Modeling clinical malaria episodes in different ecological settings in Mali, 2018-2022

Objectives

Following the scaling-up of malaria control strategies in Mali, understanding the changes in age-specific prevalence of infection and risk factors associated with remains necessary to determine new priorities to progress toward disease elimination. This study aimed to estimate the risk of clinical malaria using longitudinal data across three different transmission settings in Mali.

Methods

Cohort-based longitudinal studies were performed from April 2018 to December 2022. Incidence of malaria was measured through community health center-based passive case detection. Generalized estimation equation model was used to assess risk factors for clinical malaria.

Results

A total of 21,453 clinical presentations were reported from 4500 participants, mainly from July to November. Data shows a significant association between malaria episodes, sex, age group, season, and year. Women had lower risk, the risk of clinical episode increased with age up to 14 years then declined, and in both sites, the dry-season risk of clinical episode was significantly lower compared to the rainy season.

Conclusion

Determining factors associated with the occurrence of clinical malaria across different ecological settings across the country could help in the development of new strategies aiming to accelerate malaria elimination in an area where malaria transmission remains intense.

Seasonal Malaria Chemoprevention Therapy in Children Up To 9 Years of Age: Protocol for a Cluster-Randomized Trial Study

BACKGROUND

Seasonal malaria chemoprevention (SMC) is recommended by the World Health Organization for the sub-Sahel region in sub-Saharan Africa for preventing malaria in children 3 months old to younger than 5 years. Since 2016, the Malian National Malaria Control Program has deployed SMC countrywide during its high malaria transmission season at a rate of 4 monthly cycles annually. The standard SMC regimen includes sulfadoxine-pyrimethamine (SP) plus amodiaquine (AQ). Resistance against SP is suspected to be rising across West Africa; therefore, assessing the effectiveness of an alternative antimalarial drug for SMC is needed to provide a second-line regimen when it is ultimately needed. It is not well understood whether SMC effectively prevents malaria in children aged 5 years or older.

OBJECTIVE

The primary goal of the study is to compare 2 SMC regimens (SP-AQ and dihydroartemisinin-piperaquine [DHA-PQ]) in preventing uncomplicated Plasmodium falciparum malaria in children 3 months to 9 years old. Secondly, we will assess the possible use of DHA-PQ as an alternative SMC drug in areas where resistance to SP or AQ may increase following intensive use.

METHODS

The study design is a 3-arm cluster-randomized design comparing the SP-AQ and DHA-PQ arms in 2 age groups (younger than 5 years and 5-9 years) and a control group for children aged 5-9 years. Standard SMC (SP-AQ) for children younger than 5 years was provided to the control arm, while SMC with SP-AQ was delivered to children aged 3 months to 9 years (arm 2), and SMC with DHA-PQ will be implemented in study arm 3 for children up to 9 years of age. The study was performed in Mali's Koulikoro District, a rural area in southwest Mali with historically high malaria transmission rates. The study's primary outcome is P falciparum incidence for 2 SMC regimens in children up to 9 years of age. Should DHA-PQ provide an acceptable alternative to SP-AQ, a plausible second-line prevention option would be available in the event of SP resistance or drug supply shortages. A significant byproduct of this effort included bolstering district health information systems for rapid identification of severe malaria cases.

RESULTS

The study began on July 1, 2019. Through November 2022, a total of 4556 children 3 months old to younger than 5 years were enrolled. Data collection ended in spring 2023, and the findings are expected to be published later in early 2024.

CONCLUSIONS

Routine evaluation of antimalarial drugs is needed to establish appropriate SMC age targets. The study goals here may impact public health policy and provide alternative therapies in the event of drug shortages or resistance.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04149106, https://clinicaltrials.gov/ct2/show/NCT04149106.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/51660.

Prognostics of multiple malaria episodes and nutritional status in children aged 6 to 59 months from 2013 to 2017 in Dangassa, Mali

Background In Africa, the relationship between nutritional status and malaria remains complex and difficult to interpret in children. Understanding it is important in the development of malaria control strategies. This study evaluated the effect of nutritional status on the occurrence of multiple malaria episodes in children aged 6 to 59 months between 2013 and 2017 living in the village of Dangassa, Mali. Methods A community-based longitudinal study was conducted using cross-sectional surveys (SSCs) at the beginning (June) and end (November) of the malaria transmission season associated with passive case detection (PCD) at the Dangassa Community Health Center. Children with asymptomatic malaria infection during cross-sectional surveys were selected and their malaria episodes followed by PCD. Palustrine indicators in person-months were estimated using an ordinal-logistic model repeated on subjects during follow-up periods. Results The incidence rate (IR) during the period of high transmission (June to October), for 1 episode and for 2 + episodes peaked in 2013 with 65 children (IR = 95.73 per 1000 person-months) and 24 cases (IR = 35.35 per 1000 person-months), respectively. As expected, the risk of multiple episodes occurring during the period of high transmission was 3.23 compared to the period of low transmission after adjusting for other model parameters (95% CI = [2.45-4.26], p = 0.000). Children with anemia were at high risk of having multiple episodes (OR = 1.6, 95% CI [1.12-2.30], p = 0.011). However, the risk of having 2 + episodes for anemic children was higher during the period of low transmission (RR = 1.67, 95% CI [1.15-2.42], p = 0.007) compared to the period of high transmission (RR = 1.58, 95% CI [1.09-2.29], p = 0.016). The trend indicated that anemic and underweight children were significantly associated with multiple malaria episodes during the period of low transmission (p < = 0.001). Conclusion Our results indicate that multiple episodes of malaria are significantly related to the nutritional status (anemia and underweight) of the child during the two transmission seasons and more pronounced during the dry season (period of low transmission). Further research including other malnutrition parameters will be needed to confirm our findings.

