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Hitchings MDT, Berthé F, Aruna P, Shehu I, Hamza MA, Nanama S, Steve-Edemba C, Grais RF, Isanaka S. Correction: Effectiveness of a monthly schedule of follow-up for the treatment of uncomplicated severe acute malnutrition in Sokoto, Nigeria: A cluster randomized crossover trial. PLoS Med 2024; 21:e1004370. [PMID: 38507664 PMCID: PMC10954311 DOI: 10.1371/journal.pmed.1004370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/22/2024] Open
Abstract
[This corrects the article DOI: 10.1371/journal.pmed.1003923.].
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Schwartz DJ, Langdon A, Sun X, Langendorf C, Berthé F, Grais RF, Trehan I, Isanaka S, Dantas G. Effect of amoxicillin on the gut microbiome of children with severe acute malnutrition in Madarounfa, Niger: a retrospective metagenomic analysis of a placebo-controlled trial. Lancet Microbe 2023; 4:e931-e942. [PMID: 37866373 PMCID: PMC10620469 DOI: 10.1016/s2666-5247(23)00213-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 06/27/2023] [Accepted: 06/30/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Children with severe acute malnutrition are treated with antibiotics as outpatients. We aimed to determine the effect of 7 days of amoxicillin on acute and long-term changes to the gut microbiome and antibiotic resistome in children treated for severe acute malnutrition. METHODS We conducted a secondary analysis of a randomised, double-blinded, placebo-controlled trial (NCT01613547) of amoxicillin in children (aged 6-59 months) with severe acute malnutrition treated as outpatients in Madarounfa, Niger. We randomly selected 161 children from the overall cohort (n=2399) for initial 12-week follow-up from Sept 23, 2013 to Feb 3, 2014. We selected a convenience sample of those 161 children, on the basis of anthropometric measures, for follow-up 2 years later (Sept 28 to Oct 27, 2015). Children provided faecal samples at baseline, week 1, week 4, week 8, week 12, and, for those in the 2-year follow-up cohort, week 104. We conducted metagenomic sequencing followed by microbiome and resistome profiling of faecal samples. 38 children without severe acute malnutrition and six children with severe acute malnutrition matching the baseline ages of the original cohort were used as reference controls. FINDINGS In the 12-week follow-up group, amoxicillin led to an immediate decrease in gut microbiome richness from 37·6 species (95% CI 32·6-42·7) and Shannon diversity index (SDI) 2·18 (95% CI 1·97-2·39) at baseline to 27·7 species (95% CI 22·9-32·6) species and SDI 1·55 (95% CI 1·35-1·75) at week 1. Amoxicillin increased gut antibiotic resistance gene abundance to 6044 reads per kilobase million (95% CI 4704-7384) at week 1, up from 4800 (3391-6208) at baseline, which returned to baseline 3 weeks later. 35 children were included in the 2-year follow-up; the amoxicillin-treated children (n=22) had increased number of species in the gut microbiome compared with placebo-treated children (n=13; 60·7 [95% CI 54·7-66·6] vs 36·9 [29·4-44·3]). Amoxicillin-treated children had increased Prevotella spp and decreased Bifidobacterium spp relative to age-matched placebo-treated children, indicating a more mature, adult-like microbiome. INTERPRETATION Amoxicillin treatment led to acute but not sustained increases in antimicrobial resistance genes and improved gut microbiome maturation 2 years after severe acute malnutrition treatment. FUNDING Bill & Melinda Gates Foundation; Médecins sans Frontières Operational Center Paris; National Institute of Allergy and Infectious Diseases; National Institute of General Medical Sciences; Eunice Kennedy Shriver National Institute of Child Health and Human Development; Edward Mallinckrodt Jr Foundation; Doris Duke Foundation.
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Affiliation(s)
- Drew J Schwartz
- The Edison Family Center for Genome Sciences & Systems Biology, Washington University School of Medicine in St Louis, St Louis, MO, USA; Center for Women's Infectious Disease Research, Washington University School of Medicine in St Louis, St Louis, MO, USA; Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, MO, USA; Department of Molecular Microbiology, Washington University School of Medicine in St Louis, St Louis, MO, USA; Department of Obstetrics & Gynecology, Washington University School of Medicine in St Louis, St Louis, MO, USA
| | - Amy Langdon
- The Edison Family Center for Genome Sciences & Systems Biology, Washington University School of Medicine in St Louis, St Louis, MO, USA; Clinical Research Training Center, Washington University School of Medicine in St Louis, St Louis, MO, USA
| | - Xiaoqing Sun
- The Edison Family Center for Genome Sciences & Systems Biology, Washington University School of Medicine in St Louis, St Louis, MO, USA; Department of Pathology & Immunology, Washington University School of Medicine in St Louis, St Louis, MO, USA
| | | | | | | | - Indi Trehan
- Departments of Pediatrics, Global Health, and Epidemiology, University of Washington, Seattle, WA, USA
| | - Sheila Isanaka
- Department of Research, Epicentre, Paris, France; Department of Nutrition, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Gautam Dantas
- The Edison Family Center for Genome Sciences & Systems Biology, Washington University School of Medicine in St Louis, St Louis, MO, USA; Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, MO, USA; Department of Molecular Microbiology, Washington University School of Medicine in St Louis, St Louis, MO, USA; Department of Pathology & Immunology, Washington University School of Medicine in St Louis, St Louis, MO, USA; Department of Biomedical Engineering, Washington University School of Medicine in St Louis, St Louis, MO, USA.
