Use of HRP-2-based rapid diagnostic test for Plasmodium falciparum malaria: assessing accuracy and cost-effectiveness in the villages of Dielmo and Ndiop, Senegal

Background: In 2006, the Senegalese National Malaria Control Programme (NMCP) has recommended artemisinin-based combination therapy (ACT) as the first-line treatment for uncomplicated malaria and, in 2007, mandated testing for all suspected cases of malaria with a Plasmodium falciparum HRP-2-based rapid diagnostic test for malaria (RDT(Paracheck (R)). Given the higher cost of ACT compared to earlier anti-malarials, the objectives of the present study were i) to study the accuracy of Paracheck (R) compared to the thick blood smear (TBS) in two areas with different levels of malaria endemicity and ii) analyse the cost-effectiveness of the strategy of the parasitological confirmation of clinically suspected malaria cases management recommended by the NMCP. Methods: A cross-sectional study was undertaken in the villages of Dielmo and Ndiop (Senegal) nested in a cohort study of about 800 inhabitants. For all the individuals consulting between October 2008 and January 2009 with a clinical diagnosis of malaria, a questionnaire was filled and finger-prick blood samples were taken both for microscopic examination and RDT. The estimated costs and cost-effectiveness analysis were made considering five scenarios, the recommendations of the NMCP being the reference scenario. In addition, a sensitivity analysis was performed assuming that all the RDT-positive patients and 50% of RDT-negative patients were treated with ACT. Results: A total of 189 consultations for clinically suspected malaria occurred during the study period. The sensitivity, specificity, positive and negative predictive values were respectively 100%, 98.3%, 80.0% and 100%. The estimated cost of the reference scenario was close to 700(sic) per 1000 episodes of illness, approximately twice as expensive as most of the other scenarios. Nevertheless, it appeared to us cost-effective while ensuring the diagnosis and the treatment of 100% of malaria attacks and an adequate management of 98.4% of episodes of illness. The present study also demonstrated that full compliance of health care providers with RDT results was required in order to avoid severe incremental costs. Conclusions: A rational use of ACT requires laboratory testing of all patients presenting with presumed malaria. Use of RDTs inevitably has incremental costs, but the strategy associating RDT use for all clinically suspected malaria and prescribing ACT only to patients tested positive is cost-effective in areas where microscopy is unavailable

Les processus d’identification des plus pauvres à l’épreuve du terrain : une comparaison Bénin-Mali-Sénégal

Contexte : Depuis 2014, dans le cadre de politiques de santé et de protection sociale, le Bénin, le Mali et le Sénégal ont élaboré des procédures de ciblage « actif » des personnes vulnérables ou indigentes, par opposition à l’identification « passive », au point de service, qui prévalait jusque-là. Appuyé par la Banque Mondiale dans le cadre des programmes de filets sociaux, ce modèle de ciblage repose sur une pré-identification communautaire validée par une enquête sur les moyens d’existence (Proxy Means Testing, PMT) et s’est imposé comme méthode nationale et unique. Cette recherche vise à analyser de façon comparative les procédures nationales de ciblage et à rendre compte des difficultés de mise en œuvre de ce modèle « mixte » supposé limiter les erreurs d’inclusion et d’exclusion. Elle ouvre une discussion concernant la mise en place de Registres nationaux uniques. Méthode : Cette étude se base sur une revue documentaire et des enquêtes socio-anthropologiques de terrain réalisées en 2016 et 2017. Des entretiens semi-directifs ont été menés avec diverses parties prenantes aux niveaux institutionnel et opérationnel, à Kaolack (Sénégal), Bamako, Bougouni et Dioïla (Mali) et dans le Mono (Bénin). Résultats : Bien que des différences de procédures existent entre les trois pays, notamment l’instauration de quotas via un ciblage géographique préalable au Sénégal, une même logique prévaut. Des comités locaux, présumés fins connaisseurs et représentatifs de la population, pré-identifient des individus ou ménages pauvres, dont les conditions d’existence sont ensuite vérifiées par des enquêteurs indépendants. L’enquête PMT (in)valide ainsi les choix effectués au niveau communautaire à partir de critères théoriquement objectifs, quantifiables et pertinents pour classer les ménages selon leur niveau de pauvreté. Cependant, de nombreuses erreurs d’inclusion et d’exclusion ont été dénoncées par les acteurs au Bénin comme au Sénégal. Elles sont associées à des pratiques de clientélisme ou de favoritisme lors du ciblage communautaire ainsi qu’aux biais inhérents au dispositif d’enquête et à ses difficultés de mise en œuvre. Face à cette « revanche des contexte », connue et reconnue tant au niveau opérationnel qu’institutionnel, des procédures de recours, des ajustements et de nouvelles vérifications sont envisagées ou mises en œuvre, sans remise en question du modèle. Conclusion : Ce modèle mixte d’identification des indigents sous-tend aujourd’hui la création de Registres nationaux/sociaux uniques, qui ont pour objectif de mieux coordonner les actions et cibler les bénéficiaires des différents programmes sociaux. Au-delà des erreurs de ciblage et des dysfonctionnements constatés sur le terrain, la mise en place de ces registres ne peut s’affranchir d’une réflexion critique sur le caractère dynamique de la situation d’indigence, ainsi que sur les conséquences d’un tel dispositif sur la cohésion sociale, dans un contexte où les taux de pauvreté sont élevés et la logique de redistribution des bénéfices au sein de la population semble prévaloir au niveau local.ARC Effi-Sant

