Making Removals Part of Informed Choice: A Mixed-Method Study of Client Experiences With Removal of Long-Acting Reversible Contraceptives in Senegal

BACKGROUND

Ensuring access to removal services for implants and intrauterine devices (IUDs) is essential to realize informed choice and voluntary family planning. We document removal desires and experiences among women who received an implant or IUD from the public sector in 3 districts of Senegal.

METHODS

We conducted a phone survey of 1,868 implant and IUD users, 598 follow-up surveys with those who had ever asked a provider for a removal, and 24 in-depth interviews (IDIs) with women who had ever wanted an implant removal. We analyzed survey data descriptively and IDI data thematically.

RESULTS

Fifty-eight percent of implant users and 54% of IUD users reported having wanted a removal. Desired pregnancy and contraceptive-induced menstrual changes (CIMCs) were the main reasons for removal desires. Fifty-four percent of implant users and 55% of IUD users who asked a provider for a removal reported challenges accessing services, with over two-thirds noting long lines or wait times. Sixty-three percent of implant users and 73% of IUD users who saw a provider were satisfied with the outcome of their first interaction. Over 90% of participants had not been told about the removal cost at insertion. Almost all participants who had their method removed obtained a complete removal during their first clinical procedure. Around two-thirds of participants who obtained a removal did not take up another method at that time. IDIs confirmed the influence of CIMCs on removal desires and show some partner influence is common in removal decision making. Barriers include lack of available qualified providers and supplies. Provider interactions play an important role in satisfaction with removal services.

CONCLUSION

Participants' experiences accessing removal services were generally positive. Areas of potential improvement include client flow, counseling messages at insertion, and when advising clients to keep their method, pricing, and post-removal reinsertion or method switching.

Clinical, logistic, and geographic factors in ensuring adequate access to implant removals: A cross-sectional survey of public facilities and GIS modeling of geographic access in two districts of Senegal

Introduction

Ensuring adequate access to contraceptive implant removal services requires an understanding of potential clinical, logistical, and geographic challenges.

Methods

We conducted a cross-sectional survey of 39 public health facilities in two districts of Senegal. To assess facility readiness, we reported the proportion of facilities meeting all minimum conditions for regular and difficult implant removals. We then describe characteristics of referral networks. Geographic access modeling was conducted in a geographic information system to estimate the proportion of women of reproductive age living within specific travel times of facilities ready for regular and difficult removals.

Results

72% of facilities met all conditions for regular removals, and 8% for difficult removals. In both cases, the main gaps related to equipment availability (79% of facilities had the minimum equipment for regular removals and 8% for difficult removals). 72% of facilities organized in three referral networks sent clients to other facilities for cases they could not manage. Of 11 receiving or single-network facilities, seven were ready for regular removals and one for difficult removals. Altogether, 36% of women in Dakar Centre and 99% of women in Kolda lived within two hours of a facility that was equipped to handle regular removals, compared to 15% and 69%, respectively, for difficult removals.

Conclusion

Data such as those provided in this assessment are important to provide a realistic picture of the state of readiness of the health system and its ability to meet the inevitable demand for implant removals. Referral networks should be considered as an emerging strategy to avail sufficient capacity at the systems level, including for managing difficult removals. However, careful thought should be given to the location of facilities that are ready to receive cases in order to target upgrades.

Ensuring sufficient service capacity for removals of long-acting reversible contraceptives: a mixed-method study of provider experiences in Senegal

Background: As the number of implants and intrauterine devices (IUD) used in sub-Saharan Africa continues to grow, ensuring sufficient service capacity for removals is critical. This study describes public sector providers’ experiences with implant and IUD removals in two districts of Senegal.

Methods: We conducted a cross-sectional study with providers trained to insert implants and IUDs from all public facilities offering long-acting reversible contraceptives. Data collection elements included a survey with 55 providers and in-depth interviews (IDIs) with eight other providers. We performed descriptive analysis of survey responses and analyzed qualitative data thematically.

