Community Knowledge, Attitude, and Practices Regarding Mosquitoes and Mosquito-Borne Viral Diseases in Kinshasa, Democratic Republic of the Congo

BACKGROUND AND OBJECTIVES

Mosquito-borne viral diseases (MBVDs) create a dramatic health situation worldwide. There is a need to improve the understanding of factors to be addressed in intervention programmes. This study explored community knowledge, attitudes, and practices (KAP) regarding MBVD in Kinshasa.

MATERIALS AND METHODS

A cross-sectional survey was carried out between January and April 2019. The socio-demographic and KAP data collected through a questionnaire were analysed using Epi Info 7.

RESULTS

The study included 1464 male and female respondents aged from 18 to 70 years old. Open garbage cans and outdoor water storage units were found in 61.2% and 33.4% of respondent residences, respectively. Polluted water bodies (80.3%) were the most mentioned as mosquito breeding places. Among 86.6% of the respondents that had heard about yellow fever, 12% knew that it is an MBVD. The majority of respondents (72.5%) were perceived to be at risk of contracting MBVD. Environment sanitation (58%) and insecticide use (25%) were among the measures implemented to control mosquitoes. The greater overall knowledge score and attitude were not associated with good practice.

CONCLUSION

The residents of Kinshasa had limited knowledge of MBVD. Raising awareness and educational sessions are essential in empowering the community regarding the correct attitudes and practices to effectively manage the risk posed by MBVD.

Sustainable strategies for Ebola virus disease outbreak preparedness in Africa: a case study on lessons learnt in countries neighbouring the Democratic Republic of the Congo

BACKGROUND

From May 2018 to September 2022, the Democratic Republic of Congo (DRC) experienced seven Ebola virus disease (EVD) outbreaks within its borders. During the 10th EVD outbreak (2018-2020), the largest experienced in the DRC and the second largest and most prolonged EVD outbreak recorded globally, a WHO risk assessment identified nine countries bordering the DRC as moderate to high risk from cross border importation. These countries implemented varying levels of Ebola virus disease preparedness interventions. This case study highlights the gains and shortfalls with the Ebola virus disease preparedness interventions within the various contexts of these countries against the background of a renewed and growing commitment for global epidemic preparedness highlighted during recent World Health Assembly events.

MAIN TEXT

Several positive impacts from preparedness support to countries bordering the affected provinces in the DRC were identified, including development of sustained capacities which were leveraged upon to respond to the subsequent coronavirus disease 2019 (COVID-19) pandemic. Shortfalls such as lost opportunities for operationalizing cross-border regional preparedness collaboration and better integration of multidisciplinary perspectives, vertical approaches to response pillars such as surveillance, over dependence on external support and duplication of efforts especially in areas of capacity building were also identified. A recurrent theme that emerged from this case study is the propensity towards implementing short-term interventions during active Ebola virus disease outbreaks for preparedness rather than sustainable investment into strengthening systems for improved health security in alignment with IHR obligations, the Sustainable Development Goals and advocating global policy for addressing the larger structural determinants underscoring these outbreaks.

CONCLUSIONS

Despite several international frameworks established at the global level for emergency preparedness, a shortfall exists between global policy and practice in countries at high risk of cross border transmission from persistent Ebola virus disease outbreaks in the Democratic Republic of Congo. With renewed global health commitment for country emergency preparedness resulting from the COVID-19 pandemic and cumulating in a resolution for a pandemic preparedness treaty, the time to review and address these gaps and provide recommendations for more sustainable and integrative approaches to emergency preparedness towards achieving global health security is now.

Emergence and Evolutionary Response of Vibrio cholerae to Novel Bacteriophage, Democratic Republic of the Congo1

Cholera causes substantial illness and death in Africa. We analyzed 24 toxigenic Vibrio cholerae O1 strains isolated in 2015-2017 from patients in the Great Lakes region of the Democratic Republic of the Congo. Strains originating in southern Asia appeared to be part of the T10 introduction event in eastern Africa. We identified 2 main strain lineages, most recently a lineage corresponding to sequence type 515, a V. cholerae cluster previously reported in the Lake Kivu region. In 41% of fecal samples from cholera patients, we also identified a novel ICP1 (Bangladesh cholera phage 1) bacteriophage, genetically distinct from ICP1 isolates previously detected in Asia. Bacteriophage resistance occurred in distinct clades along both internal and external branches of the cholera phylogeny. This bacteriophage appears to have served as a major driver for cholera evolution and spread, and its appearance highlights the complex evolutionary dynamic that occurs between predatory phage and bacterial host.

Using Population Mobility Patterns to Adapt COVID-19 Response Strategies in 3 East Africa Countries

The COVID-19 pandemic spread between neighboring countries through land, water, and air travel. Since May 2020, ministries of health for the Democratic Republic of the Congo, Tanzania, and Uganda have sought to clarify population movement patterns to improve their disease surveillance and pandemic response efforts. Ministry of Health-led teams completed focus group discussions with participatory mapping using country-adapted Population Connectivity Across Borders toolkits. They analyzed the qualitative and spatial data to prioritize locations for enhanced COVID-19 surveillance, community outreach, and cross-border collaboration. Each country employed varying toolkit strategies, but all countries applied the results to adapt their national and binational communicable disease response strategies during the pandemic, although the Democratic Republic of the Congo used only the raw data rather than generating datasets and digitized products. This 3-country comparison highlights how governments create preparedness and response strategies adapted to their unique sociocultural and cross-border dynamics to strengthen global health security.

Association between Conflict and Cholera in Nigeria and the Democratic Republic of the Congo

Cholera outbreaks contribute substantially to illness and death in low- and middle-income countries. Cholera outbreaks are associated with several social and environmental risk factors, and extreme conditions can act as catalysts. A social extreme known to be associated with infectious disease outbreaks is conflict, causing disruption to services, loss of income, and displacement. To determine the extent of this association, we used the self-controlled case-series method and found that conflict increased the risk for cholera in Nigeria by 3.6 times and in the Democratic Republic of the Congo by 2.6 times. We also found that 19.7% of cholera outbreaks in Nigeria and 12.3% of outbreaks in the Democratic Republic of the Congo were attributable to conflict. Our results highlight the value of providing rapid and sufficient assistance during conflict-associated cholera outbreaks and working toward conflict resolution and addressing preexisting vulnerabilities, such as poverty and access to healthcare.

To parachute or not

This editorial was prompted by a criticism of our inability to identify all existing local oncologic human resources prior to the initiation of a women's cancer care platform in the Democratic Republic of the Congo. We discuss the act of parachuting, i.e., intermittent visits by investigators from high-income countries to low-and middle-income countries, its dichotomization (positive and negative), role in bilateral collaborations between high-income and low-and middle-income countries, contributing etiologies and potential harms. Lastly, we highlight our use of parachuting to successfully transfer breast and cervical cancer diagnostic and surgical skills to healthcare providers in a low-income African nation, while simultaneously building clinical infrastructure for women's cancers. We conclude with recommendations that pertain to the development of better research ecosystems in Africa.

Review of Neurosurgery in the Democratic Republic of Congo: Historical Approach of a Local Context

Neurosurgical practice in the Democratic Republic of Congo (DRC) is challenged by limited resources and infrastructure. The DRC has 16 local residing neurosurgeons for 95 million inhabitants, a ratio of 1 neurosurgeon per 5.9 million Congolese citizens. This is attributable to decades of political unrest and a loosely regulated health care system. Understanding the role of neurosurgery in a historical context is necessary to appreciate and overcome current challenges in the delivery of neurosurgical care. We describe past and present political, social, and economic challenges surrounding the development of neurosurgical practice and training. Highlights of early innovators, current challenges, and a suggested framework to guide future advances in neurosurgical practice are provided. Interviews with Dr. Antoine Beltchika Kalubye, the oldest living neurosurgeon in the DRC, and Dr. Jean-Pierre Kalala Okito, current president of the Congolese Society of Neurosurgery, provide a detailed account of events. Firsthand narrative was supplemented via literature review and collaboration with registrars in the DRC to review current neurosurgery programs. Our discussions revealed that decades of political unrest and inconsistent management of health care resources are responsible for the current state of healthcare, including the dearth of local neurosurgeons. The neurosurgery workforce deficit in the DRC remains substantial. It is essential to understand local neurosurgical history, in its present state and breadth of challenges, to inform future development of neurosurgical care and to secure equitable partnerships between local stakeholders and the international community.

A Qualitative Evaluation of COVID-19 Preventative Response Activities in South Kivu, Democratic Republic of the Congo

OBJECTIVE

In this evaluation of COVID-19 preventative response programs in South Kivu, Democratic Republic of the Congo (DRC), we aimed to explore community understandings of COVID-19, assess operational successes and challenges of COVID response activities, and identify barriers to practicing COVID-19 preventative behaviors.

METHODS

Thirty-one semi-structured interviews were conducted from April to September 2021 in South Kivu, DRC, with community members (n = 16) and programmatic stakeholders (n = 15) (healthcare providers, government officials, and developmental and NGO staff engaged in COVID-19 response).

