Health services uptake among nomadic pastoralist populations in Africa: A systematic review of the literature.

The estimated 50 million nomadic pastoralists in Africa are among the most "hard-to-reach" populations for health-service delivery. While data are limited, some studies have identified these communities as potential disease reservoirs relevant to neglected tropical disease programs, particularly those slated for elimination and eradication. Although previous literature has emphasized the role of these populations' mobility, the full range of factors influencing health service utilization has not been examined systematically. We systematically reviewed empirical literature on health services uptake among African nomadic pastoralists from seven online journal databases. Papers meeting inclusion criteria were reviewed using STROBE- and PRISMA-derived guidelines. Study characteristics were summarized quantitatively, and 10 key themes were identified through inductive qualitative coding. One-hundred two papers published between 1974-2019 presenting data from 16 African countries met our inclusion criteria. Among the indicators of study-reporting quality, limitations (37%) and data analysis were most frequently omitted (18%). We identified supply- and demand-side influences on health services uptake that related to geographic access (79%); service quality (90%); disease-specific knowledge and awareness of health services (59%); patient costs (35%); contextual tailoring of interventions (75%); social structure and gender (50%); subjects' beliefs, behaviors, and attitudes (43%); political will (14%); social, political, and armed conflict (30%); and community agency (10%). A range of context-specific factors beyond distance to facilities or population mobility affects health service uptake. Approaches tailored to the nomadic pastoralist lifeway, e.g., that integrated human and veterinary health service delivery (a.k.a., "One Health") and initiatives that engaged communities in program design to address social structures were especially promising. Better causal theorization, transdisciplinary and participatory research methods, clearer operational definitions and improved measurement of nomadic pastoralism, and key factors influencing uptake, will improve our understanding of how to increase accessibility, acceptability, quality and equity of health services to nomadic pastoralist populations.

Sputum culture conversion as a prognostic marker for end-of-treatment outcome in patients with multidrug-resistant tuberculosis: a secondary analysis of data from two observational cohort studies.

BACKGROUND: Sputum culture conversion is often used as an early microbiological endpoint in phase 2 clinical trials of tuberculosis treatment on the basis of its assumed predictive value for end-of-treatment outcome, particularly in patients with drug-susceptible tuberculosis. We aimed to assess the validity of sputum culture conversion on solid media at varying timepoints, and the time to conversion, as prognostic markers for end-of-treatment outcome in patients with multidrug-resistant (MDR) tuberculosis. METHODS: We analysed data from two large cohort studies of patients with MDR tuberculosis. We defined sputum culture conversion as two or more consecutive negative cultures from sputum samples obtained at least 30 days apart. To estimate the association of 2 month and 6 month conversion with successful treatment outcome, we calculated odds ratios (ORs) and 95% CIs with random-effects multivariable logistic regression. We calculated predictive values with bivariate random-effects generalised linear mixed modelling. FINDINGS: We assessed data for 1712 patients who had treatment success, treatment failure, or who died. Among patients with treatment success, median time to sputum culture conversion was significantly shorter than in those who had poor outcomes (2 months [IQR 1-3] vs 7 months [3 to ≥24]; log-rank p<0·0001). Furthermore, conversion status at 6 months (adjusted OR 14·07 [95% CI 10·05-19·71]) was significantly associated with treatment success compared with failure or death. Sputum culture conversion status at 2 months was significantly associated with treatment success only in patients who were HIV negative (adjusted OR 4·12 [95% CI 2·25-7·54]) or who had unknown HIV infection (3·59 [1·96-6·58]), but not in those who were HIV positive (0·38 [0·12-1·18]). Thus, the overall association of sputum culture conversion with a successful outcome was substantially greater at 6 months than at 2 months. 2 month conversion had low sensitivity (27·3% [95% confidence limit 16·6-41·4]) and high specificity (89·8% [82·3-94·4]) for prediction of treatment success. Conversely, 6 month sputum culture conversion status had high sensitivity (91·8% [85·9-95·4]), but moderate specificity (57·8% [42·5-71·6]). The maximum combined sensitivity and specificity for sputum culture conversion was reached between month 6 and month 10 of treatment. INTERPRETATION: Time to sputum culture conversion, conversion status at 6 months, and conversion status at 2 months in patients without known HIV infection can be considered as proxy markers of end-of-treatment outcome in patients with MDR tuberculosis, although the overall association with treatment success is substantially stronger for 6 month than for 2 month conversion status. Investigators should consider these results regarding the validity of sputum culture conversion at various timepoints as an early predictor of treatment efficacy when designing phase 2 studies before investing substantial resources in large, long-term, phase 3 trials of new treatments for MDR tuberculosis. FUNDING: US Agency for International Development, US Centers for Disease Control and Prevention, Division of Intramural Research of the US National Institute of Allergy and Infectious Diseases, Korea Centers for Disease Control and Prevention.

