The quest for greater equity: a national cross-sectional study of the experiences of Black Canadian medical students

BACKGROUND

Black medical students have been consistently underrepresented in Canadian medical schools, and data on the impact of discrimination on their medical education remain limited. In this cross-sectional study, we aimed to investigate the experiences of Black medical students through the Black Medical Students' Association of Canada (BMSAC).

METHODS

We developed a 63-item instrument around the domains of inclusion and diversity, wellness, discrimination, career advancement and diversity in medical education. The anonymous web-based questionnaire was sent to 128 medical students and first-year residents from all 17 Canadian medical schools via the BMSAC listserv. We obtained frequencies for demographic data and self-reported experiences.

RESULTS

We received 52 responses. Of respondents, 59% had at least 1 personal encounter with discrimination in medical school. Discrimination was experienced in both clinical and academic contexts, notably from patients, peers and hospital staff. Students further along in their medical training were more likely to endorse having experienced discrimination in medical school. Most respondents had positive experiences with academic and clinical inclusion, as well as resiliency in the face of discrimination. However, most respondents had negative experiences relating to reporting discrimination, their well-being, career advancement, sentiments of minority tax and low diversity in medical education.

INTERPRETATION

We found that discrimination has important implications on the learning experiences of Black medical students surveyed from the BMSAC. This directly challenges the notion that Canadian medical schools are impervious to racism and highlights the need for advocacy and systemic changes to eliminate institutional racism.

Vaccine innovation prioritisation strategy: Findings from three country-stakeholder consultations on vaccine product innovations

As part of the Vaccine Innovation Prioritisation Strategy (VIPS), three immunization-stakeholder consultations were conducted between September 2018 and February 2020 to ensure that countries' needs drove the prioritization of vaccine product innovations. All consultations targeted respondents with immunization program experience. They included: (1) an online survey to identify immunization implementation barriers and desired vaccine attributes in three use settings, (2) an online survey to identify and evaluate the most important immunization challenges for ten exemplar vaccines, and (3) in-depth interviews to better understand the perceived programmatic benefits and challenges that could be addressed by nine innovations and to rank the innovations that could best address current challenges. The first consultation included responses from 442 participants in 61 countries, representing 89% of the 496 respondents who correctly completed at least one section of the online survey. For facility-based settings, missed opportunities for vaccination due to reluctance to open multidose vaccine vials was the barrier most frequently selected by respondents. In community-based (outreach) and campaign settings, limited access to immunization services due to geographic barriers was most frequently selected. Multidose presentations with preservative or single-dose presentations were most frequently selected as desired vaccine attributes for facility-based settings while improved thermostability was most frequently selected for outreach and campaign settings. The second online survey was completed by 220 respondents in 54 countries. For the exemplar vaccines, vaccine ineffectiveness or wastage due to heat or freeze exposure and missed opportunities due to multidose vial presentations were identified as the greatest vaccine-specific challenges. In-depth interviews with 84 respondents in six countries ranked microarray patches, dual-chamber delivery devices, and heat-stable/controlled temperature chain qualified liquid vaccines as the three innovations that could have the greatest impact in helping address current immunization program challenges. These findings informed the VIPS prioritization and provided broader application to designing immunization interventions to better meet country needs.

Health Care Worker Preferences and Perspectives on Doses per Container for 2 Lyophilized Vaccines in Senegal, Vietnam, and Zambia

When providing immunization services, health care workers balance the mandate of achieving high coverage with limiting vaccine wastage. Workers in 3 countries said that containers with fewer vaccine doses for measles and BCG would enable them to immunize all children who present, while reducing concerns about wasting vaccine.

Introduction:

Limited information exists on health care workers’ (HCWs) perceptions about use of multidose vaccine vials and their preferences about doses per container (DPC). We present findings from qualitative studies conducted in Senegal, Vietnam, and Zambia to explore HCWs’ behavior regarding opening vials and their perceptions and preferences for the number of doses in vials of BCG and measles-containing vaccine (MCV). Zambia and Senegal currently offer MCV in 10-dose vials and BCG in 20-dose vials; 10-dose vials are used for both vaccines in Vietnam. Unused doses in vials of these reconstituted vaccines must be discarded within 6 hours.

Methods:

Key informant interviews (KIIs) were conducted with frontline HCWs in Senegal, Vietnam, and Zambia. In Senegal and Vietnam, the KIIs were conducted as part of broader formative research; in Zambia, KIIs were conducted in control districts using 10-dose MCV vials only and in intervention districts that switched from 10- to 5-dose vials during the study. During analysis, themes common to all 3 countries were synthesized. Critical themes relevant to country contexts were also examined.

Results:

HCWs in all 3 countries preferred containers with fewer doses for BCG and MCV to reduce wastage and increase the likelihood of vaccinating every eligible child. HCWs in Senegal and HCWs using 10-dose vials in Zambia reported sending unvaccinated children away because not enough children were present to warrant opening a new vial. In Vietnam, where sessions are typically held monthly, and in Zambia when the 5-dose vials were used, almost all HCWs reported opening a vial of MCV for even 1 child.

Discussion:

HCWs prefer vials with fewer DPC. Their concerns about balancing coverage and wastage influence their decisions to vaccinate every eligible child; and their perspectives are crucial to ensuring that all target populations are reached with vaccines in a timely manner.

