Low use of artemisinin-based combination therapy for febrile children under five and barriers to correct fever management in Benin: a decade after WHO recommendation.

BACKGROUND: Artemisinin-based combination therapy (ACT), used to treat uncomplicated malaria cases, is one of the main strategies of malaria control and elimination. One of the main objectives of the Benin National Malaria Control Program's (NMCP) strategic plan is to ensure that at least 80% of uncomplicated malaria is treated with ACT within 24 h. Therefore, it was of great interest to measure whether the country case management of fever amongst children under five, adhered to the NMCP's strategic plan and look into the barriers to the use of ACT. METHODS: A cross-sectional survey based on a cluster and multi-stage sampling was conducted in two rural health districts in Benin. We recruited 768 and 594 children under five years were included in the northern and in the southern respectively. Data was collected on the general use of ACT and on the correct use of ACT that adheres to the NMCP's strategy, as well as the barriers that prevent the proper management of fever amongst children. To assess the certain predictors of ACT usage, logistic regression was used, while taking into account the cluster random effect. RESULTS: Among febrile children aged 6 to 59 months, 20.7% in the south and 33.9% in north received ACT. The correct use of ACT, was very low, 5.8% and in southern and 8.6% northern areas. Caregivers who received information on ACT were 3.13 time more likely in the south and 2.98 time more likely in the north to give ACT to their feverish child, PPR = 3.13[1.72-4.15] and PPR = 2.98 [2.72-3.11] respectively. Chloroquine and quinine, other malaria treatments not recommended by NMCP, were still being used in both areas: 12.3 and 3.3% in the south and 11.4 and 3.0% in the north. CONCLUSION: In Benin, the use and the correct use of ACT for febrile children remains low. The study also showed that having received information about the use of ACT is positively associated with the use of ACT. This point highlights the fact that efforts may not have been sufficiently integrated with social communication, which should be based on the behavioural determinants of populations.

[Prevalence and factors associated with cryptococcal antigenemia in HIV-infected patients in Cotonou/Benin]. / Prévalence de l'antigénémie cryptococcique et les facteurs associés chez les patients infectés par le VIH à Cotonou au Bénin.

OBJECTIVE: Determine the prevalence of cryptococcal antigenemia and associated factors in HIV-infected patients in Cotonou in order to introduce systematic screening in national guidelines. PATIENTS AND METHODS: This is a cross-sectional, descriptive and analytical study conducted from June to September 2015 in four outpatient treatment centers with adult patients infected with HIV, receiving or not antiretroviral treatment with a number of CD4≤200cell/µL and who have given their informed consent to participate in the study. For each enrolled patient, after signing the informed consent form, it was made a clinical examination and administration of a questionnaire to collect general information, treatment and biological data. Then a blood sample for counting CD4 lymphocytes and the search of cryptococcal antigenemia were done. RESULTS: In total, 355 patients were included in the study with a mean age of 40±10.2years. The overall prevalence of cryptococcal antigenemia is 1.7%. All patient with cryptococcal antigenemia have a CD4 count below 100cells/µL with a majority having CD4 count below 50cells/µL. Body mass index<18.5kg/m2, an alteration of the general condition with a CD4 lymphocyte counts<50cells/µL are the main factors associated with the occurrence of cryptococcal antigenemia. CONCLUSION: This pilot study showed a low prevalence of cryptococcal antigenemia in the study population, but higher in highly immuno-deficient patients with CD4 counts<50cells/µl. Given the results obtained, the introduction of routine screening among patients infected with HIV could be reserved to those with CD4 counts<50cells/µl.

[Place of vulvovaginal candidiasis in the lower genital tract infections and associated risk factors among women in Benin]. / Place des candidoses vulvo-vaginales au cours des infections génitales basses et facteurs de risque associés chez les femmes au Bénin.

