Showing papers by "World Health Organization published in 2004"

The World Mental Health (WMH) Survey Initiative Version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI).

Abstract: This paper presents an overview of the World Mental Health (WMH) Survey Initiative version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) and a discussion of the methodological research on which the development of the instrument was based. The WMH-CIDI includes a screening module and 40 sections that focus on diagnoses (22 sections), functioning (four sections), treatment (two sections), risk factors (four sections), socio-demographic correlates (seven sections), and methodological factors (two sections). Innovations compared to earlier versions of the CIDI include expansion of the diagnostic sections, a focus on 12-month as well as lifetime disorders in the same interview, detailed assessment of clinical severity, and inclusion of information on treatment, risk factors, and consequences. A computer-assisted version of the interview is available along with a direct data entry software system that can be used to keypunch responses to the paper-and-pencil version of the interview. Computer programs that generate diagnoses are also available based on both ICD-10 and DSM-IV criteria. Elaborate CD-ROM-based training materials are available to teach interviewers how to administer the interview as well as to teach supervisors how to monitor the quality of data collection.

Global data on visual impairment in the year 2002

Abstract: This paper presents estimates of the prevalence of visual impairment and its causes in 2002, based on the best available evidence derived from recent studies. Estimates were determined from data on low vision and blindness as defined in the International statistical classification of diseases, injuries and causes of death, 10th revision. The number of people with visual impairment worldwide in 2002 was in excess of 161 million, of whom about 37 million were blind. The burden of visual impairment is not distributed uniformly throughout the world: the least developed regions carry the largest share. Visual impairment is also unequally distributed across age groups, being largely confined to adults 50 years of age and older. A distribution imbalance is also found with regard to gender throughout the world: females have a significantly higher risk of having visual impairment than males. Notwithstanding the progress in surgical intervention that has been made in many countries over the last few decades, cataract remains the leading cause of visual impairment in all regions of the world, except in the most developed countries. Other major causes of visual impairment are, in order of importance, glaucoma, age-related macular degeneration, diabetic retinopathy and trachoma.

The World Health Organization's WHOQOL-BREF quality of life assessment: psychometric properties and results of the international field trial. A report from the WHOQOL group.

Abstract: Quality of life (QOL) assessments that are easily administered and which do not impose a great burden on the respondent are needed for use in large epidemiological surveys, clinical settings and clinical trials. Using data from the WHOQOL-BREF field trials, the objectives of this work are to examine the performance of the WHOQOL-BREF as an integrated instrument, and to test its main psychometric properties. The WHOQOL-BREF is a 26-item version of the WHOQOL-100 assessment. Its psychometric properties were analysed using cross-sectional data obtained from a survey of adults carried out in 23 countries (n = 11,830). Sick and well respondents were sampled from the general population, as well as from hospital, rehabilitation and primary care settings, serving patients with physical and mental disorders and with respect to quotas of important socio-demographic variables. The WHOQOL-BREF self-assessment was completed, together with socio-demographic and health status questions. Analyses of internal consistency, item-total correlations, discriminant validity and construct validity through confirmatory factor analysis, indicate that the WHOQOL-BREF has good to excellent psychometric properties of reliability and performs well in preliminary tests of validity. These results indicate that overall, the WHOQOL-BREF is a sound, cross-culturally valid assessment of QOL, as reflected by its four domains: physical, psychological, social and environment.

A life course approach to diet, nutrition and the prevention of chronic diseases.

