Showing papers in "Tropical Medicine & International Health in 2009"

From malaria control to eradication: The WHO perspective

Abstract: Efforts to control malaria have been boosted in the past few years with increased international funding and greater political commitment. Consequently, the reported malaria burden is being reduced in a number of countries throughout the world, including in some countries in tropical Africa where the burden of malaria is greatest. These achievements have raised new hopes of eradicating malaria. This paper summarizes the outcomes of a World Health Organization's expert meeting on the feasibility of such a goal. Given the hindsight and experience of the Global Malaria Eradication Programme of the 1950s and 1960s, and current knowledge of the effectiveness of antimalarial tools and interventions, it would be feasible to effectively control malaria in all parts of the world and greatly reduce the enormous morbidity and mortality of malaria. It would also be entirely feasible to eliminate malaria from countries and regions where the intensity of transmission is low to moderate, and where health systems are strong. Elimination of malaria requires a re-orientation of control activity, moving away from a population-based coverage of interventions, to one based on a programme of effective surveillance and response. Sustained efforts will be required to prevent the resurgence of malaria from where it is eliminated. Eliminating malaria from countries where the intensity of transmission is high and stable such as in tropical Africa will require more potent tools and stronger health systems than are available today. When such countries have effectively reduced the burden of malaria, the achievements will need to be consolidated before a programme re-orientation towards malaria elimination is contemplated. Malaria control and elimination are under the constant threat of the parasite and vector mosquito developing resistance to medicines and insecticides, which are the cornerstones of current antimalarial interventions. The prospects of malaria eradication, therefore, rest heavily on the outcomes of research and development for new and improved tools. Malaria control and elimination are complementary objectives in the global fight against malaria.

The HIV-exposed, uninfected African child.

Abstract: The increasing success of prevention of mother-to-child HIV transmission programmes means that in Africa, very large numbers of HIV-exposed, uninfected (HIV-EU) children are being born. Any health problems that these children may have will thus be of enormous public health importance, but to date have been largely neglected. There is some evidence that HIV-EU African children are at increased risk of mortality, morbidity and slower early growth than their HIV-unexposed counterparts. A likely major cause of this impaired health is less exposure to breast milk as mothers are either less able to breastfeed or stop breastfeeding early to protect their infant from HIV infection. Other contributing factors are parental illness or death resulting in reduced care of the children, increased exposure to other infections and possibly exposure to antiretroviral drugs. A broad approach for psychosocial support of HIV-affected families is needed to improve health of HIV-EU children. High quality programmatic research is needed to determine how to deliver such care.

Pneumonia in severely malnourished children in developing countries - mortality risk, aetiology and validity of WHO clinical signs: a systematic review

Abstract: Objectives: to quantify the degree by which moderate and severe degrees of malnutrition increase the mortality risk in pneumonia, to identify potential differences in the aetiology of pneumonia between children with and without severe malnutrition, and to evaluate the validity of WHO-recommended clinical signs (age-specific fast breathing and chest wall indrawing) for the diagnosis of pneumonia in severely malnourished children. Methods: systematic search of the existing literature using a variety of databases (Medline, EMBASE, the Web of Science, Scopus and CINAHL). Results: mortality risk: sixteen relevant studies were identified, which universally showed that children with pneumonia and moderate or severe malnutrition are at higher risk of death. For severe malnutrition, reported relative risks ranged from 2.9 to 121.2; odds ratios ranged from 2.5 to 15.1. For moderate malnutrition, relative risks ranged from 1.2 to 36.5. Aetiology: eleven studies evaluated the aetiology of pneumonia in severely malnourished children. Commonly isolated bacterial pathogens were Klebsiella pneumoniae, Staphylococcus aureus, Streptococcus pneumoniae, Escherichia coli, and Haemophilus influenzae. The spectrum and frequency of organisms differed from those reported in children without severe malnutrition. There are very few data on the role of respiratory viruses and tuberculosis. Clinical signs: Four studies investigating the validity of clinical signs showed that WHO-recommended clinical signs were less sensitive as predictors of radiographic pneumonia in severely malnourished children. Conclusions: pneumonia and malnutrition are two of the biggest killers in childhood. Guidelines for the care of children with pneumonia and malnutrition need to take into account this strong and often lethal association if they are to contribute to the UN Millennium Development Goal 4, aiming for substantial reductions in childhood mortality. Additional data regarding the optimal diagnostic approach to and management of pneumonia and malnutrition are required from regions where death from these two diseases is common

Epidemiology and prevention of human papillomavirus and cervical cancer in sub-Saharan Africa: a comprehensive review.

Abstract: Summary Objectives To identify the gaps of knowledge and highlight the challenges and opportunities for controlling cervical cancer in sub-Saharan Africa (SSA). Methods A comprehensive review of peer-reviewed literature to summarize the epidemiological data on human papillomavirus (HPV) and invasive cervical cancer (ICC) by HIV status, to review feasible and effective cervical screening strategies, and to identify barriers in the introduction of HPV vaccination in SSA. Results ICC incidence in SSA is one of the highest in the world with an age-standardized incidence rate of 31.0 per 100 000 women. The prevalence of HPV16/18, the two vaccine preventable-types, among women with ICC, does not appear to differ by HIV status on a small case series. However, there are limited data on the role of HIV in the natural history of HPV infection in SSA. Cervical screening coverage ranges from 2.0% to 20.2% in urban areas and 0.4% to 14.0% in rural areas. There are few large scale initiatives to introduce population-based screening using cytology, visual inspection or HPV testing. Only one vaccine safety and immunogenicity study is being conducted in Senegal and Tanzania. Few data are available on vaccine acceptability, health systems preparedness and vaccine cost-effectiveness and long-term impact. Conclusions Additional data are needed to strengthen ICC as a public health priority to introduce, implement and sustain effective cervical cancer control in Africa.