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Bliznashka L, Grantz KH, Botton J, Berthé F, Garba S, Hanson KE, Grais RF, Isanaka S. Burden and risk factors for relapse following successful treatment of uncomplicated severe acute malnutrition in young children: Secondary analysis from a randomised trial in Niger. Maternal & Child Nutrition 2022; 18:e13400. [PMID: 35866201 PMCID: PMC9480908 DOI: 10.1111/mcn.13400] [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] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 04/22/2022] [Accepted: 06/16/2022] [Indexed: 11/30/2022]
Abstract
This study aimed to quantify the burden of relapse following successful treatment for uncomplicated severe acute malnutrition (SAM) and to identify associated risk factors in rural Niger. We used data from 1490 children aged 6−59 months discharged as recovered from an outpatient nutritional programme for SAM and followed for up to 12 weeks after admission. Postdischarge SAM relapse was defined as weight‐for‐height Z‐score <−3, mid‐upper arm circumference (MUAC) <115 mm or bipedal oedema after having been discharged as recovered. Postdischarge hospitalisation was defined as admission to inpatient SAM treatment or hospitalisation for any cause after having been discharged as recovered. We used multivariate log‐binomial models to identify independent risk factors. After programmatic discharge, 114 (8%) children relapsed to SAM and 89 (6%) were hospitalised. Factors associated with SAM relapse were discharge during the lean season (relative risk [RR] = 1.80 [95% confidence interval [CI] = 1.22−2.67]) and larger household size (RR = 1.56 [95% CI = 1.01−2.41]), whereas older child age (RR = 0.94 [95% CI = 0.88−1.00]), higher child MUAC at discharge (RR = 0.93 [95% CI = 0.87−1.00]) and maternal literacy (RR = 0.54 [95% CI = 0.29−0.98]) were protective factors. Discharge during the lean season (RR = 2.27 [95% CI = 1.46−3.51]) was independently associated with postdischarge hospitalisation. Future nutritional programmes in the context of Niger may consider modification of anthropometric discharge criteria or the provision of additional home support or follow‐up during the lean season as potential interventions to prevent relapse. More research including postdischarge follow‐up is needed to better understand the sustainability of treatment outcomes after discharge and the type of intervention that may best sustain recovery over time. Clinical Trial Registration: ClinicalTrials.gov number, NCT01613547. Following successful discharge from a community‐based nutritional programme for severe acute malnutrition (SAM) treatment in rural Niger, the prevalence of SAM relapse was 8% and the prevalence of postdischarge hospitalisation was 6% within 12 weeks from admission. Factors associated with SAM relapse were child age at programme admission, child mid‐upper arm circumference (MUAC) at discharge, discharge from the nutritional programme during the lean season, and maternal literacy. Anthropometry at discharge was a primary risk factor for relapse. MUAC at discharge performed better than weight‐for‐height Z‐score (WHZ) in classifying SAM relapse cases. ‘Optimal’ cut‐offs, defined using the Liu method which maximises the product of the sensitivity and specificity, were MUAC of 121 mm with 66% sensitivity and 67% specificity and WHZ of −1.38 with 54% sensitivity and 57% specificity. Future programmes may consider additional support or follow‐up of children at high risk of postdischarge relapse or hospitalisation, including those discharged during the lean season. Modification of current anthropometric discharge criteria may also be explored as an actionable target to further reduce the risk of relapse.
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Affiliation(s)
- Lilia Bliznashka
- Global Academy of Agriculture and Food Systems University of Edinburgh Edinburgh United Kingdom
| | - Kyra H. Grantz
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore Maryland USA
| | - Jérémie Botton
- Faculty of Pharmacy University Paris‐Sud, University Paris‐Saclay Châtenay‐Malabry France
| | | | | | | | | | - Sheila Isanaka
- Department of Research Epicentre Paris France
- Department of Nutrition Harvard T. H., Chan School of Public Health Boston Massachusetts USA
- Department of Global Health and Population Harvard T. H., Chan School of Public Health Boston Massachusetts USA
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Isanaka S, Tang K, Berthé F, Grais RF, Pandya A. Cost-effectiveness of routine versus indicated antibiotic therapy in the management of severe wasting in children. Cost Eff Resour Alloc 2022; 20:38. [PMID: 35922807 PMCID: PMC9351197 DOI: 10.1186/s12962-022-00374-z] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 07/23/2022] [Indexed: 11/10/2022] Open
Abstract
Background In the outpatient management of severe wasting, routine antibiotic therapy is recommended for all children upon admission regardless of whether clinical signs of infection are present. Indicated antibiotic therapy, where antibiotics are provided only upon presentation of clinical signs of infection, may be considered for its potential to allow for more prudent antibiotic use and greater program coverage, reducing the risk of antibiotic resistance as well as costs and logistical burdens associated with treatment. We therefore conducted a cost-effectiveness analysis to measure the effects of indicated antibiotic therapy compared to routine antibiotic therapy in terms of incremental cost-per-life-year saved in Niger. Methods We used a cohort model to conduct a cost-effectiveness analysis from a healthcare system perspective to project and weigh the lifetime discounted costs and effects of indicated antibiotic therapy compared to routine antibiotic therapy in the treatment of uncomplicated severe wasting in children in Niger. We calculated incremental cost-effectiveness ratios (ICERs) in terms of treatment-related healthcare costs per discounted life-years saved (LYS), and conducted program coverage scenario and sensitivity analyses to assess model uncertainty. Results The ICER for indicated antibiotic therapy compared to routine antibiotic therapy was $8.5/LYS, which is under the cost-effectiveness threshold for Niger. The probability of the indicated strategy being optimal was 76.1% when program coverage was equal to coverage associated with routine therapy but was 100% likely to be optimal in probabilistic sensitivity analysis scenarios where indicated program coverage improved 5 percentage points. Conclusions Indicated antibiotic therapy likely represents a cost-effective strategy, particularly if indicated treatment can result in expanded coverage. With the risk of increasing antibiotic resistance worldwide, antibiotic stewardship and simplified treatment protocols for severe wasting using indicated antibiotic therapy may represent good value for money in some low risk populations. Supplementary Information The online version contains supplementary material available at 10.1186/s12962-022-00374-z.