Abstract: Objective: To briefly review the current understanding of the aetiology and prevention of chronic diseases using a life course approach, demonstrating the lifelong influences on the development of disease. Design: A computer search of the relevant literature was done using Medline-‘life cycle’ and ‘nutrition’ and reviewing the articles for relevance in addressing the above objective. Articles from references dated before 1990 were followed up separately. A subsequent search using Clio updated the search and extended it by using ‘life cycle’, ‘nutrition’ and ‘noncommunicable disease’ (NCD), and ‘life course’. Several published and unpublished WHO reports were key in developing the background and arguments. Setting: International and national public health and nutrition policy development in light of the global epidemic in chronic diseases, and the continuing nutrition, demographic and epidemiological transitions happening in an increasingly globalized world. Results of review: There is a global epidemic of increasing obesity, diabetes and other chronic NCDs, especially in developing and transitional economies, and in the less affluent within these, and in the developed countries. At the same time, there has been an increase in communities and households that have coincident under- and over-nutrition. Conclusions: The epidemic will continue to increase and is due to a lifetime of exposures and influences. Genetic predisposition plays an unspecified role, and with programming during fetal life for adult disease contributing to an unknown degree. A global rise in obesity levels is contributing to a particular epidemic of type 2 diabetes as well as other NCDs. Prevention will be the most cost-effective and feasible approach for many countries and should involve three mutually reinforcing strategies throughout life, starting in the antenatal period.

Hepatitis B virus epidemiology, disease burden, treatment, and current and emerging prevention and control measures

Abstract: Hepatitis B virus (HBV) infection is a serious global health problem, with 2 billion people infected worldwide, and 350 million suffering from chronic HBV infection. The 10th leading cause of death worldwide, HBV infections result in 500 000 to 1.2 million deaths per year caused by chronic hepatitis, cirrhosis, and hepatocellular carcinoma; the last accounts for 320 000 deaths per year. In Western countries, the disease is relatively rare and acquired primarily in adulthood, whereas in Asia and most of Africa, chronic HBV infection is common and usually acquired perinatally or in childhood. More efficacious treatments, mass immunization programs, and safe injection techniques are essential for eliminating HBV infection and reducing global HBV-related morbidity and mortality. Safe and effective vaccines against HBV infection have been available since 1982. The implementation of mass immunization programs, which have been recommended by the World Health Organization since 1991, have dramatically decreased the incidence of HBV infection among infants, children, and adolescents in many countries. However, not all countries have adopted these recommendations and there remains a large number of persons that were infected with HBV prior to the implementation of immunization programs. Antiviral treatment is the only way to reduce morbidity and mortality from chronic HBV infection. Conventional interferon alfa and lamivudine have been the primary treatments to date. Conventional interferon alfa produces a durable response in a moderate proportion of patients but has undesirable side-effects and must be administered subcutaneously three times per week. Lamivudine also produces a response in a modest proportion of patients and causes few side-effects. However, prolonged treatment is often necessary to prevent relapse on cessation of therapy, and continuous treatment can lead to the development of lamivudine resistance. Promising emerging new treatments include adefovir, entecavir and peginterferon alfa-2a (40 kDa).

Leishmaniasis: current situation and new perspectives.

Abstract: Leishmaniasis represents a complex of diseases with an important clinical and epidemiological diversity. Visceral leishmaniasis (VL) is of higher priority than cutaneous leishmaniasis (CL) as it is a fatal disease in the absence of treatment. Anthroponotic VL foci are of special concern as they are at the origin of frequent and deathly epidemics (e.g. Sudan). Leishmaniasis burden remains important: 88 countries, 350 million people at risk, 500,000 new cases of VL per year, 1-1.5 million for CL and DALYs: 2.4 millions. Most of the burden is concentrated on few countries which allows clear geographic priorities. Leishmaniasis is still an important public health problem due to not only environmental risk factors such as massive migrations, urbanisation, deforestation, new irrigation schemes, but also to individual risk factors: HIV, malnutrition, genetic, etc em leader Leishmaniasis is part of those diseases which still requires improved control tools. Consequently WHO/TDR research for leishmaniasis has been more and more focusing on the development of new tools such as diagnostic tests, drugs and vaccines. The ongoing effort has already produced significant results. The newly available control tools should allow a scaling up of control activities in priority areas. In anthroponotic foci, the feasibility of getting a strong impact on mortality, morbidity and transmission, is high.

The treatment gap in mental health care.