Results: Nearly all providers surveyed were trained in both implant and IUD insertion and removal; 42% had received training in the last two years. Over 90% of providers felt confident inserting and removing implants and removing IUDs; 15% were not confident removing non-palpable implants and 27% IUDs with non-visible strings. Challenges causing providers to refer clients or postpone removals include lack of consumables (38%) for implants, and short duration of use for implants (35%) and IUDs (20%). Many providers reported counseling clients presenting for removals to keep their method (58% implant, 31% IUD), primarily to attempt managing side effects. Among providers with removal experience, 78% had ever received a removal client with a deeply-placed implant and 33% with an IUD with non-visible strings. Qualitative findings noted that providers were willing to remove implants and IUDs before their expiration date but first attempted treatment or counseling to manage side effects. Providers reported lack of equipment and supplies as challenges, and mixed success with difficult removals.

Conclusions: Findings on provider capacity to perform insertions and regular removals are positive overall. Potential areas for improvement include availability of equipment and supplies, strengthening of counseling on side effects, and support for managing difficult removals.

Rapidly rising cases with omicron In Senegal

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Omicron variant continues to progress in Senegal with the appearance of new contaminations.

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IRESSEF detected the first positive case of the Omicron variant on Friday, December 3, 2021.

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Since this date, the number of Omicron variant infections has increased over the weeks.

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Molecular surveillance of the Omicron variant is carried out in real time to inform the medical authorities.

Parents as carers on a neonatal unit: Qualitative study of parental and staff perceptions in a low-income setting

Aim To determine parents' experiences on a neonatal unit in a low-income country, how they and staff perceive the role of parents and if parents' role as primary carers could be extended.

BACKGROUND

A busy, rural district hospital in Rwanda. Rwandan neonatal mortality is falling, but achieving Sustainable Development Goal target is hampered by trained staff shortage.

METHODS

Qualitative thematic content analysis of semi-structured interviews with 12 parents and 16 staff.

RESULTS

Parental concerns were around their baby's survival, stress and discharge. They were satisfied with their baby's care but feared their baby may die. Mothers described stress from remaining in hospital throughout baby's stay, providing all non-technical care including tube or breast feeds day and night, followed by kangaroo mother care until discharge. They expressed loneliness from lack of visitors, difficulty finding food and somewhere to sleep, financial worries, concern about family at home, and were desperate to be discharged. Staff focused on shortage of nurses limiting technical care, ability to educate parents and provide follow-up. Neither groups thought parents' role could be extended.

CONCLUSION

Staff, including senior management, were mainly focused on increasing nursing numbers. Parents' concerns were psychosocial and about coping emotionally with their baby's care and practical concerns about inpatient facilities, particularly lack of food and accommodation and absence from home. Staff preoccupation with nurse numbers made them concentrate on medical care, but parental issues identified are more likely to be provided by experienced mothers, allied health professionals, mothers' groups or community health workers.

The Externalities of Advocacy: The High Cost of Standing Up for Patients' Dignity in Senegal

Background and context: In Senegal, pediatric oncology patients arrive at the hospital at advanced stages of disease. Their large tumors, as well as the side effects of chemotherapy make children experience intense pain. In this low-resource setting, morphine supply was quite irregular. Doctors don´t prescribe morphine due to shortages; but few prescriptions also lead to limited orders. A vicious circle with only 1 victim: the patient. Hearing children in pain was agonizing for everyone: patients, caregivers and healthcare practitioners. Aim: This advocacy narrative illustrates how the fight for access to morphine in pediatric oncology has led to both positive and negative externalities. We will highlight ways in which this fight for morphine has provoked political tensions moving the issue forward, but has also affected the careers of health workers involved. Strategy/Tactics: Morphine is a cheap drug, yet it is extremely regulated by international laws. It takes political will to influence national morphine orders. This advocacy strategy was built on raising awareness and setting morphine shortage on the political agenda. Not providing morphine in oncology goes against international standards of care. But most importantly, letting patients suffer without “existing” relief is a breach of basic human right to live - and also die - in dignity. Program/Policy process: Conversations began within the pediatric oncology department. Focus groups highlighted caregivers' feelings of powerlessness before their suffering child. Interviews with key informants (doctor and nurses) were instrumental to a widely diffused Human Rights Watch report exploring the medical and political causes to morphine supply shortages, as well as its psychological repercussions on patient care. A BBC documentary was broadcasted soon after. Subsequently, meetings were held between the Ministry of Health, the National Supply Pharmacy and leading local oncologists. Outcomes: Morphine orders were multiplied by 10, leading to much improved pain management for patients. However, Senegal was portrayed negatively on the international scenes, much to the Health Minister´s dismay. The consequences were incurred by the health workers who contributed to the international publications/reports. What was learned: Health practices can inform policy just like policy can inform health practices. It is a cyclical process. Creating advocacy coalitions and rallying the help of the international community are effective strategies. However, in the political arena, health workers need more than commitment to human rights and quality care. Even in democratic republics, systems can penalise outspoken activists. We have learned that health care practitioners (especially working in public settings) who wish improvement for their patients must learn to be tactical and diplomatic. International partners will return to their home countries, but local actors will pay the high cost of advocacy.

