Establishing women's cancer care services in a fragile, conflict and violence affected ecosystem in Africa

BACKGROUND

The majority of the world's poorest women (income < $1.90/day) reside in fragile, conflict and violence (FCV)-affected countries, like the Democratic Republic of the Congo. Health services in these settings have traditionally focused on immediate relief efforts, communicable diseases and malnutrition. Recent data suggests there is need to widen the focus to include cancer, as its incidence and mortality rates are rising.

METHODS

Employing competency-based learning strategies, Congolese health professionals were trained to perform same-day cervical cancer screening and treatment of precancerous lesions of the cervix; same-day clinical breast examination and breast ultrasound diagnostics; surgical treatment of invasive cancers of the breast and cervix; and infusion of cytotoxic chemotherapy. Outpatient breast and cervical cancer care clinics, a chemotherapy suite and surgical theatres were outfitted with equipment and supplies.

RESULTS

Combining local and regional hands-on training seminars with wise infrastructure investments, a team of US and Zambian oncology experts successfully implemented a clinical service platform for women's cancers in a private sector health facility in the Democratic Republic of the Congo.

CONCLUSION

We forged a novel partnership between oncology health professionals from Africa and its Diaspora, international philanthropic organisations, a cancer medicine access initiative and an established African cancer centre to build women's cancer services in a FVC-affected African setting.

Leveraging a matrix of stakeholders to facilitate access to chemotherapy for women's cancers in the Democratic Republic of the Congo

Background

Cancer incidence is increasing worldwide. Over the next 20 years, the growing proportion of cases in low- and middle-income countries (LMICs) will account for an estimated 70% of all cancers diagnosed. The vast majority of cancer patients in LMICs will require chemotherapy, due to the advanced stage of their disease at the time of initial presentation. Unfortunately, the availability of cancer drugs in these environments is sparse, resulting in premature death and years of life lost. In an effort to lay a foundation for women’s cancer control in the Democratic Republic of the Congo (DRC), we implemented a programme which combined workforce development, infrastructure creation and cancer drug access. This manuscript reports on our experience with the latter.

Methods

A private sector healthcare facility was selected as the programme implementation site. Workforce capacity was developed through a south–south partnership with an African national cancer centre. Cancer drugs were procured through a global cancer medicine access initiative.

Results

A new chemotherapy infusion unit was successfully established at the Biamba Marie Mutombo Hospital in Kinshasa, DRC. A team of Congolese healthcare providers was trained at the Cancer Disease Hospital in Zambia to safely and effectively administer chemotherapy for breast and cervical cancer. Over 100 breast and cervical cancer patients have been treated with 337 courses of chemotherapy, without any serious adverse events.

Conclusion

Common barriers to cancer drug access and its administration can be eliminated using regional educational resources to build oncologic workforce capacity, private sector healthcare facilities for infrastructure support and pharmaceutical consortiums to procure low-cost cancer medicines. By leveraging a matrix of global, regional and local stakeholders, the prevailing status quo of very limited access to chemotherapy for women’s cancers was creatively disrupted in DRC, Africa’s largest fragile, conflict and violence-affected country.

A North-South-South partnership in higher education to develop health research capacity in the Democratic Republic of the Congo: the challenge of finding a common language

BACKGROUND

Globally, increasing numbers of higher education institutions (HEIs) in non-English-speaking countries have adopted English as a medium of instruction (EMI), because of the perception that this provides opportunities to attract high-calibre students and academic staff, and engage with the international research community. We report an evaluation of a North-South-South collaboration to develop health research capacity in the Democratic Republic of the Congo (DRC) by establishing a postgraduate programme in nutritional epidemiology at the Kinshasa School of Public Health (KSPH), where EMI was adopted. We report experiences and perceptions of stakeholders, facilitators and students about using EMI.

METHODS

In-depth qualitative interviews were conducted between October and December 2019 among convenience sampled stakeholders (8), facilitators (11) and students (12) involved in the programme from all three partner institutions (University of Kinshasa; University of KwaZulu-Natal, South Africa; University of Bergen, Norway). Interviews were conducted in participants' language of preference (English or French), audio-recorded, transcribed verbatim and translated into English when required. Analysis employed a thematic approach.

RESULTS

Most participants viewed EMI positively, reporting that studying in English created opportunities to access relevant literature, improve interactions with the scientific community and advance their careers. As a result of adopting EMI, some students had opportunities to present research findings at international conferences and publish their research in English. English-speaking researchers from partner institutions were able to participate in supervision of students' research. However, inadequate English competency, particularly among students, was challenging, with some students reporting being unable to understand or interact in class, which negatively affected their academic performance. Further, EMI created barriers at KSPH among academic staff who were not proficient in English, leading to poor participation among non-English-speaking staff and lack of integration with other postgraduate programmes. Participants suggested additional English language support for EMI.

CONCLUSION

Partnerships between HEIs could be a powerful tool to develop research capacity in low-income countries in line with United Nations Sustainable Development Goals. EMI could be a solution to language barriers faced by many such partnerships, but wide-ranging support to develop English proficiency among staff and students is essential to ensure that the challenges do not outweigh the benefits.

Diet of Grauer's Gorillas (Gorilla beringei graueri) in a Low-Elevation Forest

Although the vast majority of critically endangered Grauer's gorillas (Gorilla beringei graueri) inhabit low-elevation rain forests, current insights into this ape's life history and ecology stem predominantly from 2 small populations ranging in highland habitats. Here, we provide an initial and non-exhaustive overview of food items of Grauer's gorillas in the Nkuba Conservation Area (NCA), a lower-elevation (500-1,500 m) forest located between Kahuzi-Biega National Park and Maiko National Park in the Democratic Republic of the Congo. Community-based conservation efforts at the NCA aim to protect a population of unhabituated Grauer's gorillas, which we have studied since 2014. Between 2014 and 2020, we simultaneously tracked 1-3 gorilla groups and recorded a total of 10,514 feeding signs on at least 100 plant species, ants, termites, and fungi. Vegetative plant parts (plant stems, leaves, pith, bark, and roots), especially of Marantaceae and Fabaceae, made up close to 90% of recorded feeding signs, with fruit accounting for most of the remainder and a small (<1%) number of feeding signs on invertebrates and fungi. We found that the most frequently recorded food items were consumed year-round, though fruit intake seems to peak in the September-December wet season, possibly reflecting patterns in fruit phenology. The diet of Grauer's gorillas in the NCA differed from that of Grauer's gorillas in highland habitat and instead showed similarities with Grauer's gorillas at the lowland forest of Itebero and with western lowland gorillas (G. gorilla), which live under ecologically comparable conditions.

Molecular characterization of chikungunya virus during the 2019 outbreak in the Democratic Republic of the Congo

Early 2019, a chikungunya virus (CHIKV) outbreak hit the Democratic Republic of the Congo (DRC). Though seldomly deadly, this mosquito-borne disease presents as an acute febrile (poly)arthralgia often followed by long-term sequelae. Although Aedes aegypti is the primary vector, an amino acid substitution in the viral envelope gene E1 (A226V) is causing concern as it results in increased transmission by Aedes albopictus, a mosquito with a much wider geographical distribution. Between January and March 2019, we collected human and mosquito samples in Kinshasa and Kongo Central province (Kasangulu and Matadi). Of the patients that were tested within 7 days of symptom onset, 49.7% (87/175) were RT–qPCR positive, while in the mosquito samples CHIKV was found in 1/2 pools in Kinshasa, 5/6 pools in Kasangulu, and 8/26 pools in Matadi. Phylogenetic analysis on whole-genome sequences showed that the circulating strain formed a monophyletic group within the ECSA2 lineage and harboured the A226V mutation. Our sequences did not cluster with sequences from previously reported outbreaks in the DRC nor with other known A226V-containing ECSA2 strains. This indicates a scenario of convergent evolution where A226V was acquired independently in response to a similar selection pressure for transmission by Ae. albopictus. This is in line with our entomological data where we detected Ae. albopictus more frequently than Ae. aegypti in two out of three affected areas. In conclusion, our findings suggest that CHIKV is adapting to the increased presence of Aedes albopictus in DRC.

Effects of implementing a postabortion care strategy in Kinshasa referral hospitals, Democratic Republic of the Congo

Objectives

To evaluate the effects of the implementation of a postabortion care (PAC) strategy in Kinshasa referral hospitals, this study analyzed the quality of postabortion care services, including postabortion contraception, and the duration of hospitalization.

Methodology

We estimated the effects of the PAC strategy using a quasi-experimental study by evaluating the outcomes of 334 patients with the diagnosis of a complication of induced abortion admitted to 10 hospitals in which the PAC strategy was implemented compared to the same outcomes in 314 patients with the same diagnosis admitted to 10 control facilities from 01/01/2016 to 12/31/2018. In response to government policy, the PAC strategy included the treatment of abortion complications with recommended uterine evacuation technology, the family planning counseling and service provision, linkages with other reproductive health services, including STI evaluation and HIV counseling and/or referral for testing, and partnerships between providers and communities. The information was collected using a questionnaire and stored using open data kit software. We supplemented this information with data abstracted from patient records, facility registries of gynecological obstetrical emergencies, and family planning registries. We analyzed data and developed regression models using STATA15. Thus, we compared changes in use of specific treatments and duration of hospitalization using a "difference-in-differences" analysis.