The West Africa ICEMR Partnerships for Guiding Policy to Improve the Malaria Prevention and Control

The Mali National Malaria Control Program (NMCP) recently established a phased set of goals for eliminating malaria in Mali by 2030. Over the past decade, the scale-up of NMCP-led malaria control interventions has led to considerable progress, as evidenced by multiple malariometric indicators. The West Africa International Center of Excellence in Malaria Research (WA-ICEMR) is a multidisciplinary research program that works closely with the NMCP and its partners to address critical research needs for malaria control. This coordinated effort includes assessing the effectiveness of control interventions based on key malaria research topics, including immune status, parasite genetic diversity, insecticide and drug resistance, diagnostic accuracy, malaria vector populations and biting behaviors, and vectorial capacity. Several signature accomplishments of the WA-ICEMR include identifying changing malaria age demographic profiles, testing innovative approaches to improve control strategies, and providing regular reporting on drug and insecticide resistance status. The NMCP and WA-ICEMR partnership between the WA-ICEMR and the NMCP offers a comprehensive research platform that informs the design and implementation of malaria prevention and control research programs. These efforts build local expertise and capacity for the next generation of malaria researchers and guide local policy, which is crucial in sustaining efforts toward eliminating malaria in West Africa.

Présentation clinique, survie et facteurs associés à la mortalité: une étude prospective dans trois centres COVID-19 en Afrique de l’Ouest

Introduction

En Afrique, bien que le nombre total de décès dus a la COVID-19 semble plus faible quand dans les pays du nord, il existe peu de données sur la gravité de la maladie. Nous rapportons ici le tableau clinique et l’issue chez les malades infectés par le SARS-CoV-2 et suivis dans les centres de traitement COVID-19 (CTC) de deux pays d’Afrique de l’Ouest.

Matériels et méthodes

Le Burkina Faso et la Guinée ont mis en place trois CTC de référence pour hospitaliser tous les malades infectés par le SARS-CoV-2, quelle que soit leur gravité. Nous présentons les données recueillies auprès de ces patients symptomatiques hospitalisés dans ces trois CTC, entre mars et novembre 2020. Les données ont été collectées à l’aide du formulaire de déclaration des cas de COVID-19 de l’OMS. Une régression logistique a été réalisée pour analyser l’association entre l’évolution défavorable et les caractéristiques cliniques à l’admission.

Résultats

Au total, 1805 patients (1151 [64 %] hommes, âge médian 41 ans, 22 % [388] ≥ 60) ont été admis avec un COVID-19 confirmé. La durée médiane entre le début des symptômes et l’admission en CTC était de 7 jours (IQR : 4–11). Les symptômes principaux à l’admission était l’asthénie (748, 41 %) et la toux (833, 46 %) et près de la moitié des patients (867, 48 %) présentaient une forme légère de la maladie. Au cours de l’hospitalisation, 443 (25 %) patients ont présenté au moins une fois une SpO₂ < 94 %, 237 (13 %) ont reçu une oxygénothérapie et 266 (15 %) ont été traités par des corticostéroïdes. La quasi-totalité (1697, 95 %) des patients a reçu un traitement dit spécifique (hydroxychloroquine ± azithromycine ± lopinavir/ritonavir). La mortalité globale était de 5 %, elle était de 1 %, 5 % et 14 % chez les patients de < 40, 40–59 et ≥ 60 ans. Trente et un pou cent des patients atteignaient un critère de composite d’évolution défavorable comportant le décès ou la désaturation (< 94 %) ou la mise sous oxygène. En analyse multivariée, le risque de décès était plus élevé chez les hommes (aOR : 2, IC95 % : 1,1–3,6), les personnes âgées ≥ 60 ans (aOR : 2,9, IC95 % : 1,7–4,8) et celles souffrant d’hypertension artérielle chronique (aOR : 2,1, IC95 % : 1,2–3,4). Le risque d’évolution défavorable était plus élevé chez les hommes (aOR : 1,6, IC95 % : 1,3–2,1), les personnes âgées ≥ 60 ans (aOR : 3,1, IC95 % : 2,4–4), celles souffrant d’hypertension artérielle chronique (aOR : 1,7, IC95 % : 1,3–2,2) ou de diabète (aOR : 2,3, IC95 % : 1,6–3,1).

