Implementing Joint External Evaluations of the International Health Regulations (2005) capacities in all countries in the WHO African region: process challenges, lessons learnt and perspectives for the future

Following the West Africa Ebola virus disease outbreak (2013-2016), the Joint External Evaluation (JEE) is one of the three voluntary components recommended by the WHO for evaluating the International Health Regulations (2005) capacities in countries. Here, we share experience implementing JEEs in all 47 countries in the WHO African region. In February 2016, the United Republic of Tanzania (Mainland) was the first country globally to conduct a JEE. By April 2022, JEEs had been conducted in all 47 countries plus in the island of Zanzibar. A total of 360 subject matter experts (SMEs) from 88 organisations were deployed 607 times. Despite availability of guidelines, the process had to be contextualised while avoiding jeopardising the quality and integrity of the findings. Key challenges were: inadequate understanding of the process by in-country counterparts; competing country priorities; limited time for validating subnational capacities; insufficient availability of SMEs for biosafety and biosecurity, antimicrobial resistance, points of entry, chemical events and radio-nuclear emergencies; and inadequate financing to fill gaps identified. Key points learnt were: importance of country leadership and ownership; conducting orientation workshops before the self-assessment; availability of an external JEE expert to support the self-assessment; the skills, attitudes and leadership competencies of the team lead; identifying national experts as SMEs for future JEEs to promote capacity building and experience sharing; the centrality of involving One Health stakeholders from the beginning to the end of the process; and the need for dedicated staff for planning, coordination, implementation and timely report writing. Moving forward, it is essential to draw from this learning to plan future JEEs. Finally, predictable financing is needed immediately to fill gaps identified.

How prepared is the world? Identifying weaknesses in existing assessment frameworks for global health security through a One Health approach

The COVID-19 pandemic has exposed faults in the way we assess preparedness and response capacities for public health emergencies. Existing frameworks are limited in scope, and do not sufficiently consider complex social, economic, political, regulatory, and ecological factors. One Health, through its focus on the links among humans, animals, and ecosystems, is a valuable approach through which existing assessment frameworks can be analysed and new ways forward proposed. Although in the past few years advances have been made in assessment tools such as the International Health Regulations Joint External Evaluation, a rapid and radical increase in ambition is required. To sufficiently account for the range of complex systems in which health emergencies occur, assessments should consider how problems are defined across stakeholders and the wider sociopolitical environments in which structures and institutions operate. Current frameworks do little to consider anthropogenic factors in disease emergence or address the full array of health security hazards across the social-ecological system. A complex and interdependent set of challenges threaten human, animal, and ecosystem health, and we cannot afford to overlook important contextual factors, or the determinants of these shared threats. Health security assessment frameworks should therefore ensure that the process undertaken to prioritise and build capacity adheres to core One Health principles and that interventions and outcomes are assessed in terms of added value, trade-offs, and cobenefits across human, animal, and environmental health systems.

Investing in preparedness for rapid detection and control of epidemics: analysis of health system reforms and their effect on 2021 Ebola virus disease epidemic response in Guinea

The 2014-2016 West Africa Ebola Virus Disease (EVD) Epidemic devastated Guinea's health system and constituted a public health emergency of international concern. Following the crisis, Guinea invested in the establishment of basic health system reforms and crucial legal instruments for strengthening national health security in line with the WHO's recommendations for ensuring better preparedness for (and, therefore, a response to) health emergencies. The investments included the scaling up of Integrated Disease Surveillance and Response; Joint External Evaluation of International Health Regulation capacities; National Action Plan for Health Security; Simulation Exercises; One Health platforms; creation of decentralised structures such as regional and prefectural Emergency Operation Centres; Risk assessment and hazard identification; Expanding human resources capacity; Early Warning Alert System and community preparedness. These investments were tested in the subsequent 2021 EVD outbreak and other epidemics. In this case, there was a timely declaration and response to the 2021 EVD epidemic, a lower-case burden and mortality rate, a shorter duration of the epidemic and a significant reduction in the cost of the response. Similarly, there was timely detection, response and containment of other epidemics including Lassa fever and Marburg virus disease. Findings suggest the utility of the preparedness activities for the early detection and efficient containment of outbreaks, which, therefore, underlines the need for all countries at risk of infectious disease epidemics to invest in similar reforms. Doing so promises to be not only cost-effective but also lifesaving.

