Renaud Becquet

Background: Undernutrition and infectious diseases form a vicious cycle that endangers child survival in low-resource settings, including in Northern Nigeria. The NutriVax-Measles trial was designed to evaluate a strategy combining preventive small-quantity lipid-based nutrient supplements (SQ-LNS) distributions with community mobilization and routine immunization services for children aged 6-23 months to improve measles vaccination uptake. To inform future programs co-delivering nutrition supplementation and immunization services at scale, we aimed to assess the feasibility and acceptability of measles vaccination, SQ-LNS distribution, and the NutriVax strategy. Methods: A qualitative study was conducted at the end of the trial using in-depth interviews (n=53) and focus group discussions (n=8) with key stakeholders: caregivers, health care workers, community health workers, and community representatives. Thematic analysis was guided by multiple conceptual frameworks. Results: The majority of the participants expressed satisfaction with measles vaccines in both arms, and with SQ-LNS in the NutriVax arm, as they perceived the benefits for their children’s health. In both arms, community awareness sessions and previous experience of outbreaks were key to motivating caregivers to bring their children to healthcare centres. Although distance to health facilities was identified as one of the main barriers to accessing care, SQ-LNS was perceived as an important source of motivation to bring their child to the clinic where they subsequently received vaccination. All stakeholder groups emphasized the importance of community leaders’ support and targeted male sensitization to address the prevailing sociocultural norms. Additionally, improved service organization to reduce waiting time was considered crucial to enhance caregivers’ acceptability of the intervention. Conclusion: Both measles vaccination and SQ-LNS provision were acceptable and feasible, supporting the NutriVax strategy within primary healthcare settings in fragile health systems. Successful implementation depends on sustained community sensitization, continued engagement of fathers and community leaders, and service delivery decentralized as close as possible to beneficiaries. KEY MESSAGES: What is already known?: Co-delivering small-quantity lipid-based nutrient supplements (SQ-LNS) with routine immunization is an effective strategy to improve vaccination coverage in Northern Nigeria. Yet, evidence on how vaccination and SQ-LNS are perceived, implemented, and experienced by stakeholders at health-care and community levels remains scarce. What are the new findings?: SQ-LNS was an important source of motivation for caregivers to bring their children to health facilities, creating opportunities for vaccination. Persistent barriers to vaccination included socio-cultural misconceptions, gender norms, long waiting time and distance to health facilities. What do the new findings imply?: Sustained community engagement, including targeted male sensitization, is important to improve measles vaccination acceptability. Successful implementation of co-delivery programs also requires well-organized service delivery, with services decentralized to health facilities as close as possible to beneficiaries, particularly to reduce travel distances and waiting times.

Background: Adverse maternal outcomes remain a critical public health concern in the Central African Republic. The Wakobo ti kodro project (2023 – 2024) evaluated an intervention combining collaboration between trained traditional birth attendants (TBAs) and health care workers (HCWs) with the use of a tablet-based digital application for community-based pregnancy monitoring. This study aimed to assess the acceptability and feasibility of this digital health intervention used by TBAs. Methods: We employed a mixed-methods design. In-depth individual interviews were conducted with TBAs, HCWs, women, husbands, community leaders and district representatives. All TBAs also completed a questionnaire and a subset participated in a focus group discussion. Conceptual frameworks were used to analyse qualitative and quantitative data. Then, findings were integrated through joint analysis. Findings: The tablet-based application, designed with pictograms, was perceived as usable by TBAs, provided that regular supervision was ensured. Its use was well accepted by TBAs who reported enhanced credibility and increased confidence, as well as by HCWs and community members. The application was perceived as a relevant tool for improving high-risk pregnancy identification at community level, and for strengthening links between the community and the healthcare system. However, power outages limited its optimal use. Nevertheless, all interviewees expressed strong willingness to sustain this intervention. Interpretation: The use of a tablet-based digital application by TBAs was well accepted and feasible, provided regular supervision of TBAs and community leaders involvement. Anticipating and addressing logistical challenges is also essential for the successful implementation and sustainability of such digital maternal health interventions.

Undernutrition and infectious diseases form a vicious cycle that poses a dual threat to vulnerable children in low- and middle-income countries. Integrating small-quantity lipid-based nutrient supplements (SQ-LNS) distribution into routine immunization services in children 6–23 months may act as both a nutritional intervention and as an incentive for increased vaccine uptake. We will conduct a two-arm superiority pragmatic parallel cluster-randomized controlled trial with baseline measures in 20 wards of Nguru and Karasuwa Local Government Areas, Yobe State, Northeast Nigeria. Wards will be randomly allocated 1:1 to either the standard National Program on Immunization (NPI) arm or the NutriVax arm, which combines NPI with SQ-LNS distribution. After up to 12 months of implementation, measles immunization coverage will be assessed at two levels: population-level coverage in children aged 12–23 months (primary outcome, endline cross-sectional survey) and individual-level coverage in children aged 6–12 months (key secondary outcome, longitudinal survey). Each cross-sectional survey (baseline and endline) will include 1560 participants. The longitudinal survey will enroll 600 participants. Sampling will use a multi-stage design with probability proportional to size and systematic random household selection. All outcomes will be analyzed by intention-to-treat. Qualitative interviews will assess feasibility and acceptability. Cost-efficiency differences between arms will be estimated using an incremental cost-efficiency ratio. To our knowledge, this is the first trial to evaluate whether a preventive nutrition supplement can also serve as an incentive to increase vaccination coverage. Findings will provide evidence to guide governments and donors in settings where high rates of undernutrition and low immunization coverage persist as major public health challenges. Protocol Number NCT06387511 (clinicaltrials.gov).

