[Effects of Monitoring "Out-of-Area" Vaccinated Children on Data Quality, San Pedro Health District, Côte D'ivoire in 2019]

In order to improve the quality of vaccination data from the health centers, we carried out the follow-up of "out-of-area" children, vaccinated in the district of San Pedro. The objective of this work was to measure the effects of taking into account the "out-of-area" vaccinated children on the quality of the data and the immunization performance of the health centers. This monitoring, which was carried out between March and August 2019, consisted of four steps: the vaccination of "out-of-area" children by the health center, the monthly update in the register of the status of vaccinated "out-of-area" children, the accounting of these children, and the re-evaluation of the health center's vaccine performance. A total of 37 of the 40 district centers had 980 "out-of-area" vaccinated children, representing 5.7% of the immunization target. The quarter of these children resided outside the district. The vaccination of "out-of-area" children included all EPI vaccines, but especially BCG, DTP-HepB-Hib and Pneumococcus_13. The number of "outside the extra-district area" vaccinated children had not changed the district's immunization coverage. On the other hand, in the health centers concerned, the accuracy of the data had been improved in 65% of the centers for DTP-HepB-Hib_1, in 70% of the centers for RR and in 65% of the centers for the overall immunization dropout rate. The approach used had made it possible to improve the quality of immunization data from health centers at no additional cost.

[Performance of the Strategy to Catch Up with Drop Out and Unvaccinated Children in Côte d'Ivoire in 2018]

To improve the performance of Côte-d'Ivoire's immunization program, we have implemented a strategy to catch up with drop out children (DOC) and unvaccinated children (UVC) in 14 Health Districts (HDs) with the lowest measles vaccination coverage. This article presents the effectiveness and cost of this strategy. We selected the areas with the highest numbers of DOC: 5 health areas (HAs) per HD and 5 villages/neighborhoods per HA. The strategy, which was implemented by civil society organizations, health centre managers (HCMs) and community health workers (CHWs), combined sensitization of community leaders and groups, home visits (HV) and referral of children to the HCs for immunization. Out of the 17,912 reported DOC, 9,425 found (52.6%) and 8,245 were vaccinated (46% of declared, 87.5% of found). The HCMs reported 484 UVC while the home visits identified 1,315 of which 1,087 were vaccinated (82.7%). Out of a total declared number of 18,396 children to be caught up, 10,740 found (58.4%) and 9,332 vaccinated, i.e. 50.8% (9,332/18,396) of children to be caught up and 86.9% (9,332/10,740) of children found. The total specific recurrent cost of the strategy was XOF 22,375,008, with XOF 2,083 (22,375,008/10,740) per child found and XOF 2,398 (22,375,009/9,332) per child found and vaccinated. In view of these results, this strategy should be implemented in all of the country's low-performing HDs.

[Cost Analysis of the Immunization Program Supportive Supervision in Côte-d'Ivoire]

One of the major obstacles to improve the performance of immunization programs is the lack of competent health personnel. To increase the availability of qualified health personnel, the Agence de Médecine Préventive (Agency of Preventive Medicine) has set up a technical assistance focused on supportive supervision. The objective of this study is to analyze the cost of this supportive supervision in 10 health districts of Côte-d'Ivoire. The data extracted from the financial and technical reports of the supportive supervisions included personnel costs (salary, per diem), transportation, communication, office supplies, vehicle maintenance and depreciation. The analysis consisted of estimating the total cost of the supportive supervision, the total cost per item and the average cost of a supervisory visit. The conduct of 40 supportive supervision visits amounted to 44,675.12 USD. Of this amount, recurring costs were 40,112.12 USD (89.79%) and non-recurring costs were 4,563 USD (10.21%). The unit cost per supervisory visit was 1,116.88 USD. The cost of personnel was the largest cost. The total cost of the formative supervision would be reduced by 58.68% through the resort to local facilities' staff for the supervision, and the review of the useful life of the vehicles. The costs for implementing supportive supervision were acceptable in comparison to the benefits. Mastering personnel costs, optimizing the scheduling of supervision tours and frequency of visits focused on districts with the lowest EPI indicators could lead to cost savings.

[Impact of a targeted technical assistance to improve vaccine coverage in Cameroon, Côte d'Ivoire, and Mauritania in 2014]

