BackgroundIn therapeutic feeding programs (TFP), mid-upper arm circumference (MUAC) shows advantages over weight-for-height Z score (WHZ) and is recommended by the World Health Organization (WHO) as an independent criterion for screening children 6–59 months old. Here we report outcomes and treatment response from a TFP using MUAC ≤118 mm or oedema as sole admission criteria for severe acute malnutrition (SAM).MethodsPatient data from September 2007 to March 2009 for children admitted by MUAC ≤118 mm or oedema to a Médecins Sans Frontières (MSF) TFP in Burkina Faso were retrospectively analyzed. Analysis included anthropometric measurements at admission and discharge, program outcomes and treatment response.ResultsOf 24,792 patient outcomes analyzed, nearly half (48.8%; n = 12,090) were admitted with MUAC 116–118 mm. Most patients (88.7%; n = 21,983) were 6–24 months old. At admission, 52.7% (n = 5,041) of those with MUAC 116–118 mm had a WHZ <−3 SD. At discharge, 89.1% (n = 22,094) recovered (15% weight gain or oedema resolution), 7.9% (n = 1,961) defaulted, 1.5% (n = 384) failed to respond to treatment, and 1.0% (n = 260) died. Average weight gain was 5.4 g/kg/day, and average MUAC gain was 0.42 mm/day. Patients with MUAC ≤114 mm at admission had higher average daily weight and MUAC gains at discharge compared to those admitted with MUAC 116–118 mm, but those in the latter category required longer lengths of stay to achieve recovery (P<0.001).ConclusionThis analysis suggests that MUAC ≤118 mm as TFP admission criterion is a useful alternative to WHZ. Regarding treatment response, rates of weight and MUAC gain were acceptable. Applying 15% weight gain as discharge criterion resulted in longer lengths of stay for less malnourished children. Since MUAC gain parallels weight gain, it may be feasible to use MUAC as both an admission and discharge criterion.

BackgroundDespite hepatitis B vaccination at birth and at 6, 10 and 14 weeks of age, hepatitis B virus (HBV) infection continues to be endemic in the Lao People’s Democratic Republic (PDR). We carried out a cross-sectional serological study in infants, pre-school children, school pupils and pregnant women to determine their burden of disease, risk of infection and vaccination status.MethodsA total of 2471 participants between 9 months and 46 years old were recruited from urban (Vientiane Capital, Luang Prabang), semi-urban (Boulhikhamxai and Savannakhet) and remote rural areas (Huaphan). All sera were tested for anti-HBs and anti-HBc. Sera testing positive for anti-HBc alone were further tested for the presence of HBsAg.ResultsA low prevalence of HBsAg (0.5%) was detected among infants from Vientiane and Luang Prabang, indicating some success of the vaccination policy. However, only 65.6% had protective anti-HBs antibodies, suggesting that vaccination coverage or responses remain sub-optimal, even in these urban populations.In pre-school children from remote areas in Huaphan, 21.2% were positive for anti-HBc antibodies, and 4.6% were for HBsAg positive, showing that a significant proportion of children in these rural regions have early exposure to HBV. In pre-school children with 3 documented HBV vaccinations, only 17.0% (15/55) were serologically protected.Among school-children from semi-urban regions of Luang Prabang, Boulhikhamxai and Savannakhet provinces, those below the age of 9 who were born after HBV vaccine introduction had anti-HBc and HBsAg prevalence of 11.7% and 4.1%, respectively. The prevalence increased to 19.4% and 7.8% of 10–14 year olds and to 27% and 10.2% of 15–19 year olds.Pregnant women from Luang Prabang and Vientiane had very high anti-HBc and HBsAg prevalence (49.5% and 8.2%), indicating high exposure and risk of onward vertical transmission to the unborn infant.ConclusionsOverall, the results demonstrate a dramatic deficiency in vaccination coverage and vaccine responses and/or documentation within the regions of Lao PDR studied, which included urbanized areas with better health care access. Timely and effective hepatitis B vaccination coverage is needed in Lao PDR.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2334-14-457) contains supplementary material, which is available to authorized users.

