SARS-CoV-2 seroprevalence and living conditions in Bamako (Mali): a cross-sectional multistage household survey after the first epidemic wave, 2020

OBJECTIVES

In low-income settings with limited access to diagnosis, COVID-19 information is scarce. In September 2020, after the first COVID-19 wave, Mali reported 3086 confirmed cases and 130 deaths. Most reports originated from Bamako, with 1532 cases and 81 deaths (2.42 million inhabitants). This observed prevalence of 0.06% appeared very low. Our objective was to estimate SARS-CoV-2 infection among inhabitants of Bamako, after the first epidemic wave. We assessed demographic, social and living conditions, health behaviours and knowledges associated with SARS-CoV-2 seropositivity.

SETTINGS

We conducted a cross-sectional multistage household survey during September 2020, in three neighbourhoods of the commune VI (Bamako), where 30% of the cases were reported.

PARTICIPANTS

We recruited 1526 inhabitants in 3 areas, that is, 306 households, and 1327 serological results (≥1 years), 220 household questionnaires and collected answers for 962 participants (≥12 years).

PRIMARY AND SECONDARY OUTCOME MEASURES

We measured serological status, detecting SARS-CoV-2 spike protein antibodies in blood sampled. We documented housing conditions and individual health behaviours through questionnaires among participants. We estimated the number of SARS-CoV-2 infections and deaths in the population of Bamako using the age and sex distributions.

RESULTS

The prevalence of SARS-CoV-2 seropositivity was 16.4% (95% CI 15.1% to 19.1%) after adjusting on the population structure. This suggested that ~400 000 cases and ~2000 deaths could have occurred of which only 0.4% of cases and 5% of deaths were officially reported. Questionnaires analyses suggested strong agreement with washing hands but lower acceptability of movement restrictions (lockdown/curfew), and mask wearing.

CONCLUSIONS

The first wave of SARS-CoV-2 spread broadly in Bamako. Expected fatalities remained limited largely due to the population age structure and the low prevalence of comorbidities. Improving diagnostic capacities to encourage testing and preventive behaviours, and avoiding the spread of false information remain key pillars, regardless of the developed or developing setting.

ETHICS

This study was registered in the registry of the ethics committee of the Faculty of Medicine and Odonto-Stomatology and the Faculty of Pharmacy, Bamako, Mali, under the number: 2020/162/CA/FMOS/FAPH.

Sex work among female workers in the traditional mining sector in Mali - results from the ANRS-12339 Sanu Gundo cross-sectional study in 2015

Female sex workers (FSW) in mining sites are considered to be at very high risk of HIV infection. We aimed to characterize FSW at the Kôkôyô artisanal gold mining site in Mali, and identify factors associated with sex work using data from ANRS-12339 Sanu Gundo, a cross-sectional survey conducted in 2015 at the mine by ARCAD-SIDA, a Malian non-governmental organisation. People attending HIV-prevention activities were invited to participate in the quantitative and qualitative parts of the survey. A probit logistic regression was used for data analysis. Of 101 women who participated in the survey, 26.7% reported sex work as their main activity. Multivariate analysis showed that the probability of sex work as a main activity decreased by 1% per 1-year age increase (p = 0.020). Sex work was significantly more likely to be reported by single, divorced and widowed women (25.4% probability; p = 0.007). FSW were significantly more likely to be non-Malian (36.3% probability; p = 0.003), more likely to have a secondary activity (77% probability; p = 0.002), to work fewer than 56h/week (40.2% probability; p = 0.001) and to be in good health (12.1% probability; p = 0.016). In addition, being aware of the existence of sexually transmitted infection, using psychoactive substances, and having unprotected receptive anal sex during the previous six months were significantly associated with sex work (50.2%; p = 0.006; 45.6%, p = 0.003; and 7.4%, p = 0.016 probability, respectively). Qualitative findings confirm that poverty and boyfriends' refusal to use condoms remain key barriers to systematic condom use among FSW.

[Value of shared electronic health records for the management of homeless people]

AIM

To assess the acceptability for GPS to use the French shared Electronic Health Record (Dossier Médical Partagé, "DMP") when caring for Homeless People (HP).

METHODS

Mixed, sequential, qualitative-quantitative study. The qualitative phase consisted of semi-structured interviews with GPs involved in the care of HP. During the quantitative phase, questionnaires were sent to 150 randomized GPs providing routine healthcare in Marseille. Social and practical acceptability was studied by means of a Likert Scale.