FINDINGS

Most community members were aware of COVID-19 and its global burden, but few were aware of local transmission in their area. Some community members attributed COVID-19 to actions of malevolent neighbors, miasma ("bad air"), or spirits. Awareness of COVID-19 preventative measures was widespread, largely because of radio and TV health promotion programs. Community members and programmatic stakeholders both said community-level non-compliance to COVID-19 preventative measures was high despite high awareness of preventative methods. Community members expressed concern that face masks distributed as part of preventative programs contained the COVID-19 virus. Programmatic stakeholders emphasized the need for broader health system strengthening with improved coordination, provision of resources to health facilities at the provincial level, and prioritization of research. Lessons learned from addressing Ebola were leveraged for COVID-19 health promotion, rapid training of healthcare personnel, and surveillance.

CONCLUSIONS

Community-informed approaches are needed for effective COVID-19 preventative response programs in South Kivu, DRC. Our study identified successes and challenges in COVID-19 response activities. Future research should assess the effectiveness of integrating preventive programs with COVID-19 vaccination efforts.

Synophtalmia on a newborn

Synophtalmia or cyclopia is a rare presentation of alobar holoprosencephaly. Cases which have been reported are stillborn or dead in post-delivery period. We are presenting a 3000-g live full-term newborn girl delivered by caesarean section with a well-marked cyclopia, but who died 30 min post-delivery. The case did not present with other abnormalities. The literature showed that genetic disorders are associated with cyclopia. A prenatal anomaly scan can help in the early detection of the condition and timely termination of the pregnancy can be conducted.

Formative Research for the Development of Evidence-Based Targeted Water, Sanitation, and Hygiene Interventions to Reduce Cholera in Hotspots in the Democratic Republic of the Congo: Preventative Intervention for Cholera for 7 Days (PICHA7) Program

Compared to the general public, household members of cholera patients are at a 100 times higher risk of contracting cholera during the 7-day high-risk period after a cholera patient has been admitted to a health facility for treatment. The Preventative-Intervention-for-Cholera-for-7-days (PICHA7) program aims to reduce household transmission of cholera during this 7-day high-risk period through a health facility-initiated water, sanitation, and hygiene (WASH) program promoting handwashing with soap, water treatment, and safe water storage. The PICHA7 program is delivered to cholera patient households through: (1) a pictorial flipbook delivered by a health promoter; (2) a cholera prevention package (handwashing station, drinking water vessel with lid and tap, and chlorine tablets); and (3) weekly WASH mobile messages sent to patient households in the Democratic Republic of the Congo (DRC). The objectives of this study were to conduct formative research to identify facilitators and barriers of the promoted WASH behaviors for cholera patient households and to tailor the PICHA7 program to target these facilitators and barriers. Formative research included 93 semi-structured interviews with diarrhea patient households and healthcare workers during exploratory research and a pilot study of 518 participants. Barriers to the promoted WASH behaviors identified during exploratory and pilot study interviews included: (1) low awareness of cholera transmission and prevention; (2) unaffordability of soap for handwashing; and (3) intermittent access to water limiting water for handwashing. For intervention development, narratives of the lived experiences of patient households in our study were presented by health promoters to describe cholera transmission and prevention, and soapy water and ash were promoted in the program flipbook and mobile messages to address the affordability of soap for handwashing. A jerry can was provided to allow for additional water storage, and a tap with a slower flow rate was attached to the handwashing station to reduce the amount of water required for handwashing. The pilot findings indicate that the PICHA7 program has high user acceptability and is feasible to deliver to cholera patients that present at health facilities for treatment in our study setting. Formative research allowed for tailoring this targeted WASH program for cholera patient households in the DRC.

Slipping through the cracks: a qualitative study to explore pathways of HIV care and treatment amongst hospitalised patients with advanced HIV in Kenya and the Democratic Republic of the Congo

Advanced HIV causes substantial mortality in sub-Saharan Africa despite widespread antiretroviral therapy coverage. This paper explores pathways of care amongst hospitalised patients with advanced HIV in rural Kenya and urban Democratic Republic of the Congo, with a view to understanding their care-seeking trajectories and poor health outcomes. Thirty in-depth interviews were conducted with hospitalised patients with advanced HIV who had previously initiated first-line antiretroviral therapy, covering their experiences of living with HIV and care-seeking. Interviews were audio-recorded, transcribed and translated before being coded inductively and analysed thematically. In both settings, participants' health journeys were defined by recurrent, severe symptoms and complex pathways of care before hospitalisation. Patients were often hospitalised after multiple failed attempts to obtain adequate care at health centres. Most participants managed their ill-health with limited support networks, lived in fragile economic situations and often experienced stress and other mental health concerns. Treatment-taking was sometimes undermined by strict messaging around adherence that was delivered in health facilities. These findings reveal a group of patients who had "slipped through the cracks" of health systems and social support structures, indicating both missed opportunities for timely management of advanced HIV and the need for interventions beyond hospital and clinical settings.

Environmental Drivers of Monkeypox Transmission in the Democratic Republic of the Congo

Monkeypox (MPX) is an emergent severe zoonotic disease resembling that of smallpox. To date, most cases of human MPX have been reported in the Democratic Republic of the Congo (DRC). While the number of cases has increased steadily in the DRC over the last 30 years, the environmental risk factors that drive the spatiotemporal dynamics of MPX transmission remain poorly understood. This study aimed to investigate the spatiotemporal associations between environmental risk factors and annual MPX incidence in the DRC. All MPX cases reported weekly at the health zone level over a 16-year period (2000-2015) were analyzed. A Bayesian hierarchical generalized linear mixed model was conducted to identify the spatiotemporal associations between annual MPX incidence and three types of environmental risk factors illustrating environment as a system resulting from physical, social and cultural interactions Primary forest (IRR 1.034 [1.029-1.040]), economic well-being (IRR 1.038 [1.031-1.047]), and temperature (IRR 1.143 [1.028-1.261]) were positively associated with annual MPX incidence. Our study shows that physical environmental risk factors alone cannot explain the emergence of MPX outbreaks in the DRC. Economic level and cultural practices participate from environment as a whole and thus, must be considered to understand exposure to MPX risk Future studies should examine the impact of these factors in greater detail.

Reconsidering priorities for forest conservation when considering the threats of mining and armed conflict

Many threats to biodiversity can be predicted and are well mapped but others are uncertain in their extent, impact on biodiversity, and ability for conservation efforts to address, making them more difficult to account for in spatial conservation planning efforts, and as a result, they are often ignored. Here, we use a spatial prioritisation analysis to evaluate the consequences of considering only relatively well-mapped threats to biodiversity and compare this with planning scenarios that also account for more uncertain threats (in this case mining and armed conflict) under different management strategies. We evaluate three management strategies to address these more uncertain threats: 1. to ignore them; 2. avoid them; or 3. specifically target actions towards them, first individually and then simultaneously to assess the impact of their inclusion in spatial prioritisations. We apply our approach to the eastern Democratic Republic of the Congo (DRC) and identify priority areas for conserving biodiversity and carbon sequestration services. We found that a strategy that avoids addressing threats of mining and armed conflict more often misses important opportunities for biodiversity conservation, compared to a strategy that targets action towards areas under threat (assuming a biodiversity benefit is possible). We found that considering mining and armed conflict threats to biodiversity independently rather than simultaneously results in 13 800-14 800 km² and 15 700-25 100 km² of potential missed conservation opportunities when undertaking threat-avoiding and threat-targeting management strategies, respectively. Our analysis emphasises the importance of considering all threats that can be mapped in spatial conservation prioritisation.

Mental distress before and during the COVID-19 pandemic: A longitudinal study among communities affected by Ebola virus disease in the DR Congo

BACKGROUND

Associated with high mortality rate, fear, and anxiety, Ebola Virus Disease (EVD) is a significant risk factor for mental distress. This longitudinal study aims to investigate the prevalence and predictors associated with mental distress among populations affected by EVD outbreaks in the Province of Equateur in DR Congo.

METHODS

Surveys were administered in zones affected by the 2018 EVD outbreak in Equateur Province with a 16-month interval. Measures assessed sociodemographic characteristics, mental distress (GHQ-12), COVID-19 and EVD exposure and related stigmatization, and Resilience. Models of logistic regression and path analysis were used to estimate factors related to mental distress outcomes.

RESULTS

Prevalence of mental distress decreased from Wave 1 to Wave 2 (Mental distress_T1= 57.04%, Mental distress_T2= 40.29%, x²= 23.981, p<.001). Clinical mental distress score at follow-up was predicted by greater levels of exposure to Ebola at baseline (B= .412, p<.001) and at Wave 2 (B= .453, p<.001) as well as Ebola stigmatization at baseline (B= .752, p<.001), and Protestant religion (B= .474, p=.038). Clinical mental distress score at follow-up was significantly associated with higher levels of exposure to COVID-19 (B= .389, p=.002) and COVID-19 related stigmatization (B= .480, p<.001). COVID-19 related stigmatization partially mediated the association between exposure to EVD (Time 1) and mental distress (B= .409, p<.001).

CONCLUSIONS

Although a decrease in mental distress symptoms was observed, its prevalence remains high. The results show that mental health programs need to develop better health and education communication strategies to reduce stigmatization.