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Affiliation(s)
- Sheila Isanaka
- Department of Research, Epicentre, 14-34 avenue Jean Juarès, 75019, Paris, France. .,Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Kevin Tang
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Rebecca F Grais
- Department of Research, Epicentre, 14-34 avenue Jean Juarès, 75019, Paris, France
| | - Ankur Pandya
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Hitchings MDT, Berthé F, Aruna P, Shehu I, Hamza MA, Nanama S, Steve-Edemba C, Grais RF, Isanaka S. Effectiveness of a monthly schedule of follow-up for the treatment of uncomplicated severe acute malnutrition in Sokoto, Nigeria: A cluster randomized crossover trial. PLoS Med 2022; 19:e1003923. [PMID: 35231024 PMCID: PMC8887725 DOI: 10.1371/journal.pmed.1003923] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 01/20/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Community-based management of severe acute malnutrition (SAM) involves weekly or biweekly outpatient clinic visits for clinical surveillance and distribution of therapeutic foods. Distance to outpatient clinics and high opportunity costs for caregivers can represent major barriers to access. Reducing the frequency of outpatient visits while providing training to caregivers to recognize clinical danger signs at home between outpatient visits may increase acceptability, coverage, and public health impact of SAM treatment. We investigated the effectiveness of monthly clinic visits compared to the standard weekly follow-up in the outpatient treatment of uncomplicated SAM in northwestern Nigeria. METHODS AND FINDINGS We conducted a cluster randomized crossover trial to test the noninferiority of nutritional recovery in children with uncomplicated SAM receiving monthly follow-up compared to the standard weekly schedule. From January 2018 to November 2019, 3,945 children aged 6 to 59 months were enrolled at 10 health centers (5 assigned to monthly follow-up and 5 assigned to weekly follow-up) in Sokoto, Nigeria. In total, 96% of children (n = 1,976 in the monthly follow-up group and 1,802 in the weekly follow-up group) were followed until program discharge, and 91% (n = 1,873 in the monthly follow-up group and 1,721 in the weekly follow-up group) were followed to 3 months postdischarge. The mean age at admission was 15.8 months (standard deviation [SD] 7.1), 2,097/3,945 (53.2%) were girls, and the mean midupper arm circumference (MUAC) at admission was 105.8 mm (SD 6.0). In a modified intention-to-treat analysis, the primary outcome of nutritional recovery, defined as having MUAC ≥125 mm on 2 consecutive visits, was analyzed using generalized linear models, with generalized estimating equations to account for clustering. Nutritional recovery was lower in the monthly follow-up group compared to the weekly group (1,036/1,976, 52.4% versus 1,059/1,802, 58.8%; risk difference: -6.8%), and noninferiority was not demonstrated (lower bound of the confidence interval [CI] was -11.5%, lower than the noninferiority margin of 10%). The proportion of children defaulting was lower in the monthly group than in the weekly group (109/1,976, 5.5% versus 151/1,802, 8.4%, p = 0.03). Three months postdischarge, children in the monthly group were less likely to relapse compared to those in the weekly group (58/976, 5.9% versus 78/1,005, 7.8%, p = 0.03), but cumulative mortality at 3 months postdischarge was higher in the monthly group (159/1,873, 8.5% versus 106/1,721, 6.2%, p < 0.001). Study results may depend on context-specific factors including baseline level of care and the clinical status of children presenting to health centers, and, thus, generalizability of these results may be limited. CONCLUSIONS Where feasible, a weekly schedule of clinic visits should be preferred to maintain effectiveness of SAM treatment. Where geographic coverage of programs is low or frequent travel to outpatient clinics is difficult or impossible, a monthly schedule of visits may provide an alternative model to deliver treatment to those in need. Modifications to the outpatient follow-up schedule, for example, weekly clinic visits until initial weight gain has been achieved followed by monthly visits, could increase the effectiveness of the model and add flexibility for program delivery. TRIAL REGISTRATION ClinicalTrials.gov NCT03140904.
