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Razafinjato B, Rakotonirina L, Cordier LF, Rasoarivao A, Andrianomenjanahary M, Marovavy L, Hanitriniaina F, Andriamiandra IJ, Mayfield A, Palazuelos D, Cowley G, Ramarson A, Ihantamalala F, Rakotonanahary RJL, Miller AC, Garchitorena A, McCarty MG, Bonds MH, Finnegan KE. Evaluation of a novel approach to community health care delivery in Ifanadiana District, Madagascar. PLOS Glob Public Health 2024; 4:e0002888. [PMID: 38470906 DOI: 10.1371/journal.pgph.0002888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 01/17/2024] [Indexed: 03/14/2024]
Abstract
Despite widespread adoption of community health (CH) systems, there are evidence gaps to support global best practice in remote settings where access to health care is limited and community health workers (CHWs) may be the only available providers. The nongovernmental health organization Pivot partnered with the Ministry of Public Health (MoPH) to pilot a new enhanced community health (ECH) model in rural Madagascar, where one CHW provided care at a stationary CH site while additional CHWs provided care via proactive household visits. The program included professionalization of the CHW workforce (i.e., targeted recruitment, extended training, financial compensation) and twice monthly supervision of CHWs. For the first eighteen months of implementation (October 2019-March 2021), we compared utilization and proxy measures of quality of care in the intervention commune (local administrative unit) and five comparison communes with strengthened community health programs under a different model. This allowed for a quasi-experimental study design of the impact of ECH on health outcomes using routinely collected programmatic data. Despite the substantial support provided to other CHWs, the results show statistically significant improvements in nearly every indicator. Sick child visits increased by more than 269.0% in the intervention following ECH implementation. Average per capita monthly under-five visits were 0.25 in the intervention commune and 0.19 in the comparison communes (p<0.01). In the intervention commune, 40.3% of visits were completed at the household via proactive care. CHWs completed all steps of the iCCM protocol in 85.4% of observed visits in the intervention commune (vs 57.7% in the comparison communes, p-value<0.01). This evaluation demonstrates that ECH can improve care access and the quality of service delivery in a rural health district. Further research is needed to assess the generalizability of results and the feasibility of national scale-up as the MoPH continues to define the national community health program.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Alishya Mayfield
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Daniel Palazuelos
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
- Partners In Health, Boston, Massachusetts, United States of America
| | | | | | - Felana Ihantamalala
- Pivot, Ranomafana, Fianarantsoa, Madagascar
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Rado J L Rakotonanahary
- Pivot, Ranomafana, Fianarantsoa, Madagascar
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Ann C Miller
- Pivot, Ranomafana, Fianarantsoa, Madagascar
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Andres Garchitorena
- Pivot, Ranomafana, Fianarantsoa, Madagascar
- Institut de Recherche pour le Développement, MIVEGEC Laboratory, University of Montpellier, Centre National de la Recherche Scientifique, Antananarivo, Madagascar
| | | | - Matthew H Bonds
- Pivot, Ranomafana, Fianarantsoa, Madagascar
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Karen E Finnegan
- Pivot, Ranomafana, Fianarantsoa, Madagascar
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
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2
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Evans MV, Ihantamalala FA, Randriamihaja M, Aina AT, Bonds MH, Finnegan KE, Rakotonanahary RJL, Raza-Fanomezanjanahary M, Razafinjato B, Raobela O, Raholiarimanana SH, Randrianavalona TH, Garchitorena A. Applying a zero-corrected, gravity model estimator reduces bias due to heterogeneity in healthcare utilization in community-scale, passive surveillance datasets of endemic diseases. Sci Rep 2023; 13:21288. [PMID: 38042891 PMCID: PMC10693580 DOI: 10.1038/s41598-023-48390-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 11/26/2023] [Indexed: 12/04/2023] Open
Abstract
Data on population health are vital to evidence-based decision making but are rarely adequately localized or updated in continuous time. They also suffer from low ascertainment rates, particularly in rural areas where barriers to healthcare can cause infrequent touch points with the health system. Here, we demonstrate a novel statistical method to estimate the incidence of endemic diseases at the community level from passive surveillance data collected at primary health centers. The zero-corrected, gravity-model (ZERO-G) estimator explicitly models sampling intensity as a function of health facility characteristics and statistically accounts for extremely low rates of ascertainment. The result is a standardized, real-time estimate of disease incidence at a spatial resolution nearly ten times finer than typically reported by facility-based passive surveillance systems. We assessed the robustness of this method by applying it to a case study of field-collected malaria incidence rates from a rural health district in southeastern Madagascar. The ZERO-G estimator decreased geographic and financial bias in the dataset by over 90% and doubled the agreement rate between spatial patterns in malaria incidence and incidence estimates derived from prevalence surveys. The ZERO-G estimator is a promising method for adjusting passive surveillance data of common, endemic diseases, increasing the availability of continuously updated, high quality surveillance datasets at the community scale.
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Affiliation(s)
- Michelle V Evans
- MIVEGEC, Univ. Montpellier, CNRS, IRD, Montpellier, France.