Genetic and Structural Variation in the O-Antigen of Salmonella enterica Serovar Typhimurium Isolates Causing Bloodstream Infections in the Democratic Republic of the Congo

Salmonella enterica serovar Typhimurium causes a devastating burden of invasive disease in sub-Saharan Africa with high levels of antimicrobial resistance. No licensed vaccine is available, but O-antigen-based candidates are in development, as the O-antigen moiety of lipopolysaccharides is the principal target of protective immunity. The vaccines under development are designed based on isolates with O-antigen O-acetylated at position C-2 of abequose, giving the O:5 antigen. Serotyping data on recent Salmonella Typhimurium clinical isolates from the Democratic Republic of the Congo (DRC), however, indicate increasing levels of isolates without O:5. The importance and distribution of this loss of O:5 antigen in the population as well as the genetic mechanism responsible for the loss and chemical characteristics of the O-antigen are poorly understood. In this study, we Illumina whole-genome sequenced 354 Salmonella Typhimurium isolates from the DRC, which were isolated between 2002 and 2017. We used genomics and phylogenetics combined with chemical approaches (¹H nuclear magnetic resonance [NMR], high-performance anion-exchange chromatography with pulsed amperometric detection [HPAEC-PAD], high-performance liquid chromatography–PAD [HPLC-PAD], and HPLC-size exclusion chromatography [HPLC-SEC]) to characterize the O-antigen features within the bacterial population. We observed convergent evolution toward the loss of the O:5 epitope predominantly caused by recombination events in a single gene, the O-acetyltransferase gene oafA. In addition, we observe further O-antigen variations, including O-acetylation of the rhamnose residue, different levels of glucosylation, and the absence of O-antigen repeating units. Large recombination events underlying O-antigen variation were resolved using long-read MinION sequencing. Our study suggests evolutionary pressure toward O-antigen variants in a region where invasive disease by Salmonella Typhimurium is highly endemic. This needs to be taken into account when developing O-antigen-based vaccines, as it might impact the breadth of coverage in such regions.

New species of the genus Chimarra Stephens from Africa (Trichoptera, Philopotamidae) and characterization of the African groups and subgroups of the genus

This paper is primarily based on collections in Tanzania and Ghana in 1990-1991 and 1991-1994, respectively. In all, 46 species of Chimarra were collected, 31 of them new species. All these species are illustrated or re-illustrated and described in the paper. Additionally, five species from Africa from collections in Illinois and Minnesota, four of them new, are included. This provided the incentive to review the species of Chimarra from the African subregion and assign the majority of them to species groups and subgroups. In the process, several species were synonymized. In all 147 valid species are recognized, of which 51 are treated in this paper. Two major species groups are recognized for Africa, the marginata Group and the georgensis Group. The former is based on the type species for the genus; this is the first formal characterization of this group, as distinct from other species groups in the subgenus. Mainland African species in the marginata Group mostly fall into four large species-diverse subgroups, but a number of smaller subgroups are also recognized. Membership in these subgroups is specified for the majority of African species and characters defining the subgroups informally discussed. The georgensis Group includes a single Asian species and nine previously described African species. They are assigned to two subgroups, one newly recognized in this paper. Several additional species were considered unassigned to subgroup within the georgensis Group. The majority of the new species described in this paper belong to the georgensis Group.

Health system resilience during COVID-19 understanding SRH service adaptation in North Kivu

Background

There is often collateral damage to health systems during epidemics, affecting women and girls the most, with reduced access to non-outbreak related services, particularly in humanitarian settings. This rapid case study examines sexual and reproductive health (SRH) services in the Democratic Republic of the Congo when the COVID-19 hit, towards the end of an Ebola Virus Disease (EVD) outbreak, and in a context of protracted insecurity.

Methods

This study draws on quantitative analysis of routine data from four health zones, a document review of policies and protocols, and 13 key-informant interviews with staff from the Ministry of Public Health, United Nations agencies, international and national non-governmental organizations, and civil society organizations.

Results

Utilization of SRH services decreased initially but recovered by August 2020. Significant fluctuations remained across areas, due to the end of free care once Ebola funding ceased, insecurity, number of COVID-19 cases, and funding levels. The response to COVID-19 was top-down, focused on infection and prevention control measures, with a lack of funding, technical expertise and overall momentum that characterized the EVD response. Communities and civil society did not play an active role for the planning of the COVID-19 response. While health zone and facility staff showed resilience, developing adaptations to maintain SRH provision, these adaptations were short-lived and inconsistent without external support and funding.

Conclusion

The EVD outbreak was an opportunity for health system strengthening that was not sustained during COVID-19. This had consequences for access to SRH services, with limited-resources available and deprioritization of SRH.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-022-01443-5.

Women and girls often face increased challenges to accessing healthcare during epidemics on top of pre-existing health disparities. There is emerging evidence that COVID-19 has had negative impacts on the health of women and girls in sub-Saharan Africa due to diverted funding, reduced services, negative socioeconomic impacts, and increased or new barriers to access. In the DRC, COVID-19 hit shortly after the end of an Ebola epidemic within a context of protracted insecurity. This study used mixed methods and drew upon 13 interviews to examine the effects of COVID-19 on SRH services in North Kivu and how the health system did or did not adapt to ensure continued access and utilization of SRH services. There was limited prioritization of SRH during COVID-19. Although the government issued policies on how to adapt SRH services, these were developed centrally, without much guidance on how to operationalize these policies in different contexts. Consequently, healthcare providers and civil society actors developed their own ways to continue activities at local levels, not necessarily in a systematic way. There was limited longer-term strengthening of the health system that could adapt to the subsequent COVID-19 pandemic aside from increased capacity of healthcare providers to manage infection prevention and control measures. However, this was hampered by the lack of personal protective equipment that received no external support. Therefore, donors need to consider how resources can be leveraged to support sustained strengthening of the health system to be able to adapt to shocks even when resources are limited.

Does glucose-6-phosphate dehydrogenase deficiency worsen the clinical features of sickle cell disease? A multi-hospital-based cross-sectional study

BACKGROUND

The impact of glucose-6-phosphate dehydrogenase deficiency(G-6-PD) on the clinical course of sickle cell disease(SCD) is still controversial. The objectives of this study were to determine the prevalence of G-6-PD deficiency in patients with SCD and its effect on their clinical course.

METHODS

A cross-sectional study of 122 SCD patients and 211 healthy blood donors was conducted in Kisangani city. Data were collected through clinical examination supplemented by patient medical records, and laboratory tests based on a survey form. G-6-PD activity was measured by spectrophotometry and the screening for SCD by the HemoTypeSC^® rapid test. Statistical analysis was done using SPSS ver. 20.0.

RESULTS

The prevalence of G-6-PD deficiency did not differ between SCD and non-SCD subjects, 35.2% vs. 33.6% respectively(p = .767). When comparing the hemoglobin level between SCD patients with and without G-6-PD deficiency, no significant difference was observed. However, in the 6 months prior to the study, SCD patients with G-6-PD deficiency had on average more transfusions than non-deficient SCD patients, 0.64 ± 0.897 vs. 0.24 ± 0.486(p = .004). Similarly, considering the clinical events of the last 12 months prior to the study, there were more hospitalizations, major vaso-occlusive crises and anemia requiring blood transfusion among G-6-PD deficient SCD patients compared to no-deficient, respectively 1.42 ± 1.451vs. 0.76 ± 1.112(p = .007); 1.37 ± 1.092 vs. 0.85 ± 1.014(p = .005); 0.74 ± 0.902 vs. 0.38 ± 0.739 (p = .007).

CONCLUSION

The prevalence of G-6-PD deficiency in SCD patients was high but did not differ from that observed in controls. In addition, G-6-PD deficiency appeared to worsen the clinical features of SCD. Nevertheless, prospective studies further clarifying this observation are needed.

Competent and deficient provision of childbirth services: a descriptive observational study assessing the quality of intrapartum care in two provinces of the Democratic Republic of the Congo

Background

A majority of women in the Democratic Republic of the Congo (DRC) give birth in a health facility, but maternal and newborn mortality remains high. In rural areas, the quality of facility-based delivery care is often low. This study examines clinical quality of intrapartum care in two provinces of the DRC.

Methods

We observed process and input elements of delivery care provision at 29 facilities in Kwilu and Kwango provinces. Distinguishing non-performance attributable to provider behavior vs. input constraints, we compared both providers’ adherence to clinical standards (“competent care”) and non-adherence to processes for which required inputs were available (“deficient care”).

Results

Observing a total of 69 deliveries, care was most competent for partograph use (75% cases) and hemorrhage prevention (73%), but least for postpartum monitoring (4%). Competent care was significantly associated with higher case volumes (p = ·03), skilled birth attendance (p = ·05), and nulliparous women (p = ·02). Care was most deficient for infection prevention (62%) and timely care (49%) and associated with cases observed at hospitals and lower delivery volume.

Conclusions

Low quality was commonly not a result of missing equipment or supplies but related to providers’ non-adherence to standard protocols. Low case volumes and the absence of skilled attendants seemed to be main factors for sub-standard quality care. Birth assistance during labor stage 2 was the only intrapartum stage heavily affected by the unavailability of essential equipment. Future interventions should strengthen links between birth attendants’ practice to clinical protocols.