[Rhegmatogenous retinal detachment: Topography of breaks and agreement with lincoff's rules]

PURPOSE

To study the topography of retinal breaks and their agreement with Lincoff's rules.

MATERIALS AND METHODS

We performed a retrospective descriptive study of patients with recent rhegmatogenous retinal detachments followed on the ophthalmology service of Abass Ndao Hospital from January 2006 through December 2016. Patients with no prior retinal treatment were included.

RESULTS

Over 11 years, we reviewed 97 patients with 107 eyes with retinal detachments. The mean age of our patients was 51.7 years, range 23-79 years. There were 69 male patients, for a male:female ratio of 2.46. Refraction revealed that 38.1% of patients were myopes. Fourteen percent (14%) of patients had experienced trauma to the eye with the detachment. The right eye was involved in 54.6% of patients. The onset was insidious in 54.6% of cases and sudden in 23.7% of cases. All patients had decreased visual acuity, associated with a scotoma in 26.8% of cases. Visual acuity was decreased to light perception through 7/10. In 64.9% of cases, Lincoff's rules were observed.

DISCUSSION

Lincoff's rules are still relevant for localization of the breaks in retinal detachments.

CONCLUSION

Diagnosis of a retinal detachment is an essential step, since it determines the treatment. Lincoff's rules still have a role in finding the retinal break in retinal detachments.

Bi-directional drones to strengthen healthcare provision: experiences and lessons from Madagascar, Malawi and Senegal

Drones are increasingly being used globally for the support of healthcare programmes. Madagascar, Malawi and Senegal are among a group of early adopters piloting the use of bi-directional transport drones for health systems in sub-Saharan Africa. This article presents the experiences as well as the strengths, weaknesses, opportunities and threats (SWOT analysis) of these country projects. Methods for addressing regulatory, feasibility, acceptability, and monitoring and evaluation issues are presented to guide future implementations. Main recommendations for governments, implementers, drone providers and funders include (1) developing more reliable technologies, (2) thorough vetting of drone providers' capabilities during the selection process, (3) using and strengthening local capacity, (4) building in-country markets and businesses to maintain drone operations locally, (5) coordinating efforts among all stakeholders under government leadership, (6) implementing and identifying funding for long-term projects beyond pilots, and (7) evaluating impacts via standardised indicators. Sharing experiences and evidence from ongoing projects is needed to advance the use of drones for healthcare.

[Giant retinal tears: Senegalese experience]

PURPOSE

To appreciate the epidemiological characteristics and to show the therapeutic aspects of the giant retinal tears.

PATIENTS AND METHODS

We conducted a retrospective study from January 2014 to June 2017 on subjects with giant retinal tears. Patients with media opacities limiting examination were excluded.

RESULTS

We identified 17 cases of giant retinal tears. The frequency of detachments related to a giant retinal tear was 17% compared to all retinal tears. The mean age was 50.75 years with a sex ratio (M/F) of 6.5. We found three cases of high myopia, one case of hyperopia and four trauma cases. All patients had a decrease in visual acuity. The average time to consultation was four weeks. The mean intraocular pressure was 8mmHg. The tear was found in the left eye in eight cases and in the right eye in five cases; two cases were bilateral. We performed intraocular surgery in five eyes and laser in four eyes. We achieved anatomical reattachment and functional improvement in all operated patients.

COMMENTS AND CONCLUSION

The prognosis of a giant retinal tear remains guarded, especially if patients are seen and treated late. Laser photocoagulation of giant tears remains effective, especially in cases of early diagnosis.

An economic evaluation of the controlled temperature chain approach for vaccine logistics: evidence from a study conducted during a meningitis A vaccine campaign in Togo

Introduction

A recent innovation in support of the final segment of the immunization supply chain is licensing certain vaccines for use in a controlled temperature chain (CTC), which allows excursions into ambient temperatures up to 40°C for a specific number of days immediately prior to administration. However, limited evidence exists on CTC economics to inform investments for labeling other eligible vaccines for CTC use. Using data collected during a MenAfriVac™ campaign in Togo, we estimated economic costs for vaccine logistics when using the CTC approach compared to full cold chain logistics (CCL) approach.

Methods

We conducted the study in Togo's Central Region, where two districts were using the CTC approach and two relied on a fullCCL approach during the MenAfriVac™ campaign. Data to estimate vaccine logistics costs were obtained from primary data collected using costing questionnaires and from financial cost data from campaign microplans. Costs are presented in 2014 US dollars.

Results

Average logistics costs per dose were estimated at $0.026±0.032 for facilities using a CTC and $0.029±0.054 for facilities using the fullCCL approach, but the two estimates were not statistically different. However, if the facilities without refrigerators had not used a CTC but had received daily deliveries of vaccines, the average cost per dose would have increased to $0.063 (range $0.007 to $0.33), with larger logistics cost increases occurring for facilities that were far from the district.

Conclusion

Using the CTC approach can reduce logistics costs for remote facilities without cold chain infrastructure, which is where CTC is designed to reduce logistical challenges of vaccine distribution.