- NGO Pivot, Ranomafana, Ifanadiana, Madagascar.
- Department of Global Health and Social Medicine, Blavatnik Institute at Harvard Medical School, Boston, MA, USA.
| | - Felana A Ihantamalala
- NGO Pivot, Ranomafana, Ifanadiana, Madagascar
- Department of Global Health and Social Medicine, Blavatnik Institute at Harvard Medical School, Boston, MA, USA
| | - Mauricianot Randriamihaja
- MIVEGEC, Univ. Montpellier, CNRS, IRD, Montpellier, France
- NGO Pivot, Ranomafana, Ifanadiana, Madagascar
| | | | - Matthew H Bonds
- NGO Pivot, Ranomafana, Ifanadiana, Madagascar
- Department of Global Health and Social Medicine, Blavatnik Institute at Harvard Medical School, Boston, MA, USA
| | - Karen E Finnegan
- NGO Pivot, Ranomafana, Ifanadiana, Madagascar
- Department of Global Health and Social Medicine, Blavatnik Institute at Harvard Medical School, Boston, MA, USA
| | - Rado J L Rakotonanahary
- NGO Pivot, Ranomafana, Ifanadiana, Madagascar
- Department of Global Health and Social Medicine, Blavatnik Institute at Harvard Medical School, Boston, MA, USA
| | | | | | - Oméga Raobela
- National Malaria Program, Ministry of Health, Antananarivo, Madagascar
| | | | | | - Andres Garchitorena
- MIVEGEC, Univ. Montpellier, CNRS, IRD, Montpellier, France
- NGO Pivot, Ranomafana, Ifanadiana, Madagascar
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3
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Pourtois JD, Tallam K, Jones I, Hyde E, Chamberlin AJ, Evans MV, Ihantamalala FA, Cordier LF, Razafinjato BR, Rakotonanahary RJL, Tsirinomen'ny Aina A, Soloniaina P, Raholiarimanana SH, Razafinjato C, Bonds MH, De Leo GA, Sokolow SH, Garchitorena A. Climatic, land-use and socio-economic factors can predict malaria dynamics at fine spatial scales relevant to local health actors: Evidence from rural Madagascar. PLOS Glob Public Health 2023; 3:e0001607. [PMID: 36963091 PMCID: PMC10021226 DOI: 10.1371/journal.pgph.0001607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 01/23/2023] [Indexed: 02/24/2023]
Abstract
While much progress has been achieved over the last decades, malaria surveillance and control remain a challenge in countries with limited health care access and resources. High-resolution predictions of malaria incidence using routine surveillance data could represent a powerful tool to health practitioners by targeting malaria control activities where and when they are most needed. Here, we investigate the predictors of spatio-temporal malaria dynamics in rural Madagascar, estimated from facility-based passive surveillance data. Specifically, this study integrates climate, land-use, and representative household survey data to explain and predict malaria dynamics at a high spatial resolution (i.e., by Fokontany, a cluster of villages) relevant to health care practitioners. Combining generalized linear mixed models (GLMM) and path analyses, we found that socio-economic, land use and climatic variables are all important predictors of monthly malaria incidence at fine spatial scales, via both direct and indirect effects. In addition, out-of-sample predictions from our model were able to identify 58% of the Fokontany in the top quintile for malaria incidence and account for 77% of the variation in the Fokontany incidence rank. These results suggest that it is possible to build a predictive framework using environmental and social predictors that can be complementary to standard surveillance systems and help inform control strategies by field actors at local scales.
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Affiliation(s)
- Julie D Pourtois
- Biology Department, Stanford University, Stanford, CA, United States of America
- Hopkins Marine Station, Stanford University, Pacific Grove, CA, United States of America
| | - Krti Tallam
- Biology Department, Stanford University, Stanford, CA, United States of America
| | - Isabel Jones
- Biology Department, Stanford University, Stanford, CA, United States of America
- Hopkins Marine Station, Stanford University, Pacific Grove, CA, United States of America
| | - Elizabeth Hyde
- School of Medicine, Stanford University, Stanford, CA, United States of America
| | - Andrew J Chamberlin
- Hopkins Marine Station, Stanford University, Pacific Grove, CA, United States of America
| | - Michelle V Evans
- MIVEGEC, Université de Montpellier, CNRS, IRD, Montpellier, France
| | - Felana A Ihantamalala
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
- NGO Pivot, Ifanadiana, Madagascar
| | | | | | - Rado J L Rakotonanahary
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
- NGO Pivot, Ifanadiana, Madagascar
| | | | | | | | - Celestin Razafinjato