Predictive Factors of HIV-1 Drug Resistance and Its Distribution among Female Sex Workers in the Democratic Republic of the Congo (DRC)

The predictive factors of HIV-1 drug resistance and its distribution are poorly documented in female sex workers (FSWs) in the Democratic Republic of the Congo (DRC). However, the identification of predictive factors can lead to the development of improved and effective antiretroviral therapy (ART). The objective of the current study was to determine the predictive factors of HIV-1 drug resistance and its distribution based on FSWs in the studied regions in the Democratic Republic of the Congo (DRC). HIV-positive FSWs who were diagnosed as part of the DRC Integrated Biological and Behavioral Surveillance Survey (IBBS) were included in this study. A total of 325 FSWs participated. The HIV-1 viral load (VL) was measured according to the Abbott m2000sp and m2000rt protocols. The homogeneity chi-square test was conducted to determine the homogeneity of HIV-1 drug resistance distribution. Using a significance level of 0.05, multivariate analyses were performed to identify factors associated with HIV-1 drug resistance to ART. HIV drug resistance mutation (HIVDRM) distribution was homogeneous in the three study regions (p = 0.554) but differed based on the HIV-1 VLs of the FSWs. FSWs with high HIV-1 VLs harbored more HIVDRMs (p = 0.028) of predominantly pure HIV-1 strains compared with those that had low HIV-1 VLs. Sexually transmitted infection (STI) history (aOR [95%CI] = 8.51 [1.62, 44.74]), high HIV-1 VLs (aOR [95%CI] = 5.39 [1.09, 26.74]), and HIV-1-syphilis coinfection (aOR [95%CI] = 9.71 [1.84, 51.27]) were associated with HIV drug resistance among FSWs in the DRC. A history of STIs (e.g., abnormal fluid) in the 12 months prior to the survey, a high HIV-1 VL, and HIV-1-syphilis coinfection were associated with HIV-1 drug resistance among FSWs in the DRC. Efforts should be made to systematically test for other infections which increase the HIV-1 VL, in the case of HIV-1 coinfection, in order to maintain ART effectiveness across the DRC.

Immunogenicity of rVSVΔG-ZEBOV-GP Ebola vaccination in exposed and potentially exposed persons in the Democratic Republic of the Congo

This paper describes findings from a seroepidemiologic study involving a cohort of Ebola-vaccinated individuals from North Kivu, Democratic Republic of the Congo (DRC), who were studied as part of a collaborative effort between American and Congolese scientists and epidemiologists. Our study examines antibody response at 21 d and 6 mo postvaccination after single-dose rVSVΔG-ZEBOV-GP vaccination among Ebola virus disease–exposed and potentially exposed populations in the DRC. At 21 d of follow-up, 87.2% had an antibody response. Additionally, 95.6% demonstrated antibody persistence at 6 mo of follow-up. These findings give crucial evidence that antibody response and persistence after Ebola vaccination is robust in outbreak settings in the DRC, knowledge that significantly informs the use of vaccination for outbreak control.

Despite more than 300,000 rVSVΔG-ZEBOV-glycoprotein (GP) vaccine doses having been administered during Ebola virus disease (EVD) outbreaks in the Democratic Republic of the Congo (DRC) between 2018 and 2020, seroepidemiologic studies of vaccinated Congolese populations are lacking. This study examines the antibody response at 21 d and 6 mo postvaccination after single-dose rVSVΔG-ZEBOV-GP vaccination among EVD-exposed and potentially exposed populations in the DRC. We conducted a longitudinal cohort study of 608 rVSVΔG-ZEBOV-GP–vaccinated individuals during an EVD outbreak in North Kivu Province, DRC. Participants provided questionnaires and blood samples at three study visits (day 0, visit 1; day 21, visit 2; and month 6, visit 3). Anti-GP immunoglobulin G (IgG) antibody titers were measured in serum by the Filovirus Animal Nonclinical Group anti-Ebola virus GP IgG enzyme-linked immunosorbent assay. Antibody response was defined as an antibody titer that had increased fourfold from visit 1 to visit 2 and was above four times the lower limit of quantification at visit 2; antibody persistence was defined as a similar increase from visit 1 to visit 3. We then examined demographics for associations with follow-up antibody titers using generalized linear mixed models. A majority of the sample, 87.2%, had an antibody response at visit 2, and 95.6% demonstrated antibody persistence at visit 3. Being female and of young age was predictive of a higher antibody titer postvaccination. Antibody response and persistence after Ebola vaccination was robust in this cohort, confirming findings from outside of the DRC.

Poliovirus immunity among adults in the Democratic Republic of the Congo: a cross-sectional serosurvey

BACKGROUND

Vaccination efforts to eradicate polio currently focus on children under 5 years of age, among whom most cases of poliomyelitis still occur. However, in the Democratic Republic of the Congo (DRC), an outbreak of wild poliovirus type 1 occurred in 2010-2011 in which 16% of cases occurred among adults; in a related outbreak in the neighboring Republic of Congo, 75% of cases occurred among the same adult age-group. Given that infected adults may transmit poliovirus, this study was designed to assess adult immunity against polioviruses.

METHODS

We assessed poliovirus seroprevalence using dried blood spots from 5,526 adults aged 15-59 years from the 2013-2014 Demographic and Health Survey in the DRC.

RESULTS

Among adults in the DRC, 74%, 72%, and 57% were seropositive for neutralizing antibodies for poliovirus types 1, 2, and 3, respectively. For all three serotypes, seroprevalence tended to be higher among older age groups, those living in households with more children, and among women.

CONCLUSIONS

Protection against poliovirus is generally low among adults in the DRC, particularly for type 3 poliovirus. The lack of acquired immunity in adults suggests a potentially limited poliovirus circulation over the lifetime of those surveyed (spanning 1954 through 2014) and transmission of vaccine-derived poliovirus in this age group while underscoring the risk of these outbreaks among adults in the DRC.

Predictors of acute stress disorder in victims of violence in Eastern Democratic Republic of the Congo

Background: The Democratic Republic of the Congo underwent more than 25 years of war resulting in millions of deaths and in survivants struggling with trauma related disorders. The factors contributing to acute stress disorder following a traumatic event remain little understood. Emotion regulation might play a role in the development of acute stress disorder among victims of war-related violence. Objectives: We assessed the association between acute stress disorder expression and cognitive strategies of emotion regulation among injured victims of violence in the Eastern Democratic Republic of the Congo. Methods: This cross-sectional study included 120 patients (77% males, mean age 30 ± 11 years) with traumatic wounds admitted at the Bukavu General Hospital. We assessed acute stress disorder through the Stanford Acute Reaction Stress Questionnaire and emotion regulation strategies through the Cognitive emotional regulation questionnaire. Results: Using Pearson Chi2 and Student t-test we found that compared with patients without acute stress disorder (N = 56), patients with acute stress disorder (N = 64) were more likely to be victims of armed robbery (p = .02), of a bullet (p = .04), of having wounds with fracture (p = .03) or neurological damage (p = .05). In multivariate logistic regression, wounds with neurological damage [OR = 2.23 (1.03-6.05)] and maladaptive emotion regulation, namely self-blame [OR = 1.71 (1.01-3.21)] and rumination [OR = 1.97 (1.04-4.13)], were significant predictors of acute stress disorder. Conclusion: Acute stress disorder was prevalent in the aftermath of violence induced injuries and might be associated with emotion regulation strategies such as self-blame and rumination. HIGHLIGHTS Acute stress disorder is strongly associated with maladaptive emotion regulation strategies such as self-blame and rumination.Interventions targeting emotion regulation may reduce acute stress reactions in the aftermath of violence induced injuries.

Co-occurrence of sickle cell disease and oculocutaneous albinism in a Congolese patient: a case report

BACKGROUND

Sickle cell disease and oculocutaneous albinism are rare autosomal recessive disorders both related to mutations on chromosome 11. The diagnosis of patients suffering from both pathologies is necessary to enable dedicated monitoring of any complications at the ophthalmic and skin level. However, few cases are described in the literature.

CASE PRESENTATION

A 14-month-old Congolese male child affected by oculocutaneous albinism, presented with pallor and jaundice. Blood indices revealed severe hemolytic anemia, which led to the diagnosis of sickle cell disease. The patient received a blood transfusion and close follow-up.

CONCLUSIONS

The co-inheritance of sickle cell disease and oculocutaneous albinism is a reality in the Democratic Republic of Congo, although it is rarely described. Given the current state of our knowledge, specific surveillance, specifically regarding cutaneous and ophthalmological complications, should be offered in this particular population. To enable this dedicated follow-up, sensitization to screening for sickle cell anemia in albino individuals should be carried out.

The spread of cholera in western Democratic Republic of the Congo is not unidirectional from East-West: a spatiotemporal analysis, 1973-2018

Background

Cholera outbreaks in western Democratic Republic of the Congo (DRC) are thought to be primarily the result of westward spread of cases from the Great Lakes Region. However, other patterns of spatial spread in this part of the country should not be excluded. The aim of this study was to explore alternative routes of spatial spread in western DRC.

Methods

A literature review was conducted to reconstruct major outbreak expansions of cholera in western DRC since its introduction in 1973. We also collected data on cholera cases reported at the health zone (HZ) scale by the national surveillance system during 2000–2018. Based on data from routine disease surveillance, we identified two subperiods (week 45, 2012–week 42, 2013 and week 40, 2017–week 52, 2018) for which the retrospective space–time permutation scan statistic was implemented to detect spatiotemporal clusters of cholera cases and then to infer the spread patterns in western DRC other than that described in the literature.