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Affiliation(s)
- Matt D. T. Hitchings
- Department of Biology, University of Florida, Gainesville, Florida, United States of America
- Emerging Pathogens Institute, University of Florida, Gainesville, Florida, United States of America
| | | | - Philip Aruna
- Médecins Sans Frontières–Operational Center Amsterdam, Amsterdam, the Netherlands
| | | | | | - Siméon Nanama
- UNICEF West and Central Regional Office, Dakar, Senegal
| | | | | | - Sheila Isanaka
- Epicentre, Paris, France
- Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
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Menzies NA, Berthé F, Hitchings M, Aruna P, Hamza MA, Nanama S, Steve-Edemba C, Shehu I, Grais RF, Isanaka S. Cost-effectiveness of monthly follow-up for the treatment of uncomplicated severe acute malnutrition: An economic evaluation of a randomized controlled trial. PLOS Glob Public Health 2022; 2:e0001189. [PMID: 36962786 PMCID: PMC10022243 DOI: 10.1371/journal.pgph.0001189] [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: 07/14/2022] [Accepted: 11/07/2022] [Indexed: 12/14/2022]
Abstract
Severe acute malnutrition (SAM) is a major source of mortality for children in low resource settings. Alternative treatment models that improve acceptability and reduce caregiver burden are needed to improve treatment access. We assessed costs and cost-effectiveness of monthly vs. weekly follow-up (standard-of-care) for treating uncomplicated SAM in children 6-59 months of age. To do so, we conducted a cost-effectiveness analysis of a cluster-randomized trial of treatment for newly-diagnosed uncomplicated SAM in northwestern Nigeria (clinicaltrials.gov ID NCT03140904). We collected empirical costing data from enrollment up to 3 months post-discharge. We quantified health outcomes as the fraction of children recovered at discharge (primary cost-effectiveness outcome), the fraction recovered 3 months post-discharge, and total DALYs due to acute malnutrition. We estimated cost-effectiveness from both provider and societal perspectives. Costs are reported in 2019 US dollars. Provider costs per child were $67.07 (95% confidence interval: $64.79, $69.29) under standard-of-care, and $78.74 ($77.06, $80.66) under monthly follow-up. Patient costs per child were $21.04 ($18.18, $23.51) under standard-of-care, and $14.16 ($12.79, $15.25) under monthly follow-up. Monthly follow-up performed worse than standard-of-care for each health outcome assessed and was dominated (produced worse health outcomes at higher cost) by the standard-of-care in cost-effectiveness analyses. This result was robust to statistical uncertainty and to alternative costing assumptions. These findings provide evidence against monthly follow-up for treatment of uncomplicated SAM in situations where weekly follow-up of patients is feasible. While monthly follow-up may reduce burdens on caregivers and providers, other approaches are needed to do so while maintaining the effectiveness of care.
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Affiliation(s)
- Nicolas A Menzies
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Center for Health Decision Science, Harvard TH Chan School of Public Health, Boston, Massachusetts, United States of America
| | | | - Matt Hitchings
- Department of Biology and Emerging Pathogens Institute, University of Florida, Gainesville, Florida, United States of America
| | - Philip Aruna
- Médecins sans Frontières-Operational Center Amsterdam, Amsterdam, Netherlands
| | | | - Siméon Nanama
- UNICEF West and Central Regional Office, Dakar, Senegal
| | | | | | | | - Sheila Isanaka
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Epicentre, Paris, France
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
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Isanaka S, Andersen CT, Hanson KE, Berthé F, Grais RF, Briend A. Energy needs in the treatment of uncomplicated severe acute malnutrition: Secondary analysis to optimize delivery of ready-to-use therapeutic foods. Matern Child Nutr 2020; 16:e12989. [PMID: 32144946 PMCID: PMC7507348 DOI: 10.1111/mcn.12989] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 01/24/2020] [Accepted: 02/18/2020] [Indexed: 11/28/2022]
Abstract
Outpatient therapeutic feeding protocols for the treatment of uncomplicated severe acute malnutrition in children were initially based on weight gain data from inpatient settings and expert knowledge of the physiological requirements during recovery. However, weight gain and energy requirements from historic inpatient settings may differ from modern outpatient settings and therefore may not be appropriate to guide current therapeutic feeding protocols. We calculated the weight gain and average estimated total daily energy requirement of children successfully treated for uncomplicated severe acute malnutrition as outpatients in Niger (n = 790). Mean energy provided by six therapeutic feeding protocols was calculated and compared with average estimated energy requirements in the study population. Overall weight gain was 5.5 g·kg-1 ·day-1 among recovered children. Average energy requirements ranged from 92 to 110 kcal·kg-1 ·day-1 depending on the estimation approach. Two current therapeutic feeding protocols were found to provide an excess of energy after the first week of treatment in our study population, whereas four research protocols tended to provide less energy than the estimated requirement after the first week of treatment. Alternative feeding protocols have the potential to simplify and lead to important savings for programmes but should be evaluated to show adequacy to meet the energy needs of children under treatment, as well as feasibility and cost efficiency. Our findings rely on theoretical calculations based on several assumptions and should be confirmed in field studies.
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Affiliation(s)
- Sheila Isanaka
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Epicentre, Paris, France
| | - Christopher T Andersen
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Kerstin E Hanson
- Médecins Sans Frontières, Operational Center Paris, Paris, France
| | | | | | - André Briend
- Center for Child Health Research, University of Tampere School of Medicine, Tampere, Finland.,Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
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Isanaka S, Grantz KH, Berthé F, Schaefer M, Adehossi E, Grais RF. Extended Follow-up From a Randomized Clinical Trial of Routine Amoxicillin in the Treatment of Uncomplicated Severe Acute Malnutrition in Niger. JAMA Pediatr 2020; 174:295-297. [PMID: 31930369 PMCID: PMC6990797 DOI: 10.1001/jamapediatrics.2019.5189] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This study is an extended follow-up of a randomized clinical trial of routine amoxicillin use for infants experiencing uncomplicated severe acute malnutrition in Niger.