The impact of distance of residence from a peripheral health facility on pediatric health utilisation in rural western Kenya

Abstract: Objective To explore the impact of distance on utilisation of peripheral health facilities for sick child visits in Asembo, rural western Kenya. Methods As part of a demographic surveillance system (DSS), censuses of all households in the Asembo population of 55,000 are conducted three times a year, data are collected at all outpatient pediatric visits in seven DSS clinics in Asembo, and all households are GIS-mapped and linkable to a child's unique DSS identification number. Between May 1, 2003 and April 30, 2004, 3501 clinic visits were linked to 2432 children among 10,973 DSS-resident children Results Younger children and children with more severe illnesses travelled further for clinic visits. The median distance travelled varied by clinic. The rate of clinic visits decreased linearly at 0.5 km intervals up to 4 km, after which the rate stabilised. Using Poisson regression, controlling for the nearest DSS clinic for each child, socio-economic status and maternal education, and accounting for household clustering of children, for every 1 km increase in distance of residence from a DSS clinic, the rate of clinic visits decreased by 34% (95% CI, 31-37%) from the previous kilometer. Conclusion Achieving equity in access to health care for children in rural Kenya will require creative strategies to address a significant distance-decay effect in health care utilisation.

The poorest of the poor: a poverty appraisal of households affected by visceral leishmaniasis in Bihar, India.

Abstract: OBJECTIVE To provide data about wealth distribution in visceral leishmanisis (VL)-affected communities compared to that of the general population of Bihar State, India. METHODS After extensive disease risk mapping, 16 clusters with high VL transmission were selected in Bihar. An exhaustive census of all households in the clusters was conducted and socio-economic household characteristics were documented by questionnaire. Data on the general Bihar population taken from the National Family Health Survey of India were used for comparison. An asset index was developed based on Principal Components Analysis and the distribution of this asset index for the VL communities was compared with that of the general population of Bihar. RESULTS 83% of households in communities with high VL attack rates belonged to the two lowest quintiles of the Bihar wealth distribution. All socio-economic indicators showed significantly lower wealth for those households. CONCLUSION Visceral leishmanisis clearly affects the poorest of the poor in India. They are most vulnerable, as this vector-born disease is linked to poor housing and unhealthy habitats. The disease leads the affected households to more destitution because of its impact on household income and wealth. Support for the present VL elimination initiative is important in the fight against poverty.

Impact of antenatal common mental disorders upon perinatal outcomes in Ethiopia: the P-MaMiE population-based cohort study

Abstract: This study provides preliminary evidence of important public health consequences of poor maternal mental health in low-income countries but does not replicate the strong association with low birth ...

China's new strategy to block Schistosoma japonicum transmission: experiences and impact beyond schistosomiasis.

Abstract: Despite sustained efforts for its control made over the past 50+ years, the re-emergence of schistosomiasis in China was noted around the turn of the new millennium. Consequently, a new integrated strategy was proposed to stop the contamination of schistosome eggs to the environment, which emphasizes health education, access to clean water and adequate sanitation, mechanization of agriculture and fencing of water buffaloes, along with chemotherapy. Validation of this integrated control strategy in four pilot counties in the provinces of Anhui, Hubei, Hunan and Jiangxi revealed significant reductions in the rate of Schistosoma japonicum infection in humans and intermediate host snails. Importantly, this strategy showed an impact on diseases beyond schistosomiasis, signified by concomitant reductions in the prevalence of soil-transmitted helminth infections. In view of China's new integrated strategy for transmission control of schistosomiasis showing an ancillary benefit on other helminthic diseases, we encourage others to investigate the scope and limits of integrated control of neglected tropical diseases.

Critical care in low-income countries.

Abstract: Critical care in low-income countries remains rudimentary. When defined as all aspects of care for patients with sudden, serious, reversible disease, critical care is not disease or age specific and includes triage and emergency medicine, hospital systems, quality of care and Intensive Care Units. This review collates the literature on critical care in low-income countries and explores how the care can be both feasible and effective. Emergency care including triage is often one of the weakest parts of the health system; but if well organized it can be life-saving and cost-effective. Emergency triage and treatment has been developed for paediatric admissions with promising results. Hospital systems do not currently prioritize the critically ill and few hospitals have Intensive Care Units. The quality of care given to inpatients on hospital wards is often poor and could be improved in many ways. There is a lack of training and awareness of the principles of critical care. Basic critical care concentrating on ABC - airway, breathing and circulation - need not be resource intensive. Oxygen is a cheap and effective treatment for pneumonia and other severe disease, but is not always available. Improved critical care could have a significant effect on the burden of disease and effects of ill health. Research into the most cost-effective treatments and methods of caring for critically ill patients is urgently needed.

Determinants of delay in care-seeking for febrile children in eastern Uganda.

Abstract: OBJECTIVE To explore factors associated with delay in seeking treatment outside the home for febrile children under five. METHODS Using a pre-tested structured questionnaire, all 9176 children below 5 years in Iganga-Mayuge Demographic Surveillance Site were enumerated. Caretakers of children who had been ill within the previous 2 weeks were asked about presenting symptoms, type of home treatment used, timing of seeking treatment and distance to provider. Children who sought care latest after one night were compared with those who sought care later. RESULTS Those likely to delay came from the lowest socio-economic quintile (OR 1.45; 95% CI 1.06-1.97) or had presented with pallor (OR 1.58; 95% CI 1.10-2.25). Children less likely to delay had gone to drug shops (OR 0.70; 95% CI 0.59-0.84) or community medicine distributors (CMDs) (OR 0.33; 95% CI 0.15-0.74), had presented with fast breathing (OR 0.75; 95% CI 0.60-0.87), used tepid sponging at home (OR 0.43; 95% CI 0.27-0.68), or perceived the distance to the provider to be short (OR 0.72; 95% CI 0.60-0.87). CONCLUSION Even in the presence of 'free services', poverty is associated with delay to seek care. Drug shops and CMDs may complement government efforts to deliver timely treatment. Health workers need to sensitize caretakers to take children for care promptly. Methods to elucidate time in population-surveys in African settings need to be evaluated.

