Posts or Comments 05 July 2022

Elimination &Health Systems &NTDs &Polio &Surveillance &Trachoma Bill Brieger | 29 May 2022

When is Disease Elimination not Elimination?

A May 28th press release from the World Health Organization states that, “Togo eliminates trachoma as a public health problem.” The article explains that …

Validation of trachoma elimination as a public health problem in Togo was based on evidence. Several population-based trachoma surveys were conducted starting from 2006 to 2017. The 2017 survey using WHO recommended methodology found that the prevalence of key indicators was below the WHO trachoma elimination threshold. There was also evidence that Togo’s health system is able to identify and treat new cases of late complications of trachoma.

This raises the question, is Trachoma gone from Togo or does trachoma continue to exist at some low level whereby, as WHO notes, Togo has joined, “12 other countries that have been validated by WHO for having eliminated trachoma as a public health problem.”

This description of disease elimination contrasts sharply with the global concerns when “health authorities in Malawi have declared an outbreak of wild poliovirus type 1 after a case was detected in a young child in the capital Lilongwe. This is the first case of wild poliovirus in Africa in more than five years.” Wild polio virus had been declared eliminated in Africa, and just one case in one country grabs international attention.

Would one case of trachoma tomorrow receive the same concern in Togo? Apparently not according to the WHO definition, “Elimination of trachoma as a public health problem is defined as: (i) a prevalence of trachomatous trichiasis (TT) “unknown to the health system” of < 1 case per 1000 total population; and (ii) a prevalence of trachomatous inflammation-follicular (TF) in children aged 1–9 years of < 5%, in each formerly endemic district.”

So, while no cases of smallpox, guinea worm or polio would be tolerated after elimination has been declared, parents of a child who develops trachoma in Togo tomorrow would be told that your child’s case is only 1 in a 1000 and not of concern to public health. The caveat is though that “the health system (must be) able to identify and manage incident TT cases.” Presumably, if such management capacity does not exist, the disease in question could spread and elimination would be eliminated.

Another Neglected Tropical Disease, Lymphatic Filariasis, faces the same challenge in terms of elimination status. WHO explained in its guidance that, “In 1997, the 50th World Health Assembly resolved to eliminate LF as a public-health problem (resolution WHA50.29). In response, WHO proposed a comprehensive strategy for achieving the elimination goal that included interrupting transmission in endemic communities and implementing interventions to prevent and manage LF-associated disabilities The LF guidance stresses “Effective monitoring, epidemiological assessment and evaluation are necessary to achieve the aim of interrupting LF transmission,” or in a word Surveillance. There is clear concern for “absence of transmission” and worries about “recrudescence.”

While polio has a vaccine and guinea worm relies on providing safe community water, LF and Trachoma elimination depends on mass drug administration (MDA) at planned intervals until such time as transmission is reduced. All require a strong health system to implement, but the challenges of maintaining MDAs until such time as elimination has been validated is somewhat more challenging. In this context the communication is extremely important. Just because WHO validates the elimination of a disease as a public health problem, does not give policy makers license to ignore that disease. Advocacy is continually needed such that even after apparent elimination, neglected diseases will not be forgotten and health systems themselves not neglected.

Development &poverty &Vaccine Bill Brieger | 28 Apr 2022

African Immunization Week Press Briefing: Reducing Poverty, Saving Lives

The World Health Organization’s African Regional Office held a press briefing to mark World Immunization Week/African Immunization Week. Three experts shared their observations of developments and trends and responded to questions over the course of an hour on Thursday 28th April. The panelists included Dr Benido Impouma, Director, Communicable and Noncommunicable Diseases, WHO Regional Office for Africa, Professor Helen Rees, Executive Director, Wits Reproductive Health and HIV Institute, University of Witwatersrand, South Africa, and Hon. Dr Kailash Jagutpal, Minister of Health and Wellness, Government of Mauritius. In addition, Dr. Mory Keita answered questions about the latest Ebola Virus Disease (EVD) in the Democratic Republic of the Congo (DRC).

Concerns about COVID-19 featured in this immunization briefing for several reasons. First was the low coverage of COVID vaccines on the continent. Second was the way that COVID put demands on health workers’ time as well as on precautions to be undertaken, which limited the reach and coverage of immunization services for other vaccine preventable diseases (VPDs). Also, the resulting reduction in immunization coverage was responsible for other deadly outbreaks, notably measles. Between January and March 2022, for example, there was a 400% increase in measles cases compared to the same period last year.