Qualitative Assessment of Vaccination Hesitancy Among Members of the Apostolic Church of Zimbabwe: A Case Study

Vaccine hesitancy or lack of confidence in vaccines is considered a threat to the success of vaccination programs. The rise and spread of measles outbreaks in southern Africa in 2009-2010 were linked to objections among Apostolic Church members, estimated at about 3.5 million in Zimbabwe as of 2014. To inform planning of interventions for a measles-rubella vaccination campaign, we conducted an assessment of the factors contributing to vaccine hesitancy using data from various stakeholders. Among nine districts in three regions of Zimbabwe, we collected data on religious attitudes toward, and perceptions of, vaccines through focus group discussions with health workers serving Apostolic communities and members of the National Expanded Programme on Immunization; semi-structured interviews with religious leaders; and open-ended questions in structured interviews with Apostolic parents/caregivers. Poor knowledge of vaccines, lack of understanding and appreciation of the effectiveness of vaccinations, religious teachings that emphasize prayers over the use of medicine, lack of privacy in a religiously controlled community, and low levels of education were found to be the main factors contributing to vaccine hesitancy among key community members and leaders. Accepting vaccination in public is a risk of sanctions. Poor knowledge of vaccines is a major factor of hesitancy which is reinforced by religious teachings on the power of prayers as alternatives. Because parents/caregivers perceive vaccines as dangerous for their children and believe they can cause death or disease, members of the Apostolic Church have more confidence in alternative methods such as use of holy water and prayers to treat diseases. Under these circumstances, it is important to debunk the myths about the power of holy water on the one hand and disseminate positive information of the efficacy of vaccines on the other hand in order to reduce hesitancy. Education about vaccines and vaccination in conjunction with government intervention, for example, through the use of social distancing policies can provide a framework for reducing hesitancy and increasing demand for vaccination.

Improving access to malaria medicine through private-sector subsidies in seven African countries

Improving access to quality-assured artemisinin combination therapies (ACTs) is an important component of malaria control in low- and middle-income countries. In 2010 the Global Fund to Fight AIDS, Tuberculosis, and Malaria launched the Affordable Medicines Facility--malaria (AMFm) program in seven African countries. The goal of the program was to decrease malaria morbidity and delay drug resistance by increasing the use of ACTs, primarily through subsidies intended to reduce costs. We collected data on price and retail markups on antimalarial medicines from 19,625 private for-profit retail outlets before and 6-15 months after the program's implementation. We found that in six of the AMFm pilot programs, prices for quality-assured ACTs decreased by US$1.28-$4.34, and absolute retail markups on these therapies decreased by US$0.31-$1.03. Prices and markups on other classes of antimalarials also changed during the evaluation period, but not to the same extent. In all but two of the pilot programs, we found evidence that prices could fall further without suppliers' losing money. Thus, concerns may be warranted that wholesalers and retailers are capturing subsidies instead of passing them on to consumers. These findings demonstrate that supranational subsidies can dramatically reduce retail prices of health commodities and that recommended retail prices communicated to a wide audience may be an effective mechanism for controlling the market power of private-sector antimalarial retailers and wholesalers.

Estimates of the incidence of induced abortion and consequences of unsafe abortion in Senegal

CONTEXT

Abortion is highly restricted by law in Senegal. Although women seek care for abortion complications, no national estimate of abortion incidence exists.

METHODS

Data on postabortion care and abortion in Senegal were collected in 2013 using surveys of a nationally representative sample of 168 health facilities that provide postabortion care and of 110 professionals knowledgeable about abortion service provision. Indirect estimation techniques were applied to the data to estimate the incidence of induced abortion in the country. Abortion rates and ratios were calculated for the nation and separately for the Dakar region and the rest of the country. The distribution of pregnancies by planning status and by outcome was estimated.

