Showing papers in "Bulletin of The World Health Organization in 2011"
TL;DR: The estimate of the global incidence of JE remains substantial despite improvements in vaccination coverage, and more and better incidence studies in selected countries, particularly China and India, are needed to further refine these estimates.
Abstract: OBJECTIVE: To update the estimated global incidence of Japanese encephalitis (JE) using recent data for the purpose of guiding prevention and control efforts. METHODS: Thirty-two areas endemic for JE in 24 Asian and Western Pacific countries were sorted into 10 incidence groups on the basis of published data and expert opinion. Population-based surveillance studies using laboratory-confirmed cases were sought for each incidence group by a computerized search of the scientific literature. When no eligible studies existed for a particular incidence group, incidence data were extrapolated from related groups. FINDINGS: A total of 12 eligible studies representing 7 of 10 incidence groups in 24 JE-endemic countries were identified.Approximately 67 900 JE cases typically occur annually (overall incidence: 1.8 per 100 000), of which only about 10% are reported to the World Health Organization. Approximately 33 900 (50%) of these cases occur in China (excluding Taiwan) and approximately 51 000 (75%) occur in children aged 0-14 years (incidence: 5.4 per 100 000). Approximately 55 000 (81%) cases occur in areas with well established or developing JE vaccination programmes, while approximately 12 900 (19%) occur in areas with minimal or no JE vaccination programmes. CONCLUSION: Recent data allowed us to refine the estimate of the global incidence of JE, which remains substantial despite improvements in vaccination coverage. More and better incidence studies in selected countries, particularly China and India, are needed to further refine these estimates.
693 citations
Journal Article•
TL;DR: In this paper, the authors present a review of Japanese encephalitis (JE) in Asia, focusing on rural and suburban areas where rice culture and pig farming coexist.
Abstract: Introduction Japanese encephalitis (JE) is among the most important viral encephalitides in Asia, especially in rural and suburban areas where rice culture and pig farming coexist. (1-3) It has also occurred rarely and sporadically in northern Australia and parts of the Western Pacific. (4-6) JE is due to infection with the JE virus (JEV), a mosquito-borne flavivirus. The main JEV transmission cycle involves Culex tritaeniorhynchus mosquitoes and similar species that lay eggs in rice paddies and other open water sources, with pigs and aquatic birds as principal vertebrate amplifying hosts. (1,2,7) Humans are generally thought to be dead-end JEV hosts, i.e. they seldom develop enough viremia to infect feeding mosquitoes. Fewer than 1% of human JEV infections result in JE. Approximately 20-30% of JE cases are fatal and 30-50% of survivors have significant neurologic sequelae. (8) JE is primarily a disease of children and most adults in endemic countries have natural immunity after childhood infection, but all age groups are affected. In most temperate areas of Asia, JEV is transmitted mainly during the warm season, when large epidemics can occur. In the tropics and subtropics, transmission can occur year-round but often intensifes during the rainy season. (1-3) The global incidence of JE is unknown because the intensity and quality of JE surveillance and the availability of diagnostic laboratory testing vary throughout the world. Countries that have implemented high-quality childhood JE vaccination programmes have seen a dramatic decline in JE incidence. Although JE is reportable to the World Health Organization (WHO) by its Member States, reporting is highly variable and incomplete. In the late 1980s, Burke and Leake estimated that 50 000 new cases of JE occurred annually among the 2.4 billion people living in the 16 Asian countries considered endemic at the time (approximate overall annual incidence: 2 per 100 000). (2) In the intervening two decades, despite major population growth, urbanization, changes in agricultural practices and increased use of the JE vaccine in many countries, this figure has been widely quoted, including very recently. (9-13) In 2000, assuming an annual, age-group-specific incidence of 25 cases per 100 000, Tsai estimated that in the absence of vaccination 175 000 cases of JE would occur annually among Asian children aged 0-14 years living in rural areas. (14) The current study used more recent, published, local or national incidence estimates and current population data to produce an updated estimate of the annual global incidence of JE. Methods We approximated the JE-affected territory of each of the 24 countries endemic for JE using a recent update (15) of an earlier approximation by Tsai (16) with some modifications (Table 1, available at: http://www.who.int/bulletin/ volumes/89/10/10-085233). Based on these same approximations, (15,16) we then stratified the JE-affected territory of some countries (e.g. China excluding Taiwan, India and Nepal) into two or more incidence strata. Because suitable studies of JE incidence were not available for every endemic country or incidence stratum, we sorted JE-endemic countries and incidence strata into 10 incidence groups (A, B, C1, C2 and D through I) based primarily on geographic proximity, ecologic similarity, vaccine programme similarity. Table 1 briefly describes the status of each endemic country's JE vaccination programme as of 2009, according to recent publications and unpublished sources. (8,17-20) Incidence data We identified studies that contained potentially useful data on the incidence of JE in Asia in a manner similar to the one used in a recent study of global typhoid fever incidence. (21) Whenever possible, this review followed the relevant guidelines for Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). (22) The review process is described as follows and no protocol is available. …
539 citations
TL;DR: Maternal depression was associated with early childhood underweight and stunting in the children of depressed mothers and early identification, treatment and prevention of maternal depression may help reduce child stunting and underweight in developing countries.
Abstract: OBJECTIVE: To investigate the relationship between maternal depression and child growth in developing countries through a systematic literature review and meta-analysis. METHODS: Six databases were searched for studies from developing countries on maternal depression and child growth published up until 2010. Standard meta-analytical methods were followed and pooled odds ratios (ORs) for underweight and stunting in the children of depressed mothers were calculated using random effects models for all studies and for subsets of studies that met strict criteria on study design, exposure to maternal depression and outcome variables. The population attributable risk (PAR) was estimated for selected studies. FINDINGS: Seventeen studies including a total of 13 923 mother and child pairs from 11 countries met inclusion criteria. The children of mothers with depression or depressive symptoms were more likely to be underweight (OR: 1.5; 95% confidence interval, CI: 1.2-1.8) or stunted (OR: 1.4; 95% CI: 1.2-1.7). Subanalysis of three longitudinal studies showed a stronger effect: the OR for underweight was 2.2 (95% CI: 1.5-3.2) and for stunting, 2.0 (95% CI: 1.0-3.9). The PAR for selected studies indicated that if the infant population were entirely unexposed to maternal depressive symptoms 23% to 29% fewer children would be underweight or stunted. CONCLUSION: Maternal depression was associated with early childhood underweight and stunting. Rigorous prospective studies are needed to identify mechanisms and causes. Early identification, treatment and prevention of maternal depression may help reduce child stunting and underweight in developing countries.
