MDC Alumni Newsletter - Instituut voor Tropische Geneeskunde

MDC Alumni Newsletter
Institute of Tropical Medicine
June 2004
Issue 9
Summary
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THE FIGHT FOR AN EFFICACIOUS ANTIMALARIAL
TREATMENT IN AFRICA
Editorial
DOTS: is it “doubts”
in Russia?
10
Resistance to commonly used antimalarial drugs represents the
major drawback and obstacle for controlling malaria in endemic
countries. Currently, the geographic distribution of P. falciparum
resistance to chloroquine (CQ) almost corresponds to that of the
parasite itself and it is severe in many countries. Several countries
have changed their first line treatment from CQ to other regimens,
usually sulfadoxine-pyrimethamine (SP), but resistance to the latter
has rapidly reached critical levels in some areas of East and Central
Africa and a public health disaster might be imminent.
Unfortunately only few available alternative drugs are ready for
deployment. It is generally agreed that endemic countries should
opt for combination treatment, i.e. the association of 2 or more
antimalarial drugs with different metabolic targets. Artemisinin
derivatives (AS) and consequently artemisinin-containing
combinations (ACT) have several advantages as they produce a
rapid clinical and parasitological cure, reduce gametocyte carriage
rate and are generally well tolerated. In Africa, studies on ACT
(artesunate with either CQ, amodiaquine (AQ) or SP) have been
carried out in a few thousands children with uncomplicated malaria.
Good safety and efficacy were reported when the partner drug was
also efficacious. However, at least 2 of the 3 drugs mentioned
above (CQ and SP) can no longer be considered as useful partner
drugs for combination with AS because of their confirmed low
efficacy.
A multi-centric "in
vivo" efficacy study
in Sierra Leone
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14
Kala azar in Sudan
A Logical
Framework
Approach for Conflict
Resolution?
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17
MDC 0304 News
News from the
options & short
courses
19
Words can save
lives
20
Training
Communicable
Disease Control
Programme
Managers in
Indonesia
21
Despite the high resistance to CQ and SP, these drugs are still used
and funded in many African countries. This is the reason why a
group of scientists (among others the writer) wrote a letter to the
Lancet accusing international organisations of promoting and
funding non-efficacious antimalarial drugs. The letter had the
aggressive title of ‘WHO, the Global Fund, and medical malpractice
in malaria treatment’ and stated that African countries “seek financial
aid from the Global Fund for AIDS, Tuberculosis, and Malaria (GFATM)
to purchase ACT, they are forcefully pressured out of it by governments such as
the USA, whose aid officials say that ACT is too expensive and “not ready for
prime time”. WHO acquiesces to this pressure to cut costs, and despite a policy
that names ACT as the gold standard of treatment, WHO signs its approval
when GFATM funds cheap but ineffective chloroquine or sulfadoxinepyrimethamine to treat P falciparum malaria.” The letter continued on
the same aggressive tone: “We do not exaggerate to state that, based on the
outcomes, there is no ethical or legal difference that separates them from conduct
otherwise condemned as medical malpractice (compare the case in which a doctor
or pharmacist who, like these institutions, knowingly furnished treatments that
failed perhaps 80% of the time, while withholding the alternatives as “too
expensive”).” Needless to say, this letter provoked an indignant
reaction from the GFATM itself defining the Lancet article as
"factually incorrect, in just about every respect".
Report on the MCMMscBT and
RIPROSAT
networks’ colloquium
in RDC
26
Brewing religion and
medical science in
the same pot
27
News from our
Alumni
Instituut voor Tropische
Geneeskunde
Nationalestraat 155
B-2000 Antwerpen, België
Tel.: 32-3-2476666
Fax: 32-3-2161431
web: www.itg.be
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Nevertheless, thanks to such pressure the GFATM agreed to instruct African countries to retrospectively
modify all malaria grants awarded to specify only the newer drug. This move will cost the fund more than
a billion dollars over the next five years. All future funding will stipulate the use of artemisinin. The
policy change is expected to force most countries to change their national drug policies. Eventually the
GFATM admits that the move was given "further impetus" by the discussion that followed the
publication of the article on "malpractice" in The Lancet. Several East African countries are changing or
about to change their antimalarial drug policy to ACT. The fight for given efficacious antimalarial
treatment is not over and there is still a lot to do but we have won a battle. It is now widely recognised
that treating malaria with a drug that does not cure 20-30% of patients is not acceptable anymore. This is
already an important result.
1. Attaran A, Barnes KI, Curtis C, D’Alessandro U, Fanello CI, Galinsky
MR, Kokwaro G, Looareesuwan S, Makanga M, Mutabingwa TK,
Talisuna A, Trape JF, Watkins WM. (2004) WHO, the Global Fund
and medical malpractice in malaria treatment. Lancet. 363: 237-40.
2. Fatoumata Nafo-Traoré. Response to accusations of medical
malpractice by WHO and the Global Fund. (2004) Lancet. 363: 397.
3. Vinand M Nantulya, Jon Lidén. Response to accusations of medical
malpractice by WHO and the Global Fund. (2004) Lancet. 363: 397-8.
Umberto d'Alessandro
E-mail: [email protected]
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DOTS: IS IT “DOUBTS” IN RUSSIA?
An African talking from Joseph Stalin’s Prisons
Esayas Abay
I had the chance to work for MSF in one of the most complicated and
challenging, but very interesting TB projects in the world in the Russian
Federation. As there is not much information coming out from that corner of the
world and there are few contexts with similar scenarios, I found sharing my
experience with the Alumni valuable.
During the Soviet Union era, the unlimited
financial allocations and the stable socioeconomic situation led to the development of an
all-embracing TB control structure. Although
resource consuming and cost inefficient, this
strategy allowed to decrease TB incidence from
almost 200 per 100 000 per year in the sixties to
40 per 100 000 per year in the middle of the
eighties. Several generations of TB specialists
were trained in the light of these indisputable
achievements of the Soviet Phthisiatry.
Individualized clinical approach prevailed over
public health concerns. The idea that a
“phthisiatric service has-to-be-financed
TB control in the Russian Federation:
now and then
In the era of socialist Soviet Union the public
health structure was highly centralized, i.e.
planned and budgeted by the state. Special
attention was paid to TB, which was considered
as one of the most dangerous infectious diseases.
The main features of the statewide TB control
strategies were shaped in the sixties. This
strategy concentrates mainly on clinical
approaches with no notion of cost effectiveness
and differs from Western principles in several
ways.
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abundantly by the state” has emerged among TB
specialists.
The rigidity of the TB structure became clear in
the beginning of the nineties with the collapse of
the Soviet Union and the subsequent transition
from a planned to a market oriented economy.
In the rapidly deteriorating economic situation,
the TB service (cut from the central budgeting)
proved to be unable to deal with the growing
incidence: limited means were allocated to the
maintenance of the heavy existing structures and
it became starkly apparent that it was no longer
possible to maintain the expensive approach.
The concept of “priority”, unnecessary before,
was unwelcome – since it would imply to agree
that means are limited – and was not supported
by the existing legislation.
TB incidence continued to show sharp and
steady increase and reached up to 90/100,000
inhabitants in the year 2000. The mortality rate
of TB is also growing dramatically since the
beginning of the nineties. In 1999, 29078
patients died, among them 2894 in prisons.
Russia now ranks among the first eleven
countries with high TB burden in the World.
The collapse of the system resulted also in
unregulated, incomplete and inadequate TB
treatment, which on its turn resulted in the
emergence of multidrug resistant Tb (MDRTB)-“Ebola with wings”. MDR-TB implies
resistance to at least Isoniazid (INH) and
Rifampicin (RIF), the two most potent
antituberculous drugs.
The growing HIV prevalence is another threat.
Adult HIV prevalence in Russia is estimated
about 1.2% and 90% of HIV infected patients
are intravenous drug abusers. Intravenous drug
abusing is also rampant in Russian prisons.
Differences between Russian and DOTS TB
control strategy
The Russian TB control strategy differs from the
WHO-DOTS strategy in several ways: case
finding by fluorography-screenings (miniature Xray) including mass screening, little priority for
detection of sputum-smear positives or sources
of infection and a different classification system
(largely based on fluorography findings) are
used. Various adjunctive therapies, several
remedies and devices unknown to DOTS
strategy and western approach, are popular.
Surgery, including approaches from the prechemotherapy era like artificial pneumothorax,
pneumoperitonium, lobectomy and radical
thoracoplasty, are extensively practiced. In
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addition to the oral, intravenous or
intramuscular administration of
antimycobacterial drugs, inhalation, intrapleural
or intrabronchial administration is also practiced.
Galvanization and electromagnetic therapies,
which are believed to improve the
microcirculation in the region of the lesion and
reduce scarring, are used concurrently with
chemotherapy. Autotransfusion of irradiated
blood in which blood is collected by
venosection, heparinized and passed through a
glass chamber irradiated with ultraviolet light
and transfused back into the patient, is still
widely practiced. Its role is argued to be both
bactericidal and immunostimulatory. These
therapies are not confined to anti-TB medicine.
Inhalation of a saline substance (hallo or gallo
therapy) and physiotherapy are also used as part
of TB treatment.
Additional treatments are given as
immunostimulators or immunomodifiers, as
antioxidants or as liver tonic to reduce the
incidence of hepatitis, and include vitamin E and
sodium thiosulphate, calcium chloride, calcium
gluconate and steroids. Tuberculin therapy is
also used. This consists of weekly subcutaneous
injections over a 6-10 week period. It is
employed for poorly responding cases with
active disease. Chemoprophylaxis is also widely
used.
An individualized clinical approach with
different duration of treatment with little
attention to public health principles, are among
the main differences between the two
approaches. More over, the system has longterm follow-up based on radiographic lesions
and a guaranteed social support. Unlike the
western or DOTS approach a patient declared
cured remains under follow up on average for
two years or more. To put it in simple words,
going out of the TB system is more difficult than
coming in.
In contrast to the Russian TB control approach
the WHO-DOTS strategy is comprehensive and
standardized. It considers both clinical aspects of
TB control and the implications in terms of
public health. More over, the strategy has costeffectiveness as a core guiding principle. Even
though the term sustainability is widely used in
the DOTS approach, in practice it is not as
simple as putting it on paper. In contrary to the
Russian TB control approach, which solely
inclines to prove efficacy, the WHO-DOTS
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approach relies on both efficacy of
chemotherapy and effectiveness of the overall
TB control approach.
TB has been deemed too expensive and
considered not to be feasible out side referral
centers. It has been argued that drugsusceptibility testing and second-line drugs are
not cost-effective because of limited resources
and that intensive clinical management is
impossible because of lack of infrastructure.
More over, second line drugs are less effective
and less patient friendly and have more side
effects. MDR-TB carries a high case-fatality rate
when not treated. Unfortunately, the organism
has mutated more quickly than our own ability
to respond with new and effective drugs.
Nevertheless, DOTS is not the magic bullet of
TB control. Our field experience both in Russia
and Africa has shown the need to adjust it to the
context. The purpose of this paper is not to
defend obstinately the DOTS strategy.
Kemerovo Region penitentiary system in
Central Siberia- the breeding ground or the
“hot-spot” of TB
At the beginning of 1998 there were 1,1 million
inmates in Russia (750 inmates per 100,000
inhabitants), perhaps the highest rate in the
world. Of them 100,000 were expected to have
active TB.
There are as many as 27 penitentiary institutions
in Kemerovo region. The number of prisoners
in the region was 29,600. This constitutes 1% of
the total 3 million inhabitants of the region.
Because of some legal reform this figure is
declining gradually.