Conclusion

La maladie à COVID-19 est aussi grave en Afrique qu’ailleurs et les facteurs de risque de décès sont identiques que dans les pays du nord.

[Consent To The Episiotomy About 331 Cases At The Health Reference Center Of The "Commune I" Of The District Of Bamako]

Episiotomy is a surgical act performed during childbirth to widen the vaginal opening; like any other medical procedure, its benefits and risks must be made known to patients in accordance with the legal and regulatory provisions of each country.The principle of immunity of the human body makes that the consent in the care is the keystone of the doctor-patient relationship, this consent is the first legitimization of the medicalact. The consent has to «be free and lit» as far as the decision of the patient must be taken without any constraint or pressure having obtained all the necessary information. This practice is not respected most of the time in our countries in spite of the fact that it's not observance engages the responsibility of the practitioner.

OBJECTIVE

Study the consent of women who have undergone an episiotomy at the reference health center of "commune I" in the District of Bamako.

METHOD AND MATERIAL

This is a prospective cross-sectional study conducted at the Obstetric Gynecology Department of the "Commune I" Health Center of the Bamako District from March 1, 2010 to February 29, 2012, involving 331 patients. We conducted the history and physical examination of women seen in post natal consultation who had undergone an episiotomy, a survey sheet was completed for each of them meeting our criteria. Data capture and analysis was done on SPSS 18; the texts and tables were processed on Microsoft Word Office 2007 software; Graphic representations were processed on Microsoft Excel Office 2007.

ETHICAL ASPECTS

Women were informed of the study's objectives and interests; Confidential and anonymous insurance.

RESULTS

In our study the practice of the episiotomy concerned 32, 19 % of the cases of assisted childbirths. The average age of the patients was of 25 years with extremes going of 14-46 years, the rigidity of the perineum was the main indication of the episiotomy in 41.1% of cases. Only 32.02% of the participants were previously informed prior to the practice of episiotomy. The information given was well understood in the same proportions is 32, 02% of cases and the assent lit with the episiotomy was obtnained in 29.31%. of cases. The information given was well understood in the same proportions of 32.02% of cases and informed consent to episiotomy was obtained in 29.31% of cases.

CONCLUSION

In our study, the majority of our women have undergone episiotomy without any consent; the respect of the fundamental rights of the sick by health personnel, through the search for free and informed consent throughout the process of care, any breach of this duty constitutes a violation of the legal and ethical provisions.

[Appendiceal Duplication In A Patient Operated For Chilled Appendix Breastplate At Gao Regional Hospital]

Appendiceal duplication is the very rare malformation. It was first described by Picoli in 1892. It is a condition that is most often seen in the first years of life, sometimes some forms may remain asymptomatic and only occur in adulthood. We report the case of appendiceal duplication in a patient operated for chilled appendix breastplate at Gao Regional Hospital.

CONCLUSION

appendiceal duplication is a rare abnormal abnormality of intraoperative discovery in general. Each surgeon must think about it during an appendectomy.

[Diagnosis and therapeutic aspects of the amoebic liver abscesses in the surgery at point "G" Hospital]

AIM

Our aim was to evaluate the diagnosis and therapeutic aspects of the amoebic liver abscesses in the surgery «A» department of the University hospital Point "G".

PATIENTS AND METHODS

Were included in this study, patients admitted to the surgery «A» department for amoebic liver abscess confirmed by a positive amoebic serology and the chocolate appearance of bacteria-free pus. Bacterial liver abscesses were not included into this study.

RESULTS

Over a 10-year period, 52 cases of patients diagnosed with amoebic liver abscess were collected in the department. There were 41 men and 11 women, with a sex ratio of 3.7. The mean age was 37.8 years old with extremes of 15 and 66 years. The most represented professions were farmers (36.5%) followed by salesmen (26.7%) and students (11.5%). The average outpatient visit delay time was 18.5 days with the extremes of 5 and 34 days. The most frequent clinical signs were pain in the right hypochondrium (86.5%), fever (78.8%) and hepatomegaly (61.5%). Abdominal ultrasound showed a single located abscess in 44 patients (84.6%) and these abscesses were localized in the right hepatic lobe in 34 patients(65.4%). The average volume of the abscess was 366.5 cm³ with the extremes of 36 cm³ and 1580 cm³. Amoebic serology was positive in 38 patients (80.9%). Cytobacteriological analysis of pus in 37 patients (71%) was negative. Patients underwent an ultrasound assisted needle aspiration of pus in 65.4% he. Laparotomy and a laparoscopic approach were performed in 7.7% and in 5.8%, respectively. The clinical course was uneventfulin 94.2%. The mean hospital stay duration was 16.5 days with the extremes of 4 and 29 days. No death was recorded during hospitalization.

CONCLUSION

Amoebic liver abscess is an uncommon pathology in a surgical setting. Abdominal ultrasound andechography guided liver puncture allowed the diagnosis. Laparoscopic approach minimizes the burden of the laparotomy.

Does metabolic syndrome or its individual components affect pain and function in knee osteoarthritis women?