384 citations
TL;DR: There is an urgent need to identify and implement feasible and sustainable approaches to strengthen HAI prevention, surveillance and control in Africa and it is revealed that its frequency is much higher than in developed countries.
Abstract: OBJECTIVE: To assess the epidemiology of endemic health-care-associated infection (HAI) in Africa. METHODS: Three databases (PubMed, the Cochrane Library, and the WHO regional medical database for Africa) were searched to identify studies published from 1995 to 2009 on the epidemiology of HAI in African countries. No language restriction was applied. Available abstract books of leading international infection control conferences were also searched from 2004 to 2009. FINDINGS: The eligibility criteria for inclusion in the review were met by 19 articles, only 2 of which met the criterion of high quality. Four relevant abstracts were retrieved from the international conference literature.The hospital-wide prevalence of HAI varied between 2.5% and 14.8%; in surgical wards, the cumulative incidence ranged from 5.7% to 45.8%.The largest number of studies focused on surgical site infection, whose cumulative incidence ranged from 2.5% to 30.9%. Data on causative pathogens were available from a few studies only and highlighted the importance of Gram-negative rods, particularly in surgical site infection and ventilator-associated pneumonia. CONCLUSION: Limited information is available on the endemic burden of HAI in Africa, but our review reveals that its frequency is much higher than in developed countries.There is an urgent need to identify and implement feasible and sustainable approaches to strengthen HAI prevention, surveillance and control in Africa.
344 citations
TL;DR: The number of mesothelioma deaths reported and the number of countries reporting deaths increased during the study period, probably due to better disease recognition and an increase in incidence, and may be an early indication that the disease burden is slowly shifting towards those that have used asbestos more recently.
Abstract: OBJECTIVE: To carry out a descriptive analysis of mesothelioma deaths reported worldwide between 1994 and 2008. METHODS: We extracted data on mesothelioma deaths reported to the World Health Organization mortality database since 1994, when the disease was first recorded. We also sought information from other English-language sources. Crude and age-adjusted mortality rates were calculated and mortality trends were assessed from the annual percentage change in the age-adjusted mortality rate. FINDINGS: In total, 92 253 mesothelioma deaths were reported by 83 countries. Crude and age-adjusted mortality rates were 6.2 and 4.9 per million population, respectively. The age-adjusted mortality rate increased by 5.37% per year and consequently more than doubled during the study period.The mean age at death was 70 years and the male-to-female ratio was 3.6:1.The disease distribution by anatomical site was: pleura, 41.3%; peritoneum, 4.5%; pericardium, 0.3%; and unspecified sites, 43.1%.The geographical distribution of deaths was skewed towards high-income countries: the United States of America reported the highest number, while over 50% of all deaths occurred in Europe. In contrast, less than 12% occurred in middle- and low-income countries. The overall trend in the age-adjusted mortality rate was increasing in Europe and Japan but decreasing in the United States. CONCLUSION: The number of mesothelioma deaths reported and the number of countries reporting deaths increased during the study period, probably due to better disease recognition and an increase in incidence. The different time trends observed between countries may be an early indication that the disease burden is slowly shifting towards those that have used asbestos more recently.
342 citations
TL;DR: Country-specific policies are needed to overcome the large shortage of mental health-care staff and services throughout LMICs, which would need to be increased by 239,000 full-time equivalent professionals.
Abstract: Objective To estimate the shortage of mental health professionals in low- and middle-income countries (LMICs). Methods We used data from the World Health Organization's Assessment Instrument for Mental Health Systems (WHO-AIMS) from 58 LMICs, country-specific information on the burden of various mental disorders and a hypothetical core service delivery package to estimate how many psychiatrists, nurses and psychosocial care providers would be needed to provide mental health care to the total population of the countries studied. We focused on the following eight problems, to which WHO has attached priority: depression, schizophrenia, psychoses other than schizophrenia, suicide, epilepsy, dementia, disorders related to the use of alcohol and illicit drugs, and paediatric mental disorders. Findings All low-income countries and 59% of the middle-income countries in our sample were found to have far fewer professionals than they need to deliver a core set of mental health interventions. The 58 LMICs sampled would need to increase their total mental health workforce by 239 000 full-time equivalent professionals to address the current shortage. Conclusion Country-specific policies are needed to overcome the large shortage of mental health-care staff and services throughout LMICs.
325 citations
TL;DR: The global burden of CPA as a sequel to PTB is substantial and warrants further investigation, since CPA responds to long-term antifungal therapy, improved case detection should be urgently undertaken.
Abstract: OBJECTIVE: To estimate the global burden of chronic pulmonary aspergillosis (CPA) after pulmonary tuberculosis (PTB), specifically in cases with pulmonary cavitation. METHODS: PTB rates were obtained from the World Health Organization and a scoping review of the literature was conducted to identify studies on residual pulmonary cavitation after PTB and estimate the global incidence of CPA after PTB. Having established that from 21% (United States of America) to 35% (Taiwan, China) of PTB patients developed pulmonary cavities and that about 22% of these patients developed CPA, the authors applied annual attrition rates of 10%, 15% and 25% to estimate the period prevalence range for CPA over five years. Analysis was based on a deterministic model. FINDINGS: In 2007, 7.7 million cases of PTB occurred globally, and of them, an estimated 372 000 developed CPA: from 11 400 in Europe to 145 372 in South-East Asia. The global five-year period prevalence was 1 174 000, 852 000 and 1 372 000 cases at 15%, 25% and 10% annual attrition rates, respectively. The prevalence rate ranged from < 1 case per 100 000 population in large western European countries and the United States of America to 42.9 per 100 000 in both the Democratic Republic of the Congo and Nigeria. China and India had intermediate five-year period prevalence rates of 16.2 and 23.1 per 100 000, respectively. CONCLUSION: The global burden of CPA as a sequel to PTB is substantial and warrants further investigation. CPA could account for some cases of smear-negative PTB. Since CPA responds to long-term antifungal therapy, improved case detection should be urgently undertaken.
303 citations
TL;DR: To bring international attention to a growing public health threat, the World Health Organization (WHO) selected antimicrobial resistance as the theme for World Health Day 2011.