This major threat for the global TB control will
not stay within the Siberian prison walls and
national boundaries will not confine the disease.
Therefore, dealing with TB in Siberian prisons
which are plaqued by a high drug resistance rate
goes far beyond controlling TB in the region by
contributing also to the global effort to control
TB, especially MDR-TB.
The objective and evolution of the MSF TBproject in Kemerovo Region of Central
Siberia
The TB catastrophe in colony 33, one of the
major hospitals of the penitentiary system of the
region, which took the life of 400 out of 1500
prisoners in 1995 became the first reason for
MSF to intervene in the penitentiary system of
the region from 1996 onward. The general
objective of the project was to reduce the
morbidity and mortality of TB through
adequate and integrated case management
in the region.
Tuberculosis has afflicted the population of the
region severely, especially in the penitentiary
system, which is a breeding ground or “hotspot” of TB. The incidence of TB among
inmates is about 7000 new cases annually per
100.000 population; more than 60 times higher
than in the general population. Several reasons
explain this high TB rate. The prisoners often
come from the low-income part of the
population, with poor access to health care and
poor living conditions. They are often alcoholics,
drug abusers and crime-recidivists. The prison
environment with over crowding (especially in
pre-trial detention centers), poor hygiene, lack of
sunlight and inadequate ventilation makes it a
perfect breeding ground for the TB bacilli.
Prisoners in Russia are also particularly
susceptible to develop active TB disease, because
of poor nutrition. Prisoners can also get TB
before their detention and this again contributes
to the further spread of TB in the penitentiary
system. HIV has not been a major problem, so
far, but the problem is increasing and the risk of
an outbreak in the penitentiary system is high,
especially among intravenous drug abusers.
The project implemented the DOTS strategy of
TB control which is adjusted to the context: the
prison set up, the high MDR-TB rates in both
new and re-treatment cases, the Russian TB
control approach, infection control, and
treatment based on sputum smear examination,
culture and drug sensitivity test results (DST).
Infection control includes separation of patients
according to their DST status in addition to their
sputum smear and culture examination results.
This is to avoid cross infection or intramural
transmission of different patterns of TB drug
resistance. But, our strategy was limited by over
crowding, lack of space and some legal
procedures within the Russian penitentiary
system. Other infection control aspects include
organizing different sputum collection rooms
(according to patient profile or schedule which
reduces the risk of cross infection), health
The very high drug resistance rate, particularly
multi drug resistant TB (MDR-TB), which is
stubbornly entrenched in the prisons and
plaqueing the control program, is among the
highest in the world. Effective therapy of MDR-
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education, using highly efficient masks,
disinfecion methods, safety cabinets (in rooms
where the slides are fixed and colored), UV light
and negative vacuum pressure.
between the civil and the penitentiary system, a
psychosocial component was added in the
project. It was also expected to play a vital role
in terms of insuring adherence of patients to
treatment in the foreseen DOTS-plus project.
The diagnostic methods include microscopic
sputum examination, different sophisticated
As DOTS is a classical approach, mainly
radiography methods, and culture and DST
intended for areas with low or acceptable rates
examinations of samples. Expansion of the
of TB drug resistance, it is not expected to give
project within the penitentiary system of the
all the answers for all problems in relation to
region including
drug resistance, which is
decentralizing the case
rampant in the setting. The
finding activity to the
Prevalence of Multi-Drug
grass root levels and the
Resistant TB (MDR-TB) in
establishment of a referral
the penitentiary project was
laboratory by upgrading of
20.8% and 41% in new and
existing laboratories and
re-treatment cases
providing training to the
respectively. This is a
staff including
terrifyingly high rate of
international training and
MDR-TB. In colony 33, the
decentralization of sputum
biggest hospital colony of the
smear examination to
project, there was a large
peripheral colonies, took
pool of 600 inmates with
place at different points of
MDR-TB.
the evolution of the
project. The ITM
Thus, the prospect of having
laboratory was the
a DOTS-Plus project using
international reference
the existing DOTS as its
WHO/TBP/Colors Magazine/J. Mollison
laboratory for the external
corner stone was thought to
quality control of the
be a sound approach to beef
Arkadiy Yusev (Russian Federation) is 23. He
project and a training
up the battle to achieve the
has been in the TB prison for a year, after
place for the laboratory
final goal of breaking further
catching the disease in 2001. The tattoo on his
staff working in the
transmission of drug resistant
forehead reads, “Hello, I’m your sorrow.”
project.
TB and treating the existing
MDR-TB cases. The Green
There is about 25% turn over of detainees or
Light Committee, the WHO working group for
prisoners every year i.e. about 6 to 8 thousand
approval of MDR-TB projects including access
people go out of the prison to the civil
to cheaper second line anti-TB drugs, approved
community or vice-versa. This shows the strong
the launching of the project. Of course there are
epidemiological link between the penitentiary
different controversial issues around MDR-TB
and the civil system of the region implicates that
and its treatment with second and third line antiTB cannot be controlled by concentrating only
TB drugs. This includes the confused jargon of
on the penitentiary system. After having realized
our era: "not cost effective”.
this, a pilot DOTS project was set up in the civil
system. To involve different TB control actors in
Beside this MSF had an advocacy and lobbying
the region, including Russian TB institutes, and
role for penal reform, human right issues and the
to have a comprehensive TB control approach
improvement of the living conditions in prisons.
for the region, a center of excellence was created
with the support of the University of AlabamaWhat are the achievements of the project?
USA, with the support of Gorgas Memorial
The evolution of the project with its different
Institute. To serve the same purpose another
components and the adaptation of the strategies
expert council was created at regional level.
at different points after its inception,
demonstrate the project was well curtailed and
For diverse reasons prisoners are vulnerable to
had sound approaches, as it included clinical
multiple psychosocial problems. As a response
medicine, epidemiology, public health,
to this major problem and to act as a bridge
humanitarian and psychosocial aspects.
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Only in the penitentiary system about 11,000
patients were treated in the project untill the end
of 2003. The cohort analysis included new
patients and patients with not well documented
previous history of treatment or non DOTS
(non-standardized short course chemotherapy)
treatment including those with MDR-TB.
These patients were treated with the relatively
better and available treatment schemes with first
line anti-TB drugs under standardized short
course chemotherapy regimen.
The major challenges in implementing the
project
• Lack of political commitment- the “political
medicine of TB”
• Very high rate of drug resistant TBparticularly MDR-TB with higher risk of
cross infection and amplification of
resistance
• Different school of thought of TB controlRussian versus DOTS
• Overreliance on X-ray
• Lack of access to update international
literatures (except those translated and
distributed by MSF)
• The tendency to look at foreign organizations
as “milky cow” or donors, not partners
• Conflicts of interest
• Tendency to create a parallel program which
does not consider scientific evidence and risk
to compromise the proper regulation and
management of the TB program
• Centralized and autocratic type of
administration which hinders professional
freedom or job security of medical staff“the rule of hire and fire”
• Bureaucratic system
• Problems related to the legislation in the
Russian penitentiary system which can have a
negative impact on TB control
• Overcrowding and poor living conditions in
the prisons
• Protracted penal reform in the Russian
penitentiary system
• Lack of a well organized TB control program
in the civil system
• Lack of a link between the penitentiary and
civil TB control program
• Poorly functioning social system
Of course, treating MDR-TB with standard
short course chemotherapy using first line
antituberculous drugs may also lead to iatrogenic
worsening of the patterns of resistance of
individual patients. That is, the infecting strain is
exposed to brief courses of drugs which can not
kill the microbe but which can induce further
resistance, rendering even carefully designed
subsequent regimens less effective. This is called
amplification effect of short-course
chemotherapy. About 95% of the patients who
failed after a re-treatment DOTS regimen with
first line drugs (chronic cases) were MDR-TB
cases and were not included in the above
treatment.
In terms of measuring direct indicators of
success of a TB control program, the mortality
rate, which is one of the main indicators of TB
control program performance, still remains
below 5% or in the acceptable range according
to WHO. The cure rate, the other indicator of
performance of TB control, should be at least
85% in new smear positive cases. In this project
it has been possible to achieve on average a cure
rate of 65% in new smear positive cases. The
drug resistance rate is very high in re-treatment
cases compared to new cases and it is again
reflected in the treatment outcome by showing
an average cure rate of 50%. The average failure
rate for new sputum smear positive cases and retreatment positive cases is about 20% and 31%
respectively. Ideally it is expected to be around
5% or lower. The very high rate of treatment
failure is explained by very high drug resistance
rates both in new and re-treatment cases
included in the project. It also results in high
relapse rates.
The “snap-shot” versus the track record
Despite the development of the project with its
promising achievements it has encountered
different thorny challenges and problems at
different points of its evolution. The main ones
were the very poor political commitment from
the counterpart side and the biomedical problem
of MDR-TB. The poor political commitment,
which is primarily due to other political reasons,
is like an asphyxiated neonate born by caesarean
section in the middle of a major disaster. It does
not serve any noble purpose.
Some Russian authorities, particularly at the
different decision making levels in the still
centralized system, were deliberately and
Taking the very high drug resistance rate,
particularly the MDR-TB, into account, the
above mortality, cure and failure rates are by any
standard quite good achievements.
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stubbornly working against the project and its
approach. Just for the sake of politics they are
committed to and stubbornly defend the starkly
failed TB control approach. The same persons
perceive DOTS as an approach mainly for poor
countries. But, the DOTS strategy of this project
was not the classical DOTS, but was adjusted to
the context. I have mentioned it in the diagnosis,
treatment, follow-up, infection control and
laboratory parts. DOTS is also implemented in
some western countries. But there were also
many professional Russians who are concerned
about the disaster in their country, are open for
ideas coming from another part of the globe and
discussions, and who accepted the scientific
approaches of the project. This group includes
people with a vast experience from different
Russian teaching institutes and from our
immediate counter part. But, sad to say it, some
of them lost their job simply because they were
open and courageous to recognise scientific
realities and start "to call a spade a spade”.
One of the things the persons working against
the project were trying to show was the
inadequacy of the standard short course
regimens including for TB patients susceptible
to first-line anti-TB drugs. They even went to
the extent of incriminating it as the main cause
of the high MDR-TB rate and relapse rate in the
context. It sounds absurd! The disaster and the
epidemic started before the launching of the
project. The points forwarded by irresponsible
authorities as consequences of the new approach
were rather the main reasons to launch the
project. This is like bringing the horse behind
the cart. If what they claim is right, why only in
Russia? Why not in other corners of the world?
This is also naked reality in other states of the
former Soviet Union.
The studies they used to prove their claim were
done by clinicians with no epidemiology
background. More over, the studies did not
fulfill the requirements of a standard
epidemiological study like appropriate sampling
methods and size, controlling confounding
factors and using appropriate statistical tests to
show the strength of the associations etc. I
remember I had to confront them in one of their
workshops on which they tried to present their
studies with such kind of questions and other
factors which can give you misleading results,
expecting the topic would lead to hot
professional debate which would serve noble
purposes or enhance professionalism. But, the
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responses I got were simply yes, you are right, it
can be, etc. This is simply failure to defend what
you are saying or failure to substantiate or put
evidence for what you are talking about. Of
course, they do not have any evidence! It is
simply to escape from responsibility or seeking
an escape goat for one’s failure.
A study was conducted in the project in
collaboration with the mycobacteriology unit of
ITM using DST and DNA-fingerprint profiles
from successive Mycobacterium tuberculosis isolates
obtained from a cohort of 234 patients to
determine the incidence of re-infection while on
treatment and drug resistance amplification after
standard short-course chemotherapy (SCC).