Background: Simplified approaches of acute malnutrition (AM) treatment have been conducted over the past 5 years intending to unify processes and increase coverage among children aged 6 to 59 months without medical complication. The Optimsing treatment for Acute Malnutrition (OptiMA) and the Combined Protocol for Acute Malnutrition Study (ComPAS) are mid-upper arm circumference (MUAC)-based approaches treating children with MUAC < 125 mm or oedema with one sole product—ready-to-use therapeutic food—at a gradually tapered doses. This trial aims to compare the OptiMA and ComPAS strategies to the standard nutritional protocol of Niger assessed by a favourable outcome in the treatment of uncomplicated AM at 6 months post-randomisation and in terms of recovery rate after treatment of uncomplicated SAM (WHZ < − 3 or MUAC < 115mm or oedema) and among the most vulnerable children (MUAC < 115mm or oedema). Methods: A non-inferiority individually randomised controlled clinical trial was conducted at the primary health centres level and in the community in the Zinder region in Niger in March 2021. Participants are children aged 6–59 months attending outpatient health centres with MUAC < 125mm or oedema without medical complications. All participants are followed for 6 months. Simplified strategies propose a gradual reduction of RUTF according to MUAC and weight in OptiMA and MUAC only in ComPAS. Favourable outcome is compositely defined at 6 months post-inclusion as being alive, not acutely malnourished by the definition applied at inclusion and without any additional episode of AM throughout the 6-month observation period. Recovery is defined throughout the 6 months post-randomisation by a minimum of 4-week duration of treatment, an axillary temperature < 37.5°C, an absence of bipedal oedema and a MUAC ≥ 125 mm for two consecutive weeks. The sample size calculation required 567 children per arm for the main objective, 295 and 384 children per arm for the secondary objectives among SAM and MUAC < 115 mm children, respectively. Per-protocol and intention-to-treat analyses will be conducted for each outcome. Discussion: This trial is intending to generate much-needed evidence on various simplified and optimised AM treatment approaches and to participate in reaching a consensus on such nutrition protocols. Trial registration: ClinicalTrials.gov NCT04698070. Registered on January 6, 2021

Introduction: Sex differences have already been reported in sub‐Saharan Africa for attrition and immunological response after antiretroviral therapy (ART) initiation, but follow‐up was usually limited to the first two to three years after ART initiation. We evaluated sex differences on the same outcomes in the 10 years following ART initiation in West African adults.Methods: We used cohort data of patients included in the IeDEA West Africa collaboration, who initiated ART between 2002 and 2014. We modelled no‐follow‐up and 10‐year attrition risks, and immunological response by sex using logistic regression analysis, survival analysis with random effect and linear mixed models respectively.Results: A total of 71,283 patients (65.8% women) contributed to 310,007 person‐years of follow‐up in 16 clinics in eight West African countries. The cumulative attrition incidence at 10‐year after ART initiation reached 75% and 68% for men and women respectively. Being male was associated with an increased risk of no follow‐up after starting ART (5.1% vs. 4.0%, adjusted Odds Ratio: 1.25 [95% CI: 1.15 to 1.35]) and of 10‐year attrition throughout the 10‐year period following ART initiation: adjusted Hazard Ratios were 1.22 [95% CI: 1.17 to 1.27], 1.08 [95% CI: 1.04 to 1.12] and 1.04 [95% CI: 1.01 to 1.08] during year 1, years 2 to 4 and 5 to 10 respectively. A better immunological response was achieved by women than men: monthly CD4 gain was 30.2 and 28.3 cells/mL in the first four months and 2.6 and 1.9 cells/μL thereafter. Ultimately, women reached the average threshold of 500 CD4 cells/μL in their sixth year of follow‐up, whereas men failed to reach it even at the end of the 10‐year follow‐up period. The proportion of patients reaching the threshold was much higher in women than in men after 10 years since ART initiation (65% vs. 44%).Conclusions: In West Africa, attrition is unacceptably high in both sexes. Men are more vulnerable than women on both attrition and immunological response to ART in the 10 years following ART initiation. Innovative tracing strategies that are sex‐adapted are needed for patients in care to monitor attrition, detect early high‐risk groups so that they can stay in care with a durably controlled infection.

Introduction Acute malnutrition (AM) is a continuum condition, arbitrarily divided into moderate and severe AM (SAM) categories, funded and managed in separate programmes under different protocols. Optimising acute MAlnutrition (OptiMA) treatment aims to simplify and optimise AM management by treating children with mid-upper arm circumference (MUAC) Methods and analysis This study was a non-inferiority, individually randomised controlled clinical trial conducted at community level in the Democratic Republic of Congo. Children 6–59 months presenting with MUAC Ethics and dissemination Ethics approvals were obtained from the National Health Ethics Committee of the Democratic Republic of Congo and from the Ethics Evaluation Committee of Inserm, the French National Institute for Health and Medical Research (Paris, France). We will submit results for publication to a peer-reviewed journal and disseminate findings in international and national conferences and meetings. Trial registration number NCT03751475. Registered 19 September 2018, https://clinicaltrials.gov/ct2/show/NCT03751475.