The impact of gender and income on survival and retention in a South African antiretroviral therapy programme

Abstract: Summary objectives Despite the rapid expansion of antiretroviral therapy (ART) services in Africa, there are few data on whether outcomes differ for women and men and what factors may drive such variation. We investigated the association of gender and income with survival and retention in a South African ART programme. methods A total of 2196 treatment-naive adults were followed for 1 year on ART. Proportional hazards regression was used to explore associations between baseline characteristics and survival and loss-to-follow-up (LTFU). results Patients were predominantly female (67%). Men presented at an older age and with more advanced HIV disease, and during early ART the crude death rate was higher among men than women (22.8 vs 12.5 ⁄100 person-years; P = 0.002). However in multivariate analysis, gender was not signifi- cantly associated with survival after adjusting for baseline clinical and immunovirological status (HR = 1.46, 95% CI = 0.96-2.22; P = 0.076). In late ART (4-12 months), there was no gender dif- ference in mortality rates (3.5 vs 3.8 ⁄100 person-years; P = 0.817). In multivariate analysis, survival was strongly associated with age (HR = 1.05, 95% CI = 1.02-1.09; P 150 vs <50 cells ⁄ll (HR = 0.35, 95% CI = 0.14-0.87; P = 0.023) and any monthly income vs none (HR = 0.47, 95% CI = 0.25-0.88; P = 0.018). Having some monthly income was protective against LTFU at 1 year on ART (adjusted HR = 0.56, 95% CI = 0.39-0.82; P = 0.002). conclusion Men's high early mortality on ART appears due largely to their presentation with more advanced HIV disease. Efforts are needed to enrol men into care earlier in HIV disease and to reduce socio-economic inequalities in ART programme outcomes.

Reducing costs and operational constraints of dengue vector control by targeting productive breeding places: a multi-country non-inferiority cluster randomized trial.

Abstract: Summary objectives To test the non-inferiority hypothesis that a vector control approach targeting only the most productive water container types gives the same or greater reduction of the vector population as a non-targeted approach in different ecological settings and to analyse whether the targeted intervention is less costly. methods Cluster randomized trial in eight study sites (Venezuela, Mexico, Peru, Kenya, Thailand, Myanmar, Vietnam, Philippines), with each study area divided into 18–20 clusters (sectors or neighbourhoods) of approximately 50–100 households each. Using a baseline pupal-demographic survey, the most productive container types were identified which produced ‡55% of all Ae. aegypti pupae. Clusters were then paired based on similar pupae per person indices. One cluster from each pair was randomly allocated to receive the targeted vector control intervention; the other received the ‘blanket’ (nontargeted) intervention attempting to reach all water holding containers. results The pupal-demographic baseline survey showed a large variation of productive container types across all study sites. In four sites the vector control interventions in both study arms were insecticidal and in the other four sites, non-insecticidal (environmental management and ⁄ or biological control methods). Both approaches were associated with a reduction of outcome indicators in the targeted and non-targeted intervention arm of the six study sites where the follow up study was conducted (PPI, Pupae per Person Index and BI, Breteau Index). Targeted interventions were as effective as non-targeted ones in terms of PPI. The direct costs per house reached were lower in targeted intervention clusters than in non-targeted intervention clusters with only one exception, where the targeted intervention was delivered through staff-intensive social mobilization. conclusions Targeting only the most productive water container types (roughly half of all water holding container types) was as effective in lowering entomological indices as targeting all water holding containers at lower implementation costs. Further research is required to establish the most efficacious method or combination of methods for targeted dengue vector interventions.

Geographical distribution and epidemiological features of Old World cutaneous leishmaniasis foci, based on the isoenzyme analysis of 1048 strains

Abstract: A series of 1048 Leishmania strains from Old World cutaneous leishmaniasis foci, isolated between 1981 and 2005, were studied by isoenzyme analysis. The strains were obtained from humans, rodents, dogs and sandflies from 33 countries. The four typically dermotropic species, Leishmania major, L. tropica, L. aethiopica and L. killicki, were found. The viscerotropic species L. donovani and L. infantum, which can occasionally be responsible for cutaneous leishmaniasis, are not considered in this paper. Leishmania major was the least polymorphic species (12 zymodemes, 638 strains). Leishmania tropica was characterized by a complex polymorphism varying according to focus (35 zymodemes, 329 strains). Leishmania aethiopica, a species restricted to East Africa, showed a high polymorphism, in spite of a limited number of strains (23 zymodemes, 40 strains). Leishmania killicki, mainly restricted to Tunisia had a single zymodeme for 39 strains. Recently a parasite close to L. killicki (one zymodeme, two strains) was isolated in Algeria, which lead us to revise the taxonomic status of this taxon.

Rapid malaria diagnostic tests vs. clinical management of malaria in rural Burkina Faso: safety and effect on clinical decisions. A randomized trial.

Abstract: Summary objectives To assess if the clinical outcome of patients treated after performing a Rapid Diagnostic Test for malaria (RDT) is at least equivalent to that of controls (treated presumptively without test) and to determine the impact of the introduction of a malaria RDT on clinical decisions. methods Randomized, multi-centre, open clinical trial in two arms in 2006 at the end of the dry and of the rainy season in 10 peripheral health centres in Burkina Faso: one arm with use of RDT before treatment decision, one arm managed clinically. Primary endpoint: persistence of fever at day 4. Secondary endpoints: frequency of malaria treatment and of antibiotic treatment. results A total of 852 febrile patients were recruited in the dry season and 1317 febrile patients in the rainy season, and randomized either to be submitted to RDT (P_RTD) or to be managed presumptively (P_CLIN). In both seasons, no significant difference was found between the two randomized groups in the frequency of antimalarial treatment, nor of antibiotic prescription. In the dry season, 80.8% and 79.8% of patients with a negative RDT were nevertheless diagnosed and treated for malaria, and so were 85.0% and 82.6% negative patients in the rainy season. In the rainy season only, both diagnosis and treatment of other conditions were significantly less frequent in RDT positive vs. negative patients (48.3% vs. 61.4% and 46.2% vs. 59.9%, P = 0.00 and 0.00, respectively). conclusion Our study was inconclusive on RDT safety (clinical outcome in the two randomized groups), because of an exceedingly and unexpectedly low compliance with the negative test result. Further research is needed on best strategies to promote adherence and on the safety of a test based strategy compared with the current, presumptive treatment strategy.