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Affiliation(s)
- Sheila Isanaka
- Department of Research, Epicentre, Paris, France,Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts,Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Kyra H Grantz
- Department of Research, Epicentre, Paris, France,Department of Biology and Emerging Pathogens Institute, University of Florida, Gainesville
| | | | - Myrto Schaefer
- Médecins Sans Frontières Operational Center Paris, Paris, France
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Tang K, Berthé F, Nackers F, Hanson K, Mambula C, Langendorf C, Marquer C, Isanaka S. Hand hygiene compliance and environmental contamination with gram-negative bacilli in a rural hospital in Madarounfa, Niger. Trans R Soc Trop Med Hyg 2019; 113:749-756. [PMID: 31608960 PMCID: PMC6907005 DOI: 10.1093/trstmh/trz070] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [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: 11/16/2018] [Revised: 05/12/2019] [Accepted: 07/03/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Healthcare-associated infections pose a major, yet often preventable risk to patient safety. Poor hand hygiene among healthcare personnel and unsanitary hospital environments may contribute to this risk in low-income settings. We aimed to describe hand hygiene behaviour and environmental contamination by season in a rural, sub-Saharan African hospital setting. METHODS We conducted a concurrent triangulation mixed-methods study combining three types of data at a hospital in Madarounfa, Niger. Hand hygiene observations among healthcare personnel during two seasons contributed quantitative data describing hand hygiene frequency and its variability in relation to seasonal changes in caseload. Semistructured interviews with healthcare personnel contributed qualitative data on knowledge, attitudes and barriers to hand hygiene. Biweekly environmental samples evaluated microbial contamination from October 2016 to December 2017. Triangulation identified convergences, complements and contradictions across results. RESULTS Hand hygiene compliance, or the proportion of actions (handrubbing or handwashing) performed out of all actions required, was low (11% during non-peak and 36% during peak caseload seasons). Interviews with healthcare personnel suggesting good general knowledge of hand hygiene contradicted the low hand hygiene compliance. However, compliance by healthcare activity was convergent with poor knowledge of precise hand hygiene steps and the motivation to prevent personal acquisition of infection identified during interviews. Contamination of environmental samples with gram-negative bacilli was high (45%), with the highest rates of contamination observed during the peak caseload season. CONCLUSION Low hand hygiene compliance coupled with high contamination rates of hospital environments may increase the risk of hospital-acquired infections in sub-Saharan African settings.
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Affiliation(s)
- Kevin Tang
- Department of Research, Epicentre-France, 8 Rue Saint Sabin 75011 Paris, France
| | - Fatou Berthé
- Epicentre-Niger: Quartier Plateau, Boulevard Mali Bero Issa Beri (IB) Rue 31, Porte N 93, BP 13 330, Niamey, Niger
| | - Fabienne Nackers
- Department of Research, Epicentre-France, 8 Rue Saint Sabin 75011 Paris, France
| | - Kerstin Hanson
- Médecins Sans Frontières, Operational Centre Paris: 8 Rue Saint Sabin 75011 Paris, France
| | - Christopher Mambula
- Médecins Sans Frontières, Operational Centre Paris: 8 Rue Saint Sabin 75011 Paris, France
| | - Celine Langendorf
- Department of Research, Epicentre-France, 8 Rue Saint Sabin 75011 Paris, France
| | - Caroline Marquer
- Department of Research, Epicentre-France, 8 Rue Saint Sabin 75011 Paris, France
| | - Sheila Isanaka
- Department of Research, Epicentre-France, 8 Rue Saint Sabin 75011 Paris, France.,Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health: 677 Huntington Ave, Boston, MA 02115, USA
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10
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Isanaka S, Berthé F, Nackers F, Tang K, Hanson KE, Grais RF. Feasibility of engaging caregivers in at-home surveillance of children with uncomplicated severe acute malnutrition. Matern Child Nutr 2019; 16:e12876. [PMID: 31336045 PMCID: PMC7038908 DOI: 10.1111/mcn.12876] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 06/29/2019] [Accepted: 07/03/2019] [Indexed: 11/25/2022]
Abstract
Many factors can contribute to low coverage of treatment for severe acute malnutrition (SAM), and a limited number of health facilities and trained personnel can constrain the number of children that receive treatment. Alternative models of care that shift the responsibility for routine clinical and anthropometric surveillance from the health facility to the household could reduce the burden of care associated with frequent facility-based visits for both healthcare providers and caregivers. To assess the feasibility of shifting clinical surveillance to caregivers in the outpatient management of SAM, we conducted a pilot study to assess caregivers' understanding and retention of key concepts related to the surveillance of clinical danger signs and anthropometric measurement over a 28-day period. At the time of a child's admission to nutritional treatment, a study nurse provided a short training to groups of caregivers on two topics: (a) clinical danger signs in children with SAM that warrant facility-based care and (b) methods to measure and monitor their child's mid-upper arm circumference. Caregiver understanding was assessed using standardized questionnaires before training, immediately after training, and 28 days after training. Knowledge of most clinical danger signs (e.g., convulsions, edema, poor appetite, respiratory distress, and lethargy) was low (0-45%) before training but increased immediately after and was retained 28 days after training. Agreement between nurse-caregiver mid-upper arm circumference colour classifications was 77% (98/128) immediately after training and 80% after 28 days. These findings lend preliminary support to pursue further study of alternative models of care that allow for greater engagement of caregivers in the clinical and anthropometric surveillance of children with SAM.