Abstract: Mental disorders are highly prevalent and cause considerable suffering and disease burden. To compound this public health problem, many individuals with psychiatric disorders remain untreated although effective treatments exist. We examine the extent of this treatment gap. We reviewed community-based psychiatric epidemiology studies that used standardized diagnostic instruments and included data on the percentage of individuals receiving care for schizophrenia and other non-affective psychotic disorders, major depression, dysthymia, bipolar disorder, generalized anxiety disorder (GAD), panic disorder, obsessive-compulsive disorder (OCD), and alcohol abuse or dependence. The median rates of untreated cases of these disorders were calculated across the studies. Examples of the estimation of the treatment gap for WHO regions are also presented. Thirty-seven studies had information on service utilization. The median treatment gap for schizophrenia, including other non-affective psychosis, was 32.2%. For other disorders the gap was: depression, 56.3%; dysthymia, 56.0%; bipolar disorder, 50.2%; panic disorder, 55.9%; GAD, 57.5%; and OCD, 57.3%. Alcohol abuse and dependence had the widest treatment gap at 78.1%. The treatment gap for mental disorders is universally large, though it varies across regions. It is likely that the gap reported here is an underestimate due to the unavailability of community-based data from developing countries where services are scarcer. To address this major public health challenge, WHO has adopted in 2002 a global action programme that has been endorsed by the Member States.

The global burden of chronic diseases: overcoming impediments to prevention and control.

Abstract: Chronic diseases are the largest cause of death in the world. In 2002, the leading chronic diseases—cardiovascular disease, cancer, chronic respiratory disease, and diabetes—caused 29 million deaths worldwide. Despite growing evidence of epidemiological and economic impact, the global response to the problem remains inadequate. Stakeholders include governments, the World Health Organization and other United Nations bodies, academic and research groups, nongovernmental organizations, and the private sector. Lack of financial support retards capacity development for prevention, treatment, and research in most developing countries. Reasons for this include that up-to-date evidence related to the nature of the burden of chronic diseases is not in the hands of decision makers and strong beliefs persist that chronic diseases afflict only the affluent and the elderly, that they arise solely from freely acquired risks, and that their control is ineffective and too expensive and should wait until infectious diseases are addressed. The influence of global economic factors on chronic disease risks impedes progress, as does the orientation of health systems toward acute care. We identify 3 policy levers to address these impediments elevating chronic diseases on the health agenda of key policymakers, providing them with better evidence about risk factor control, and persuading them of the need for health systems change. A more concerted, strategic, and multisectoral policy approach, underpinned by solid research, is essential to help reverse the negative trends in the global incidence of chronic disease.

Guidelines for Preventing Health-Care-- Associated Pneumonia, 2003 Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee

Abstract: This report updates, expands, and replaces the previously published CDC "Guideline for Prevention of Nosocomial Pneumonia". The new guidelines are designed to reduce the incidence of pneumonia and other severe, acute lower respiratory tract infections in acute-care hospitals and in other health-care settings (e.g., ambulatory and long-term care institutions) and other facilities where health care is provided. Among the changes in the recommendations to prevent bacterial pneumonia, especially ventilator-associated pneumonia, are the preferential use of oro-tracheal rather than naso-tracheal tubes in patients who receive mechanically assisted ventilation, the use of noninvasive ventilation to reduce the need for and duration of endotracheal intubation, changing the breathing circuits of ventilators when they malfunction or are visibly contaminated, and (when feasible) the use of an endotracheal tube with a dorsal lumen to allow drainage of respiratory secretions; no recommendations were made about the use of sucralfate, histamine-2 receptor antagonists, or antacids for stress-bleeding prophylaxis. For prevention of health-care--associated Legionnaires disease, the changes include maintaining potable hot water at temperatures not suitable for amplification of Legionella spp., considering routine culturing of water samples from the potable water system of a facility's organ-transplant unit when it is done as part of the facility's comprehensive program to prevent and control health-care--associated Legionnaires disease, and initiating an investigation for the source of Legionella spp. when one definite or one possible case of laboratory-confirmed health-care--associated Legionnaires disease is identified in an inpatient hemopoietic stem-cell transplant (HSCT) recipient or in two or more HSCT recipients who had visited an outpatient HSCT unit during all or part of the 2-10 day period before illness onset. In the section on aspergillosis, the revised recommendations include the use of a room with high-efficiency particulate air filters rather than laminar airflow as the protective environment for allogeneic HSCT recipients and the use of high-efficiency respiratory-protection devices (e.g., N95 respirators) by severely immunocompromised patients when they leave their rooms when dust-generating activities are ongoing in the facility. In the respiratory syncytial virus (RSV) section, the new recommendation is to determine, on a case-by-case basis, whether to administer monoclonal antibody (palivizumab) to certain infants and children aged <24 months who were born prematurely and are at high risk for RSV infection. In the section on influenza, the new recommendations include the addition of oseltamivir (to amantadine and rimantadine) for prophylaxis of all patients without influenza illness and oseltamivir and zanamivir (to amantadine and rimantadine) as treatment for patients who are acutely ill with influenza in a unit where an influenza outbreak is recognized. In addition to the revised recommendations, the guideline contains new sections on pertussis and lower respiratory tract infections caused by adenovirus and human parainfluenza viruses and refers readers to the source of updated information about prevention and control of severe acute respiratory syndrome.