RESULTS

In 2012, an estimated 51,500 induced abortions were performed in Senegal, and 16,700 (32%) resulted in complications that were treated at health facilities. The estimated abortion rate was 17 per 1,000 women aged 15-44 and the abortion ratio was 10 per 100 live births. The rate was higher in Dakar (21 per 1,000) than in the rest of the country (16 per 1,000). Poor women were far more likely to experience abortion complications, and less likely to receive treatment for complications, than nonpoor women. About 31% of pregnancies were unintended, and 24% of unintended pregnancies (8% of all pregnancies) ended in abortion.

CONCLUSIONS

Unsafe abortion exacts a heavy toll on women in Senegal. Reducing the barriers to effective contraceptive use and ensuring access to postabortion care without the risk of legal consequences may reduce the incidence of and complications from unsafe abortion.

Communicating the AMFm message: exploring the effect of communication and training interventions on private for-profit provider awareness and knowledge related to a multi-country anti-malarial subsidy intervention

BACKGROUND

The Affordable Medicines Facility - malaria (AMFm), implemented at national scale in eight African countries or territories, subsidized quality-assured artemisinin combination therapy (ACT) and included communication campaigns to support implementation and promote appropriate anti-malarial use. This paper reports private for-profit provider awareness of key features of the AMFm programme, and changes in provider knowledge of appropriate malaria treatment.

METHODS

This study had a non-experimental design based on nationally representative surveys of outlets stocking anti-malarials before (2009/10) and after (2011) the AMFm roll-out.

RESULTS

Based on data from over 19,500 outlets, results show that in four of eight settings, where communication campaigns were implemented for 5-9 months, 76%-94% awareness of the AMFm 'green leaf' logo, 57%-74% awareness of the ACT subsidy programme, and 52%-80% awareness of the correct recommended retail price (RRP) of subsidized ACT were recorded. However, in the remaining four settings where communication campaigns were implemented for three months or less, levels were substantially lower. In six of eight settings, increases of at least 10 percentage points in private for-profit providers' knowledge of the correct first-line treatment for uncomplicated malaria were seen; and in three of these the levels of knowledge achieved at endline were over 80%.

CONCLUSIONS

The results support the interpretation that, in addition to the availability of subsidized ACT, the intensity of communication campaigns may have contributed to the reported levels of AMFm-related awareness and knowledge among private for-profit providers. Future subsidy programmes for anti-malarials or other treatments should similarly include communication activities.

Social inequality and antenatal care: impact of economic welfare on pregnancy monitoring in Senegal

AIM

To explore the links between antenatal care (ANC) non-attendance and economic welfare. METHOD AND SUBJECT: This was a cross-sectional, descriptive and analytical study of women aged 15 to 49 years living in Senegal in 2005. Data were from the Demography and Health Survey using a two-stage random sampling procedure. Participants were classed by quintile using an economic well-being score based on housing characteristics and ownership of sustainable goods. The quality of ANC was determined from the number of visits, the qualification of the person delivering care, and content (counseling, weight, height and blood pressure measurements). Logistic regression was used for data analysis.

RESULTS

A total of 6927 women were surveyed. Mean age was 28.15 years (±2.6); 20.3% were primiparous; 61.2% resided in rural areas; 70.0% had received no education. Each of the first four economic quintiles included about 20% (19.2% to 21.5%) of the participants while 16.9% were in the fifth (richest) quintile. A total of 457 women (6.6%) did not undergo any ANC visit. ANC non-attendance increased with parity, decreased with education level and was higher in rural areas than in urban areas, OR=7.2 (95% CI [5.1-10.1]). It decreased with increasing economic well-being: OR=0.6 [0.47-0.75] 2nd quintile vs. 1st, OR=0.02 [0.01-0.05] 5th quintile vs. 1st, p<0.05 overall.

CONCLUSION

Economic welfare plays a major role in determining use of ANC. The only way to solve health problems is to reduce inequalities. The solution to this problem is beyond the scope of health but concerns an overall economic program involving the entire community, including policy-makers.