Accuracy and quality of immunization information systems in forty‐one low income countries

Abstract: OBJECTIVES. To measure the accuracy and quality of immunization information systems in a range of low-income countries eligible to receive GAVI support.METHODS. The Data Quality Audit (DQA) uses a WHO validated, standard methodology to compare data collected from health unit (HU) records of immunizations administered with reports of immunizations at central level and to collect quality indicators of the reporting system. The verification factor (VF), as a measure of accuracy, expresses the proportion of immunizations reported at national level that can be tracked down to the HU. A VF of 80% or above entitles countries to receive additional GAVI financial support. Quality indicators are assigned points which were summed to obtain quality scores (QS) at national, district and HU levels. DQAs included here were conducted between 2002 and 2005 in 41 countries, encompassing 1082 primary healthcare units in 188 randomly selected districts.RESULTS. Almost half of countries obtained a VF below 80% and only nine showed consistently high VF and QS scores. The most frequent weaknesses in the information systems were inconsistency of denominators used to estimate coverage, poor availability of guidelines (e.g. for late reporting), incorrect estimations of vaccine wastage and lack of feedback on immunization performance. In all six countries that failed a first DQA and undertook a second DQA, the VF and all QSs improved, not all of them statistically significantly.CONLUSIONS. The DQA is a diagnostic tool to reveal a number of crucial problems that affect the quality of immunization data in all tiers of the health system. It identifies good performance at HU and district levels which can be used as examples of best practices. The DQA methodology brings data quality issues to the top of the agenda to improve the monitoring of immunization coverage.

Feasibility, acceptability and cost of home-based HIV testing in rural Kenya.

Abstract: OBJECTIVE: To demonstrate the feasibility acceptability and cost of home-based HIV testing and to examine the applicability of the model to high HIV prevalence settings. METHODS: Quantitative qualitative and cost data were collected during a home-based HIV testing program in a high-prevalence rural area of Kenya; data on age gender and marital status along with HIV test results were collected. This was complemented with qualitative research including key informant interviews with counselors and program managers to highlight experiences and challenges. Direct costs of the interventions were estimated through the review of budgets and monthly expenditure sheets. RESULTS: Of 3180 15-49-year olds exposed to a community awareness campaign 2033 (63.9%) agreed to be visited by counselors of whom 1984 (97.6%) agreed to be tested and receive the results. Adult HIV prevalence was 8.2% and married women were 4.8 times more likely to be HIV-positive than those never married. Counselors reported feeling welcomed and noted the enthusiasm of the community towards testing. The total cost of the exercise was $17569. The program cost was $2.60 for each of the 6750 community members $5.88 for each person tested and $84 per positive case detected. CONCLUSION: This study suggests that home-based HIV testing is feasible with high uptake and has the potential to substantially expand access to HIV testing services. There is a strong economic case for the extension of such a screening program to other communities.

Determinants of survival in AIDS patients on antiretroviral therapy in a rural centre in the Far-North Province, Cameroon.

Abstract: had died and 59 ⁄ 1187 were lost to follow-up. The survival probability was 77% at 1 year [95% CI: 75–80] and 47% at 5 years [95% CI: 40–55]. The median survival time was 58 months. CD4 count, haemoglobin, BMI, sex and clinical stage at enrolment were independent predictors of mortality. conclusion This study confirms the clinical benefit of ART programs in a remote and resourceconstrained setting operating in routine conditions. The challenge ahead is to secure earlier access to ART and to maintain its longer-term benefit.

Turning points, reproduction number, and impact of climatological events for multi-wave dengue outbreaks.

