Effectiveness of decentralizing outpatient acute malnutrition treatment with community health workers and a simplified combined protocol: a cluster randomized controlled trial in emergency settings of Mali

Background

Outpatient treatment of acute malnutrition is usually centralized in health centers and separated into different programs according to case severity. This complicates case detection, care delivery, and supply chain management, making it difficult for families to access treatment. This study assessed the impact of treating severe and moderate cases in the same program using a simplified protocol and decentralizing treatment outside health centers through community health workers (CHWs).

Methods

A three-armed cluster randomized controlled trial under a non-inferiority hypothesis was conducted in the Gao region of Mali involving 2,038 children between 6 and 59 months of age with non-complicated acute malnutrition. The control arm consisted of 549 children receiving standard treatment in health centers from nursing staff. The first intervention arm consisted of 800 children treated using the standard protocol with CHWs added as treatment providers. The second intervention arm consisted of 689 children treated by nurses and CHWs under the ComPAS simplified protocol, considering mid-upper arm circumference as the sole anthropometric criterion for admission and discharge and providing a fixed dose of therapeutic food for severe and moderate cases. Coverage was assessed through cross-sectional surveys using the sampling evaluation of access and coverage (SLEAC) methodology for a wide area involving several service delivery units.

Results

The recovery rates were 76.3% in the control group, 81.8% in the group that included CHWs with the standard protocol, and 92.9% in the group that applied the simplified protocol, confirming non-inferiority and revealing a significant risk difference among the groups. No significant differences were found in the time to recovery (6 weeks) or in anthropometric gain, whereas the therapeutic food expenditure was significantly lower with the simplified combined program in severe cases (43 sachets fewer than the control). In moderate cases, an average of 35 sachets of therapeutic food were used. With the simplified protocol, the CHWs had 6% discharge errors compared with 19% with the standard protocol. The treatment coverage increased significantly with the simplified combined program (SAM +42.5%, MAM +13.8%).

Implications

Implementing a simplified combined treatment program and adding CHWs as treatment providers can improve coverage while maintaining non-inferior effectiveness, reducing the expenditure on nutritional intrants, and ensuring the continuum of care for the most vulnerable children.

Cinétique de la réponse humorale après administration d’un vaccin SARS-COV-2 mRNA dans une cohorte de patients transplantés et greffés rénaux

Introduction

Kidney transplant recipients and patients on hemodialysis are immunocompromised populations, prioritized for COVID 19 vaccination, but excluded from vaccine trials. Data are lacking regarding humoral response to COVID vaccination in immunocompromised patients.

Description

We investigated early serological response after COVID 19 vaccination with Pfizer/BioNTech (BNT162b2) mRNA vaccine in groups of patients undergoing hemodialysis (n = 78), kidney transplant recipients (n = 74), and in healthy controls. Antibody titers against SARS-CoV-2 at days 0, 14, 28, 36 and 58 after the first injection were measured.

Methods

Antibody titers against SARS-CoV-2 at days 0, 14, 28, 36 and 58 after the first injection were measured.

Results

A total of 74 transplant recipients (mean age 64.8 ± 11.5 years, 38.9% women), 78 hemodialysis patients (mean age 73.5 ± 12.8 years, 40.2% women) and 7 healthy controls (mean age 51.6 ± 6.8, 42% women) were included. In controls, antibodies were detected at a significant level (> 13 AU/ml) at day 14 post-injection, and increased progressively, to peak at day 36 (median 1372 AU/mL [IQR 490.2-4540.5]). Patients undergoing hemodialysis had lower titers that peaked at day 58 (median 4.0 AU/mL [IQR: 1.85-12.2] at day 14; 6.6 AU/mL [IQR 2.1-19.0] at day 36; 276 AU/mL [IQR 83.4-526.0] at day 58). A significant antibody level was detected in only 3 kidney transplant recipients at day 36. In hemodialysis patients, age, serum albumin and Kt/V were positively correlated with serological response (P < 0.043 and P < 0.019 respectively); non responders to HBV vaccine had the lowest titers of anti-SARS-CovV-2 antibodies (Fig. 1).

Conclusion

Our results suggest that the post-vaccine humoral response is strongly inhibited by immunosuppressant therapy in kidney transplant recipients, while it is lowered by the uremic condition in patients undergoing hemodialysis.

Relationship between entomological inoculation rate, Plasmodium falciparum prevalence rate, and incidence of malaria attack in rural Gabon

To assess the relationships between variations of Plasmodium falciparum transmission and those of peripheral parasitaemia prevalence or malaria attack incidence rates in regions with limited fluctuations of transmission, we conducted a follow-up in two Gabonese populations. Entomological surveys were carried out from May 1995 to April 1996 in Dienga, and from May 1998 to April 1999 in Benguia. In Dienga, malaria transmission was seasonal, being not detected during two 3-month periods. Mean entomological inoculation rate (EIR) was 0.28 infective bite/person/night. In Benguia, malaria transmission was perennial with seasonal fluctuations, mean EIR being 0.76 infective bite/person/night. In Dienga, 301 schoolchildren were followed from October 1995 to March 1996. Clinical malaria attack was defined as fever associated with >5000 parasites/microl of blood. P. falciparum prevalence varied from 28 to 42%, and monthly malaria attack incidence from 30 to 169 per thousand. In Benguia, the entire population (122 persons) was followed from November 1998 to April 1999. Prevalence varied from 22 to 50%, and monthly malaria attack incidence from 52 to 179 per thousand. In each area, entomological variations were not related to parasite prevalence, but preceded malaria attack incidence with 1- or 2-month time lag, corresponding to the pre-patency period that differs in the two populations, possibly according to differences in immunity related to parasite transmission.

Molecular identification of Pasteurella dagmatis peritonitis in a patient undergoing peritoneal dialysis

Pasteurella dagmatis was identified as the etiologic agent of peritonitis in a continuous ambulatory peritoneal dialysis patient by utilizing a molecular kit in our hospital's clinical laboratory. This method would appear a useful approach to identify a species of Pasteurella not included in the existing database of commercial identification kits when discrepancies exist between phenotypic tests.