Summary Background Madagascar accounts for 75% of global plague cases reported to WHO, with an annual incidence of 200–700 suspected cases (mainly bubonic plague). In 2017, a pneumonic plague epidemic of unusual size occurred. The extent of this epidemic provides a unique opportunity to better understand the epidemiology of pneumonic plagues, particularly in urban settings. Methods Clinically suspected plague cases were notified to the Central Laboratory for Plague at Institut Pasteur de Madagascar (Antananarivo, Madagascar), where biological samples were tested. Based on cases recorded between Aug 1, and Nov 26, 2017, we assessed the epidemiological characteristics of this epidemic. Cases were classified as suspected, probable, or confirmed based on the results of three types of diagnostic tests (rapid diagnostic test, molecular methods, and culture) according to 2006 WHO recommendations. Findings 2414 clinically suspected plague cases were reported, including 1878 (78%) pneumonic plague cases, 395 (16%) bubonic plague cases, one (<1%) septicaemic case, and 140 (6%) cases with unspecified clinical form. 386 (21%) of 1878 notified pneumonic plague cases were probable and 32 (2%) were confirmed. 73 (18%) of 395 notified bubonic plague cases were probable and 66 (17%) were confirmed. The case fatality ratio was higher among confirmed cases (eight [25%] of 32 cases) than probable (27 [8%] of 360 cases) or suspected pneumonic plague cases (74 [5%] of 1358 cases) and a similar trend was seen for bubonic plague cases (16 [24%] of 66 confirmed cases, four [6%] of 68 probable cases, and six [2%] of 243 suspected cases). 351 (84%) of 418 confirmed or probable pneumonic plague cases were concentrated in Antananarivo, the capital city, and Toamasina, the main seaport. All 50 isolated Yersinia pestis strains were susceptible to the tested antibiotics. Interpretation This predominantly urban plague epidemic was characterised by a large number of notifications in two major urban areas and an unusually high proportion of pneumonic forms, with only 23% having one or more positive laboratory tests. Lessons about clinical and biological diagnosis, case definition, surveillance, and the logistical management of the response identified in this epidemic are crucial to improve the response to future plague outbreaks. Funding US Agency for International Development, WHO, Institut Pasteur, US Department of Health and Human Services, Laboratoire d'Excellence Integrative Biology of Emerging Infectious Diseases, Models of Infectious Disease Agent Study of the National Institute of General Medical Sciences, AXA Research Fund, and the INCEPTION programme.

Comprehensive studies of 92 commercial sex workers in Senegal, Africa included an oral examination in which we obtained measurements of decayed, missing, and filled (DMF) teeth; plaque index; gingival index; recession; probing depth (PD); clinical attachment loss (CAL); and the presence of HIV-associated periodontal lesions, under conditions wherein the examiner was unaware of the subject's HIV status. Twenty-seven subjects (29%) were HIV seropositive, 19 of whom were positive for HIV-1, 7 positive for HIV-2, and 1 positive for both. Most subjects were not taking any medications and previous dental care was limited. HIV-seronegative and HIV-seropositive subjects were similar in mean age, number of DMF teeth, percentage of sites with visible plaque, and number of sites with recession. However, the frequency of sites with gingival bleeding, with PD > or = 6 mm, and with CAL > or = 6 mm was significantly greater in seropositive than seronegative subjects. No differences were observed between HIV-1 and HIV-2 positive subjects. About 26% of HIV-seropositive subjects and about 5% of the seronegative subjects exhibited at least one site with concurrent PD > or = 6 mm and CAL > or = 6 mm. HIV-associated periodontal lesions were seen in 3 HIV-seropositive subjects (2 linear gingival erythema, 1 necrotizing periodontitis). One HIV-seronegative subject exhibited necrotizing gingivitis. In this population with multiple risks to oral health, both HIV-1 and HIV-2 infections were associated with a significantly increased prevalence of periodontal disease.

Background: Noma is an infectious but opportunistic disease that often results in severe facial disfigurements and mortality if untreated. As noma progresses quickly, early detection and treatment are important to prevent its development.Objectives: The objective of this study was to investigate primary healthcare workers’ knowledge and management of noma in a rural part of Zambia.Methods: A cross-sectional self-completed survey was conducted among 35 healthcare workers from two district hospitals and 15 rural health centres in Serenje District, Zambia. Participants’ practice competences and knowledge were grouped into ‘optimal’, ‘medium’, ‘suboptimal’ and ‘very low’.Results: Most of the healthcare workers stated that they perform mouth examination of a child below five years of age who is suffering from measles, malnutrition or HIV. A majority diagnosed gingivitis correctly and 40% had a medium level of practice competence of the same noma stage. All participants had a suboptimal or very low level on overall practice competence regarding management of noma and two-thirds had a very low level of reported knowledge.Conclusion: General knowledge on noma and competences of diagnosing and treating noma patients was low among healthcare workers. Lack of knowledge could present a barrier for correctly managing noma at an early stage. Improving knowledge among healthcare workers is one way to prevent the development of the disease. In order to prevent noma from the start, actions need to be focussed on improving (oral) hygiene and health education as well. Telemedicine could also be considered as it can help healthcare workers in handling noma patients through enabling communication and exchange of information with specialist.

