Using evidence to inform response to the 2017 plague outbreak in Madagascar: a view from the WHO African Regional Office.

The 2017 plague outbreak in Madagascar was unprecedented in the African region, resulting in 2417 cases (498 confirmed, 793 probable and 1126 suspected) and 209 deaths by the end of the acute urban pneumonic phase of the outbreak. The Health Emergencies Programme of the WHO Regional Office for Africa together with the WHO Country Office and WHO Headquarters assisted the Ministry of Public Health of Madagascar in the rapid implementation of plague prevention and control measures while collecting and analysing quantitative and qualitative data to inform immediate interventions. We document the key findings of the evidence available to date and actions taken as a result. Based on the four goals of operational research - effective dissemination of results, peer-reviewed publication, changes to policy and practice and improvements in programme performance and health - we evaluate the use of evidence to inform response to the outbreak and describe lessons learned for future outbreak responses in the WHO African region. This article may not be reprinted or reused in any way in order to promote any commercial products or services.

Virology. Mutation rate and genotype variation of Ebola virus from Mali case sequences.

The occurrence of Ebola virus (EBOV) in West Africa during 2013-2015 is unprecedented. Early reports suggested that in this outbreak EBOV is mutating twice as fast as previously observed, which indicates the potential for changes in transmissibility and virulence and could render current molecular diagnostics and countermeasures ineffective. We have determined additional full-length sequences from two clusters of imported EBOV infections into Mali, and we show that the nucleotide substitution rate (9.6 × 10(-4) substitutions per site per year) is consistent with rates observed in Central African outbreaks. In addition, overall variation among all genotypes observed remains low. Thus, our data indicate that EBOV is not undergoing rapid evolution in humans during the current outbreak. This finding has important implications for outbreak response and public health decisions and should alleviate several previously raised concerns.

[Malaria knowledge, attitudes and practices among women living in the rural area of Poponguine, Senegal]. / Connaissances, attitudes et pratiques des femmes sur le paludisme, dans la zone rurale de Poponguine, Sénégal.

Malaria is a major public health and development problem in Senegal where it is the leading cause of morbidity and mortality. Children under five and pregnant women are the most vulnerable groups. The purpose of this transverse, descriptive, analytical study was to assess rural women's knowledge, attitudes and practices regarding malaria. It was conducted in the Poponguine district of Senegal from April 1 to 15, 2005. The estimated population size needed for this cluster survey was 800. Women between the ages of 15 and 45 years who had been living in the district for more than one year were recruited for study. The mean age of the population was 28 years (95% confidence interval, 27.7 - 28.8). Teenagers accounted for over one eighth of the population (13.75%) and three fourths (75.87%) were married. Almost half (49.6%) were attending school and nearly two thirds (65.5%) were classified at the low socioeconomic level. Most (82.25%) knew that mosquitoes transmitted malaria and that the main signs were fever or warm body (82.25% and 81% respectively). However knowledge about the clinical features of severe malaria was poor. Geographical and financial access to IB was good for most of the women interviewed. Over half had a good understanding of preventive strategies for children less than five years of age and pregnant women, i.e., use of insecticide-treated nets (ITN) (62.9%) and of intermittent preventive therapy (IPT) during pregnancy (52.4%). Most (92%) declared that they would go to the health center for care in case of malaria. The main sources of information were medical personal (60.4%) or community volunteers (62,9%). Coverage for ITN and IPT was 33% and 71.1% respectively. There was a good correlation between good knowledge and practices (p<0.05). The main predictors of good knowledge were age and level of education. Practices by mothers were correlated with age, source of income, and marital status. Based on the findings of the study our recommendations for the Poponguine district are in agreement with those of the national malaria control program, i.e., reinforcement of the behavior change program to improve public knowledge about malaria. Further study will be needed to gain more epidemiological insight.