Understanding the policy environment for immunization supply chains: Lessons learned from landscape analyses in Uganda and Senegal

As immunization programs around the world undergo rapid change and expansion, supply chain and logistics systems have become strained, making it increasingly challenging for national public health systems to provide reliable, safe, and efficient access to vaccines. Governments and immunization partners have been aware of this problem for several years, and in 2010, the World Health Organization (WHO) launched the Effective Vaccine Management (EVM) process to help countries identify shortcomings in their immunization supply chains and develop plans for systematic improvement. EVM improvement plans now exist in all Gavi-eligible countries plus many middle- and upper-income countries; however, implementation has been slow and in many cases fraught with financial, managerial, structural, and political roadblocks. Recognizing that significant change of any kind requires a supportive policy environment and strong leadership, PATH began working in Uganda and Senegal to landscape the policy environment around immunization and identify relevant policies, administrative and technical roles and responsibilities, and other issues that may be affecting the supply chain for immunization. The policy landscape assessments included a desk review and a series of structured, in-depth interviews with key international, national, and local stakeholders. The findings highlighted a number of critical issues and challenges in both countries that may be preventing supply chains from functioning optimally. These challenges include a need for better coordination and planning between immunization programs and supply chain managers; the need for sufficient, timely and reliable financing for all aspects of immunization programs; the need for high-level managers trained in immunization supply chain management; and an urgent need for better, more timely data for decision-making. Overcoming these challenges will require the involvement of high-level political actors-including ministers of health and finance, parliamentarians, and other officials who have the ability to approve and influence policy, personnel, and structural changes; ensure work plans are backed with adequate resources for implementation; and hold program managers accountable for achieving agreed indicators.

Mycobacterium tuberculosis drug-resistance in previously treated patients in Ouagadougou, Burkina Faso

BACKGROUND

Tuberculosis drug-resistance becomes common in sub-Saharan Africa; however, very few data are available in Burkina Faso. The aim of this study is to assess the acquired resistance of Mycobacterium tuberculosis complex strains identified in TB patients to four first-line drugs in Ouagadougou.

METHODS

One hundred and ten (110) pulmonary tuberculosis patients with acid-fast bacilli-positive sputum and in situation of failure, relapse, or treatment abandonment were included in the study. Ninety six strains, including 92 (95.8%) M. tuberculosis and 4 (4.2%) M. africanum, were isolated from the sputum samples of these patients. Their drug susceptibility testing was performed using the proportion method. The first-line drugs tested were isoniazid (INH), streptomycin (STR), ethambutol (EMB), and rifampicin (RIF).

RESULTS

The overall drug-resistance rate of M. tuberculosis was 67.4% (n=60), including 3.4% to one drug, 18% to two, 10.1% to three, and 35.9% to four drugs. The resistance to INH, RIF, EMB, and STR were 67.4%, 51.7%, 50.6%, and 44.9%, respectively. Two strains of M. africanum were resistant to all drugs. Forty-six (51.7%) strains were multidrug-resistant (resistant to at least INH and RIF).

CONCLUSIONS

In previously treated patients, the level of resistance of M. tuberculosis complex to commonly used anti-tuberculosis drugs is very high in Ouagadougou. Our results showed that multidrug-resistant tuberculosis could be a public health problem in Burkina Faso.

Risk factors for multidrug-resistant tuberculosis in four centers in Burkina Faso, West Africa

This is a case-control study conducted to examine the risk factors for multidrug resistance (MDR) among patients with pulmonary tuberculosis (TB) in four centers in Burkina Faso, West Africa: Ouagadougou, Bobo-Dioulasso, Gorom-Gorom, and Dori. Fifty-six MDR-TB cases and 304 controls were enrolled of which 40 MDR-TB cases and 222 controls were from Ouagadougou. The majority of cases were male, with 39 among MDR-TB cases and 205 in controls. The MDR-TB cases were aged from 14 to 75 years versus 11 to 75 years in the controls. The total risk assessment battery score was 11. Living outside of Burkina Faso (adjusted odds ratio [OR] = 0.017; 95% confidence interval [95% CI]: 0.001-0.325), known TB contact (OR = 0.045; 95% CI: 0.004-0.543), and patients with previous history of TB treatment (OR = 0.004; 95% CI: 0.000-0.0.052) were significantly associated with MDR-TB. TB contact and mainly previous treatment were the strongest determinants of MDR-TB. Also, living outside Burkina was a risk factor.

Effects of dietary crude protein and supplemental urea levels on nitrogen and phosphorus utilization by feedlot cattle

Three dietary CP concentrations (11.5, 13.0, and 14.5% of DM) and 3 supplemental urea levels (100, 50, and 0% of supplemental N) were used in a completely randomized block design experiment conducted at 2 locations to determine N and P balance and serum urea N (SUN) concentrations of feedlot cattle. Crossbred steers [British and British x Continental; initial BW = 315.0 +/- 3.2 kg at location 1 (n = 27) and initial BW = 353.2 +/- 8.4 kg at location 2 (n = 27)] were used in 3 nutrient balance sampling periods (SP) at the beginning, middle, and end of the feeding period (154 d in location 1 and 159 d in location 2). Fecal N (g/d; P = 0.03), urinary N (g/d; P < 0.01), urinary urea N (UUN; g/d; P < 0.01), apparent N absorption (g/d; P < 0.01), and SUN concentration (mg/dL; P < 0.01) increased linearly as dietary CP concentration increased. Nitrogen retention (g/d) was not affected (P = 0.61) by dietary CP concentration. Phosphorus intake (g/d; P = 0.02), fecal P (g/d; P = 0.04), and urinary P (g/d; P = 0.01) increased linearly as dietary CP increased, reflecting changes in diet composition with increasing CP concentrations. As dietary urea levels increased, urinary N (g/d; P = 0.04), UUN (g/d; P = 0.01), and apparent N absorption (g/d; P = 0.04) increased linearly, but P intake (g/d; P = 0.10) and urinary P (g/d; P = 0.02) decreased linearly. No interactions were observed between SP and dietary treatments for most variables. Evaluation of SP means, however, showed that as days on feed increased, fecal N (g/d; P = 0.01), urinary N (g/d; P < 0.01), UUN (g/d; P < 0.01), apparent absorption of N (g/d; P < 0.01), SUN (mg/dL; P < 0.01), and urinary P (g/d; P < 0.01) increased linearly, whereas retained N (g/d) decreased linearly (P < 0.01) with increasing days on feed. These data suggest that changes in dietary CP and urea levels, as well as stage of the feeding period, markedly alter N and P utilization by feedlot cattle.