Dr. Impouma that COVID ‘taught the lesson’ that catch-up campaigns for VPDs were not only necessary but could be handled successfully. Finally, health services learned the importance of integration, whether joining COVID and Yellow Fever vaccination efforts in Ghana or integrating COVID with maternal and child services and immunizations. Ultimately, health workers learned that by strengthening ‘routine’ immunization, health systems overall could be strengthened thus, making progress on achieving Health For all through Universal Health Coverage.

Dr. Jagutpal shared key considerations for successful life-course immunization programs. Mauritius offers free, universal vaccination from birth. Thirty VPDs are addressed ranging from Human Papilloma Virus to flu and not of course, COVID-19. Success is based on involvement of all stakeholders through regular meetings where real time decisions can be made. Mauritius in one of the first to formalize the COVID Vaccine Pass Card and has achieved 60% full vaccine coverage including booster shots.

Prof Rees noted that the term ‘routine services’ makes vaccines seem boring and less important, when in fact, they should be seen as “Core Services”. This central role of vaccines goes beyond preventing specific diseases. By saving children’s lives and reducing the time demands on parents who care for children suffering VPDs, immunization promotes human development, reduces poverty, enhances the economy, and strengthens employment. There remain children who have had no vaccines. Identifying these ‘zero dose’ children and the communities in which they cluster can help us focus on ameliorating the vulnerabilities of their families and bring multi-sectoral resources to bear on strengthening poor communities.

Dr Keita reviewed the two recent cases, now deaths from Ebola in Équateur Province in DRC, its third EVD outbreak. Ebola vaccine teams have started working, reaching 78 contacts. He lamented that much of the DRC has a natural ecological predisposition for the animal reservoirs of Ebola, so more effort on making regular vaccines and treatment available is required. As Prof Rees pointed out, this setting is a perfect example of the need for a One Health approach to many of our health challenges which are zoonotic in nature. Even with coronaviruses, animal reservoirs are a central element of transmission.

Additional research is recommended in several areas. The slowly increasing laboratory capacity in Africa was mentioned. It contributed to finding Omicron and its variants. Potential new ones may have been identified recently. Seropositivity analysis has found that 80-90% of people tested may already have COVID antibodies. Research can clarify the role of vaccines in these circumstances. Research as well as regular program monitoring is still needed to determine the factors that may cause children to miss vaccines. It is often not the case that parents are ‘hesitant’, but that system and community factors combine to prevent them from seeking care. Research can also assist in finding vaccines and tools for tackling other deadly pathogens such as Lassa Fever.

Vaccines save lives from endemic diseases, but in the long-term vaccinated families and communities can fight poverty which itself is a leading factor in illness and death. This will accomplish the theme of this year’s observance, “Long Life for All.

Advocacy &Vaccine Bill Brieger | 25 Apr 2022

World Immunization Week Starts with World Malaria Day

One might think initially that the convergence of World Malaria Day and World Immunization Week would simply be a coincidence. This year there is a major connection since WHO has approved the first ever RTS,S/AS01 malaria vaccine which has undergone decades to clinical testing and most recently, a successful 3-year pilot intervention in Malawi, Kenya, and Ghana.

During her keynote address at the Johns Hopkins Malaria Institute’s World Malaria Day Webinar today, The WHO Regional Director for the African Region, Dr. Matshidiso Moeti, stressed the importance of integrated disease control efforts drawing on the region’s efforts to tackle neglected tropical diseases, COVID-19 and of course, malaria. She highlighted the importance of surveillance, and in That context pointed out a serious fact. The population of sub-Saharan Africa had doubled since the start of the Roll Back Malaria initiative, meaning that to achieve the same level of coverage of key interventions, one needs to reach many more people, whether for malaria control or child immunization.

Thus, increasing targets and goals affect both immunization and malaria programs, as well as efforts to roll out the malaria vaccine. At present there is only one producer of the vaccine, GlaxoSmithKline, and while that company is working with another company in India to produce RTS,S in the global south, GSK is maintaining control of the AS01 adjuvant. Production targets have so far been geared to meeting the needs in the pilot districts of the three intervention countries, and for the foreseeable future this will address less than 10% of need in P. falciparum endemic areas, especially in Africa.

WHO and partners including UNICEF and GAVI are in the process of figuring out equitable ways to distribute what is available now and encouraging the ramp up of vaccine production. The need to vaccine technology transfer to Africa is also being considered. Additionally, eyes are focused on new malaria vaccine candidates which might come on board in about five years.