BACKGROUND

Current studies and research support the role of metabolic syndrome (MetS) in knee osteoarthritis (OA). However, few studies have focused on its impact on knee OA parameters. The aim of this study was to investigate if metabolic syndrome or its individual components affect the intensity of pain, functional disability, and radiographic severity in knee osteoarthritis women.

MATERIALS AND METHODS

We conducted a cross sectional study including confirmed radiographic knee osteoarthritis according to Kellgren and Lawrence scale, with and without metabolic syndrome according to the National Cholesterol Education Program Adult Treatment Panel III criteria. The two groups were compared for pain Visual Analogue Scale (VAS), Lequesne index, Womac function, and radiological grade after adjusting for significant covariates. Multiple regression analysis was used to identify the independent effects of each specific component for metabolic syndrome on knee osteoarthritis parameters.

RESULTS

One hundred thirty women were included. The mean age was 56.68±8.07 [34-75] years, and the mean BMI was 32.54±2.92 [23-37] kg/m2. The prevalence of metabolic syndrome was 48.5%. Women with and without metabolic syndrome had similar knee osteoarthritis parameters. However, accumulation of MetS components was associated with higher level of pain (OR = 3.7, CI = [1.5-5.9], p=0.001), independently of age and BMI. Multiple regression analyses showed, after adjusting for all covariates, that hyperglycemia had a positive impact on pain (p=0.009), waist circumference was positively associated with Lequesne index (p=0.04), high triglycerides level was significantly associated with increased pain (p=0.04) and higher Lequesne score (p=0.05), and Systolic blood pressure was positively correlated with Lequesne index (p=0.01).

CONCLUSION

In addition to weight reduction, appropriate treatment of metabolic syndrome needs to become an important management strategy for knee pain and functional impairment.

[Interest of laparoscopic surgery in the management of chronic abdominal pains in the surgery "A" department of the of the Point G University Hospital]

AIM

to evaluate the contribution of laparoscopic surgery in the management of chronic abdominal pains of unspecified etiology.

METHODS

A retrospective descriptive study was conducted over a period of 49 months (March 2008 to March 2012), in the surgery A service of the Point G university hospital.

RESULTS

52 patients suffering from chronic abdominal pain for 3 months have been listed. There were 36 women and 16 men, with a sex-ratio of 2.25. The pathologies found in laparoscopy were: 16 cases of adherences, 16 cases of gynaecological diseases, 6 cases of chronic appendicitis, 5 cases of chronic cholecystitis, 6 cases of abdominal tumors and 3 cases of intrauterine contraceptives in abdomen. Conversion to laparotomy was not made and mortality was null. No lesion was found in 11.54% of cases. The mean duration of hospitalization was 2 days. The duration of follow-up of the patients was 18 months with a minimum of 6 months and a maximum of 24 months. No painful symptomatology was found in 6 months in 88.46% of the cases. Persistent stomach pains were found in 3% of the cases. 8.54% of the patients had an improvement of symptomatology.

CONCLUSION

Chronic abdominal pains put a diagnosis problem in surgery. Laparoscopy is a reference technique to diagnose this pain and to discuss them.

Ebola outbreak in Conakry, Guinea: epidemiological, clinical, and outcome features

OBJECTIVES

The authors studied the epidemiological, clinical, and outcome features of the Ebola virus disease in patients hospitalized at the Ebola treatment center (ETC) in Conakry to identify clinical factors associated with death.

MATERIALS AND METHODS

A prospective study was conducted from March 25 to August 20, 2014. The diagnosis of Ebola virus infection was made on real-time PCR.

RESULTS

Ninety patients, with a positive test result, were hospitalized. Their mean age was 34.12±14.29 years and 63% were male patients. Most worked in the informal sector (38%) and in the medical and paramedical staff (physicians 12%, nurses 6%, and laboratory technicians 1%). Most patients lived in the Conakry suburbs (74%) and in Boffa (11%). The main clinical signs were physical asthenia (80%) and fever (72%). Hemorrhagic signs were observed in 26% of patients. The comparison of clinical manifestations showed that hiccups (P=0.04), respiratory distress (P=0.04), and hemorrhagic symptoms (P=0.01) were more frequent among patients who died. Malaria (72%) and diabetes (2%) were the most frequent co-morbidities. The crude case fatality rate was 44% [95% confidence interval (33-54%)]. The average hospital stay was 7.96±5.81 days.

CONCLUSION

The first Ebola outbreak in Conakry was characterized by the young age of patients, discrete hemorrhagic signs related to lethality. Its control relies on a strict use of preventive measures.