Connaissances, attitudes et pratiques des femmes sur le paludisme, dans la zone rurale de Poponguine, Sénégal

Au Sénégal, le paludisme est un problème majeur de santé publique et de développement, car il représente la première cause de morbidité et de mortalité. Ce sont les enfants de 0-5 ans et les femmes enceintes qui sont les plus vulnérables. L'objectif est d'évaluer les connaissances, attitudes et pratiques des femmes en zone rurale sur le paludisme. Il s'agit d'une étude transversale, descriptive et analytique menée dans le district de Poponguine du 1er au 15 avril 2005. Il s'agissait d'une enquête en grappe. La taille de l'échantillon calculée était égale à 800. La population d'étude était constituée par des femmes vivant dans le district depuis plus de 1 an et âgées de 15 à 45 ans. L'âge moyen des femmes était de 28 ans, (intervalle de confiance à 95% = 27,7 ­ 28,8). Parmi ces femmes, 49,6% étaient scolarisées et 65,5% avaient un niveau socioéconomique faible. 82,25% savaient que le paludisme est dû à la piqûre d'un moustique. Le signe principal (la fièvre ou corps chaud) a été cité dans 81% des cas. Cependant les signes du paludisme grave n'étaient pas bien connus. Il existait une bonne connaissance des mesures préventives aussi bien chez l'enfant que chez la femme enceinte : la Moustiquaire Imprégnée (MI) (62,9%) et la pratique du Traitement Préventif Intermittent (TPI) lors de la grossesse (52,4%). Il existait une bonne accessibilité géographique et financière des femmes interrogées par rapport aux MI. Plus de la moitié des femmes interrogées (92%) disait avoir recours à la structure sanitaire en cas de grossesse et/ou pour un enfant suspect de paludisme. Le personnel de santé (60,4%) et les relais communautaires (62,9%) constituaient la principale source d'information. La couverture en MI était de 33% et le taux d'utilisation du TPI de 71,1%. Il existait une relation significative entre le niveau de connaissances et les pratiques (p < 0,05). Les facteurs déterminant les connaissances étaient l'âge et le niveau d'instruction. Les pratiques des mères étaient influencées par l'âge, la source de revenus et la situation matrimoniale. A l'issue de cette étude, nous recommandons, pour le district de Poponguine, en accord avec le programme national de lutte contre le paludisme de renforcer le programme de sensibilisation afin d'amener les populations à améliorer leur connaissance en matière de paludisme et à changer de comportement mais aussi de mener une enquête qualitative pour compléter cette étude épidémiologique

[Monitoring and evaluation of health care programs in Subsaharian Africa]. / Monitoring et évaluation des programmes de santé en Afrique subsaharienne.

The monitoring and evaluation is usually the weakest component of health programs in sub-Saharan Africa, what is undermining the sustainability of funding. The problems are complex and the weaknesses of the health systems are reflected on the monitoring and evaluation of specific programs. This paper gives an insight of the problems faced during field missions for monitoring and evaluation. The steps for building the M&E system have been reviewed and keys points for implementation have been provided.

