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Background: Indoor spraying of walls and ceilings with residual insecticide remains a primary method of malaria control. Insecticide resistance in malaria vectors is a growing problem. Novel insecticides for indoor residual spraying (IRS) which can improve the control of pyrethroid resistant malaria vectors are urgently needed. Insecticide mixtures have the potential to improve efficacy or even to manage resistance in some situations but this possibility remains underexplored experimentally. Chlorfenapyr is a novel pyrrole insecticide which has shown potential to improve the control of mosquitoes which are resistant to current WHO-approved insecticides. Method: The efficacy of IRS with chlorfenapyr applied alone or as a mixture with alpha-cypermeththrin (a pyrethroid) was evaluated in experimental huts in Cove, Southern Benin against wild free flying pyrethroid resistant Anopheles gambiae sl. Comparison was made with IRS with alpha-cypermethrin alone. Fortnightly 30-minute in situ cone bioassays were performed to assess the residual efficacy of the insecticides on the treated hut walls. Results: Survival rates of wild An gambiae from the Cove hut site in WHO resistance bioassays performed during the trial were >90% with permethrin and deltamethrin treated papers. Mortality of free-flying mosquitoes entering the experimental huts was 4% in the control hut. Mortality with alpha-cypermethrin IRS did not differ from the control (5%, P>0.656). The highest mortality was achieved with chlorfenapyr alone (63%). The alpha-cypermethrin + chlorfenapyr mixture killed fewer mosquitoes than chlorfenapyr alone (43% vs. 63%, P<0.001). While the cone bioassays showed a more rapid decline in residual mortality with chlorfenapyr IRS to <30% after only 2 weeks, fortnightly mortality rates of wild free-flying An gambiae entering the chlorfenapyr IRS huts were consistently high (50–70%) and prolonged, lasting over 4 months. Conclusion: IRS with chlorfenapyr shows potential to significantly improve the control of malaria transmission in pyrethroid resistant areas compared to pyrethroid IRS or the mixture. Thirty minute in situ cone bioassays are not predictive of the performance of chlorfenapyr IRS under field conditions. [ABSTRACT FROM AUTHOR]

Background: Buruli ulcer [BU] is a chronic and debilitating neglected tropical skin disease caused by Mycobacterium ulcerans. The treatment of moderate to severe BU affects the well-being of entire households and places a strain on both gender relations within households and social relations with kin asked for various types of support. In this paper, we employ the conceptual lenses provided by the Household Production of Health approach to understanding the impact of illness on the household as a unit of analysis, gender studies, and social support related research to better understand BU health care decision making and the psychosocial experience of BU hospitalization. Methods: An ethnography attentive to circumstance and the nested contexts within which stakeholders respond to BU was conducted employing semi-structured interviews, illness narratives, and case studies. An iterative process of data collection with preliminary analyses and reflection shaped subsequent interviews. Interviews were conducted with 45 women in households having a member afflicted with BU in two communes of Benin with high prevalence rates for BU. The first commune [ZE] has a well-established decentralized BU treatment program and a well-functioning referral network linked to the Allada reference hospital specializing in the care of BU and other chronic ulcers. The second commune [Ouinhi] is one of the last regions of the country to introduce a decentralized BU treatment program. A maximum variation purposeful sample was selected to identify information-rich health care decision cases for in-depth study. Principal findings: Study results demonstrated that although men are the primary decision makers for healthcare decisions outside the home, women are largely responsible for arranging care for the afflicted in hospital in addition to managing their own households. A woman’s agency and ability to influence the decision-making process is largely based on whatever social support and substitute labor she can mobilize from her own network of kin relations. When support wanes, women are placed in a vulnerable position and often end up destitute. Decentralized BU treatment is preferred because it enables a woman to remain in her own household as a patient or caretaker of an ill family member while engaging in child care and petty revenue earing activities. Remaining in the hospital (a liminal space) as either patient or caretaker also renders a woman vulnerable to rumor and innuendo about sexual liaisons and constitutes a form of social risk. Social risk in some cases eclipses the physical risk of the disease in what we would describe as a hierarchy of risks. Conclusion: This study illustrates the importance of decentralized treatment programs for NTDs such as BU. Such programs enable patients to remain in their homes while being treated, and do not displace women responsible for the welfare of the entire household. When women are displaced the well-being of the entire household is placed in jeopardy. [ABSTRACT FROM AUTHOR]