25-Hydroxy vitamin D and its relationship with clinical and laboratory parameters in patients with rheumatoid arthritis

The objective of this study is to evaluate the prevalence of vitamin D insufficiency in patients with rheumatoid arthritis (RA) and its association with disease activity, severity and physical disability. We included patients with rheumatoid arthritis followed in Rheumatology Department of Hassan II University Hospital, Fez, Morocco. Patients suffering from liver and kidney insufficiency and those who had received vitamin D in the previous 12 months have been excluded. Statistical analysis was done using SPSS v 18. A bivariate analysis and logistic regression were used to identify factors associated with vitamin D deficiency. One hundred seventy patients were included with a mean age of 50 ± 12.1 [17-83] years, and a female predominance (88.1%). All of our patients had hypovitaminosis D. The prevalence of 25(OH)-D insufficiency and deficiency was 64.5 and 35.5% successively. In unadjusted analysis, vitamin D concentration was inversely associated with pain visual analog scale VAS score (p < 0.001), asthenia VAS (p < 0.001), morning stiffness (p = 0.03), number of tender joints (p = 0.004), number of swollen joints (p < 0.001), inflammatory markers (p = 0,012), Disease Activity Score (p = 0.009), physical disability using Health Assessment Questionnaire (HAQ) (p = 0.001), and severity of the disease (p < 0.001). After logistic regression persisted association with female sex (OR = 4.3, CI = [0.94 to 20.976], p = 0.05), asthenia VAS (OR = 1.029, CI = [1.011 to 1.046], p = 0.001), and with the severity of the disease (OR = 2.910, CI = [1.314-6.441], p = 0.008). The vitamin D deficiency is common in our patients with RA. This deficiency is associated with female sex, severe asthenia, and the severity of the disease.

[Treatment of malignant gastric tumors in the surgery "a" department of the Point G teaching hospital: 84 cases]

OBJECTIVE

To evaluate the short-term results of the treatment of malignant gastric tumors.

PATIENTS AND METHODS

A 3-year retrospective study from january 2007 to december 2010 was conducted in the Surgery "A" department of the Point G Teaching Hospital. The clinical records of 84 patients with gastric cancers were collected. Included in this study were patients who underwent surgery for malignant gastric tumors confirmed by histology. Patients who did not undergo surgery and those who presented tumors of the cardia were not included in this study.

RESULTS

The treatment consisted of a subtotal gastrectomy with ganglionic curettage taking out the first and the second relays in 33 patients (39.28%), total gastrostomy in 3 patients (3.57%), and the remaining 48 patients (57.14%) underwent gastro-entero anastomosis. Morbidity was 10.7%, represented by 7 cases of parietal suppuration and 2 cases of evisceration. Mortality rate was 11.11%, due to poor general condition of the patients. The global 1-year survival rate was 36.9%. The one and two-year survival rates after subtotal gastrostomy were 93.9% and 75.75%, respectively. No survival case was noticed one year after total gastrectomy and gastric enteric anastomosis.

CONCLUSION

Partial gastrectomy with ganglionic curettage when possible associated with an early diagnosis could allow a sharp improvement of the gastric tumors' survival rate.

[Epidemio-clinical and therapy study of femoral fractures in children]

OBJECTIVES

Evaluate the epidemio-clinical and therapeutic aspects of the femur's fracture of the child.

MATERIEL AND METHODS

It was about a prospective study done from October 1st, 2005 to September 30, 2006 on all children of 0 to 15 years old admitted for femur fracture, treated and followed in the trauma center of hôpital Gabriel Touré. Disappeared patients have not been included.

RESULTS

We brought together during a period of 12 months 47 cases of fracture in 45 children representing 26 % of the activities of trauma unit of hôpital Gabriel Touré. Among our patients 25 were boys and 20 girls. The average age was 7.5 yeras +/-4. The public highway accident was the first cause (68.8%) followed by domestic accident (22.2%), sportive (6.6%), obstetrical (2.2%). The treatment was orthopaedic in 52.17% and surgical in 47.83%. Complications were the following: residual pain in 6.6%, length disparity of the limbs in 4.4%, secondary slipping in 2.2% and hypertrophic callus in 2.2%. P>0.05. The results were good in 71.7 % of the cases, passable in 24 % and bad in 4.3% of the cases.

CONCLUSION

Femur fracture is a frequent affection by which the first cause remains the public highway accident.

[Early postoperative complications at the Pediatric Service of the Gabriel Touré University Hospital Center]

AIM

To determine the hospital frequency, identify the risks factors and evaluate the mortality of the early postoperative complication.

PATIENTS AND METHODS

It was about a prospective study done from January first to May 31st 2006. All children from 0 to 15 years old operated in settled or urgent surgery and follow in the service were concerned of this study.

RESULT

We brought together 47 cases of complication in 40 patients on a total of 631 children operated in five months. The average age of our patients was of 51.9 months +/- 47.4. The average period of hospital stay was of 4.3 days +/-3.12. A germ was found in the pus in 13 patients. A lung opaqueness was found in three patient's and a germ was present in the urine in 3 also. The average period of appearance of complications was of 7.7 days +/-1.3. The infection of the operating site occupied 2.5%, evisceration 1.1%, haematoma 0.9%, digestive fistula 0.3% and postoperative occlusion 0.15%. The death rate was 1.9%.

CONCLUSION

The type of surgery, the mode of recruitment, the duration and conditions of the hospital stay were the factors of the postoperative complications.