Results

Beyond westward and cross-border spread in the West Congo Basin from the Great Lakes Region, other dynamics of cholera epidemic propagation were observed from neighboring countries, such as Angola, to non-endemic provinces of southwestern DRC. Space–time clustering analyses sequentially detected clusters of cholera cases from southwestern DRC to the northern provinces, demonstrating a downstream-to-upstream spread along the Congo River.

Conclusions

The spread of cholera in western DRC is not one-sided. There are other patterns of spatial spread, including a propagation from downstream to upstream areas along the Congo River, to be considered as preferential trajectories of cholera in western DRC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06986-9.

Investigating molecular mechanisms of insecticide resistance in the Eastern Democratic Republic of the Congo

BACKGROUND

Malaria vector control in the Democratic Republic of the Congo is plagued by several major challenges, including inadequate infrastructure, lack of access to health care systems and preventative measures, and more recently the widespread emergence of insecticide resistance among Anopheles mosquitoes. Across 26 provinces, insecticide resistance has been reported from multiple sentinel sites. However, to date, investigation of molecular resistance mechanisms among Anopheles vector populations in DRC has been more limited.

METHODS

Adult Anopheles gambiae sensu lato (s.l.) and Anopheles funestus s.l. were collected from two sites in Sud-Kivu province and one site in Haut-Uélé province and PCR-screened for the presence of 11 resistance mutations, to provide additional information on frequency of resistance mechanisms in the eastern DRC, and to critically evaluate the utility of these markers for prospective country-wide resistance monitoring.

RESULTS

L1014F-kdr and L1014S-kdr were present in 75.9% and 56.7% of An. gambiae s.l. screened, respectively, with some individuals harbouring both resistant alleles. Across the three study sites, L43F-CYP4J5 allele frequency ranged from 0.42 to 0.52, with evidence for ongoing selection. G119S-ace1 was also identified in all sites but at lower levels. A triple mutant haplotype (comprising the point mutation CYP6P4-I236M, the insertion of a partial Zanzibar-like transposable element and duplication of CYP6AA1) was present at high frequencies. In An. funestus s.l. cis-regulatory polymorphisms in CYP6P9a and CYP6P9b were detected, with allele frequencies ranging from 0.82 to 0.98 and 0.65 to 0.83, respectively.

CONCLUSIONS

This study screened the most up-to-date panel of DNA-based resistance markers in An. gambiae s.l. and An. funestus s.l. from the eastern DRC, where resistance data is lacking. Several new candidate markers (CYP4J5, G119S-ace1, the triple mutant, CYP6P9a and CYP6P9b) were identified, which are diagnostic of resistance to major insecticide classes, and warrant future, larger-scale monitoring in the DRC to inform vector control decisions by the National Malaria Control Programme.

Evaluation of Early Warning, Alert and Response System for Ebola Virus Disease, Democratic Republic of the Congo, 2018-2020

The 10th and largest Ebola virus disease epidemic in the Democratic Republic of the Congo (DRC) was declared in North Kivu Province in August 2018 and ended in June 2020. We describe and evaluate an Early Warning, Alert and Response System (EWARS) implemented in the Beni health zone of DRC during August 5, 2018–June 30, 2020. During this period, 194,768 alerts were received, of which 30,728 (15.8%) were validated as suspected cases. From these, 801 confirmed and 3 probable cases were detected. EWARS showed an overall good performance: sensitivity and specificity >80%, nearly all (97%) of alerts investigated within 2 hours of notification, and good demographic representativeness. The average cost of the system was US $438/case detected and US $1.8/alert received. The system was stable, despite occasional disruptions caused by political insecurity. Our results demonstrate that EWARS was a cost-effective component of the Ebola surveillance strategy in this setting.

Novel Use of Capture-Recapture Methods to Estimate Completeness of Contact Tracing during an Ebola Outbreak, Democratic Republic of the Congo, 2018-2020

Despite its critical role in containing outbreaks, the efficacy of contact tracing, measured as the sensitivity of case detection, remains an elusive metric. We estimated the sensitivity of contact tracing by applying unilist capture-recapture methods on data from the 2018–2020 outbreak of Ebola virus disease in the Democratic Republic of the Congo. To compute sensitivity, we applied different distributional assumptions to the zero-truncated count data to estimate the number of unobserved case-patients with any contacts and infected contacts. Geometric distributions were the best-fitting models. Our results indicate that contact tracing efforts identified almost all (n = 792, 99%) of case-patients with any contacts but only half (n = 207, 48%) of case-patients with infected contacts, suggesting that contact tracing efforts performed well at identifying contacts during the listing stage but performed poorly during the contact follow-up stage. We discuss extensions to our work and potential applications for the ongoing coronavirus pandemic.

High susceptibility to severe malaria among patients with A blood group versus those with O blood group: A cross-sectional study in the Democratic Republic of the Congo

This study aimed to assess the association of severe malaria infection with the ABO blood groups among acute febrile patients at the General Hospital of Rungu, in the Democratic Republic of the Congo. This cross-sectional study was conducted between August and October 2018. Plasmodium falciparum-infected individuals were categorized as severe malaria and uncomplicated malaria. A total of 400 febrile patients were enrolled. The majority (n = 251; 62.8%) was positive P. falciparum in microscopy test, of whom 180 (71.7%) had uncomplicated malaria and 71 (28.3%) severe malaria; 32.3%, 18.3%, 2.8%, and 46.6% were found to be blood group of A, B, AB, and O, respectively. In the multivariate analysis using the logistic regression models, severe malaria was high among patients with A blood group compared to those with O blood group (45.8% vs. 13.7%; adjusted odds ratio: 5.3 [95% confidence interval: 2.7–10.5]; P < 0.001). This survey demonstrates that patients with A blood group had a high susceptibility to severe malaria compared to those with O blood group.

Identifying psychosocial determinants of water, sanitation, and hygiene (WASH) behaviors for the development of evidence-based Baby WASH interventions (REDUCE program)

Diarrheal disease remains a leading cause of child mortality, globally. In the Democratic Republic of the Congo (DRC), each year there are an estimated 45 million episodes of diarrhea in children under five years of age. The Reducing Enteropathy, Diarrhea, Undernutrition, and Contamination in the Environment (REDUCE) program seeks to develop theory-driven, evidence-based approaches to reduce diarrheal diseases among young children. The REDUCE prospective cohort study in Walungu Territory in Eastern DRC took guidance from the risks, attitudes, norms, abilities, and self-regulation model, the integrated behavioral model for water, sanitation, and hygiene (WASH), and other behavior change theories to identify psychosocial factors associated with WASH behaviors. Psychosocial factors were measured among 417 caregivers at baseline and caregiver responses to child mouthing of dirty fomites and handwashing with soap was assessed by 5-hour structured observation at the 6-month follow-up. Caregivers who agreed that their child could become sick if they put dirt in their mouth (perceived susceptibility) and caregivers that agreed they could prevent their child from playing with dirty things outside (self-efficacy) were significantly more likely to stop their child from mouthing a dirty fomite. Higher perceived susceptibility, self-efficacy, and disgust, and lower dirty reactivity, were associated with higher handwashing with soap behaviors. This study took a theory-driven and evidence-based approach to identify psychosocial factors to target for intervention development. The findings from this study informed the development of the REDUCE Baby WASH Modules that have been delivered to over 1 million people in eastern DRC.

A Multidisciplinary Investigation of the First Chikungunya Virus Outbreak in Matadi in the Democratic Republic of the Congo

Early March 2019, health authorities of Matadi in the Democratic Republic of the Congo alerted a sudden increase in acute fever/arthralgia cases, prompting an outbreak investigation. We collected surveillance data, clinical data, and laboratory specimens from clinical suspects (for CHIKV-PCR/ELISA, malaria RDT), semi-structured interviews with patients/caregivers about perceptions and health seeking behavior, and mosquito sampling (adult/larvae) for CHIKV-PCR and estimation of infestation levels. The investigations confirmed a large CHIKV outbreak that lasted February–June 2019. The total caseload remained unknown due to a lack of systematic surveillance, but one of the two health zones of Matadi notified 2686 suspects. Of the clinical suspects we investigated (n = 220), 83.2% were CHIKV-PCR or IgM positive (acute infection). One patient had an isolated IgG-positive result (while PCR/IgM negative), suggestive of past infection. In total, 15% had acute CHIKV and malaria. Most adult mosquitoes and larvae (>95%) were Aedes albopictus. High infestation levels were noted. CHIKV was detected in 6/11 adult mosquito pools, and in 2/15 of the larvae pools. This latter and the fact that 2/6 of the CHIKV-positive adult pools contained only males suggests transovarial transmission. Interviews revealed that healthcare seeking shifted quickly toward the informal sector and self-medication. Caregivers reported difficulties to differentiate CHIKV, malaria, and other infectious diseases resulting in polypharmacy and high out-of-pocket expenditure. We confirmed a first major CHIKV outbreak in Matadi, with main vector Aedes albopictus. The health sector was ill-prepared for the information, surveillance, and treatment needs for such an explosive outbreak in a CHIKV-naïve population. Better surveillance systems (national level/sentinel sites) and point-of-care diagnostics for arboviruses are needed.