Background: Mycobacterium ulcerans infection, commonly known as Buruli ulcer (BU), is a debilitating neglected tropical disease. Its management remains complex and has three main components: antibiotic treatment combining rifampicin and streptomycin for 56 days, wound dressings and skin grafts for large ulcerations, and physical therapy to prevent functional limitations after care. In Benin, BU patient care is being integrated into the government health system. In this paper, we report on an innovative pilot program designed to introduce BU decentralization in Ouinhi district, one of Benin’s most endemic districts previously served by centralized hospital-based care. Methodology/Principal findings: We conducted intervention-oriented research implemented in four steps: baseline study, training of health district clinical staff, outreach education, outcome and impact assessments. Study results demonstrated that early BU lesions (71% of all detected cases) could be treated in the community following outreach education, and that most of the afflicted were willing to accept decentralized treatment. Ninety-three percent were successfully treated with antibiotics alone. The impact evaluation found that community confidence in decentralized BU care was greatly enhanced by clinic staff who came to be seen as having expertise in the care of most chronic wounds. Conclusions/Significance: This study documents a successful BU outreach and decentralized care program reaching early BU cases not previously treated by a proactive centralized BU program. The pilot program further demonstrates the added value of integrated wound management for NTD control. [ABSTRACT FROM AUTHOR]

Good governance (GG) is an important concept that has evolved as a set of normative principles for low- and middle-income countries (LMICs) to strengthen the functional capacity of their public bodies, and as a conditional prerequisite to receive donor funding. Although much is written on good governance, very little is known on how to implement it. This paper documents the process of developing a strategy to implement a GG model for Health Technology Management (HTM) in the public health sector, based on lessons learned from twenty years of experience in policy development and implementation in Benin. The model comprises six phases: (i) preparatory analysis, assessing the effects of previous policies and characterizing the HTM system; (ii) stakeholder identification and problem analysis, making explicit the perceptions of problems by a diverse range of actors, and assessing their ability to solve these problems; (iii) shared analysis and visioning, delineating the root causes of problems and hypothesizing solutions; (iv) development of policy instruments for pilot testing, based on quick-win solutions to understand the system’s responses to change; (v) policy development and validation, translating the consensus solutions identified by stakeholders into a policy; and (vi) policy implementation and evaluation, implementing the policy through a cycle of planning, action, observation and reflection. The policy development process can be characterized as bottom-up, with a central focus on the participation of diverse stakeholders groups. Interactive and analytical tools of action research were used to integrate knowledge amongst actor groups, identify consensus solutions and develop the policy in a way that satisfies criteria of GG. This model could be useful for other LMICs where resources are constrained and the majority of healthcare technologies are imported. [ABSTRACT FROM AUTHOR]