RESULTS

19 GPs were interviewed during the qualitative phase, and 105 GPs answered the questionnaire during the quantitative phase (response rate: 73%). GPs had a poor knowledge about DMP. More than half (52.5%) of GPs were likely to effectively use DMP for HP. GPs felt that the "DMP" could improve continuity, quality, and security of care for HP. They perceived greater benefits of the use the DMP for HP than for the general population, notably in terms of saving time (p = 0.03). However, GPs felt that HP were vulnerable and wanted to protect their patients; they worried about security of data storage. GPs identified specific barriers for HP to use DMP: most of them concerned practical access for HP to DMP (lack of social security card, or lack of tool for accessing internet).

CONCLUSION

A shared electronic health record, such as the French DMP, could improve continuity of care for HP in France. GPs need to be better informed, and DMP functions need to be optimized and adapted to HP, so that it can be effectively used by GPs for HP.

Prevalence of HIV at the Kokoyo informal gold mining site: what lies behind the glitter of gold with regard to HIV epidemics in Mali? A community-based approach (the ANRS-12339 Sanu Gundo cross-sectional survey)

OBJECTIVES

The aim of this article was to estimate HIV prevalence and the factors associated with HIV seropositivity in the population living and working at the informal artisanal small-scale gold mining (IASGM) site of Kokoyo in Mali, using data from the Sanu Gundo survey. Our main hypothesis was that HIV prevalence is higher in the context of IASGM than in the country as a whole.

DESIGN

The ANRS-12339 Sanu Gundo was a cross-sectional survey conducted in December 2015. The quantitative survey consisted of face-to-face administration of questionnaires. Five focus groups were conducted for the qualitative survey. HIV prevalence was calculated for the sample, and according to the type of activity performed in IASGM.

SETTINGS

The IASGM site of Kokoyo, one of the largest sites in Mali (between 6000 and 1000 people).

PARTICIPANTS

224 respondents: 37.5% were gold-diggers, 33% retail traders, 6.7% tombolomas (ie, traditional guards) and 9% female sex workers. The remaining 13.8% reported another activity (mainly street vending).

PRIMARY AND SECONDARY OUTCOME MEASURES

HIV prevalence and HIV prevalence according to subgroup, as defined by their activity at the Kokoyo IASGM. A probit logistic regression was implemented to estimate the characteristics associated with HIV seropositivity.

RESULTS

HIV prevalence for the total sample was 8% (95% CI 7.7% to 8.3%), which is much higher than the 2015 national prevalence of 1.3%Joint United Nations Programme on HIV/AIDS (UNAIDS). The probability of HIV seropositivity was 7.8% (p=0.037) higher for female non-sex workers than for any other category, and this probability increased significantly with age. Qualitative data revealed the non-systematic use of condoms with sex workers; and long distance from health services was the main barrier to accessing care.

CONCLUSIONS

Integrated policymaking should pay special attention to infectious diseases among populations in IASGM zones. Bringing information/prevention activities closer to people working in gold mining zones is an urgent public health action.

Improving access and continuity of care for homeless people: how could general practitioners effectively contribute? Results from a mixed study

OBJECTIVES

To analyse the views of general practitioners (GPs) about how they can provide care to homeless people (HP) and to explore which measures could influence their views.

DESIGN

Mixed-methods design (qualitative -> quantitative (cross-sectional observational) → qualitative). Qualitative data were collected through semistructured interviews and through questionnaires with closed questions. Quantitative data were analysed with descriptive statistical analyses on SPPS; a content analysis was applied on qualitative data.

SETTING

Primary care; views of urban GPs working in a deprived area in Marseille were explored by questionnaires and/or semistructured interview.

PARTICIPANTS

19 GPs involved in HP's healthcare were recruited for phase 1 (qualitative); for phase 2 (quantitative), 150 GPs who provide routine healthcare ('standard' GPs) were randomised, 144 met the inclusion criteria and 105 responded to the questionnaire; for phase 3 (qualitative), data were explored on 14 'standard' GPs.