Cultures were performed before starting
treatment and 3 and 8 months after starting the
treatment. The study evidenced an excellent cure
rate for patients initially infected with a
susceptible strain or a strain showing mono-or
dual-resistance different from MDR, receiving
supervised Category II treatment. Furthermore,
this study clearly evidenced the short coming of
SCC in an over-crowded prison population with
high prevalence of drug-resistance: (1)
exogenous re-infection with multi- or poly-drug
resistant strains occurred during treatment, (2)
resistance amplification was demonstrated, and
(3) MDR disease persisted despite treatment.
Studies like the above one supported by DNAfingerprint profile or RFLP (restrictive fragment
linked polymorphism) could settle the dilemma
of relapse and re-infection. Moreover, without
genetic microbiology tests like the mentioned
ones, prisons with an extremely high prevalence
of TB, particularly-MDR-TB and an
environment which provides the optimal
conditions for transmission, like overcrowding,
poor ventilation, lack of sun light, can not be the
right place to assess the relapse or re-infection
rates. Other factors like the poor nutritional
condition of prisoners and HIV co-infection are
also associated with rapid progression to active
disease.
Even though the DOTS-plus project was not
officially launched, the authorities created in
parallel the so-called Russian “DOTS-plus” and
started treating patients with MDR-TB with their
own quality non-approved and incomplete
package of second line drugs. Even more
astonishing is the fact they started a program
without guidelines. The drugs are the last line of
defense against TB and its failure could cause
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7.
supra-drug resistance TB (drug resistance to
second line anti-TB drugs). Basic principles like
doing a DST (drug sensitivity test) before
selecting a treatment scheme were not respected.
Patients were put on simple blind treatment with
an incomplete package of drugs with non
existing patient follow up or link with the civil
system for prisoners released after starting the
treatment. We were strongly advocating,
including at MoH and other higher levels, to do
at least DST in the laboratory established and
fully supported by MSF before putting MDR-TB
patients on second line drugs. This is just to
avoid the creation of supra-drug resistant-TB
due to resistance amplification as a consequence
of incomplete combination of second line drugs,
as there is no real 3rd line defense against supraresistant-TB (TB resistant to second line or last
defense TB drugs). Acquiring supra-resistant-TB
is tantamount to death. What we feared and
advocated to avoid became reality within a short
time and our laboratory data revealed supraresistant TB for some of the main second line
anti-TB drugs.
Conclusion: on lesson learned
It is absolutely right that MSF got a very rich
experience in the field of TB control in Russia,
with its unusual context and high rate of drug
resistant TB. Very informative and scientific
documents were produced, based on this vast
practical experience. This definitely helps to train
competent human resources and to run TB
projects effectively in other places where needed.
It is also a basis for lobbying at different levels
including at international level.
The rigid and failed system of TB control
compounded by other epidemiological and
biomedical factors like MDR-TB, which is sky
rocketing, has complicated the TB control
activities of not only the specific context, but has
also become a threat for the global effort to
control TB. No need to debate or bet. The first
one is the sole reason for the second one. It is
not a sort of microbial El Nino. Efficient and
rational uses of resources now spend for the
futile effort to maintain the expensive system,
might at least contribute to avoid further
progress of the disaster if it does not totally avert
it.
On the eve of launching the long awaited WHO
Green Light Committee approved standard
DOTS-plus project which was also expected to
be the turning point for all our projects, the
Russian MoH at the eleventh hour made it
crystal clear: launching this project could only be
realized under the scrutiny of the new Russian
MDR-TB guideline which was published late.
This is like adding insult on injury. Some of the
internationally recommended second line antiTB drugs were not registered in Russia and we
were not allowed to use them. Here comes the
question to compromise or not on basic things
like guidelines, drugs and principles of treatment.
Compromising on these points is not only to be
irresponsible and to destroy the reputation of
MSF, but it is also to put the prisoners at greater
risk of another disaster, which is untreatable.
After all, getting MDR-TB or supra-resistant-TB
is not part of their sentence. This position
plunged the two parties in major disagreement
and unleashed subsequent problems, which put
the further collaboration at stake. To reach a
breakthrough we exhausted all our patience and
left no stone unturned. Different negotiations
took place at higher levels, both from MSF and
Russians side, which were not fruitful, and finally
MSF headquarter took the decision to close the
TB projects in Russia in the middle of
September 2003.
. 8.
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.
Political commitment is one of the five major
pillars of the WHO package TB control strategy
known as “DOTS” by its brand name. One
cannot imagine a better place than MSF projects
in Russia to prove that political commitment is
really the major pillar of DOTS. This broken
pillar has hindered all the potential to fight back
the great disaster and this could lead the
treatable epidemic to an untreatable one. Of
course one cannot conclude there is a total lack
of political commitment, since there is political
commitment. But, for an unrealistic and
irrational approach which does not consider
epidemiological or biomedical evidence. One can
also not put aside the neglected human right
dimension of the problem.
A failed system or non-regulated TB program by
itself is more dangerous than the TB bacilli. It is
a niche for flourishing of MDR-TB. This is a
well-established fact in today's Russia.
Prisons are not an isolated world, they are a subset of the social system as a whole. So, there is a
strong epidemiological link between the
penitentiary and civil system. The lack of
continuity and equivalence between civilian and
prison health services and how one is
influencing the success of the other, is one of
the most important lessons learned.
.
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.
. . . . .
TB, particularly MDR-TB in prisons, is a
significant public health problem and also a
peculiar modern human right challenge. So,
Russian prisons are places where one starts to
open his eyes and tries to see TB not only from
biomedical perspective, but also from
psychological, social, humanitarian and human
right dimensions. This is not just a simple
reflection. Realities on the ground oblige you to
do so. Facts convince you. Without exploring all
the above-mentioned dimensions one can't
realize his/her dream. But you may not have full
or direct control on each dimension. Multiple
dimensions need multiple actors.
DOTS alone could not be the reversing gear for
the disaster in a context with a high drug
resistance rate like ours. It should serve as a
corner stone to treat drug susceptible TB and
prevent further creation of drug resistant TB. Its
effectiveness depends on the existence of a wellmanaged DOTS-plus program. The more the
drug resistant TB is spreading, the less the effect
of DOTS will be. By the end of the day, having
only DOTS may simply mean removal of drugsensitive strains of M.tuberculosis, to leave behind
the more resistant strains. It should be backed by
the DOTS-plus, which uses second line, and
third line anti-TB drugs with DST based
individualized treatment schemes and longer
courses of treatment. The management should
also be adapted to the context.
It is high time to have an internationally well
concerted effort by influential groups including
WHO, human rights activists and others to pay
attention to the problem. Including advocacy,
lobbying, creating access to cheaper second line
drugs, promoting basic human rights, fighting
for an enhanced penal reform etc. The widely
used and deafening argument against MDR-TB
treatment labeling it as “not cost effective”,
should leave its place to sentences like “the right
to have the best and available treatment at a
certain point of time”. Other wise, costeffectiveness may simply mean postponing
problems to tomorrow when they will be of an
even higher magnitude. We may also reach to a
point to question if it is really fair to put human
life in terms of cost.
There should be a balance between justice and
public health. A more enhanced penal reform is
of vital importance. By doing so we will halt
ongoing transmission of the disease, and reduce
the risk of making detention tantamount to a
.
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sentence to tuberculosis. By doing so, we will at
least respond, at least, to the mandate of
protecting the public’s health.
In areas like Russia cost-effectiveness is not a
priority to pass your message. Even though, it is
not the purpose to present the detailed
economic analysis of the current Russia, there
are different indirect evidences and observations
witnessing that the economic situation is
reviving. The crisis situation just after the
“perestroika” or in the beginning of the nineties
has changed significantly. When we come back
to the context of TB, the addition of second line
anti-TB drugs, to first line anti-TB drugs by the
Russian TB program is a clear example. This is
not to argue that the current economic situation
and resource allocation could shoulder the old
system or fight back the new disaster-MDR-TB.
If it also implies other crucial components like
the quality of the drugs, the completeness of the
drug package, installment of the practically
needed infection control system, and the
fulfillment of basic microbiological principles of
treating MDR-TB. The rapidly changing
epidemiology of TB, particularly in prisons,
where it overlaps with HIV, is another challenge.
If the economic situation continues to improve
this way the critical point would be more of the
organisation of the system than lack of
resources. This strikes important questions in my
mind about the principle of MSF: is it treating
the needy people where resources are limited? or
correcting wrong systems?
Thanks for your patience,
Esayas Abay
(MDC 2001-2002)
E-mail: [email protected]
Note:
The contents of this paper are mainly taken from
documents I wrote for the project and from my
different power point presentations on different
workshops in Moscow. Different references are used
to have the background information on Russian TB
control and microbiological aspects of TB. Any
comment, suggestion, or question is welcome. Next
time I will comeback from another place with news
on TB, HIV and ARV.
. . . . . .
. . . . . .
9.
A MULTI-CENTRIC "IN VIVO" EFFICACY STUDY IN
SIERRA LEONE
Marlon Garcia
I resumed my ancient job with Médecins sans Frontières (MSF) in Paris last
September, at this time I was looking to develop more expertise related to my
MDC thesis subject: “Assessment of anti malarial drugs efficacy”. In OctoberNovember, MSF sent me to Sierra Leone (West Africa) to coordinate the
presentation of the final results of a multi-centric “in vivo” efficacy study (see
chapter 3) but also to lead the discussion with the MOH and advise the coordination teams concerning
the national protocol.
1. Country profile
Sierra Leone has a total population of over 5.2
million people with 45% aged below 15 years
(2001 estimate). This country has the lowest
Human Development Index with only 18%
female literacy rate and 45% male literacy rate.
The main religions are traditional African beliefs
(70 %), Muslim (25 %) and Christian (5%). The
complete dismantling of the public system, more
than 2 million of internal displaced people,
thousands of refugees and a precarious economy
are the consequences of more than ten years of
war. The “post conflict” period started in 2002
with a peace agreement and pacific presidential
and parliamentary elections. Obviously,
pacification and reconstruction are the priorities
for the current government,
nevertheless the scarcity of public
funds, well-trained public staff
120000
and the weakness in the
100000
application of the new
80000
governmental policies are
60000
delaying this process. The
40000
regional pacification remains
20000
fragile and Sierra Leone is still
0
under the surveillance of around
13,000 U.N. peacekeepers who
patrol the national boundaries,
the capital and the key towns in
the south.
infections (ARI) are the main causes of
morbidity and mortality. Malaria represents
37.4% of all causes of disease during the first
half of 2003 (MOH records) and the
transmission seems to be stable throughout the
year, with peaks at the beginning and at the end
of the rainy season (May –Nov). As illustrated in
the figure N°1, the epidemiological trend (based
on data collected by the MOH during the last
three years) shows two peaks, the first in March
and the second and higher one, starts in May
until the end of August. However, because the
health information system was seriously affected
by the war (less than 50% of health structures
are notifying regularly) this information has still
to be checked.
Fig 1: Malaria trends in Sierra Leone by year
J
F
M
2000
A
Ma
J
2001
Jl
A
S
2002
O
N
D
2003
source MOH
2. Health and Malaria Situation
3. The national protocol and its efficacy
(the evidence)
According to the World Health Organization
(WHO), this country ranks the lowest of the
191 countries assessed, with the poorest health
care system (based on overall health of the
population, and comparing access to health care
for rich and poor). The Infant Mortality Rate is
157 per 1,000 (the highest in the world).