Influence of dietary crude protein concentration and source on potential ammonia emissions from beef cattle manure

Emissions of ammonia, as well as other gases and particulates, to the atmosphere are a growing concern of livestock producers, the general public, and regulators. The concentration and ruminal degradability of CP in beef cattle diets may affect urinary and fecal excretion of N and thus may affect ammonia emissions from beef cattle feed yards. To determine the effects of dietary CP concentration and degradability on potential ammonia emissions, 54 steers were randomly assigned to nine dietary treatments in a 3 x 3 factorial arrangement of treatments. Treatments consisted of three dietary CP concentrations (11.5, 13, and 14.5%) and three supplemental urea:cottonseed meal ratios (100:0, 50:50, and 0:100 of supplemental N). Steers were confined to tie stalls, and feces and urine excreted were collected and frozen after approximately 30, 75, and 120 d on feed. One percent of daily urine and feces excretion were added to polyethylene chambers containing 1,550 g of soil. Chambers were sealed, and ammonia emissions were trapped in an acid solution for 7 d using a vacuum system. As the protein concentration in the diet increased from 11.5 to 13%, in vitro daily ammonia emissions increased (P < 0.01) 60 to 200%, due primarily to increased urinary N excretion. As days on feed increased, in vitro ammonia emissions also increased (P < 0.01). Potential ammonia losses were highly correlated (P < 0.01) to urinary N (r2 = 0.69), urinary urea-N (r2 = 0.58) excretion, serum urea-N concentration (r2 = 0.52), and intake of degradable protein N (r2 = 0.23). Although dietary composition can affect daily ammonia losses, daily ammonia emissions must be balanced with effects on animal performance to determine optimal protein concentrations and forms in the diet.

[Sero-epidemiological study of cowdriosis in Moorish zebu cattle from Senegal]

The seroprevalence against heartwater for maure zebus coming from Mali and Mauritania is analysed by indirect ELISA using the major antigenic protein number 1-B (MAP1-B). Sero-epidemiological results realized on maure zebu cattle give a good adequation between the abundance or absence of the vector tick in the two countries for 98% of prevalence in Mali (infected area) and 0% of prevalence in Mauritania (non infected area).

[Malignant ovarian germ cell tumours: a trial of 36 cases]

OBJECTIVE

With personal results and a review of the literature, we report the eventual interest of surgical staging in malignant ovarian germ cell tumours.

PATIENTS AND METHODS

This was a retrospective study of 36 patients (21.5-[8-61]) with malignant ovarian germ cell tumours between January 1984 and December 2004. There were 4 groups: no 1--dysgerminoma only, no 2--immature teratoma, no 3--malignant ovarian germ cell tumours with secretion. All the patients had a minimal follow up of 18 months after treatment. We reported conservative or non-conservative surgery, if surgical staging was made and description of eventual neoadjuvant or adjuvant chemotherapies and finally the recurrences and deaths.

RESULTS

Stages of FIGO were: group 1--IA n=2, IC n=2, IIB n=1, IIIA n=2, IIIC n=3; group 2--IA n=3 (G1, G2, G2), IC n=1 (G3); group 3--IA n=8, IC n=4, IIA n=1, IIIA n=1, IIIB n=3, IIIC n=5. Three patients had neoadjuvant chemotherapy. All the patients had cytoreductive surgery (conservative surgery n=31) with staging in 15 cases. Twenty-six patients had adjuvant chemotherapy. Five years global survival was 92%.

DISCUSSION AND CONCLUSION

Surgery in a young patient with malignant ovarian germ cells tumours must be conservative (adnexectomy) (preserving fertility and because of good prognostic). In case of stage IA with part of dysgerminoma and/or immature teratoma and/or embryonal carcinoma certified by surgical staging, strict follow up could be organized (clinic, radiology, AFP, HCG). In case of more than stage IA, chemotherapy is indicated after conservative surgery and surgical staging.