- Programme National de Lutte contre le Paludisme, Ministère de la Santé Publique, Antananarivo, Madagascar
| | - Matthew H Bonds
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
- NGO Pivot, Ifanadiana, Madagascar
| | - Giulio A De Leo
- Biology Department, Stanford University, Stanford, CA, United States of America
- Hopkins Marine Station, Stanford University, Pacific Grove, CA, United States of America
| | - Susanne H Sokolow
- Woods Institute for the Environment, Stanford University, Stanford, CA, United States of America
- Marine Science Institute and Department of Ecology, Evolution and Marine Biology, University of California, Santa Barbara, CA, United States of America
| | - Andres Garchitorena
- MIVEGEC, Université de Montpellier, CNRS, IRD, Montpellier, France
- NGO Pivot, Ifanadiana, Madagascar
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4
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ten Bosch Q, Andrianaivoarimanana V, Ramasindrazana B, Mikaty G, Rakotonanahary RJL, Nikolay B, Rahajandraibe S, Feher M, Grassin Q, Paireau J, Rahelinirina S, Randremanana R, Rakotoarimanana F, Melocco M, Rasolofo V, Pizarro-Cerdá J, Le Guern AS, Bertherat E, Ratsitorahina M, Spiegel A, Baril L, Rajerison M, Cauchemez S. Analytical framework to evaluate and optimize the use of imperfect diagnostics to inform outbreak response: Application to the 2017 plague epidemic in Madagascar. PLoS Biol 2022; 20:e3001736. [PMID: 35969599 PMCID: PMC9410560 DOI: 10.1371/journal.pbio.3001736] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 08/25/2022] [Accepted: 06/30/2022] [Indexed: 11/18/2022] Open
Abstract
During outbreaks, the lack of diagnostic “gold standard” can mask the true burden of infection in the population and hamper the allocation of resources required for control. Here, we present an analytical framework to evaluate and optimize the use of diagnostics when multiple yet imperfect diagnostic tests are available. We apply it to laboratory results of 2,136 samples, analyzed with 3 diagnostic tests (based on up to 7 diagnostic outcomes), collected during the 2017 pneumonic (PP) and bubonic plague (BP) outbreak in Madagascar, which was unprecedented both in the number of notified cases, clinical presentation, and spatial distribution. The extent of these outbreaks has however remained unclear due to nonoptimal assays. Using latent class methods, we estimate that 7% to 15% of notified cases were Yersinia pestis-infected. Overreporting was highest during the peak of the outbreak and lowest in the rural settings endemic to Y. pestis. Molecular biology methods offered the best compromise between sensitivity and specificity. The specificity of the rapid diagnostic test was relatively low (PP: 82%, BP: 85%), particularly for use in contexts with large quantities of misclassified cases. Comparison with data from a subsequent seasonal Y. pestis outbreak in 2018 reveal better test performance (BP: specificity 99%, sensitivity: 91%), indicating that factors related to the response to a large, explosive outbreak may well have affected test performance. We used our framework to optimize the case classification and derive consolidated epidemic trends. Our approach may help reduce uncertainties in other outbreaks where diagnostics are imperfect. The response to the 2017 plague outbreak in Madagascar was complicated by the lack of a perfect or "gold standard" diagnostic. This study shows how multiple, imperfect diagnostic tests can be used to improve the response to an outbreak.
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Affiliation(s)
- Quirine ten Bosch
- Mathematical Modelling of Infectious Diseases Unit, Institut Pasteur, Université Paris Cité, CNRS UMR2000, F-75015 Paris, France
- Quantitative Veterinary Epidemiology, Department of Animal Sciences, Wageningen University and Research, Wageningen, the Netherlands
- * E-mail:
| | | | | | - Guillain Mikaty
- Environment and Infectious Risks Research Unit, Laboratory for Urgent Response to Biological Threats (ERI-CIBU), Institut Pasteur, Paris, France
| | | | - Birgit Nikolay
- Mathematical Modelling of Infectious Diseases Unit, Institut Pasteur, Université Paris Cité, CNRS UMR2000, F-75015 Paris, France
| | | | - Maxence Feher
- Environment and Infectious Risks Research Unit, Laboratory for Urgent Response to Biological Threats (ERI-CIBU), Institut Pasteur, Paris, France
| | - Quentin Grassin
- Environment and Infectious Risks Research Unit, Laboratory for Urgent Response to Biological Threats (ERI-CIBU), Institut Pasteur, Paris, France
| | - Juliette Paireau
- Mathematical Modelling of Infectious Diseases Unit, Institut Pasteur, Université Paris Cité, CNRS UMR2000, F-75015 Paris, France