Results

The implementation of PAC strategy in Kinshasa referral hospitals has resulted in the utilization of WHO recommended uterine evacuation method MVA (29.3% more in the experimental structures, p = 0.025), a significant decline in sharp-curettage (19.3% less, p = 0.132), and a decline in the duration of hospitalization of patients admitted for PAC (1 day less, p = 0.020). We did not observe any change in the use of PAC services, mortality, and the provision of post abortion contraception.

Conclusion

Despite significant improvement in the management of PAC, the uptake in WHO approved technology—namely MVA, and the duration of hospitalization, these outcomes while a significant improvement for DRC, indicate that additional quality improvement strategies for management of PAC and risk-mitigating strategies to reduce barriers to care are required.

[Why does the Ebola virus epidemic continue to plague the Democratic Republic of the Congo?]

Why does the ebola virus epidemic continue to plague the democratic republic Of the congo?Ebola virus disease outbreak continues in North Kivu and Ituri provinces in the Democratic Republic of the Congo, despite a marked improvement in management of medical care and prevention of the disease. Since August 2018, the disease has been evolving in a complex epidemic field, forgotten by the international press. In the sensitive geopolitic context with this area of armed conflicts more than 20 years, we describe the socio-cultural and geopolitic parameters that have an impact on the evolution of disease in the eastern of Democratic Republic of the Congo.

Patients with severe schistosomiasis mansoni in Ituri Province, Democratic Republic of the Congo

BACKGROUND

Severe hepatosplenic complications arise in patients with chronic Schistosoma mansoni infection after heavy exposure to disease agents in endemic areas. These complications are rarely reported and, hence, underestimated.

CASE PRESENTATION

We report on eight patients with severe morbidity associated with S. mansoni infection in Ituri Province, northeastern Democratic Republic of Congo (DRC). The patients were identified during a community-based survey in 2017; one patient was seen at the district hospital. After taking the patients' history, a clinical examination and an abdominal ultrasonographical examination were performed. S. mansoni infection was diagnosed in fecal (Kato-Katz technique) and urine (point-of-case circulating cathodic antigen test) samples. These eight patients with severe intestinal and hepatosplenic complications were identified from four villages with high S. mansoni infection prevalence and related morbidity. The patients' ages ranged from 19 to 57 years; four patients were women. Three patients reported hematemesis. Two patients were severely anemic. All patients reported non-specific abdominal symptoms, such as diarrhea (six patients), abdominal pain (seven patients), and blood in the stool (five patients), as well as weight loss (two patients). Abdominal ultrasonography revealed ascites in four patients. All patients had portal hypertension with hepatomegaly (seven patients) or splenomegaly (five patients). Of the six patients with a discernable liver parenchyma pattern, five displayed pattern F and three patient displayed pattern E. Liver parenchyma was not visible for two patients with severe ascites. An S. mansoni infection was confirmed in six patients, with infection intensity ranging from light to heavy. All S. mansoni positive patients were treated with praziquantel (40 mg/kg body weight) and referred to the district hospital for follow-up. One patient with severe ascites died two weeks after we saw her. Due to security and accessibility reasons, the villages could not be visited again and the patients were lost to follow-up.

CONCLUSIONS

Our observations of patients with severe schistosomiasis document the severe degree of endemicity of S. mansoni in the province and suggest an urgent need for adequate schistosomiasis control measures that target vulnerable population groups and address severe complications.

Potential Parasitic Causes of Epilepsy in an Onchocerciasis Endemic Area in the Ituri Province, Democratic Republic of Congo

A high burden of epilepsy is observed in Africa where parasitological infections are endemic. In 2016, in an Onchocerciasis endemic area in the Logo health zone, in Ituri province in the Democratic Republic of Congo, a door-to-door study showed an epilepsy prevalence of 4.6%, and 50.6% of persons with epilepsy were infected with Onchocerca volvulus. In the current study, the serum of 195 people infected with O. volvulus persons with epilepsy were tested to determine the proportion of co-infections with Taenia solium, Toxocara canis and Strongyloides. These proportions were, respectively, 8.2, 18.5 and 12.8%. Persons with a T. solium co-infection were older than those without co-infection (p = 0.021). In six (37.5%) of the T. solium co-infected persons, the first seizures appeared after the age of 30 years compared to three (2.1%) persons without a co-infection (p < 0.0001). Our study suggests that an O. volvulus infection is the main parasitic cause of epilepsy in the Ituri province, but in some persons, mainly in those with late onset epilepsy and with focal seizures, the epilepsy may be caused by neurocysticercosis. As the population in the area rears pigs, activities to limit T. solium transmission should be implemented.

Formative research for the development of baby water, sanitation, and hygiene interventions for young children in the Democratic Republic of the Congo (REDUCE program)

BACKGROUND

Research exploring the unique exposure pathways to fecal pathogens for young children and innovative water, sanitation, and hygiene (WASH) interventions for susceptible pediatric populations is needed to reduce the burden of diarrheal diseases and stunting globally. The Reducing Enteropathy, Diarrhea, Undernutrition, and Contamination in the Environment (REDUCE) program seeks to 1) identify exposure pathways to fecal pathogens that are significant contributors to morbidity for young children in South Kivu, Democratic Republic of the Congo, and 2) develop and evaluate scalable interventions that reduce fecal contamination and exposure from these pathways. The formative research portion of the project sought to identify feasible and acceptable WASH interventions to modify behaviors found to be associated with diarrheal disease and impaired growth in our REDUCE cohort study.

METHODS

Ninety-one semi-structured interviews, 6 focus group discussions, and a pilot study of 102 households were conducted during 24 months of formative research. Thirty-one interviews and six focus group discussions were conducted with caregivers, community health workers, and village leaders to explore existing WASH practices and to identify barriers and facilitators to WASH behaviors. Findings were organized using the Integrated Behavioral Model for Water, Sanitation and Hygiene to facilitate interpretation and identify determinants to Baby WASH behaviors in this setting. Care Group modules and enabling technology were developed based on exploratory findings and then revised during a two-part, iterative pilot study. Sixty interviews were conducted with participants in a pilot study of the REDUCE Baby WASH Care Group modules to learn about their experiences with the intervention.

RESULTS

Six REDUCE Baby WASH Care Group modules were developed based on formative research findings and covered the following topics: 1) living with animals; 2) child mouthing of fomites and feces; 3) composting animal feces; 4) child feces disposal; 5) handwashing with soap; and 6) water treatment.

CONCLUSION

This study took a theory-driven and evidence-based approach to formative research and the development of the REDUCE Baby WASH Care Group modules. Intervention design focused on interrupting the exposure routes for infants and young children to fecal pathogens in the environment and promoting low-cost, low-burden Baby WASH behavioral recommendations and enabling technology. These developed REDUCE Baby WASH Care Group modules are currently being rolled out to over 1,000,000 beneficiaries in Democratic Republic of the Congo.

A comparison of the international protocols for the forensic assessment of conflict-related sexual violence victims

International protocols for forensic investigations are often created by committee and in isolation. When field tested, the results of such tests are rarely reported to the wider forensic community. This study presents a comparative study of one such protocol, the International Protocol on the Documentation and Investigation of Sexual Violence in Conflict: Best Practice in the Documentation of Sexual Violence as a Crime or Violation of International Law. The protocol was used in a pilot study involving 20 victims of conflict-related sexual assault in the Democratic Republic of the Congo (DRC). The results of the pilot study were compared with an existing database of 341 victims of sexual assault (also from the same region of the DRC) who were examined using another protocol developed and utilized by Medicins Sans Frontier (MSF). The results clearly indicate the international protocol was far superior in all aspects, including comprehensive data capture and ease-of-use. Although the MSF protocol is intended for humanitarian purposes, all medical records are subject to potential downstream forensic applications. Given constraints in funding and resources in conflict zones, the wide-spread adoption of the full international protocol would ensure that every victim receives a complete, forensically valid examination suitable for the future pursuit of justice.

Decreased number of hospitalized children with severe acute lower respiratory infection after introduction of the pneumococcal conjugate vaccine in the Eastern Democratic Republic of the Congo

Introduction

acute lower respiratory infections (ALRI) are a leading killer of children under five worldwide including the Democratic Republic of the Congo (DR Congo). We aimed to determine the morbidity and case fatality rate due to ALRI before and after introduction of the 13-valent pneumococcal conjugate vaccine (PVC13) in DR Congo 2013.

Methods

data were collected from medical records of children with a diagnosis of ALRI, aged from 2 to 59 months, treated at four hospitals in the Eastern DR Congo. Two study periods were defined; from 2010 to 2012 (before introduction of PCV13) and from 2014 to 2015 (after PCV13 introduction).

Results

out of 21,478 children admitted to the hospitals during 2010-2015, 2,007 were treated for ALRI. The case fatality rate among these children was 4.9%. Death was significantly and independently associated with malnutrition, severe ALRI, congenital disease and symptoms of fatigue. Among the ALRI hospitalised children severe ALRI decreased from 31% per year to 18% per year after vaccine introduction (p = 0.0002) while the fatality rate remained unchanged between the two study periods. Following introduction of PCV13, 63% of the children diagnosed with ALRI were treated with ampicillin combined with gentamicin while 33% received ceftriaxone and gentamicin.