Malaria, diarrhoea, cholera and acute respiratory
The first line treatment for uncomplicated
malaria in Sierra Leone is Chloroquine (CQ),
Sulphadoxine Pyrimethamine (S/P) and Quinine
(Q) are the second and third line. High
treatment failure rates to the first two drugs were
noticed in some sentinels sites in the past.
Quinine is stills effective but the seven days
regime seems to be a constraint for an adequate
. 10. . . . . . .
. . . . . .
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adherence. An “in vivo” study, conducted in
Matru Jong Hospital by MSF Belgium showed
62% of clinical failure at day 28 for CQ and a
12% (D14) and 21% (D28) for SP (Bachy 2001).
Amodiaquine (AQ), a potential alternative drug,
is also used by the population in Sierra Leone.
However, it is not included in the national
protocol and the evidence of its efficacy -in this
country- is sparse and subject to interpretations.
To resolve the lack of countrywide data, a multicentric “in vivo” efficacy study was conducted
during 2002-2003 in six districts of Sierra Leone
(see map below). This study supported by
different stakeholders (EPICENTRE/MSF/
MERLIN/CONCERN/ECHO) had three
study groups (CQ,SP and AQ) and received the
approval of MOH and WHO-AFRO.
According to the literature and recent WHO
recommendations, the way forward is the use of
a combination therapy (CT) employing two
effective drugs. Many CT are available, however
in order to obtain a better efficacy and avoid the
development of further resistance for the
accompanying drug, this CT should be an
Artemisinine Combination Therapy (ACT) (For
example: Artesunate + AQ).
Figure 3: Multi-centric “in vivo” efficacy study
results (source EPICENTRE)
At the end of my mission, the MOH and other
partners recognized the necessity to start the
process and reach consensus to update the
policy. The first step could be the presentation
of the results and alternatives, during a
conference where all the stakeholders will be
invited to participate. At the same time MSF
proposes to the MOH to conduct an
“implementation project”, where the cost
effectiveness and compliance of the combination
Artesunate +AQ could be tested.
The MOH is committed to organize this
conference and MSF will provide the necessary
support and advocacy, to ensure that the goal to
“provide prompt and effective treatment to all
malaria patients” in Sierra Leone will be reached.
The main conclusion according to the results
showed in the map, is the necessity to stop the
use of the first and second line drug. Both have
a treatment failure rate above 25%, which is the
threshold defined by WHO to stop immediately
the use of the tested drug. In some study sites,
the alternative study drug (AQ) showed a
treatment failure rate above 10% and according
to WHO, at this level its use in mono-therapy
has to be avoided (WHO/RBM 2003).
4. Recommendations and constraints
As is made clear by the results of the study, the
update of the national treatment protocol has
become a matter of great urgency. Most of the
malaria partners agree on this recommendation.
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This update has to follow a process of consensus
with the participation of all partners involved in
the malaria control in this country. However,
several factors are delaying the process:
1. The political will of policy makers to start
the process.
2. The costs involved in case of changes at
national scale. The costs do not only
correspond to the new drugs (ACT) but also
to the indirect costs allocated for training
staff and reaching an adequate health system
coverage.
3. Some of the news drugs aren’t registered in
the national essential drugs list or the
registration procedure takes a long time.
4. The economical interest, the contracts
between the national programs and their
suppliers to buy CQ during several years, the
local and regional commercial pressure and
the question on what to do with the current
drugs stocks, are examples.
5. The difficulty to reach a consensus among
the involved partners in a post conflict
country is also an enormous challenge.
Marlon Garcia
(MCM 2002-2003)
E-mail: [email protected]
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. 11.
KALA AZAR IN SUDAN
Nuha Hamid
In the Sudan, visceral leishmaniasis (Kala azar) has been reported since 1904
(Neave). The main endemic area is in the eastern part of the country and stretches
from the western bank of the White Nile to the Sudan-Ethiopian border in the
east and in north from the reaches of Atbara River to an area around Malakal and
Sobat River in Upper Nile State in the south.
Upper Nile state is one of the major endemic states of kala-azar in Sudan, with 13% (9556) of the reported
kala-azar cases of last year.
The Federal MOH received a call from the WHO office in Khartoum on 29 December, with the message
that MSF-Holland reported an increased load of kala-azar patients coming from Olang area and nearby
villages around the Sobat corridor.
MSF-H accounted that on 30 December a team was sent to the area to investigate the possible epidemic
and open a treatment centre at Olang. After this call, the leishmania control program and epidemiology
department decided to send a team in collaboration with WHO to investigate the presence of an outbreak.
From the literature we know a serious outbreak of VL among the displaced people from the Western
Upper Nile has been reported in the Khartoum area, during the period 1986-1995. An estimated 100,000
people out of a population of 300,000 died of the disease in a relatively small area in Western Upper Nile
Province in Southern Sudan.
Methodology:
The prospect of peace in Sudan in the coming
months would potentially be associated with
movement of the community from the IDP
camps to the Southern area of Sudan, some of
which are endemic for visceral leischmaniasis,
thus creating a potential risk for epidemics.
. 12. . . . . . .
ec
D
ov
N
ct
O
Se
pt
us
t
Au
g
Ju
ly
ne
Ju
M
ay
Ap
ril
M
ar
ch
No. deaths
Collection of the information was done as follows (* acronyms at the end):
• Meetings and interviews with
key informant person at State
Distribution of kala-azar deaths by months for the years
MOH
2001 / 2002 / 2003, Malakal, Upper Nile state
• Reports from State MOH
18
and MSF-H
2001
16
• Interview of doctors in
2002
14
Malakal Hospital (Central
2003
12
hospital)
10
• Patients records
8
• Interviews with MSF6
Holland teams (Malakal,
4
Adong and Olang)
2
• Interviews with patients
0
(Malakal and Olang)
• LST survey as an
epidemiological tool,
collection of DAT and LNA
Months
for suspected cases
• Community meetings with community leaders in villages
Olang is situated in the Sobat corridor, at 176
km from Malakal, and has a population of 3,000
people. The ecology is so similar to Gedaref
state, where you can see a cracked black cotton
soil, and a vegetation with Acacia seyal and
Balanites aegyptica.
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.
% distribution of kala-azar cases/state year 2003
Upper
Nile
13%
Unity Others
4% 2%
Sennar
5%
Gedaref
76%
There is a non-functioning dispensary, that for
the time being is closed because there is no
health worker available to run it. MSF-Holland
opened a clinic in the guesthouse. They
succeeded to set up a small lab, which is able to
do microscopy for parasitological diagnosis
(Malaria and kala-azar) and can determine
hemoglobine levels.
The perception of the community on the
outbreak is very clear. During discussions with
the patients they always mentioned one of their
family members or neighbours were treated
either in Malakal or Bim Bim centre during the
last months. This confirms that this year there is
a real increase in the number of patients, which
needs further explanation.
We noticed an absence of prevention methods
and the knowledge about the disease is limited.
* Acronyms
VL: Visceral Leishmaniasis
LST: Leishmanin Skin Test
DAT: Direct Agglutination Test
Recommendation after the visit
According to my opinion, at the time being there
is no severe epidemic, most probably it is a
normal seasonal peak. As you know the
transmission is during summer (March-May) and
the cases start in winter (Oct-Dec). The real
problem is the complete absence of health
facilities, trained health workers and drugs. So
there is a great need to open a health centre and
to assure regular drug supply.
When we discussed this with the population, the
commissioner was ready to provide a space and
to build a centre with local materials. The role
of the state MOH is to provide them with staff,
and the responsibility of the program is to train
them. The drug supply will come from different
sources like WHO, MSF-H and other NGOs
who are interested to work in this area. Currently
there is no problem with kala-azar treatment.
Secondly, as I mentioned, the population is not
aware of prevention methods. For this
population LLITNs can be of great help. The
estimated number needed for the whole locality
is 7,000.
For the diagnosis I recommend to use either
parasitology or DAT but it should link with LST.
As I can conclude from the survey, the adult
population is strongly positive for LST which
indicates their level of immunity. The DAT
result will give us more information.
Nuha Hamid
(MDC 2001-2002)
E-mail: [email protected]
LNA: Lymph Node Aspiration
IDP: Internally Displaced People
LLITNs: Long Lasting Insecticide Treated Nets
The MDC Alumni Newsletter redaction team welcomes contributions in English and French on issues
deemed relevant for MDC alumni. There are no stringent requirements regarding format or length.
We favour short contributions, even informal ones. Longer contributions can also be accepted, but
should then answer to higher standards of scientific writing. We have no objection that materials have
been published elsewhere. You can send your contribution by mail, by fax or by e-mail. A computer
file in Word facilitates our work. We reserve the right to edit and shorten the text of your
contributions, especially when they contain lengthy presentations of the context or general
introductions.
The redaction team also welcomes suggestions for copies of articles to be included in the Newsletter –
especially when written by MDC alumni.
Address: Yvette Baeten, Institute of Tropical Medicine, Nationalestraat 155, B-2000 Antwerp,
Belgium; Fax: 32-3-2476333; E-mail: [email protected]
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. 13.
A LOGICAL FRAMEWORK APPROACH FOR
CONFLICT RESOLUTION?
Joseph Kemmegne
The 2002/2003 MDC curriculum put emphasis on the utilization of practical
tools for analysing and developing health projects. Many examples of
applications of the logical framework to specific topics pertaining to
reproductive health and tropical diseases were presented. The program
manager or coordinator will certainly confront these problems but may also be
called upon by similar situations related to human resources management
yielding strong implications for the results of health projects. The highly complex nature of the
environment in which a project is carried out – reduction of malaria-related mortality or reduction of
maternal health – may require using one of the tools that have been taught to us in order to secure
favourable field conditions before the start of the project. A conflict between stakeholders involved in
project implementation is a recurrent problem, the management of this problem might benefit from a
Logical Framework approach.
Four regions (called dioceses in the catholic
church jargon) of the Eastern province of
Cameroon have received financial support from
Cordaid (a Dutch international organization) and
Catholic Relief Service “CRS” (a US
international organization) for the
implementation of two separate projects:
1)Reorientation of Primary Health Care and
2)Tackling HIV/AIDS. These projects were
respectively managed by four Diocese Health
Coordinators and four Diocese HIV/AIDS
coordinators, meaning two coordinators per
diocese. However, from the hierarchical point of
view, the former act as the supervisors of the
latter although this arrangement has not been
taken into account during project formulation.
The Eastern province of Cameroon is one of the
country’s poorest and its socio-economic and
health indicators have been among the worst in
the country. The support of the abovementioned organizations was aimed at
strengthening the capacity of catholic health care
structures (27 integrated health centers, 1
hospital, and a specialized center for leprosy and
tuberculosis) to ensure partial health coverage in
this utterly secluded region. Midterm evaluations
have highlighted intrinsic deficiencies and
inadequacies of the projects and suggested their
termination. These evaluations also
recommended the formulation and
implementation of a new Reorientation of
Primary Health Care project in which
HIV/AIDS interventions would be integrated in
order to guarantee better success when
compared to the mitigated results of the two
initial projects.
. 14. . . . . . .
.
Shortly after my return from Antwerp I was
recruited as Health Project Manager
(HPM) by the CRS office coordinating activities
in Cameroon, Chad, Republic of Central Africa,
and Equatorial Guinea . I was given the
responsibility for writing the new project,
implementing it and mostly for securing a
positive outcome. A situational analysis
performed prior to the formulation of the new
project has shown that conflicts between the
main actors involved in implementation were
among the major problems the Reo-PHC and
HIV/AIDS projects had to face. Addressing this
conflict issue became a priority for the new
HPM. But first there was a need for
understanding the problem through
identification of its underlying causes before
proposing solutions that could eventually be
monitored throughout the new project’s
implementation process. The question was to
figure out how to do so. The Logical Framework
approach appeared to be appealing in addressing
this issue. Hence, the HPM invited the different
parties concerned to a conciliatory workshop
during which a problem tree/diagram and
objectives were developed.