Within the framework of its strategic goal of vaccine coverage (VC) improvement, GAVI, The Vaccine Alliance has entrusted the Agence de médecine préventive (agency for preventive medicine, AMP) with technical assistance services to Cameroon, Cote d'Ivoire (Ivory Coast), and Mauritania. This support was provided to selected priority districts (PDs) with the worst Penta3 coverage performances. In 2014, PDs benefited from technical and management capacities in vaccinology strengthening for district medical officers, supportive supervisions and technical assistance in health logistics, data management and quality. We analyzed the effects of the AMP technical assistance on the improvement of the cumulative Penta3 coverage, which is the key performance indicator of the expanded programme on immunization (EPI) performance. We compared Penta3 coverage between PDs and other non-priority districts (NPDs), Penta3 coverage evolution within each PD, and the distribution of PDs and NPDs according to Penta3 coverage category between January and December 2014. Technical assistance had a positive effect on the EPI performance. Indeed Penta3 coverage progression was higher in PDs than in NPDs throughout the period. Besides, between January and December 2014, the Penta3 VC increased in 70%, 100% and 86% of DPs in Cameroon, Côte d'Ivoire and Mauritania, respectively. Furthermore, the increase in the number of PDs with a Penta3 coverage over 80% was higher in DPs than in NPDs: 20% versus 8% for Cameroon, 58% versus 29% for Côte d'Ivoire and 17% versus 8% for Mauritania. Despite positive and encouraging results, this technical assistance service can be improved and efforts are needed to ensure that all health districts have a VC above 80% for all EPI vaccines. The current challenge is for African countries to mobilize resources for maintaining the knowledge and benefits and scaling such interventions in the public health area.

[Population's behaviour and expectations concerning malaria control in Ouidah, Benin, April 2006)]

The aim of this study conducted in April 2006 in Ouidah (Benin), was to measure some results indicators of the implementation of "Roll Back Malaria" in Benin. Impregnated bed nets are available in 25.6% of the households and are used by 21.2% of children under five years old and 26.7% of pregnant women. The main reasons for this use are protection against harmful effect of mosquitoes (74%) and prevention of the malaria transmission (51%). The cost of impregnated bed net purchased is in average 2115 FCFA. Malaria morbidity in household is very high (48%) among children under five years old. The percentage of feverish children correctly treated in household according to the National Malaria Control Program's protocol is 1%. The major expectations of the households are supply of impregnated bed nets free of charge (33%), reduction of its delivery price (18%), its availability in health facilities (15%) and free treatment of malaria cases (12%).

[Experience with field epidemiology training programs in Africa: Cours IEIAA]

The International Course on Epidemiology and Applied Data Processing in Africa (Cours IEIAA) is a practical 4-week French-language training course for professional health care personnel working in Africa. The first course was organized in 1998 by the Association pour l'Aide à la Médecine Préventive (Association for the Promotion of Preventive Medicine). The course organizing committee includes a pedagogical director and a faculty of field epidemiology experts. Course activities are designed to give attendees competency in epidemiology, biostatistics, computer techniques and communication. Attendance is funded mainly through education grants from the French Foreign Affairs Ministry, WHO, UNICEF, Belgian Technical Cooperation, Swiss Technical Cooperation, and German GTZ. Based on 7 years of experience, consideration is now being given to transforming this course into a tutorial Field Epidemiology Training Program modeled after those now operating in Ghana and Uganda [TEPHINET members Programs located in Africa].

Effectiveness of incidence thresholds for detection and control of meningococcal meningitis epidemics in northern Togo

BACKGROUND

Early outbreak detection is necessary for control of meningococcal meningitis epidemics. A weekly incidence of 15 cases per 100 000 inhabitants averaged over 2 consecutive weeks is recommended by the World Health Organization (WHO) for detection of meningitis epidemics in Africa. This and other thresholds are tested for ability to predict outbreaks and timeliness for control measures.

METHODS

Meningitis cases recorded for 1990-1997 in health centres of northern Togo were reviewed. Weekly and annual incidences were determined for each district. Ability of different weekly incidence thresholds to detect outbreaks was assessed according to sensitivity, specificity, and positive and negative predictive values. The number of cases potentially prevented by reactive vaccination in 1997 was calculated for each threshold.

RESULTS

Outbreaks occurred in 1995-1996 and in 1996-1997. The WHO-recommended threshold had good specificity but low sensitivity. Thresholds of 10 and 7 cases per 100,000 inhabitants in one week had sensitivity and specificity of 100% and increased the time available for intervention by more than one or two weeks, respectively. A maximum of 65% of cases could have been prevented during the 1997 epidemic, with up to 8% fewer cases prevented for each week of delay in achieving vaccine coverage.

CONCLUSIONS

In northern Togo, thresholds of 7 or 10 cases per 100,000 inhabitants per week were excellent predictors of meningitis epidemics and allowed more time for a reactive vaccination strategy than current recommendations.

Effect of daily iron supplementation on iron status, cell-mediated immunity, and incidence of infections in 6-36 month old Togolese children

OBJECTIVE

To assess the impact of a daily oral iron supplementation on hematological status, cell-mediated immunity and susceptibility to infections in children living in an environment where iron deficiency, malaria and other infections are frequent.

DESIGN

Randomized, double-blind iron supplementation including a placebo group.

SETTING

A village in Togo, West Africa.

SUBJECTS

Of the 229 6-36-month-old children of both sexes recruited, 197 with hemoglobin concentration >/=80 g/l were included and 163 completed the study.

INTERVENTION

Children received daily a placebo (n=79) or a dose of 2-3 mg of elemental iron per kg of body weight (n=84) for 3 months. Hematological, nutritional and immune status were assessed at the beginning and at the end of the supplementation period, and 6 months later. Morbidity was recorded throughout the study.