The current malaria vaccine, while reducing severe disease, does not have the highest efficacy, and experts caution that is is therefore, not a silver bullet. They do explain that the vaccine is an important addition to the malaria toolkit, and should be a central part of integrated malaria control planning. At present though, we are not only running in place to meet the needs of an ever increasing number of children at risk, and we also must cope in an ethical and efficient way with limited supplies of the vaccine for the near future. This is the double challenge to start Malaria Day and Vaccine Week.

 

 

Environment &Mosquitoes Bill Brieger | 22 Apr 2022

What do mosquitoes think of Earth Day?

On Earth Day (and hopefully throughout the year) we contemplate what humans have done to ecosystems and climate. Should mosquitoes actually think about us at all, they might be grateful for the changes that increase their breeding sites.

Deforestation and modern agricultural practices favor the Anopheles group. Expanding urbanization makes life easier for the Aedes family.

Overall warming may open up new parts of the world for mosquitoes, though hotter and drier areas left behind make mosquito propagation more difficult. These highly mobile creatures may have few complaints for now, though proposed efforts to disperse particles in the atmosphere for cooling effect and current efforts to release sterile male mosquitoes into the environment might worry people as well as mosquitoes.

Human activity has modified the environment, and mosquitoes have taken advantage where they can. Environmental efforts to beat back mosquitoes need to be thought through very carefully to avoid more unintended consequences.

 

Agriculture &Children &Climate &Coordination &Development &Elimination &Environment &Epidemiology &Food Security Bill Brieger | 15 Apr 2022

Malaria elimination challenges around the world

In the past week, news has featured challenges to malaria elimination around the globe. Starting in Papua New Guinea which accounted for accounted for 86% of all cases in the Western Pacific Region in 2020. While there are 39% fewer cases in the region since 2000, there was an increase of 300,000 cases between 2019 and 2020. It is mainly in the six countries of the Greater Mekong subregion where progress has been steady.

Moving east to the Brazilian Amazon, one finds wildcat gold mining operations are not only destroying Native American ecosystems but are carving huge holes in the earth which are perfect breeding conditions for mosquitoes. This means that malaria cases among the Yanomami indigenous people living in the Brazilian Amazon have increased by more than 12 times since 2014.

Also within South America, one finds that although Paraguay was certified by the World Health Organization (WHO) as free of local transmission of malaria in 2018, experts are warning that travelers entering the country from areas with malaria transmission could easily reintroduce the disease. Hence vigilance is urged.

Crossing next to sub-Saharan Africa, one reads of studies showing an increasing link between malaria and agriculture across the region. As population expands in the region, more food, water and agricultural commodities are required. Irrigation and deforestation to clear land for agriculture increase the risk of childhood malaria in sub-Saharan Africa. The experts recommend that African ministries of agriculture, health, and environment need to collaborate on safer development policies and practices, not only to curb malaria, but the devastating effects of climate change.

Finally continuing back to Asia, one finds what might be termed an epidemiological conflict between Nepal, which is nearing malaria elimination for 2025, and its southern neighbor India, which is a source of imported malaria. Although the number of indigenous cases is nearing zero, health authorities fear that imported cases of of malaria from India are so high that local transmission could be reignited.

Malaria is clearly a global health problem. Collaboration and coordination across continents is needed to eliminate the scourge.

Elimination &Monkeys &Zoonoses Bill Brieger | 09 Jan 2022

Humans, Monkeys, and Malaria in Costa Rica: Implications for Elimination

A just-published article by Andrea Chaves and colleagues entitled, “Presence and potential distribution of malaria-infected New World primates of Costa Rica”, Specifically their results state that, “PCR analysis for the Plasmodium presence was conducted in 384 samples of four primates …

  • Howler monkey [n?=?130]
  • White-face monkey [n?=?132]
  • Squirrel monkey [n?=?50]
  • red spider monkey [n?=?72]),

… from across Costa Rica. Three Plasmodium species were detected in all primate species (P. falciparum, P. malariae/P. brasilianum, and P. vivax). Overall, the infection prevalence was 8.9%, but each Plasmodium species ranged 2.1–3.4%. The niche model approach showed that the Pacific and the Atlantic coastal regions of Costa Rica presented suitable climatic conditions for parasite infections. However, the central pacific coast has a more trustable prediction for malaria in primates.”