A public health approach for leprosy detection based on a very short term-training of primary health care workers in basic dermatology

INTRODUCTION

In countries where leprosy control is integrated to general heath services, health workers, at primary health care level, often manage a large number of patients with skin diseases including leprosy. The distinction of leprosy from others skin diseases requires more skill and attention. Basic dermatological knowledge will help these staff to provide a better quality of care. A few years ago, a short term training programme focussed on leprosy and some common skin diseases was set up in Mali through a pilot project. This study will evaluate the impact of this training on the detection of leprosy at primary health care level.

METHODS

health care workers from two health districts were invited to participate in the training. Trainee was submitted to an anonymous written test before training, immediately after and 12-18 months post-training using a standardized scoring system. The suspected or referred leprosy cases before and after training were compared. Data were recorded and analysed with the software Epi info version 6.04.

RESULTS

Overall, 495 HCW attended the three anonymous written tests (before training, just after and 12-18 months later). The proportion of participants who gave correct answers before training, just after were respectively: 33 and 57% for correct diagnosis, 5 and 39% for test of sensation and 28 and 47% for referral. Eight patients suspected of leprosy were referred for further examination; in these, five cases of leprosy were detected.

DISCUSSION

The training showed a huge improvement in the skill of the participants in managing leprosy patients. This study addresses how leprosy control can be improved by involving primary health care staff and by the implementation of only a single day's training on basic dermatology.

CONCLUSION

The role of the dermatologist in this post-elimination era of leprosy needs to be reconsidered and adapted to the increasing need to take multiple programmes, inclusive of dermatology and leprosy, into primary health care services and those interested in leprosy control should fund these programmes.

Safety and immunogenicity of the malaria candidate vaccines FP9 CS and MVA CS in adult Gambian men

We assessed the safety and immunogenicity of prime-boost vectors encoding the Plasmodium falciparum circumsporozoite (CS) protein expressed either in the attenuated fowl-pox virus (FP9) or modified vaccinia virus Ankara (MVA). Thirty-two adult Gambians in groups of four to eight received one, two or three doses of FP9 CS and/or MVA CS. No serious adverse event was observed following vaccination. The most immunogenic regimen was two doses of FP9 followed by a single dose of MVA 4 weeks later (an average of 1000 IFN-gamma spot forming units/million PBMCs). This level of effector T-cell responses appears higher than that seen in previously reported studies of CS-based candidate malaria vaccines.

[Vulvar complications of urogenital schistosomiasis: study of 8 cases in Ségou, Mali]

We present a retrospective study of eight cases of vulvar bilharziasis who attended our institution for dermatological visit from 1998 to 2001. The mean age was 11 years old (range: 7 to 13). The clinical examination found wart like or ulcerated nodules, papules and/or diffuse infiltration. All the lesions were located on the left side of the vulvae (labium) and/or the groin. S. haematobium was the only causative agent identified in all specimens. The exclusive left side location of the lesions reported here has never been mentioned in the previous studies. The physiopathology of this finding is possibly linked to factors similar to those explaining the Cockett syndrome. Further examinations, including ultrasonography of the pelvis in larger series, are needed to learn more about the mechanism of this clinical entity.

High prevalence of non-leprotic hypochromic patches among children in a rural area of Mali, West Africa

The identification of one or several hypochromic patches (HP) on the skin is a key stage in the diagnosis of leprosy on dark skin. However, HP are often caused by other disorder than leprosy. A study to determine the prevalence and causes of HP among children was carried out in a rural area of Mali in November 2001. All children under 15 years of age in two villages in an endemic area were screened by two dermatologists. Among the 1729 children seen, HP were identified in 71 patients, with a prevalence of 4.1%. The most common cause of HP was tinea versicolor, which was present in 39.4% of children with HP, followed by pityriasis alba in 31%, naevus achromicus in 24% and vitiligo in 5.6%. No case of leprosy was detected. Our study raises several points with practical consequences for the detection of leprosy cases: the high prevalence of non-leprous HP compared to leprosy, the reliability of the clinical diagnosis of leprosy, and the role of general health care workers in the detection of leprosy cases. Helping those who should be involved in that detection in distinguishing true cases from other hypochromic disorders appears to be a priority.

Comparison of schistosome transmission in a single- and a double-cropped area in the rice irrigation scheme, 'Office du Niger', Mali

Rice is becoming increasingly important as a staple food in West Africa and there is a need to increase production to meet the demand and one way to achieve this is to harvest two annual crops. It is possible that such intensified irrigation could affect transmission of schistosomes and this study attempts to compare schistosome transmission in single and double-cropped areas of an irrigation scheme, 'Office du Niger', in Mali. Double cropping has been practised for some years in the Niono area while in the Kolongotomo area still only a single crop is grown. Parasitological surveys conducted in 10 villages (5 from each of these 2 areas) showed that Schistosoma haematobium was less prevalent in the area with single cropping than in the area with double cropping. In order to compare transmission patterns between the two areas, all human-water contact sites around four villages (two from each area) were identified and included in transmission studies. From August 1996 to June 1997, eight surveys were conducted, at intervals of approximately 45 days, in each of these sites to record density of the intermediate hosts, density of infected snails, environmental factors (especially density of aquatic macrophytes), and frequency of human-water contacts. Although the data provide useful information on transmission patterns in Niono and Kolongotomo areas, they fail to demonstrate clear-cut differences in snail population dynamics and transmission patterns between the two areas. A key element in snail habitats in both areas is the abundance of aquatic macrophytes, especially the submerged species. Snail control using environmental modification should focus on controlling these plants in human-water contact sites.