Framing the future of the COVID-19 response operations in 2022 in the WHO African region

BACKGROUND

With the evolving epidemiological parameters of COVID-19 in Africa, the response actions and lessons learnt during the pandemic's past two years, SARS-COV 2 will certainly continue to circulate in African countries in 2022 and beyond. As countries in the African continent need to be more prepared and plan to 'live with the virus' for the upcoming two years and after and at the same time mitigate risks by protecting the future most vulnerable and those responsible for maintaining essential services, WHO AFRO is anticipating four interim scenarios of the evolution of the pandemic in 2022 and beyond in the region.

OBJECTIVE

In preparation for the rollout of response actions given the predicted scenarios, WHO AFRO has identified ten strategic orientations and areas of focus for supporting member states and partners in responding to the COVID-19 pandemic in Africa in 2022 and beyond.

METHODS

WHO analysed trends of the transmissions since the first case in the African continent and reviewed lessons learnt over the past months.

RESULTS

Establishing a core and agile team solely dedicated to the COVID-19 response at the WHO AFRO, the emergency hubs, and WCOs will improve the effectiveness of the response and address identified challenges. The team will collaborate with the various clusters of the regional office, and other units and subunits in the WCOs supported with good epidemics intelligence. COVID-19 pandemic has afflicted global humanity at unprecedented levels.

CONCLUSION

Two years later and while starting the third year of the COVID-19 response, we now need to change and adapt our strategies, tools and approaches in responding timely and effectively to the pandemic in Africa and save more lives.

Assessment of COVID-19 pandemic responses in African countries: thematic synthesis of WHO intra-action review reports

OBJECTIVES

We conducted a review of intra-action review (IAR) reports of the national response to the COVID-19 pandemic in Africa. We highlight best practices and challenges and offer perspectives for the future.

DESIGN

A thematic analysis across 10 preparedness and response domains, namely, governance, leadership, and coordination; planning and monitoring; risk communication and community engagement; surveillance, rapid response, and case investigation; infection prevention and control; case management; screening and monitoring at points of entry; national laboratory system; logistics and supply chain management; and maintaining essential health services during the COVID-19 pandemic.

SETTING

All countries in the WHO African Region were eligible for inclusion in the study. National IAR reports submitted by March 2021 were analysed.

RESULTS

We retrieved IAR reports from 18 African countries. The COVID-19 pandemic response in African countries has relied on many existing response systems such as laboratory systems, surveillance systems for previous outbreaks of highly infectious diseases and a logistics management information system. These best practices were backed by strong political will. The key challenges included low public confidence in governments, inadequate adherence to infection prevention and control measures, shortages of personal protective equipment, inadequate laboratory capacity, inadequate contact tracing, poor supply chain and logistics management systems, and lack of training of key personnel at national and subnational levels.

CONCLUSION

These findings suggest that African countries' response to the COVID-19 pandemic was prompt and may have contributed to the lower cases and deaths in the region compared with countries in other regions. The IARs demonstrate that many technical areas still require immediate improvement to guide decisions in subsequent waves or future outbreaks.