WHO global strategy on diet, physical activity and health.

Abstract: On May 22, 2004, the 57th World Health Assembly (WHA) adopted a Global Strategy on Diet, Physical Activity and Health [1]. The Director-General of the World Health Organization (WHO) described the adoption of the strategy as a landmark achievement in global public health [2]. The Global Strategy addresses two of the major risk factors responsible for the heavy and growing burden of noncommunicable diseases, namely, unhealthy diet and physical inactivity, which now account for some 60% of global deaths and almost half (47%) of the global burden of diseases [3]. The 2002 World Health Report revealed how only a few risk factors were responsible for the leading causes of death and disability worldwide. Dietary and activity risks scored high, and among the 10 leading causes of death are high blood pressure, elevated blood cholesterol, low intake of fruits and vegetables, high body mass index, undernutrition, and physical inactivity [4]. WHO developed the strategy over the past two years through an inclusive and wide-ranging consultation process that involved Member States, United Nations agencies, civil society organizations, and the private sector. The adoption of the strategy comes at a critical time in which countries have a relatively short period to intervene and act before the disease burden and human and economic costs of diseases, such as cardiovascular diseases, will be out of control. This is particularly true for developing countries [5]. Key policy recommendations outlined by the strategy include the following: Policies concerning the environment

Evidence-Based Public Health: Moving Beyond Randomized Trials

Abstract: Randomized controlled trials (RCTs) are essential for evaluating the efficacy of clinical interventions, where the causal chain between the agent and the outcome is relatively short and simple and where results may be safely extrapolated to other settings. However, causal chains in public health interventions are complex, making RCT results subject to effect modification in different populations. Both the internal and external validity of RCT findings can be greatly enhanced by observational studies using adequacy or plausibility designs. For evaluating large-scale interventions, studies with plausibility designs are often the only feasible option and may provide valid evidence of impact. There is an urgent need to develop evaluation standards and protocols for use in circumstances where RCTs are not appropriate.

Systems for grading the quality of evidence and the strength of recommendations I: critical appraisal of existing approaches The GRADE Working Group.

Abstract: A number of approaches have been used to grade levels of evidence and the strength of recommendations. The use of many different approaches detracts from one of the main reasons for having explicit approaches: to concisely characterise and communicate this information so that it can easily be understood and thereby help people make well-informed decisions. Our objective was to critically appraise six prominent systems for grading levels of evidence and the strength of recommendations as a basis for agreeing on characteristics of a common, sensible approach to grading levels of evidence and the strength of recommendations. Six prominent systems for grading levels of evidence and strength of recommendations were selected and someone familiar with each system prepared a description of each of these. Twelve assessors independently evaluated each system based on twelve criteria to assess the sensibility of the different approaches. Systems used by 51 organisations were compared with these six approaches. There was poor agreement about the sensibility of the six systems. Only one of the systems was suitable for all four types of questions we considered (effectiveness, harm, diagnosis and prognosis). None of the systems was considered usable for all of the target groups we considered (professionals, patients and policy makers). The raters found low reproducibility of judgements made using all six systems. Systems used by 51 organisations that sponsor clinical practice guidelines included a number of minor variations of the six systems that we critically appraised. All of the currently used approaches to grading levels of evidence and the strength of recommendations have important shortcomings.