Abstract: To bring international attention to a growing public health threat, the World Health Organization (WHO) selected antimicrobial resistance as the theme for World Health Day 2011. Antimicrobial resistance is a threat to all branches of medical and public health practice. It challenges the control of infectious diseases, jeopardizes progress on health outcomes by increasing morbidity and mortality and imposes huge costs on societies. In the European Union, about 25000 patients die each year from infections caused by selected multidrug-resistant bacteria and the associated costs are estimated at about 1.5 billion euros per year.
284 citations
TL;DR: The review highlights the urgent need for more evidence on effective prevention interventions and for integrating sound evaluation into new initiatives, both to monitor and improve their impact and to expand the global evidence base in this area.
Abstract: Violence against women has been described as “perhaps the most shameful human rights violation, and the most pervasive.”1 Addressing violence against women is central to the achievement of Millennium Development Goal (MDG) 3 on women's empowerment and gender equality, as well as MDGs 4, 5 and 6.2 It is also a peace and security issue. In spite of this recognition, investment in prevention and in services for survivors remains woefully inadequate.
Research on violence against women – especially male partner violence – has increased. Since 2005, when the first results of the World Health Organization (WHO) Multi-Country Study on Women’s Health and Domestic Violence3 were launched, the number of intimate partner violence prevalence studies increased fourfold, from 80 to more than 300, in 2008. We now have population-based prevalence data on intimate partner violence from more than 90 countries, although there are still some regions – such as the Middle East and west Africa – where there is relatively limited data. Similarly, there is also a growing body of evidence about the range of negative health and development consequences of this violence.
Women suffer violent deaths either directly – through homicide – or indirectly, through suicide, maternal causes and AIDS. Violence is also an important cause of morbidity from multiple mental, physical, sexual and reproductive health outcomes, and it is also linked with known risk factors for poor health, such as alcohol and drug use, smoking and unsafe sex.4,5 Violence during pregnancy has also been associated with an increased risk of miscarriage, premature delivery and low birth weight.6,7
When the cumulative impacts on mortality and morbidity are assessed, the health burden is often higher than for other, more commonly accepted, public health priorities. In Mexico City, for example, rape and intimate partner violence against women was estimated to be the third most important cause of morbidity and mortality, accounting for 5.6% of all disability-adjusted life years lost.8 In Victoria, Australia, partner violence accounted for 7.9% of the overall disease burden among women of reproductive age and was a larger risk to health than factors such as raised blood pressure, tobacco use and increased body weight.9
In addition to the human costs, research also shows that violence has huge economic costs, including the direct costs to health, legal, police and other services. In 2002, Health Canada estimated that the direct medical costs of all forms of violence against women was 1.1 billion Canadian dollars.10 In low-resource settings, relatively few women may seek help from formal services, but because of the high prevalence of violence, the overall costs are substantial. In Uganda, for example, the cost of domestic violence was estimated at 2.5 million United States dollars in 2007.11
The broader social costs are profound but difficult to quantify.12 Violence against women is likely to constrain poverty reduction efforts by reducing women’s participation in productive employment. Violence also undermines efforts to improve women’s access to education, with violence and the fear of violence contributing to lower school enrolment for girls. Domestic violence has also been shown to affect the welfare and education of children in the family.
This growing understanding of the impact of violence needs to be translated into investment in primary, secondary and tertiary level prevention: including both services that respond to the needs of women living with or who have experienced violence and interventions to prevent violence. WHO has recently published Preventing intimate partner and sexual violence against women: taking action and generating evidence.13 This publication summarizes the existing evidence on strategies for primary prevention, identifying those that have been shown to be effective and those that seem promising or theoretically feasible. The review highlights the urgent need for more evidence on effective prevention interventions and for integrating sound evaluation into new initiatives, both to monitor and improve their impact and to expand the global evidence base in this area. It recognizes how infant and early childhood experiences influence the likelihood of people later becoming perpetrators or victims of intimate partner and sexual violence, as well as the need for early childhood interventions, especially for children growing up in families where there is abuse. It also recognizes the importance of strategies to empower women, financially and personally, and of challenging social norms that perpetuate this violence. Laws and policies that promote and protect the human rights of women are also necessary, if not sufficient, to address violence against women. In addition, health and other services need to be available and responsive to the needs of women suffering abuse. Concerted action is needed in all of these areas, but there is limited research on the most effective approaches.
To help address this gap, the Bulletin would like to invite submissions of papers describing research that addresses violence against women. We are particularly interested in research with a strong intervention focus, including ways to get violence against women onto different policy agendas and lessons about how to address some of the challenges policy-makers face; innovative approaches to prevention or to service provision, including community-based programmes in both conflict- and crises-affected and more stable settings; research to address more neglected forms of violence against women, and evidence on the costs and cost-effectiveness of intervention responses. Descriptive research that contributes to a better understanding of the global prevalence and costs of violence, or that provides evidence about the root causes of such violence will also be considered. Submissions can be made throughout 2011 at: http://submit.bwho.org
260 citations
TL;DR: Whether progress towards gender empowerment can take place without a corresponding increase in smoking among women remains to be seen and strong tobacco control measures are needed in countries where women are being increasingly empowered.
Abstract: OBJECTIVE: To determine whether in countries with high gender empowerment the female-to-male smoking prevalence ratio is also higher. METHODS: Bivariate and multiple regression analyses were performed to explore the relation between the United Nations Development Programme's gender empowerment measure (GEM) and the female-to-male smoking prevalence ratio (calculated from the 2008 WHO global tobacco control report ). Because a country's progression through the various stages of the tobacco epidemic and its gender smoking ratio (GSR) are thought to be influenced by its level of development, we explored this correlation as well, with economic development defined in terms of gross national income (GNI) per capita and income inequality (Gini coefficient). FINDINGS: The GSR was significantly and positively correlated with the GEM (r = 0.680; P < 0.001). In addition, the GEM was the strongest predictor of the GSR (β, adjusted: 0.47; P < 0.0001) after controlling for GNI per capita and for Gini coefficient. CONCLUSION: Whether progress towards gender empowerment can take place without a corresponding increase in smoking among women remains to be seen. Strong tobacco control measures are needed in countries where women are being increasingly empowered.