SUMMARYObjectives: According to The World Oral Health Report 2003, oral diseases remain a major public health problem worldwide. However, oral health is seen as a very low priority in the African Region, where extreme poverty means that the limited resources available to the health sector are directed towards life-threatening conditions such as HIV/AIDS, tuberculosis and malaria. The mission of the Oral Health Programme at the Regional Office of WHO for Africa is to assist Member States to achieve those goals by means of a Regional Strategy. In fact in September 1998, the WHO Regional Committee for Africa adopted a ten year (1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008) Oral Health Plan for the African Region (AFR/RC48/9) with the aim of fundamentally improving community oral health. Its cornerstone is provision of the technical and managerial resources to efficiently and effectively deliver affordable intervention that matches the oral health needs of the community.Data Sources: This review presents major achievements made since the WHO Regional Strategy was launched in 1998 and priority actions which should be taken to further implement the Regional Strategy.Conclusions: WHO/AFRO recommends more commitment at country level to improve oral health and to reinforce partnerships in order to mobilize and coordinate the human, financial, material and institutional resources needed to implement, monitor and evaluate the Regional Strategy.

Background Noma is a quickly progressing, neglected opportunistic infection. It starts in the mouth as an oral lesion but can relatively quickly develop into extensive facial destruction and lead to death if not treated in time. This study aims to shed light on primary healthcare workers’ practice competences in working with and knowledge of noma. Methods A structured questionnaire using questions and case scenarios was filled out by 76 healthcare workers in Burkina Faso. Half of the nurses included in this study participated in a 2-day noma training. Data were analysed descriptively and Fisher’s exact test was used to study differences between occupational groups using Stata. Results Most healthcare workers reported having examined the mouth of children with diseases predisposing to noma. The total practice competence was poor, with almost 70% having suboptimal or very low competences. However, competences varied between different stages of noma disease. Knowledge scores varied between occupational groups. The majority of nurses and odontostomatology specialist nurses had optimal or good knowledge of noma. Significant differences in knowledge and practice competence were found between nurses who attended a 2-day training course on noma and those who did not. Conclusions Health care workers in this study had quite poor practice competences in managing noma. The knowledge scores of these health workers were moderate. It is important for healthcare workers to be able to identify noma patients at an early stage, as at this point the disease can still be completely reversed.

The 2017 plague outbreak in Madagascar was unprecedented in the African region, resulting in 2417 cases (498 confirmed, 793 probable and 1126 suspected) and 209 deaths by the end of the acute urban pneumonic phase of the outbreak. The Health Emergencies Programme of the WHO Regional Office for Africa together with the WHO Country Office and WHO Headquarters assisted the Ministry of Public Health of Madagascar in the rapid implementation of plague prevention and control measures while collecting and analysing quantitative and qualitative data to inform immediate interventions. We document the key findings of the evidence available to date and actions taken as a result. Based on the four goals of operational research - effective dissemination of results, peer-reviewed publication, changes to policy and practice and improvements in programme performance and health - we evaluate the use of evidence to inform response to the outbreak and describe lessons learned for future outbreak responses in the WHO African region. This article may not be reprinted or reused in any way in order to promote any commercial products or services.

No abstract

Objective To quantify the prevalence and burden of HIV type 2 (HIV-2) and HIV-1 RNA in the oral cavity of antiretroviral therapy-naive HIV-infected Senegalese individuals and to identify correlates of oral HIV viral loads. Design A cross-sectional study of 163 HIV-1 and 27 HIV-2-infected antiretroviral therapy-naive Senegalese adults. Methods Participants received clinical and oral exams and provided blood and oral wash samples for viral load and plasma CD4 count ascertainment. Logistic and interval regression models were used to identify univariate and multivariable associations between presence and level of oral HIV RNA and various immunovirologic, local and demographic factors. Results Presence of detectable oral HIV RNA was less common in HIV-2-infected compared with HIV-1-infected study participants (33% vs 67%, OR 0.25, 95% CI 0.11 to 0.59). HIV type was no longer associated with oral shedding of HIV when plasma viral load was considered. Detection of oral HIV RNA was associated with increased plasma viral load in both HIV-1-infected and HIV-2-infected individuals (HIV-1, OR 1.89, 95% CI 1.24 to 2.61; HIV-2, OR 1.93, 95% CI 1.1 to 3.39). Oral HIV-1 detection was also associated with periodontal disease (OR 3.02, 95% CI 1.16 to 7.87). Conclusions Oral shedding of HIV-2 RNA is less common than HIV-1 RNA, a likely consequence of lower overall viral burden. Both systemic and local factors may contribute to shedding of HIV in the oral cavity.