Conclusion

three years after PCV13 introduction in the Eastern part of the DR Congo, we found a reduced risk of severe ALRI among children below five years. Broad-spectrum antibiotics were frequently used for the treatment of ALRI in the absence of any microbiological diagnostic support.

A New Variant Among Newcastle Disease Viruses Isolated in the Democratic Republic of the Congo in 2018 and 2019

Newcastle disease (ND) is a highly transmissible and devastating disease that affects poultry and wild birds worldwide. Comprehensive knowledge regarding the characteristics and epidemiological factors of the ND virus (NDV) is critical for the control and prevention of ND. Effective vaccinations can prevent and control the spread of the NDV in poultry populations. For decades, the Democratic Republic of the Congo (DRC) has reported the impacts of ND on commercial and traditional poultry farming systems. The reports were preliminary clinical observations, and few cases were confirmed in the laboratory. However, data on the phylogenetic, genetic, and virological characteristics of NDVs circulating in the DRC are not available. In this study, the whole-genome sequences of three NDV isolates obtained using the next-generation sequencing method revealed two isolates that were a new variant of NDV, and one isolate that was clustered in the subgenotype VII.2. All DRC isolates were velogenic and were antigenically closely related to the vaccine strains. Our findings reveal that despite the circulation of the new variant, ND can be controlled in the DRC using the current vaccine. However, epidemiological studies should be conducted to elucidate the endemicity of the disease so that better control strategies can be implemented.

Child Mouthing of Feces and Fomites and Animal Contact are Associated with Diarrhea and Impaired Growth Among Young Children in the Democratic Republic of the Congo: A Prospective Cohort Study (REDUCE Program)

OBJECTIVE

To identify exposure pathways to fecal pathogens that are significant contributors to diarrheal diseases and impaired growth in young children, and to evaluate scalable interventions to reduce fecal contamination from these pathways.

STUDY DESIGN

Reducing Enteropathy, Undernutrition, and Contamination in the Environment (REDUCE) was a prospective cohort study of 370 children <5 years of age was conducted in Walungu Territory, South Kivu, Democratic Republic of the Congo. Child mouthing behaviors were assessed through caregiver reports and 5-hour structured observations. Caregiver reports of child contact with animals and child diarrhea were also obtained. Anthropometric measurements were collected at baseline and at a 6-month follow-up.

RESULTS

Children observed putting soil in their mouth during structured observation at baseline had a significantly higher odds of diarrhea at the 6-month follow-up (OR, 1.79; 95% CI, 1.04 to 3.07). Children observed mouthing feces during structured observation had a significant reduction in height-for-age z-score (HAZ) from baseline to the 6-month follow-up (ΔHAZ, -0.69; 95% CI, -1.34 to -0.04). A significant reduction in HAZ was also observed for children with caregiver reports of touching guinea pigs (-0.33; 95% CI, -0.58 to -0.08) and rabbits (-0.34; 95% CI, -0.64 to -0.04) and children with feces in their sleeping space during unannounced spot checks (-0.41; 95% CI, -0.74 to -0.09).

CONCLUSIONS

These findings emphasize the urgent need for infant water, sanitation, and hygiene interventions targeting child mouthing behaviors, fecal contamination in child living spaces, and child contact with domestic animals to reduce exposure to fecal pathogens among susceptible populations.

Occupational COVID-19 Prevention among Congolese Healthcare Workers: Knowledge, Practices, PPE Compliance, and Safety Imperatives

The SARS-CoV-2 (COVID-19) pandemic has had a tremendous impact on the functionality of health systems and world affairs. We assessed knowledge, attitudes, and practices (KAPs) of healthcare workers (HCWs) in the Democratic Republic of the Congo (DRC). This was a cross-sectional study conducted in 23 referral hospitals located in three towns of the DRC (Lubumbashi, Kamina, Mbuji-Mayi). In total, 613 HCWs were surveyed using the World Health Organization's (WHO's) "Exposure Risk Assessment in the Context of COVID-19" questionnaire. Participants included medical doctors (27.2%) and other categories of HCWs (72.8%). The mean age was 40.3 ± 11.7 years. Over 80% (range: 83-96%) of respondents had sufficient knowledge on each of the three domains: COVID-19 symptoms, disease transmission, and patient care approach. However, attitudes and practices scores were relatively low. Only 27.7% of HCWs were willing to receive a COVID-19 vaccine when it is available, whereas 55% of HCWs complied with good practices; 49.4% wore masks consistently and, surprisingly, only 54.9% used personal protective equipment (PPE) consistently at work and during contact with patients. Knowledge level was positively associated with the use of social media as a primary source of COVID-19-related information and the category of residence, with HCWs from towns already affected by the COVID-19 epidemic being more likely to have positive attitudes (adjusted OR, 1.64; 95%CI, 1.32-2.20) and comply with good practices (aOR, 2.79; 95%CI, 1.93-4.06). This study showed that most Congolese HCWs had sufficient knowledge on COVID-19, whereas the majority did not comply with consistent PPE use. The government of the DRC should urgently take major steps in capacity building for HCWs in outbreak preparedness and supplying hospitals with PPE.

Midwives' integration of post abortion manual vacuum aspiration in the Democratic Republic of Congo: a mixed methods case study & positive deviance assessment

Background

Despite a recognized need for midwives to provide post abortion care, there exist barriers preventing them from integrating lifesaving skills such as manual vacuum aspiration (MVA) into practice. This collaborative research with the Professional Association of Congolese Midwives (SCOSAF), sought to understand how certain midwives in the Democratic Republic of Congo (DRC) have overcome barriers to successfully integrate MVA for post abortion care. Specifically, in order to provide locally-driven solutions to the problem of inadequate post abortion care in the DRC, this study aimed to identify examples of positive deviance, or midwives who had successfully integrated MVA in complex working environments following an in-service training facilitated by their midwifery association, SCOSAF.

Methods

Creswell’s mixed method comparative case study design was used to identify positive deviant midwives who had practiced MVA one or more times post training and to explore their strategies and enabling factors. Other midwives who had not practiced MVA post training permitted for a comparison gro cup and further interpretations. Sources of data included a sequential survey and semi-structured interviews.

Results

All 102 midwives invited to be surveyed were recruited and 34% reported practicing MVA post training (positive deviant midwives). No statistical significance was found between the two groups’ demographics and practice facility type. Overall, both groups had positive attitudes regarding midwifery-led MVA and legalization of abortion. Positive deviant midwives demonstrated and described more confidence and competence to practice and teach MVA. They were more likely to identify as teachers and overcome interprofessional barriers by teaching MVA to physicians, medical students and other midwives and position themselves as experts during post abortion emergencies.

Conclusion

Results provided important insight to midwives’ integration of post abortion care in Kinshasa. Strategies used by positive deviant midwives in emergencies allowed them to navigate challenging contexts in order to practice MVA, while simultaneously increasing the credibility of their profession and the dissemination of evidenced-based MVA practice. Programs designed to work with and promote positive deviant midwives as knowledge brokers could be tested for their overall impact on the diffusion of midwifery-led MVA to improve access to safe, respectful reproductive care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05997-7.

Risk factors for Ebola exposure in healthcare workers in Boende, Tshuapa Province, Democratic Republic of the Congo

Healthcare workers (HCW) are more likely to be exposed to Ebola virus (EBOV) during an outbreak compared to people in the general population due to close physical contact with patients and potential exposure to infectious fluids. However, not all will fall ill. Despite evidence of subclinical and paucisymptomatic Ebola Virus Disease (EVD), the prevalence and associated risk factors remains unknown. We conducted a serosurvey among healthcare workers in the town of Boende in Tshuapa Province, Democratic Republic of Congo (DRC). Human anti-EBOV Glycoprotein (GP) IgG titers were measured using a commercially available ELISA kit. We assessed associations between anti-EBOV IgG seroreactivity, defined as ≥2.5 units/mL and risk factors using univariable and multivariable logistic regression. Sensitivity analyses explored a more conservative cutoff >5 units/mL. Overall, 22.5% of HCWs were seroreactive for EBOV. In multivariable analyses, using any form of personal protective equipment (PPE) when interacting with a confirmed, probable, or suspect EVD case was negatively associated with seroreactivity [0.23 (95% CI: 0.07, 0.73)]. Our results suggest high exposure to EBOV among HCWs and provide additional evidence for asymptomatic or minimally symptomatic EVD. Further studies should be conducted to determine the probability of onward transmission and if seroreactivity is associated with immunity.

DNA analysis reveals non-falciparum malaria in the Democratic Republic of the Congo

BACKGROUND

The World Health Organization (WHO) attributes the entirety of malaria infection and transmission in the Democratic Republic of the Congo (DRC) to Plasmodium falciparum, one of the several species of malaria known to infect humans. Recent studies have put forth some evidence that transmission of Plasmodium vivax may also be occurring in the DRC. As interventions and treatments differ between malaria species, it is crucial to maintain the most accurate understanding of malaria species diversity in each region.