249 citations
Journal Article•
TL;DR: In this article, the authors developed a deterministic scenario model using Excel to estimate the adult burden of CPA in the largest countries of every WHO region and showed that the mortality figures quoted by the World Health Organization (WHO) were for the point 12 months after the diagnosis of PTB.
Abstract: Introduction With more than 36 million people cured of tuberculosis between 1995 and 2008 (1) and 9 million new cases diagnosed worldwide each year, (2) the health of those affected over the long term warrants attention. Treated pulmonary tuberculosis (PTB) can lead to complications, including progressive loss of lung function, (3) persistent pulmonary symptoms (3) and chronic pulmonary aspergillosis (CPA). (4-6) Of the long-term sequelae of PTB, CPA is perhaps the most subtle, yet the most severe. (4-11) In the 1960s the Research Committee of the British Thoracic and Tuberculosis Association estimated the prevalence of CPA in patients who had a residual cavity of at least 2.5 cm on the chest radiograph following treatment for PTB. (9,12) It assessed more than 500 patients from 55 chest clinics twice--once about 12 months after the sputum became negative for acid fast bacilli, (12) and again three years later? Remarkably, 25% of the patients had detectable Aspergillus precipitins in blood and both precipitins and radiological features of an aspergilloma were detectable in 14% at 12 months and in 22% at 3-4 years. PTB and CPA present with similar symptoms. This, combined with inadequate facilities for testing for immunoglobulin G (IgG) antibodies (precipitins) against A. fumigatus in many places, probably results in the underdiagnosis of CPA both at initial presentation (13) and following treatment for PTB. For example, in early case series of people with respiratory illness and negative acid fast bacillus (AFB) sputum smears in sub-Saharan Africa, A. fumigatus was among the pathogens identified. (14) CPA is an important differential diagnosis of what appears to be smear-negative tuberculosis. CPA occurs in various forms: simple aspergilloma, chronic cavitary pulmonary aspergillosis and chronic fibrosing pulmonary aspergillosis, both with and without an aspergilloma. (4) Unlike invasive aspergillosis, CPA occurs in immunocompetent patients. Morbidity is considerable and is marked by both systemic and respiratory symptoms and haemoptysis. (7,8) Weight loss, profound fatigue, severe shortness of breath and life-threatening haemoptysis are common. Progressive pulmonary fibrosis and loss of lung function, also common, could partly account for the unexplained loss of lung function in these patients. Even when treated, CPA has a case fatality rate of 20-33% in the short-term and of 50% over a span of 5 years. (5,8) The country-specific PTB statistics and mortality rates published by the World Health Organization (WHO) (15) make it possible to estimate the burden of chronic sequelae after treatment for PTB. Our objective was to use these published clinical and population data as inputs to model estimates of the likely burden of CPA related to PTB worldwide. Methods We developed a deterministic scenario model using Excel (Microsoft, Bellevue, United States of America). Fig. I shows our approach to estimating the adult burden of CPA in the largest countries of every WHO region. We started with WHO estimates of the number of new cases of PTB and of deaths from PTB (15) and assumed that the mortality figures quoted by the WHO were for the point 12 months after the diagnosis of PTB. [FIGURE 1 OMITTED] We searched the literature with the following questions in mind: (i) What is the frequency of pulmonary cavitation after completion of the treatment for PTB? (ii) How common is CPA following PTB? (iii) Are there any radiological risk factors (such as cavitation) for CPA? (iv) What is the range of the 12-month survival for PTB (to estimate the numbers at risk of developing CPA development)? and (v) What is the range of the 12-month survival for CPA (to estimate attrition and convert incidence to period prevalence)? We initially adopted a systematic search strategy but quickly realized that the literature was limited and that scoping reviews for all five questions were more appropriate. …
TL;DR: High coverage with HPV vaccine among young adolescent girls was achieved through various delivery strategies in the developing countries studied and Reinforcing positive motivators for vaccine acceptance is likely to facilitate uptake.
Abstract: OBJECTIVE: To assess human papillomavirus (HPV) vaccination coverage after demonstration projects conducted in India, Peru, Uganda and Viet Nam by PATH and national governments and to explore the reasons for vaccine acceptance or refusal. METHODS: Vaccines were delivered through schools or health centres or in combination with other health interventions, and either monthly or through campaigns at fixed time points. Using a two-stage cluster sample design, the authors selected households in demonstration project areas and interviewed over 7000 parents or guardians of adolescent girls to assess coverage and acceptability. They defined full vaccination as the receipt of all three vaccine doses and used an open-ended question to explore acceptability. FINDINGS: Vaccination coverage in school-based programmes was 82.6% (95% confidence interval, CI: 79.3-85.6) in Peru, 88.9% (95% CI: 84.7-92.4) in 2009 in Uganda and 96.1% (95% CI: 93.0-97.8) in 2009 in Viet Nam. In India, a campaign approach achieved 77.2% (95% CI: 72.4-81.6) to 87.8% (95% CI: 84.3-91.3) coverage, whereas monthly delivery achieved 68.4% (95% CI: 63.4-73.4) to 83.3% (95% CI: 79.3-87.3) coverage. More than two thirds of respondents gave as reasons for accepting the HPV vaccine that: (i) it protects against cervical cancer; (ii) it prevents disease, or (iii) vaccines are good. Refusal was more often driven by programmatic considerations (e.g. school absenteeism) than by opposition to the vaccine. CONCLUSION: High coverage with HPV vaccine among young adolescent girls was achieved through various delivery strategies in the developing countries studied. Reinforcing positive motivators for vaccine acceptance is likely to facilitate uptake.
TL;DR: Family planning programmes in sub-Saharan Africa show varying success in reaching all social segments, but inequities persist in all countries.
Abstract: OBJECTIVE: To examine the use of contraception in 13 countries in sub-Saharan Africa; to assess changes in met need for contraception associated with wealth-related inequity; and to describe the relationship between the use of long-term versus short-term contraceptive methods and a woman's fertility intentions and household wealth. METHODS: The analysis was conducted with Demographic and Health Survey data from 13 sub-Saharan African countries. Wealth-related inequities in the use of contraception were calculated using household wealth and concentration indices. Logistic regression models were fitted for the likelihood of using a long-term contraceptive method, with adjustments for: wealth index quintile, fertility intentions (to space births versus to stop childbearing), residence (urban/rural), education, number of living children, marital status and survey year. FINDINGS: The use of contraception has increased substantially between surveys in Ethiopia, Madagascar, Mozambique, Namibia and Zambia but has declined slightly in Kenya, Senegal and Uganda. Wealth-related inequalities in the met need for contraception have decreased in most countries and especially so in Mozambique, but they have increased in Kenya, Uganda and Zambia with regard to spacing births, and in Malawi, Senegal, Uganda, the United Republic of Tanzania and Zambia with regard to limiting childbearing. After adjustment for fertility intention, women in the richest wealth quintile were more likely than those in the poorest quintile to practice long-term contraception. CONCLUSION: Family planning programmes in sub-Saharan Africa show varying success in reaching all social segments, but inequities persist in all countries.