Last year, Tobias Mourier et al. reported another human/non-human primate connection in Brazil. According to them, “Analysis of the P. simium genome confirmed a close phylogenetic relationship between P. simium and P. vivax, and suggests a very recent American origin for P. simium. The presence of the DBP1 deletion in all human-derived isolates tested suggests that this deletion, in combination with other genetic changes in P. simium, may facilitate the invasion of human red blood cells and may explain, at least in part, the basis of the recent zoonotic infections.

The connection between human and primate malaria also flows toward humans as traditional human plasmodium infections decrease in prevalence in Malaysia. Lai are co-researchers explain that, “The incidence of zoonotic malaria Plasmodium knowlesi infection is increasing and now has been the major cause of malaria in Malaysia.”

In fact, the 2021 World Malaria Report noted that, “Malaysia had no cases of human malaria for 3 consecutive years, but in 2020 reported 2607 cases of P. knowlesi, a zoonotic malaria.” The report does not specify efforts to handle this issue.

These studies raise a continuing question about the feasibility of eliminating malaria in countries when those plasmodium species that infect humans also infect other primates and vice versa. As we have noted before, monkeys do not use bednets. As long as primate Plasmodium reservoirs exist, our ability to eliminate the disease will remain elusive.

Chronic/NCDs &Community &Training Bill Brieger | 08 Jan 2022

Freedom Park Lagos Hosts Revolving Hearts Foundation CPR Training & AED Presentation

In their 2021 presentation at the American Society of Tropical Medicine and Hygiene, “Hands-only CPR Training Program of Secondary School Students in Ibadan, Nigeria”, Olufunso Odunukan and colleagues of the Revolving Heart Foundation mentioned that plans were underway to expand the training. Below, they share their recent public training in Lagos, Nigeria.

Freedom Park Lagos played host to the Revolving Hearts Foundation (RHF) – a non-governmental organisation which advocates Cardiopulmonary Resuscitation (CPR) trainings and more of the presence/ use of Automated External Defibrillator (AED) in public places in Nigeria (and by extension Africa). The foundation represented by its visionary Dr. Olufunso Odunukan, an interventional cardiologist based in the United States, took a wide cadre of staff – from management to the most junior level, and vendor representatives through a detailed and practical session of administering CPR in a bid to save more lives and reduce loss due to not-quick-enough basic interventions in the face of a cardiac arrest or someone passing out due to a heart attack.

The NGO also presented an AED to the management of Freedom Park and in the same training showed how to set up the device following previously programmed instructions on the gadget. After that, with the use of mannequins and simulated AED materials, the RHF representative Dr. Odunukan took the participants through a very hands-on and practical experience of deploying CPR in a model situation. There was a video presentation that detailed what to do in the event a person suffers a cardiac arrest in a public place, at home, on the sidewalk, on stage or similar places.

The participants who included a wide array – cleaners, vendor workers, senior staff and middle management all gave good feedback as to the extent and impact that the training would have, even beyond the four walls of the Park. They also participated in a skit of a proper situation where they might need to take charge or be part of helping in an emergency situation, especially with the benefit of the lessons they had picked up in the training.

Dr. Odunukan equally advocated that this shouldn’t be a one-off session as the training could be replicated from time to time, so that everyone is prepared and savvy in the proper manner to be able to intervene and save lives, at least as a first aid in such situations, until professional medical assistance arrives. After the latter, on behalf of RHF, he presented the AED to the management of Freedom Park represented by the C.O.O.  Ms. Iyabo Aboaba who gladly accepted the device and reiterated the necessity of such gesture with the pledge to put it to good use, in line with the vision of the NGO to save more lives.

The training which lasted about 1hour 30 minutes ended with FAQs and an interactive and enlightening session based on the model skit and how to replicate an efficient process in the event of a real-life situation.

Antenatal Care (ANC) &Behavior Change &Communication &ITNs Bill Brieger | 20 Nov 2021

Factors affecting adoption of malaria-preventive behaviors among populations at high risk of malaria in Cote d’Ivoire

Save the Children designs programs to protect children and families from malaria. An important aspect of the design process is learning about the factors that influence community members’ behaviors related to the prevention of the disease. Here we learn about behavioral factors that must be considered to design effective programs. This information is being presented at the 2021 American Society of Tropical Medicine and Hygiene Annual Meeting. See Author List below.