Viral load in tissues during the early and chronic phase of non-pathogenic SIVagm infection

African green monkeys (AGMs) persistently infected with SIVagm do not develop AIDS, although their plasma viremia levels can reach those reported for pathogenic HIV-1 and SIVmac infections. In contrast, the viral burden in lymph nodes in SIVagm-infected AGMs is generally lower in comparison with HIV/SIVmac pathogenic infections, at least during the chronic phase of SIVagm infection. We searched for the primary targets of viral replication, which might account for the high viremias in SIVagm-infected AGMs. We evaluated for the first time during primary infection SIVagm dissemination in various lymphoid and non-lymphoid tissues. Sixteen distinct organs at a time point corresponding to maximal virus production were analyzed for viral RNA and DNA load. At days 8 and 9 p.i., viral RNA could be detected in a wide range of tissues, such as jejunum, spleen, mesenteric lymph nodes, thymus and lung. Quantification of viral DNA and RNA as well as of productively infected cells revealed that viral replication during this early phase takes place mainly in secondary lymphoid organs and in the gut (5 x 10(4)-5 x 10(8) RNA copies/10(6) cells). By 4 years p.i., RNA copy numbers were below detection level in thymus and lung. Secondary lymphoid organs displayed 6 x 10(2)-2 x 10(6) RNA copies/10(6) cells, while some tissue fragments of ileum and jejunum still showed high viral loads (up to 10(9) copies/10(6) cells). Altogether, these results indicate a rapid dissemination of SIVagm into lymphoid tissues, including the small intestine. The latter, despite showing marked regional variations, most likely contributes significantly to the high levels of viremia observed during SIVagm infection.

[Aspects of antihyperglycemic oral bitherapy in 76 cases of non insulindependent diabetes in Dakar]

Some reasons justify the introduction of the association of sulfonylurea and metformine when monotherapy is ineffective. Hereafter a period of monotherapy by sulfonylurea or metformine only bitherapy has been instituted. Socio-demography, number of consultations, type of monotherapy and of association, duration of treatment, body mass index, fasting blood glycemia and post-prandial glycemia, blood pressure and type of complication were studied. There were 2.5 times more women than men with lower mean age for women. The majority of patients were from Dakar (81.6%). More than half of patients were women at home (60.5%). Present obesity (plethoric diabetes) or past obesity (metaplethoric diabetes) concerned 90.3% of patients. Patients have done 9.14 4.39 consultations under bitherapy. The gliclazide-metformin association was observed 37 times and the glibenclamide-metformin association 67 times. The duration of monotherapy was 45.9 39.7 months and that of bitherapy 92.5 43.7 months. The variations of body mass index showed a diminution of 1.26 kg/m2 and for fasting blood glycemia and augmentation of 0.011 g/L and post-prandial a diminution of 0.05 g/L. The body mass index variations in diabetic patients showed a diminution of weight more in plethoric patients in bitherapy compared to monotherapy. This study is retrospective and cannot show the optimal efficacy of bitherapy. But the combination of enhancement of glucose captation and lowering of hepatic glucose production has been shown during this bitherapeutic association. Addition of metformine and treatment with sulfonylurea make a combination that significatively improves glycemic control but also cholesterol level and allows obtation of better weight in type 2 non insulin-dependent diabetes with insulinoresistance.

[Maternal morbidity and qualification of health-care workers: comparison between two different populations in Senegal]

OBJECTIVE

High fertility rates and high maternal mortality ratios have led most cooperation agencies to place high priority on health of women and children. The objective of this study was to compare maternal morbidity and mortality tin two populations with widely contrasting availability of health care in order to test the hypothesis that differences in maternal outcome mainly result from the qualification of health carers.

METHODS

This population-based study included a cohort of pregnant women which was part of a multicenter study of maternal morbidity in six countries in West Africa (MOMA). We compared health outcome in two different populations of Senegal (Saint-Louis and Kaolack).3,777 pregnant women were follow through pregnancy, delivery and pureperium. Maternal morbidity was assessed from the women's recall at each visit of the investigator and from obstetric complications diagnosed by the birth attendant within health facilities.

RESULTS

Maternal mortality was higher in the Kaolack area where women gave birth mainly in district health care centers, most often assisted by traditional birth attendants, than in Saint-Louis where women giving birth in health facilities were principally referred to the regional hospital and were generally assisted by midwives (874 and 151 maternal deaths per 100,000 live births respectively, p<0.01). Diagnosed maternal morbidity, however, was higher in Saint-Louis than in the Kaolack area, especially for births in health facilities (9.50 and 4.84 episodes of obstetric complications per 100 lie births respectively, p<0.01). Univariate and multivariate analyses showed that diagnosed morbidity was mainly associated with degree of training of the health attendant in facility deliveries and that antenatal care had no effect.

DISCUSSION

Midwives in health facilities appear to detect more obstetric complications than traditional birth attendants. Immediate detection leads to immediate care and to a lower case-fatality rate. This could explain the differences in maternal outcome between two urban centers with contrasting health care availability.

CONCLUSION

These results suggest that one of the strongest weapons in the fight against maternal mortality is the employment of the most qualified personnel possible for monitoring labor.

High levels of viral replication during primary simian immunodeficiency virus SIVagm infection are rapidly and strongly controlled in African green monkeys