Abstract: Summary Objectives To study climatological and public health events which might have affected the 2007 two-wave dengue outbreak in Taiwan, an island with both tropical and subtropical regions, where the 2007 dengue incidence exceeded the combined total of the previous four years. Methods A multi-phase Richards model was fitted to weekly cumulative dengue data to pinpoint the turning points of the outbreak. We obtained the ‘initial’ reproduction numbers for the two waves of the outbreak. By means of correlation analysis we explored the possible impact of climatological events on the occurrence of turning points. Results Three turning points occurred around early August, late August/early September, and late October/early November. The ‘initial’ reproduction number for the first wave was Ri = 4.67 (95% CI: 0*–10.92), where 0* = max{0, lower bound}, and Ri = 3.93 (95% CI: 1.74–6.13) for the second wave. The highest correlation was between dengue incidence and two climatological variables: maximum temperature at a lag of 5 weeks (r = 0.66 and 0.71) and total precipitation at a lag of seven weeks (r = 0.53). Conclusions The first two turning points were partially attributable to two typhoons around early to mid-August that brought a sharp drop in temperature and substantial rainfall. The drop in temperature first drove the dengue incidence down, then the rainfall drove it up at the beginning of fall. In recent years, Taiwan has witnessed increasingly frequent large summer dengue outbreaks that persisted into early winter, perhaps due to warmer autumns. This highlights the possible impact of global warming on the spread of infectious diseases. Tournants, nombre de reproduction et impact des evenements climatologiques pour l’epidemie a vagues multiples de la dengue Objectifs: Etudier la climatologie et les evenements de sante publique qui pourraient avoir influe sur l’epidemie de dengue a deux vagues en 2007 a Taiwan, une ile avec a la fois des regions tropicales et subtropicales, au cours de laquelle l’incidence de la dengue a depasse le total combine des quatre annees precedentes. Methodes: Un modele multi phasique de Richards a ete appliquea des donnees cumulatives hebdomadaires de dengue afin d’identifier les tournants de l’epidemie. Nous avons obtenu les nombres ‘initiaux’ de reproduction pour les deux vagues de l’epidemie. Par le biais d’analyse de correlation, nous avons explore l’impact possible des evenements climatiques sur l’apparition de tournants critiques. Resultats: Trois tournants ont eu lieu: vers debut aout, fin aout/debut septembre et fin octobre/debut novembre. Le nombre “initial” de reproduction (Ri) pour la premiere vague etait = 4,67 (IC95%: 0* - 10,92), ou 0*= max {0, limite inferieure} et Ri = 3,93 (IC95: 1,74 - 6,13) pour la deuxieme vague. La correlation la plus forte etait celle entre l’incidence de la dengue et deux variables climatologiques: la temperature maximale sur un decalage de cinq semaines (r = 0,66 et 0,71) et le total des precipitations sur un decalage de sept semaines (r = 0,53). Conclusions: Les deux premiers tournants etaient en partie attribuables a deux typhons vers le debut et la mi-aout, qui ont entraine une forte baisse de la temperature et des precipitations importantes. La chute de la temperature a d’abord menea la diminution de l’incidence de la dengue, puis la pluie l’a fait augmenter au debut de l’automne. Au cours des dernieres annees, Taiwan a connu de fortes epidemies de dengue en ete de plus en plus frequentes qui persistaient jusqu’au debut de l’hiver, peut-etre dues a des automnes plus chauds. Ceci souligne l’impact possible du rechauffement climatique sur la propagation des maladies infectieuses. Puntos de inflexion, Numero Reproductivo, e Impacto de Eventos Climatologicos sobre Brotes Consecutivos de Dengue Objetivos: Estudiar los eventos climatologicos y de salud publica que pueden haber afectado los dos brotes epidemicos de dengue del 2007 en Taiwan, una isla con regiones tanto tropicales como subtropicales, en donde la incidencia de dengue en el 2007 excedio el total combinado de los cuatro anos anteriores. Metodos: Un modelo multi-fase de Richards fue ajustado con datos semanales acumulativos de dengue con el fin de identificar los puntos de inflexion del brote epidemico. Hemos obtenido los numero de reproduccion “iniciales” para los dos brotes consecutivos. Mediante un analisis de correlacion hemos explorado el posible impacto de eventos climatologicos sobre la ocurrencia de puntos de inflexion. Resultados: Tres de los puntos de inflexion ocurrieron alrededor de principios de Agosto, finales de Agosto/comienzos de Septiembre, y finales de Octubre/comienzos de Noviembre. El numero de reproduccion “inicial” para la primera ola fue de Ri=4.67 (95%IC: 0*-10.92), donde 0*=max{0, limite inferior }, y Ri=3.93 (95%IC: 1.74-6.13) para la segunda ola. La mayor correlacion era entre la incidencia de dengue y dos variables climatologicas: temperatura maxima en un intervalo de cinco semanas (r = 0.66 y 0.71) y la precipitacion total en un intervalo de siete semanas (r = 0.53). Conclusiones: Los primeros dos puntos de inflexion eran parcialmente atribuibles a dos tifones ocurridos alrededor de mediados de Agosto que conllevaron a una caida pronunciada en la temperatura y lluvias sustanciales. La caida en la temperatura llevo inicialmente a un descenso en la incidencia del dengue, pero las lluvias resultaron en un nuevo incremento a comienzos del otono. En los ultimos anos, Taiwan ha sido testigo de un aumento, cada vez mayor, en la frecuencia de grandes brotes de dengue durante el verano, que tal vez debido a otonos mas calidos, han persistido hasta comienzos del invierno. Esto subraya el posible impacto del calentamiento global sobre la diseminacion de enfermedades infecciosas.

The effect of a soap promotion and hygiene education campaign on handwashing behaviour in rural India: a cluster randomised trial

Abstract: Summary Objective To investigate the effectiveness of a hygiene promotion intervention based on germ awareness in increasing handwashing with soap on key occasions (after faecal contact and before eating) in rural Indian households. Methods Cluster randomised trial of a hygiene promotion intervention in five intervention and five control villages. Handwashing was assessed through structured observation in a random sample of 30 households per village. Additionally, soap use was monitored in a sub-sample of 10 households per village using electronic motion detectors embedded in soap bars. Results The intervention reached 40% of the target population. Germ awareness increased as well as reported handwashing (a possible indicator of perceived social norms). Observed handwashing with soap on key occasions was rare (6%), especially after faecal contact (2%). Observed handwashing with soap on key occasions did not change 4 weeks after the intervention in either the intervention arm (−1%, 95% CI −2%/+0.3%), or the control arm (+0.4%, 95% CI −1%/+2%). Data from motion detectors indicated a significant but small increase in overall soap use in the intervention arm. We cannot confidently identify the nature of this increase except to say that there was no change in a key measure of handwashing after defecation. Conclusion The intervention proved scalable and effective in raising hygiene awareness. There was some evidence of an impact on soap use but not on the primary outcome of handwashing at key times. However, the results do not exclude that changes in knowledge and social norms may lay the foundations for behaviour change in the longer term.

Diagnosis of antiretroviral therapy failure in Malawi: poor performance of clinical and immunological WHO criteria.