Public Health Program for Decreasing Risk for Ebola Virus Disease Resurgence from Survivors of the 2013-2016 Outbreak, Guinea

At the end of the 2013–2016 Ebola virus disease outbreak in Guinea, we implemented an alert system for early detection of Ebola resurgence among survivors. Survivors were asked to report health alerts in their household and provide body fluid specimens for laboratory testing. During April–September 2016, a total of 1,075 (88%) of 1,215 survivors participated in the system; follow up occurred at a median of 16 months after discharge (interquartile range 14–18 months). Of these, 784 acted as focal points and reported 1,136 alerts (including 4 deaths among survivors). A total of 372 (91%) of 408 eligible survivors had >1 semen specimen tested; of 817 semen specimens, 5 samples from 4 survivors were positive up to 512 days after discharge. No lochia (0/7) or breast milk (0/69) specimens tested positive. Our findings underscore the importance of long-term monitoring of survivors’ semen samples in an Ebola-affected country.

Joint external evaluation of the International Health Regulation (2005) capacities: current status and lessons learnt in the WHO African region

The International Health Regulations (IHR, 2005) are an essential vehicle for addressing global health security. Here, we report the IHR capacities in the WHO African from independent joint external evaluation (JEE). The JEE is a voluntary component of the IHR monitoring and evaluation framework. It evaluates IHR capacities in 19 technical areas in four broad themes: ‘Prevent’ (7 technical areas, 15 indicators); ‘Detect’ (4 technical areas, 13 indicators); ‘Respond’ (5 technical areas, 14 indicators), points of entry (PoE) and other IHR hazards (chemical and radiation) (3 technical areas, 6 indicators). The IHR capacity scores are graded from level 1 (no capacity) to level 5 (sustainable capacity). From February 2016 to March 2019, 40 of 47 WHO African region countries (81% coverage) evaluated their IHR capacities using the JEE tool. No country had the required IHR capacities. Under the theme ‘Prevent’, no country scored level 5 for 12 of 15 indicators. Over 80% of them scored level 1 or 2 for most indicators. For ‘Detect’, none scored level 5 for 12 of 13 indicators. However, many scored level 3 or 4 for several indicators. For ‘Respond’, none scored level 5 for 13 of 14 indicators, and less than 10% had a national multihazard public health emergency preparedness and response plan. For PoE and other IHR hazards, most countries scored level 1 or 2 and none scored level 5. Countries in the WHO African region are commended for embracing the JEE to assess their IHR capacities. However, major gaps have been identified. Urgent collective action is needed now to protect the WHO African region from health security threats.

Ebola Virus Transmission Caused by Persistently Infected Survivors of the 2014-2016 Outbreak in West Africa

The 2014–2016 Ebola virus (EBOV) disease outbreak affected over 29000 people and left behind the biggest cohort (over 17000 individuals) of Ebola survivors in history. Although the persistence of EBOV in body fluids of survivors was reported before the recent outbreak, new evidence revealed that the virus can be detected up to 18 months in the semen, which represents the biggest risk of Ebola resurgence in affected communities. In this study, we review the knowledge on the Ebola flare-ups that occurred after the peak of the 2014–2016 Ebola epidemic in West Africa.

First occurrence of Rift Valley fever outbreak in Niger, 2016

Rift Valley fever (RVF) is a mosquito‐borne viral zoonosis causing abortions and high mortality among animals, whereas in humans, the disease is usually mild or asymptomatic. In September 2016, the Republic of Niger declared the first RVF outbreak in the northern region of Tahoua near the Malian border. This study describes the outbreak and reports the results of serological and molecular investigations of the human and animal samples collected. Serum samples from both human and animal suspected cases have been confirmed at the Centre de Recherche Médicale et Sanitaire (CERMES) and the Laboratoire Centrale d'Elevage (LABOCEL) public health and animal reference laboratories, respectively. Techniques for biological confirmation were real time reverse transcription polymerase chain reaction (RT‐PCR) and enzyme linked immunosorbent assay (ELISA). Phylogenetic trees were established after genetic sequencing of the small and medium segments of the RVF virus (RVFV) genome. Out of the 399 human samples collected, 17 (4.3%) were confirmed positive for RVFV. Overall, 33 (8.3%) deaths occurred out of which five (29%) were among the 17 confirmed cases. Regarding animals, 45 samples were tested, three of which were RT‐PCR positive and 24 were IgG positive. The phylogenetic analyses showed that the Niger strains clustered with Senegal 2013 and Mauritania 2015 RVFV strains. This first outbreak of RVF was very challenging for public and animal health laboratories in Niger. Besides resulting in human deaths, important loss of cattle has been reported. Therefore, vigilance has to be strengthened emphasising vector control strategies and active surveillance among animals.