Participants were separated in two groups (one
for the health coordinators, the other for the
HIV/AIDS coordinators) in order to avoid that
some would not be able to speak freely in the
presence of their superiors. In each group a tree
was drawn on flipchart (visual representation of
reality). At the level of the stem, the central
problem of conflict was mentioned. The
underlying causes of the problem were drawn
from a series of questions (Why?, What explains
this? etc) and placed between the roots of the
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tree. Then questions such as: What is
happening?, What are the consequences of this?,
allowed to identify the cause/effect relations
appearing at the branches. During the plenary
session the mentioned causes were placed and
sorted on the problem diagram highlighting the
cause and effect relations between factors that
contributed to the conflict between the parties
involved. The content of the problem diagram
was then transformed into a diagram of
objectives showing the relations between “
means and ends”.
Lessons were learnt from this exercise which
lasted just under four hours. In little time the
program manager was able to get a broader and
more detailed view of the problem, its causes
and implications. The actors themselves
identified solutions deemed relevant in
addressing the problem ( objectives and actions
to be conducted ). This could guarantee the
success of the application of actions foreseen.
One could already feel the change in attitude of
those involved. The relative anxiety of the
participants at the beginning of the exercise gave
way to smiles and a more relaxed demeanour at
the end: a sign of hope that something has
changed or will change. Indeed we didn't
develop a logical framework specific to this
problem, but the project’s overall logical
framework integrates activities and intermediary
results in direct relation to the conflict. With
regard to this, several activities are foreseen such
as setting-up a system for monitoring and
reporting conflict situations, creating a
coordination committee that will meet three
times a year in order to address the issue of
conflict between the actors of the project.
Securing a favourable environment for the
implementation of a project can be as important
as the project itself. Coordinating a project also
implies keeping an eye on potential risks. The
question is to know if the logical framework was
appropriate in this case and to know if the new
project called REDSSEC “Redynamisation des
soins de santé à l’Est, Caméroun” (Revitalisation
of health care in the East, Cameroon) won't be
confronted to similar conflicts. We will know in
15 months upon completion of the midterm
evaluation.
Joseph Kemmegne
(MCM 2002-2003)
Email: [email protected]
. . . . . . . . . . . . . . . . .
MDC 0304 News
Marjan Pirard
December
When the previous Newsletter was in press, MDC participants had 3 tests and a data analysis exercise
ahead. “How to deal with stress” was the issue. After 2 weeks of suffering (would this reduce their
QALY’s?) the next issue was: “How to get rid of your stress”. It was party time: MDC participants
showed their managerial capacities by
organising a party on 24 hours notice. Next
day the co-ordination team surprised them
with a “real” lunch: the “not-so-wellappreciated-sandwiches” on the menu were
replaced by Chinese food. In the evening Bart
Criel’s volleyball club in Bazel welcomed a bus
full of ICHD and MDC participants. To
celebrate Christmas, the student service
organised a dinner in style. We tried out some
Belgian specialities in the Grand Café Leroy.
Odrie Ziro from Zimbabwe broke with the
traditions: for the first time we had a female
speech. Makorokoto(*) Odrie!
(*) Congratulations in Shona
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. 15.
January
Back to reality after the Christmas holidays. We
started the first term with applied epidemiology.
Marleen made an appeal to switch from the
theory of the textbooks to our own field
experience. So Marjan shared her experience
with setting up surveillance systems and
organising surveys in Santa Cruz, Bolivia. We
worked out a new format for the field visit:
Students visited Belgian surveillance sites at data
collection and data analysis level and
presented an evaluation report before
an expert panel. Something to be
repeated.
Then we moved on to more technical
issues: Katja Polman introduced the
method of linear regression and
Annette Erhart explained the
principles of a Meta analysis. Both belong to the
parasitology department, we are indeed an
interdepartmental course.
We ended the month with a session on critical
appraisal of systematic reviews. An excellent
lecturer from CEBAM, the Belgian Centre of
Evidence Based Medicine managed to put things
into perspective by illustrating the difference
between statistical significance and clinical (or
public health) relevance.
During a 1 day Workshop on Hepatitis B
students had the opportunity to listen to the
results of collaboration between researchers and
vaccination programme managers in 2 countries
(South Africa and Belgium) facing different
epidemiological contexts. They were also invited
on the World TB day Commemorative
Workshop which also focused on the same
countries but widened the scope to social
science.
It was a good introduction to Qualitative
Research, which was explored by Pieter Remes
who was flown in from Chicago.
With Anne Buvé we then focused on ethical
issues in Research: the Helsinki Declaration and
a few controversial studies provided food for
thought and debate. Later Umberto
D’Alessandro took over to give hints for
research proposal development. He also
prepared some fake protocols for critical
analysis. Ward Schrooten from the department
of clinical sciences worked out the new module
on survival analysis. We hope students won’t
skip any longer the methods section in articles
using Kaplan-Meier or Cox Regression
In between all these demanding activities MDC
students gathered with their ICHD colleagues
for their joint venture: the Vertical Analysis. A
group of interested staff members had some
preliminary meetings to review the modalities of
this exercise in order to improve the quality of
its process and outcome. Students proved this
“old recipe” works when the conditions are
favourable.
At the end of the second term, we thought
participants were armed to discuss policy issues.
Wim Van Damme worked out an interactive
programme with the help of Govert Van
Heusden and Marjan Pirard. It is indeed possible
to build your theory on the wealth of
experiences that the participants harbour.
February - March
February 2nd 9 o’clock sharp: the course on
logistic regression starts. Students felt a bit
uneasy with a new teacher from the LSTMH and
a frightening subject, but Matthias Borchert
masters his subject and his public with the help
of the ‘Random Student Identifier’. After a week
the participants gained in self-confidence and
Matthias was sent home with a kiss and Belgian
chocolate.
The next 2 weeks the floor was for Vincent De
Brouwere and his guest speakers Jan Coenen
and Yvette Jacob in the module “Programme
Management and Evaluation”. Students were
guided through stakeholder analysis, problem
trees, strategy papers, log frames, budgets and
evaluation indicators. Mado Keja from
Cameroon prepared a case study to heat the
debate on supervision of vertical programmes in
the context of horizontal services. As
programme managers also have to deal with
researchers and politicians Evidence Based
Medicine as well as advocacy were on the agenda
and links were made with the Research and
Health Policy module.
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Marianne Pirard
E-mail: [email protected]
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NEWS FROM THE OPTIONS
& SHORT COURSES
Marjan Pirard and Thérèse Delvaux
April – June 2004
The third term started as usual with 2 options
for MDC: Tropical Diseases (TD) or
Reproductive Health (RH) and the Short courses
in Planning and Management of TD or RH
programmes. Fifteen new students from a good
mix of African, Asian and Latin-American
countries joined our 19 MDC participants and
after 1 week they seemed well integrated.
HIV module
Marie Laga tried to match the coherence of the
programme with the availability of lecturers. We
went over prevention, care, programme
management and policy issues. We discussed
with microbiologists, epidemiologists, clinicians,
public health physicians, drug management,
blood bank or condom specialists, big shots
from international organisations, grass root
people, bureaucrats, activists and last but not
least people living with HIV. We listened to
lectures, cried while watching a movie,
exchanged views with participants working in
very different settings, participated in heated
debates, were confronted with new ideas and
taboos, were touched by testimonies, made
presentations of logframes and tried to cope
with the daily dose of paper distributed.
After 3 weeks we gained a lot of knowledge but
we also gained 35 more activists for the fight
against AIDS. All regretted we had to split for
the rest of the course.
Tropical Diseases
Since we were the minority this year we moved
to Room X and from HIV we moved to another
disease of the big three: Malaria. Umberto
D’Alessandro and Marc Coosemans prepared a
challenging programme. Some names we read in
the scientific literature got a face: The veteran
Louis Molineux helped us to answer the
question whether insecticide treated bednets
reduce mortality, Bill Watkins frightened us with
the complexity of antimalarial drug resistance
and Pedro Alonso strengthened our hope that
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one day we will have a vaccine. Marc and
Umberto brought us back to the basics: vector
control and case management. Students then
tried to formulate a malaria control programme
adapted to the different settings in Uganda,
Vietnam and Peru.
We will Roll Back Malaria but also Stop TB.
Marie Laurence Lambert invited a good mix of
specialists from important organisations
involved in TB control as IUATLD, Damien
Foundation, WHO and ... ITM. A new name on
the programme was Peter Godfrey-Faussett.
Though his topic was complex, his message was
clear: fingerprinting is exciting but we shouldn’t
turn our head and forget the basics in TB
control. The backbone of the module was the
case study on TB control in Gokwe district in
Zimbabwe prepared by Ludwig Apers. Three
Zimbabweans were invited to check the
feasibility of the LogFrames students made. We
could also build on the experience of
participants: Bhatta Narendra analysed the
factors contributing to non adherence in Nepal,
Marthe Frieden brought us to the management
of TB in malnourished children in the Somali
region in Ethiopia, Lely Solari presented a
scoring system as a way to prevent nosocomial
transmission and we ended with Miguel Angel
Lazo and the success story of TB control in
Cuba. Their challenge is now elimination!
The Tropical Disease Option is not only about
HIV, malaria and TB. We also try to put
neglected diseases on the forefront. Pascal
Lutumba and Jo Robays confronted the students
with a deadly disease with a deadly treatment.
The dilemmas in trypanosomiasis control are not
easy to handle. From ‘active’ case detection we
moved to ‘passive’ case management of
leishmaniasis. The module brought the state of
the art on diagnosis, treatment and vector
control with Marleen Boelaert, Veerle Van
Lerberghe and Wim Van Bortel and then it was
up to the students to propose a strategy for
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Sudan in each of these three fields. Khalid Abdel
Rahman shared his difficulties in the discussions
with the administration in the MOH and the
academic world. We have to be prepared for real
life.
first week. Her intervention ended up with
watching the now famous movie ‘Amah Djah
Foule’. The complex topic of cervical cancer was
comprehensively addressed by Patricia Claeys
form ICRH in Gent and we finished the week at
the Library looking at the RH numerous sources
of information and sites on internet. Then, our
colleague François Crabbé, who is now a ‘used’
guest teacher of the short course, came from
Cambodia to share his experience on the 100%
condom use programmes, sex workers, policies
and strategies, management, monitoring and
evaluation of STI programmes. We had to
design a logical framework (from a simple
example) but it was a good preparation for the
final exercise! Professor A. Meheus was of
course this year again aboard to speak about STI
surveillance.
As an intermezzo we tackled technical issues.
Nathalie Obsomer explained us about the
possible applications of Geographical
Information Systems, Jean Claude Dujardin did
the same for PCR and Philippe Gillet asked our
attention for the potential and the drawbacks of
laboratories in disease control.
Students were then asked to look into the
specificity of programmes that have elimination
or eradication as an objective. Francisco Rio
presented the case of filariasis and
dracunculiasis. In exercise students had to
practice their advocacy skills to convince their
authorities about the importance of these
forgotten diseases. As always Dirk Engels
brought a comprehensive overview of the
problem of schistosomiasis and soil-transmitted
helminthiasis. He ended with a plea for a more
integrated approach to the control of ‘neglected
diseases’. The participants will certainly take this
message home.
Then we moved to the Family Planning module.