In contrast to pathogenic human immunodeficiency virus and simian immunodeficiency virus (SIV) infections, chronic SIVagm infections in African green monkeys (AGMs) are characterized by persistently low peripheral and tissue viral loads that correlate with the lack of disease observed in these animals. We report here data on the dynamics of acute SIVagm infection in AGMs that exhibit remarkable similarities with viral replication patterns observed in peripheral blood during the first 2 weeks of pathogenic SIVmac infections. Plasma viremia was evident at day 3 postinfection (p.i.) in AGMs, and rapid viral replication led by days 7 to 10 to peak viremias characterized by high levels of antigenemia (1.2 to 5 ng of p27/ml of plasma), peripheral DNA viral load (10(4) to 10(5) DNA copies/10(6) peripheral blood mononuclear cells [PBMC]), and plasma RNA viral load (2 x 10(6) to 2 x 10(8) RNA copies/ml). The lymph node (LN) RNA and DNA viral load patterns were similar to those in blood, with peaks observed between day 7 and day 14. These values in LNs (ranging from 3 x 10(5) to 3 x 10(6) RNA copies/10(6) LN cell [LNC] and 10(3) to 10(4) DNA copies/10(6) LNC) were at no time point higher than those observed in the blood. Both in LNs and in blood, rapid and significant decreases were observed in all infected animals after this peak of viral replication. Within 3 to 4 weeks p. i., antigenemia was no longer detectable and peripheral viral loads decreased to values similar to those characteristic of the chronic phase of infection (10(2) to 10(3) DNA copies/10(6) PBMC and 2 x 10(3) to 2 x 10(5) RNA copies/ml of plasma). In LNs, viral loads declined to 5 x 10(1) to 10(3) DNA copies and 10(4) to 3 x 10(5) RNA copies per 10(6) LNC at day 28 p.i. and continued to decrease until day 84 p.i. (<10 to 3 x 10(4) RNA copies/10(6) LNC). Despite extensive viremia during primary infection, neither follicular hyperplasia nor CD8(+) cell infiltration into LN germinal centers was detected. Altogether, these results indicate that the nonpathogenic outcome of SIVagm infection in its natural host is associated with a rapidly induced control of viral replication in response to SIVagm infection, rather than with a poorly replicating virus or a constitutive host genetic resistance to virus replication.

[Infections in Senegalese children and adolescents with sickle cell anemia: epidemiological aspects]

Infection is the main factor of morbidity and mortality in children with sickle cell disease (SCD). The objective of this study is to determine it's epidemiologic outline in senegalese children and adolescents with SCD. We retrospectively studied infection data in all the charts of a cohort of 323 patients with SCD (307 SS, 13 SC and 3 s beta + thalassemia) followed at Albert Royer children hospital from january 1991 to december 1997. Serum sampling was systematically made for HIV and antigen HBs serology in all patients we received in the last 3 months (october to december 1997). Patients were aged from 5 months to 22 years (medium age = 8 years). 813 infection episodes were diagnosed, concerning 184 patients (56 per cent). SS patients were more affected (59 per cent) than the others (23 per cent, p = 0.04). ENT and broncho-pulmonary onsets were more frequent but had a generally benign course. Menigitidis, septicemia and osteomyelitis were exclusively diagnosed in SS patients. Their prevalences in this group were respectively: 1.0 per cent, 4.9 per cent and 9.8 per cent. HIV serology was determined in 155 patients, including 41 per cent with blood transfusion antecedents. All tests were negative. HBs antigen was determined in 104 patients and seroprevalence was 7.7 per cent in the whole group and 6.0 per cent in patients with transfusion antecedents and 7.7 per cent for the others. Plasmodium falciparum malaria onset was observed in 9.6 per cent of our patients and there was no case of cerebral malaria. Infection was involved in 9 of the 11 cases of death. Then infection constitute the major problem in children and adolescents with SCD in Dakar. However prevalences of severe onsets are comparable to data in Europe despite our poor follow up conditions. Senegal haplotype may lead to a good tolerance of SCD. Negative HIV serology and low HBs antigen seroprevalence in transfused patients are attributed to a relatively low level of HIV prevalence in the general population and a good transfusion security in Senegal.

Maternal morbidity and mortality in two different populations of Senegal: a prospective study (MOMA survey)

OBJECTIVE

To compare maternal morbidity and mortality in two urban populations with contrasting availability of health care, and to test the hypothesis that differences in maternal outcome result mainly from the management of delivery in health facilities.

DESIGN

A population-based study of a cohort of pregnant women which was part of a multicentre study of maternal morbidity in six countries of western Africa (MOMA).

SETTING

Two different urban areas of Senegal (Saint-Louis and Kaolack).

POPULATION

3,777 pregnant women who were followed up throughout pregnancy, delivery and puerperium.

MAIN OUTCOME MEASURES

Maternal morbidity and mortality: morbidity was assessed from women's recall at each visit by the investigator and from obstetric complications diagnosed by the birth attendant within health facilities.

RESULTS

Maternal mortality was higher in the Kaolack area where women gave birth mainly in district health care centres, usually assisted by traditional birth attendants, than in Saint-Louis where women giving birth in health facilities went principally to the regional hospital and were usually assisted by midwives (874 and 151 maternal deaths per 100,000 live births, respectively, P < 0 x 01). Maternal morbidity, however, was higher in Saint-Louis than in Kaolack area, especially for births in health facilities (9 x 50 and 4 x 84 episodes of obstetric complications per 100 live births, respectively, P < 0 x 01). Univariate and multivariate analyses showed that morbidity was mainly associated with the training of the birth attendant in facility deliveries and that antenatal care had no effect.

CONCLUSION

Midwives in health facilities appear to detect more obstetric complications than traditional birth attendants. Immediate detection leads to immediate care and to low fatality rates. This could explain differences in maternal outcome between two urban centres with contrasting health care availability. These results suggest that one of the strongest weapons in the fight against maternal mortality is the employment of the most qualified personnel possible for monitoring labour.