Understanding the drivers of malaria-related behavior helps national malaria control programs and implementing partners to plan national malaria strategies and to tailor interventions accordingly. This study examined the factors affecting adoption of malaria behaviors and those that drive or inhibit them among populations at high risk of malaria in Cote d’Ivoire.

This study was a multi-method, qualitative study with an exploratory approach using focus group discussions (FGDs), in-depth interviews (IDIs) and life stories. The study was conducted in 12 health districts across 10 health regions of Cote d’Ivoire in both urban and rural areas. FGDs and life stories were conducted with pregnant women and mothers of children under 5 and men (heads of household). IDIs were conducted with a number of stakeholders including: departmental district directors; midwives, nurses, community health workers, leaders of women’s groups, community leaders, and the local media.

The findings from this study show that incorrect knowledge about LLINs, LLIN dislike and discomfort, housing structure and size, sleeping arrangements for children under 5, and lack of LLIN recycling strategies were among the root causes for incorrect, non-use and/or inconsistent use of LLINs. In terms of ANC attendance, the main reported barriers were influence of their beliefs and norms, cost, perceived poor services provided, bad experiences from gynecological examinations, and the distance of health facilities in rural areas. Additionally, the lack of information on the benefits of SP for prevention of malaria in pregnancy and the use of traditional medicine were the main barriers for SP in pregnancy. Cost, poor services by health care providers and stock outs were the main barriers to diagnosis and treatment for children U5.  The main factor that influenced the adoption of preventive measures was free LLIN distribution through ANC viists and mass distribution campaigns.

Findings from this study are useful to inform the revision of the Social Behavior Change Communication Strategy in Cote d’Ivoire. Additionally, they can inform key messaging and the design of interventions in a context where malaria is the main cause of morbidity and mortality and children under 5 and pregnant women are the most affected.

AUTHOR LIST:

Jacob Y. Agniman1, Manasse N. Kassi1, Yssouf Ouattara1, Edouard C. Balogoun1, Serge B. Assi2, Philomène A. Beda1, Michel N’da-Ezoa3, Aristide E. Kouadio1, Joel Koffi1, Apollinaire N. Kouadio1, Paul Bouey4, Sara Canavati4, Eric Swedberg4 — 1Save the Children, Abidjan, Côte D’Ivoire, 2Le Programme Nationale de Lutte contre le Paludisme (PNLP), Abidjan, Côte D’Ivoire, 3Socio-Anthropologue de la Santé, Abidjan, Côte D’Ivoire, 4Save the Children, Washington, DC, United States

Antenatal Care (ANC) &Communication &Health Systems &ITNs Bill Brieger | 20 Nov 2021

Education and knowledge help fighting malaria, but health systems strengthening in Cote d’Ivoire

Save the Children recognizes the importance of strong health systems to deliver malaria interventions. Here they arsharing a wealth of information on these efforts at the 2021 American Society of Tropical Medicine and Hygiene Annual Meeting. Here is an abstract from one of their malaria efforts. See Author List below.

Since 2010, Cote d’Ivoire has made significant progress in the fight against malaria; however, since 2016 progress has stagnated and malaria incidence is steadily increasing. The aims of this study were to assess knowledge, attitudes and practices among heads of households, pregnant women and caretakers of children under 5 years of age (U5) and IPTp-SP compliance.

A mixed-methods study was conducted in rural and urban areas in 20 health districts of Cote d’Ivoire. A total of 1,812 households composed of 8,813 members were surveyed using a structured questionnaire. Qualitative data were gathered through twenty focus group discussions. Data triangulation was used during analysis.

Fever was the main malaria symptom reported by heads of households (38.5%) followed by headache (25.5%). Additionally, many FGD participants also reported sadness as a symptom of malaria. The primary cause of malaria was mosquito bites, followed by fatigue, the sun, and salty water, 70.7%, 15.1% and 10.9%, 3.3% respectively. The main prevention methods reported were sleeping under an ITN (60.4%), spraying the house (25.9%), taking medication (5.8%), and using a fan (7.9%). In FGDs, additional means of prevention were discussed including sanitation of the environment, personal hygiene, and stopping alcohol consumption.

The majority of women with at least one child reported having attended at least three ANC visits in their last pregnancy (85.1%). The cost of ANC was a main factor affecting attendance.  Overall, 78.2% of them received SP and of these women, 98.1% said they received it during their ANC visits. However, only 55.4% received 3 doses or more of SP and 76.79% received SP free of charge. The reasons for not taking SP were stock outs, side effects, bitter taste, and preference for injections.