Regarding contraceptive technology, we stayed
within the family, since it is now being taught by
Marcel Vekemans’sister in law (!) Dr Anne
Verougstraete. For your information,
contraceptive patches and vaginal rings are now
available in Belgium. Then the public health
impact of unsafe abortion was discussed and we
watched the whole BBC reportage on ‘Sex in the
Holy City’ (some MDC participants had already
seen a part of it), which dealt with some aspects
of the sensitive issue of abortion and condom
use. Our short course participant, Tukur Jido
(both OB/GYN and teacher!) from Nigeria
made a interesting presentation about postabortion care in Kano State. Prof Jean-Jacques
Amy from Free University of Brussels took the
place of Fabienne Richard (almost on the way to
Burkina Faso, where she is going to work with
hear husband Bart) to bring forward the topic of
female genital mutilations. Dr Halida Akhter,
working for more than 20 years in the field of
FP in Bangladesh, could, during one day, explain
the success story of the FP programme in
Bangladesh and share with us her extensive
experience. Finally, our winning team, Isolde and
D. Beghin, gave the last but not least touch of
our FP module with their evaluation exercise.
MDC and Short Course students are now ready
to formulate their own intervention project with
some guidance of South Research. We all look
forward to the final poster session and are eager
to know who will win the prize from the public!
Reproductive Health
For those who were not present, last year HIV
and STI modules had been merged in one big
HIV/STI module with two parts: one common
part (three weeks together with the Tropical
Disease option) where some aspects of STI such
as case management/syndromic approach were
included. The second part (two weeks, following
the common part), addressed more specific
issues on HIV/STI and also management,
monitoring and evaluation of STI/HIV
programmes. In order to cover during the three
‘common’ weeks the issues of management and
evaluation of HIV programmes, which were
thought to be crucial within our planning and
management course, it was decided this year to
go back to the ‘old’ format.
Therefore, after the three ‘common’ weeks on
HIV, we started with the STI module. A great
deal of experience from the field was brought to
ITM this year! Bea Vuylsteke came especially
from Abidjan to spend time with us during the
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Oh! Carine (Ronsmans) you are here!
Time to already start our last weeks and the
maternal health module! We spoke of course
with Carine and Vincent (De Brouwere) how
difficult it is to measure maternal mortality. The
participants had to review the evidence about
strategies how to decrease maternal mortality
(Dear Health Minister, do you remember?).
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This year, a formal synthesis on antenatal care
and skilled attendants was presented and Patrick
Kolsteren (ITM) gave a synthesis on nutrients
during pregnancy and a great presentation on
breastfeeding in the context of PMTCT.
During the second week, Charles
Vangeenderhuyzen from ULB, explained his
experience with a flat fee scheme in Mauritania
and we discussed the important issue of ‘How to
pay for maternity care services’. Regarding
evidence-based medicine, we learn how to work
with the RH Library number 7 (2004) that just
came out. The highlight of the week was also a
presentation on the Indonesian model to reduce
maternal mortality by two participants of the
short course, Yayuk Hartriyanti and Prastowo
Nugroho.
One big step still needs to be achieved: the final
exercise on formulation of an individual
intervention project. We are looking for the
reception on the last day!
We finally got a room in the basement that fits to have
our coffeebreaks.
We already celebrated Marianne's birthday in it !
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WORDS CAN SAVE LIVES
Marthe Frieden, for the MDC group who opted for Tropical Diseases and the
International Course on Planning and Management of Tropical Disease
Control Programmes
I love words, because words can save lives.
Take for example homoscedasticity ! Those days
that laid the foundation to this course, when my
brains hit their limits with linear and logistic
regression, “homoscedasticity” saved my life. Like
a safety valve in a pressure cooker it prevented
my grey matter from flying off. And Kussito
from Ethiopia was “quite very” happy to add a
new English word to his already exhaustive
vocabulary.
Some words changed our lives. See, nothing
would have been the same without discomatanga. It would stimulate fantasy and let the
music play. Even Dennis from Cuba would
agree that this is the real community
participation.
Yes, some words are just like music, a refreshing
sound in demanding times. Take the new antimalaria drug Lapdap-lapdap-lapdap-lapdap.
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Denise, doesn’t that sound like a tam-tam in the
hills of Rwanda?
Other words help to kick off the memory. How
could I ever have remembered the name of
Doni from Indonesia, hadn’t there been the
CD4 dynabeads ? Look it is as simple as that:
dynabeasts, dynosaures, dynos, Doni!
Some words made me emotional. So I fell in
love with spoligotyping of MTB isolates. It has a
soft reassuring sound, but beware, just like
Steven Spielbergs gremlins it is hiding
complexity. Type for example spoligo and you
may end up printing fingers, or like Win Oo from
Myanmar said “footprints”.
Certain words, still, are more obscure, they lack
magnificence, and only stand out because of
their heaviness; is a geometric mean a weighted
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average of building blocks, milestones,
steppingstones and stumbling steps ? Only our
economist, Alberto from Cuba would know!
Other words are more appropriate for a rhyme:
Lamivudine, Zidovudine, Zinedin. Is Khalid
from Sudan watching football late at night or are
his daughter’s plays the cause of his delays? Do
you know what, in Sudan, you name it, they have
it… even a peace agreement!
But words can also lead to endless sentences; so
when listening to our respected teachers became
hardship and suffering, then my thoughts would
swiftly balance from paradigms to zymodemes
(help, I can’t remember where I got it from, this
word); one can wonder why they trigger off
fantasies of paradise and diadems; which princess
is waiting for Charles in Uganda’s green malaria
endemic plains?
Very refreshing, the sound of Aniq’s voice from
Bangladesh. If only the teacher would give her
time to formulate her questions! How
frustrating, these never spoken words ! May be
she should start using abbreviations, acronyms,
like TRYPS, or DOTS or even shorter, DOT.
And mind you, there is a difference. By the way,
do you know DQT? Obviously this is Dang
Quang Tan from Vietnam!
These last days, my favourite word was
dracunculus. Ask Leli from Peru to pronounce
“dracuncula”. She will stretch it in the middle like
a chewing gum and it will sound so lovely. But
don’t expect the same from Miguel Angel from
Cuba, for he will swallow the middle and it will
sound like “Dracula”.
And finally there is this word that echoes
knowledge and clairvoyance, that I will cherish
like a treasure, the word that carries science and
therefore the power to save lives. And Michael
Woubishet from Ethiopia is the winner, because
he ran 20 km and this was printed in the local
newspaper, Le Soir. This is what we call
EVIDENCE.
Words can be stretched, words can be
swallowed, and words can also be lost, like TB
patients; but we did not loose one of the words
of wisdom of Bhatta from Nepal.
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TRAINING COMMUNICABLE DISEASE CONTROL
PROGRAMME MANAGERS IN INDONESIA
Yodi Mahendradhata
Dear colleagues – the previous issue of the MDC newsletter reached me in the
most appropriate time, I was in the middle of organising a short course on
“Managing communicable disease control programmes in a decentralised health
system”.
That topic might sound familiar – yes, it’s very
similar to the MDC short course on planning
and management of tropical disease control.
This particular course was organised jointly by
the Center of Health Service Management and
the Field Epidemiology Training Programme of
Gadjah Mada University, Indonesia. The course
in previous years has been organised as one of
the modules in our master programme in field
epidemiology. The former version however was
very much management oriented and has only a
minimal flavour of communicable disease
control. Upon my return from Antwerp, our
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administrators asked me to take over the course
and redesign it to meet the needs of the
programme managers in the field who now have
to take up more management responsibilities
under the newly decentralised system. My main
reference for revising the course was none other
than the MDC short course.
Our newly designed course was conducted
within a one week timeframe consisting of five
modules: (1) Strategic global issues in disease
control; (2) Health system decentralisation and
disease control; (3) Principles of strategic
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management and operations management; (4)
Planning and budgeting; and (5) Advocacy for
disease control. Only one week was allowed for
the course due to the credit limit allocated by the
current master training programme.
We had 38 participants for this first run, of
which 15 were regular master students. Most of
the participants were disease control programme
managers at district and provincial level, while
the remaining are researchers, health care
practitioners and one fresh medical graduate.
The student body represented virtually all parts
of Indonesia from West to East, North to
South. Our country consists of 13 667 islands
with a population of more than 200 million
spread over an area the same length as the
United States. So for us being able to attract
people from all over the country was quite an
achievement. The teaching staff included one
WHO medical officer, the Secretary of the CDC
Directorate General, a MSF Belgium medical
officer, and our own teaching staff team,
including yours truly. One of the sessions I had
to deliver was on integration and disease control,
an issue which I got to learn a lot during my
programme in Antwerp.
Feedbacks from the participants suggested that
they were satisfied with the overall programme
and thought most of the subjects discussed were
relevant to their work. The main criticism was
that the course was still too "academic", thus
requiring more revisions to make things more
practical, perhaps by involving more
practitioners as resource persons. Obviously also
the one week timeframe (a far cry from the 10weeks timeframe of the MDC short course) was
severely limiting. The course was somewhat
more of an appetizer, a bowl of mixed salad
served to expose the participants to various
elements of programme management. We’re
now trying to negotiate for a longer time frame
for next year’s course.
Evidently, the real test to the course would be to
what extend it helps our trainees in doing their
work in the field. We are certainly keen to get
feedbacks from our course alumni in due course.
The MDC will also continue to be our
benchmark, our gold standard for disease
control programme management training. In
relation to this, we are very much fortunate to
have the able support of Marleen, Patrick and
other colleagues at ITM in the coming years for
strengthening our capacity through the
European Commission – Asia Link project.
We are looking forward to share with you more
about our course as it grows. Who knows, one
of these days we may have the pleasure to invite
you to our archipelago to share your experience
and expertise in disease control!
Yodi
(MDC 2001-2002)
E-mail: [email protected]
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REPORT ON THE MCM-MscBT AND RIPROSAT
NETWORKS’ COLLOQUIUM ON
“TACKLING ZOONOSES AND ANIMAL PROTEIN DEFICIENCY FOR
DEVELOPMENT IN THE DEMOCRATIC REPUBLIC OF CONGO”
January 22 – 24, 2004, Kinshasa
1. Context of the colloquium
This colloquium was jointly organised by two
networks of Congolese graduates from the
“Master of Science in Disease Control” (MDCMscBT) and “Master of Science in Tropical
Animal Health” (RIPROSAT) courses of the
Prince Leopold Institute of Tropical Medicine in
Antwerp, Belgium. It took place in Kinshasa
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fom January 22 to January 24 under the auspices
of the Belgian Cooperation (DGDC) through
the supervision of ITM.
2. Objectives of the gathering
The forum’s objectives are as follows:
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• To reflect on the incidence of zoonoses and
their impact on public health and national
development.
• To reduce animal protein deficiency in
nutrition and to advocate means to increase
production and consumption within the
country.
• To determine common topics of interest in
order to reinforce collaboration among
different groups of ITM alumni ( medical
practitioners, veterinarians, zoo-technicians,
agronomists, and biologists)
• To provide the different groups with an
opportunity to broaden their horizons.
the audience on the fact that the reemergence of
previously controlled zoonoses and malnutrition
are indications of environmental degradation
and show the incapacity of the Congolese people
to effectively utilise available animal resources.
She recommended that appropriate studies be
conducted with the purpose of suppressing these
diseases and rationally exploiting animal proteins
in order to contribute to the countries socioeconomic and health development. Finally there
was a wish for collaboration between disease
control and nutrition specialists with the
government in order to improve the current
situation.
The Minister of Health was represented by his
Fourth Directorate. The Minister of Agriculture,
Fishery, and Animal Husbandry could not attend
but his Secretary General, Dr. Hubert Ali
Ramazani, was fortunately present.