Ebola virus disease, stigmatization, peritraumatic distress, and posttraumatic stress disorder in the Democratic Republic of the Congo: A moderated mediation model

BACKGROUND

Mechanisms worsening the development of Posttraumatic stress disorder (PTSD) symptoms among individuals affected by high-mortality epidemics are unclear. This study examined the prevalence of PTSD and related risk factors among populations affected by the Ebola virus disease (EVD) outbreak, and investigated whether peritraumatic distress mediates the impact of exposure level to EVD on PTSD symptoms, and the moderation role of stigmatization.

METHODS

The sample included 1614 participants (50% women) affected by EVD in Democratic Republic of the Congo (DRC). Participants completed the PTSD Check-List for DSM-5, Peritraumatic Distress Inventory, and measures evaluating levels of exposure and stigmatization related to EVD. Descriptive analyses and a moderated mediation model were computed.

RESULTS

A total of 58.81% participants (95% CI: 56.41%; 61.21%) met PTSD diagnostic criteria. Participants living in rural areas presented greater risk, while there is no significant difference between men and women. Peritraumatic distress mediated partially the association between exposure to EVD and PTSD symptoms. Moreover, this relationship was moderated by stigmatization related to EVD.

LIMITATIONS

As the design was cross-sectional, this study could not examine the causality of PTSD symptoms among communities affected by EVD.

CONCLUSIONS

This study shows high prevalence rates and important risk factors associated with PTSD in populations affected by EVD. It indicates elements that could help to develop and implement prevention and intervention programs in affected communities.

Alobar holoprosencephaly in mining-related areas of the Eastern region of the Democratic Republic of the Congo: A case series

BACKGROUND

Recent case reports described three cases of holoprosencephaly (HPE) in the area with high mining-related pollution of the southern region of the Democratic Republic of the Congo (DRC). We reported two male neonates with clinically diagnosed HPE in the localities of Fizi and Kitutu, two mineral areas in the Eastern region of the same country (DRC), where artisanal surface mining is predominant with high exposure to radiation and heavy metals from mining.

CASES' PRESENTATIONS

Two newborns from adult and multigravida mothers without pregnancy complication. The birth weights were 3,200 g and 2,500 g, respectively, and the malformations noticed were essentially the single median eye, the absent nose, polydactyly for one case, and proboscis for the other case. They both died a few minutes later after birth.

CONCLUSION

The etiologic factors of HPE remain unknown but seem to be multifactorial from both genetic and environmental factors. We hypothesize under reserve for these two cases that mining and radiation expositions were likely potential environmental associated factors to the occurrence of these malformations.

Variable residual activity of K-Othrine® PolyZone and Actellic® 300 CS in semi-field and natural conditions in the Democratic Republic of the Congo

Background

Indoor Residual Spray (IRS) against vector mosquitoes is a primary means for combating malaria transmission. To combat increased patterns of resistance to chemicals against mosquito vectors, alternative candidate insecticide formulations should be screened. With mortality as the primary endpoint, the persistence of residual efficacy of a polymer-enhanced pyrethroid suspension concentrate containing deltamethrin (K-Othrine® PolyZone—KOPZ) applied at 25 mg active ingredient (ai)/m² was compared with a microencapsulated organophosphate suspension formulation of pirimiphos-methyl (Actellic® 300CS—ACS) applied at 1 g ai/m².

Methods

Following standard spray application, periodic contact bioassays were conducted for at least 38 weeks on four types of wall surfaces (unbaked clay, baked clay, cement, and painted cement) sprayed with either KOPZ or ACS in simulated semi-field conditions. Similarly, two types of existing walls in occupied houses (painted cement and baked clay) were sprayed and examined. A colonized strain of female Anopheles arabiensis mosquitoes were exposed to treated or untreated surfaces (controls) for 30 min. For each wall surface test period, 40 treatment mosquitoes (4 cones × 10) in semi-field and 90 (9 cones × 10) in ‘natural’ house conditions were used per wall. 30 mosquitoes (3 cones × 10) on a matching unsprayed surface served as the control. Insecticide, wall material, and sprayed location on wall (in houses) were compared by final mortality at 24 h.

Results

Insecticide, wall material, and sprayed location on wall surface produced significant difference for mean final mortality over time. In semi-field conditions, KOPZ produced a 72% mean mortality over a 38-week period, while ACS gave 65% (p < 0.001). Painted cement wall performed better than other wall surfaces throughout the study period (73% mean mortality). In the two occupied houses, KOPZ provided a mean mortality of 88%, significantly higher than ACS (p < 0.001). KOPZ provided an effective residual life (≥ 80% mortality) between 7.3 and 14 weeks on experimental walls and between 18.3 and 47.2 weeks in houses, while ACS persisted between 3 and 7.6 weeks under semi-field conditions and between 7.1 and 17.3 weeks in houses. Household painted cement walls provided a longer effective residual activity compared to baked clay for both formulations. Greater mortality was recorded at the top and middle sections of sprayed wall compared to the bottom portion near the floor.

Conclusion

KOPZ provided longer residual activity on all surfaces compared to ACS. Painted cement walls provided better residual longevity for both insecticides compared to other surfaces. Insecticides also performed better in an occupied house environment compared to semi-field constructed walls. This study illustrates the importance of collecting field-based observations to determine appropriate product active ingredient formulations and timing for recurring IRS cycles.

Effects of Door-to-Door Hang-Up Visits on the Use of Long-Lasting Insecticide-Treated Mosquito Nets in the Democratic Republic of the Congo: A Cluster Randomized Controlled Trial

Malaria accounts for 14% of child deaths in the Democratic Republic of the Congo, and one of the key interventions used to prevent malaria is to distribute insecticide-treated bednets (ITNs), especially long-lasting insecticidal nets (LLINs). The global health community and the Roll Back Malaria initiative have been struggling to achieve universal health coverage using ITNs, and recent studies have reported mixed results about the effects of door-to-door visits and mass distribution campaigns. We aimed to compare LLIN use for those provided by door-to-door hang-up visits and by conventional fixed distribution from distribution centers accompanied by a mass distribution campaign. A cluster randomized control trial was conducted in rural areas of Maniema Province, Democratic Republic of the Congo (DR Congo). Cross-sectional surveys were conducted on 2120 and 2156 households, respectively, with at least one child aged less than five in 76 villages. We assessed the effectiveness of door-to-door hang-up visits on the use of LLINs by exploring the interaction between the “intervention group” and “time” using generalized estimating equation models. Increased LLINs use was observed in all age groups in both arms, but usage differences were not significantly different (relative risk (RR) of LLINs use among children < 5 in the intervention group versus the control group after adjusted for clustering: 1.06, 95% CI: 0.85–1.33). We conclude that the door-to-door hang-up visits are not sufficient to persuade individuals (pregnant woman, children < 5, or all study participants) to use LLINs, although it did appear to be effective for the youngest children in the household.

Perceptions of ebola virus disease among the bambuti hunter group: a mixed-methods study

The second largest Ebola virus disease (EVD) epidemic occurred in the Democratic Republic of the Congo (DRC) from 2018-20. The Bambuti, a hunter population in the Ituri Forest of the DRC, may be vulnerable to the zoonotic spread of EVD due to their frequent handling of forest animals. We conducted five focus group discussions and surveyed 113 Bambuti and 91 Bantu (control group), to discern how the Bambuti perceived and responded to EVD. Thematic analysis of focus group discussions revealed three major themes: (1) deprivation and discrimination; (2) mistrust; and (3) epistemic dissonance with public health messages emphasizing risks posed by forest animals. In surveys, 98% of Bambuti were deprived using the multidimensional poverty index (versus 78% of Bantu controls, p < 0.0001) and 77% had no formal education (versus 29% of controls, p < 0.0001). Bambuti were more dependent on wild meat for survival (51% versus 32% of controls, p = 0.008) and more frequently opposed the implementation of a bushmeat ban (48% versus 19% of controls, p < 0.0001). Trust in government was similar among Bambuti and Bantu. Comprehensive EVD knowledge was poor overall, and lower among the Bambuti (2% versus 8% of controls, p = 0.041). Compliance with public health measures was associated with higher levels of education and trust in government but did not differ between Bambuti and Bantu survey respondents. Together, our findings point to a particular vulnerability of the Bambuti to the effects of EVD, attributable at least in part to multidimensional poverty.

Relationship between women's decision-making power over their own health care and use of modern contraception in the Democratic Republic of the Congo: a cross-sectional secondary data analysis

BACKGROUND

In sub-Saharan Africa, the use of modern contraception (MC) is a critical intervention aimed at reducing mortality rates associated with unintended, high-risk pregnancies. However, among Congolese women aged 15-49, the prevalence of MC use is low. Research suggests that women's general participation in decision-making is important in increasing MC use. However, little is known about the specific role of women's decision-making power over their own health care and how it relates to MC use. Thus, this study aimed to investigate the relationship between women's decision-making power over their own health care and use of MC.