Differentiation of the Major Listeria monocytogenes Serovars by Multiplex PCR

Abstract: A new multiplex PCR assay was developed to separate the four major Listeria monocytogenes serovars isolated from food and patients (1/2a, 1/2b, 1/2c, and 4b) into distinct groups. The PCR test, which constitutes a rapid and practical alternative to laborious classical serotyping, was successfully evaluated with 222 Listeria strains.

Diagnostics for the developing world.

Abstract: Although 'diseases of affluence', such as diabetes and cardiovascular disease, are increasing in developing countries, infectious diseases still impose the greatest health burden. Annually, just under 1 million people die from malaria, 4.3 million from acute respiratory infections, 2.9 million from enteric infections and 5 million from AIDS and tuberculosis. Other sexually transmitted infections and tropical parasitic infections are responsible for hundreds of thousands of deaths and an enormous burden of morbidity. More than 95% of these deaths occur in developing countries. Simple, accurate and stable diagnostic tests are essential to combat these diseases, but are usually unavailable or inaccessible to those who need them.

Use of the inactivated intranasal influenza vaccine and the risk of Bell's palsy in Switzerland.

Abstract: Background After the introduction of an inactivated intranasal influenza vaccine that was used only in Switzerland, 46 cases of Bell's palsy were reported. Methods We conducted a matched case–control study and a case-series analysis. All primary care physicians, ear, nose, and throat specialists, and neurologists in German-speaking regions of Switzerland were requested to identify cases of Bell's palsy diagnosed in adults between October 1, 2000, and April 30, 2001. Each physician was invited to select three control patients for each patient with Bell's palsy, with matching according to age, date of the clinic visit, and physician. Vaccination information was provided by the physicians. Results A total of 773 patients with Bell's palsy were identified. Of the 412 (53.3 percent) who could be evaluated, 250 (60.7 percent) were enrolled and matched with 722 control patients; the other 162 patients had no controls. In the case–control study, we found that 68 patients with Bell's palsy (27.2 percent) and 8 con...

Improving the quality of health care for chronic conditions

Abstract: Chronic conditions are increasingly the primary concern of healthcare systems throughout the world. In response to this challenge, the World Health Organization has joined with the MacColl Institute for Healthcare Innovation to adapt the Chronic Care Model (CCM) from a global perspective. The resultant effort is the Innovative Care for Chronic Conditions (ICCC) framework which expands community and policy aspects of improving health care for chronic conditions and includes components at the micro (patient and family), meso (healthcare organisation and community), and macro (policy) levels. The framework provides a flexible but comprehensive base on which to build or redesign health systems in accordance with local resources and demands.

Refractive error and visual impairment in urban children in southern China

Abstract: Purpose To assess the prevalence of refractive error and visual impairment in school-age children in a metropolitan area of southern China. Methods Random selection of geographically defined clusters was used to identify children 5 to 15 years of age in Guangzhou. Children in 22 clusters were enumerated through a door-to-door survey and examined in 71 schools and 19 community facilities from October 2002 to January 2003. The examination included visual acuity measurements, ocular motility evaluation, retinoscopy, and autorefraction under cycloplegia and examination of the external eye, anterior segment, media, and fundus. Results A total of 5053 children living in 4814 households were enumerated, and 4364 (86.4%) were examined. The prevalence of uncorrected, presenting, and best-corrected visual acuity 20/40 or worse in the better eye was 22.3%, 10.3%, and 0.62%, respectively. Refractive error was the cause in 94.9% of the 2335 eyes with reduced vision, amblyopia in 1.9%, other causes in 0.4%, and unexplained causes in the remaining 2.8%. External and anterior segment abnormalities were seen in 1496 (34.3%) children, mainly minor conjunctival abnormalities. Media and fundus abnormalities were observed in 32 (0.73%) children. Myopia (spherical equivalent of at least -0.50 D in either eye) measured with retinoscopy affected 73.1% of children 15 years of age, 78.4% with autorefraction. The prevalence of myopia was 3.3% in 5-year-olds with retinoscopy and 5.7% with autorefraction. Females had a significantly higher risk of myopia. Hyperopia (+2.00 D or more) measured with retinoscopy was present in 16.7% of 5-year-olds, 17.0% with autorefraction. The prevalence of hyperopia was below 1% in 15-year-olds, with both methods. Astigmatism (cylinder of > or = 0.75 D) was present in 33.6% of children with retinoscopy and in 42.7% with autorefraction. Conclusions The prevalence of reduced vision because of myopia is high in school-age children living in metropolitan Guangzhou, representing an important public health problem. One third of these children do not have the necessary corrective spectacles. Effective strategies are needed to eliminate this easily treated cause of significant visual impairment.

