Two large studies published in 2023 report more rapid reductions in postpartum haemorrhage (PPH) mortality after health-facility births than many would think possible in a low- or middle-income country, using very different study designs yet broadly similar interventions. In this commentary and the accompanying study, we report on how Niger is sustaining its nationwide results through four subsequent years among over 2 million health-facility births with little external support. In an era of greatly reduced external funding for health, these studies provide strong justification for testing elsewhere too, to determine whether these approaches should be scaled globally.
OBJECTIVES:Niger in West Africa reduced maternal mortality by 34.5% among 1 380 799 health-facility births over 72 months through 2020 by more than halving postpartum haemorrhage (PPH) mortality in health facilities nationwide, using low-cost obstetrics technologies and 11 public health disease-eradication tools. Monthly support ended in December 2020 because of a lack of funding. Sustainability of innovations is important, given declining external funding and expectations that even very poor countries fund health from domestic taxes. Therefore, the current study assessed for PPH mortality rebound, also because 2015-20 results had been better than expected. METHODS:Routinely collected government maternal mortality data during the 2015-20 project period and the 2021-4 post-project period were tested using Poisson regression models, and the Cochran-Armitage test for trend. RESULTS:Among 2 158 021 health-facility births from 2021 to 2024, no significant change was seen in the proportion of maternal deaths caused by PPH, PPH case fatality, PPH cases per 100 000 births, or PPH deaths/1000 births compared with the preceding 4 years. CONCLUSIONS:Niger's >50% PPH mortality reduction was sustained for 4 years without external attention to its implementation. Given sustained success emanating from capacity-strengthening, the strategy should be tested in other settings where maternal mortality remains high.
The Onchocerciasis Control Programme in West Africa implemented vector control (VC) and ivermectin mass drug administration (MDA) to eliminate blindness, intensifying efforts in Special Intervention Zones (SIZ). Togo aims to eliminate onchocerciasis transmission (EOT) by 2030. We use the EPIONCHO-IBM model to project microfilarial prevalence trends across Togo's five regions by SIZ status, MDA coverage (65%-80%) and VC efficacy (60%-100%). We compare projections with prevalence surveys (400 villages, 1970-2017) stratified by hypoendemic, mesoendemic, hyperendemic, and holoendemic baseline endemicity, and calculate EOT probabilities for 2024, 2027, and 2030. Combined VC and MDA reduced prevalence nationwide. After cessation of VC, prevalence continued to decline in hypo-to-mesoendemic areas under annual MDA, while hyperendemic areas required biannual MDA. In holoendemic areas, prevalence rebounded even with biannual MDA, indicating that alternative strategies are needed. EPIONCHO-IBM reproduces Togo's onchocerciasis trends throughout five decades of intervention and provides a transferable framework to guide policy towards 2030 goals.
The Onchocerciasis Control Programme in West Africa implemented vector control (VC) and ivermectin mass drug administration (MDA) to eliminate blindness. In Special Intervention Zones (SIZ), efforts were intensified. Togo aims to eliminate onchocerciasis transmission (EOT) by 2030. The stochastic EPIONCHO-IBM transmission model was used to project Onchocerca volvulus microfilarial prevalence trends in Togo’s five regions according to SIZ status, treatment coverage (65%-80% of total population) and VC efficacy (60%-100%). Model outputs were compared with microfilarial prevalence surveys (1970–2017, 400 villages) following four endemicity (baseline microfilarial prevalence) levels: hypoendemic (30%), mesoendemic (50%), hyperendemic (70%), and holoendemic (90%). EOT probabilities were calculated for 2024, 2027 and 2030. VC plus MDA substantially reduced prevalence. In holoendemic areas, this decline was not sustained after VC cessation despite biannual MDA. Baseline hypo- and mesoendemic areas can proceed with stop-MDA surveys (already underway). Highly endemic river basins would benefit from alternative treatment strategies (ATS). EPIONCHO-IBM captured Togo’s onchocerciasis trends throughout five decades of intervention. While most areas of the country may no longer require MDA, some are unlikely to reach EOT with current intervention strategies, indicating the need for ATS. Our modelling approach could be used in other endemic countries to inform policy decisions towards the 2030 elimination goals.
Abstract Background Due to the burden of schistosomiasis (SCH) and soil-transmitted helminths (STH), Togo Ministry of Health launched a program for Preventive Chemotherapy Neglected Tropical Diseases (PC-NTDs) in 2009, initiating integrated mass drug administration (MDA) the following year for the three PC-NTDs: SCH, STH and onchocerciasis. Significant reduction of infection across the country was noted in 2015 during the first impact assessment, following 5 years of high-coverage MDA implemented at the sub-district level for SCH and district level for STH. After another 5 years of effective MDA, a second survey was conducted in 2021 to re-evaluate the situation of SCH and STH. Methods A cross-section of school-aged children was taken across ten districts of Togo. A total of 302 schools in 92 sub-districts were sampled, with 24 school-aged children per school resulting in 7248 children surveyed. Urine samples were tested by haemastix® for Schistosoma haematobium, with urine filtration for the presence of eggs conducted on haematuria-positive samples. Stool samples were collected in a subset of 34 sub-districts in seven out of the ten surveyed districts, where STH and Schistosoma mansoni endemicity was high during the 2015 impact assessment. Duplicate (two) Kato-Katz analysis was performed for each stool sample. Sociodemographic and school-level water, sanitation and hygiene information was also collected. Results Overall, SCH prevalence was 5.90% (95% CI: 5.4–6.5), with 5.09% (95% CI: 4.64–5.67) for S. haematobium and 2.56% (95% CI: 1.98–3.29) for S. mansoni. STH prevalence was 19.7% (95% CI: 18.2–21.4), with 19.6% (95% CI: 18.1–21.3) hookworm, 0.08% (95% CI: 2.2–5.8) Trichuris trichiura and 0.04% (95% CI: 0.01–0.33) Ascaris lumbricoides. Compared to baseline, a significant reduction in both SCH (22.2% to 5.90%) and STH (29.2% t0 19.7%) prevalence was observed. Children aged 5–9 years were less infected than older peers aged 10–14 years: 4.76% vs. 7.53% (P < 0.01) for SCH and 17.2% vs. 23.0% (P < 0.01) for STH. Conclusions After 10 years of high coverage integrated MDA, Togo has achieved low prevalence SCH infection through the sub-district MDA implementation with considerable infection heterogeneity within sub-districts. As STH infection has not reached a level where the infections are not a public health problem, the sub-district treatment strategy could also be adopted in addition to improvement of treatment coverage among preschool age children and hygiene and sanitation practices. Graphical Abstract