OBJECTIVE: Determine the place of vulvo-vaginal candidiasis (VVC) in the lower genital infections and seek risk factors among women in Benin. PATIENTS AND METHODS: The study was conducted in the laboratory of mycology of Hôpital de la Mère et de l'Enfant Lagune (Homel) from 1st March to 31st July, 2013. It involved all the women who were asked a vaginal swab and gave their consent in written form. After administration of a questionnaire, the vaginal samples were collected with sterile cotton swabs for a test with potassium hydroxide, an estimation of vaginal pH, direct microscopic examination, fresh, and after a Gram stain and culture on Sabouraud-chloramphenicol, ordinary agar and fresh blood agar. RESULTS: One hundred and thirty-one women were included in the study period. Clinical signs were dominated by vaginal discharge (74.8%), followed by vulvar pruritus (51.9%) and dyspareunia (36.6%). Culture on Sabouraud was positive in 51 cases or 38.9%. Candida albicans was isolated in 96.1% of cases, against 3.9% of Candida glabrata. The risk factors involved were: pregnancy, antibiotics, synthetic underclothing and frequent wearing tight pants. In addition of Candida, Gardnerella vaginalis was found in 36.6% of samples with an association with C. albicans in 28.2% of cases. CONCLUSION: This study showed that vulvovaginal candidiasis is the leading cause of lower genital tract infections in women in Benin with involvement of several risk factors which research is needed to develop appropriate preventive measures.

[Epidemiology of urinary schistosomiasis among school children in Péhunco area, Northern Benin. Malacological survey]. / Épidémiologie de la schistosomose urinaire chez les enfants scolarisés de la commune de Péhunco dans le Nord Bénin: prospection malacologique.

Schistosomiasis is a public health problem in Benin but prevalence estimates vary widely. Parasitological (from May to September 2010) and malacological surveys (from September 2010 to June 2012) were conducted to determine the current status of urinary schistosomiasis among 1 585 schoolchildren from 18 primary schools of Péhunco area, North-West Benin, using two parasitological tests. Pupils were enrolled with a mean age of 11 years (from 7 to 16 years-old age) and 51.48% of them were girls. Urines samples were examined using both urine reagent strips and filtration method. Structured questionnaires were used to identify environmental and socio-economic factors. Malacological surveys were conducted to ascertain general freshwater snail diversity and specific diversity of the schistosome host snails. The results showed a general prevalence of 29.40% with boys (36.67%) significantly more affected than girls (22.55%). Among the 844 collected snails, 5 species freshwater snails were identified: two species known as potential schistosome intermediate host snails, Bulinus forskalii and B. globosus, and three species known as non-schistosome transmitting snails Lymnaea natalensis, Physa marmorata and Melanoides tuberculata. B. forskalii was a most largely distributed snail and none of snails were found naturally infected by schistosome. No freshwater snails were found naturally infected by schistosome.

[Evaluation of a rapid diagnostic test in the diagnosis of toxoplasmosis in pregnant women in Cotonou (Bénin)]. / Évaluation d'un test de diagnostic rapide pour le diagnostic de la toxoplasmose chez les femmes enceintes à Cotonou (Bénin).

The aim of the study was to evaluate the performance of the ImmunoComb® Toxo IgG and ImmunoComb® Toxo IgMassays (rapid diagnostic test) in the laboratory diagnosis of toxoplasmosis in pregnant women in Cotonou. We interviewed 266 pregnant women, who first answered an epidemiological questionnaire, and collected blood samples for measurement of IgG and IgM anti T. gondii antibodies with the ImmunoComb toxo assays and with the ARCHITECT CIMA method. The sensitivity, specificity, positive predictive values (PPV) and negative predictive values (NPV) were calculated to determine the performance of the rapid test. The seroprevalences of IgG against T. gondii by CIMA technique and rapid test were respectively 48.9% and 48.5%. The prevalence increased with age. Performances for IgG were: sensitivity 97%, specificity 100%, PPV 100%, NPV = 97.10%. For IgM, Sensitivity: 33.3% Specificity: 100%, PPV 100%, NPV = 99.2%. Seroprevalence obtained shows that about half of the study population is not immune against T. gondii and requires regular serological monitoring until delivery. According to these results, and given the needs of toxoplasmosis diagnosis on the field characterized by an important decrease of immunized women, this test may be recommended in the laboratory diagnosis of toxoplasmosis in peripheral levels of the health pyramid.

[Schistosomiasis and soil-transmitted helminthiasis among schoolchildren of Nikki and Pèrèrè, two northeastern towns of Benin]. / Schistosomose et géohelminthoses dans le nord-est du Bénin: cas des écoliers des communes de Nikki et de Pèrèrè