Measurement and standardization protocols for anthropometry used in the construction of a new international growth reference.

Abstract: Thorough training, continuous standardization, and close monitoring of the adherence to measurement procedures during data collection are essential for minimizing random error and bias in multicenter studies. Rigorous anthropometry and data collection protocols were used in the WHO Multicentre Growth Reference Study to ensure high data quality. After the initial training and standardization, study teams participated in standardization sessions every two months for a continuous assessment of the precision and accuracy of their measurements. Once a year the teams were restandardized against the WHO lead anthropometrist, who observed their measurement techniques and retrained any deviating observers. Robust and precise equipment was selected and adapted for field use. The anthropometrists worked in pairs, taking measurements independently, and repeating measurements that exceeded preset maximum allowable differences. Ongoing central and local monitoring identified anthropometrists deviating from standard procedures, and immediate corrective action was taken. The procedures described in this paper are a model for research settings.

Multiple Ebola Virus Transmission Events and Rapid Decline of Central African Wildlife

Abstract: Several human and animal Ebola outbreaks have occurred over the past 4 years in Gabon and the Republic of Congo. The human outbreaks consisted of multiple simultaneous epidemics caused by different viral strains, and each epidemic resulted from the handling of a distinct gorilla, chimpanzee, or duiker carcass. These animal populations declined markedly during human Ebola outbreaks, apparently as a result of Ebola infection. Recovered carcasses were infected by a variety of Ebola strains, suggesting that Ebola outbreaks in great apes result from multiple virus introductions from the natural host. Surveillance of animal mortality may help to predict and prevent human Ebola outbreaks.

Rates, barriers and outcomes of HIV serostatus disclosure among women in developing countries: implications for prevention of mother-to-child transmission programmes

Abstract: This paper synthesizes the rates, barriers, and outcomes of HIV serostatus disclosure among women in developing countries. We identified 17 studies from peer-reviewed journals and international conference abstracts — 15 from sub-Saharan Africa and 2 from south-east Asia — that included information on either the rates, barriers or outcomes of HIV serostatus disclosure among women in developing countries. The rates of disclosure reported in these studies ranged from 16.7% to 86%, with women attending free-standing voluntary HIV testing and counselling clinics more likely to disclose their HIV status to their sexual partners than women who were tested in the context of their antenatal care. Barriers to disclosure identified by the women included fear of accusations of infidelity, abandonment, discrimination and violence. Between 3.5% and 14.6% of women reported experiencing a violent reaction from a partner following disclosure. The low rates of HIV serostatus disclosure reported among women in antenatal settings have several implications for prevention of mother-to-child transmission of HIV (pMTCT) programmes as the optimal uptake and adherence to such programmes is difficult for women whose partners are either unaware or not supportive of their participation. This article discusses these implications and offers some strategies for safely increasing the rates of HIV status disclosure among women.