Plasmodium falciparum infection of the placenta affects newborn immune responses

The effects of exposure to placental malaria infection on newborn immunological responses, in particular Th1/Th2 cytokines and antigen-presenting cell (APC) function, were compared between cord blood mononuclear cells (CBMC) from parasitized and non-parasitized placentas of Gambian women. Cells were analysed in vitro for their ability to respond to mitogens [phorbol myristate acetate (PMA)/ionomycin, phytohaemagglutinin (PHA)], a malaria-unrelated test antigen [purified protein derivative of Mycobacterium tuberculin[purified protein derivative (PPD)] and Plasmodium falciparum schizont extracts. Mitogens induced strong proliferation and secretion of high concentrations of both IL-13 and sCD30 in CBMC from both groups. Conversely, significantly lower amounts of IFN-gamma were induced in the parasitized group in response to low doses of PHA. Protein antigens induced very low amounts of all tested cytokines, in particular IFN-gamma. However, a significantly higher release of sCD30 was observed in response to schizont extracts in the parasitized group. Addition of LPS to activate APC to low doses of PHA or schizont extracts increased the IFN-gamma production in both groups but levels remained lower in CBMC from the parasitized group. This result correlates with the lower production of IL-12 found following lipopolysaccharide (LPS) stimulation in this group. Taken together, these data show that placental infection with P. falciparum affects Th1 differentiation and sCD30 priming of neonatal lymphocytes and that the probable mode of action is via APC.

[Systematic search for parasites among leprosy patients in Mali]

Practice of multidrug therapy in leprosy (combination Dapsone + Rifampicine + Clofazimine) established since 1981, has significantly reduced the incidence of the disease. However, immunosuppression due to treatment of multi-drugs therapy induced adverse reactions with glucocorticoid and the change in host immune response due to the leprosy itself, might increase the risk of parasitic infections. To test this hypothesis, we carried out a case-control study at the "Institut Marchoux" in Bamako. Stool and urine samples from all patients included in the study were examined for parasites identification. In addition, we performed thick and thin blood film to identify malaria infection and skin biopsy (snip) to detect onchocerciasis. A total of 121 cases of leprosy and 219 controls aged 10-84 years old were included in the study from March 1999 to February 2000. Sixty two percent (n = 121) of cases were treated with glucocorticoid. The prevalence of infection due to Entamoeba coli and Entamoeba histolytica were higher in cases than in controls (p = 0.02). The prevalence of infection due to hookworms was higher in cases than in controls. There was no difference of the infections to the other intestinal parasites. Three cases of cryptosporidiosis and one case of isosporosis were observed in leprosy group vs none in the control group. There was no significant difference between cases and controls with regard to prevalence of Schistosoma haematobium, Trichomonas vaginalis and Onchocera volvulus. The prevalence of Plasmodium falciparum was 4.9% (6/121) in the leprosy case and 7.8% (17/219) in the control group. In conclusion, despite the corticotherapy and immunosuppression due to leprosy, there was no difference in prevalence of pathogenic parasites. Entomoeba coli, Entamoeba histolytica which have significantly higher prevalence among the cases were not pathogen therefore there was no higher risk of severe intestinal parasitosis among the cases of leprosy. Treatment with glycocorticoid in patients with leprosy did not suggest any impact on the prevalence of this parasitic infections. In addition, multidrug therapy did not show any effect on the carriage of Plasmodium falciparum.

[Evaluation of the clinical classification of new cases of leprosy. Study conducted at the Marchoux Institute in Bamako, Mali]

INTRODUCTION

The difficulties related to the bacilloscopic diagnosis of leprosy, providing a more reliable classification of cases, in 1995 led the WHO to recommend the use of a new classification, in endemic countries, based on clinical criteria alone, in order to simplify the poly-chemotherapeutic regimens. According to our experience in the Marchoux Institute, this classification may lead to errors in diagnosis through overzealous or mis-interpretation of the two forms of leprosy. The aim of our study was to evaluate the concordance between this clinical classification and that based on a bacilloscopic examination.

PATIENTS AND METHODS

We conducted a descriptive study of new cases of leprosy seen at the Marchoux Institute, without distinction in gender or age, from January to December 2000. All the patients included underwent clinical examination and a bacilloscopic exploration to provide a double classification. The concordance between the two classifications was assessed using the Kappa test.