RESULTS

In the quantitative phase, 79% of the 105 GPs already treated HP. Most of the difficulties they encountered while treating HP concerned social matters (mean level of perceived difficulties=3.95/5, IC 95 (3.74 to 4.17)), lack of medical information (mn=3.78/5, IC 95 (3.55 to 4.01)) patient's compliance (mn=3.67/5, IC 95 (3.45 to 3.89)), loneliness in practice (mn=3.45/5, IC 95 (3.18 to 3.72)) and time required for the doctor (mn=3.25, IC 95 (3 to 3.5)). From qualitative analysis we understood that maintaining a stable follow-up was a major condition for GPs to contribute effectively to the care of HP. Acting on health system organisation, developing a medical and psychosocial approach with closer relation with social workers and enhancing the collaboration between tailored and non-tailored programmes were also other key answers.

CONCLUSIONS

If we adapt the conditions of GPs practice, they could contribute to the improvement of HP's health. These results will enable the construction of a new model of primary care organisation aiming to improve access to healthcare for HP.

[Neighbourhood rural medicine: an experience of rural doctors in Mali]

The main constraint to improving access to health services of quality in rural areas is to attract qualified health personnel in these areas. A fifteen years experience in rural health in Mali has shown that it is possible to develop community medicine practices in an African context that do integrate individual care and public health activities. The policy of decentralization of health services encouraged local communities and municipalities to recruit rural doctors themselves. An initiative of rural doctors materialized with this event as they founded a national association and adhere to the principles of a Charter to provide quality health care at an affordable cost. A mechanism of quality improvement was established with the participation of several partners: a professional association, a funding non-governmental organization, and groups of academic staff and health managers. This paper describes the evolution of the rural doctors' experience, its philosophy, conditions that made it successful, constraints it had to overcome and the attitude of partners. It highlights the potential of health care personnel in Africa to provide primary health care well beyond traditional programs on prevalent diseases and to respond to both urgent individual needs and pressing public health requirements.

[Public hospital in French-speaking Africa]

Traditional consensus holds that hospitals are ill-suited to the healthcare priorities in Africa countries whose policies must focused mainly on promoting primary services. Indeed hospitals are generally considered as inefficient and wasteful of financial resources that could be used for more important healthcare priorities. Long excluded from major development programs, most hospital facilities have gone from crisis to crisis over the last 10 years and are now unable to provide adequate services. The sometimes dramatic state of these institutions raises serious doubt not only about the effectiveness of current healthcare policies but also about the long-term survival of the healthcare systems now being established. But this situation is not the result of fate but rather of the failure of public hospitals to adapt their organization to the realities of today's world. Indeed hospital services are provided within a purely administrative structure with total disregard for the principles of good management. A new vision for revival of healthcare systems make hospitals a key component in a network of healthcare institutions and recommends that they be included in an in-depth reform of healthcare systems that consider any healthcare act as a service in the "economic" sense of the word and its availability as the end-result of a production process. To ensure fulfillment of the public service mission of the hospital, the resulting "entrepreneurial" approach must be accompanied by appropriation of subsidies so that charges are affordable to a majority of the population, implementation of welfare programs to insure that even the poorest users have sufficient resources, and development of monitoring capabilities.

[Ten years experience in Mali community health centers]

At the end of 10 years' existence, the community health centres of Mali show a way of organisation which meets the public health requirements and demands of financial viability of any health establishment. Their originality lays in several factors: their legal personality, their private status, their financial support of the medical staff, their management by a users association and the public utilities agreement they have signed with the department. In spite of their success which makes their numbers reach 350, they suffer from great deficiencies, which are resulted by the lack of democratic traditions within the associations, a inappropriate transparency of their accounts and an inefficient supervision from the part of the department. The main questions posed by this new experience concern the limits of the concept of community, the importance of citizenship in the development dynamics, the participation of private institutions in the accomplishment of public utilities, the jacobin and authoritarian attitude of the department representatives, the contradictions between multiplication of centres to improve geographic access and the requirements of financial viability.

[Public hospitals in Sub-Saharan African countries and their perspectives]

Hospitals have a very important role to play within the care system of Sub-Saharan African countries, not only because they care for patients sent by other health services, but also because they participate in the training of health professionals. In spite of many reforms, they are trapped in a vicious circle, which, to be broken, means moving from too highly stratified administrative system to a system of enterprise. This system must focus on performance, while guaranteeing necessary public service. Such change requires adopting new methods and ways of thinking for providing a complete health service for the patients, that is adequate access to quality health care. This will entail hospitals being given a free hand in their management, effective measurements of quality and expenditure evaluation being devised and supervision by the state Health department. By allowing hospitals to attract more affluent members of society, they will be better able to meet their obligations towards the poor.