TL;DR: The South African government must implement measures to improve the undesirably high level of food insecurity in poorer households, as indicated by a consistent emerging trend.
Abstract: OBJECTIVE: To assess the status of food security - i.e. access to food, food availability and food utilization - in South Africa. METHODS: A systematic search of national surveys that used the Community Childhood Hunger Identification Project (CCHIP) index to measure food security in South Africa over a period of 10 years (1999-2008) was conducted. Anthropometric data for children aged 1-9 years were used to assess food utilization, and household food inventory data were used to assess food availability. FINDINGS: Only three national surveys had used the CCHIP index, namely, the 1999 and 2005 National Food Consumption Surveys (NFCS) and the 2008 South African Social Attitudes Survey. These surveys showed a relatively large decrease in food insecurity between 1999 and 2008. However, the consistent emerging trend indicated that in poorer households women were either feeding their children a poor diet or skipping meals so their children could eat. In terms of food access and availability, the 1999 NFCS showed that households that enjoyed food security consumed an average of 16 different food items over 24 hours, whereas poorer households spent less money on food and consumed fewer than 8 different food items. Moreover, children had low mean scores for dietary diversity (3.58; standard deviation, SD: ± 1.37) and dietary variety (5.52; SD: ± 2.54) scores. In terms of food utilization, the NFCS showed that stunting in children decreased from 21.6% in 1999 to 18% in 2005. CONCLUSION: The South African government must implement measures to improve the undesirably high level of food insecurity in poorer households.
TL;DR: The experience is that performance-based financing can catalyse comprehensive reforms and help address structural problems of public health services, such as low responsiveness, inefficiency and inequity.
Abstract: Performance-based financing is generating a heated debate. Some suggest that it may be a donor fad with limited potential to improve service delivery. Most of its critics view it solely as a provider payment mechanism. Our experience is that performance-based financing can catalyse comprehensive reforms and help address structural problems of public health services, such as low responsiveness, inefficiency and inequity. The emergence of a performance-based financing movement in Africa suggests that it may contribute to profoundly transforming the public sectors of low-income countries.
TL;DR: In western Africa, progress towards adoption of contraception has been dismally slow and access to contraceptives, though improving, is still shockingly limited, and the United Nations population projections for this subregion are likely to be exceeded.
Abstract: OBJECTIVE: To review progress towards adoption of contraception among married or cohabiting women in western and eastern Africa between 1991 and 2004 by examining subjective need, approval, access and use. METHODS: Indicators of attitudes towards and use of contraception were derived from Demographic and Health Surveys, which are nationally representative and yield internationally comparable data. Trends were examined for 24 countries that had conducted at least two surveys between 1986 and 2007. FINDINGS: In western Africa, the subjective need for contraception remained unchanged; about 46% of married or cohabiting women reported a desire to stop and/or postpone childbearing for at least two years. The percentage of women who approved of contraception rose from 32 to 39 and the percentage with access to contraceptive methods rose from 8 to 29. The proportion of women who were using a modern method when interviewed increased from 7 to 15% (equivalent to an average annual increase of 0.6 percentage points). In eastern African countries, trends were much more favourable, with contraceptive use showing an average annual increase of 1.4 percentage points (from 16% in 1986 to 33% in 2007). CONCLUSION: In western Africa, progress towards adoption of contraception has been dismally slow. Attitudinal resistance remains a barrier and access to contraceptives, though improving, is still shockingly limited. If this situation does not change radically in the short run, the United Nations population projections for this subregion are likely to be exceeded. In eastern Africa, the prospects for a future decline in fertility are much more positive.
TL;DR: The evidence available is limited and includes findings from non-randomized studies showing a minimal risk with one-off sampling of up to 5% of TBV, consistent with the conclusion that all identified guidelines are within the limits of "minimal risk".
Abstract: OBJECTIVE: To determine paediatric blood sample volume limits that are consistent with physiological "minimal risk." METHODS: A literature review was performed to search for evidence concerning the adverse effects of blood sampling in children and for guidelines on sampling volume in paediatric research. The search included Medline, EMBASE, other web-based and non-web-based sources and the bibliographies of the sources identified. Experts were also consulted. FINDINGS: Five studies and nine guidelines were identified. Existing guidelines specify paediatric blood sample volume limits ranging from 1% to 5% of total blood volume (TBV) over 24 hours and up to 10% of TBV over 8 weeks. The evidence available is limited and includes findings from non-randomized studies showing a minimal risk with one-off sampling of up to 5% of TBV. CONCLUSION: The evidence available is consistent with the conclusion that all identified guidelines are within the limits of "minimal risk." However, more and better evidence is required to draw firmer conclusions. Researchers and institutional review boards need to take into account the total sampling volume needed for both clinical care and research rather than for each alone. The child's general state of health should be considered and extra caution should be observed particularly with children whose illness can deplete blood volume or haemoglobin or hinder their replenishment. Local policies must also address the appropriateness and local acceptability of collection procedures and of the blood volumes drawn.
TL;DR: In this article, the association between gestational weight gain and maternal body mass index (BMI) among Vietnamese women and the risk of delivering an infant too small or too large for gestational age was examined.