The who Multicentre Growth Reference Study: Planning, Study Design, and Methodology:

Abstract: The World Health Organization (WHO) Multicentre Growth Reference Study (MGRS) is a community-based, multicountry project to develop new growth references for infants and young children. The design combines a longitudinal study from birth to 24 months with a cross-sectional study of children aged 18 to 71 months. The pooled sample from the six participating countries (Brazil, Ghana, India, Norway, Oman, and the United States) consists of about 8,500 children. The study subpopulations had socioeconomic conditions favorable to growth, and low mobility, with at least 20% of mothers following feeding recommendations and having access to breastfeeding support. The individual inclusion criteria were absence of health or environmental constraints on growth, adherence to MGRS feeding recommendations, absence of maternal smoking, single term birth, and absence of significant morbidity. In the longitudinal study, mothers and newborns were screened and enrolled at birth and visited at home 21 times: at weeks 1, 2, 4, and 6; monthly from 2 to 12 months; and every 2 months in their second year. In addition to the data collected on anthropometry and motor development, information was gathered on socioeconomic, demographic, and environmental characteristics, perinatal factors, morbidity, and feeding practices. The prescriptive approach taken is expected to provide a single international reference that represents the best description of physiological growth for all children under five years of age and to establish the breastfed infant as the normative model for growth and development.

Global estimate of the incidence of clinical pneumonia among children under five years of age

Abstract: OBJECTIVE: Clinical pneumonia (defined as respiratory infections associated with clinical signs of pneumonia, principally pneumonia and bronchiolitis) in children under five years of age is still the leading cause of childhood mortality in the world. In this paper we aim to estimate the worldwide incidence of clinical pneumonia in young children. METHODS: Our estimate for the developing world is based on an analysis of published data on the incidence of clinical pneumonia from community based longitudinal studies. Among more than 2000 studies published since 1961, we identified 46 studies that reported the incidence of clinical pneumonia, and 28 of these met pre-defined quality criteria. FINDINGS: The estimate of the median incidence from those studies was 0.28 episodes per child-year (e/cy). The 25-75% interquartile range was 0.21-0.71. We assessed the plausibility of this estimate using estimates of global mortality from acute respiratory infections and reported case fatality rates for all episodes of clinical pneumonia reported in community-based studies or the case-fatality rate reported only for severe cases and estimates of the proportion of severe cases occurring in a defined population or community. CONCLUSION: The overlap between the ranges of the estimates implies that a plausible incidence estimate of clinical pneumonia for developing countries is 0.29 e/cy. This equates to an annual incidence of 150.7 million new cases, 11-20 million (7-13%) of which are severe enough to require hospital admission. In the developed world no comparable data are available. However, large population-based studies report that the incidence of community-acquired pneumonia among children less than five years old is approximately 0.026 e/cy, suggesting that more than 95% of all episodes of clinical pneumonia in young children worldwide occur in developing countries.

Migration of health-care workers from developing countries: strategic approaches to its management

Abstract: Of the 175 million people (2.9% of the world's population) living outside their country of birth in 2000, 65 million were economically active. The rise in the number of people migrating is significant for many developing countries because they are losing their better-educated nationals to richer countries. Medical practitioners and nurses represent a small proportion of the highly skilled workers who migrate, but the loss for developing countries of human resources in the health sector may mean that the capacity of the health system to deliver health care equitably is significantly compromised. It is unlikely that migration will stop given the advances in global communications and the development of global labour markets in some fields, which now include nursing. The aim of this paper is to examine some key issues related to the international migration of health workers and to discuss strategic approaches to managing migration.

Effective use of fluorides for the prevention of dental caries in the 21st century: the WHO approach.

Abstract: Despite great improvements in the oral health of populations across the world, problems still persist particularly among poor and disadvantaged groups in both developed and developing countries. According to the World Oral Health Report 2003, dental caries remains a major public health problem in most industrialized countries, affecting 60-90% of schoolchildren and the vast majority of adults. Although it appears that dental caries is less common and less severe in developing countries of Africa, it is anticipated that the incidence of caries will increase in several countries of that continent, due to changing living conditions and dietary habits, and inadequate exposure to fluorides. Research on the oral health effects of fluoride started around 100 years ago; the focus has been on the link between water and fluorides and dental caries and fluorosis, topical fluoride applications, fluoride toothpastes, and salt and milk fluoridation. Most recently, efforts have been made to summarize the extensive database through systematic reviews. Such reviews concluded that water fluoridation and use of fluoride toothpastes and mouthrinses significantly reduce the prevalence of dental caries. WHO recommends for public health that every effort must be made to develop affordable fluoridated toothpastes for use in developing countries. Water fluoridation, where technically feasible and culturally acceptable, has substantial advantages in public health; alternatively, fluoridation of salt and milk fluoridation schemes may be considered for prevention of dental caries.

