afrique Centrale

Autour de l'execution du Programme National de Lutte contre la Trypanosomiase en Republique Centrafricaine au cours de la periode 1990-1992 s'est instauree une reflexion valant proposition pour une approche strategique differente. La chaine de prospection alors utilisee reposait sur des methodes classiques de depistage immunologique; de recherche parasitologique et de traitement des trypanosomes averes. Un piegeage etait par ailleurs entrepris. En depit des contraintes habituelles; politiques et techniques; qui pesent sur les programmes de lutte; le Programme National a connu un deroulement satisfaisant pendant deux ans. Pourtant; du fait de la strategie utilisee dans le foyer hyper-endemique de Nola; de nombreux suspects immunologiques ne rentraient pas en traitement; en meme temps que restait stable l'incidence. La nouvelle strategie proposee consiste a instaurer un traitement pour tous les suspects immunologiques meme si la recherche parasitaire reste negative. L'inconvenient principal de cette approche se situe au niveau du traitement a la Pentamidine de sujets consideres a tort en phase I (faux positifs immunologiques). Le risque iatrogene discute est celui d'un diabete potentiellement induit. D'autres contraintes; logistiques; d'acceptabilite et de faisabilite doivent etre apprecies. Pourtant; face a un foyer hyper-endemique; il semble judicieux de proposer aux autorites nationales ce changement strategique

Characteristics of serogroup A Neisseria meningitidis strains isolated in the Central African Republic in February 1992.

A severe epidemic of serogroup A meningococcus meningitis occurred in the northwest Central African Republic from January to March 1992. Strains from 24 patients were characterized using serotyping, testing of susceptibility to antibiotics, and multilocus enzyme electrophoresis. In 23 of the 24 patients the causal strain was found to be 4:P1.9/clone III-1. These results indicate that such strains continue to spread in Africa and have taken hold in areas outside the "meningitis belt." This may be a consequence of changing climatic conditions.