METHODS

Blood samples were taken from aymptomatic children 0-5 years old living in three regions of the DRC in 2014. For this study, samples were taken from a larger pool of samples, collected as part of a population-based survey in three regions. Plasmodium infection was screened for using nested polymerase chain reaction (PCR) assays and species were confirmed by cloning and DNA sequencing.

RESULTS

Of 336 samples screened by PCR, 62.2% (n=209) initially tested positive for P. falciparum and 14.6% (n=49) initially tested positive for P. vivax. Sanger sequencing was performed on PCR-positive Plasmodium samples to confirm identity of Plasmodium species. Sequencing showed Plasmodium malariae in one blood sample and Plasmodium ovale in another sample. Plasmodium vivax was detected in 12/65 cases (18.5%). Overall, 14/65 sequenced cases (21.5%) were infected with a non-falciparum malaria. 330bp 18s P. vivax DNA sequences were obtained.

CONCLUSIONS

This study reveals Plasmodium vivax and other non-falciparum malaria across several regions of the DRC, and enforces the importance of further testing and more precise diagnostics when testing for and treating malaria in the DRC. Here, we find a higher proportion of cases of P. vivax malaria than found in previous studies. This is the most robust DNA sequencing of Plasmodium vivax in the DRC to date.

Analytical Performance of the Exacto Test HIV Self-Test: A Cross-Sectional Field Study in the Democratic Republic of the Congo

The Democratic Republic of the Congo (DRC) has begun implementing HIV self-testing to boost the first “95” of the UNAIDS 95-95-95 targets by 2025. This study aims to assess the performance and usability of the Exacto Test HIV (Biosynex, Strasbourg, France) self-test in the lab and in the field. The Exacto Test HIV self-test demonstrated high virological performance (sensitivity, 99.6%; specificity, 100%) in the lab and in the field in the hand of untrained users (sensitivity, 100%; specificity, 98.9%). Taken together, the excellent performance and usability characteristics of the Exacto Test HIV (Biosynex) self-test make the kit a viable option for HIV self-testing in the DRC.

Increased HIV in Greater Kinshasa Urban Health Zones: Democratic Republic of Congo (2017-2018)

BACKGROUND

Diagnosis of people living with HIV (PLHIV) is the first step toward achieving the new Fast Track Strategy to end AIDS by 2030: 95-95-95. However, reaching PLHIV is especially difficult in resource-limited settings such as the Democratic Republic of Congo (DRC), where reliable prevalence data is lacking. This study evaluated the prevalence of HIV in patients in the urban Kinshasa area.

METHODS

Individuals seeking healthcare were tested for HIV between February 2017 and July 2018 at existing Kinshasa urban clinics. The study was conducted in two phases. Case finding was optimized in a pilot study phase using a modified cell phone-based Open\Data Kit (ODK) collection system. HIV prevalence was then determined from data obtained between March-July of 2018 from 8320 individuals over the age of 18 years receiving care at one of 47 clinics in Kinshasa.

RESULTS

The prevalence of HIV in our study was 11.0% (95% CI 10.3-11.6%) overall and 8.14% in the subset of N = 1240 participants who were healthy mothers seeking prenatal care. These results are in sharp contrast to President's Emergency Plan for AIDS Relief (PEPFAR) estimates of 2.86%, but are consistent with data from surrounding countries.

CONCLUSION

While this data is sub-national and reflects an urban healthcare setting, given the large population of Kinshasa and rapidly changing age demographics, the results suggest that HIV prevalence in the DRC is substantially higher than previously reported.

Assessing conservation attitudes and behaviors of Congolese children neighboring the world's first bonobo (Pan paniscus) release site

Poaching and habitat destruction in the Congo Basin threaten African great apes including the bonobo (Pan paniscus), chimpanzees (Pan troglodytes), and gorillas (Gorilla spp.) with extinction. One way to combat extinction is to reintroduce rescued and rehabilitated apes and repopulate native habitats. Reintroduction programs are only successful if they are supported by local populations. Ekolo ya Bonobo, located in Equateur province of the Democratic Republic of Congo (DRC), is the world's only reintroduction site for rehabilitated bonobos. Here we assess whether children, of the Ilonga-Pôo, living adjacent to Ekolo ya Bonobo demonstrate more pro-ape conservation attitudes than children living in, Kinshasa, the capital city. We examined children's attitudes toward great apes because children are typically the focus of conservation education programs. We used the Great Ape Attitude Questionnaire to test the Contact Hypothesis, which posits that proximity to great ape habitat influences pro-conservation attitudes toward great apes. Ilonga-Pôo children who live in closer contact with wild bonobos felt greater responsibility to protect great apes compared to those in Kinshasa who live outside the natural habitat of great apes. These results suggest that among participants in the DRC, spatial proximity to a species fosters a greater sense of responsibility to protect and conserve. These results have implications for the successful implementation of great ape reintroduction programs in the Congo Basin. The data analyzed in this study were collected in 2010 and therefore provide a baseline for longitudinal study of this reintroduction site.

The Impact of Different Types of Violence on Ebola Virus Transmission During the 2018-2020 Outbreak in the Democratic Republic of the Congo

BACKGROUND

Our understanding of the different effects of targeted versus nontargeted violence on Ebola virus (EBOV) transmission in Democratic Republic of the Congo (DRC) is limited.

METHODS

We used time-series data of case counts to compare individuals in Ebola-affected health zones in DRC, April 2018-August 2019. Exposure was number of violent events per health zone, categorized into Ebola-targeted or Ebola-untargeted, and into civilian-induced, (para)military/political, or protests. Outcome was estimated daily reproduction number (Rt) by health zone. We fit linear time-series regression to model the relationship.

RESULTS

Average Rt was 1.06 (95% confidence interval [CI], 1.02-1.11). A mean of 2.92 violent events resulted in cumulative absolute increase in Rt of 0.10 (95% CI, .05-.15). More violent events increased EBOV transmission (P = .03). Considering violent events in the 95th percentile over a 21-day interval and its relative impact on Rt, Ebola-targeted events corresponded to Rt of 1.52 (95% CI, 1.30-1.74), while civilian-induced events corresponded to Rt of 1.43 (95% CI, 1.21-1.35). Untargeted events corresponded to Rt of 1.18 (95% CI, 1.02-1.35); among these, militia/political or ville morte events increased transmission.

CONCLUSIONS

Ebola-targeted violence, primarily driven by civilian-induced events, had the largest impact on EBOV transmission.

Comparison of practicability and effectiveness between unassisted HIV self-testing and directly assisted HIV self-testing in the Democratic Republic of the Congo: a randomized feasibility trial

Background

HIV self-testing (HIVST) can be performed using directly assisted and unassisted approaches in facilities or communities to reach different populations. The aim of this study was to compare the practicability and effectiveness of the two delivery approaches for HIVST, unassisted HIVST (UH) and directly assisted HIVST (DAH), in the field setting of Kisangani, the Democratic Republic of the Congo (DRC).

Methods

A randomized (1:1), non-blinded, non-inferiority trial using a blood-based and facility-based HIVST method was carried out in four facilities in Kisangani, the DRC, targeting populations at high risk for HIV infection. The primary outcome was the difference in the practicability of the HIV self-test between the two arms. Practicability was defined as successfully performing the test and correctly interpreting the result. Requests for assistance, positivity rate, linkage to care, and willingness to buy an HIV self-test kit constituted the secondary outcomes for HIVST effectiveness. The adjusted risk ratios (aRRs) were calculated using Poisson regression.

Results

The rate of successfully performing the test was same (93.2%) in the UH and DAH arms. The rate of correctly interpreting the results was 86.9% in the UH arm versus 93.2% in the DAH arm, for a difference of − 6.3%. After the follow-up 72 h later, participants in the UH arm had a significantly lower chance of correctly interpreting the test results than those in the DAH arm (aRR: 0.60; P = 0.019). Although the positivity rate was 3.4% among the participants in the DAH arm and 1.7% among those in the UH arm, no significant differences were found between the two arms in the positivity rate, requests for assistance, and linkage to care. Willingness to buy an HIV self-test was higher in the UH arm than in the DAH arm (92.3% versus 74.1%; aRR: 4.20; P < 0.001).

Conclusion

The results of this study indicate that UH is as practicable and effective as DAH among individuals at high risk for HIV infection in Kisangani, the DRC. However, additional support tools need to be assessed to improve the interpretation of the self-test results when using the UH approach.

Trial registration

PACTR201904546865585. Registered 03 April 2019 - Retrospectively registered, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=6032

Child hand contamination is associated with subsequent pediatric diarrhea in rural Democratic Republic of the Congo (REDUCE Program)

OBJECTIVE

The Reducing Enteropathy, Undernutrition, and Contamination in the Environment (REDUCE) program focuses on identifying exposure pathways to faecal pathogens for young children in the Democratic Republic of the Congo (DRC) and on developing scalable interventions to reduce faecal contamination from these pathways.

METHODS

A prospective cohort study of 690 participants was conducted to investigate the association between hand, food, and environmental faecal contamination and diarrhoeal disease prevalence among young children in Walungu Territory, South Kivu, DRC. A total of 1923 hand rinse, soil, food, object, surface, stored water and water source samples were collected during unannounced spot checks after baseline enrolment and analysed for Escherichia coli. Caregiver reports of diarrhoea were obtained from children < 5 years at a 6-month follow-up.