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Affiliation(s)
- Sheila Isanaka
- Department of Research, Epicentre, Paris, France.,Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | | | - Kevin Tang
- Department of Research, Epicentre, Paris, France
| | - Kerstin E Hanson
- Médecins Sans Frontières Operational Center of Paris, Paris, France
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Isanaka S, Hitchings MDT, Berthé F, Briend A, Grais RF. Linear growth faltering and the role of weight attainment: Prospective analysis of young children recovering from severe wasting in Niger. Matern Child Nutr 2019; 15:e12817. [PMID: 30903806 PMCID: PMC6849732 DOI: 10.1111/mcn.12817] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 01/11/2019] [Accepted: 03/15/2019] [Indexed: 12/17/2022]
Abstract
Efforts to reduce the impact of stunting have been largely independent of interventions to reduce the impact of wasting, despite the observation that the conditions can coexist in the same child and increase risk of death. To optimize the management of malnourished children—who can be wasted, stunted, or both—the relationship between stunting and wasting should be elaborated. We aimed to describe the relationship between concurrent weight and height gain during and after rehabilitation from severe wasting. We conducted a secondary analysis of a randomized trial for the outpatient treatment of severe wasting, including 1,542 children who recovered and were followed for 12 weeks. We described the overlap of stunting and severe wasting and the change in stunting over time. We showed the relationship between concurrent weight and height gain using adjusted generalized estimating equations and calculated the mean rate of change in weight‐for‐height z score (WHZ) and height‐for‐age z score (HAZ) during and after rehabilitation. At baseline, 79% (n = 1,223/1,542) and 49% (n = 757/1,542) of children were stunted and severely stunted, respectively. Prevalence increased over time among children <24 months. During rehabilitation when weight was not yet fully recovered, we found rapid WHZ gain but limited HAZ gain. Following successful rehabilitation, WHZ gain slowed. The rate of HAZ gain was negative after rehabilitation but increased relative to the period during treatment. The potential relationship between weight and height gain calls for increased coverage of wasting treatment to not only prevent child mortality but also reduce linear growth faltering.
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Affiliation(s)
- Sheila Isanaka
- Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, United States.,Department of Research, Epicentre, Paris, France
| | - Matt D T Hitchings
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, United States
| | | | - André Briend
- Center for Child Health Research, University of Tampere School of Medicine, Tampere, Finland.,Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
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Madzorera I, Duggan C, Berthé F, Grais RF, Isanaka S. The role of dietary diversity in the response to treatment of uncomplicated severe acute malnutrition among children in Niger: a prospective study. BMC Nutr 2018; 4:35. [PMID: 32153896 PMCID: PMC7050850 DOI: 10.1186/s40795-018-0242-y] [Citation(s) in RCA: 3] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 07/10/2018] [Indexed: 11/21/2022] Open
Abstract
Background Community-based treatment of severe acute malnutrition (SAM) has proven to be safe and cost-effective, although identifying additional factors that can increase recovery and decrease treatment failure may improve program effectiveness. We examine the association of dietary diversity and clinical and program treatment outcomes among children treated for uncomplicated SAM in Niger. Methods Two thousand four hundred twelve children were enrolled in a randomized trial of routine amoxicillin in the treatment of uncomplicated SAM from 2012 to 2014. All children received ready to use therapeutic food (RUTF) and standard clinical care. Child dietary diversity was assessed using a 7-day food frequency questionnaire and 8-food group diet diversity score. We assessed the association of dietary diversity at admission with nutritional recovery, hospitalization, and death at program discharge and 12 weeks, and weight and height gain. Results Food groups most commonly consumed by children in seven days preceding SAM treatment were cereals, roots and tubers (N = 2364, 99.5%) and vitamin A rich fruits and vegetables (N = 2253, 94.8%). Egg (N = 472, 19.9%) and dairy (N = 659, 27.7%) consumption was low. Mean (SD) diet diversity score was significantly lower in the lean vs. non-lean season [2.7 (1.1) vs. 2.9 (1.0)]. There was no evidence that dietary diversity increased nutritional recovery at discharge (RR: 1.02, 95% CI: 1.00, 1.04) or 12 weeks (RR: 0.98, 95%CI: 0.94, 1.02). No significant association was found with risk of hospitalization or death, or weight and height gain. Egg consumption was protective against death at discharge (RR: 0.53, 95% CI: 0.39, 0.70) and 12 weeks (RR: 0.66, 95% CI: 0.45, 0.96). Vitamin A rich fruits and vegetable consumption was associated with greater risk of mortality in children at discharge (RR: 1.30, 95% CI: 1.08, 1.56) and 12 weeks (RR: 1.19, 95% CI: 1.03, 1.36). Conclusions We did not find evidence that dietary diversity influenced nutrition recovery or response to treatment for children with uncomplicated SAM in Niger. It is feasible consumption of nutrient-dense foods like eggs may be important for recovery from SAM. There is need for continued research to further elucidate drivers of nutritional recovery from acute malnutrition in different settings. Trial registration Trial registration number: ClinicalTrials.gov NCT01613547. Registered May 26, 2012.