| | | | - Rindra Randremanana
- Epidemiology and Clinical Research Unit, Institut Pasteur de Madagascar, Antananarivo Madagascar
| | - Feno Rakotoarimanana
- Epidemiology and Clinical Research Unit, Institut Pasteur de Madagascar, Antananarivo Madagascar
| | - Marie Melocco
- Epidemiology and Clinical Research Unit, Institut Pasteur de Madagascar, Antananarivo Madagascar
| | | | - Javier Pizarro-Cerdá
- Yersinia Research Unit, Institut Pasteur, Université Paris Cité, CNRS UMR 6047, F-75015 Paris, France
- National Reference Laboratory for Plague and other Yersiniosis, Institut Pasteur, F-75015 Paris, France
- World Health Organization Collaborating Center for Plague FRA-140, Institut Pasteur, F-75015 Paris, France
| | - Anne-Sophie Le Guern
- Yersinia Research Unit, Institut Pasteur, Université Paris Cité, CNRS UMR 6047, F-75015 Paris, France
- National Reference Laboratory for Plague and other Yersiniosis, Institut Pasteur, F-75015 Paris, France
- World Health Organization Collaborating Center for Plague FRA-140, Institut Pasteur, F-75015 Paris, France
| | - Eric Bertherat
- World Health Organization, Health Emergency Programme, Department of Infectious Hazard Management, Geneva, Switzerland
| | - Maherisoa Ratsitorahina
- Direction, Institut Pasteur de Madagascar, Antananarivo, Madagascar
- Directorate of Health and Epidemiological Surveillance, Ministry of Public Health, Antananarivo, Madagascar
| | - André Spiegel
- Direction, Institut Pasteur de Madagascar, Antananarivo, Madagascar
| | - Laurence Baril
- Epidemiology and Clinical Research Unit, Institut Pasteur de Madagascar, Antananarivo Madagascar
| | | | - Simon Cauchemez
- Mathematical Modelling of Infectious Diseases Unit, Institut Pasteur, Université Paris Cité, CNRS UMR2000, F-75015 Paris, France
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5
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Rajaonarifara E, Bonds MH, Miller AC, Ihantamalala FA, Cordier L, Razafinjato B, Rafenoarimalala FH, Finnegan KE, Rakotonanahary RJL, Cowley G, Ratsimbazafy B, Razafimamonjy F, Randriamanambintsoa M, Raza-Fanomezanjanahary EM, Randrianambinina A, Metcalf CJ, Roche B, Garchitorena A. Impact of health system strengthening on delivery strategies to improve child immunisation coverage and inequalities in rural Madagascar. BMJ Glob Health 2022; 7:bmjgh-2021-006824. [PMID: 35012969 PMCID: PMC8753401 DOI: 10.1136/bmjgh-2021-006824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 12/19/2021] [Indexed: 11/21/2022] Open
Abstract
Background To reach global immunisation goals, national programmes need to balance routine immunisation at health facilities with vaccination campaigns and other outreach activities (eg, vaccination weeks), which boost coverage at particular times and help reduce geographical inequalities. However, where routine immunisation is weak, an over-reliance on vaccination campaigns may lead to heterogeneous coverage. Here, we assessed the impact of a health system strengthening (HSS) intervention on the relative contribution of routine immunisation and outreach activities to reach immunisation goals in rural Madagascar. Methods We obtained data from health centres in Ifanadiana district on the monthly number of recommended vaccines (BCG, measles, diphtheria, tetanus and pertussis (DTP) and polio) delivered to children, during 2014–2018. We also analysed data from a district-representative cohort carried out every 2 years in over 1500 households in 2014–2018. We compared changes inside and outside the HSS catchment in the delivery of recommended vaccines, population-level vaccination coverage, geographical and economic inequalities in coverage, and timeliness of vaccination. The impact of HSS was quantified via mixed-effects logistic regressions. Results The HSS intervention was associated with a significant increase in immunisation rates (OR between 1.22 for measles and 1.49 for DTP), which diminished over time. Outreach activities were associated with a doubling in immunisation rates, but their effect was smaller in the HSS catchment. Analysis of cohort data revealed that HSS was associated with higher vaccination coverage (OR between 1.18 per year of HSS for measles and 1.43 for BCG), a reduction in economic inequality, and a higher proportion of timely vaccinations. Yet, the lower contribution of outreach activities in the HSS catchment was associated with persistent inequalities in geographical coverage, which prevented achieving international coverage targets. Conclusion Investment in stronger primary care systems can improve vaccination coverage, reduce inequalities and improve the timeliness of vaccination via increases in routine immunisations.