Background: Reducing social distance between hospital staff and patients and establishing clear lines of communication is a major challenge when providing in-patient care for people afflicted by Buruli ulcer (BU) and chronic ulcers. Research on hospitals as therapeutic communities is virtually non-existent in Africa and is currently being called for by medical anthropologists working in the field of health service and policy planning. This paper describes a pioneering attempt to establish a therapeutic community for patients suffering from BU and other chronic ulcers requiring long term hospital care in Benin. Methods: A six-month pilot project was undertaken with the objectives of establishing a therapeutic community and evaluating its impact on practitioner and patient relations. The project was designed and implemented by a team of social scientists working in concert with the current and previous director of a hospital serving patients suffering from advanced stage BU and other chronic ulcers. Qualitative research initially investigated patients’ understanding of their illness and its treatment, identified questions patients had about their hospitalization, and ascertained their level of social support. Newly designed question–answer health education sessions were developed. Following these hospital wide education sessions, open forums were held each week to provide an opportunity for patients and hospital staff to express concerns and render sources of discontent transparent. Patient group representatives then met with hospital staff to problem solve issues in a non-confrontational manner. Psychosocial support for individual patients was provided in a second intervention which took the form of drop-in counseling sessions with social scientists trained to serve as therapy facilitators and culture brokers. Results: Interviews with patients revealed that most patients had very little information about the identity of their illness and the duration of their treatment. This knowledge gap surprised clinic staff members, who assumed someone had provided this information. Individual counseling and weekly education sessions corrected this information gap and reduced patient concerns about their treatment and the status of their healing process. This led to positive changes in staff–patient interactions. There was widespread consensus among both patients and staff that the quality of communication had increased significantly. Open forums providing an opportunity for patients and staff to air grievances were likewise popular and patient representative meetings resulted in productive problem solving supported by the hospital administration. Some systemic problems, however, remained persistent challenges. Patients with ulcers unrelated to BU questioned why BU patients were receiving preferential treatment, given special medicines, and charged less for their care. The idea of subsidized treatment for one disease and not another was hard to justify, especially given that BU is not contagious. Conclusion: This pilot project illustrates the basic principles necessary for transforming long term residential hospitals into therapeutic communities. Although the focus of this case study was patients suffering from chronic ulcers, the model presented is relevant for other types of patients with cultural adaptation. [ABSTRACT FROM AUTHOR]

Lead and malaria both present significant health risks to children in Sub-Saharan Africa. Previous studies have shown that high blood lead levels in children act as a protective factor against subsequent malaria incidence. The main objective of this study was to investigate associations between blood lead level and malaria outcomes prospectively in Beninese children from 12 to 24 months of age. Two-hundred and four children were assessed for lead at 12 months and closely followed until 24 months for malaria; when symptoms and parasite density were also recorded. Univariate and multivariate negative binomial and linear regression models tested associations between blood lead level quartile and total episodes of malaria (total symptomatic and asymptomatic episodes) and parasite density, respectively. Median blood lead level among children measured at 12 months was 56.50 (4.81–578) μg/L. During the 12-month follow-up, 172 (84.31%) children had at least one malaria episode. Univariate and multivariate negative binomial and linear regressions did not reveal significant associations between blood lead level quartile and malaria outcomes. Iron deficiency was not found to be an effect modifier. Results from this prospective child-cohort study investigating associations between blood lead level and malaria did not confirm results from previous cross-sectional studies. Further research is needed to further explore this relationship and other co-morbidities due to malaria and lead. [ABSTRACT FROM AUTHOR]