METHODS

A cross-sectional secondary data analysis was conducted using the most recent data from the 2013-2014 Democratic Republic of the Congo (DRC) Demographic and Health Survey. Women who were considered in need of contraception based on their family planning preferences were included in the study population (N = 6422). Multivariate logistic regression was used to determine whether women's decision-making power over their own health care was associated with the use of MC.

RESULTS

Only one in ten women reported using a modern method of contraception. Logistic regression showed that women who made decisions alone regarding their own health care were more likely to use MC than women who had no say in these decisions, even after controlling for important covariates (OR 1.48; 95% CI 1.00, 2.17).

CONCLUSION

The results of this study lend further support that promoting women's autonomy and right to independently make decisions regarding their own health may be important in increasing the use of MC in the DRC. However, in order to effectively empower women to negotiate for the use of MC, qualitative research is needed to further assess the relationship between decision-making power and MC use.

Bacteria and viruses in the upper respiratory tract of Congolese children with radiologically confirmed pneumonia

BACKGROUND

Acute pneumonia remains a leading cause of death among children below 5 years of age in the Democratic Republic of the Congo (DR Congo), despite introduction of the 13-valent pneumococcal conjugate vaccine (PCV13) in 2013. Potential pathogens in the nasopharynx of hospitalised children with pneumonia have not been studied previously in DR Congo. Here we compare clinical characteristics, risk factors and nasopharyngeal occurrence of bacteria and viruses between children with severe and non-severe pneumonia.

METHODS

Between June 2015 and June 2017, 116 children aged from 2 to 59 months hospitalised due to radiologically confirmed pneumonia at Panzi referral university hospital, Bukavu, Eastern DR Congo were included in the study and sampled from nasopharynx. A multiplex real-time PCR assay for detection of 15 different viruses and 5 bacterial species was performed and another multiplex PCR assay was used for pneumococcal serotype/serogroup determination.

RESULTS

During the study period 85 (73%) of the children with radiologically confirmed pneumonia met the WHO classification criteria of severe pneumonia and 31 (27%) had non-severe pneumonia. The fatality rate was 9.5%. Almost all (87%) children were treated with antibiotics before they were hospitalised, in most cases with amoxicillin (58%) or trimethoprim-sulfamethoxazole (20%). The frequency of potential pathogens in the nasopharynx of the children was high, and any viral or bacterial nucleic acids present at high levels, irrespective of species or type, were significantly associated with severe pneumonia as compared with non-severe cases (52% versus 29%, p = 0.032). White blood cell count > 20,000/μL and C-Reactive Protein > 75 mg/dL were associated with severe pneumonia at admission. Fatal outcome was in the multivariable analysis associated with having a congenital disease as an underlying condition. One or more pneumococcal serotypes/serogroups could be identified in 61 patients, and out of all identified serotypes 31/83 (37%) were non-PCV13 serotypes.

CONCLUSIONS

The occurrence of any bacteria or any viruses at high levels was associated with severe pneumonia at admission. Children with congenital disorders might need a higher attention when having symptoms of acute respiratory infection, as developed pneumonia could lead to fatal outcome.

Use of Iris Scanning for Biometric Recognition of Healthy Adults Participating in an Ebola Vaccine Trial in the Democratic Republic of the Congo: Mixed Methods Study

Background

A partnership between the University of Antwerp and the University of Kinshasa implemented the EBOVAC3 clinical trial with an Ebola vaccine regimen administered to health care provider participants in Tshuapa Province, Democratic Republic of the Congo. This randomized controlled trial was part of an Ebola outbreak preparedness initiative financed through Innovative Medicines Initiative-European Union. The EBOVAC3 clinical trial used iris scan technology to identify all health care provider participants enrolled in the vaccine trial, to ensure that the right participant received the right vaccine at the right visit.

Objective

We aimed to assess the acceptability, accuracy, and feasibility of iris scan technology as an identification method within a population of health care provider participants in a vaccine trial in a remote setting.

Methods

We used a mixed methods study. The acceptability was assessed prior to the trial through 12 focus group discussions (FGDs) and was assessed at enrollment. Feasibility and accuracy research was conducted using a longitudinal trial study design, where iris scanning was compared with the unique study ID card to identify health care provider participants at enrollment and at their follow-up visits.

Results

During the FGDs, health care provider participants were mainly concerned about the iris scan technology causing physical problems to their eyes or exposing them to spiritual problems through sorcery. However, 99% (85/86; 95% CI 97.1-100.0) of health care provider participants in the FGDs agreed to be identified by the iris scan. Also, at enrollment, 99.0% (692/699; 95% CI 98.2-99.7) of health care provider participants accepted to be identified by iris scan. Iris scan technology correctly identified 93.1% (636/683; 95% CI 91.2-95.0) of the participants returning for scheduled follow-up visits. The iris scanning operation lasted 2 minutes or less for 96.0% (656/683; 95% CI 94.6-97.5), and 1 attempt was enough to identify the majority of study participants (475/683, 69.5%; 95% CI 66.1-73.0).

Conclusions

Iris scans are highly acceptable as an identification tool in a clinical trial for health care provider participants in a remote setting. Its operationalization during the trial demonstrated a high level of accuracy that can reliably identify individuals. Iris scanning is found to be feasible in clinical trials but requires a trained operator to reduce the duration and the number of attempts to identify a participant.

Trial Registration

ClinicalTrials.gov NCT04186000; https://clinicaltrials.gov/ct2/show/NCT04186000

Uptake of HIV/AIDS Services Following a Positive Self-Test Is Lower in Men Than Women in the Democratic Republic of the Congo

As far as HIV self-testing (HIVST) is concerned, proving the link to HIV care for users with a positive result contributes to understanding the implementation of HIVST. We sought to examine whether there were differences by sex in the uptake of HIV services following a positive self-test in the Democratic Republic of the Congo (DRC). This was a mixed-methods study exploring linkage to care for HIVST through a secondary analysis of collected data from three pilot surveys recently conducted in three cities (Kinshasa, Kisangani, and Kindu) during 2018 and 2020 in the DRC. Linkage to HIV care was defined as delayed when observed beyond 1 week. A total of 1,652 individuals were self-tested for HIV. Overall, the proportion of linkage to HIV care was high (n = 258; 82.2%) among individuals having a positive result with HIV self-test (n = 314), but it was significantly lower in men (65.2%) than women (89.2%). Furthermore, linkage to HIV care of men was significantly delayed as compared with that of women (40.0 vs. 20.7%). These findings show a lower uptake of care following a positive self-test in men than women. This trend already previously observed in sub-Saharan Africa shed light on the need to increase linkages to care among men newly diagnosed through HIV self-testing.

Insecticide resistance profiles in malaria vector populations from Sud-Kivu in the Democratic Republic of the Congo

BACKGROUND

Insecticide resistance has become a widespread problem causing a decline in the effectiveness of vector control tools in sub-Saharan Africa. In this situation, ongoing monitoring of vector susceptibility to insecticides is encouraged by the WHO to guide national malaria control programmes. Our study was conducted from April to November 2018 in Tchonka (Sud-Kivu, Democratic Republic of the Congo) and reported primary data on the resistance status of Anopheles funestus and Anopheles gambiae.

METHODS

Insecticide susceptibility bioassays were performed on wild populations of A. funestus and A. gambiae using WHO insecticide-impregnated papers at discriminating concentration. In addition, PCR was performed to identify mosquito species and to detect kdr and ace-1R mutations involved in insecticide resistance.

RESULTS

Bioassay results show resistance to all tested insecticides except pirimiphos-methyl, propoxur, fenitrothion and malathion with a mortality rate ranging from 95.48 to 99.86%. The addition of piperonyl butoxide (PBO) increased the susceptibility of vectors to deltamethrin and alpha-cypermethrin by exhibiting a mortality ranging from 91.50 to 95.86%. The kdr mutation was detected at high frequencies (approximately 0.98) within A. gambiae while ace-1R was not detected.

CONCLUSIONS

This study provides useful data on the insecticide resistance profiles of malaria vector populations to better manage vector control. Our results highlight that, despite the high level of resistance, organophosphorus compounds and pyrethroids + PBO remain effective against the vectors.

Costs and Outcomes of Integrated Human African Trypanosomiasis Surveillance System Using Rapid Diagnostic Tests, Democratic Republic of the Congo

We integrated sleeping sickness case detection into the primary healthcare system in 2 health districts in the Democratic Republic of the Congo. We replaced a less field-friendly serologic test with a rapid diagnostic test, which was followed up by human African trypanosomiasis microscopic testing, and used a mixed costing methodology to estimate costs from a healthcare provider perspective. We screened a total of 18,225 persons and identified 27 new cases. Average financial cost (i.e., actual expenditures) was US $6.70/person screened and $4,464/case diagnosed and treated. Average economic cost (i.e., value of resources foregone that could have been used for other purposes) was $9.40/person screened and $6,138/case diagnosed and treated. Our study shows that integrating sleeping sickness surveillance into the primary healthcare system is feasible and highlights challenges in completing the diagnostic referral process and developing a context-adapted diagnostic algorithm for the large-scale implementation of this strategy in a sustainable and low-cost manner.

Quality of timolol eye drops marketed in Kinshasa, Democratic Republic of the Congo

OBJECTIVE

To assess the quality of timolol eye drops sold in Kinshasa, Democratic Republic of Congo (DRC).