RESULTS

Iron supplementation had a significant and positive effect on iron status of children and no impact on the incidence of infections, especially malaria. Its probable effect on immune status was masked by interference of infections and their treatment, which contributed to improve hematological and immune status in both groups.

CONCLUSION

According to the negative consequences of anemia and iron deficiency on global child development, control of iron deficiency by oral iron supplementation in young children has to be conducted, associated with prophylaxis and treatment of malaria and repeated deworming.

SPONSORSHIP

Program supported by IRD. European Journal of Clinical Nutrition (2000) 54, 29-35

[An epidemic of meningococcal meningitis in the region of Savanes in Togo in 1997: research and control strategies]

Neisseria meningitidis is responsible for high levels of morbidity and mortality in the developing countries of the African meningitis belt. There are frequent meningococcal meningitis epidemics in this region affecting almost 1,000 people in every 100,000 (1%). Epidemics generally occur during the dry season but the interval between epidemics is variable (between 2 and 25 years). The reasons for these recurrent epidemics are unclear. There is a safe and effective polysaccharide vaccine against meningococci A and C. Unfortunately, the immunity it provides decreases with time, especially in young children (aged less than 5 years) and it is thus not included in the Expanded Program on Immunization (EPI). WHO recommends mass vaccination using a threshold approach. This control strategy is effective if vaccination begins very soon after the threshold is crossed. There was an outbreak of group A meningococcal meningitis in the Savanes region of northern Togo in December 1996. The national surveillance system put out an alert and control measures were implemented. These involved improvement of the surveillance system, and containment immunization in villages for early cases followed by a mass immunization campaign in the entire region, distribution of oily chloramphenicol and decentralized case management. The target population for mass vaccination included everyone older than 6 months of age living in the Savanes region. The aim was to vaccinate at least 80% of the target population. There were 2,992 cases of meningitis reported in the Savanes region between December 1996 and May 1997 (in a population of about 500,000). This gives a cumulative incidence rate of 581 per 100,000 population. The epidemic was bimodal, with the first peak in the number of cases occurring at the end of January and the second peak in March. There were 60,700 vaccinations in two of the four districts of the region in December and January, as part of the containment strategy and 346,469 vaccinations in the four districts of the region during February, as part of the mass vaccination campaign. By the end of the mass campaign, 67.3% of the target population in the region as a whole had been vaccinated, with 61% vaccinated in the Kpendjal district and 78% in the Oti district. There was an increase in the number of cases 2 weeks after the end of the mass vaccination campaign. This was attributed to the inadequate level of vaccination achieved. Only 52% of the urban population of Dapaong were vaccinated. The national surveillance system put out an alert early in the epidemic. The intervention was planned and adapted according to the progression of the epidemic, and national and international efforts were well coordinated. This emphasizes the importance of a rapid reaction from the surveillance system and of the choice of strategy for dealing with meningitis epidemics in sub-Sahelian Africa.

[Evaluation of the impact of iron treatment. Interference of malaria]

In Togo, where malaria occurs all the year, 151 children, from 6 months to 3 years old, were distributed in 2 groups, one of which received an iron supplementation during three months, and the other a placebo during the same time. At the end of the trial, no significant difference was observed between the two groups. However, taking into account malaria infection at the end of the trial, children who received iron supplementation and who were free of malaria infection showed improvement of their haematological status when compared to children receiving placebo and also free of malaria infection. Authors presumed that iron supplementation was masked by malaria when they evaluated effect of iron supplementation on anaemia.

The integration of family planning and childhood immunization services in Togo

Improvements in the constellation of services in the African context are largely addressed through attaining better measures of service integration, which can be achieved through improved referral across categories of health programs. The use of an unobtrusive referral message that linked family planning and the Expanded Program of Immunizations (EPI) services was tested in an operations research study in Togo. The introduction of the referral message was accompanied by an 18-percent increase in awareness of available family planning services and an increase in the average monthly number of new family planning clients of 54 percent. These positive results indicate that the use of referral can have a significant and dramatic impact on family planning services in a relatively short time. In Togo, no evidence existed of a negative impact on EPI services, and a majority of the EPI providers reported satisfaction with the effect of the referral message at the close of the study.

[Digestive parasitic diseases in young children in a tropical outpatient setting]

Parasites were looked for in stools of infants aged 6 months to 3 years living in a village in the south of Togo. These children were enrolled in a nutritional surveillance program. 42.5% of children harboured at least one parasite and 12.1% had more than one parasite: The most common parasites found included Giardia (21%), Ancylostoma (13%), and Ascaris (12.5%). Infection with a single parasite and infection with several parasites were observed from the age of nine months and 18 months, respectively; the incidence of these infections increased with advancing age. The incidence of diarrheal stools decreased with advancing age and no particular parasite seemed to be directly and exclusively responsible for diarrhea. The distribution of parasites and diarrheal symptoms were not influenced by sex. No correlation was found between nutritional status and presence of a parasitic infection or diarrhea. After treatment, reinfection with Ancylostoma (65%), whipworm (50%), and Giardia (34.2%) were common.