Background: There is evidence from experimental hut and household studies that the entomological efficacy of long lasting pyrethroid treated nets (LLINs) is compromised in areas of pyrethroid resistance. The rapid increase in resistance intensity in African malaria vectors could further undermine the performance of these nets. The pyrethroid resistance intensity in Anopheles gambiae s.l. M’bé from central Côte d’Ivoire is reported to be high (> 1700 fold). Whether this translates into an increase in entomological indicators of malaria transmission needs investigation. Method: The efficacy of two long lasting insecticidal nets (LN) MiraNet and MagNet, both alpha-cypermethrin based was evaluated in experimental huts against pyrethroid resistant Anopheles gambiae in M’bé, central Côte d’Ivoire. All nets were deliberately holed to simulate wear-and-tear and were tested unwashed and after 20 standardized washes. Results: The entry rates of An. gambiae s.l. into huts with insecticide treated nets were 62–84% lower than entry into huts with untreated nets (p < 0.001). Exit rates of An. gambiae s.l. with unwashed MiraNet and MagNet LNs were significantly greater than with untreated nets (50–60% vs 26%) and this effect after washing 20 times nets did not decrease. Blood-feeding with both nets was significantly inhibited relative to the untreated reference net (31–55%) (p < 0.001). Washing MiraNet LN 20 times had no significant impact on protection against An. gambiae s.l. bites but it did cause a significant fall by 40% in protection with MagNet LN (p < 0.001). All insecticide treated nets induced higher mortality of An. gambiae s.l. than the untreated net (p < 0.05). The impact though significant was limited (14–30%). The personal protection against An. gambiae s.l. bites derived from all treatments was high (75–90%). The overall insecticidal effect was compromised by pyrethroid resistance and was not detectable in some treatments. Conclusion: In this area of high pyrethroid resistance intensity (over 1700 fold), both MiraNet and MagNet LNs still conferred appreciable personal protection against mosquito bites despite inducing only slightly greater mortality of pyrethroid resistant Anopheles mosquitoes than untreated nets. The impact is comparable to moderately intense Benin resistance area (207 fold) and Burkina Faso (over 1000 fold). This preserved level of protection plus the small but sensitive killing of mosquitoes may continue to impact vectorial capacity despite high intensity of resistance. Nevertheless, there is an obvious need for strategies and nets with novel mode of action to enhance vector control. [ABSTRACT FROM AUTHOR]

We present a rationale for, and results from, the pilot of a direct individual-to-institution remittance system in the context of school fee payment in rural Benin. Data confirm that school fees act as an impediment to educational attainment, and in very rural poor settings such as northern Benin, students often depend on extended family and kinship networks to pay fees. But existing remittance options are costly, in terms of fees, time, and risk. We pilot a new technology bundle in a single public high school in northeastern Benin, and evaluate its effectiveness. Here we describe the technical and institutional implementation of the project, as well as our findings from the first year of operation. We discuss takeaways and implications for scale-up. [ABSTRACT FROM AUTHOR]

Introduction: There is an urgent need for new insecticides for indoor residual spraying (IRS) which can provide improved and prolonged control of malaria vectors that have developed resistance to existing insecticides. The neonicotinoid, clothianidin represents a class of chemistry new to public health. Clothianidin acts as an agonist on nicotinic acetyl choline receptors. IRS with a mixture of Clothianidin and another WHO approved insecticide such as deltamethrin could provide improved control of insecticide resistant malaria vector populations and serve as a tool for insecticide resistance management. Methods: The efficacy and residual activity of a novel IRS mixture of deltamethrin and clothianidin was evaluated against wild pyrethroid resistant An. gambiae sl in experimental huts in Cove, Benin. Two application rates of the mixture were tested and comparison was made with clothianidin and deltamethrin applied alone. To assess the residual efficacy of the treatments on different local wall substrates, the inner walls of the experimental huts were covered with either cement, mud or plywood. Results: Clothianidin demonstrated a clear delayed expression in mortality of wild pyrethroid resistant An. gambiae sl in the experimental huts which reached its full effect 120 hours after exposure. Overall mortality over the 12-month hut trial was 15% in the control hut and 24–29% in the deltamethrin-treated huts. The mixture of clothianidin 200mg/m2 and deltamethrin 25mg/m2 induced high overall hut mortality rates (87% on mud walls, 82% on cement walls and 61% on wooden walls) largely due to the clothianidin component and high hut exiting rates (67–76%) mostly due to the deltamethrin component. Mortality rates remained >80% for 8–9 months on mud and cement walls. The residual activity trend was confirmed by results from monthly in situ cone bioassays with laboratory susceptible An. gambiae Kisumu strain. Conclusion: IRS campaigns with the mixture of clothianidin plus deltamethrin have the potential to provide prolonged control of malaria transmitted by pyrethroid resistant mosquito populations. [ABSTRACT FROM AUTHOR]