METHODS

Seven samples of timolol maleate 0.5% were purchased over the counter in seven randomly selected public pharmacies in 3 neighborhoods in Kinshasa. They were submitted to a quality assessment that included visual inspection, spectrophotometry, high performance liquid chromatography (HPLC), and bacteriologic assessment.

RESULTS

The samples came from France (n=2), India (n=2) and DRC (n=3). Overall, 3 (2 from India and 1 from the DRC) of the 7 samples, or 3 out of the 5 from developing countries, showed various abnormalities consistent with substandard drugs. One sample (India) demonstrated an incorrect pH, while 3 (2 from India and one from the DRC) had lower than stated volumes as well as lower than required concentrations of the active pharmaceutical ingredient. In addition, one sample from the DRC was bacteriologically contaminated.

CONCLUSION

These results suggest that some timolol maleate eye drops from Congolese and Indian manufacturers sold in Kinshasa are of substandard quality. This may reflect deficiencies in the manufacturers and local authorities charged with regulation of the quality control and sale of pharmaceuticals. Passing a visual inspection does not necessarily indicate that a drug is not substandard. Analytical chemistry testing and bacteriologic analysis are required to determine with certainty the quality of the drug.

Individual, household and neighborhood risk factors for malaria in the Democratic Republic of the Congo support new approaches to programmatic intervention

BACKGROUND

The Democratic Republic of the Congo (DRC) remains one of the countries most impacted by malaria despite decades of control efforts, including multiple mass insecticide treated net (ITN) distribution campaigns. The multi-scalar and complex nature of malaria necessitates an understanding of malaria risk factors over time and at multiple levels (e.g., individual, household, community). Surveillance of households in both rural and urban settings over time, coupled with detailed behavioral and geographic data, enables the detection of seasonal trends in malaria prevalence and malaria-associated behaviors as well as the assessment of how the local environments within and surrounding an individual's household impact malaria outcomes.

METHODS

Participants from seven sites in Kinshasa Province, DRC were followed for over two years. Demographic, behavioral, and spatial information was gathered from enrolled households. Malaria was assessed using both rapid diagnostic tests (RDT) and polymerase chain reaction (PCR) and seasonal trends were assessed. Hierarchical regression modeling tested associations between behavioral and environmental factors and positive RDT and PCR outcomes at individual, household and neighborhood scales.

RESULTS

Among 1591 enrolled participants, malaria prevalence did not consistently vary seasonally across the sites but did vary by age and ITN usage. Malaria was highest and ITN usage lowest in children ages 6-15 years across study visits and seasons. Having another member of the household test positive for malaria significantly increased the risk of an individual having malaria [RDT: OR = 4.158 (2.86-6.05); PCR: OR = 3.37 (2.41-4.71)], as did higher malaria prevalence in the 250 m neighborhood around the household [RDT: OR = 2.711 (1.42-5.17); PCR: OR = 4.056 (2.3-7.16)]. Presence of water within close proximity to the household was also associated with malaria outcomes.

CONCLUSIONS

Taken together, these findings suggest that targeting non-traditional age groups, children >5 years old and teenagers, and deploying household- and neighborhood-focused interventions may be effective strategies for improving malaria outcomes in high-burden countries like the DRC.

Role of Wildlife in Emergence of Ebola Virus in Kaigbono (Likati), Democratic Republic of the Congo, 2017

After the 2017 Ebola virus (EBOV) outbreak in Likati, a district in northern Democratic Republic of the Congo, we sampled small mammals from the location where the primary case-patient presumably acquired the infection. None tested positive for EBOV RNA or antibodies against EBOV, highlighting the ongoing challenge in detecting animal reservoirs for EBOV.

Optimized supply chain model reduces health system costs in DRC

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After implementing optimized model, we observed 34% reduction in supply chain costs.

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Costs increased for Provincial store but decreased for Zones and health facilities.

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Streamlined distribution practices supported cost reductions for transportation.

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After implementing optimized model, costs increased in control Zones and facilities.

Objective

In 2017, an optimized immunization supply chain (iSC) model was implemented in Equateur Province, Democratic Republic of the Congo. The optimized model aimed to address iSC challenges and featured direct deliveries to service delivery points (SDPs), longer replenishment intervals and increased cold chain capacity. This assessment examines iSC costs before and 5 months after implementing the optimized model.

Materials & Methods

We used a nonexperimental pre-post study design to compare iSC costs before and after implementation. We applied an activity-based costing approach with a comparison arm to assess procurement, management, storage and transportation costs for three iSC tiers: Province (n = 1); Zone (n = 4) and SDP (n = 15). We included data from 3 treatment Zones and 11 treatment SDPs; 1 control Zone and 4 control SDPs. We used sample and population data to estimate iSC costs for the entirety of Equateur Province.

Results

In the period immediately before implementing the optimized model, estimated annual iSC costs were $974,237. Following implementation, estimated annual iSC costs were $642,627—a 34% ($331,610) reduction. This change in costs was influenced by a 43% ($180,313) reduction in SDP costs, a 67% ($198,092) reduction in Zonal costs and an 18% ($46,795) increase in Provincial costs. After implementing the optimized model, average iSC costs for treatment Zones was $6,895 (SD: $6,072); for the control Zone was $21,738; for treatment SDPs was $989 (SD: $969); and for control SDPs was $1,356 (SD: $1,062).

Conclusions

We observed an absolute reduction in iSC costs in treatment Zones while control Zone post-implementation iSC costs remained the same or increased. The greatest cost reductions were for storage and transport at Zones and SDPs. Although cost implications of this model must continue to be evaluated over time, these findings are promising and will inform decisions around project expansion.

The Burden of Malaria in the Democratic Republic of the Congo

Despite evidence that older children and adolescents bear the highest burden of malaria, large malaria surveys focus on younger children. We used polymerase chain reaction data from the 2013-2014 Demographic and Health Survey in the Democratic Republic of Congo (including children aged <5 years and adults aged ≥15 years) and a longitudinal study in Kinshasa Province (participants aged 6 months to 98 years) to estimate malaria prevalence across age strata. We fit linear models and estimated prevalences for each age category; adolescents aged 10-14 years had the highest prevalence. We estimate approximately 26 million polymerase chain reaction-detectable infections nationally. Adolescents and older children should be included in surveillance studies.

Clinical and Epidemiological Findings from Enhanced Monkeypox Surveillance in Tshuapa Province, Democratic Republic of the Congo During 2011-2015

BACKGROUND

Monkeypox is a poorly described emerging zoonosis endemic to Central and Western Africa.

METHODS

Using surveillance data from Tshuapa Province, Democratic Republic of the Congo during 2011-2015, we evaluated differences in incidence, exposures, and clinical presentation of polymerase chain reaction-confirmed cases by sex and age.

RESULTS

We report 1057 confirmed cases. The average annual incidence was 14.1 per 100 000 (95% confidence interval, 13.3-15.0). The incidence was higher in male patients (incidence rate ratio comparing males to females, 1.21; 95% confidence interval, 1.07-1.37), except among those 20-29 years old (0.70; .51-.95). Females aged 20-29 years also reported a high frequency of exposures (26.2%) to people with monkeypox-like symptoms.The highest incidence was among 10-19-year-old males, the cohort reporting the highest proportion of animal exposures (37.5%). The incidence was lower among those presumed to have received smallpox vaccination than among those presumed unvaccinated. No differences were observed by age group in lesion count or lesion severity score.

CONCLUSIONS

Monkeypox incidence was twice that reported during 1980-1985, an increase possibly linked to declining immunity provided by smallpox vaccination. The high proportion of cases attributed to human exposures suggests changing exposure patterns. Cases were distributed across age and sex, suggesting frequent exposures that follow sociocultural norms.

Management of sickle cell disease: current practices and challenges in a northeastern region of the Democratic Republic of the Congo

BACKGROUND

The Democratic Republic of the Congo (DRC) is the third most affected country worldwide by sickle cell disease (SCD). However, this disease is still orphaned in the country; large-scale control actions are rare, and little is known about its management.

OBJECTIVE

To assess current practices in the management of SCD in Kisangani, DRC.

METHODS

This cross-sectional study was conducted in six health facilities in Kisangani. It involved 198 presumed sickle cell patients attending the above health facilities. The study focused on the sociodemographic and clinical data of the participants, obtained through a clinical examination and their medical records. Diagnostic confirmation of SCD was made by high-performance liquid chromatography coupled to mass spectrometry. Data were analyzed using SPSS 20.0.

RESULTS

The diagnosis of SCD was confirmed in 194 (98.0%; 95% CI: 94.9-99.2) participants, while it was not confirmed in 4 (2.0%; 95% CI: 0.8-5.1) participants. The diagnosis was mainly made by the Emmel test (42.9%). 45.8% of participants had previously been transfused with the blood of their parents. Folic acid was taken by 48.5% of participants and the previous intake of hydroxyurea was reported in 5.1% of participants. The participants vaccinated against Pneumococcus were 13.6% and against Haemophilus influenzae type b 28.3%. Penicillin prophylaxis was received by only 1.5% and malaria prophylaxis by 11.6% of participants.

CONCLUSION

Standard-care practices for SCD patients in Kisangani are insufficient. The Congolese government should regard this disease as a health priority and consider actions to improve its management.