[Epidemiology of human urban schistosomiasis in Bamako in Mali (the case of the "populous" quarter of Bankoni)]

From may 1989 to january 1990, we have studied parasitologic index in snails population, stools and urines examination in children (1-15 years) in one of the greatest "spontaneous" quarter of Bamako. 584 stools samples and 563 urines were tested. 4.717 snails were captured during six months. From all these data, we conclude that in Bankoni S. haematobium is mesoendemic (36.6%) and S. mansoni hypoendemic (3.4%). B. truncatus is the most important host for urogenital schistosomiasis. The two seasonal revers (Tienkole and Bankoni) are unfavourable to B. pfeifferi's production. B. globosus and B. forskalii are not frequent in this suburban area. This investigation, shows that a selective mass treatment with praziquantel is the better public health care strategy in Bankoni quarter.

[Human brucellosis in Mali. Results of a seroepidemiological study]

Prevalence of human brucellosis was evaluated in three contrasted ecoclimatic zones with different peopling of Mali. Rose bengal plate agglutination tests were carried out on capillary blood microsamples taken from 2173 subjects and indirect immunofluorescence tests were performed on 148 blood samples collected on filter paper disks. These seroepidemiological studies demonstrate the presence of the anthropozoonosis in the entire country and the influence of ecoclimatic and demographic factors on human brucellosis distribution in Mali. The high prevalence (24.4%) found in the sahelian region of Gourma shows the necessity of a national control programme. A similar prevalence has been found in other countries of tropical Africa which were formerly considered as almost free of human brucellosis. The findings suggest that seroimmunological tests should be performed systematically to detect brucellosis in immigrants coming to Europe from tropical Africa as well as in Europeans who have been travelling or staying in this region.

[The influence of malaria chemoprophylaxis on health of a rural community in West Africa (author's transl)]

In the village population of Mali situated in the sudan savanna, malariometric indices and hematocrit values were performed before and after mass drug administration given every 15 days by a nurse to three-quarters of the population, with the remaining quarter receiving a placebo. In this population, endemic malaria was stable and high, essentially caused by Plasmodium falciparum. The "protected" population showed a decrease of parasite rate and spleen rate with concomitent rise in hematocrit values. Following the rainy season, when transmission of malaria is highest, the normally observed increase in malariometric indices with lowered hematocrit values were not seen during chemoprophylaxis. While splenomegaly found in rural children is related to malaria, the main etiology of anaemia observed in this age group is probably malaria but a role is played by others factors.

Associations in filarial infections in man in the savanna zones of Mali and Upper Volta

In 14 villages located in the West African savanna belt, 1,305 people were examined for microfilariae in blood and skin. The results indicate that the associations between filariae in infected patients are not the result of chance alone. The frequency of associations between Wuchereria bancrofti and Tetrapetalonema perstans was highly significant, whereas Onchocerca volvulus appeared to be associated with W. bancrofti only in the absence of T. perstans.

[An example of the application of factorial analysis of correspondences to infant mortality and its prevention in a rural area of West Africa]

A retrospective study through questionnaire was made among over 800 women of a Pre-Sahel region of Mali. It confirmed the very high infant and child mortality in this population: over 250% mortality under 1 year of age and over 400% under 6 years of age. The factorial analysis of correspondences proved adequate to determine the main characteristics of the local mortality pattern. In chronological order, the most important causes are obstetrical factors (1st day of life), umbilical tetanus (1 week to 1 month of age), malaria (1 month to 1 year of age), pneumopathies (including pertussis and lung complications of measles), toxicoses and nutritional syndromes (over 1 year of age). Preventive measures at various levels are proposed on the basis of these findings. They belong to three broad groups: -Overall socioeconomic development with effective participation of the rural communities concerned. -Development of an appropriate primary health care structure, with a primary health care team in each village. -Strengthening of the programmes of control of the most important communicable diseases. Such simple and cheap actions should, given a clear political will of the national authorities and a modicum of trust in the future on the part of local leaders, be rapidly implementable even in the most underprivileged countries and bring a significant amount of progress in the rural areas.