Pneumonia causes around 750 000 child deaths per year in sub-Saharan African (SSA) countries. The lack of accessibility to prompt and effective treatment is an important contributor to this burden. Community case management of pneumonia (CCMp) uses trained community health workers (CHWs) to administer antibiotics to suspected child pneumonia cases in villages. This strategy has been gaining momentum in low- and middle-income countries, and the World Health Organization and United Nations children's fund have recently encouraged countries to broaden community case management to other diseases. Recommendations in favour CCMp are based on three meta-analyses showing its efficacy to reduce childhood mortality and morbidity attributable to pneumonia although most of the studies in the meta-analyses were conducted in Asian countries. This is problematic as community case management strategies have been implemented in very different ways in Asian and SSA countries, partly due to differences in malaria prevalence. Therefore, we conducted a narrative synthesis to systematically review the evidence on CCMp in SSA. Results show that there is a lack of evidence concerning its efficacy and effectiveness in SSA, irrespective of whether case management is integrated with other diseases or not. CHWs encounter difficulties in counting the respiratory rate. Their adherence to the guidelines is poorer when they are required to manage several illnesses or children with severe signs. CCMp thus encompasses issues of over-treatment and missed treatment, with potentially negative consequences such as increased lethality in severe cases and antibiotics resistance. The current lack of evidence concerning its efficacy, effectiveness and the factors leading to successful implementation, coupled with CHWs' poor adherence, demand a thorough examination of the legitimacy of implementing CCMp in SSA countries.

BackgroundDuring late 2012 and early 2013 several outbreaks of diphthe-ria were notified in the North of the Lao People’s Democratic Republic. The aim of this study was to determine whether the re-emergence of this vaccine-preventable disease was due to insufficient vaccination coverage or reduction of vaccine effectiveness within the affected regions.MethodsA serosurvey was conducted in the Huaphan Province on a cluster sampling of 132 children aged 12–59 months. Serum samples, socio-demographic data, nutri-tional status and vaccination history were collected when available. Anti-diphtheria and anti-tetanus IgG antibody levels were measured by ELISA.ResultsOverall, 63.6% of participants had detectable diphtheria antibodies and 71.2% tetanus antibodies. Factors independently associated with non-vaccination against diphtheria were the distance from the health centre (OR: 6.35 [95% CI: 1.4–28.8], p = 0.01), the Lao Theung ethnicity (OR: 12.2 [95% CI:1,74–85, 4], p = 0.01) and the lack of advice on vac-cination given at birth (OR: 9.8 [95% CI: 1.5–63.8], (p = 0.01) while the level of maternal edu-cation was a protective factor (OR: 0.08 [95% CI: 0.008–0.81], p = 0.03). Most respondents claimed financial difficulties as the main reason for non-vaccination. Out of 55 children whose vaccination certificates stated that they were given all 3 doses of diphtheria-containing vaccine, 83.6% had diphtheria antibodies and 92.7% had tetanus antibodies. Furthermore, despite a high prevalence of stunted and underweight children (53% and 25.8%, respectively), the low levels of anti-diphtheria antibodies were not correlated to the nutritional status.ConclusionsOur data highlight a significant deficit in both the vaccination coverage and diphtheria vaccine effectiveness within the Huaphan Province. Technical defi-ciencies in the methods of storage and distribution of vaccines as well as unreliability of vac-cination cards are discussed. Several hypotheses are advanced to explain such a decline in immunity against diphtheria and recommendations are provided to prevent future outbreaks.

BackgroundExpanding access to antiretroviral therapy (ART) in sub-Saharan Africa requires implementation of alternative care delivery models to traditional physician-centered approaches. This longitudinal analysis compares outcomes of patients initiated on antiretroviral therapy (ART) by non-physician and physician providers.MethodsAdults (≥15 years) initiating ART between September 2007 and March 2010, and with >1 follow-up visit were included and classified according to the proportion of clinical visits performed by nurses or by clinical officers (≥80% of visits). Multivariable Poisson models were used to compare 2-year program attrition (mortality and lost to follow-up) and mortality by type of provider. In sensitivity analyses only patients with less severe disease were included.ResultsA total of 10,112 patients contributed 14,012 person-years to the analysis: 3386 (33.5%) in the clinical officer group, 1901 (18.8%) in the nurse care group and 4825 (47.7%) in the mixed care group. Overall 2-year program retention was 81.8%. Attrition was lower in the mixed care and higher in the clinical officer group, compared to the nurse group (adjusted incidence rate ratio [aIRR]=0.54, 95%CI 0.45-0.65; and aIRR=3.03, 95%CI 2.56-3.59, respectively). While patients initiated on ART by clinical officers in the mixed care group had lower attrition (aIRR=0.36, 95%CI 0.29-0.44) than those in the overall nurse care group; no differences in attrition were found between patients initiated on ART by nurses in the mixed care group and those included in the nurse group (aIRR=1.18, 95%CI 0.95-1.47). Two-year mortality estimates were aIRR=0.72, 95%CI 0.49-1.09 and aIRR=5.04, 95%CI 3.56-7.15, respectively. Slightly higher estimates were observed when analyses were restricted to patients with less severe disease.ConclusionThe findings of this study support the use of a mixed care model with well trained and regularly supervised nurses and medical assistants to provide HIV care in countries with high HIV prevalence.