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Affiliation(s)
- Elinambinina Rajaonarifara
- Sciences & Ingénierie, Sorbonne Universite, Paris, France .,UMR 224 MIVEGEC, Univ. Montpellier-CNRS-IRD, Montpellier, France.,NGO PIVOT, Ranomafana, Madagascar
| | - Matthew H Bonds
- NGO PIVOT, Ranomafana, Madagascar.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Ann C Miller
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | | | - Karen E Finnegan
- NGO PIVOT, Ranomafana, Madagascar.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | | | | | | | | | - C Jessica Metcalf
- Dept of Ecology and Evol. Biology, Princeton University, Princeton, New Jersey, USA
| | - Benjamin Roche
- UMR 224 MIVEGEC, Univ. Montpellier-CNRS-IRD, Montpellier, France.,Universidad Nacional Autónoma de México, Coyoacan, Distrito Federal, Mexico
| | - Andres Garchitorena
- UMR 224 MIVEGEC, Univ. Montpellier-CNRS-IRD, Montpellier, France.,NGO PIVOT, Ranomafana, Madagascar
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6
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Evans MV, Andréambeloson T, Randriamihaja M, Ihantamalala F, Cordier L, Cowley G, Finnegan K, Hanitriniaina F, Miller AC, Ralantomalala LM, Randriamahasoa A, Razafinjato B, Razanahanitriniaina E, Rakotonanahary RJL, Andriamiandra IJ, Bonds MH, Garchitorena A. Geographic barriers to care persist at the community healthcare level: Evidence from rural Madagascar. PLOS Glob Public Health 2022; 2:e0001028. [PMID: 36962826 PMCID: PMC10022327 DOI: 10.1371/journal.pgph.0001028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 11/26/2022] [Indexed: 12/28/2022]
Abstract
Geographic distance is a critical barrier to healthcare access, particularly for rural communities with poor transportation infrastructure who rely on non-motorized transportation. There is broad consensus on the importance of community health workers (CHWs) to reduce the effects of geographic isolation on healthcare access. Due to a lack of fine-scale spatial data and individual patient records, little is known about the precise effects of CHWs on removing geographic barriers at this level of the healthcare system. Relying on a high-quality, crowd-sourced dataset that includes all paths and buildings in the area, we explored the impact of geographic distance from CHWs on the use of CHW services for children under 5 years in the rural district of Ifanadiana, southeastern Madagascar from 2018-2021. We then used this analysis to determine key features of an optimal geographic design of the CHW system, specifically optimizing a single CHW location or installing additional CHW sites. We found that consultation rates by CHWs decreased with increasing distance patients travel to the CHW by approximately 28.1% per km. The optimization exercise revealed that the majority of CHW sites (50/80) were already in an optimal location or shared an optimal location with a primary health clinic. Relocating the remaining CHW sites based on a geographic optimum was predicted to increase consultation rates by only 7.4%. On the other hand, adding a second CHW site was predicted to increase consultation rates by 31.5%, with a larger effect in more geographically dispersed catchments. Geographic distance remains a barrier at the level of the CHW, but optimizing CHW site location based on geography alone will not result in large gains in consultation rates. Rather, alternative strategies, such as the creation of additional CHW sites or the implementation of proactive care, should be considered.
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Affiliation(s)
| | | | | | - Felana Ihantamalala
- NGO PIVOT, Ranomafana, Ifanadiana, Madagascar
- Department of Global Health and Social Medicine, Blavatnik Institute at Harvard Medical School, Boston, MA, United Sates of America
| | | | | | | | | | - Ann C Miller
- Department of Global Health and Social Medicine, Blavatnik Institute at Harvard Medical School, Boston, MA, United Sates of America
| | | | | | | | | | | | | | - Matthew H Bonds
- NGO PIVOT, Ranomafana, Ifanadiana, Madagascar
- Department of Global Health and Social Medicine, Blavatnik Institute at Harvard Medical School, Boston, MA, United Sates of America
| | - Andres Garchitorena
- MIVEGEC, Univ. Montpellier, CNRS, IRD, Montpellier, France
- NGO PIVOT, Ranomafana, Ifanadiana, Madagascar
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7
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Ihantamalala FA, Bonds MH, Randriamihaja M, Rakotonirina L, Herbreteau V, Révillion C, Rakotoarimanana S, Cowley G, Andriatiana TA, Mayfield A, Rich ML, Rakotonanahary RJL, Finnegan KE, Ramarson A, Razafinjato B, Ramiandrisoa B, Randrianambinina A, Cordier LF, Garchitorena A. Geographic barriers to establishing a successful hospital referral system in rural Madagascar. BMJ Glob Health 2021; 6:bmjgh-2021-007145. [PMID: 34880062 PMCID: PMC8655550 DOI: 10.1136/bmjgh-2021-007145] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/17/2021] [Indexed: 12/13/2022] Open
Abstract
Background The provision of emergency and hospital care has become an integral part of the global vision for universal health coverage. To strengthen secondary care systems, we need to accurately understand the time necessary for populations to reach a hospital. The goal of this study was to develop methods that accurately estimate referral and prehospital time for rural districts in low and middle-income countries. We used these estimates to assess how local geography can limit the impact of a strengthened referral programme in a rural district of Madagascar. Methods We developed a database containing: travel speed by foot and motorised vehicles in Ifanadiana district; a full mapping of all roads, footpaths and households; and remotely sensed data on terrain, land cover and climatic characteristics. We used this information to calibrate estimates of referral and prehospital time based on the shortest route algorithms and statistical models of local travel speed. We predict the impact on referral numbers of strategies aimed at reducing referral time for underserved populations via generalised linear mixed models. Results About 10% of the population lived less than 2 hours from the hospital, and more than half lived over 4 hours away, with variable access depending on climatic conditions. Only the four health centres located near the paved road had referral times to the hospital within 1 hour. Referral time remained the main barrier limiting the number of referrals despite health system strengthening efforts. The addition of two new referral centres is estimated to triple the population living within 2 hours from a centre with better emergency care capacity and nearly double the number of expected referrals. Conclusion This study demonstrates how adapting geographic accessibility modelling methods to local scales can occur through improving the precision of travel time estimates and pairing them with data on health facility use.