RESULTS

Two hundred new cases of leprosy were included. Out of 126 clinically multi-bacillary cases, 61 were confirmed bacteriologically, and 65 were false positives. Out of 74 clinical cases with few bacilli, 2 were bacteriologically multi-bacilli. The concordance between the two classifications was average (Kappa=0.40). There was a significant difference between the percentages of multi-bacilli observed in both classifications (p<10(-8)).

DISCUSSION

The clinical classification may well overestimate the multi-bacillary form. In the absence of a reliable bacilloscopic apparatus, a more detailed clinical classification of leprosy forms must be developed.

[Noma in HIV-infected adults]

INTRODUCTION

Noma is a necrotic stomatitis, frequent in undernourished children in tropical countries. Its occurrence in adults is extremely rare and has recently been described during AIDS. We report two new cases.

OBSERVATIONS

The first patient, a 37 year-old farmer, consulted for a mutilating ulcer of the commissure of the right lip. The second patient, a 25 year-old woman, consulted for an ulcerating and necrotic tumefaction of the left cheek. Anamnesis reconstructed the chronology of the lesions and a cutaneous biopsy revealed non-specific ulcers. The status of health of both patients was poor and they both exhibited positive HIV serology.

DISCUSSION

The diagnosis of noma is easy and based on clinical manifestations. The characteristic aspect is that of a mutilating ulcer of the face with conventional progression: tumefaction, followed by ulceration and finally elimination necrosis. This disease predominates in children. Its discovery in adults is a sign of poor prognosis because it may reveal an HIV infection at the AIDS stage.

CONCLUSION

It is important to draw the attention of practitioners on the interest of performing HIV serology when confronted with an adult exhibiting a noma, and to evoke a noma when confronted with a tumefaction of the face rapidly progressing towards necrosis.

[Predictive value of consultation reasons in the diagnosis of leprosy in Bamako (Mali)]

INTRODUCTION

One of the weak points in the strategy for eliminating leprosy is the poor quality of screening. To overcome this, the World Health Organization (WHO) encourages endemic countries to run campaigns for the elimination of leprosy by circulating educational messages and mobilizing the medical community for early screening of cases. The aim of our study was to identify the motives for consultation with high predictive value for the diagnosis of leprosy and to determine the late diagnosis factors and hence assist the staff on site to improve the results of their leprosy elimination campaigns.

PATIENTS AND METHODS

The study consisted, during the second trimester of 1999, in interviewing all the patients consulting for the first time the Marchoux Institute or the units screening for leprosy in the Bamako area. The interview recorded the motives for consultation, the delay before consulting and the reasons for late consulting. To assess their positive predictive value, the motives for consultation were related to the diagnosis retained (leprosy or not).

RESULTS

One thousand one hundred and seventy seven patients were interviewed. The motive for consulting, "suspected leprosy", scored the highest positive predictive value (PPV) (80 p. 100): 12 cases of leprosy were diagnosed by 15 consultants having suspected leprosy. Neurological problems were the second motive for consultation (PPV=61.9 p. 100). The most frequent motive for consultation was spots or "macules" (20 p. 100 of consultations), but only provided a positive predictive value of 19 p. 100. Prior consultations and non-specialized treatments were identified as factors of delay in diagnosing leprosy (P<0.001).

CONCLUSIONS

Diagnosis of leprosy cannot be based on the motives for dermatological consultation alone. The macules are the most apparent signs, but of low predictive value. Nevertheless, they are an early but non-specific sign of leprosy and are often neglected by the patient. Other than macules, attention must be paid to the neurological signs (dysesthesia, motor disorders) when screening for leprosy. These signs may appear early on, or be observed at a late stage in the progression of the disease.

[New cases of leprosy at the Marchoux Institute: a comparative study 1988-1997]

BACKGROUND

The prevalence of leprosy had declined greatly over the last decade. The purpose of this work was to determine whether changes in the epidemiology, clinical and bacteriological patterns occurred among patients with leprosy treated at the Marchoux Institute in 1988 and in 1997.

PATIENTS AND METHODS

We conducted a descriptive cross-sectional study, reviewing retrospectively all files of patients with leprosy seen in 1988 in comparison with a prospective series of leprosy patients seen in 1997. Only new cases of leprosy, prior to treatment and with skin and/or nervous lesions irrespective of the bacilloscopy results, were included in the two series.

RESULTS

We included 93 patients among 246 patient files in 1988. There were 119 new cases in 1997. The following variables showed changes: mean delay to consultation (41.2 months in 1988 versus 26.1 months in 1997; patient's suspicion of having leprosy (93 patients in 1988 versus 22 in 1997); notion of contact (35 cases in 1988 versus 45 in 1997). Multibacilli leprosy predominated over paucibacilli leprosy in 1988 (51 versus 42 cases). This trend was inverted in 1997 (44 versus 75) (p<0.009). Patients with grade 2 handicap were more numerous in 1988 (20 cases versus 2 cases, p<0.001).

CONCLUSION

These findings demonstrate a change in the epidemiology, clinical and bacilloscopic pattern of patients with leprosy from 1988 to 1997.