RESULTS

E.coli was detected in 73% of child and caregiver hand-rinse samples, 69% of soil samples from child play spaces, 54% of child food samples, 38% of objects and surfaces children were observed putting in their mouths, 74% of stored water samples, and 40% of source water samples. Children < 5 years with E. coli on their hands had significantly higher odds of diarrhoea at the 6-month follow-up (odds ratio: 2.03 (95% confidence interval: 1.05, 3.92)).

CONCLUSION

The cohort study findings from the REDUCE program have shown that child hand contamination is associated with diarrhoeal disease in rural DRC, and that there is high faecal contamination in child plays spaces and food. These findings provide evidence demonstrating the urgent need to provide clean play spaces for young children and interventions targeting hand hygiene to reduce paediatric exposure to faecal pathogens.

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.

Predictors of AIDS-related death among adult HIV-infected inpatients in Kisangani, the Democratic Republic of Congo

Introduction

Human Immunodeficiency Virus (HIV) infection continues to be a major public health concern in sub-Saharan Africa. We aimed to evaluate potential factors associated with AIDS-related death among adult HIV-infected inpatients in Kisangani, the Democratic Republic of the Congo (DRC).

Methods

this is a hospital-based retrospective, observational analysis carried out between 1^st January 2019 and 31^st March 2020 among inpatients HIV, at 12 facilities integrating the HIV prevention and care packages in Kisangani. Factors associated with AIDS-related death were analyzed using the logistic regression models.

Results

a total of 347 HIV-infected inpatients were included. Among those, the rate of AIDS-related death was 25.1% (95% CI: 20.8-29.9). The rates of AIDS-related death were lower among patients with a university education (aOR: 0.03 [95% CI: 0.00-1.0]) and higher among patients in WHO clinical stage 4 (aOR: 15.4 [6.8-27.8]), patients with poor highly active antiretroviral therapy (HAART) observance (aOR: 14.5 [2.3-40.4), and patients suffering from opportunistic infections (aOR: 9.3 [95% CI: 3.4-25.1]), including cryptococcal meningitis (aOR: 27 [95% CI: 6.0-125.7]) and viral infections associated with zona and Kaposi sarcoma (aOR: 4.8 [95% CI: 2.2-10.4]).

Conclusion

in our retrospective study on a large sample of inpatients hospitalized in Kisangani, classic causes of death were found. The association with the low level of education suggests that the economic level of the patients who die is a determining factor, difficult to correct. The identification of a limited number of other factors will allow a better medical management.

Predictors of mortality in COVID-19 patients at Kinshasa University Hospital, Democratic Republic of the Congo, from March to June 2020

Introduction

since the 1^st case of coronavirus disease 2019 (COVID-19) in Kinshasa on March 10^th2020, mortality risk factors have not yet been reported. The objectives of the present study were to assess survival and to identify predictors of mortality in COVID-19 patients at Kinshasa University Hospital.

Methods

a retrospective cohort study was conducted, 141 COVID-19 patients admitted at the Kinshasa University Hospital from March 23 to June 15, 2020 were included in the study. Kaplan Meier's method was used to described survival. Predictors of mortality were identified by COX regression models.

Results

of the 141 patients admitted with COVID-19, 67.4 % were men (sex ratio 2H: 1F); their average age was 49.6±16.5 years. The mortality rate in hospitalized patients with COVID-19 was 29% during the study period with 70% deceased within 24 hours of admission. Survival was decreased with the presence of hypertension, diabetes mellitus, low blood oxygen saturation (BOS), severe or critical stage disease. In multivariate analysis, age between 40 and 59 years [adjusted Hazard Ratio (aHR): 4.07; 95% CI: 1.16 - 8.30], age at least 60 years (aHR: 6.65; 95% CI: 1.48-8.88), severe or critical COVID-19 (aHR: 14.05; 95% CI: 6.3-15.67) and presence of dyspnea (aHR: 5.67; 95% CI: 1.46-21.98) were independently and significantly associated with the risk of death.

Conclusion

older age, severe or critical COVID-19 and dyspnea on admission were potential predictors of mortality in patients with COVID-19. These predictors may help clinicians identify patients with a poor prognosis.

Multi-model forecasts of the ongoing Ebola epidemic in the Democratic Republic of Congo, March-October 2019

The 2018–2020 Ebola outbreak in the Democratic Republic of the Congo is the first to occur in an armed conflict zone. The resulting impact on population movement, treatment centres and surveillance has created an unprecedented challenge for real-time epidemic forecasting. Most standard mathematical models cannot capture the observed incidence trajectory when it deviates from a traditional epidemic logistic curve. We fit seven dynamic models of increasing complexity to the incidence data published in the World Health Organization Situation Reports, after adjusting for reporting delays. These models include a simple logistic model, a Richards model, an endemic Richards model, a double logistic growth model, a multi-model approach and two sub-epidemic models. We analyse model fit to the data and compare real-time forecasts throughout the ongoing epidemic across 29 weeks from 11 March to 23 September 2019. We observe that the modest extensions presented allow for capturing a wide range of epidemic behaviour. The multi-model approach yields the most reliable forecasts on average for this application, and the presented extensions improve model flexibility and forecasting accuracy, even in the context of limited epidemiological data.

Antenatal care utilization in the fragile and conflict-affected context of the Democratic Republic of the Congo

Maternal mortality represents one of the widest gaps between developed and developing countries. Ninety-nine percent of maternal deaths occur in developing countries, with over half occurring in sub-Saharan Africa. This health indicator became a global priority when the United Nations' Sustainable Development Goal 3.1 set out to decrease the global maternal mortality rate to less than 70 per 100 000 births by 2030. In the Democratic Republic of the Congo (DRC), 473 of every 100 000 women who give birth die due to pregnancy-related complications. These deaths could be prevented through enhanced access and utilization of antenatal care services and skilled birth attendants. However, amid prolonged conflict, violence, and authoritarian governments, the Democratic Republic of the Congo has been classified as a fragile and conflict-affected situation and women are prone to face difficulties accessing maternal health services. This study examined the utilization of antenatal care and skilled birth attendants in the Democratic Republic of Congo using logistic regressions. Our findings show that women living in regions with extremely high levels of prolonged conflict were significantly less likely than those in regions with moderate levels of conflict to have their first antenatal care visit within the first trimester (OR = 0.29, p < 0.01), and to have four visits (OR = 0.46, p < 0.01). Overall, women in regions with extremely high levels of conflict (OR = 0.41, p < 0.01) were less likely to meet the World Health Organization's antenatal care recommendations compared to those in regions with moderate levels of conflict. The findings suggest that conflict-affected countries, such as the Democratic Republic of the Congo, require context-specific interventions if progress is to be made towards achieving Sustainable Development Goal 3.1.

Molecular characterization of rabies viruses from two western provinces of the Democratic Republic of the Congo (2008-2017)

Although rabies is enzootic in the Democratic Republic of the Congo, there is very little molecular epidemiological information about the viruses circulating in animals. In this study, a fragment of the rabies virus (RABV) nucleoprotein gene was amplified and sequenced from 21 animal brain samples collected in two western provinces of the country between 2008 and 2017. The samples tested were from cat (n = 1), dog (n = 17), goat (n = 2), and sheep (n = 1). Phylogenetic analysis revealed that the sequences generated were highly similar to each other and belonged to lineage Africa 1b clustering with a single sample identified in a canine in the Republic of Congo in 2014. This is the first molecular epidemiological study of RABV in the DRC and the data generated will assist authorities in the development of effective control strategies for rabies in the country.

Current status of resistance to antibiotics in the Democratic Republic of the Congo: A review

A review of literature was conducted to assess the prevalence and mechanisms of antibiotic resistance to date, mainly to β-lactam antibiotics, cephalosporins, carbapenems, colistin, and tigecycline in the Democratic Republic of the Congo (DRC). English and French publications were listed and analysed using PubMed/Medline, Google Scholar, and African Journals database between 1 January 1990 and 31 December 2019. For the 30 published articles found: (1) bacterial resistance to antibiotics concerned both Gram-negative and Gram-positive bacteria; (2) multidrug resistance prevalence was the same in half of Streptococcus pneumoniae isolates; (3) a worrying prevalence of methicillin-resistant Staphylococcus aureus (MRSA) was noted, which is associated with co-resistance to several other antibiotics; and (4) resistance to third-generation cephalosporins was very high in Enterobacteriaceae, mainly because of bla_CTX-M-1 group and bla_SHV genes. Data on carbapenem and colistin resistance were not available in DRC until recently. Further work is required to set up a surveillance system for antibiotic resistance in DRC.

Comparisons of social and demographic determinants of tobacco use in the Democratic Republic of the Congo

BACKGROUND

Worldwide, tobacco use has caused over 100 million deaths in the twentieth century and is projected to cause death in up to one billion people in the twenty-first century. It is a leading cause of early death and disability in over 100 countries and accounts for over 11% of global deaths, disproportionately affecting low- and middle-income countries. The purpose of the study was to examine a variety of social determinants of tobacco use in the Democratic Republic of the Congo, including region, sex, ethnicity, education, literacy, wealth index and place of residence, to gain insights with regard to tobacco use among sub-national groups.