An evaluation of polio supplemental immunization activities in Kano, Katsina, and Zamfara States, Nigeria: lessons in progress.

BACKGROUND: As 1 of 3 remaining poliovirus-endemic countries, Nigeria has become key to the global polio eradication effort. We evaluated supplemental immunization activities, including team performance, communications/mobilization activities, and vaccine acceptance, in 3 high-risk states. METHODS: We used structured survey and observation instruments, document review, and stakeholder interviews. RESULTS: Observations or surveys were conducted at 1697 households. Vaccine acceptance ranged from 87%-94%; among households rejecting polio vaccine, 38% of mothers sought measles vaccine for their children. Teams performed between 4%-42% of assigned tasks. CONCLUSIONS: Acceptance is high but teams have a critical role in surmounting residual vaccine resistance.

Using geographic information systems to track polio vaccination team performance: pilot project report.

The application of geospatial data to public health problems has expanded significantly with increased access to low-cost handheld global positioning system (GPS) receivers and free programs for geographic information systems analysis. In January 2010, we piloted the application of geospatial analysis to polio supplementary immunization activities (SIAs) in northern Nigeria. SIA teams carried GPS receivers to compare hand-drawn catchment area route maps with GPS tracks of actual vaccination teams. Team tracks overlaid on satellite imagery revealed that teams commonly missed swaths of contiguous households and indicated that geospatial data can improve microplanning and provide nearly real-time monitoring of team performance.

Predictors of poor outcomes among patients treated for multidrug-resistant tuberculosis at DOTS-plus projects.

The Objective of this analysis was to identify predictors of death, failure, and default among MDR-TB patients treated with second-line drugs in DOTS-plus projects in Estonia, Latvia, Philippines, Russia, and Peru, 2000-2004. Risk ratios (RR) with 95% confidence intervals (CI) were calculated using multivariable regression. Of 1768 patients, treatment outcomes were: cure/completed - 1156 (65%), died - 200 (11%), default - 241 (14%), failure - 118 (7%). Independent predictors of death included: age>45 years (RR = 1.90 (95%CI 1.29-2.80), HIV infection (RR = 4.22 (2.65-6.72)), extrapulmonary disease (RR = 1.54 (1.04-2.26)), BMI<18.5 (RR = 2.71 (1.91-3.85)), previous use of fluoroquinolones (RR = 1.91 (1.31-2.78)), resistance to any thioamide (RR = 1.59 (1.14-2.22)), baseline positive smear (RR = 2.22 (1.60-3.10)), no culture conversion by 3rd month of treatment (RR = 1.69 (1.19-2.41)); failure: cavitary disease (RR = 1.73 (1.07-2.80)), resistance to any fluoroquinolone (RR = 2.73 (1.71-4.37)) and any thioamide (RR = 1.62 (1.12-2.34)), and no culture conversion by 3rd month (RR = 5.84 (3.02-11.27)); default: unemployment (RR = 1.50 (1.12-2.01)), homelessness (RR = 1.52 (1.00-2.31)), imprisonment (RR = 1.86 (1.42-2.45)), alcohol abuse (RR = 1.60 (1.18-2.16)), and baseline positive smear (RR = 1.35 (1.07-1.71)). Patients with biomedical risk factors for treatment failure or death should receive heightened medical attention. To prevent treatment default, management of patients who are unemployed, homeless, alcoholic, or have a prison history requires extra measures to insure treatment completion.

Drug-resistant tuberculosis in sub-saharan Africa.

Drug-resistant tuberculosis (DRTB) is an emerging infectious disease threat to sub-Saharan Africa (SSA), particularly in the regions hit hardest by the HIV epidemic. Numerous challenges face clinicians and public health officials tasked with combating DRTB in SSA. These include difficulties providing effective diagnosis, treatment, and prevention of this illness. Furthermore, combating DRTB requires addressing various legal and ethical complexities. A sustained commitment to investigating as well as implementing new diagnostic, therapeutic, and preventative interventions is essential to defeating this threat.

Dietary intake in infants and young children in the Marshall Islands.

Changes in traditional foodways associated with increasing modernization have affected the feeding patterns of infants and young children. Declines in the duration of exclusive breastfeeding have been associated with poor nutritional status and increased morbidity from infectious diseases. We conducted a cross-sectional survey of dietary intake in children under six in four settings in the Republic of the Marshall Islands in Micronesia. The mean duration of breastfeeding in the sample was 11 months, however only 16% of subjects were exclusively breastfed for the first six months, which is recommended by the WHO, UNICEF and other policymakers. Among non-exclusively breastfed infants, supplemental foods were introduced as early as 2 months. Mean intakes for total energy, protein, carbohydrates, fat and iron were calculated for subjects providing recalls. Intake levels for energy, protein, carbohydrates and iron varied by location. Recommendations for future research and program intervention are outlined.