Effect of the Affordable Medicines Facility--malaria (AMFm) on the availability, price, and market share of quality-assured artemisinin-based combination therapies in seven countries: a before-and-after analysis of outlet survey data

BACKGROUND

Malaria is one of the greatest causes of mortality worldwide. Use of the most effective treatments for malaria remains inadequate for those in need, and there is concern over the emergence of resistance to these treatments. In 2010, the Global Fund launched the Affordable Medicines Facility--malaria (AMFm), a series of national-scale pilot programmes designed to increase the access and use of quality-assured artemisinin based combination therapies (QAACTs) and reduce that of artemisinin monotherapies for treatment of malaria. AMFm involves manufacturer price negotiations, subsidies on the manufacturer price of each treatment purchased, and supporting interventions such as communications campaigns. We present findings on the effect of AMFm on QAACT price, availability, and market share, 6-15 months after the delivery of subsidised ACTs in Ghana, Kenya, Madagascar, Niger, Nigeria, Uganda, and Tanzania (including Zanzibar).

METHODS

We did nationally representative baseline and endpoint surveys of public and private sector outlets that stock antimalarial treatments. QAACTs were identified on the basis of the Global Fund's quality assurance policy. Changes in availability, price, and market share were assessed against specified success benchmarks for 1 year of AMFm implementation. Key informant interviews and document reviews recorded contextual factors and the implementation process.

FINDINGS

In all pilots except Niger and Madagascar, there were large increases in QAACT availability (25·8-51·9 percentage points), and market share (15·9-40·3 percentage points), driven mainly by changes in the private for-profit sector. Large falls in median price for QAACTs per adult equivalent dose were seen in the private for-profit sector in six pilots, ranging from US$1·28 to $4·82. The market share of oral artemisinin monotherapies decreased in Nigeria and Zanzibar, the two pilots where it was more than 5% at baseline.

INTERPRETATION

Subsidies combined with supporting interventions can be effective in rapidly improving availability, price, and market share of QAACTs, particularly in the private for-profit sector. Decisions about the future of AMFm should also consider the effect on use in vulnerable populations, access to malaria diagnostics, and cost-effectiveness.

FUNDING

The Global Fund to Fight AIDS, Tuberculosis and Malaria, and the Bill & Melinda Gates Foundation.

Success of Senegal's first nationwide distribution of long-lasting insecticide-treated nets to children under five - contribution toward universal coverage

BACKGROUND

In 2009, the first national long-lasting insecticide-treated net (LLIN) distribution campaign in Senegal resulted in the distribution of 2.2 million LLINs in two phases to children aged 6-59 months. Door-to-door teams visited all households to administer vitamin A and mebendazole, and to give a coupon to redeem later for an LLIN.

METHODS

A nationwide community-based two-stage cluster survey was conducted, with clusters selected within regions by probability proportional to size sampling, followed by GPS-assisted mapping, simple random selection of households in each cluster, and administration of a questionnaire using personal digital assistants (PDAs). The questionnaire followed the Malaria Indicator Survey format, with rosters of household members and bed nets, and questions on campaign participation.

RESULTS

There were 3,280 households in 112 clusters representing 33,993 people. Most (92.1%) guardians of eligible children had heard about the campaign, the primary sources being health workers (33.7%), neighbours (26.2%), and radio (22.0%). Of eligible children, 82.4% received mebendazole, 83.8% received vitamin A, and 75.4% received LLINs. Almost all (91.4%) LLINs received during the campaign remained in the household; of those not remaining, 74.4% had been given away and none were reported sold. At least one insecticide-treated net (ITN) was present in 82.3% of all households, 89.2% of households with a child < 5 years and 57.5% of households without a child < 5 years. Just over half (52.4%) of ITNs had been received during the campaign. Considering possible indicators of universal coverage, 39.8% of households owned at least one ITN per two people, 21.6% owned at least one ITN per sleeping space and 34.7% of the general population slept under an ITN the night before the survey. In addition, 45.6% of children < 5 years, and 49.2% of pregnant women had slept under an ITN.

CONCLUSIONS

The nationwide integrated LLIN distribution campaign allowed household ITN ownership of one or more ITNs to surpass the RBM target of 80% set for 2010, though additional distribution strategies are needed to reach populations missed by the targeted campaign and to reach the universal coverage targets of one ITN per sleeping space and 80% of the population using an ITN.