Abstract: Summary Objectives In antiretroviral therapy (ART) scale-up programmes in sub-Saharan Africa viral load monitoring is not recommended. We wanted to study the impact of only using clinical and immunological monitoring on the diagnosis of virological ART failure under routine circumstances. Methods Clinicians in two urban ART clinics in Malawi used clinical and immunological monitoring to identify adult patients for switching to second-line ART. If patients met clinical and/or immunological failure criteria of WHO guidelines and had a viral load <400 copies/ml there was misclassification of virological ART failure. Results Between January 2006 and July 2007, we identified 155 patients with WHO criteria for immunological and/or clinical failure. Virological ART failure had been misclassified in 66 (43%) patients. Misclassification was significantly higher in patients meeting clinical failure criteria (57%) than in those with immunological criteria (30%). On multivariate analysis, misclassification was associated with being on ART 200 cells/μl [OR = 5.03 (2.05, 12.34)]. Active tuberculosis and Kaposi’s sarcoma were the most common conditions causing misclassification of virological ART failure. Conclusion Misclassification of virological ART failure occurs frequently using WHO clinical and immunological criteria of ART failure for poor settings. A viral load test confirming virological ART failure is therefore advised to avoid unnecessary switching to second-line regimens. Diagnostic de l’echec de l’ART au Malawi: mauvais performance des criteres cliniques et immunologiques de l’OMS Objectifs: Dans la therapie antiretrovirale (ART) le deploiement de programmes de suivi de la charge virale en Afrique sub-saharienne n’est pas recommande. Nous avons voulu etudier l’impact de la seule utilisation du suivi clinique et immunologique sur le diagnostic de l’echec virologique ART dans les circonstances de routine. Methodes: Les cliniciens dans deux cliniques ART urbains au Malawi ont utilise le suivi clinique et immunologique afin d’identifier les patients adultes necessitant le passage a un traitement ART de seconde ligne. Lorsque les patients repondaient aux criteres d’echec clinique et/ou immunologique des directives de l’OMS et avaient une charge virale < 400 copies/ml, il en resultait une mauvaise classification de l’echec virologique ART. Resultats: Entre janvier 2006 et juillet 2007, nous avons identifie 155 patients avec des criteres d’echec clinique et/ou immunologique de l’OMS. L’echec virologique ART a ete mal classifie chez 66 (43%) patients. L’erreur de classification a ete significativement plus elevee chez les patients repondant aux criteres d’echec clinique (57%) que chez ceux avec des criteres immunologiques (30%). En analyse multivariee, l’erreur de classification etait associee au fait d’etre sous ART depuis 200 cellules/μl (OR = 5,03 (2,05 - 12,34)). La tuberculose active et le sarcome de Kaposi etaient les conditions les plus courantes entrainant une mauvaise classification de l’echec virologique ART. Conclusion: une mauvaise classification de l’echec virologique ART se produit frequemment avec l’utilisant les criteres cliniques et immunologiques d’echec de l’ART de l’OMS dans les regions pauvres. Une mesure de la charge virale confirmant l’echec virologique ART est donc conseillee afin d’eviter des passages non necessaires vers des traitements de seconde ligne. Diagnostico de fallo del TAR en Malawi: desempeno pobre de los criterios de la OMS clinicos e inmunologicos Objetivos: En los programas de aumento a escala de la terapia antirretroviral (TAR) en Africa sub-Sahariana, la monitorizacion de la carga viral no esta recomendada. Queriamos estudiar el impacto de utilizar solamente la monitorizacion clinica e inmunologica en el diagnostico del fallo virologico del TAR bajo circunstancias rutinarias. Metodos: Los clinicos de dos clinicas urbanas de TAR en Malawi utilizaron monitorizacion clinica e inmunologica para identificar pacientes adultos para cambiar a segunda linea de tratamiento. Si los pacientes cumplian con los criterios clinicos o inmunologicos de fallo segun las guias de la OMS y tenian una carga viral de <400 copias/ml habia una clasificacion erronea del fallo virologico del TAR. Resultados: Entre enero 2006 julio 2007, identificamos 155 pacientes con criterios de la OMS para fallo inmunologico o clinico. El fallo virologico del TAR ha sido mal clasificado en 66 (43%) pacientes. La clasificacion erronea era significativamente mayor en pacientes que cumplian con los criterios clinicos de fallo (57%) que en aquellos con criterios inmunologicos (30%). En un analisis multivariado, el error en la classificacon estaba asociado con estar en TAR 200 cel/¼l (OR=5.03 (2.05, 12.34)). Una tuberculosis active y el sarcoma de Kaposi eran las condiciones mas comunes responsables de la clasificacion erronea de fallo virologico del TAR. Conclusion: La clasificacion erronea de fallo virologico del TAR ocurre frecuentemente utilizando los criterios de fallo de TAR de la OMS, tanto clinicos como inmunologicos, para entornos pobres. Una prueba de carga viral que confirme es, por lo tanto recomendable, para evitar posibles cambios a tratamientos de segunda linea.

Performance-based financing for better quality of services in Rwandan health centres: 3-year experience.

Abstract: In 2005, the Ministry of Health in Rwanda, with the support of the Belgian Technical Cooperation, launched a strategy of performance-based financing (PBF) in a group of 74 health centres (HCs), covering 2-m inhabitants. In 2006, PBF was extended to an additional group of 85 HCs, thus reaching 3.8-m inhabitants. This study evaluates the effect of PBF on HC performance from 2005 to 2007. Composite indicators for measuring quantity and quality of services were developed and evaluated through monthly formative supervisions by qualified and well-trained district supervisors. The strategy was based on a fixed fee per quality-approved service. The entire budget spent on the implementation of PBF amounted to $0.25/cap/year, of which $0.20/cap/year for subsidies and an estimated $0.05/cap/year for administration, supervision and training. A positive effect on utilization rates was only seen for activities that were previously less well organized; in this case, growth monitoring services and institutional deliveries. The quality of services, defined as the compliance rate with national and international norms, rose considerably for all services in both groups. A sustained level of quality between 80% and 95% was reached within 18 months in the first group. A similar result was reached in the second group in 8 months.

Severe malaria and concomitant bacteraemia in children admitted to a rural Mozambican hospital.

Abstract: OBJECTIVES To describe the prevalence, aetiology and prognostic implications of coexisting invasive bacterial disease in children admitted with severe malaria in a rural Mozambican Hospital. METHODS Retrospective study of data systematically collected from June 2003 to May 2007 in a rural Mozambican hospital, from all children younger than 5 years admitted with severe malaria. RESULTS Seven thousand and forty-three children were admitted with a diagnosis of malaria. 25.2% fulfilled the criteria for severe malaria. 5.4% of the children with severe malaria and valid blood culture results had a concomitant bacteraemia. Case fatality rates of severe malaria cases rose steeply when bacteraemia was also present (from 4.0% to 22.0%, P < 0.0001), and bacteraemia was an independent risk factor for death among severe malaria patients (adjusted OR 6.2, 95% CI 2.8-13.7, P = 0.0001). Streptococcus pneumoniae, Gram-negative bacteria, Staphilococcus aureus and non-typhoid Salmonella (NTS) were the most frequently isolated microorganisms among severe malaria cases. Their frequency and associated case fatality rates (CFR) varied according to age and to syndromic presentation. Streptococcus pneumoniae had a relatively low CFR, but was consistently associated with severe malaria syndromes, or anaemia severity groups. No clear-cut relationship between malarial anaemia and NTS bacteraemia was found. CONCLUSIONS The coexistence of malaria and invasive bacterial infections is a frequent and life-threatening condition in many endemic African settings. In Mozambique, S. pneumoniae is the leading pathogen in this interaction, possibly as a consequence of the high HIV prevalence in the area. Measures directed at reducing the burden of both those infections are urgently needed to reduce child mortality in Africa.