Abstract: Objective To examine the association between gestational weight gain and maternal body mass index (BMI) among Vietnamese women and the risk of delivering an infant too small or too large for gestational age. Methods A prospective health-facility-based study of 2989 pregnant Vietnamese women was conducted in the city of Nha Trang in 2007–2008. Cubic logistic regression was used to investigate the association of interest. Infants were classified into weight-forgestational-age categories according to weight centiles for the Asian population. Gestational age was based on the date of last menstrual period and adjusted by the results of first-trimester ultrasound. Findings BMI was low (< 18.5), normal (18.5–22.9) and high (≥ 23.0) in 26.1%, 65.4% and 8.5% of the women, respectively. In each of these BMI categories, the percentage of women who delivered infants too small for gestational age was 18.1, 10.0 and 9.4, respectively, and the mean gestational weight gain was 12.5 kg (standard deviation, SD: ± 3.6), 12.2 kg (SD: ± 3.8) and 11.5 kg (SD: ± 4.7), respectively. Among women with low BMI, the risk of delivering an infant too small for gestational age ranged from approximately 40% if the gestational weight gain was < 5 kg to 20% if it was 5–10 kg. Conclusion Having a low BMI, commonly found in Viet Nam, puts women at risk of delivering an infant too small for gestational age, especially when total maternal gestational weight gain is < 10 kg.
TL;DR: Current disease patterns do not explain the significant gaps observed in the availability of medicines for chronic and acute conditions, and measures are needed to better respond to the epidemiological transition towards chronic conditions in developing countries alongside current efforts to scale up treatment for communicable diseases.
Abstract: OBJECTIVE: To investigate potential differences in the availability of medicines for chronic and acute conditions in low- and middle-income countries. METHODS: Data on the availability of 30 commonly-surveyed medicines - 15 for acute and 15 for chronic conditions - were obtained from facility-based surveys conducted in 40 developing countries. Results were aggregated by World Bank country income group and World Health Organization region. FINDINGS: The availability of medicines for both acute and chronic conditions was suboptimal across countries, particularly in the public sector. Generic medicines for chronic conditions were significantly less available than generic medicines for acute conditions in both the public sector (36.0% availability versus 53.5%; P=0.001) and the private sector (54.7% versus 66.2%; P=0.007). Antiasthmatics, antiepileptics and antidepressants, followed by antihypertensives, were the drivers of the observed differences. An inverse association was found between country income level and the availability gap between groups of medicines, particularly in the public sector. In low- and lower-middle income countries, drugs for acute conditions were 33.9% and 12.9% more available, respectively, in the public sector than medicines for chronic conditions. Differences in availability were smaller in the private sector than in the public sector in all country income groups. CONCLUSION: Current disease patterns do not explain the significant gaps observed in the availability of medicines for chronic and acute conditions. Measures are needed to better respond to the epidemiological transition towards chronic conditions in developing countries alongside current efforts to scale up treatment for communicable diseases.
TL;DR: Medical tourism in Thailand, despite some benefits, has negative effects that could be mitigated by lifting the restrictions on the importation of qualified foreign physicians and by taxing tourists who visit the country solely for the purpose of seeking medical treatment.
Abstract: OBJECTIVE: To explore the positive and negative effects of medical tourism on the economy, health staff and medical costs in Thailand. METHODS: The financial repercussions of medical tourism were estimated from commerce ministry data, with modifications and extrapolations. Survey data on 4755 foreign and Thai outpatients in two private hospitals were used to explore how medical tourism affects human resources. Trends in the relative prices of caesarean section, appendectomy, hernia repair, cholecystectomy and knee replacement in five private hospitals were examined. Focus groups and in-depth interviews with hospital managers and key informants from the public and private sectors were conducted to better understand stakeholders' motivations and practices in connection with these procedures and learn more about medical tourism. FINDINGS: Medical tourism generates the equivalent of 0.4% of Thailand's gross domestic product but has exacerbated the shortage of medical staff by luring more workers away from the private and public sectors towards hospitals catering to foreigners. This has raised costs in private hospitals substantially and is likely to raise them in public hospitals and in the universal health-care insurance covering most Thais as well. The "brain drain" may also undermine medical training in future. CONCLUSION: Medical tourism in Thailand, despite some benefits, has negative effects that could be mitigated by lifting the restrictions on the importation of qualified foreign physicians and by taxing tourists who visit the country solely for the purpose of seeking medical treatment. The revenue thus generated could then be used to train physicians and retain medical school professors.
TL;DR: Integrating TB and diabetes control programmes worldwide would facilitate TB prevention among diabetes patients and increase the number of diabetics who learn of their condition, particularly among males.
Abstract: OBJECTIVE: To estimate the contribution of clinically-confirmed diabetes mellitus to tuberculosis (TB) rates in communities where both diseases are prevalent as a way to identify opportunities for TB prevention among diabetic patients. METHODS: This is a prospective study in which TB patients > 20 years old at TB clinics in the Texas-Mexico border were tested for diabetes. The risk of tuberculosis attributable to diabetes was estimated from statistics for the corresponding adult population. FINDINGS: The prevalence of diabetes among TB patients was 39% in Texas and 36% in Mexico. Diabetes contributed 25% of the TB cases studied, whereas human immunodeficiency virus (HIV) infection contributed 5% or fewer. Among TB patients, fewer Mexicans than Texans were aware that they had diabetes before this study (4% and 19%, respectively). Men were also less frequently aware than women that they had diabetes (P = 0.03). Patients who knew that they had diabetes before the study had an 8-year history of the disease, on average, before being diagnosed with TB. CONCLUSION: Patients with diabetes are at higher risk of contracting TB than non-diabetic patients. Integrating TB and diabetes control programmes worldwide would facilitate TB prevention among diabetes patients and increase the number of diabetics who learn of their condition, particularly among males. Such a strategy would lead to earlier case detection and improve the management of both TB and diabetes.
TL;DR: Modelling of the costs and potential savings resulting from intradermal delivery should be done to provide realistic expectations of the potential benefits and to support cases for investment.
Abstract: Delivery of vaccine antigens to the dermis and/or epidermis of human skin (i.e. intradermal delivery) might be more efficient than injection into the muscle or subcutaneous tissue, thereby reducing the volumes of antigen. This is known as dose-sparing and has been demonstrated in clinical trials with some, but not all, vaccines. Dose-sparing could be beneficial to immunization programmes by potentially reducing the costs of purchase, distribution and storage of vaccines; increasing vaccine availability and effectiveness. The data obtained with intradermal delivery of some vaccines are encouraging and warrant further study and development; however significant gaps in knowledge and operational challenges such as reformulation, optimizing vaccine presentation and development of novel devices to aid intradermal vaccine delivery need to be addressed. Modelling of the costs and potential savings resulting from intradermal delivery should be done to provide realistic expectations of the potential benefits and to support cases for investment. Implementation and uptake of intradermal vaccine delivery requires further research and development, which depends upon collaboration between multiple stakeholders in the field of vaccination.