METHODS

This project was a secondary data analysis of the 2013-2014 Demographics and Health Survey (DHS) for the Democratic Republic of the Congo. Logistic regressions predicting smoking, use of snuff and smoking cigars or natural tobacco as dichotomous variables were conducted. Independent variables included age, educational level, religion, rurality, literacy, wealth index, occupation and ethnicity.

RESULTS

Tobacco use is highest among those with less education and low literacy. It was also highest among the working poor. Older age and living in larger cities were predictive of smoking, although the relationship between age and smoking was not linear. There was a strong linear effect for wealth. Being in a professional, technical or managerial position was highly protective against smoking while being engaged in services, skilled and unskilled manual labor, and the army had significantly greater odds of smoking.

CONCLUSIONS

Data indicate that tobacco use in the DRC, as is common in the developing world, is heavily concentrated in the working poor with lower educational status. Higher educational status is consistently predictive of avoiding tobacco use. Additionally, examining only national-level data to ascertain tobacco use levels and patterns may lead to mistaken conclusions that can lead to inefficient and ineffective allocation of resources aimed at controlling tobacco use.

Quality of antimalarials in Kinshasa peri-urban areas with regard to local pharmaceutical legislation and regulation

BACKGROUND

In the context of old pharmaceutical legislation and regulations not adapted to current realities, the aim of the present study was to evaluate the existing pharmaceutical system in peri-urban areas of Kinshasa.

METHODS

A prospective study was carried out during the period 2016-2018. The most used antimalarial medicines were identified through household and pharmaceutical establishment surveys. The samples of the obtained medicines were assayed with generic separation methods using the high-performance liquid chromatography technique coupled to a diode array detector. The registration status was checked for 126 antimalarial brand names. A characterization was carried out in 196 pharmaceutical establishments on the basis of standards set out by the Ministry of Health.

RESULTS

Of the 75 samples assayed, 19% (14/75) were non-compliant. Of the 124 brand names, 46.0% (57/124) were unlicensed and 14.5% (18/124) had an expired licence. Of the 196 pharmaceutical establishments, only 2 (1.0%) had an authorization to practice, none met all the Ministry of Health minimum standards and 24.5% (48/196) met the World Health Organization Guidelines for the Storage of Essential Medicines and Other Health Commodities.

CONCLUSIONS

More resources should be mobilized to apply regulator sanctions.

Screening Strategies for a Sustainable Endpoint for Gambiense Sleeping Sickness

BACKGROUND

Gambiense human African trypanosomiasis ([gHAT] sleeping sickness) is a vector-borne disease that is typically fatal without treatment. Intensified, mainly medical-based, interventions in endemic areas have reduced the occurrence of gHAT to historically low levels. However, persistent regions, primarily in the Democratic Republic of Congo (DRC), remain a challenge to achieving the World Health Organization's goal of global elimination of transmission (EOT).

METHODS

We used stochastic models of gHAT transmission fitted to DRC case data and explored patterns of regional reporting and extinction. The time to EOT at a health zone scale (~100 000 people) and how an absence of reported cases informs about EOT was quantified.

RESULTS

Regional epidemiology and level of active screening (AS) both influenced the predicted time to EOT. Different AS cessation criteria had similar expected infection dynamics, and recrudescence of infection was unlikely. However, whether EOT has been achieved when AS ends is critically dependent on the stopping criteria. Two or three consecutive years of no detected cases provided greater confidence of EOT compared with a single year (~66%-75% and ~82%-84% probability of EOT, respectively, compared with 31%-51%).

CONCLUSIONS

Multiple years of AS without case detections is a valuable measure to assess the likelihood that the EOT target has been met locally.

Salmonella Typhi From Blood Cultures in the Democratic Republic of the Congo: A 10-Year Surveillance

Background

This study gives an overview of a decade (2007–2017) of hospital-based Salmonella Typhi bloodstream infection (BSI) surveillance in the Democratic Republic of the Congo (DRC), at 4 main sampling sites.

Methods

Blood cultures were sampled in hospital-admitted patients with suspected BSI, according to standardized clinical indications. The results of the surveillance period 2015–2017 were compiled with those of previous surveillance periods (2007–2010 and 2011–2014). Whole genome sequencing of isolates with decreased ciprofloxacin susceptibility (DCS) was performed.

Results

Salmonella Typhi was isolated in 1.4% (531/37 388) and 10.3% (531/5177) of suspected and culture-confirmed BSI episodes, respectively. Salmonella Typhi ranked first among the BSI pathogens in adults (n = 220), but was mostly (n = 301 [56.7%]) isolated from children, of which 72.1% (217/301) and 31.6% (95/301) were <10 years and <5 years old, respectively. Multidrug resistance (MDR), DCS, and combined MDR/DCS were found in 38.3% (n = 180), 24.5% (n = 115), and 11.9% (n = 56) of 470 first isolates, respectively. MDR and DCS rates had increased since 2007, but remained stable during 2015–2017 with no geographical clustering at the province level. Most (91/93 [97.8%]) DCS isolates sequenced belonged to Genotyphi genotype 2.5.1, and gyr S83 was the most frequent DCS mutation (76/93 [81.7%]). Infections occurred perennially, but increased during the rainy season.

Conclusions

Salmonella Typhi was a frequent cause of BSI in adults and children in DRC, with high rates of antibiotic resistance. Sustainable surveillance and implementation of vaccination are compelling.

[Medical laboratories and quality of care: the most neglected components of rural hospitals in the Democratic Republic of the Congo]

INTRODUCTION

Quality of care is essential to save people living with different diseases. However, inappropriate diagnosis may in no case lead to proper patient management as well as to quality of care. We conducted a cross-sectional descriptive analysis in three laboratories at the General Hospitals in the Democratic Republic of the Congo.

METHODS

A team of national experts in the field of laboratories conducted a survey in the three clinical laboratories of the General Hospitals in the Democratic Republic of the Congo. Observations, visits and structured interviews using a questionnaire were used to assess the performance of these clinical laboratories. We also used a national evaluation guidance for the assessment of laboratories.

RESULTS

The clinical laboratories of the General Hospitals visited showed many deficits, in particular, in infrastructures, in the basic and continuous training of the personnel, in the equipment, in supervision and quality control. Technical performances of these laboratories were not adapted to meet the needs of the population with regard to diseases frequently encountered in these areas. We also noted that these laboratories are little or almost not assisted and that there was no coordination team dedicated to the supervision and the assessment of laboratories in the hospital or even in the health zone. In addition, technicians working in their different laboratories had not been supervised over many years.

CONCLUSION

Clinical laboratory improvement would allow for proper diagnosis of different diseases. This improvement should take into account local diseases. Within the system, it is important to devote more attention to clinical laboratories. Advocacy for this neglected component of the health system is necessary, as this situation could be the same in many developing countries.

Dynamics of conflict during the Ebola outbreak in the Democratic Republic of the Congo 2018-2019

BACKGROUND

The 2018-2019 Ebola virus disease (EVD) outbreak in North Kivu and Ituri provinces in the Democratic Republic of the Congo (DRC) is the largest ever recorded in the DRC. It has been declared a Public Health Emergency of International Concern. The outbreak emerged in a region of chronic conflict and insecurity, and directed attacks against health care workers may have interfered with disease response activities. Our study characterizes and quantifies the broader conflict dynamics over the course of the outbreak by pairing epidemiological and all available spatial conflict data.

METHODS

We build a set of conflict variables by mapping the spatial locations of all conflict events and their associated deaths in each of the affected health zones in North Kivu and Ituri, eastern DRC, before and during the outbreak. Using these data, we compare patterns of conflict before and during the outbreak in affected health zones and those not affected. We then test whether conflict is correlated with increased EVD transmission at the health zone level.

FINDINGS

The incidence of conflict events per capita is ~ 600 times more likely in Ituri and North Kivu than for the rest of the DRC. We identified 15 time periods of substantial uninterrupted transmission across 11 health zones and a total of 120 bi-weeks. We do not find significant short-term associations between the bi-week reproduction numbers and the number of conflicts. However, we do find that the incidence of conflict per capita was correlated with the incidence of EVD per capita at the health zone level for the entire outbreak (Pearson's r = 0.33, 95% CI 0.05-0.57). In the two provinces, the monthly number of conflict events also increased by a factor of 2.7 in Ebola-affected health zones (p value < 0.05) compared to 2.0 where no transmission was reported and 1.3 in the rest of the DRC, in the period between February 2019 and July 2019.

CONCLUSION

We characterized the association between variables documenting broad conflict levels and EVD transmission. Such assessment is important to understand if and how such conflict variables could be used to inform the outbreak response. We found that while these variables can help characterize long-term challenges and susceptibilities of the different regions they provide little insight on the short-term dynamics of EVD transmission.

Comorbidity of sickle cell trait and albinism: a cross-sectional survey in the Democratic Republic of the Congo

INTRODUCTION

Sickle Cell Disease (SCD) and albinism are both recessive hereditary diseases in human kind with a high prevalence in sub-Saharan Africa. This study aimed to determinate the prevalence of sickle cell trait in people living with albinism (PLA).