Drug Resistance to AIDS; Tuberculosis and Malaria in the African Region

With just 10of the world population; sub-Saharan Africa has the highest burden of HIV/AIDS; tuberculosis and malaria in the world. Both access to and adequate utilization of eff ective treatment with quality-assured medicines are crucial for reducing the disease burden. However; eff orts to improve access to treatment are hampered by the development of HIV; TB and malaria drug resistance. This is a result of genetic mutations and is a major threat to control of HIV/AIDS; TB and malaria. HIV drug resistance can be minimized by good antiretroviral treatment (ART) programmes; removal of barriers to continuous access to ART and reduction of HIVtransmission. Recent surveys conducted at antenatal clinics in several countries in the African Region estimated that HIV resistance to all drug classes is less than 5. A global HIV drug resistance network established in 2001 supports countries in capacity building and guidance on standard procedures for monitoring HIV drug resistance. Multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB) are principally a result of inadequate or poorly administered treatment regimens. The new WHO Stop TB Strategy launched in 2006 identifies management of MDR-TB as a core component of TB control. The magnitude of MDR-TB in the African Region is still unknown. In 2007; 27 countries notifi ed MDR-TB cases; and six reported at least one case of XDR-TB. Following widespread resistance to chloroquine and sulphadoxine-pyrimethamine all malaria-endemic countries except two in the Region have changed the treatment policy to artemisinin-based combination therapy (ACT). The main method of monitoring antimalarial drug resistance is through therapeutic efficacy testing. Todate there has been no confi rmed resistance to ACTs in the African Region. Given the emergence and spread of resistance to HIV; TB and malaria drugs; the purpose of this paper is to describe the issues and challenges and propose a way forward with regard to the prevention and control of such resistance

[Barriers in the community management of child malaria in the city of Mékhé (Senegal)]. / Obstacles à la prise en charge communautaire du paludisme de l'enfant dans la ville de Mékhé (Sénégal).

In Senegal, governmental fight plan against malaria emphasizes the need to community actions, particularly for early treatment of child malaria at home. So, we carried out a cross sectional survey, to determine factors linked with treatment of child malaria at home. During February 2001, we had an interview with persons taking care of a child under five years. These persons were randomly chosen among population of a rural town. Their median age was 32 years, 90.5% of them were women, 77.8% were the mother of the child. Their level of knowledge about malaria was fair (hightest transmission period, promoting environmental factors); 85.1% quoted children as vulnerable group; for 85%, fever was chief sign of malaria. When the child had fever, 45% of them brought him to a health center and 44% gave him chloroquin; 67.5% related no harmful effects. But at the time of the survey, only 28.8% had chloroquin at home. Literacy was very linked with home care: literate persons knowed most frequently the way of transmission by mosquito bites (72.4% versus 52.9% p<10-4 OR=2.3[1.5-3.6]); they considered most frequently chloroquin as the malaria treatment (74% versus 60.1% p=.003 OR=1.8 [1.2-2.9]) ;they had more often chloroquin at home (35.4% versus 22.6% p=.004 OR=1.8 [1.1-2.9). In conclusion, chloroquin might be available at home. The high ratio of illiterate persons in the population taking care of children in Mekhe emphasizes the need to organize information, education and communication strategies, using persons coming from the same community. The real impact of literacy on knowledges, behaviours and practices of persons taking care of malarial child at home emphasizes the need of reinforcing it, especially for women.

[Malaria prevention in the army: experience in senegal]. / Prophylaxie du paludisme dans les armées: l'expérience du Sénégal.

The Senegalese army has acquired extensive experience in malaria prophylaxis in Sub-Saharan Africa. Until the early 90s, chloroquine-based drug prophylaxis was routinely administered during the transmission season. Currently this policy has been abandoned inside the country in favor of early treatment of infection. This change was made possible by the presence of qualified staff in all barracks. For extraterritorial interventions in Sub-Saharan Africa, drug prophylaxis is still used since most of the Senegalese population lives in the Sahelian zone without immunity to malaria and most host countries are in areas of high transmission. Treatment protocols have been defined in function of Plasmodium drug sensitivity in each country. For all West African nations except Nigeria, the protocol involves a combination of choroquine and proguanil at a dose of 300 mg per week and 200 mg per day respectively. For Central African nations in the south and east as well as for Nigeria, either mefloquine at a dose of 250 mg per week or doxycycline at a dose of 100 mg per day are used. Although acceptance has been slow, use of impregnated bednets is now an integral part of the prevention strategy. The insecticide used inside the country is deltametrin, but other products may be used during extraterritorial operations depending on vector sensitivity in the facilities host country. Vector control by spraying of insectides in and eliminating larval deposits is also an important part of the prevention strategy used by the Senegalese army which maintains a mobile unit for that purpose.