Blood polymorphism in west African breeds of sheep

This paper reports the blood groups and blood protein distribution in West African sheep breeds. About 100 animals of the Djallonke, Fulani and Touabire breeds were sampled for blood polymorphism analysis. Their blood groups were typed by haemolytic and agglutination reactions, and their blood proteins by starch gel electrophoresis. Almost all the loci analysed showed variability in the three breeds, with the Touabire and Fulani being closer to each other than to the Djallonke.

[Malaria in the southern sanitary district of Dakar (Senegal). 2. Entomologic data]

To complete a parasitological survey, entomological prospections were carried out in the southern sanitary District of Dakar, the most urbanized of the city and which includes the city centre and the oldest administrative districts. The prospections took place between June 1994 and May 1995 in sites 1.5 km apart, and distributed in such a manner that they covered the entire area. On a monthly basis, female Culicidae were collected in each site at night on human volunteers, followed the next day by the collection of early morning residual fauna in 10 bedrooms located in district concessions. For a total of 308 collections at night on human volunteers and from 1,510 rooms for the residual fauna, 22,901 female Culicidae were caught of which 167 anopheles, corresponding to 0.7%, the remaining 98.5% being Culex quinquefasciatus. This was the species that thus explained the mosquito-nuisance of which the inhabitants of the southern District complained during the period of survey. The female anopheles collected belonged to 2 species, An. arabiensis for 97.6% of those caught and An. pharoensis for 2.4%. An. arabiensis were very slightly represented in the southern District with a density of aggressive females of 0.26 bite/man/night (B/M/N) and a density per room of 0.05 female. The aggressive populations appeared to be relatively important only at the end of the rainy season (September-October) with an average of 0.65 B/M/N in sites located at the periphery of the district with a maximum of 1.33 B/M/N. The highest density of endophilic females registered at the end of the rainy season was 0.1 and its highest value in a given site was 0.36 female/room. The parturity rate of aggressive females was 43.5% and those collected in houses of 84% with an anthropophilic index of 0.98. None of the dissected An. arabiensis females (77.3% of those collected) was a carrier of Plasmodium sporozoites and the circum-sporozoite antigen was not found. A very weak density of An. arabiensis and absence of plasmodial infection among dissected females favoured the absence of malarial transmission in the southern District for the period considered. However malaria transmission could not be absolutely ruled out given the presence of hematozoa carriers, as was revealed by the longitudinal follow-up of a cohort carried out concurrently with the entomological prospections of whom some were residents having declared permanent residence in the city for over two years. This entomological data explain the results of the afore mentioned parasitological survey which, with a registered plasmodic index of 0.3%, means that the southern District can be considered as non endemic. The area is however exposed to the risk of epidemic malaria following an important proliferation of anopheles, which is always possible after heavy rains and flooding and/or an important immigration of persons coming from regions of high malarial endemicity.

Note on transferrin, hemoglobin types, and packed cell volume in Senegalese trypanotolerant Djallonke sheep

In this study we examined transferrin (Tf) and hemoglobin (Hb) types and frequencies and their relationship with Packed Cell Volume (PCV), which is considered as a selection criterion for the trypanotolerance trait. Blood samples were collected from 96 sheep and were typed for Tf and Hb. The frequencies of the alleles TfA, TfB, TfC and TfD were respectively 0.276, 0.005, 0.109, and 0.609. At the locus Hb, all animals were monomorphic B. The lowest PCV value was observed in animals homozygous for TfC, while the highest value was found in heterozygous (CD) animals; however, the difference was not significant.

Geographical distribution of HIV-1 group O viruses in Africa

OBJECTIVE

To determine to what extent HIV-1 group O strains are present in different African countries.

MATERIALS AND METHODS

A total of 14,682 samples of sera from a range of patients from 12 different African countries were tested. All the sera were tested with an enzyme-linked immunosorbent assay (ELISA) using a combination of V3 peptides from ANT-70 and MVP-5180. Samples reactive in ELISA were retested in a line immunoassay (LIA-O). Samples reactive in ELISA were also retested with an in-house Western blot to determine the presence of antibodies to gp120 of HIV-1 ANT-70. Polymerase chain reaction was performed on HIV-1 group O and group O indeterminate sera.

RESULTS

Of all the sera samples tested, only 19 sera had antibodies to group O V3 peptides exclusively and 46 were indeterminate for group O infection in LIA-O. The highest prevalence of HIV-1 group O infection among HIV-positive sera was observed in Cameroon (2.1%) and neighbouring countries, 1.1% in Nigeria and 0.9% in Gabon. The lowest rates were seen in west Africa: 0.07% in Senegal, 0.14% in Togo, 0.16% in Chad and 0.3% in Niger. Group O sera were observed in almost all the population categories tested. The ANT-70 V3 peptide in LIA-O was reactive with all of the sera considered to be HIV-1 group O antibody positive by LIA, versus 78.9% for the MVP-5180 peptide. Thirteen out of 19 group O samples of sera were tested in PCR. Eight samples were identified as group O by specific group O pol and/or V3 primers; in the remaining five samples no HIV RNA could be detected. Of the indeterminate sera samples, two were identified as group O.

CONCLUSION

In eight of the 12 countries tested, antibodies to group O viruses were identified. Numbers of HIV-1 group O viruses are low. Their presence is not restricted to Cameroon and neighbouring countries but can also be found in west and south-east Africa.