Health care waste management: a neglected and growing public health problem worldwide

Abstract: The objective of this Short Communication is to promulgate an inventory of 87 papers pertaining to health care waste management practices and challenges in 40 low and middle income countries worldwide amassed through a multi-language systematic review. Herein, we discuss the major gaps, failures, and frequently reported themes by geographic region. Following this we outline a proposed research agenda moving forward, and conclude that greater research and attention towards these unintended consequences of technologic progress in medical care delivery is needed to address and understand this growing public health threat around the world.

Community health insurance in sub-Saharan Africa: what operational difficulties hamper its successful development?

Abstract: In recent years, a number of reviews have generated evidence on the potential of community health insurance (CHI) to increase access to care and offer financial protection against the cost of illness for poor people excluded from formal insurance systems. Field experience, however, shows that in sub-Saharan Africa (SSA), a series of operational difficulties still hampers the successful development of CHI, yielding negative effects on potential progress towards increased access to care and improved financial protection. Through a careful assessment of the existing literature, including peer-reviewed articles, books, consultancy reports, and manuscripts from international organizations, we produce an analytical review of such difficulties. Our aim is to provide policy makers with the necessary knowledge on the problems at stake and with policy propositions to offset such problems, strengthening CHI and enhancing its role within SSA health systems. Our review of the literature reveals that the major difficulties currently faced by CHI in SSA are operational in nature and cluster around five areas: (i) lack of clear legislative and regulatory framework; (ii) low enrolment rates; (iii) insufficient risk management measures; (iv) weak managerial capacity; and (v) high overhead costs. Consequently, our review calls for appropriate policy interventions, specifically: (i) greater commitment towards the development of adequate legislation in support of CHI; (ii) increasing uptake of measures to expand equitable enrolment; (iii) the adoption of adequate risk management measures in all schemes; (iv) substantial investments from host countries as well as from sponsoring agencies to improve managerial capacity; and (v) collective efforts to contain overhead costs.

The household costs of health care in rural South Africa with free public primary care and hospital exemptions for the poor.

Abstract: OBJECTIVE To measure the direct cost burdens (health care expenditure as a percent of total household expenditure) for households in rural South Africa, and examine the expenditure and use patterns driving those burdens, in a setting with free public primary health care and hospital exemptions for the poor. METHODS Data on illness events, treatment patterns and health expenditure in the previous month were assessed from a cross-sectional survey of 280 households conducted in the Agincourt Health and Demographic Surveillance site, South Africa. RESULTS On average, a household experiencing illness incurred a direct cost burden of 4.5% of total household expenditure. A visit to a public clinic generated a mean burden of 1.3%. Complex sequences of treatments led 20% of households to incur a burden over 10%, with transport costs generating 42% of this burden. An outpatient public hospital visit generated a burden of 8.2%, as only 58% of those eligible obtained an exemption; inpatient stays incurred a burden of 45%. Consultations with private providers incurred a mean burden of 9.5%. About 38% of individuals who reported illness did not take any treatment action, 55% of whom identified financial and perceived supply-side barriers as reasons. CONCLUSION The low overall mean cost burden of 4.5% suggests that free primary care and hospital exemptions provided financial protection. However, transport costs, the difficulty of obtaining hospital exemptions, use of private providers, and complex treatment patterns meant state-provided protection had limitations. The significant non-use of care shows the need for other measures such as more outreach services and more exemptions in rural areas. The findings also imply that fee removal anywhere must be accompanied by wider measures to ensure improved access.

Setting priorities for health interventions in developing countries: a review of empirical studies.

Abstract: OBJECTIVE To assess and summarize empirical studies on priority-setting in developing countries. METHODS Literature review of empirical studies on priority-setting of health interventions in developing countries in Medline and EMBASE (Ovid) databases. RESULTS Eighteen studies were identified and classified according to their characteristics and methodological approaches. All studies were published after 1999, mostly between 2006 and 2008. Study objectives and methodologies varied considerably. Most studies identified sets of relevant criteria for priority-setting (17/18) and involved different stakeholders as respondents (11/18). Studies used qualitative (8/15) or quantitative (3/15) techniques, or combinations of these (4/15) to elicit preferences from respondents. In a few studies, respondents deliberated on results (3/18). A minority of studies (7/18) resulted in a rank ordering of interventions. CONCLUSIONS This review has revealed an increase in the number of empirical studies on priority-setting in developing countries in the past decade. Methods for explicit priority-setting are developing, being reported and are verifiable and replicable and can potentially lead to solutions for ad hoc policy-making in health care in many developing countries.

The economic impact of SARS in Beijing, China

Abstract: OBJECTIVE To document the impact of the severe acute respiratory syndrome (SARS) outbreak in Beijing on indicators of social and economic activity. METHODS Associations between time series of daily and monthly SARS cases and deaths and volume of public train, airplane and cargo transport, tourism, household consumption patterns and gross domestic product growth in Beijing were investigated using the cross-correlation function. RESULTS Significant correlation coefficients were found for all indicators except wholesale accounts and expenditures on necessities, with the most significant correlations occurring with a delay of 1 day to 1 month. CONCLUSIONS Especially leisure activities, local and international transport and tourism were affected by SARS particularly in May 2003. Much of this consumption was merely postponed; but irrecoverable losses to the tourist sector alone were estimated at about US$ 1.4 bn, or 300 times the cost of treatment for SARS cases in Beijing.

No decrease in annual risk of tuberculosis infection in endemic area in Cape Town, South Africa.