3. The Forum
The first day (January 22nd) presided alternately
by Dr. Molisho and Dr. Ebeja, began with three
opening speeches. First there was the president
of the colloquium’s organizing committee,
Professor J.M. Malekani. In his speech, he
insisted on defining the context of the event and
thanked ITM, Antwerp and the Belgian
Cooperation for making it possible. Then he
invited all participants to play an active role in
the colloquium activities. Finally he greeted the
presence of Ministers and other governmental
authorities who responded to the invitation.
Later there were eight presentations followed by
discussions. In the evening, a one-hour show on
a local radio station (Radio Canal CVV), to
inform the public on the importance of the
event, was animated by five participants and one
of the colloquium organisers. Among them were
a teacher, a zoo-technician, a medical doctor, a
biologist, and a journalist.
Afterwards, his Excellency Kamanda Wa
Kamanda, Minister of Scientific and Technical
Research intervened. In his speech he stressed
the importance of developing research in all
areas, especially in those of health, nutrition and
environment in order to pull the country out of
under-development. The recrudescence of
zoonoses such as sleeping sickness, the
emergence of new ones, the risks produced
when consumed meat is not inspected, the
chronic deficit of livestock production, and the
insufficient exploitation of natural food
resources are among the many issues that
research can help to address. The Minister
pleaded for diversification of food rations and
fortification with basic nutrients along with
implementation of mechanisms for better food
accessibility, as means to tackle malnutrition. He
wished that the results of this colloquium would
contribute to put the country back on the track
of development. Finally he declared the
colloquium officially open.
The second day (January 23) presided by Dr.
Mbaitwiralo and Dr. Ebeja, was marked by nine
presentations with discussions.
Professor Kiatoko was chairman on the third
day during which there were six presentations,
three poster visits and the closing session by
Professor Lumu B., representing the Minister of
Scientific and Technical Research in the
presence of the representative of the Ministry of
the Environment, Conservation of Nature,
Water and Forests.
In total, twenty three presentations were made
and followed by debate during the three days of
the colloquium. They started with three
introductions on “Human African
Trypanosomiasis and its consequences on
livestock production and public health”, “The
importance of animal proteins and the
consequences of their deficiency on human
nutrition” and “The situation of livestock
production in the country”. Among the twenty
remaining presentations, five focused on “the
recrudescence of zoonoses in the DRC”. Five
others were about “tuning-up of zoonosis
Counselor Mrs. Mbuyi Bilonda read the speech
of his Excellency Anselme Emerunga, Minister
of the Environment, Conservation of Nature,
Water and Forests. She attracted the attention of
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control techniques”. The following four
addressed “the possibilities of animal production
improvement in the DRC”. The final three had
to do with “the possibilities for improvement of
animal protein consumption in DRC”.
Additionally, three pieces of work were shown
as posters. They provided information on “the
contribution of the Lubumbashi University
farms in the fight against animal protein
deficiency in Lubumbashi”, “techniques of
cricetoma breeding” and the “physiology of their
reproduction”. All original works will be
published in the acts of the colloquium. The list
of presentations with the names of their authors
is given in annex.
Four members of the MCM-MscBT network
were absent from Kinshasa or the country while
the colloquium took place and were not able to
deliver their presentations. They were Doctors
Lukuka Kilauzi A., Mulumba Mbuyi A, Mayala
Mabasi G. et Lutumba P.
The colloquium gathered 41 participants at the
Protestant Conference Centre of
Kinshasa/Gombe with an average attendance of
30 persons daily. Among the participants, one
could find medical doctors, veterinarians, zootechnicians, agronomists, biologists,
nutritionists, university professors, researchers,
breeders and journalists. Two of them came
from the interior, one from Kananga and the
other from the Jules Van Lancker (JVK)
company of Kolo in Lower-Congo. Two
speakers from Lumumbashi only sent their
presentations.
About three weeks later (February 12 2004), a
second radio show was produced by a
multidisciplinary group of seven people who
took part in the colloquium in order to provide
more clarification and facts.
4. General Conclusions and
Recommendations
The following general conclusions were drawn
from the activities of the forum:
• The recrudescence of zoonoses in the
country is due to loosening of measures of
veterinary inspection and hygiene at slaughter
places, markets, sales points and border
posts.
• Trypanosomiasis presently thrives in the
DRC in rural areas as well as the urban ones.
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• Some zoonoses such as rabies, brucellosis,
and cysticercosis are present in the country
but their prevalence is unknown.
• The population is unaware of zoonoses in
their environment
• Zoonoses have adverse consequences,
especially the reduction of the population’s
life expectancy and productivity.
• The means to control zoonoses are not only
insufficient but obsolete
• Household food security is not secured due
to protein deficiency mainly resulting from
weak purchasing power.
• Livestock production is insufficient and
provides generally low-quality meat
• The deficit in animal protein’s in the country
leads to massive importation of meats that
are of less value and often inapropriate for
consumption. Therefore there is a loss of
hard currency and a threat to health.
• Animal protein deficiency in the population’s
nutrition has many consequences on health,
especially on the health of women and
children. Protein-calory malnutrition in the
form of Kwashiorkor is its most common
manifestation.
• Domestic animal husbandry is insufficiently
developed in DRC because of the high cost
of input and adaptation problems with some
of the species introduced.
• There are possibilities to create industrial
breeding capable of enhancing livestock
production in order to address local needs
and even exportation.
• There are numerous sources of insufficiently
exploited, let alone ignored local animal
proteins,
The following recommendations result from this
general assessment:
• Rehabilitate veterinary services and public
health facilities in order to allow better
control of zoonoses.
• Reestablish an exhaustive surveillance of
human African trypanosomiasis on three
axes: the reservoir, the vector, and the host
• Conduct appropriate complementary studies
in order to gain better knowledge of the
prevalence of existing zoonoses and the
identification of the new ones
• Establish a permanent information system
and campaigns to raise awareness and
dissemination with regard to zoonoses in the
country
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• Improve existing techniques and introduce
new ones through in-depth research
• Ensure continuing education and better
working conditions for technical and
scientific staff
• Devise policies and strategies that can favour
protein consumption in the households while
promoting the utilisation of local foods
• Inform the population of the risks of
infection related to the handling and
consumption of meat and unsafe food
products.
• Restore and re-enforce meat inspection at all
levels
• Disseminate the slaughter norms, especially
hygiene of staff, premises and materials.
• Revitalize zoo-technique research stations in
order to improve breeds of better performing
genitors
• Improve the exploitation of wild fauna in
order to increase livestock production
• Establish a credit system for breeders.
• Create training programmes and provide
multiple opportunities for scientific
gatherings (colloquia, seminars,..) in order to
facilitate exchanges and reflect on ways to
address socio-economic and health issues.
• Facilitate local animal production through
domestication of certain species such as
frogs, snails, etc…
• Encourage parcel breeding in order to
enhance household livestock production
• Establish nation-wide peace and sanction
looting and theft of livestock.
For everything remaining, a golden book was
open at the end of the colloquium in order to
collect impressions of the participants on the
activities. The majority of participants expressed
satisfaction about the exchanges made during
the event and formulated the wish that this
would not be the first nor the last but the
beginning of a long series. They very much
appreciated the multidisciplinary character of the
Colloquium. This allowed them to broaden their
way of thinking about the issues that were
presented. For instance, this was the first
opportunity for medical doctors to discuss with
veterinary doctors on ways to manage cases of
bites by rabies-stricken dogs. This event has
also allowed specialists from different
institutions to know each other and establish
friendly relations.
Moreover, it was the first time that the
RIPROSAT/DRC, mainly comprised of
veterinarians, zoo-technicians and biologists ever
organised an event of that magnitude and in
cooperation with another network, that of the
MCM-MscBT of the medical doctors. The
country’s specialists should stop working in
separate compartments if they mean to really
contribute to national development.
Finally, RIPROSAT/DRC was able to gather a
great number of its members for the first time at
the end of the colloquium. The situation of the
network was described by the current national
representative, Professor J.M. Malekani. He
announced that his mandate would be prolonged
until September when a new representative will
be elected. Presently Dr. Symphonien R.
Mbaitwiralo who was elected as deputy
representative is the second in charge of the
network. RIPROSAT/DRC expects to become
a developmental NGO in order to gain more
effectiveness in the country.
5. What has been acquired through the
works of the colloquium
The expected results have been reached. The
main zoonoses thriving in Kinshasa and other
parts of the country have been identified,
especially trypanosomiasis (sleeping sickness),
rabies, cysticercosis and brucellosis. The causes
and consequences of these diseases have been
pinpointed. The means advocated or
implemented in order to thwart the spread of
zoonoses have been discussed. The effects of
animal protein deficiency on human health and
development have been highlighted. There is
need to inform the population on the dangers of
contamination related handling or eating noninspected meat and dwelling in an unsanitary
environment.
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6. Acknowledgements
We thank the faculty of ITM, Antwerp in
Belgium, especially Director Bruno Gryseels,
and Reginald De Deken, Marjan Pirard, Thérèse
Delveaux, respectively responsible for
RIPROSAT, MCM and MDC for supervising
this colloquium. We also want to express our
most vivid gratitude towards the Belgian
Cooperation (DGDC} for sponsoring the event.
We are equally thankful to the Congolese
government that supported this scientific
initiative through the interventions of the
Ministers of Scientific and Technical Research,
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Conservation of Nature, Water and Forests and
the assiduous participation of the Secretary
General of the Ministry of Agriculture, Fishery
and Animal Husbandry during all three days of
the colloquium.
7. Composition of the organising committee
• Prof. Jean M. Malekani, Unikin, Tel.: +243
98720604, [email protected] : President
• Dr. Albert K. Lukuka, INRB, Tel.: +243
(0)815030841, [email protected] member
• Dr. Symphorien R. Mbaitwiralo, LABOVET and
cabinet of the Minister of Agriculture, Tel.: +243
(0)816993239, [email protected]: member
• Dr. Auguy K. Ebeja, THA & MSF-B, Tel.: +243
(0) 817302894, [email protected]:
member
• Dr. Didier Molisho, FOMETRO, Tel.: +243 (0)
98135971, [email protected]: member
Secretariate
• Mrs Scholastique K. Kyamundu, Chief of works,
UNIKIN, [email protected]: Administrative
secretary
• Prof. J.M. Malekani, Director of the scientifique
secretariate
8. “Cysticercosis”, SUMBU, J.
C. TUNING-UP OF TECHNIQUES TO FIGHT
ZOONOSIS
9. “In vivo breeding of Trypanosomas on
Grammomys in search for means to combat zoonotic
trypanosomiasis”, PYANA, P.
10. “Attractive power of olfactive substances for the
capture of tse-tse flies, Glossina fuscipens quanzensis in
Kinshasa”, LUAMBA, L.N.J., IYOMI, B.J. &
MANSINSA, D.P.
11. “Atrophy of Spiegel’s lobule of the liver in the
Mubinza farm, Occidental Kasai: arsenicism or
hepatic distomatosis?” TOLENGA, K.D.F. &
MALU-MALU, K.
12. “Introduction of the immuno-histochemical
method in the investigation of animal diseases
including zoonosis” MULUMBA, L.K.
13. “Epidemiological surveillance of animal wildlife”,
BOYZIBU, E.
D. FOOD SECURITY AND ZOONOSIS
14. “Animal proteins and household food security in
Kinshasa: current situation and future perspectives”,
BANEA, J.P. & WABO, N.V.