Our study revealed that knowledge of prevention measures (ITNs) and causes of malaria (mosquito bites) were high and in line with the targets of the National BCC Strategy 2021-2025. However, even though the majority of pregnant women would like to take SP, they were blocked by the health system unable to provide them with the drugs and others had to pay for them. These problems within the health system are likely to contribute to the high malaria incidence in Cote d’Ivoire.

AUTHOR LIST

Edouard C. Balogoun1, Manasse Kassi1, Philomène A. Beda1, Jacob Y. Agniman1, Serge B. Assi2, Florence Kadjo-Kouadio3, Michel N’da-Ezoa4, Aristide E. Kouadio1, Joel Koffi1, Apollinaire N. Kouadio1, Paul Bouey5, Sara Canavati5, Eric Swedberg5 — 1Save the Children, Abidjan, Côte D’Ivoire, 2Le Programme Nationale de Lutte contre le Paludisme (PNLP), Abidjan, Côte D’Ivoire, 3Médecin Spécialiste de Santé, Abidjan, Côte D’Ivoire, 4Socio-Anthropologue de la Santé, Abidjan, Côte D’Ivoire, 5Save the Children, Washington, DC, United States

ITNs &Mosquitoes Bill Brieger | 19 Nov 2021

Mosquito net knowledge, ownership, use, acceptability and preferences

Save the Children addresses various ways to protect children and families from malaria. Here we learn about Mosquito net knowledge, ownership, use, acceptability and preferences among primary caregivers of children under 5 years of age, pregnant women and household heads in Cote d’Ivoire. This information is being presented at the 2021 American Society of Tropical Medicine and Hygiene Annual Meeting. See Author List below.

Strengthening vector control measures among populations at higher risk of malaria, such as pregnant women and children under 5 years of age (U5s), is crucial to malaria control. Cote d’Ivoire has set itself a number of targets for malaria control by 2025. These include: at least 90% of the population are aware of national malaria prevention measures and at least 80% of the general population, pregnant women and children U5 sleep under an LLIN. One of the specific aims of this study was to assess mosquito net knowledge, ownership, use, acceptability and preferences of primary caregivers of children U5, pregnant women and household heads.

A mixed-methods study was conducted in rural and urban areas in 20 health districts of Cote d’Ivoire. A total of 1,812 households composed of 8,813 members were surveyed using a structured questionnaire. Only households who had one or more children under five years of age and/or a pregnant woman were included in the study. Qualitative data were gathered through twenty focus group discussions. Data triangulation of the qualitative and quantitative data was used during analysis.

Sixty percent of participants cited mosquito nets as the main malaria preventive measure. The majority of participants (95.6%) received information on the use of mosquito nets and over half of them received it from mass distribution campaign agents (51.1%). Although 79.5% of households owned at least one mosquito net, less than half (46.47%) owned one mosquito net for two people. The majority (98.2%) of participants received a free mosquito net. Nets were reportedly received mainly through mass distribution campaigns (54.99%) and ANC visits (39.0%). Self-reported mosquito net use by the head of households was 53.5%. This was higher for pregnant women and children U5, 76.2% and 83.2% respectively. However, only 53.0% of mosquito nets were suspended over a bed. Reasons for not using a mosquito nets were feeling of suffocation, heat, side effects, and poor condition of the mosquito net.

While mosquito net was reported as the main malaria preventive measure, mosquito net coverage and use remains below national targets. In addition, there was a noted gap between coverage and net use, potentially undermining the effectiveness of net-related interventions that could impact malaria control efforts in Cote d’Ivoire. The design, material, and condition of nets are important factors for user preferences that appear to drive net use.

AUTHOR LIST:

Edouard C. Balogoun1, Manasse N. Kassi1, Philomène A. Beda1, Serge B. Assi2, Jacob Y. Agniman1, Florence Kadjo-Kouadio3, Michel N’da-Ezoa4, Aristide E. Kouadio1, Joel Koffi1, Apollinaire N. Kouadio1, Paul Bouey5, Sara Canavati5, Eric Swedberg5 — 1Save the Children, Abidjan, Côte D’Ivoire, 2Le Programme Nationale de Lutte contre le Paludisme (PNLP), Abidjan, Côte D’Ivoire, 3Médecin spécialiste de Santé, Abidjan, Côte D’Ivoire, 4Socio-Anthropologue de la Santé, Abidjan, Côte D’Ivoire, 5Save the Children, Washington, DC, United States

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