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Affiliation(s)
- Felana Angella Ihantamalala
- Research, NGO PIVOT, Ifanadiana, Fianarantsoa, Madagascar .,Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew H Bonds
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,NGO PIVOT, Ranomafana, Madagascar
| | | | | | - Vincent Herbreteau
- Espace-Dev, IRD, Université des Antilles, Université de Guyane, Université de Montpellier, Université de La Réunion, Phnom Penh, Cambodia
| | - Christophe Révillion
- Espace-Dev, IRD, Université des Antilles, Université de Guyane, Université de Montpellier, Université de La Réunion, Saint-Pierre, France
| | | | | | | | - Alishya Mayfield
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,NGO PIVOT, Ranomafana, Madagascar
| | - Michael L Rich
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,NGO PIVOT, Ranomafana, Madagascar.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | | | | | | | | | | | | | - Andres Garchitorena
- NGO PIVOT, Ranomafana, Madagascar.,MIVEGEC, Université de Montpellier, CNRS, IRD, Montpellier, France
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Rakotonanahary RJL, Andriambolamanana H, Razafinjato B, Raza-Fanomezanjanahary EM, Ramanandraitsiory V, Ralaivavikoa F, Tsirinomen'ny Aina A, Rahajatiana L, Rakotonirina L, Haruna J, Cordier LF, Murray MB, Cowley G, Jordan D, Krasnow MA, Wright PC, Gillespie TR, Docherty M, Loyd T, Evans MV, Drake JM, Ngonghala CN, Rich ML, Popper SJ, Miller AC, Ihantamalala FA, Randrianambinina A, Ramiandrisoa B, Rakotozafy E, Rasolofomanana A, Rakotozafy G, Andriamahatana Vololoniaina MC, Andriamihaja B, Garchitorena A, Rakotonirina J, Mayfield A, Finnegan KE, Bonds MH. Integrating Health Systems and Science to Respond to COVID-19 in a Model District of Rural Madagascar. Front Public Health 2021; 9:654299. [PMID: 34368043 PMCID: PMC8333873 DOI: 10.3389/fpubh.2021.654299] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 05/31/2021] [Indexed: 11/17/2022] Open
Abstract
There are many outstanding questions about how to control the global COVID-19 pandemic. The information void has been especially stark in the World Health Organization Africa Region, which has low per capita reported cases, low testing rates, low access to therapeutic drugs, and has the longest wait for vaccines. As with all disease, the central challenge in responding to COVID-19 is that it requires integrating complex health systems that incorporate prevention, testing, front line health care, and reliable data to inform policies and their implementation within a relevant timeframe. It requires that the population can rely on the health system, and decision-makers can rely on the data. To understand the process and challenges of such an integrated response in an under-resourced rural African setting, we present the COVID-19 strategy in Ifanadiana District, where a partnership between Malagasy Ministry of Public Health (MoPH) and non-governmental organizations integrates prevention, diagnosis, surveillance, and treatment, in the context of a model health system. These efforts touch every level of the health system in the district-community, primary care centers, hospital-including the establishment of the only RT-PCR lab for SARS-CoV-2 testing outside of the capital. Starting in March of 2021, a second wave of COVID-19 occurred in Madagascar, but there remain fewer cases in Ifanadiana than for many other diseases (e.g., malaria). At the Ifanadiana District Hospital, there have been two deaths that are officially attributed to COVID-19. Here, we describe the main components and challenges of this integrated response, the broad epidemiological contours of the epidemic, and how complex data sources can be developed to address many questions of COVID-19 science. Because of data limitations, it still remains unclear how this epidemic will affect rural areas of Madagascar and other developing countries where health system utilization is relatively low and there is limited capacity to diagnose and treat COVID-19 patients. Widespread population based seroprevalence studies are being implemented in Ifanadiana to inform the COVID-19 response strategy as health systems must simultaneously manage perennial and endemic disease threats.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Megan B. Murray
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States
| | | | - Demetrice Jordan
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States
| | - Mark A. Krasnow
- Centre Valbio, Ranomafana, Madagascar
- Department of Biochemistry, Stanford University, Stanford, CA, United States
| | - Patricia C. Wright
- Centre Valbio, Ranomafana, Madagascar
- Institute for the Conservation of Tropical Environments, Stony Brook University, Stony Brook, NY, United States
- Department of Anthropology, Stony Brook University, Stony Brook, NY, United States
| | - Thomas R. Gillespie
- Centre Valbio, Ranomafana, Madagascar
- Department of Environmental Sciences and Program in Population Biology, Ecology, and Evolutionary Biology, Emory University, Atlanta, GA, United States
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | | | | | - Michelle V. Evans
- Odum School of Ecology and Center for the Ecology of Infectious Diseases, University of Georgia, Athens, GA, United States
| | - John M. Drake
- Odum School of Ecology and Center for the Ecology of Infectious Diseases, University of Georgia, Athens, GA, United States
| | - Calistus N. Ngonghala
- Department of Mathematics, University of Florida, Gainesville, FL, United States
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, United States
- Center for African Studies, University of Florida, Gainesville, FL, United States
| | - Michael L. Rich
- PIVOT NGO, Ranomafana, Madagascar
- Brigham and Women's Hospital, Boston, MA, United States
- Partners in Health, Boston, MA, United States
| | - Stephen J. Popper
- PIVOT NGO, Ranomafana, Madagascar
- Division of Infectious Diseases and Vaccinology, School of Public Health, University of California, Berkeley, Berkeley, CA, United States
| | - Ann C. Miller
- PIVOT NGO, Ranomafana, Madagascar
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States
| | | | | | | | | | | | | | | | | | - Andres Garchitorena
- PIVOT NGO, Ranomafana, Madagascar
- MIVEGEC, Université de Montpellier, CNRS, IRD, Montpellier, France
| | - Julio Rakotonirina
- Faculty of Medicine, University of Antananarivo, Antananarivo, Madagascar