METHODS

a cross-sectional descriptive survey was conducted in PLA attending the "Hôpital du Cinquantenaire de Kisangani". In total, by non-probabilistic convenience sampling, 82 albinos and 139 non-albinos and without any antecedents of albinism in their family were included, selected from students in the Faculty of Medicine and Pharmacy at the University of Kisangani. Blood samples were collected on "dried blood spot" and analyzed by mass spectrometry at CHU of Liège. Data were entered into an Excel file and analysed on SPSS 20.0 (Chicago, IL).

RESULTS

forty-six of the 82 albinos (56.1%) were female and 43.9% male with a sex ratio of 1.28. Among albinos, 18.3% had hemoglobin AS (HbAS) and 81.7% hemoglobin AA (HbAA) compared to 18% of subjects with hemoglobin AS and 82% hemoglobin AA in the control group. The difference was not statistically significant (Chi-square=0.003, ddl=1, p=0.9544).

CONCLUSION

this study highlighted that the prevalence of the sickle cell trait is high among people living with albinism, but does not differ from that observed in non-albinos in the Democratic Republic of the Congo. It is therefore important to raise awareness among this category of people about sickle cell disease and the importance of its premarital screening.

Global Epidemiology of Buruli Ulcer, 2010-2017, and Analysis of 2014 WHO Programmatic Targets

Buruli ulcer is a neglected tropical disease caused by Myocobacterium ulcerans; it manifests as a skin lesion, nodule, or ulcer that can be extensive and disabling. To assess the global burden and the progress on disease control, we analyzed epidemiologic data reported by countries to the World Health Organization during 2010–2017. During this period, 23,206 cases of Buruli ulcer were reported. Globally, cases declined to 2,217 in 2017, but local epidemics seem to arise, such as in Australia and Liberia. In 2013, the World Health Organization formulated 4 programmatic targets for Buruli ulcer that addressed PCR confirmation, occurrence of category III (extensive) lesions and ulcerative lesions, and movement limitation caused by the disease. In 2014, only the movement limitation goal was met, and in 2019, none are met, on a global average. Our findings support discussion on future Buruli ulcer policy and post-2020 programmatic targets.

Evaluation of a population mobility, mortality, and birth surveillance system in South Kivu, Democratic Republic of the Congo

Prospective, community-based surveillance systems for measuring birth, death, and population movement rates may have advantages over the 'gold-standard' retrospective household survey in humanitarian contexts. A community-based, monthly surveillance system was established in South Kivu, Democratic Republic of the Congo, in partnership with a local implementing partner and the national ministry of health. Data were collected on the occurrence of births, deaths, arrivals, and departures over the course of one year, and a retrospective survey was conducted at the end of the period to validate the information. Discrepancies between the two approaches were resolved by a third visit to the households with discordant records. The study found that the surveillance system was superior in terms of its specificity and sensitivity in measuring crude mortality and birth rates as compared to the survey, demonstrating the method's potential to measure accurately important population-level health metrics in an insecure setting in a timely, community-acceptable manner.

Description of the targeted water supply and hygiene response strategy implemented during the cholera outbreak of 2017-2018 in Kinshasa, DRC

Background

Rapid control of cholera outbreaks is a significant challenge in overpopulated urban areas. During late-2017, Kinshasa, the capital of the Democratic Republic of the Congo, experienced a cholera outbreak that showed potential to spread throughout the city. A novel targeted water and hygiene response strategy was implemented to quickly stem the outbreak.

Methods

We describe the first implementation of the cluster grid response strategy carried out in the community during the cholera outbreak in Kinshasa, in which response activities targeted cholera case clusters using a grid approach. Interventions focused on emergency water supply, household water treatment and safe storage, home disinfection and hygiene promotion. We also performed a preliminary community trial study to assess the temporal pattern of the outbreak before and after response interventions were implemented. Cholera surveillance databases from the Ministry of Health were analyzed to assess the spatiotemporal dynamics of the outbreak using epidemic curves and maps.

Results

From January 2017 to November 2018, a total of 1712 suspected cholera cases were reported in Kinshasa. During this period, the most affected health zones included Binza Météo, Limeté, Kokolo, Kintambo and Kingabwa. Following implementation of the response strategy, the weekly cholera case numbers in Binza Météo, Kintambo and Limeté decreased by an average of 57% after 2 weeks and 86% after 4 weeks. The total weekly case numbers throughout Kinshasa Province dropped by 71% 4 weeks after the peak of the outbreak.

Conclusion

During the 2017–2018 period, Kinshasa experienced a sharp increase in cholera case numbers. To contain the outbreak, water supply and hygiene response interventions targeted case households, nearby neighbors and public areas in case clusters using a grid approach. Following implementation of the response, the outbreak in Kinshasa was quickly brought under control. A similar approach may be adapted to quickly interrupt cholera transmission in other urban settings.

Field challenges to measles elimination in the Democratic Republic of the Congo

BACKGROUND

During a measles epidemic, the Ministry of Public Health (MOH) of the Democratic Republic of the Congo conducted supplementary immunization activities (2016-SIA) from August 28-September 3, 2016 throughout Maniema Province. From October 29-November 4, 2016, Médecins Sans Frontières and the MOH conducted a reactive measles vaccination campaign (2016-RVC) targeting children six months to 14 years old in seven health areas with heavy ongoing transmission despite inclusion in the 2016-SIA, and a post-vaccination survey. We report the measles vaccine coverage (VC) and effectiveness (VE) of the 2016-SIA and VC of the 2016-RVC.

METHODS

A cross-sectional VC cluster survey stratified by semi-urban/rural health area and age was conducted. A retrospective cohort analysis of measles reported by the parent/guardian allowed calculation of the cumulative measles incidence according to vaccination status after the 2016-SIA for an estimation of crude and adjusted VE.

RESULTS

In November 2016, 1145 children (6-59 months old) in the semi-urban and 1158 in the rural areas were surveyed. Post-2016-SIA VC (documentation/declaration) was 81.6% (95%CI: 76.5-85.7) in the semi-urban and 91.0% (95%CI: 84.9-94.7) in the rural areas. The reported measles incidence in October among children less than 5 years old was 5.0% for 2016-SIA-vaccinated and 11.2% for 2016-SIA-non-vaccinated in the semi-urban area, and 0.7% for 2016-SIA-vaccinated and 4.0% for 2016-SIA-non-vaccinated in the rural area. Post-2016-SIA VE (adjusted for age, sex) was 53.9% (95%CI: 2.9-78.8) in the semi-urban and 78.7% (95%CI: 0-97.1) in the rural areas. Post 2016-RVC VC (documentation/declaration) was 99.1% (95%CI: 98.2-99.6) in the semi-urban and 98.8% (95%CI: 96.5-99.6) in the rural areas.

CONCLUSIONS

Although our VE estimates could be underestimated due to misclassification of measles status, the VC and VE point estimates of the 2016-SIA in the semi-urban area appear suboptimal, and in combination, could not limit the epidemic. Further research is needed on vaccination strategies adapted to urban contexts.

Saving Lives Now From Ebola in Africa

In his letter, Peace is a better focus than Ebola in the Democratic Republic of the Congo (DRC), David M. Brett-Major provides a vital reminder of the tragic undercurrent of violence and political instability dominating African regions currently impacted by the second worst Ebola outbreak in modern history. He characterizes health-centric activities as a "common mistake" to remedy the "vicious cycle" of endemic violence and disease outbreaks in DRC and surrounding areas. What is truly needed is a "concerted peace and development process, with health as a voice in a chorus - not alone."

Peste des Petits Ruminants at the Wildlife-Livestock Interface in the Northern Albertine Rift and Nile Basin, East Africa

In the recent past, peste des petits ruminants (PPR) emerged in East Africa causing outbreaks in small livestock across different countries, with evidences of spillover to wildlife. In order to understand better PPR at the wildlife-livestock interface, we investigated patterns of peste des petits ruminants virus (PPRV) exposure, disease outbreaks, and viral sequences in the northern Albertine Rift. PPRV antibodies indicated a widespread exposure in apparently healthy wildlife from South Sudan (2013) and Uganda (2015, 2017). African buffaloes and Uganda kobs <1-year-old from Queen Elizabeth National Park (2015) had antibodies against PPRV N-antigen and local serosurvey captured a subsequent spread of PPRV in livestock. Outbreaks with PPR-like syndrome in sheep and goats were recorded around the Greater Virunga Landscape in Kasese (2016), Kisoro and Kabale (2017) from western Uganda, and in North Kivu (2017) from eastern Democratic Republic of the Congo (DRC). This landscape would not be considered typical for PPR persistence as it is a mixed forest-savannah ecosystem with mostly sedentary livestock. PPRV sequences from DRC (2017) were identical to strains from Burundi (2018) and confirmed a transboundary spread of PPRV. Our results indicate an epidemiological linkage between epizootic cycles in livestock and exposure in wildlife, denoting the importance of PPR surveillance on wild artiodactyls for both conservation and eradication programs.

