Search

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: 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]

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]

Background: Free tuberculosis control fail to protect patients from substantial medical and non-medical expenditure, thus a greater degree of disaggregation of patient cost is needed to fully capture their context and inform policymaking. Methods: A retrospective cross-sectional study was conducted on a convenience sample of six health districts of Southern Benin. From August 2008 to February 2009, we recruited all smear-positive pulmonary tuberculosis patients treated under the national strategy in the selected districts. Direct out-of-pocket costs associated with tuberculosis, time delays, and care-seeking pattern were collected from symptom onset to end of treatment. Results: Population description and outcome data were reported for 245 patients of whom 153 completed their care pathway. For them, the median overall direct cost was USD 183 per patient. Payments to traditional healers, self-medication drugs, travel, and food expenditures contributed largely to this cost burden. Patient, provider, and treatment delays were also reported. Pre-diagnosis and intensive treatment stages were the most critical stages, with median expenditure of USD 43 per patient and accounting for 38% and 29% of the overall direct cost, respectively. However, financial barriers differed depending on whether the patient lived in urban or rural areas. Conclusions: This study delivers new evidence about bottlenecks encountered during the TB care pathway. Financial barriers to accessing the free-of-charge tuberculosis control strategy in Benin remain substantial for low-income households. Irregular time delays and hidden costs, often generated by multiple visits to various care providers, impair appropriate patient pathways. Particular attention should be paid to pre-diagnosis and intensive treatment. Cost assessment and combined targeted interventions embodied by a patient-centered approach on the specific critical stages would likely deliver better program outcomes. [ABSTRACT FROM AUTHOR]

Background: Alternative compounds which can complement pyrethroids on long-lasting insecticidal nets (LN) in the control of pyrethroid resistant malaria vectors are urgently needed. Pyriproxyfen (PPF), an insect growth regulator, reduces the fecundity and fertility of adult female mosquitoes. LNs containing a mixture of pyriproxyfen and pyrethroid could provide personal protection through the pyrethroid component and reduce vector abundance in the next generation through the sterilizing effect of pyriproxyfen. Method: The efficacy of Olyset Duo, a newly developed mixture LN containing pyriproxyfen and permethrin, was evaluated in experimental huts in southern Benin against pyrethroid resistant Anopheles gambiae and Culex quinquefasciatus. Comparison was made with Olyset Net® (permethrin alone) and a LN with pyriproxyfen alone (PPF LN). Laboratory tunnel tests were performed to substantiate the findings in the experimental huts. Results: Overall mortality of wild pyrethroid resistant An. gambiae s.s. was significantly higher with Olyset Duo than with Olyset Net (50% vs. 27%, P = 0.01). Olyset DUO was more protective than Olyset Net (71% vs. 3%, P<0.001). The oviposition rate of surviving blood-fed An. gambiae from the control hut was 37% whereas none of those from Olyset Duo and PPF LN huts laid eggs. The tunnel test results were consistent with the experimental hut results. Olyset Duo was more protective than Olyset Net in the huts against wild pyrethroid resistant Cx. quinquefasciatus although mortality rates of this species did not differ significantly between Olyset Net and Olyset Duo. There was no sterilizing effect on surviving blood-fed Cx. quinquefasciatus with the PPF-treated nets. Conclusion: Olyset Duo was superior to Olyset Net in terms of personal protection and killing of pyrethroid resistant An. gambiae, and sterilized surviving blood-fed mosquitoes. Mixing pyrethroid and pyriproxyfen on a LN shows potential for malaria control and management of pyrethroid resistant vectors by preventing further selection of pyrethroid resistant phenotypes. [ABSTRACT FROM AUTHOR]