15. “Isolation and identification of entero-bacteriacae
in meat sold in some markets of Kinshasa”, MABI,
N.Z.J., SAMBA,N. & MASUNGI, K.G.
List of presentations
A. INTRODUCTORY PRESENTATIONS
1. Intoductory Presentation 1
16. “The facts of “grilling” as a risk of zoonosis for
humans”, MAKUMYAVIRA, A.M.
“Human African Tryanosomiasis and animal protein
deficiency in DRC”, SUMBU, J.
E. POSSIBILITIES FOR IMPROVEMENT OF ANIMAL
PRODUCTION IN DRC
2. Introductory Presentation 2
17. “Some aspects of the fight against animal protein
deficiency in the DRC”, MAFWILA, M.J.
“Importance of proteins and consequences of their
deficiency in human nutrition”, KATYA-KATYA,
M.
3. Introductory Presentation 3
“The situation of animal production in the DRC”,
KIATOKO, M.H.
B. RECRUDESCENCE OF ZOONOSIS IN THE DRC
4. “Sleeping sickness in the city of Kinshasa: a
retrospective analysis of the surveillance data for the
1996-2000 period and an update on sleeping sickness
in Isangi, Oriental province”, EBEJA, K.
5. “Bovine brucellosis in the DRC”,
MBAITWIRALO, R.S.
6. “Means to tackle the recrudescence of
trypanosomiasis in the city of Kinshasa”, MOLISHO,
S.D.
7. “The issue of rabies in the DRC”, MANWANA,
K.
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18. “Evolution of parcel breeding in some Kinshasa
neighbourhoods”, PAULUS, J.J.
19. “Influence of oestral behaviour on the fertility of
the female Cricetomys gambianus (Rodentia: Cricetidae)
in captivity”, MALEKANI, M. J.
20. “Contribution of the Jules Van Lancker (JVL)
company to national efforts to reduce animal protein
deficiency in the nutrition of the population of
DRC”, SHERIA, M.
F. POSSIBILITIES FOR IMPROVEMENT IN ANIMAL
PROTEIN CONSUMPTION IN DRC
21. “Raniculture as an eco-developmental alternative
to be experimented in DRC”, MBONZO, K.P.
22. “Ethno-zoological considerations on the
consumption and ecology of giant African snails in
the provinces of Bandundu and Bas-Congo”,
KEBOLO, B.
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23. “Utilization of Brachytrupes membranaceus Drur,
as a source of animal protein in DRC”, PUNGA, K.
3. “Oestrus occurance in captive female Cricetomys
Gambianus (Rodentia: Cricetidae)”, MALEKANI, M;
WESTLIN, L.M.: PAULUS, J.J. & POTGIETER,
H.C., 2002,257 (3): 295-305. Journal of zoology,
London
G. POSTERS
1. “Contribution of Lubumbashi University farms to
the fight against animal protein deficiency in
Lubumbashi”, MUTIMANWA, K.P.
Jean M. Malekani
President of the organising committee
National MCM-MscBT & RIPROSAT/DRC
e-mail: [email protected]
2. “Cricetomas: technical guidelines for animal
husbandry”, MUTIMANWA, K.P.
. . . . . . . . . . . . . . . . .
Brewing religion and medical science in the same pot:
the Vatican debacle
Esayas Abay
Religion has an influential role in many
communities that can be either constructive or
destructive, particularly for the vulnerable ones
who remain with the question whether to think
with their mind or with their heart, according to
philosophy of the ancient times.
I feel we found ourselves between hard and
rock. On one side the wildly spreading pandemic
on the other side an influential religious group
which can have a crucial role in the fight against
the pandemic, but is spreading a misleading
message which has a disastrous effect on the
effort to fight back the pandemic. This makes
the fight a double one.
We need to conceive an efficient system to raise
public awareness amongst both the public in
general, and the patients in particular. This issue
should not only be seen from its moral
dimension. Its legal dimension should be
considered as well.
I read an article titled “Sex
and the Holy city” and
published in the last
Alumni newsletter. I
found it not only mind boggling, but also
saddening. What is very astonishing is not only
the misleading and immoral message they are
preaching with its grave public health
implications. But, also the fact they try to put
illusive arguments to confront scientific
evidence.
Needless to say it, Vatican has a hard liner type
of position on condom use. Particularly when it
comes to condoms as means of contraception.
But, here it goes beyond using it as a means of
contraception, it is a means of saving people.
After all the whole ideology of religion isn't it
meant to be blessed, to save people and create a
better world? What we heard from the Vatican
is rather a paradox. Sorry to say it! It is
tantamount to an attempt to replace the current
generation with an HIV infected one.
Esayas Abay (MDC 2001-2002)
E-mail: [email protected]
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NEWS FROM OUR ALUMNI
• Recent Publications
—
Behets F, Andriamiadana J et al. Laboratory diagnosis of sexually transmitted infections in women with
genital discharge in Madagascar: implications for primary care. International Journal of STD & AIDS
2002; 13: 606-611.
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—
Buttiëns H, Marchal B, de Brouwere V. Skilled attendance at childbirth: let us go beyond the rethorics.
Trop Med Int Health 2004; 9: 653-654.
—
Filippi V, Brugha R, Browne E, Gohou V, Bacci A, de Brouwere V, Sahel A, Goufodji S, Alihonou E,
Ronsman K. Obstetric audit in resource-poor settings: lessons from a multi-country project auditing ‘near
miss’ obstetrical emergencies. Health Policy Plan 2004; 19: 57-66.
—
Galadanci HS, Mohammed AZ, Ochicha O, Jido TA, Uzoho CC. Genital Tract Cancers in Aminu Kano
Teaching Hospital. Tropical J Obstetric Gynecology 2003; 20
—
Jido TA, Otubu JAM. Malposition and Malpresentations: Textbook of Obstetrics and Gynecology.
Volume I, Agboola A (Ed), 2nd edition. University Services Publications, 2004.
—
Jido TA, Sadauki HM. Impact of Place of Delivery on Obstetrics Fistula. Trop J Obstetric Gynecology
2003; 20 (suppl.1)
—
Mobilités Internationales et VIH/SIDA en Algérie. Etude qualitative – Approche exploratoire de type
ethno-sociologique. Rapport Final. Décembre 2003 (M. Hammou)
—
Mony P, George KC, Chacko N. Computer use among postgraduates of a medical college in southern
India. National Medical Journal of India 2004; 17: 175-176.
—
Nagot N, Meda N, Ouangre A, Ouedraogo A, Yaro S, Sombié I, Defer MC, Barennes H, Van de Perre P.
Change of sexually transmitted infections ecology in Bobo-Dioulasso, Burkina Faso: what implications for
the syndromic approach and other HIV/STI control efforts. Sex Transm Inf 2004; 80: 124-129.
—
Rwagacondo CE, Niyitegela F, Sarushi J, Karema C, Mugisha V, Dujardin JC, Van den Enden J,
D’Alessandro U. Efficacy of amodiaquine alone and combined with sulfdoxine pyrimethamine and of
sulfadoxine pyrimethamine & sulfadoxine pyrimethamine combined with artesunate. Am J Trop Med Hyg
2003; 68: 743-747.
—
Sombié I, Cartoux M, Meda N, Tiendrébéogo S, Ouangré A, Yaro S, Ky-Zerbo O, Dao B, Fao P, Nébié Y,
Nacro B, Kpezohouen A, Van de Perre P, Mandelbrot L, Dabis F. Socio-demographic profile of HIV
infected pregnant women in Bobo-Dioulasso, Burkina Faso, 1995-1998. HIV AIDS Rev 2004; 3
—
Sombié I, Meda N, Van de Perre P, Ky-Zerbo O, Traoré A, Compaoré Issaka P, Del Campo P, Bidiga JA,
Huygens P, Ouangré A. Qualité des soins et acceptabilité des algorithmes de prise en charge des infections
sexuellement transmissibles au Burkina Faso. Revue Epid Santé Publ 2003; 51: 505-511.
—
Tudó G, González J, Obama R, Rodriguez JM, Franco JR, Espasa M, Simarro PP, Escaramis G, Ascaso C,
Garcia A, Jiménez de Anta MT. Study of resistance to anti-tuberculosis drugs in five districts of Equatorial
Guinea: rates, risk factors, genotyping of gene mutations and molecular epidemiology. Int J Tuberc Lung
Dis 2004; 8: 15-22.
If you like a copy of these publications, please contact Yvette at [email protected]
• Phd
Ludo Lavreys (MScBT 1992) defended his PhD thesis “Correlates for Human Immunodeficiency
Virus Type 1 Acquisition and Subsequent Disease Progression in Women” at Ghent University on
May 17th. Promotor was Prof. M. Temmerman. Members of the jury included Anne Buvé and Luc
Kestens.
•
From the field
— … I am fine and work runs smoothly. I am still working for MSF-B in Buhiga (Burundi), doing a
clinical job. Yet, I am implementing an HIV programme including the management of
opportunistic infections, VCT (voluntary counselling and testing) and PMTCT (prevention of
mother-to-child transmission). I visited the Khayelisha TB-HIV clinic (in a township in Cape
Town, South Africa) to see how this kind of programme runs. I am already finalizing the related
protocols and administrative documents in order to start with the programme very soon. My
contract is nearly finished, so my successor will have the heavy duty to ensure the ongoing
activities. Popol Lobo (MCM 2002-2003)
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. 27.
— … I'm now working in Indonesia on the Ambon Island (Mollucas). The official language is
Bahasa but some people also speak English, that is why you see I'm trying to improve my English.
I know it's not perfect but I hope to speak better at the end of my mission. The main task of my
job is to set up a TB project for MSF, it is a clinical project. It is a big challenge for me because it's
the first time that I have to do that, but also in English. I have to submit a project proposal at the
end of this month. Now I'm doing an analysis of the situation and I’m trying to meet my future
partners. At the end: A logical framework! That's fantastic. I'll be happy if the proposal could pass
without a lot of problems … Alain Disu (MCM 2002-2003)
— I took up my activities in our unit and I co-ordinate a clinical trial on ARV as well as the activities
related to the decentralisation of the access to ARV in Senegal. I hope the MDC team is fine. I
just received the MDC Newsletter, which I found very interesting! Ndella Diakhate (MCM
2002-2003)
— I’m working now at the Disease Control Service of the Regional Health Directorate of Dédougou.
From the district I moved to the regional level, but I’m still in the same region as before.
The Disease Control Service has the following tasks:
- The health information system and the epidemiological surveillance
- The protection of specific groups (maternal health, child health, specific vulnerable groups)
- The planning, monitoring and evaluation of district and regional activities
- The integration of different health programmes within the district activities (malaria,
tuberculosis, guinea worm, lymphatic filariasis, etc. ). Boroma Sanou (MCM 2002-2003)
— After a few months of unemployment I’m now at the “Centre Muraz de Bobo Dioulasso” in the
framework of a research project on the ARV therapy "Burkinavi". I’m in charge of the project. So
far the latest news. …
Georges Compaore (MCM 2002-2003)
— In June we received the visit of Nimer Ortuño (MCM 2002-2003), who came for a meeting at
ITM of a research team working on the problem of resistance in antimonial drugs used in the
treatment of Leishmaniasis. Between April and August he is doing laboratory work in London.
One has to be flexible but he keeps on looking for a job as a disease control manager….
•
Marriage
Daman Keita (MCM 2002-2003) and
Mahawa Sano got married on June 4th
2004 in Conakry.
The redaction thanks all those who contritubed to this Newsletter, and especially Ernest
Denerville (CIPS 2003-2004), who was so kind to translate all texts either to English or to French,
again (he also translated the previous newsletter).
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