In 2013, Benin developed strategies to control neglected tropical diseases and one of the first step was the disease mapping of the entire country in order to identify endemic districts of schistosomiasis and soil transmitted helminths (STH). This study was carried out in 30 of the 77 districts of Benin. Of these 30 districts 22 were previously treated for Lymphatic Filariasis (LF) using the Ivermectin and Albendazole combination. In each district, five schools were selected and 50 children aged 8 to 14 years were sampled in each school, making a total of 250 children sampled in the district. The schools were selected mainly according to their proximity to lakes or any bodies of water that were likely to have been used by the children. Samples of faeces and urine were collected from each pupil. Urinary schistosomiasis was identified using the urine filtration technique while STH and intestinal schistosomiasis were identified through the Kato Katz method. Overall a total of 7500 pupils were surveyed across 150 schools with a gender ratio of 1:1. Hookworm was identified in all 30 districts with a prevalence ranging from 1.2% (95%CI: 0.0–2.5) to 60% (95%CI: 53.9–66.1). Ascaris lumbricoides was detected in 19 districts with a prevalence rate between 1% (95%CI: 0.0–2.2) and 39% (95%CI: 32.9–45.0). In addition to these common STH, Trichuris trichiura, Enterobius vermicularis and Strongyloides stercoralis were found at low prevalence. Only 16 districts were endemic to Schistosoma mansoni, while 29 districts were endemic to S. haematobium. The S. haematobium prevalence ranged from 0.8% (95% CI: 0.0–1.9) to 56% (95% CI: 50.2–62.5) while the prevalence of S. mansoni varied from 0.4% (95%CI: 0.0–1.2) to 46% (95% CI: 39.8–52.2). The 22 districts, where LF was successfully eliminated, still require mass drug administration (MDA) of albendazole indicating that school-based MDA would be needed even after LF elimination in districts co-endemic to LF and STH in Benin. [ABSTRACT FROM AUTHOR]

Data on variations in the frequency of cardiovascular risk factors (CVRF) in sub-Saharan populations are limited, particularly with regard to Benin. Objective: To describe and compare the prevalences of CVRF in urban and rural populations of Benin. Methods: Subjects were drawn from participants in the Benin Steps survey, a nationwide cross-sectional study conducted in 2008 using the World Health Organisation (WHO) stepwise approach to surveillance of chronic disease risk factors. Subjects aged above 24 and below 65 years were recruited using a five-stage random sampling process within households. Sociodemographic data, behavioral data along with medical history of high blood pressure and diabetes mellitus were collected in Step 1. Anthropometric parameters and blood pressure were measured in Step 2. Blood glucose and cholesterol levels were measured in Step 3. CVRF were defined according to WHO criteria. The prevalences of CVRF were assessed and the relationships between each CVRF and the area of residence (urban or rural), were evaluated using multivariable logistic regression models. Results: Of the 6762 subjects included in the study, 2271 were from urban areas and 4491 were from rural areas. High blood pressure was more prevalent in urban than in rural areas, 29.9% (95% confidence intervals (95% CI): 27.4, 32.5) and 27.5% (95% CI: 25.6, 29.5) respectively, p = 0.001 (p-value after adjustment for age and gender). Obesity was more prevalent in urban than in rural areas, 16.4% (95% CI: 14.4, 18.4) and 5.9% (95% CI: 5.1, 6.7), p<0.001. Diabetes was more prevalent in urban than in rural areas, 3.3% (95% CI: 2.1, 4.5) and 1.8% (95% CI: 1.2, 2.4), p = 0.004. Conversely, daily tobacco smoking was more prevalent in rural than in urban areas, 9.3% (95% CI: 8.1, 10.4) and 4.3% (95% CI: 3.1, 5.6), p<0.001. No differences in raised blood cholesterol were noted between the two groups. Conclusion: According to our data, CVRF are prevalent among adults in Benin, and variations between rural and urban populations are significant. It may be useful to take account of the heterogeneity in the prevalence of CVRF when planning and implementing preventive interventions. [ABSTRACT FROM AUTHOR]