| | - Alishya Mayfield
- PIVOT NGO, Ranomafana, Madagascar
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States
- Brigham and Women's Hospital, Boston, MA, United States
| | - Karen E. Finnegan
- PIVOT NGO, Ranomafana, Madagascar
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States
| | - Matthew H. Bonds
- PIVOT NGO, Ranomafana, Madagascar
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States
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Evans MV, Garchitorena A, Rakotonanahary RJL, Drake JM, Andriamihaja B, Rajaonarifara E, Ngonghala CN, Roche B, Bonds MH, Rakotonirina J. Reconciling model predictions with low reported cases of COVID-19 in Sub-Saharan Africa: insights from Madagascar. Glob Health Action 2020; 13:1816044. [PMID: 33012269 PMCID: PMC7580764 DOI: 10.1080/16549716.2020.1816044] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 08/24/2020] [Indexed: 12/14/2022] Open
Abstract
COVID-19 has wreaked havoc globally with particular concerns for sub-Saharan Africa (SSA), where models suggest that the majority of the population will become infected. Conventional wisdom suggests that the continent will bear a higher burden of COVID-19 for the same reasons it suffers from other infectious diseases: ecology, socio-economic conditions, lack of water and sanitation infrastructure, and weak health systems. However, so far SSA has reported lower incidence and fatalities compared to the predictions of standard models and the experience of other regions of the world. There are three leading explanations, each with different implications for the final epidemic burden: (1) low case detection, (2) differences in epidemiology (e.g. low R 0 ), and (3) policy interventions. The low number of cases have led some SSA governments to relaxing these policy interventions. Will this result in a resurgence of cases? To understand how to interpret the lower-than-expected COVID-19 case data in Madagascar, we use a simple age-structured model to explore each of these explanations and predict the epidemic impact associated with them. We show that the incidence of COVID-19 cases as of July 2020 can be explained by any combination of the late introduction of first imported cases, early implementation of non-pharmaceutical interventions (NPIs), and low case detection rates. We then re-evaluate these findings in the context of the COVID-19 epidemic in Madagascar through August 2020. This analysis reinforces that Madagascar, along with other countries in SSA, remains at risk of a growing health crisis. If NPIs remain enforced, up to 50,000 lives may be saved. Even with NPIs, without vaccines and new therapies, COVID-19 could infect up to 30% of the population, making it the largest public health threat in Madagascar for the coming year, hence the importance of clinical trials and continually improving access to healthcare.
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Affiliation(s)
- Michelle V. Evans
- Odum School of Ecology and Center for the Ecology of Infectious Diseases, University of Georgia, Athens, GA, USA
| | - Andres Garchitorena
- MIVEGEC, Ecole Pierre Louis de Santé Publique, Université de Montpellier, CNRS, IRD, Montpellier, France
- PIVOT, Ranomafana, Madagascar
| | | | - John M. Drake
- Odum School of Ecology and Center for the Ecology of Infectious Diseases, University of Georgia, Athens, GA, USA
| | - Benjamin Andriamihaja
- PIVOT, Ranomafana, Madagascar
- Madagascar Institut pour la Conservation des Ecosystèmes Tropicaux, Antananarivo, Madagascar
| | - Elinambinina Rajaonarifara
- MIVEGEC, Ecole Pierre Louis de Santé Publique, Université de Montpellier, CNRS, IRD, Montpellier, France
- PIVOT, Ranomafana, Madagascar
- Sorbonne Universite, Paris, France
| | - Calistus N. Ngonghala
- Department of Mathematics and Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - Benjamin Roche
- MIVEGEC, Ecole Pierre Louis de Santé Publique, Université de Montpellier, CNRS, IRD, Montpellier, France
- IRD, Sorbonne Université, UMMISCO, Bondy, France
- Universidad Nacional Autónoma de México, Ciudad de México, México
| | - Matthew H. Bonds
- PIVOT, Ranomafana, Madagascar
- Harvard Medical School, Boston, MA, USA
| | - Julio Rakotonirina
- Faculty of Medicine, University of Antananarivo, Antananarivo, Madagascar
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Cordier LF, Kalaris K, Rakotonanahary RJL, Rakotonirina L, Haruna J, Mayfield A, Marovavy L, McCarty MG, Tsirinomen'ny Aina A, Ratsimbazafy B, Razafinjato B, Loyd T, Ihantamalala F, Garchitorena A, Bonds MH, Finnegan KE. Networks of Care in Rural Madagascar for Achieving Universal Health Coverage in Ifanadiana District. Health Syst Reform 2020; 6:e1841437. [PMID: 33314984 DOI: 10.1080/23288604.2020.1841437] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Health care is most effective when a patient's basic primary care needs are met as close to home as possible, with advanced care accessible when needed. In Ifanadiana District, Madagascar, a collaboration between the Ministry of Public Health (MoPH) and PIVOT, a non-governmental organization (NGO), fosters Networks of Care (NOC) to support high-quality, patient-centered care. The district's health system has three levels of care: community, health center, district hospital; a regional hospital is available for tertiary care services. We explore the MoPH/PIVOT collaboration through a case study which focuses on noteworthy elements of the collaboration across the four NOC domains: (I) agreement and enabling environment, (II) operational standards, (III) quality, efficiency, and responsibility, (IV) learning and adaptation. Under Domain I, we describe formal agreements between the MoPH and PIVOT and the process for engaging communities in creating effective NOC. Domain II discusses patient referral across levels of the health system and improvements to facility readiness and service availability. Under Domain III the collaboration prioritizes communication and supervision to support clinical quality, and social support for patients. Domain IV focuses on evaluation, research, and the use of data to modify programs to better meet community needs. The case study, organized by the domains of the NOC framework, demonstrates that a collaboration between the MoPH and an NGO can create effective NOC in a remote district with limited accessibility and advance the country's agenda to achieve universal health coverage.