Sociodemographic characteristics of adolescents preferring home-based HIV self-testing over facility-based voluntary counseling and testing: a cross-sectional study in Kisangani, Democratic Republic of the Congo

HIV self-testing (HIVST) offers an alternative to facility-based voluntary counseling and testing (VCT) services, particularly for vulnerable populations such as adolescents. This study aimed to determine the sociodemographic factors associated with adolescents preferring home-based HIVST over facility-based VCT in Kisangani, Democratic Republic of the Congo. A representative cross-sectional study using random sampling in clusters at three levels was conducted among adolescents (aged 15–19 years) to assess their hypothetical preference in home-based HIVST over facility-based VCT by a face-to-face, paper-based, semi-structured questionnaire, and logistic regression for statistical analysis. In 353 households, 754 adolescents were assessed for eligibility, of whom 628 were eligible. A total of 597 adolescents completed the study questionnaire. A majority of participants were aged 18–19 and of female gender. More than two-thirds of participants had never been tested for HIV and had no knowledge about HIVST before this survey. Among 597 adolescents who had completed the study questionnaire, a slight majority of participants (323/597; 54.1% [95% CI: 50.0–58.0]) preferred home-based HIVST over facility-based VCT. In a multivariate analysis, male gender (adjusted OR: 1.5, 95% CI: 1.1–2.1), marriage or partnered civil status (adjusted OR: 1.8, 95% CI: 1.1–3.1), and previous knowledge about HIVST (adjusted OR: 4.2, 95% CI: 2.6–6.8) were associated with preference for home-based HIVST over facility-based VCT. This study demonstrates that more adolescents preferred home-based HIVST over facility-based VCT in Kisangani. These observations suggest the existence of a specific sociodemographic profile associated with the acceptance of HIVST in adolescents living in sub-Saharan Africa.

Environmental and anthropogenic factors associated with increased malaria incidence in South-Kivu Province, Democratic Republic of the Congo

OBJECTIVE

To examine environmental and human factors that affect the spatial and temporal dynamism of malaria in DRC's South-Kivu province.

METHODS

In a cross-sectional study conducted between 1 January 2010 and 31 December 2015, spatial distribution was determined through thematic maps of malaria attack rate. SatScan ™ software and Monte Carlo test were used to identify spatial risk clusters. Temporal evolutions were analysed using the Cleveland algorithm. Generalized Additive Models for Location Scale and Shape and negative binomial regression were used to assess the independent human and environmental factors associated with incident malaria.

RESULTS

The cumulative annual incidence of malaria increased from 10 968/100 000 in 2013 to 15 501/100 000 in 2015 (P for trend ˂0.001); malaria lethality increased from 0.1% in 2013 to 0.3% in 2015 (P for trend = 0.62). Between 2010 and 2015, 18 of 34 health zones consistently reported the highest attack rates, which ranged from 25 000 to 50 000/100 000. Four risk clusters areas were identified, with relative risk (RR) of 1.2 to 3.0, from which malaria was reported continuously during each year. Factors significantly associated with malaria cases were agro-pisciculture practices (Incidence Risk Ratio [IRR]: 1.96; 95% CI: 1.23-3.13) and the presence of a lake in the health zone (IRR: 2.48, 95% CI: 1.51-4.42).

CONCLUSIONS

Malaria control in this setting must be intensified in peri-lacustrine areas and those in which the population is intensively engaged in standing water-associated activities.

Mosquito-borne viral diseases in the Democratic Republic of the Congo: a review

BACKGROUND

Mosquito-borne viral infections have in recent years, become a public health threat globally. This review aimed to provide an overview of the ecological and epidemiological profiles of mosquito-borne viral infections in the Democratic Republic of the Congo (DRC).

METHODS

A search of literature was conducted using Google Scholar, PubMed and the WHO website using the following keywords: "Democratic Republic of the Congo", "Zaire", "Belgian Congo" and either of the following: "mosquito-borne virus", "arbovirus", "yellow fever", "dengue", "chikungunya", "West Nile", "Rift Valley fever", "O'nyong'nyong", "Zika", "epidemiology", "ecology", "morbidity", "mortality". Published articles in English or French covering a period between 1912 and October 2018 were reviewed.

RESULTS

A total of 37 articles were included in the review. The findings indicate that the burden of mosquito-borne viral infections in DRC is increasing over time and space. The north-western, north-eastern, western and central regions have the highest burden of mosquito-borne viral infections compared to south and eastern highland regions. Yellow fever, chikungunya, dengue, Zika, Rift Valley fever, West Nile and O'nyong'nyong have been reported in the country. These mosquito-borne viruses were found circulating in human, wildlife and domestic animals. Yellow fever and chikungunya outbreaks have been frequently reported. Aedes aegypti and Ae. simpsoni were documented as the main vectors of most of the mosquito-borne viral infections. Heavy rains, human movements, forest encroachment and deforestation were identified as drivers of mosquito-borne viruses occurrence in DRC.

CONCLUSIONS

Mosquito-borne viral infections are becoming common and a serious public health problem in DRC. In the current context of climate change, there is urgent need to improve understanding on ecological and epidemiology of the diseases and strengthen surveillance systems for prompt response to epidemics in DRC.

Wild edible ectomycorrhizal fungi: an underutilized food resource from the rainforests of Tshopo province (Democratic Republic of the Congo)

BACKGROUND

Ectomycorrhizal (EcM) fungi constitute a source of income as well as proper food with considerable nutritional value. Although edible EcM fungi are highly diverse and expected to host considerable nutritional attributes, only few studies focus on their use and promotion in the province of Tshopo (DR Congo). This study provides original ethnomycological and diversity data on edible ectomycorrhizal rainforest fungi from the Man-and-Biosphere reserve of Yangambi and the reserve of Yoko.

METHODS

The list of edible fungi follows the current taxonomy. Taxa were collected in plots situated in different types of rainforests. Each taxon is supported by herbarium reference specimens. Ethnomycological data on locally consumed EcM fungi were collected from randomly selected people living near the Man-and-Biosphere reserve of Yangambi and the Yoko reserve. People were interviewed using a semi-structured questionnaire. The interview campaign involved 160 informants, all randomly selected from 6 different ethnic communities.

RESULTS

The results reveal that rainforests from the Yangambi Biosphere reserve and Yoko forest reserve provide a relatively high number of edible fungi, more than local people actually use. Mixed forest stands hold the highest diversity in saprotrophic edible fungi (p value < 0.001) while no significant difference (p value > 0.05) was observed in the number of saprotrophic and EcM fungi within monodominant forests. In spite of being accessible, this renewable natural resource is underexploited. Although a wide array of EcM fungi is available in primary forests dominated by ectomycorrhizal trees, local people's major interest goes to the saprotrophic fungi from areas with degraded mixed forests.

CONCLUSION

The lack of local interest for EcM fungi is probably related to the considerable distance people have to cover to collect them. As a result, the edible EcM fungi from the Tshopo area represent a potentially interesting but underutilized resource.

Delayed recognition of Ebola virus disease is associated with longer and larger outbreaks

The average time required to detect an Ebola virus disease (EVD) outbreak following spillover of Ebola virus (EBOV) to a primary human case has remained essentially unchanged for over 40 years, with some of the longest delays in detection occurring in recent decades. In this review, our aim was to examine the relationship between delays in detection of EVD and the duration and size of outbreaks, and we report that longer delays are associated with longer and larger EVD outbreaks. Historically, EVD outbreaks have typically been comprised of less than 100 cases (median = 60) and have lasted less than 4 months (median = 118 days). The ongoing outbreak in Democratic Republic of the Congo, together with the 2013–2016 west Africa outbreak, are stark outliers amidst these trends and had two of the longest delays in detection on record. While significant progress has been made in the development of EVD countermeasures, implementation during EVD outbreaks is problematic. Thus, EVD surveillance must be improved by the broad deployment of modern diagnostic tools, as prompt recognition of EVD has the potential to stem early transmission and ultimately limit the duration and size of outbreaks.

A grid-based sample design framework for household surveys

Traditional sample designs for household surveys are contingent upon the availability of a representative primary sampling frame. This is defined using enumeration units and population counts retrieved from decennial national censuses that can become rapidly inaccurate in highly dynamic demographic settings. To tackle the need for representative sampling frames, we propose an original grid-based sample design framework introducing essential concepts of spatial sampling in household surveys. In this framework, the sampling frame is defined based on gridded population estimates and formalized as a bi-dimensional random field, characterized by spatial trends, spatial autocorrelation, and stratification. The sampling design reflects the characteristics of the random field by combining contextual stratification and proportional to population size sampling. A nonparametric estimator is applied to evaluate the sampling design and inform sample size estimation. We demonstrate an application of the proposed framework through a case study developed in two provinces located in the western part of the Democratic Republic of the Congo. We define a sampling frame consisting of settled cells with associated population estimates. We then perform a contextual stratification by applying a principal component analysis (PCA) and k-means clustering to a set of gridded geospatial covariates, and sample settled cells proportionally to population size. Lastly, we evaluate the sampling design by contrasting the empirical cumulative distribution function for the entire population of interest and its weighted counterpart across different sample sizes and identify an adequate sample size using the Kolmogorov-Smirnov distance between the two functions. The results of the case study underscore the strengths and limitations of the proposed grid-based sample design framework and foster further research into the application of spatial sampling concepts in household surveys.