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Affiliation(s)
- Isabel Madzorera
- 1Department of Nutrition, Harvard TH Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115 USA
| | - Christopher Duggan
- 1Department of Nutrition, Harvard TH Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115 USA.,2Division of Gastroenterology and Nutrition, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA 02115 USA
| | | | - Rebecca F Grais
- 4Department of Research, Epicentre, 8 rue Saint Sabin, 75011 Paris, France
| | - Sheila Isanaka
- 1Department of Nutrition, Harvard TH Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115 USA.,4Department of Research, Epicentre, 8 rue Saint Sabin, 75011 Paris, France.,5Department of Global Health and Population, Harvard TH Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115 USA
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13
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Oldenburg CE, Guerin PJ, Berthé F, Grais RF, Isanaka S. Malaria and Nutritional Status Among Children With Severe Acute Malnutrition in Niger: A Prospective Cohort Study. Clin Infect Dis 2018; 67:1027-1034. [PMID: 29522089 PMCID: PMC6137121 DOI: 10.1093/cid/ciy207] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 03/06/2018] [Indexed: 11/14/2022] Open
Abstract
Background The relationship between malaria infection and nutritional status is complex. Previous studies suggest malaria may increase the incidence and severity of malnutrition, while malnutrition may increase the risk of malaria infection. Here, we report bidirectional associations between malaria and nutritional status among children with uncomplicated severe acute malnutrition (SAM). Methods This study is a secondary analysis of a randomized, controlled trial for the treatment of uncomplicated SAM in Niger. Children aged 6-59 months were enrolled and followed for 12 weeks. Malaria infection was assessed using an histidine-rich protein 2 (HRP2) rapid diagnostic test at admission and at any follow-up visit with fever. We assessed the association of nutritional status at admission on malaria incidence using Cox proportional hazards regression and malaria infection at admission on nutritional recovery and weight and height gain using linear regression. Results Of 2399 children included in the analysis, 1327 (55.3%) were infected with malaria at admission. Malaria incidence was 12.1 cases/100 person-months among those without malaria infection at admission. Nutritional status at admission was not associated with malaria incidence. Children with malaria infection at admission and subsequently treated with an artemisinin-based combination therapy had increased weight gain (0.38 g/kg/day; 95% confidence interval [CI], 0.07 to 0.69) and reduced height gain (-0.002 mm/day; 95% CI, -0.004 to -0.0008). Conclusions Malaria infection was common among children treated for uncomplicated SAM. Malaria infection may impair height gain. Proper medical and nutritional management should be ensured to prevent adverse effects of malaria infection. Clinical Trials Registration NCT01613547.
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Affiliation(s)
- Catherine E Oldenburg
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Philippe J Guerin
- WorldWide Antimalarial Resistance Network, University of Oxford, United Kingdom
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom
| | | | | | - Sheila Isanaka
- Department of Research, Epicentre, Paris, France
- Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Isanaka S, Kodish SR, Berthé F, Alley I, Nackers F, Hanson KE, Grais RF. Outpatient treatment of severe acute malnutrition: response to treatment with a reduced schedule of therapeutic food distribution. Am J Clin Nutr 2017; 105:1191-1197. [PMID: 28404577 DOI: 10.3945/ajcn.116.148064] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 03/10/2017] [Indexed: 11/14/2022] Open
Abstract
Background: Community-based management of severe acute malnutrition (SAM) has been shown to be safe and cost-effective, but program coverage remains low. Treatment models that maintain high levels of clinical effectiveness but allow for increased coverage are still needed. A reduced schedule of follow-up, in which children receive clinical follow-up and therapeutic foods on a monthly rather than weekly basis, may be one alternative.Objective: We aimed to describe the safety and feasibility of a monthly distribution of ready-to-use therapeutic food (RUTF) in the treatment of uncomplicated SAM, in terms of clinical response to treatment and household RUTF use.Design: We conducted a nonrandomized pilot intervention study in which 115 children eligible for outpatient treatment of SAM were provided a monthly ration of RUTF. Anthropometric measurements were taken weekly for 4 wk to monitor treatment response. Unannounced household spot checks were conducted over 4 wk to assess household use of RUTF and storage practices.Results: Adequate weight and midupper arm circumference (MUAC) gain were found throughout the 4-wk follow-up period. Observed mean ± SD weight gain from admission was 9.8 ± 6.8 g · kg-1 · d-1 in week 1 and 4.2 ± 2.1 g · kg-1 · d-1 by week 4. Unplanned household spot checks found an average surplus of RUTF sachets compared with the number expected based on the date of distribution and recommended dosing throughout the 4 wk of follow-up. The frequency at which more than the recommended dose was used (i.e., deviance of >2 sachets between available and expected stocks) was 4% and 22% of households visited in week 1 and week 4, respectively.Conclusion: Adequate treatment response and RUTF use in the outpatient treatment of SAM was maintained over 4 wk of follow-up with a monthly schedule of RUTF distribution. This study was registered at clinicaltrials.gov as NCT02994212.