The global burden of disease attributable to contaminated injections given in health care settings.

Abstract: As part of the 2000 Global Burden of Disease study, we quantified the death and disability from injection-associated infections with hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV). We modelled the fraction of incident infections attributable to health care injections in the year 2000 on the basis of the annual number of injections, the proportion of injections administered with reused equipment, the probability of transmission following percutaneous exposure, the prevalence of active infection, the prevalence of immunity and the total incidence. Infections in 2000 were converted into disability-adjusted life years (DALYs) in 2000-2030 using natural history parameters, background mortality, duration of disease, disability weights, age weights and a 3% discount rate. Four Global Burden of Disease regions where reuse of injection equipment in the absence of sterilization was negligible were excluded from the analysis. In the remaining 10 regions, in 2000, persons received an average of 3.4 injections per year, 39.3% of which were given with reused equipment. In 2000, contaminated injections caused an estimated 21 million HBV infections, two million HCV infections and 260,000 HIV infections, accounting for 32%, 40% and 5%, respectively, of new infections for a burden of 9,177,679 DALYs between 2000 and 2030. Injection overuse and unsafe practices account for a substantial burden of death and disability worldwide. There is a need for policies and plans for the safe and appropriate use of injections in countries where practices are poor.

Driven to Tiers: Socioeconomic and Racial Disparities in the Quality of Nursing Home Care

Abstract: Nursing home care is currently a two-tiered system. The lower tier consists of facilities housing mainly Medicaid residents and, as a result, has very limited resources. The nearly 15 percent of U.S. nonhospital-based nursing homes that serve predominantly Medicaid residents have fewer nurses, lower occupancy rates, and more health-related deficiencies. They are more likely to be terminated from the Medicaid/Medicare program, are disproportionately located in the poorest counties, and are more likely to serve African-American residents than are other facilities. The public reporting of quality indicators, intended to improve quality through market mechanisms, may result in driving poor homes out of business and will disproportionately affect nonwhite residents living in poor communities. This article recommends a proactive policy stance to mitigate these consequences of quality competition.

WHO systematic review of maternal morbidity and mortality: the prevalence of severe acute maternal morbidity (near miss)

Abstract: Aim: To determine the prevalence of severe acute maternal morbidity (SAMM) worldwide (near miss). Method: Systematic review of all available data. The methodology followed a pre-defined protocol, an extensive search strategy of 10 electronic databases as well as other sources. Articles were evaluated according to specified inclusion criteria. Data were extracted using data extraction instrument which collects additional information on the quality of reporting including definitions and identification of cases. Data were entered into a specially constructed database and tabulated using SAS statistical management and analysis software. Results: A total of 30 studies are included in the systematic review. Designs are mainly crosssectional and 24 were conducted in hospital settings, mostly teaching hospitals. Fourteen studies report on a defined SAMM condition while the remainder use a response to an event such as admission to intensive care unit as a proxy for SAMM. Criteria for identification of cases vary widely across studies. Prevalences vary between 0.80% – 8.23% in studies that use disease-specific criteria while the range is 0.38% – 1.09% in the group that use organ-system based criteria and included unselected group of women. Rates are within the range of 0.01% and 2.99% in studies using management-based criteria. It is not possible to pool data together to provide summary estimates or comparisons between different settings due to variations in case-identification criteria. Nevertheless, there seems to be an inverse trend in prevalence with development status of a country. Conclusion: There is a clear need to set uniform criteria to classify patients as SAMM. This standardisation could be made for similar settings separately. An organ-system dysfunction/failure approach is the most epidemiologically sound as it is least open to bias, and thus could permit developing summary estimates.