[Epidemiological surveillance and obstetrical dystocias surgery in Senegal]

Maternal morbidity and mortality remain major problems of public health in developing countries. Having long been neglected, maternal health is now being included among the priorities of a large number of countries. The rate of maternal mortality in Senegal is 850 per 100,000 live births, among the highest in the world. The main causes of maternal mortality in Africa are obstructed labour and uterine rupture, hypertensive disorders of pregnancy, puerperal infection and haemorrhage. An epidemiological survey of obstetric disorders was initiated in 1992 in Senegal to characterise the requirements for surgical coverage during pregnancy and delivery. In 1992, the national rate of caesarean section was low (0.66% of estimated births). However, rates differed greatly between regions, and between rural and urban areas. The indications for caesarean section were classified into three groups, each corresponding to a different public health issue. The rate of maternal mortality associated with surgery was high: 4.7%, of which 29% during surgery and 71% post op. Perinatal prognosis was also poor, with a mortality rate of approximately 30%. There are only 18 reference obstetrics units functioning, and they give a very uneven coverage of the country. These finding have led to new guidelines to improve the quality and cover of maternal care over the coming years.

[Ticks and hemoparasitoses in livestock in Senegal. V. The northern Guinea area]

The authors report the results of a study on ticks and hemoparasitoses among cattle, sheep and goats in the North-Guinean zone. During a period of 15 months, ticks were systematically removed from 40 cattle, 40 sheep and 40 goats in order to assess the population dynamics and to determine more accurately the preferential sites of settlement of the following different species collected from these animals: Amblyomma variegatum, Boophilus geigyi, Hyalomma truncatum, H. marginatum rufipes, Rhipicephalus sulcatus, Rh. senegalensis, Rh. lunulatus. Studies on hemoparasitoses were conducted simultaneously using blood smears and splenectomy. The following species were found in cattle: Anaplasma marginale, Ehrlichia bovis, Trypanosoma vivax, Theileria mutans, Theileria velifera. Infections detected in the small ruminants were Anaplasma ovis, Ehrlichia ovina, Trypanosoma congolense, Theileria ovis. The PCV values of apparently healthy animals as well as the seasonal variations in this haematological parameter were investigated.

Prevalence and risk determinants of human immunodeficiency virus type 2 (HIV-2) and human immunodeficiency virus type 1 (HIV-1) in west African female prostitutes

The authors studied the prevalence and risk determinants for human immunodeficiency virus type 1 (HIV-1) and type 2 (HIV-2) in female prostitutes from Dakar (1985-1990), Ziguinchor (1987-1990), and Kaolack (1987-1990), Senegal, West Africa. Each cohort showed a distinct distribution of HIVs: 10.0% HIV-2 and 4.1% HIV-1 in Dakar, 38.1% HIV-2 and 0.4% HIV-1 in Ziguinchor, and 27.4% HIV-2 and 1.3% HIV-1 in Kaolack. In 1,275 female prostitutes from Dakar, increase years of sexual activity and a history of scarification were associated with HIV-2 seropositivity. In contrast, HIV-1 seroprevalence was associated with a shorter duration of prostitution and a history of hospitalization. In 278 female prostitutes from Ziguinchor, HIV-2 seroprevalence was associated with women of Guinea-Bissau nationality and increased years of sexual activity. In 157 female prostitutes from Kaolack, HIV-2 seroprevalence was associated with increased years of sexual activity and a history of never using condoms. The authors also studied the risk determinants for HIV-2 in the 1,280 Senegalese prostitutes pooled from all three sites. Controlling for ethnic group, women from Ziguinchor and Kaolack were more likely to be HIV-2 seropositive as compared with women from the Dakar site. Increased years of sexual activity were associated with HIV-2 seropositivity, while a history of excision and BCG vaccinations decreased the risk of HIV-2 infection.

Antigenic differences between stocks of Cowdria ruminantium

Stocks of Cowdria ruminantium from Senegal, Zambia and South Africa were compared in cross immunity tests in goats. The Senegal stock caused fatal heartwater in three of 10 goats immune to the South African reference stock Ball 3, and five others showed significant febrile reactions and recovered spontaneously. Four goats immune to the Senegal stock did not show any reaction on challenge with Ball 3. The stock from Zambia was fully cross-protective with Ball 3 in experiments with three goats, but these three goats, immune to the Zambia stock and to Ball 3, showed severe febrile responses upon further challenge with the Senegal stock. The Senegal stock was highly virulent for Dutch goats and there were exceptionally large numbers of rickettsiae in brain capillaries after death. This stock has been passaged eight times in mice, without causing disease; the presence of the organism in the mice was shown by subinoculating goats. The Senegalese stock of C ruminantium is the first stock outside South Africa against which the reference Ball 3 stock does not fully immunise.

[Experimental transmission of Monanema nilotica El Bihari & coll., 1977, a filaria with skin-dwelling microfilaria parasitic in African murids]

The value of Monanema of murids as experimental models of ocular lesions due to onchocerciasis would be greatly increased if we could experiment with several host and parasite species since, in many cases, the lesions induced are more significant when the host-parasite association is poorly adapted. The life cycle of 2 isolates of Monanema nilotica is completed, one from Lemniscomys striatus from the Central african Republique and the other from Arvicanthis niloticus of Mali. As in M. globulosa, infective larvae develop in Ixodidae (Rhipicephalus sanguineus and Hyalomma truncatum); 20 to 30 larvae inoculated into the murids suffice for a patent infection.