TL;DR: Home-based abortion is safe under the conditions in place in the included studies, and women who chose home-based medical abortion were more likely to be satisfied, to choose the method again and to recommend it to a friend than women who opted for medical abortion in a clinic.
Abstract: OBJECTIVE: To compare medical abortion practised at home and in clinics in terms of effectiveness, safety and acceptability. METHODS: A systematic search for randomized controlled trials and prospective cohort studies comparing home-based and clinic-based medical abortion was conducted. The Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE and Popline were searched. Failure to abort completely, side-effects and acceptability were the main outcomes of interest. Odds ratios and their 95% confidence intervals (CIs) were calculated. Estimates were pooled using a random-effects model. FINDINGS: Nine studies met the inclusion criteria (n = 4522 participants). All were prospective cohort studies that used mifepristone and misoprostol to induce abortion. Complete abortion was achieved by 86-97% of the women who underwent home-based abortion (n = 3478) and by 80-99% of those who underwent clinic-based abortion (n = 1044). Pooled analyses from all studies revealed no difference in complete abortion rates between groups (odds ratio = 0.8; 95% CI: 0.5-1.5). Serious complications from abortion were rare. Pain and vomiting lasted 0.3 days longer among women who took misoprostol at home rather than in clinic. Women who chose home-based medical abortion were more likely to be satisfied, to choose the method again and to recommend it to a friend than women who opted for medical abortion in a clinic. CONCLUSION: Home-based abortion is safe under the conditions in place in the included studies. Prospective cohort studies have shown no differences in effectiveness or acceptability between home-based and clinic-based medical abortion across countries.
TL;DR: In China, the age-adjusted prevalence of disability has declined since 1987, with inconsistencies dependent on the type of disability, and these findings call for continuing and specific efforts to prevent disabilities in China.
Abstract: OBJECTIVE: To evaluate changes in the age-adjusted prevalence of disability in transitional China from 1987 to 2006. METHODS: Data from nationally representative surveys conducted in 1987 and 2006 were used to calculate age-adjusted disability prevalence rates by applying appropriate sample weights and directly adjusting to the age distribution of the 1990 Chinese population. Trends were assessed in terms of average annual percentage change. FINDINGS: The estimated number of disabled people in China in 1987 and 2006 was 52.7 and 84.6 million, respectively, corresponding to a weighted prevalence of 4.9% and 6.5%. The age-adjusted prevalence of disability decreased by an average of 0.5% per year (average annual percentage change, AAPC: -0.5%; 95% confidence interval, CI: -0.7 to -0.4) during 1987-2006. However, it increased by an average of 0.3% (AAPC: 0.3%; 95% CI: 0.1 to 0.5) per year in males and by an average of 1.0% (AAPC: 1.0%; 95% CI: 0.8 to 1.2) per year among rural residents, whereas among females it showed an average annual decrease of 1.5% (AAPC: -1.5%; 95% CI: -1.7 to -1.3) and among urban residents, an average annual decrease of 3.9% (AAPC: -3.9%; 95% CI: -4.3 to -3.5). Despite significant declining trends for hearing and speech, intellectual and visual disabilities, the annual age-adjusted prevalence of physical and mental disabilities increased by an average of 11.2% (AAPC: 11.2%; 95% CI: 10.5 to 11.9) and 13.3% (AAPC: 13.3%; 95% CI: 10.7 to 16.2), respectively. CONCLUSION: In China, the age-adjusted prevalence of disability has declined since 1987, with inconsistencies dependent on the type of disability. These findings call for continuing and specific efforts to prevent disabilities in China.
TL;DR: The BFP can lead to better nutritional outcomes in children 12 to 59 months of age, and longitudinal studies are needed to confirm these findings.
Abstract: OBJECTIVE: To examine the association between Brazil's Bolsa Familia programme (BFP), which is the world's largest conditional cash transfer programme, and the anthropometric indicators of nutritional status in children. METHODS: Using the opportunity provided by vaccination campaigns, the Brazilian government promotes Health and Nutrition Days to estimate the prevalence of anthropometric deficits in children. Data collected in 2005-2006 for 22 375 impoverished children under 5 years of age were employed to estimate nutritional outcomes among recipients of Bolsa Familia. All variables under study, namely child birth weight, lack of birth certificate, educational level and gender of family head, access to piped water and electricity, height for age, weight for age and weight for height, were converted into binary variables for regression analysis. FINDINGS: Children from families exposed to the BFP were 26% more likely to have normal height for age than those from non-exposed families; this difference also applied to weight for age. No statistically significant deficit in weight for height was found. Stratification by age group revealed 19% and 41% higher odds of having normal height for age at 12-35 and 36-59 months of age, respectively, in children receiving Bolsa Familia, and no difference at 0-11 months of age. CONCLUSION: The BFP can lead to better nutritional outcomes in children 12 to 59 months of age. Longitudinal studies are needed to confirm these findings.
TL;DR: In this article, the authors examined the effectiveness of the health system response to the challenge of diabetes across different settings and explore the inequalities in diabetes care that are attributable to socioeconomic factors.
Abstract: OBJECTIVE: To examine the effectiveness of the health system response to the challenge of diabetes across different settings and explore the inequalities in diabetes care that are attributable to socioeconomic factors. METHODS: We used nationally representative health examination surveys from Colombia, England, the Islamic Republic of Iran, Mexico, Scotland, Thailand and the United States of America to obtain data on diagnosis, treatment and control of hyperglycaemia, arterial hypertension and hypercholesterolaemia among individuals with diabetes. Using logistic regression, we explored the socioeconomic determinants of diagnosis and effective case management. FINDINGS: A substantial proportion of individuals with diabetes remain undiagnosed and untreated, both in developed and developing countries. The figures range from 24% of the women in Scotland and the USA to 62% of the men in Thailand. The proportion of individuals with diabetes reaching treatment targets for blood glucose, arterial blood pressure and serum cholesterol was very low, ranging from 1% of male patients in Mexico to about 12% in the United States. Income and education were not found to be significantly related to the rates of diagnosis and treatment anywhere except in Thailand, but in the three countries with available data insurance status was a strong predictor of diagnosis and effective management, especially in the United States. CONCLUSION: There are many missed opportunities to reduce the burden of diabetes through improved control of blood glucose levels and improved diagnosis and treatment of arterial hypertension and hypercholesterolaemia. While no large socioeconomic inequalities were noted in the management of individuals with diabetes, financial access to care was a strong predictor of diagnosis and management.