[Acute chest syndrom in a patient with homozygous sickle cell anemia]

The Acute Chest Syndrome (ACS) is defined by the association of chest pain with dyspnea, fever, a recent radiological abnormality and hyperleucocytosis. Acute pulmonary complications are the primary cause of mortality in sickle cell patients. We report a 19-year old male patient with homozygous sickle cell anemia who consults for respiratory symptomatology and bone algia. The diagnosis of ACS by left pneumopathy due to pneumococcal infection was based on the clinical tests, chest x-ray and blood culture. The appearance of pneumopathy in patients suffering from sickle cell anemia is explained by the functional asplenia and the inability of phagocyte cells to destruct bacteria. These incidents are triggered by alveolar hypoventilation, fat embolism from bone infarction, infections, pulmonary oedema and thrombosis. The evolution of these ACS by pneumopathy depends on their early diagnosis and treatment but also on the sensitivity of the germs to antibiotics.

[Fernand Widal syndrome: apropos of 2 cases]

The Fernand Widal syndrome combines a nasal polyposis, an asthma and aspirin sensitivity. It remains a nosological entity often unrecognized because of the trivialization of aspirin in-take on the one hand the other its etiopathogenesis which has not yet been clarified because of the inhibition of the cyclo-oxygenase. In actual fact the aspirin molecule has yet to reveal all its secrets (advantages and disadvantages). We report 2 cases of Fernand Widal syndrome observed in 2 women in their thirties with a notion of atopy in one at the Pneumophtisiology clinic at the Fann University Hospital in Dakar. The confirmed diagnosis was based on oral provocative test in addition to suggestive clinical signs which emphasize the classical triad with a chronological appearance more or less typical. The best treatment could combine inhaled corticotherapy, nasalization of sinus cavities, antihistaminics, no aspirin in take and educating the patient.

[Localized benign pleural mesothelioma observed at the Dakar University Hospital]

We report two cases of localized benign pleural mesothelioma with different clinical features. Neuropsychiatric symptoms, including coma, hemiplegia, seizures and misbehavior predominated in the first case, associated with hypoglycemia. The symptoms in the second case were essentially respiratory (cough, dyspnea, and chest pain). Treatment consisted in thoracotomy and complete surgical resection. Histopathology revealed fusiform cells and collagen stroma. These two cases illustrate the diversity of clinical expression of benign localized pleural mesothelioma and confirm their complete resolution after surgical treatment.

[Smoking habits among physicians in Dakar]

A prospective cross-sectional study was conducted in March 1999 on the prevalence of smokers and smoking habits among physicians practicing in the Dakar region. The study population was composed of 163 physicians; 128 male (78.5%) and 35 female (21.5%). The prevalence of smokers was 27.6%. The average age of the smokers was 40.5 (+/- 6.2) years (extremes between 30 and 61 years) and an average duration of 18 (+/- 6.6) years in smoking. Men smoked more than women (93.9% versus 6.7%) with 56.4% of heavy smokers. Specialists represented 63.3% and generalists 36.4%. Initiating factors were stress (28.9%), circle of friends/acquaintances (24.4%), fashion (24.4%), pleasure (20%) and advertisements (2.2%). A little over 82% smoked in public places, 68.9% in their work places and 49.5% before children. The average time duration smoking was stopped followed by relapse was 15.7 (+/- 9.7) months. 97.7% of smokers manifested their intention to stop. Nicotine dependence according too the Fagerström questionnaire was average (37.9%), high (39.6%) and very high (12.6%). Smoking is a reality in the medical environment in Dakar. Specific campaigns aimed at physicians will be necessary to hope for a sustainable change in behavior and for a much more pronounced implication in the fight against tobacco addiction.

[Respiratory manifestations of malignant lymphomas: report of 5 cases]

In this study the authors report 5 cases of malignant lymphomas consisting in a Hodgkin's disease and 4 non Hodgkinian lymphomas. Patients aged from 16 to 55 years were 4 males and 1 female, consulting in Department of respiratory disorders of the University Hospital in Dakar, Senegal, West Africa, from 1986 thru 1992. Detoriation of the general status, cough, dyspnea and cervical adenopathy were remaked in all patients. Thoracic pain and syndrom of right pleurisy were diagnosed in one case of non Hodgkinian malignantlymphoma. X Ray exploration of the chest detected 4 cases of mediastinal adenopathies and 3 pleurisis in non Hodgkinian malignant lymphomas; and reticulonodular opacities of pulmonary basis in the Hodgkin's disease case. The diagnosis has been confirmed by pathologic anatomy studis of the biopsed ganglia. The endemic characteristic of tuberculosis in developing countries make necessary to evoke it in first of any adenopathy. When the clinical feature is atypical, a biopsy of ganglia must be performed to avoid diagnosis delay which could lead to agravate the prognosis of malignant lymphomas.