[Major Causes Of Limb Amputations At The Hospital In Sikasso]

INTRODUCTION

In this study, we aimed to determine the major causes of limb amputations to improve its treatment.

PATIENTS AND METHODS

We conducted a-18 month prospective study from March 2015 to September 2016 at the Hospital of Sikasso, a hospital of second reference in Mali.

RESULTS

We carried out 50 major limb amputations including 25 men and 25 women aged 38.9 years old on average with extremes of 3 and 80 years old. The amputed limb was the upperlimb in 38 cases (76%) and the lowerlimb in 12 cases (24%). Housewives were the most represented with 18 cases (36%), followed by farmers with 15 cases (30%). The amputation was done immediately or in delayed emergency in 32 cases (54%). Trauma was the most frequent etiology with 13 cases (26%). The post-operative complications have been met in 47 cases. They have been dominated by stump pain and delayed healing in 23 cases (49%) each, suppuration in 10 cases (21%) and the stump necrosis in 3 cases (7%). The mortality rate was 8% (4 cases). We have made prosthetic apparatus for18 patients (36%).

CONCLUSION

The limb amputation is frequent and youths were the most involved. Due the lack of financial support, 64% of our patients could not afford prosthesis.

Lessons learned by surveillance during the tail-end of the Ebola outbreak in Guinea, June-October 2015: a case series

BACKGROUND

By the end of the 2013–2016 West African Ebola Virus Disease (EVD) outbreaks, a total of 3814 cases (probable and confirmed) and 2544 deaths were reported in Guinea. Clearly, surveillance activities aiming at stopping human-to-human transmission have been the breakthrough of EVD outbreak management, but their application has been at times easier said than done. This article presents five confirmed or probable EVD cases that arose in Conakry towards the end of the Guinea epidemic, which demonstrate flaws in surveillance and follow-up.

CASE PRESENTATION

For case 1, safe burial requirements were not followed. For cases 1 and 2, negative Polymerase Chain Reaction (PCR) results were interpreted as no infection. For the first case, the sample may have not been taken properly while for the second the disease was possibly at its early stage. Case 3 was stopped at a border health checkpoint and despite her high temperature she was allowed to continue the bus journey. For case 4, an oral swab sample was supposedly taken after death but could not be found for retrospective testing. Despite characteristic symptomatology, case 5 was not identified as a suspect case for as long as 3 weeks.

CONCLUSION

In epidemic contexts, health systems must be able to track all samples of suspect cases and deaths, regardless of their laboratory results. Social mobilization in communities and training in health care facilities must be strengthened at the tail of an outbreak, to avoid the natural slackening of disease surveillance, in particular for long-lasting and deadly epidemics.

Rubeoparvulum massiliense gen. nov., sp. nov., a new bacterial genus isolated from the human gut of a Senegalese infant with severe acute malnutrition

Rubeoparvulum massiliense strain mt6^T was isolated from the gut microbiota of a severely malnourished boy from Senegal and consisted of facultative anaerobic, spore-forming, nonmotile and Gram-negative rods. R. massiliense showed a 92% similarity with the 16S rRNA of Bacillus mannanilyticus. The genome of strain mt6^T is 2 843 796 bp long with a 43.75% G+C content. It contains 2735 protein-coding genes and 76 RNA genes, among which are nine rRNA genes.