Infection with schistosomiasis and soil-transmitted helminthiasis are widespread in sub-Saharan Africa and the burden of disease associated with parasites is enormous. A study was performed to determine the transmission and prevalence of human schistosomiasis and soil-transmitted helminthiasis among school children of Nikki and Perere, two north eastern towns of Benin, bordering Republic of Nigeria. Parasitological investigations by urine filtration and Kato-Katz conducted on 1,344 school children indicated a mean prevalence of S. haematobium and S. mansoni 48.44% and 0%, respectively, in the children of Nikki area and 45.24% and 4.11% in Perere area. Only schoolchildren of Sonon locality were infected by S. mansoni with a mean prevalence rate of 36.24%. KatoKatz tests releaved five species of soil-transmitted helminths: Ankylostoma duodenale (8.16% and 6.73%), Ascaris lumbricoides (6.26% and 2.30%), Enterobius vermicularis (1.09% and 1.97%), Trichuris trichiura (1.97% and 1.90%) and Strongyloides stercoralis (2.04% and 0.99%), respectively, in the schoolchildren of Nikki and Perere areas. The malacological investigations carried out in the freshwater points of each visited locality highlighted the presence of four species of freshwater snails known as intermediate host of schistosome: Biomphalaria pfeifferi, Bulinus forskalii, B. globosus and B. truncatus.Two B. globosus and B. pfeifferi collected in Sonon locality were naturally infected by schistosome, indicated the importance of their two species of snail in schistosome transmission cycle.

[Assessment of a rapid diagnostic test and portable fluorescent microscopy for malaria diagnosis in Cotonou (Bénin)]. / Évaluation d'un test de diagnostic rapide et d'un microscope à fluorescence portable pour le diagnostic du paludisme à Cotonou (Bénin).

The aim of the study was to determine the accuracy of a rapid diagnostic test (SD Bioline Malaria Ag P.f/ Pan®) and fluorescent microscopy (CyScope®) in confirming presumptive malaria diagnosis in Cotonou. Thick blood smear was used as the reference technique for comparison. Testing was conducted on persons between the ages of 6 months and 70 years at two hospitals from June to October 2010. If malaria was suspected in the sample by the nurse based on clinical findings and sent to laboratory for confirmation, one thick smear, one rapid diagnostic test and one slide for the fluorescent microscopy were performed. All tests were read in hospital laboratories involved with the quality control of thick blood smear in the parasitology laboratory of National University Hospital of Cotonou. A total of 354 patients with clinical diagnosis of malaria were included. Malaria prevalence determined by thick smear, rapid diagnostic test and fluorescent microscopy was 22.8%, 25.4%, and 25.1% respectively. The sensitivity, specificity, positive and negative predictive values compared to the thick smears were 96.3, 95.6, 86.7, and 98.9% for rapid diagnostic test; and 97.5, 96.7, 89.8, and 99.27% for fluorescent microscopy. With these performances, these tests meet acceptability standards recommended by WHO for rapid tests (sensitivity > 95%). These two methods have advantages for the confirmation of malaria diagnosis in peripheral health structures that lack the resources to conduct diagnosis confirmation by the thick blood smear.

[A randomized clinical trial comparing the effectiveness and tolerability of artemisinine-naphthoquine (Arco®) and artemether-lumefantrine (Coartem®) in the treatment of uncomplicated malaria in Benin]. / Essai clinique randomisé comparant l'efficacité et la tolérance de la combinaison artémisinine-naphthoquine (Arco®) et artéméther-luméfantrine (Coartem®) dans le traitement du paludisme simple au Bénin.

The Ministry of Health recommended in Benin, since 2004, artemisinin-based combination, artemether-lumtefantrine (Coartem®), therapy for the treatment of uncomplicated malaria. To resolve the difficulties related to observance, we are interested in a new combination, artemisinin-naphthoquine (Arco®). A study was conducted to assess and compare the efficacy and tolerability of the fixed combination artemisinin (125 mg)-naphthoquine (50 mg), a single-dose drug, administered one day versus artemether (20 mg)-lumefantrine (120 mg).The clinical assessment was a single-blinded, two-arm, randomized trial comparing Arco® combination as a single-dose regimen and three-day regimen of Coartem® for the treatment of uncomplicated falciparum malaria, from july to october 2008 and may to september 2009, with 28 days of follow-up in children. PCR genotyping was used to classify re-infection or recrudescence. The primary outcome measures for efficacy were cure rates on days 3, 7, 14, 21 and 28. Secondary outcomes included parasite clearance time and fever clearance time. The main outcome measures for safety were incidences of post-treatment clinical and laboratory adverse events. A total of 174 patients (84 in Arco® group and 90 in Coartem® group) were evaluated for clinical and parasitological outcomes. The cure rate was 98.8% for Arco® and 100% for Coartem® on day 28, with no statistically significant difference. Fever clearance was obtained within 24 hours in both groups. The parasite clearance is obtained at 48 hours in Arco® group and at 60 hours in Coartem® group. Both treatments were well tolerated without major side effects. This study therefore concluded that the combination of artemisinin-naphthoquine is as effective and well tolerated as the combination artemether-lumefantrine in the treatment of uncomplicated malaria in Benin children. This medication administered in single dose is therapy of choice to reduce compliance problems during malaria treatment and also to facilitate community-based care of malaria.