Abstract: Summary Objective To estimate the change in annual risk of tuberculosis infection (ARTI) in two neighbouring urban communities of Cape Town, South Africa with an HIV prevalence of approximately 2%, and to compare ARTI with notification rates and treatment outcomes in the tuberculosis (TB) programme. Methods In 1998–1999 and 2005, tuberculin skin test surveys were conducted to measure the prevalence of Mycobacterium tuberculosis infection and to calculate the ARTI. All 6 to 9-year-old children from all primary schools were included in the survey. Notification rates and treatment outcomes were obtained from the TB register. Results A total of 2067 children participated in the survey from 1998 to 1999 and a total of 1954 in 2005. Based on a tuberculin skin test cut-off point of 10 mm, the ARTI was 3.7% (3.4–4.0%) in the 1998–1999 survey and 4.1% (3.8–4.5%) in 2005. The notification rate for pulmonary TB increased significantly from 646 per 100 000 in 1998 to 784 per 100 000 in 2002. In Ravensmead, there was no significant change in ARTI [first survey: 3.5% (3.1–3.9%), second survey: 3.2% (2.9–3.6%)], but in Uitsig the ARTI increased significantly from 4.1% (3.6–4.6%) to 5.8% (5.2–6.5%). The difference in ARTI between the two areas was associated with differences in reported case rates and the proportion of previously treated cases. Conclusion Tuberculosis transmission remains very high in these two communities and control measures to date have failed. Additional measures to control TB are needed. Objectif: Estimer les changements dans le risque annuel d’infection de la tuberculose (RAIT) dans deux communautes urbaines voisines de Cape Town en Afrique du Sud avec un taux de prevalence du VIH d’environ 2% et comparer le RAIT aux taux de notifications et aux resultats du traitement dans le programme de lutte contre la tuberculose (TB). Methodes: En 1998-1999 et 2005, des etudes sur le test cutanea la tuberculine ont ete menees afin de mesurer la prevalence de l’infection par Mycobacterium tuberculosis et pour le calcul du RAIT. Tous les enfants de 6 a 9 ans dans toutes les ecoles primaires ont ete inclus dans l’enquete. Les taux de notifications et les resultats du traitement ont ete obtenus a partir du registre de la TB. Resultats: 2067 enfants ont participea l’enquete de 1998-1999 et 1954 en 2005. Sur la base d’une valeur seuil du test cutanea la tuberculine de 10 mm, le RAIT a ete estimea 3,7% (3,4% - 4,0%) dans l’etude menee en 1998-1999 et a 4,1% (3,8% - 4,5%) en 2005. Le taux de notification de la TB pulmonaire a augmente de 646 pour 100000 en 1998 a 784 pour 100000 en 2002. A Ravensmead il n’y avait pas de changement significatif dans le RAIT (premiere enquete: 3,5% (3,1% - 3,9%), seconde enquete: 3,2% (2,9% - 3,6%)), mais a Uitsig le RAIT a augmente de 4,1% (3,6% - 4,6%) a 5,8% (5,2% - 6,5%). La difference de RAIT entre les deux zones etait associee a des differences dans le taux de cas rapportes et la proportion de cas deja traites. Conclusion: La transmission de la TB demeure tres elevee dans ces deux communautes et les mesures de controle a ce jour ont echoue. Des mesures supplementaires pour le controle de la TB sont necessaires. Objetivo: Estimar el cambio en el riesgo anual de infeccion por tuberculosis (RAIT) en dos comunidades urbanas vecinas de Ciudad del Cabo, Sudafrica, con una prevalencia de VIH de aproximadamente 2%, y comparar el RAIT con las tasas de notificacion y los resultados del tratamiento en el programa de tuberculosis (TB). Metodos: En 1998-1999 y 2005, se realizaron pruebas dermicas de tuberculina con el fin de medir la prevalencia de infeccion por Mycobacterium tuberculosis y calcular el RAIT. Todos los ninos de 6 a 9 anos de escuelas primarias fueron incluidos en el estudio. Las tasas de notificacion y los resultados del tratamiento fueron obtenidos del registro de TB. Resultados: 2,067 ninos participaron en el estudio entre 1998 y 1999 y 1,954 en el 2005. Basandose en un punto de corte para la prueba de tuberculina de 10 mm, el RAIT fue 3.7% (3.4% - 4.0%) en el estudio de 1998-1999 y del 4.1% (3.8% - 4.5%) en el 2005. La tasa de notificacion para TB pulmonar aumento significativamente de 646 por100,000 en 1998 a 784 por 100,000 en el 2002. En Ravensmead no habia un cambio significativo para el RAIT (primer estudio: 3.5% (3.1% - 3.9%), segundo estudio: 3.2% (2.9% - 3.6%)), pero en Uitsig el RAIT aumento significativamente de 4.1% (3.6% - 4.6%) a 5.8% (5.2% - 6.5%). La diferencia en RAIT entre las dos areas estaba asociada a diferencias en las tasas de casos reportados y en la proporcion de casos previamente tratados. Conclusion: La transmision de TB continua siendo muy alta en estas dos comunidades, y las medidas de control a dia de hoy han fallado. Se requieren medidas adicionales para el control de la TB.

Determinants of handwashing practices in Kenya: the role of media exposure, poverty and infrastructure

Abstract: BACKGROUND To explore how structural constraints such as lack of reliable water supply, sanitation, educational and other socio-economic factors limit the adoption of better hygiene. METHODS In preparation for the Kenya National Handwashing Campaign, we conducted a nationwide cross sectional survey in 800 households with two components: (i) direct structured observation of hygiene practices at key junctures (food handling, cleaning a child after defaecation, toilet use), followed by (ii) a structured interview addressing potential socio-economic, water access and behavioural determinants of handwashing. RESULTS We observed a total of 5182 critical opportunities for handwashing, and handwashing with soap at 25% of these. Handwashing with soap was more often practised after faecal contact (32%) than in connection with food handling (15%). In univariate and multivariate analysis, water access, level of education, media exposure and media ownership were associated with handwashing with soap. Only households with very poor access to water and sanitation, and with the lowest levels of education and media exposure, washed their hands markedly less than the majority of the households. CONCLUSION The results underscore that structural constraints can limit hygiene practices in the very disadvantaged sections of a population, thus jeopardizing the potential success of hygiene promotion campaigns in those most at risk of disease. Nevertheless, the strong association of handwashing with media ownership and exposure supports the view that mass media can play a role in hygiene promotion.