[Regulations on tuberculosis risk in workplaces in Senegal]

National immunization and control programs have not brought about a significant decline in tuberculosis, which remains a real public health concern in our regions. Prevention in the working environment should be part of an overall prevention program for the general population. Nevertheless, companies should play a leading role because they have the necessary structure and assets. We analyzed the epidemiology of tuberculosis in the working environment using demographic data on employees in Senegal, current medicolegal data on tuberculosis in Senegal and data on prevention of tuberculosis. Our analysis led to a proposed strategy for controlling tuberculosis spread and its prevention in the working environment in Senegal.

Low and stable HIV infection rates in Senegal: natural course of the epidemic or evidence for success of prevention?

OBJECTIVES

To document the level of HIV infection in Senegal and also to review evidence of the impact of efforts in prevention, developed by the National AIDS Control Programme and the Civil Society, on the level of the HIV epidemic.

METHODS

Research, compilation and critical review of all relevant data on HIV and sexually transmission diseases (STDs) epidemiology, sexual behaviour, and the efforts in prevention developed in Senegal.

RESULTS

From 1989 to 1996, the levels of HIV infection estimated in four sentinel urban regions remained stable at around 1.2% in the population of pregnant women, and at 3% in male STD patients. It had increased to 19% in female sex workers. A strong political and community commitment led to an early response to the HIV/AIDS epidemic that has been extended since 1986. Blood transfusion safety was established at the start of the HIV epidemic. The level of knowledge of preventive practices relating to HIV/AIDS among the general population exceeded 90% in the early 1990s. From 1991 to 1996, a 30% to 66% decrease of the STD prevalence rates was observed in pregnant women and sex workers in Dakar. In 1997, 33% of men aged 15-49 years in Dakar reported having had sex with non-regular partners. Among them 67% reported condom use.

CONCLUSIONS

It is not possible to know what the course of the HIV epidemic in Senegal would have taken in the absence of efforts at prevention. Certainly, several factors that pre-dated the occurrence of AIDS in Senegal laid the groundwork for a positive response. However, data from a number of sources do reveal the successfulness of efforts in prevention. From available data, Senegal can rightfully claim to have contained the spread of HIV by intervening early and comprehensively to increase knowledge and awareness of HIV/AIDS and to promote safe sexual behaviour.

In vitro regeneration of the tropical multipurpose leguminous tree Sesbania grandiflora from cotyledon explants

A system using cotyledon pieces as explants and a BAP/NAA containing medium was developed for in vitro mass propagation of Sesbania grandiflora, a tropical nitrogen-fixing leguminous tree. The age and the lighting conditions of seedlings providing the explants were shown to be critical factors for both bud induction and bud elongation. Optimal choice for an efficient and reproducible bud induction process consisted of dark-grown seedlings, 24/36 h-old-post-imbibition, that yielded up to 96% of explants producing more than 30 buds each, after one week in culture. Bud development occurred throughout a direct organogenesis pathway, from the proximal and adaxial cut surface of the explants as proved by histological studies. Additional sites of regeneration were also obtained after wounding on the epidermal surface of explants, suggesting a large distribution of regenerative cells all along the explants. Bud elongation, i.e. stem differentiation and leaf growth, was improved by bud isolation from cotyledon explants and their further subculture in liquid bud elongation media for one week. Rooting was obtained on an auxin medium after 3 weeks and plants were established in soil with 92% success.

Vanguard family planning acceptors in Senegal

This study examines contraceptive use among clients at the three clinics providing family planning services in Dakar, Senegal in early 1983. Most clients first became interested in family planning following the birth of a child, and most are interested in spacing future pregnancies, although one-third state that they want no more children. The clinic itself was found to be an important determinant of the type of contraceptive used, with only the government-operated clinic providing a balance between IUDs, oral contraceptives, and barrier methods. Nearly half of the clients interviewed said that a lack of knowledge about contraception is the reason for the low contraceptive prevalence rates among Senegalese women; another frequently cited reason was the opposition of the husband. Most clients reported the broadcast media to be the best means of providing family planning information to potential acceptors.