[Evaluation of the quality of malaria management during the transition period of political change in Benin]. / Evaluation de la qualité de la prise en charge des paludismes au cours de la période de transition de changement de politique au Bénin.

The purpose of this retrospective study in 2006 was to evaluate the impact of control activities implemented within the framework of "Roll Back Malaria (RBM) program" on the medical indicators. Study was based on review of the files of children between 0 and 14 years treated in pediatric outpatient or hospital facilities for malaria confirmed by the thick drop smears from January 1, 2001 to December 31, 2005. A total of 1589 files were reviewed. Data was collected using a standardized form. From 2001 to 2005, the number of children treated for uncomplicated malaria seesawed while the number treated for complicated malaria increased. Proper treatment of uncomplicated malaria went from 58.78% in 2001 to 15.38% in 2005. In all study years, quinine was the most-used drug for uncomplicated malaria. Treatment of complicated malaria also improved from 40% in 2001 to 90.61% in 2005. Although malaria-related mortality remained low (< 2%), the death rate increased from 2001 to 2005. Proper treatment of uncomplicated malaria still poses a challenge using quinine indicated in complicated malaria cases. Based on these findings, it appears urgent for the MNCP to intensify training activities at the medical facilities. This is the only means of achieving the strategic goals of "initiative RBM".

[Laboratory testing including CD4 T-cell count and determination of viral load to evaluate the impact of first line antiretroviral treatment at 6 months in adults in Benin]. / Evaluation de l'efficacité du traitement anti-rétroviral par analyse des charges virales au Bénin.

The purpose of this study was to determine lymphocyte CD4 T-cell count and circulating HIV-1 RNA load in HIV-infected adults starting first line antiretroviral treatment according to the revised 2006 WHO recommendations in Cotonou, Benin. A total of 1209 adults treated mainly by lamivudine/stavudine/nevirapine, were prospectively included between November 2006 and June 2007. CD4 T-cell counts and HIV viral load (measured by branched DNA assay, Siemens, Tarytown, New York, USA) were evaluated at 6 months of treatment. Mean CD4 T-cell count showed a marked increase at six months of treatment (93/mm3 at baseline versus 387/mm3 at 6 months) with 65.2% of patients reaching a CD4 T-cell level higher than 200/mm3 and 34.8% showing CD4 T-cell counts lower than 200/mm3. At 6 months, HIV 1 viral load was undetectable (<2.70 log10 copies/ml) in only 54 patients (16.7%), detectable but lower than 3.0 log10 copies/ml in 522 (73%) patients, and high, i.e., still greater than 3.7 log10 copies/ml in 188 (27%) patients. After 18 months of follow up, 499 patients (41.3%) had undetectable circulating viral load. The three main findings of this study are that at 6 months of antiretroviral treatment i) one-third of patients remained at risk for opportunistic infection (CD4<200/mm3), ii) one-fourth met criteria for virological failure (> 5000 copies/ml), and iii) concordance between immunological and virological responses was frequent but discordance responses were observed in more than 10% of patients. Taken together, these findings underline the need to improve compliance and laboratory follow-up in patients undergoing antiretroviral therapy in Africa.

[Management of malaria in Benin: evaluation of the practices of healthcare professionals following the introduction of artemisinin derivatives]. / Prise en charge du paludisme au Bénin: évaluation des pratiques professionnelles suite à l'introduction des dérives d'artémisinine.

In 2004 the policy for malaria management in Benin changed when the National Malaria Coordination Program (NMCP) introduced artemisinin-based combination therapy (ACT) for treatment of uncomplicated malaria. Up to that time, chloroquine had been used for first-line therapy against uncomplicated malaria and sulfadoxine pyrimethamine had been used in case of failure. Artemisinin derivatives have been used for monotherapy in Benin since 2002. The purpose of this transverse study carried out among public and private centers in Cotonou from March 16 to May 17, 2005 was to determine the impact of the switch to ACT on the practices of healthcare professionals. Medical centers were randomly selected from each stratum after identification and stratification of all facilities in the healthcare pyramid. A survey questionnaire was sent to healthcare workers. A total of 690 health workers responded to the questionnaire. Most responders (95.5%) were familiar with artemisinin but a lower percentage (89.6%) prescribed them. Responders were less knowledgable about ACT drugs and Coartem was the best known combination in the minds of prescribers. Biological diagnosis was available for 50% of patients. Artemisinine (derivates) were mainly prescribed as a second choice treatment and as monotherapy whether for severe or uncomplicated malaria. They were prescribed to pregnant women in 34.6% of the cases. Dosage was incorrect in 26.1% of cases in adults and 20.9% of cases in children. These findings indicate that more effort is needed to inform healthcare workers. This is especially urgent since the country is now considering revising its malaria management policy to make ACT available at all levels of the healthcare system. An effective information campaign must be set up to ensure that health workers and drug retailers throughout the country are duly informed of the new malaria treatment policy.