The emergence of the national medical assistance scheme for the poorest in Mali

Universal health coverage is high up the international agenda. The majority of the West Africa's countries are seeking to define the content of their compulsory, contribution-based medical insurance system. However, very few countries apart from Mali have decided to develop a national policy for poorest population that is not based on contributions. This qualitative research examines the historical process that has permitted the emergence of this public policy. The research shows that the process has been very long, chaotic and suspended for long periods. One of the biggest challenges has been that of intersectoriality and the social construction of the poorest to be targeted by this public policy, as institutional tensions have evolved in accordance with the political issues linked to social protection. Eventually, the medical assistance scheme for the poorest saw the light of day in 2011, funded entirely by the government. Its emergence would appear to be attributable not so much to any new concern for the poorest in society but rather to a desire to give the social protection policy engaged in a guarantee of universality. This policy nonetheless remains an innovation within French-speaking West Africa

Single-drug immunosuppression is associated with noninferior medium-term survival in pediatric heart transplant recipients

Abstract: BACKGROUND: Patients are usually maintained on at least two immunosuppressive drugs (ISDs) after the first year post-heart transplant. Anecdotally, some children are switched to singledrug monotherapy (a single ISD) for various reasons and varying durations. Outcomes associated with differences in immunosuppression after heart transplantation are unknown for children. OBJECTIVES: A priori we defined a non-inferiority hypothesis for monotherapy compared to ≥2 ISDs. The primary outcome was graft failure, a composite of death and retransplantation. Secondary outcomes included rejection, infection, malignancy, cardiac allograft vasculopathy and dialysis. METHODS: This international, multicenter, retrospective, observational cohort study used data from the Pediatric Heart Transplant Society. We included patients who underwent first-time heart transplant <18 years of age between 1999 and 2020 with ≥1 year of follow-up data available. RESULTS: Our analysis included 3,493 patients with a median time post-transplant of 6.7 years. There were 893 patients (25.6%) switched to monotherapy at least once with the remaining 2600 patients always on ≥2 ISDs. The median time on monotherapy after the first year post-transplant was 2.8 years (range 1.1-5.9 years). We found an adjusted hazard ratio (HR) of 0.65 (95%CI: 0.47- 0.88) favoring monotherapy compared to ≥2 ISDs (p=0.002). There were no meaningful differences in the incidence of secondary outcomes between groups, except for a lower rate of cardiac allograft vasculopathy in patients on monotherapy (HR 0.58, 95%CI: 0.45-0.74). CONCLUSIONS: For pediatric heart transplant recipients placed on monotherapy, immunosuppression with a single ISD after the first year post-transplant was non-inferior to standard therapy with ≥2 ISDs in the medium term