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Affiliation(s)
| | - Katherine Kalaris
- Maternal Newborn and Reproductive Health, Clinton Health Access Initiative , Boston, Massachusetts, USA
| | | | | | | | - Alishya Mayfield
- NGO PIVOT , Ranomafana, Madagascar.,Department of Global Health Equity, Brigham and Women's Hospital , Boston, Massachusetts, USA.,Department of Global Health and Social Medicine, Harvard Medical School , Boston, Massachusetts, USA
| | | | | | | | | | | | | | | | - Andres Garchitorena
- NGO PIVOT , Ranomafana, Madagascar.,MIVEGEC Laboratory, University of Montpellier, Centre National de la Recherche Scientifique, Institut de Recherche pour le Développement , Antananarivo, Madagascar
| | - Matthew H Bonds
- NGO PIVOT , Ranomafana, Madagascar.,Department of Global Health and Social Medicine, Harvard Medical School , Boston, Massachusetts, USA
| | - Karen E Finnegan
- NGO PIVOT , Ranomafana, Madagascar.,Department of Global Health and Social Medicine, Harvard Medical School , Boston, Massachusetts, USA
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Andrianaivoarimanana V, Iharisoa AL, Rahalison L, Ralimanantsoa ML, Ratsitorahina M, Rakotonanahary RJL, Carniel E, Demeure C, Rajerison M. Short- and long-term humoral immune response against Yersinia pestis in plague patients, Madagascar. BMC Infect Dis 2020; 20:822. [PMID: 33172393 PMCID: PMC7653777 DOI: 10.1186/s12879-020-05565-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 10/30/2020] [Indexed: 11/21/2022] Open
Abstract
Background Plague, a fatal disease caused by the bacillus, Yersinia pestis, still affects resources-limited countries. Information on antibody response to plague infection in human is scarce. Anti-F1 Ig G are among the known protective antibodies against Y. pestis infection. As a vaccine preventable disease, knowledge on antibody response is valuable for the development of an effective vaccine to reduce infection rate among exposed population in plague-endemic regions. In this study, we aim to describe short and long-term humoral immune responses against Y. pestis in plague-confirmed patients from Madagascar, the most affected country in the world. Methods Bubonic (BP) and pneumonic plague (PP) patients were recruited from plague- endemic foci in the central highlands of Madagascar between 2005 and 2017. For short-term follow-up, 6 suspected patients were enrolled and prospectively investigated for kinetics of the anti-F1 IgG response, whereas the persistence of antibodies was retrospectively studied in 71 confirmed convalescent patients, using an ELISA which was validated for the detection of plague in human blood samples in Madagascar. Results Similarly to previous findings, anti-F1 IgG rose quickly during the first week after disease onset and increased up to day 30. In the long-term study, 56% of confirmed cases remained seropositive, amongst which 60 and 40% could be considered as high- and low-antibody responders, respectively. Antibodies persisted for several years and up to 14.8 years for one individual. Antibody titers decreased over time but there was no correlation between titer and time elapsed between the disease onset and serum sampling. In addition, the seroprevalence rate was not significantly different between gender (P = 0.65) nor age (P = 0.096). Conclusion Our study highlighted that the circulating antibody response to F1 antigen, which is specific to Y. pestis, may be attributable to individual immune responsiveness. The finding that a circulating anti-F1 antibody titer could persist for more than a decade in both BP and PP recovered patients, suggests its probable involvement in patients’ protection. However, complementary studies including analyses of the cellular immune response to Y. pestis are required for the better understanding of long-lasting protection and development of a potential vaccine against plague.
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Affiliation(s)
| | | | - Lila Rahalison
- Plague Unit, Institut Pasteur de Madagascar, 101, Antananarivo, Madagascar
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