Prise en charge du paludisme au Benin : evaluation des pratiques professionnelles suite a l'introduction des derives d'artemisinine

la politique de prise en charge du paludisme au Benin a change en 2004 par l'introduction des combinaisons therapeutiques a base d'artemisinine (CTA) par le Programme National de Lutte contre le Paludisme (PNLP) pour le traitement du paludisme simple. Avant cette date; la chloroquine etait le medicament de premiere intention de prise en charge du paludisme simple avec la sulfadoxine pyrimethamine en cas d'echec. Par ailleurs; les derives d'artemisinine etaient utilises en monotherapie au Benin depuis 2002. Afin d'etudier l'evolution des comportements therapeutiques de prise en charge du paludisme par les agents de sante; une etude transversale a ete realisee aupres du personnel de sante du secteur public et prive de la ville de Cotonou du 16 mars au 17 mai 2005. Les formations sanitaires ont ete tirees au sort dans chaque strate apres recensement et stratification de toutes les formations sanitaires selon la pyramide sanitaire. L'enquete a utilise un questionnaire adresse aux agents de sante. Au total 690 agents de sante ont ete enquetes. Les derives de l'artemisinine sont connus de 95;5des agents de sante enquetes mais ne sont prescrits que par 89;6d'entre eux. Les CTA sont moins connues et le Coartemr reste la combinaison la mieux connue des prescripteurs. Un diagnostic biologique etait disponible dans la moitie des cas. Les derives de l'Artemisinine sont prescrits surtout en deuxieme intention et en monotherapie que ce soit pour le traitement du paludisme simple ou du paludisme grave. Ils sont prescrits chez la femme enceinte dans 34;6des cas. Les posologies sont incorrectes dans 26;1des cas chez l'adulte et dans 20;9des cas chez l'enfant. Ces resultats justifient l'intensification de la formation des agents de sante; d'autant plus que le pays envisage dans le cadre du changement de sa politique de prise en charge du paludisme; de rendre disponible les CTA a tous les niveaux de la pyramide sanitaire. Un systeme de communication efficace doit etre mis en place en vue d'une large diffusion de la nouvelle politique de traitement

Analyse de la situation des parasitoses en milieu scolaire à Dangbo au Bénin

Dans le cadre de la mise en œuvre d'une stratégie de lutte intégrée contre les parasitoses en milieu scolaire, une étude transversale et descriptive a été réalisée dans la commune de Dangbo. L'objectif est de faire une analyse de la situation des parasitoses (paludisme, bilharziose uro génitale, géohelminthioses) chez les enfants d'âge scolaire. Patients et méthodes : L'approche par questionnaire a été utilisée auprès des élèves de huit écoles âgés de 7 à 12 ans. Des prélèvements de sang, de selles et des urines ont été effectués pour la réalisation d'une goutte épaisse, d'un examen d'urines par filtration ainsi qu'un examen des selles par la technique de KATO- KATZ. Résultats : La prévalence globale des parasitoses est de 74,80%. La parasitose la plus fréquente est la bilharziose (58,18%) suivie du paludisme (40,30%) et enfin des parasitoses intestinales (2,27). Le paludisme demeure la parasitose dont les signes et les moyens de prévention sont les mieux connus. Parmi les facteurs favorisants, nous pouvons citer, la nature de l'eau utilisée, la mauvaise connaissance des causes et des moyens de prévention des parasitoses, la défécation et l'élimination des urines dans la nature, le milieu écologique. Conclusion : Cette étude suggère la mise en place d'une stratégie intégrée de lutte prenant en compte des séances d'Information, Education, Communication sur l'aménagement et l'assainissement du milieu, les causes et les mesures de prévention afin de réduire la prévalence de ces parasitoses en milieu scolaire et dans la communauté