A molecular model for neurodevelopmental disorders

Genes implicated in neurodevelopmental disorders (NDDs) important in cognition and behavior may have convergent function and several cellular pathways have been implicated, including protein translational control, chromatin modification, and synapse assembly and maintenance. Here, we test the convergent effects of methyl-CpG binding domain 5 (MBD5) and special AT-rich binding protein 2 (SATB2) reduced dosage in human neural stem cells (NSCs), two genes implicated in 2q23.1 and 2q33.1 deletion syndromes, respectively, to develop a generalized model for NDDs. We used short hairpin RNA stably incorporated into healthy neural stem cells to supress MBD5 and SATB2 expression, and massively parallel RNA sequencing, DNA methylation sequencing and microRNA arrays to test the hypothesis that a primary etiology of NDDs is the disruption of the balance of NSC proliferation and differentiation. We show that reduced dosage of either gene leads to significant overlap of gene-expression patterns, microRNA patterns and DNA methylation states with control NSCs in a differentiating state, suggesting that a unifying feature of 2q23.1 and 2q33.1 deletion syndrome may be a lack of regulation between proliferation and differentiation in NSCs, as we observed previously for TCF4 and EHMT1 suppression following a similar experimental paradigm. We propose a model of NDDs whereby the balance of NSC proliferation and differentiation is affected, but where the molecules that drive this effect are largely specific to disease-causing genetic variation. NDDs are diverse, complex and unique, but the optimal balance of factors that determine when and where neural stem cells differentiate may be a major feature underlying the diverse phenotypic spectrum of NDDs.

Surgical treatment of endemic goiter in a nonhospital setting without general anesthesia in Africa

BACKGROUND

Endemic goiter remains a serious public health problem and 75 % of people affected live in underdeveloped countries where treatment is difficult for various reasons. The aim of this article is to report our experience in African countries with the management and surgical treatment of endemic goiter, performed in a nonhospital setting and without general anesthesia in the context of a collaborative development project by experienced endocrine surgeons.

METHODS

Fifty-six black African patients with a goiter were studied. Those in poor general health, the elderly, patients with either small goiters or clinical hyperthyroidism, and those presenting with an acute episode of malaria were excluded from the study. Cervical epidural anesthesia with spontaneous ventilation was used and a partial thyroidectomy was performed. The technique used, its immediate complications, and early and late follow-up were analyzed.

RESULTS

Surgery was performed on 31 patients with grades 3 and 4 goiter without mortality and a morbidity rate of 11.9 %, with 97 % of all complications being minor. There were no instances of dysphonia or symptomatic hypocalcemia and the mean stay was 1.57 days (range 1.25-1.93). Follow-up in the first year was 71 % and no case of severe or recurrent hypothyroidism was detected.

CONCLUSIONS

Surgery without general anesthesia performed in a nonhospital setting in underdeveloped countries in patients with goiter is a viable option with good results and low morbidity.

[Gastroduodenal ulcer in the rural setting in Mali]

The goal of our study was to describe the epidemiologic , clinical and endoscopic aspects of gastroduodenal ulcers at the regional hospital of sikasso (HRS). This prospective study was held from january 2002 to december 2003.All of the patients underwent an upper digestive tract endoscopy. Gastroduodenal ulcers comprised 10.88% of all of the digestive tract endoscopies. The average age of patients was 42.51 + 14.60 years with a gender ratio of 1.88 in favor of men. The overwhelm patients were lower middle class income. The main clinical symptoms were epigastric pain and dyspepsia. The ulcers were most often found in the duodenum (DI).

[Erectile dysfunction and diabetes in Conakry (Guinea): frequency and clinical characteristics from 187 diabetic patients]

Sexual dysfunction is frequent in the diabetic population. In Africa, medical care for erectile dysfunction is underprovided, profoundly altering the quality of life of the patients. We report the prevalence of erectile dysfunction in 187 diabetic patients followed in the department of Endocrinology of the Conakry teaching hospital. Prevalence was estimated from the French version of the International Index of Erectile Function (IIEF). Erectile dysfunction concerned 90 patients (48%) of whom a severe form was observed in 54%, a moderate form in 35% and a mild form in 12%. The patients who presented erectile dysfunction were significantly older, displayed longer duration of diabetes with more complications (sensorial neuropathy and macroangiopathy) and often took drugs for associated cardiovascular diseases. In 28% of the cases, erectile dysfunction was associated with a decline in libido and in 26% with ejaculation disorders. In conclusion, erectile dysfunction is frequent and severe among diabetic patients in Guinea. The medical staff plays an essential role to initiate early diagnosis, promote psychological support and provide medication, if possible.