TL;DR: Semiquantitative slide agglutination and single-tube Widal tests may be suitable when pretest probability is high and blood cultures are unavailable, but their performance does not justify deployment in routine care settings in sub-Saharan Africa.
Abstract: OBJECTIVE: To evaluate three commercial typhoid rapid antibody tests for Salmonella Typhi antibodies in patients suspected of having typhoid fever in Mpumalanga, South Africa, and Moshi, United Republic of Tanzania. METHODS: The diagnostic accuracy of Cromotest® (semiquantitative slide agglutination and single tube Widal test),TUBEX®and Typhidot® was assessed against that of blood culture. Performance was modelled for scenarios with pretest probabilities of 5% and 50%. FINDINGS: In total 92 patients enrolled: 53 (57.6%) from South Africa and 39 (42.4%) from the United Republic of Tanzania. Salmonella Typhi was isolated from the blood of 28 (30.4%) patients. The semiquantitative slide agglutination and single-tube Widal tests had positive predictive values (PPVs) of 25.0% (95% confidence interval, CI: 0.6-80.6) and 20.0% (95% CI: 2.5-55.6), respectively. The newer typhoid rapid antibody tests had comparable PPVs: TUBEX®, 54.1% (95% CI: 36.9-70.5); Typhidot® IgM, 56.7% (95% CI: 37.4-74.5); and Typhidot® IgG, 54.3% (95% CI: 36.6-71.2). For a pretest probability of 5%, PPVs were: TUBEX®, 11.0% (95% CI: 6.6-17.9); Typhidot® IgM, 9.1% (95% CI: 5.8-14.0); and Typhidot® IgG, 11.0% (6.3-18.4). For a pretest probability of 50%, PPVs were: TUBEX®, 70.2% (95% CI: 57.3-80.5); Typhidot® IgM, 65.6% (95% CI: 54.0-75.6); and Typhidot® IgG, 70.0% (95% CI: 56.0-81.1). CONCLUSION: Semiquantitative slide agglutination and single-tube Widal tests performed poorly. TUBEX® and Typhidot® may be suitable when pretest probability is high and blood cultures are unavailable, but their performance does not justify deployment in routine care settings in sub-Saharan Africa.
TL;DR: The main forces that drive medical travel are discussed and the implications on health systems, in particular the impacts on access to health care, financing and the health workforce are discussed, are discussed.
Abstract: In a globalizing world, public health is no longer confined to national borders. In recent years we have observed an increasing movement of patients across international borders. The full extent of this trend is yet unknown, as data are sparse and anecdotal. If this trend continues, experts are convinced that it will have major implications for public health systems around the globe. Despite the growing importance of medical travel, we still have little empirical evidence on its impact on public health, especially on health systems. This paper summarizes the most recent debates on this topic. It discusses the main forces that drive medical travel and its implications on health systems, in particular the impacts on access to health care, financing and the health workforce. This paper also offers guidance on how to define medical travel and how to improve data collection. It advocates for more scientific research that will enable countries to harness benefits and limit the potential risks to public health arising from medical travel.
TL;DR: The percentage of people with high total serum cholesterol who are effectively treated remains small in selected high- and middle-income countries, and Untreated high blood cholesterol represents a missed opportunity in the face of a global epidemic of chronic diseases.
Abstract: OBJECTIVE: To determine the fraction of individuals with high total serum cholesterol who get diagnosed and effectively treated in eight high- and middle-income countries METHODS: Using data from nationally representative health examination surveys conducted in 1998-2007, we studied a probability sample of 79 039 adults aged 40-79 years from England, Germany, Japan, Jordan, Mexico, Scotland, Thailand and the United States of America For each country we calculated the prevalence of high total serum cholesterol (total serum cholesterol > 62 mmol/l or > 240 mg/dl) and the mean total serum cholesterol level We also determined the fractions of individuals being diagnosed, treated with cholesterol-lowering medication and effectively controlled (total serum cholesterol < 62 mmol/l or < 240 mg/dl) FINDINGS: The proportion of undiagnosed individuals was highest in Thailand (78%; 95% confidence interval, CI: 74-82) and lowest in the United States (16%; 95% CI: 13-19) The fraction diagnosed but untreated ranged from 9% in Thailand (95% CI: 8-11) to 53% in Japan (95% CI: 50-57) The proportion being treated who had attained evidence of control ranged from 4% in Germany (95% CI: 3-5) to 58% in Mexico (95% CI: 54-63) Time series estimates showed improved control of high total serum cholesterol over the past two decades in England and the United States CONCLUSION: The percentage of people with high total serum cholesterol who are effectively treated remains small in selected high- and middle-income countries Many of those affected are unaware of their condition Untreated high blood cholesterol represents a missed opportunity in the face of a global epidemic of chronic diseases
TL;DR: The fact that despite ten years ofPandemic preparedness activities no formal definition of pandemic influenza has been formulated reveals important underlying assumptions about the nature of this infectious disease.
Abstract: There has been considerable controversy over the past year, particularly in Europe, over whether the World Health Organization (WHO) changed its definition of pandemic influenza in 2009, after novel H1N1 influenza was identified. Some have argued that not only was the definition changed, but that it was done to pave the way for declaring a pandemic. Others claim that the definition was never changed and that this allegation is completely unfounded. Such polarized views have hampered our ability to draw important conclusions. This impasse, combined with concerns over potential conflicts of interest and doubts about the proportionality of the response to the H1N1 influenza outbreak, has undermined the public trust in health officials and our collective capacity to effectively respond to future disease threats. WHO did not change its definition of pandemic influenza for the simple reason that it has never formally defined pandemic influenza. While WHO has put forth many descriptions of pandemic influenza, it has never established a formal definition and the criteria for declaring a pandemic caused by the H1N1 virus derived from "pandemic phase" definitions, not from a definition of "pandemic influenza". The fact that despite ten years of pandemic preparedness activities no formal definition of pandemic influenza has been formulated reveals important underlying assumptions about the nature of this infectious disease. In particular, the limitations of "virus-centric" approaches merit further attention and should inform ongoing efforts to "learn lessons" that will guide the response to future outbreaks of novel infectious diseases.