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Affiliation(s)
- Sheila Isanaka
- Departments of Nutrition and .,Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA; and.,Epicentre and
| | | | | | | | | | - Kerstin E Hanson
- Médecins Sans Frontières, Operational Center Paris, Paris, France
| | - Rebecca F Grais
- Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA; and.,Epicentre and
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15
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Isanaka S, Langendorf C, Berthé F, Gnegne S, Li N, Ousmane N, Harouna S, Hassane H, Schaefer M, Adehossi E, Grais RF. Routine Amoxicillin for Uncomplicated Severe Acute Malnutrition in Children. N Engl J Med 2016; 374:444-53. [PMID: 26840134 DOI: 10.1056/nejmoa1507024] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND High-quality evidence supporting a community-based treatment protocol for children with severe acute malnutrition, including routine antibiotic use at admission to a nutritional treatment program, remains limited. In view of the costs and consequences of emerging resistance associated with routine antibiotic use, more evidence is required to support this practice. METHODS In a double-blind, placebo-controlled trial in Niger, we randomly assigned children who were 6 to 59 months of age and had uncomplicated severe acute malnutrition to receive amoxicillin or placebo for 7 days. The primary outcome was nutritional recovery at or before week 8. RESULTS A total of 2412 children underwent randomization, and 2399 children were included in the analysis. Nutritional recovery occurred in 65.9% of children in the amoxicillin group (790 of 1199) and in 62.7% of children in the placebo group (752 of 1200). There was no significant difference in the likelihood of nutritional recovery (risk ratio for amoxicillin vs. placebo, 1.05; 95% confidence interval [CI], 0.99 to 1.12; P=0.10). In secondary analyses, amoxicillin decreased the risk of transfer to inpatient care by 14% (26.4% in the amoxicillin group vs. 30.7% in the placebo group; risk ratio, 0.86; 95% CI, 0.76 to 0.98; P=0.02). CONCLUSIONS We found no benefit of routine antibiotic use with respect to nutritional recovery from uncomplicated severe acute malnutrition in Niger. In regions with adequate infrastructure for surveillance and management of complications, health care facilities could consider eliminating the routine use of antibiotics in protocols for the treatment of uncomplicated severe acute malnutrition. (Funded by Médecins sans Frontières Operational Center Paris; ClinicalTrials.gov number, NCT01613547.).
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Affiliation(s)
- Sheila Isanaka
- From the Department of Research, Epicentre (S.I., C.L., F.B., S.G., R.F.G.), and Médecins sans Frontières Operational Center Paris (M.S.), Paris; the Departments of Nutrition (S.I.) and Global Health and Population (S.I., N.L.), Harvard T.H. Chan School of Public Health, Boston; and the Ministry of Health (N.O.), Forum Santé Niger (S.H.), and National Hospital (E.A.), Niamey, and UNICEF, Maradi (H.H.) - all in Niger
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Abstract
Analysis of data from a questionnaire survey of 2,000 young Malians undertaken by the authors in 2002 demonstrates that, even in underprivileged urban and rural populations, changes in sexual behavior are emerging. Among women, first sex and motherhood are taking place slightly later, and a minority is now dissociating sexuality and procreation. Our data confirm the considerable impact of female education on this transition. Girls'sexual activity before procreation is also influenced by lower religiosity. Among men, in contrast, in a traditional context of late sexual debut and fatherhood, the trend is toward earlier sexual activity and procreation. Fatherhood is delayed, however, among better-educated, wealthier, and less religious urban men, who therefore experience a longer period of sexual activity before they begin to build their own families. The study concludes with an analysis of the possible association of the sexual transition with young people's increased vulnerability resulting from their adoption of risky sexual behaviors and from unfavorable conditions surrounding the arrival of their first child.
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Affiliation(s)
- Claudine Sauvain-Dugerdil
- University of Geneva, Laboratoire de démographie et d'etudes familiales, Uni Mail-40 boulevard du Pont-d'Arve, CH-1211, Geneva 4, Switzerland.
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Diallo S, Diarra B, Diop S, Toloba Y, Berthé F, Sissoko B, Gomez P, M'Baye O, Keita B. [Knowledge of the Bamako general population of tuberculosis]. Mali Med 2009; 24:48-51. [PMID: 19666381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The hope of the World Health Organization (WHO) in the fight against tuberculosis rests today on the implementation of the strategy DOTS. The success of this strategy passes obligatorily by an implication of the parents, neighbors in one word of the population living with the patient; this is why we fixed our objective to study knowledge on the tuberculosis of the people of more than 18 years of the district of Bamako. We carried out a cross-sectional study supplemented by focus-groups in 3 districts of Bamako near the general population (socio-medical personnel, old tuberculous, and helping natural) for the period from the 1st of June to July 15, 2004. Our sample was composed of 246 people for the individual questionnaires and of 47 per 8 meetings of focus group: the sex ratio was 2,5 in favour of the men and 60,2% of our subjects had less than 30 years. In the general population of Bamako 24,8% had a good knowledge, 49,0% an average knowledge and 26,2% a bad knowledge. 48,8 % of those which had a good knowledge were the pupils, students and civils servant. So in general the population had a good knowledge on symptomatology (90,2 %), it on the other hand had the knowledge very limited on the etiology (only 10,6% of the subject knew that tuberculosis is caused by a mycobactery) or on the modes of transmission (cigarettes, soap, meat). The population of Bamako has a very passable level of knowledge on tuberculosis. If this level is good with regard to symptomatology, it is very insufficient on the etiology or on the transmission of the disease. To improve this knowledge one needs a sensitizing supported for television and the radio in the dialects and national languages.
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Affiliation(s)
- S Diallo
- Service de pneumologie, Hôpital du point G : BP 333 Bamako Mali
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