[Control of tuberculosis as seen "in the field": popular perceptions of the disease and access to care in Conakry, Guinea]

Tuberculosis is a public health priority especially in developing countries. A variety of control programs have been implemented. The purpose of this survey was to study the perceptions and practices of the victims of this disease "in the field". The findings of this survey carried out in a cohort of 65 patients and their families in Conakry, Guinea underline the importance of popular perceptions of the disease in care-seeking behavior. This survey also shows that health care workers share the same perceptions as the general population, which constitutes a major impediment for screening and treatment.

[Ureteroplasty by penile pedicular flap]

The authors relate a retrospective study on 30 cases of urethral stenosis and four cases of urethral rupture with a mean follow up of 28 months (8 to 44 months). The mean age of the patients was 47.5 years (6 to 85 years). The main aetiology was inflammatory sclerosis (73.5%). The predilection was bulbar (52.94%). The main symptom was constituted by dysuria (n = 24). The peri-urethral sclerosis was found in 44, 12% of cases. The penile flap as tube or patch. Immediate complications were a loosen of sutures (n = 7), urinary fistula (n = 4). The later complications were essentially recidives (n = 6). The results were good in 73.5% of cases.

[Harpoon scrotal injury: unusual accident in submarine fishing]

The authors report a case of transfixing injury of the scrotum while diving. The patient was seen one hour after the accident. The harpoon traversed the right side of the scrotum from below upwards. Emergency surgical exploration only revealed effraction of the sinus of the epididymis and the abdominal muscles. The overall risk for fertility was suggested in view of a possible lesion of the epididymal canal.

[Bladder lithiasis]

OBJECTIVE

to study the particularities of the bladder lithiasis in our countries. This was a retrospective study of 94 cases (62 men and 32 women) of bladder lithiasis over a period of 13 years. The lithogenic factors; clinic, paraclinic and therapeutic aspects have been studied. Morphoconstitutional analysis has been carded out in collaboration with Cristal Laboratory (St Cloud hospital center in France).

RESULTS

mean age was 24.2+/-20.7 years old. The principals mains of consultation were: dysuria (n =36), mictionnal pain (n = 28), hematuria (n = 15). Facilitating factors have been found in 27% of cases. In 10 cases, there was an association bladdder lithiasis and bladdder-vaginal fistula. Radiologic test was dominated by intraveinous urographic (53.19 of cases). The metabolic test showed hypercalcemia and cristalluria in 2 cases. In 7,45 % of cases, we have founding a renal failure. An urinary tract infection have been noticed in 42 % of cases. Open surgery has been the main treatement (96 %) associating in 15 % of cases the treatement of an uropathy. In one case the bladder lithiasis weighed 1120 g. The morphologic and spectrophotometric analysis of the lithiasis have been achieved in 13 % of cases showing the predominance of struvite.

CONCLUSION

the bladder lithiasis is still common in our countries; it could be good for us to access endoorporeals and extracorporeals therapeutic equipements in orderto reduce the indications of open surgery.

[Vesico-uterine fistulae. Report of 5 cases]

The authors report 5 cases of uterovesical fistula (UVF) and analyse some of the clinical and therapeutic aspects of this disease. The mean age of these 5 patients was 31.2 +/- 6.9 years. The trauma responsible for the fistula was caesarean section in every case. The presenting complaints were dominated by cyclic haematuria (n = 5). Intravenous urography did not contribute to the diagnosis, while hysterosalpingography demonstrated the UVF in 3 out of 4 cases. Treatment was surgical for all patients and consisted of closure of the fistula in 3 cases and hysterectomy in 2 cases. With a mean follow-up of 2 +/- 1.2 years, no pregnancies were reported in the 3 patients treated by closure of the fistula. On the other hand, the urinary results were satisfactory with good continence and resolution of the cyclic haematuria. The authors emphasize the importance of prevention of UVF by well conducted caesarean section.

Renal venous thrombosis: an unusual cause of fetal distress

Renal venous thrombosis (RVT) is a rare event in neonates and infants. Its incidence varies from 0.5 per thousand concerning admissions in neonatal intensive care units to 0.5% in autopsic findings. Some cases may occur in the antenatal period. Clinical presentation in infants includes a mass in the flank. hematuria and thrombocytopenia. We report a case of RVT which was diagnosed at 34 weeks' gestation by ultrasound in a fetus showing cardiotocographic signs of fetal distress. We observed the typical pattern reported by pediatric radiologists: renal enlargement, loss of the cortico-medullary boundary, echoic streaks following the direction of interlobular veins, lack of definition of renal sinus echoes and loss of venous flow in the right kidney by Doppler velocimetry. After delivery by caesarean section and transient hyperbilirubinemia and moderately impaired renal function the infant weighing 2435 g had a full recovery at 1 week and a normal evolution at 1 month of life.

Acute respiratory infections in children: a community-based study comparing a primary health center and a pediatric unit, Republic of Guinea

OBJECTIVE

A community-based study was carried out in the Republic of Guinea in order to evaluate the frequency of occurrence, severity of illness, risk factors and the results of planned treatment of acute respiratory infections (ARI) in children under the age of 15 years.

DESIGN

The study was performed over a 1-year period in 2 distinct areas, 1 rural and 1 urban. A total of 2622 ARI were identified among children under 15 years of age. In the rural area, data were collected by primary health-care workers and by 2 physicians who were trained to supervise the study.

RESULTS

Among the rural population, 1422 ARI were identified. In the city center, Conakry, 1200 ARI were identified in one children's hospital. The child population under 5 years of age was significantly greater in the rural area (95.2%) than in the city center (83.2%) (P < 0.0001). Malnutrition affected 10.6% of all the children. There were discrepancies in symptoms and signs affecting the 2 groups but the severity scores, including children under 5 years of age, were not significantly different: including children under 5 years of age, were not significantly different: 10-11% of the children were considered to have severe disease and 6.2% required urgent referral to hospital. Upper and lower respiratory infections (URI and LRI) were equally represented (49.9% and 50.1% respectively). Distribution of each type of ARI was significantly different in the 2 groups: there were significantly more URI in the city center, especially tonsillitis. Bronchitis and bronchopneumonia occurred significantly more often in the rural area. Pneumonia and bronchopneumonia represented 9.8% of all ARI. Use of antibiotic therapy was known in 2557 patients: 1268 URI and 1289 LRI. In children with URI, 69.7% did not receive antibiotic therapy, 29.9% received 1 antibiotic and 0.03% received 2 antibiotics successively. Children from the city center received significantly more antibiotics than in the rural health center. In children with LRI, 17.8% did not receive antibiotic therapy, 81.7% received 1 antibiotic and 0.05% received 2 antibiotics successively. There was no significant difference between the 2 centers in antibiotic prescription. Clinical outcome showed that 93% of children were considered to be cured at day 7 and 99.4% at day 14. 14 children with severe pneumonia died. The infection cost (antibiotics plus other drugs prescribed as supportive care) was 0.45 US$ per child in the rural area and 9.7 US$ in the children's hospital.

CONCLUSION

This supervised study constitutes the first large longitudinal study concerning respiratory infections in West Africa. It demonstrates that simple guidelines are valid in order to prevent mortality and complications. Care appropriate to population requirements in term of infectious diseases can be delivered with low cost and low technology.